I. COLONIAL NORTH AMERICA AND NINETEENTH-CENTURY UNITED STATES

North American physicians fashioned their ethics as professionals from the dominant cultural ideals of their era, from norms hallowed through centuries of professional tradition, from rules and regulations of newly established medical institutions, and from laws and legal institutions operative in the communities in which they practiced.

Christian Practitioners

The soil of religious values grounded the quest for professional ethics. For the majority of British and French physicians who settled North America in the seventeenth and eighteenth centuries, Jesus was as real and significant as Asclepius, Hygeia, and Panaceia had been to the author of the Hippocratic Oath. An intimate causal connection existed between character and professional righteousness. The beliefs and rituals of Christian institutions formed character. The ethically acceptable physician displayed the characteristics of a Christian.

Cotton Mather, a Puritan cleric who wielded considerable power throughout New England during the early eighteenth century, was a major figure in the evolution of North American medical ethics. He believed that Christian physicians who abided by the secrecy clause of the Hippocratic Oath became special confessors who had extraordinary opportunities for offering "admonitions of piety" to their trusting and needful patients (Mather, 1966). Because sin was the ultimate cause of all diseases—spiritual, mental, and physical—Mather expected physicians to prescribe Christian beliefs as well as drugs (Mather, 1972). Though he acknowledged confusion about the variety of remedies proposed as cures for any single disease, he would not dishonor "skillful and faithful" physicians (Beall and Shryock).

Though many Bostonians objected, Mather advocated inoculation during smallpox epidemics. He believed that the ultimate success of smallpox inoculation depended on God's mercy, but the validity of inoculation required trial-and-error testing and statistical comparisons between those naturally infected and those artificially inoculated. If deaths were prevented or suffering mitigated, as had occurred in Africa and Turkey, then inoculation was a good practice for doctors in North America. Its goodness as praxis was determined by the scientific demonstrations of practical trials involving mathematical standards and utilitarian outcomes that would be the basis for the reform of medical therapeutics during the nineteenth and twentieth centuries.

Gentlemen Practitioners

North American physicians repeatedly urged students and colleagues to be both Christians and gentlemen in their interactions with each other and with patients. The principal characteristics of a gentleman included proper birth, sufficient wealth, unblemished character, adequate learning, and civic service. While the importance of birth and wealth faded in the more egalitarian atmosphere of the New World, that of character, learning, and civic virtue grew stronger. Was a physician good because he cured many sick patients, or because he was a Christian and a gentleman? Doctors who prepared the earliest biographical dictionaries of deceased physicians in the United States and Canada judged their worth by Christian and gentleman standards, not by curative or preventive statistics (Thacher). Hallmarks of professional goodness depended on allegiance to the dominant cultural ideals.

Educated Doctors

Those who promoted higher standards for judging physicians frequently decried the immoralities of uneducated practitioners. In 1765, two years after the British assumed rule of New France (Canada) and ten years before the battles of Lexington and Concord, John Morgan proclaimed that most North American practitioners were ignorant, unsteady, irresolute, idle, negligent, and merciless. After six years as an apprentice to John Redman in Philadelphia, four years as a military surgeon, three years of medical studies in London and Edinburgh, and the luster of a European "grand tour," it was easy for Morgan to feel superior.

Wanting to improve this deplorable situation, Morgan and others established the first colonial medical school at the College of Philadelphia (1765). Samuel Bard, another Edinburgh graduate, delivered the first commencement address at King's College Medical School in New York City in 1769. Bard's judgment, no less harsh than Morgan's, was a fusion of Christian ethics, gentlemanly values, and academic ideals: "As those who have neither emulation nor honesty, who neither have abilities, or will give themselves the trouble of acquiring them, I would recommend it to such, seriously to consider the sixth commandment, 'Thou Shalt Do No Murder'" (Bard, p. 6). Morgan, Bard, and others fervently advocated formal education to produce morally acceptable doctors.

Because of the influx of practitioners from the United States and Great Britain, and because of British restrictions on degree-granting institutions in the colonies, enduring medical schools were not established in Canada until the third decade of the nineteenth century. In 1830, when the medical school at McGill University was one year old, twenty regular medical schools functioned in the United States. Graduates of these schools usually championed academic norms as measures of professional goodness: collegiate studies before medical ones, a systematic formal education in a medical school, improving medical science by careful clinical observations, development of effective teacher-pupil relationships, and continuing studies after formal education. Physicians were professionally good if they were Christians, gentlemen, and scholars.

Legal Proprieties

North American physicians were not considered wholly ethical unless they were law-abiding citizens. Throughout Canada's early history, its doctors associated professional propriety with approval by licensing authorities, established as early as 1788 when the British Parliament passed a licensure act governing the Canadian settlements (Heagerty). Two Canadian groups assumed licensing responsibilities: the College of Physicians and Surgeons of Lower Canada in 1847 and the College of Physicians and Surgeons of Ontario in 1869. The voluntary medical societies organized in Canada before 1850 were not concerned with licensing.

The situation was quite different in the United States. Legislators granted exclusive licensing rights to medical societies in some states and to separate boards of physicians in other states. Such licensing bodies had been established in most states by 1832. During the subsequent forty years, however, existing states repealed or ignored their medical licensing laws, and new states adopted none. Since possession of a medical degree was sufficient for licensing in many states, there seemed to be little need for sustaining separate powers for societies or boards. No group enforced these laws uniformly or effectively. Nor had the laws prevented the growth and development of medical quackery and sectarianism.

Legislators believed that free Americans could be trusted to discover the good physician and to sue the bad one. Even if a physician in the United States could be judged a good professional without being licensed, as was the situation between 1835 and 1875, he did not want to be accused of malpractice, much less convicted in court.

During the first half of the nineteenth century, the American culture, unlike the Canadian, experienced an outburst of religious pluralism, the populist effects of expansion to the West, an economic atmosphere of laissez-faire, and widespread opposition to centralized regulation by governmental authorities. These conditions fostered the lack of interest in licensure laws and the willingness of legislators to charter schools for homeopaths, hydropaths, and other sectarian practitioners.

These social and cultural conditions caused many practitioners to believe that standards of professional propriety were disappearing in a sea of populist relativism. If models of personal morality, such as Christian or gentleman, were so varied and even conflicting (Could Jewish doctors be good?), and if standards of knowing were so pluralistic that legislators relinquished efforts to distinguish among them, what could be done by practitioners who still believed in the integrity and dignity of a medical profession?

Codes of Ethics

To cope with the pluralism and relativism of the modern era, physicians created codes of professional ethics. During the last decade of the eighteenth century, Thomas Percival, a general practitioner in Manchester, England, had developed a systematic view of medical ethics based on the premise that it was possible to comprehend a moral order suitable for all medical practitioners. Universal truths about good professional behavior could be learned and applied by all conscientious and respectable doctors. Percival delineated these truths within a fourfold categorization of physicians as persons, caregivers, livelihood competitors, and civil servants.

The following admonitions exemplify Percival's approach. Physicians should be Christian gentlemen: considerate, reasonable, self-critical, temperate, educated. Doctors ought to interrogate patients privately and have special regard for their feelings and prejudices. Practitioners should consult openly and respectfully with each other, searching for proper remedies and sharing responsibilities in the care of the sick. Doctors ought to honor the trust of their communities by providing medical services free to public institutions and by providing medical knowledge needed by courts and governing officials. Percival included these and numerous other exhortations in a book on medical ethics published in 1803.

This book, together with John Gregory's lectures on medical education and medical ethics published in 1772, became a handy guide for North American practitioners who wanted practical criteria for judging propriety but had little interest in theoretical formulations of moral philosophy that might bring them too close to the Catholic traditions of the medieval universities. Most of these doctors were Protestants, and many were stalwart Puritans who, like Cotton Mather, deliberately rejected the "new moral philosophy" of the seventeenth and eighteenth centuries. In their view, these modern philosophies contained too much ancient paganism and too little Christianity, and placed more reliance on observation and reason than on faith and ritual.

Despite such theoretical objections, American physicians became exemplars of the "new moral philosophy" as they created codes of professional ethics during the first half of the nineteenth century. In 1808 an association of Boston physicians adopted a code of medical ethics composed of nine sections that addressed consultations between physicians, interfering with another doctor's practice, arbitration of differences between doctors, discouraging the use of quack medicines, promoting professional respectability, fees and exemptions from fees, practicing for a sick or absent doctor, and seniority among practitioners. All of these precepts could be found in the second chapter of Percival's Medical Ethics. Titled "Boston Medical Police," this code became the model for codes adopted by at least thirteen medical societies in eleven states during the ensuing thirty-four years.

In 1823 the New York State Medical Society adopted a code that resurrected the broader scope of Percival's original view. The New York doctors presented ethical claims about the personal character of physicians, quackery, consultations, patient care, and public obligations. In 1832 an original code was adopted by the Medico-Chirurgical Society of Baltimore. Norms were offered about the obligations of physicians to each other, quackery, consultations, and fees. This code also included a separate section about duties of patients toward physicians, an approach that had been taken by Benjamin Rush in a lecture to students. Rush thought that citizens should employ only serious-minded, educated doctors. Patients should not burden doctors with too many details of their illnesses, and they should strictly follow their doctors' orders and pay their fees promptly.

These examples of distinctive codes from Boston, New York City, Baltimore, and Philadelphia demonstrate the extraordinary interest in codifying professional ethics among American doctors, an interest that culminated in the adoption of a national code in 1847 by the newly established American Medical Association (AMA).

The AMA doctors accepted Percival's fourfold pattern of categorizing professional ethics and many of the specific claims cherished by the British practitioner. They advocated excellence of moral character, though Christian norms were no longer identified as the exclusive grounds for this character, probably because Isaac Hays, a prominent Jewish physician in Philadelphia, was a member of the committee that drafted the code. Though the AMA doctors valued proper education, they insisted that loyalty to professional colleagues was more important than scientific attainments. Article IV explicitly forbade association or consultation with irregular practitioners, that is, physicians whose "practice is based on an exclusive dogma, to the rejection of the accumulated experience of the profession," an injunction directed primarily against homeopaths. Standards of patient care included careful attention to professional secrecy, a proper number of visits to the sick, absence of gloomy prognoses, and refusal to abandon patients who have incurable diseases.

Physicians also had excellent opportunities for influencing the personal character of patients. Section 7 of Article I of Chapter 1 of the code is quite specific: "The opportunity which a physician not unfrequently enjoys of promoting and strengthening the good resolutions of his patients, suffering under the consequences of vicious conduct, ought never to be neglected." Sustaining Cotton Mather's view of the sickroom as a stage for confession and redemption, the AMA doctors accepted professional roles as moral therapists. Since "moral" then included what would be called psychotherapy today, the AMA code also sanctioned the devotion of those physicians who had chosen careers as superintendents of institutions caring for the mentally ill.

The AMA doctors emphasized the ideal of shared obligations between physicians and patients, between the profession and the public. Copying Rush, the AMA committee codified the rights of American physicians in a long list of obligations of patients toward their physicians. In the last chapter of the code these duties of patients were expressed more generally as the obligations of the public to the profession, for example, in supporting medical schools and allowing them to acquire cadavers for anatomical dissection. In return, the profession acknowledged a relatively new dimension of professional ethics by its willingness to provide medical knowledge to the governing groups of their communities. This knowledge was needed, for example, in adjudicating civil and criminal proceedings as well as in deliberations about the proper kinds of laws and institutions needed for sanitation, quarantine, and other public health measures.

Worthington Hooker, a general practitioner who later became a professor at Yale, focused on the ideal of reciprocal obligations in Physician and Patient (1849), the only comprehensive view of professional ethics published in book form by a North American practitioner before 1900. Hooker's religious beliefs were almost as conservative as those of Cotton Mather, but Hooker believed that moral philosophizing was acceptable for a Christian apologist. He became a moral philosopher of medicine. Like other conscientious midcentury doctors, he knew that religious, educational, and legal institutions had failed to provide a fully acceptable set of moral standards for judging physicians. Hooker believed that doctors were obliged to discover acceptable standards of professional behavior, to publicly proclaim these standards in a format that would be comprehensible to both professionals and the public, and to determine whether such standards had been honored by individual doctors. A code of medical ethics adopted and enforced by a national organization could become the cultural and social instrument for shaping a uniform and universal moral order for American doctors. Hooker viewed his book as an extensive commentary on the AMA code.

Thus, Hooker and many others touted the advantages of the AMA code. Professional righteousness in the United States could be measured by the extent of adherence to this code. Professionally virtuous doctors maintained professional secrecy, made the proper number of visits to the sick, did not offer gloomy prognoses, cared for the incurably sick, requested consultations as needed, and abided by the numerous other precepts in this code that was adopted voluntarily by many societies. In 1855 the AMA decided that all state and local societies wishing to send delegates to its meetings had to adopt its code of ethics.

Not a few chided the AMA's officers about the absence of enforcement procedures. Some state and local societies reprimanded members for consulting with irregular practitioners and occasionally expelled members for criminal offenses, gross immorality, or the sale of secret medicines. The AMA established a judicial council in 1873, but there is no evidence that the council enforced the code regularly or extensively. Similar difficulties affected Canadian practitioners.

One year after its establishment in 1867, the Canadian Medical Association adopted a code of ethics that was almost identical with the AMA code. Minor changes had been made in wording. One clause in the article about obligations of the public to physicians had been omitted, and a new paragraph in Section 3 of Article I permitted beginning practitioners to announce the existence of their offices in the public press. Although some doctors lauded its rules and enforcement was attempted, this code was hardly the final word in matters of medical ethics for most Canadian practitioners.

The attitudes of Canadians contrasted sharply with the sentiments of many practitioners in the United States who believed that the AMA code was as important as the Bible and the Constitution. If the American government could create a bill of rights suitable for all citizens, then the American medical profession could prepare a bill of rights suitable for all reputable medical practitioners. The AMA code of 1847 was that document. In filling a moral vacuum caused by religious pluralism, unacceptable educational standards, loss of confidence in traditional remedies, and ineffective licensure laws, the AMA code became the set of sacred values voluntarily created and professed by respectable and honorable doctors. Sick patients could place their trust in practitioners who gave their allegiance to this code.

In 1880, when one editor doubted that the majority of Canadian medical practitioners had ever read the code adopted by the Canadian Medical Association ("Code of Medical Ethics," 1880a), journal editors in the United States were about to receive an onslaught of articles for and against the AMA code. The problem involved the prohibition against consultation with any practitioners other than those exhibiting allegiance to the code. In 1882 the New York State Medical Society revised its code of ethics so that its members could consult with legally qualified practitioners regardless of their scientific or sectarian status. Seventeen state societies condemned this action, and the AMA refused to admit the New York delegates to its annual meeting. In the following year, the AMA expected all delegates to sign a pledge to obey its original code of ethics. Articles for and against the code and supporting or opposing the renegade New York physicians appeared in nearly all state medical journals. The code-loving conservatives withdrew from the New York State Medical Society and started a new organization that became larger than the original society. Conservatism was the order of the day; the code of 1847 withstood revision until 1903.

Exemplifying a practical application of the moral philosophy taught as a senior year course in most American colleges of the nineteenth century, the AMA code and its predecessors had nurtured professional unity and social respectability during the heyday of Jacksonian egalitarianism in the United States. These codified norms sustained important traditions in Western medicine, reminded all practitioners of essential duties to their patients and colleagues, and encouraged doctors to participate in those public institutions designed for the health and welfare of all.

Science Versus Codes

Those members of the New York State Medical Society who revised their code of ethics in 1882 exemplified a new breed of medical practitioner emerging in North America during the last three decades of the nineteenth century. These individuals could not accept the AMA code's claim that intraprofessional loyalty was more important than scientific truth. When Francis Delafield announced in 1886 that he and his colleagues wanted an association in which there would be no medical politics and no medical ethics, he heralded a fundamental change in the approach of North American practitioners to the perennial challenge of fashioning an acceptable set of professional ethics. Delafield and his colleagues wanted to associate with those practitioners who were able "to contribute something real to the common stock of knowledge" in medical practice (Konold, p. 39). They could no longer tolerate those practitioners who rested secure with a fundamentalist allegiance to the code of one organization whose precepts were rooted in eighteenth-century British experiences. The iconoclastic doctors of the late nineteenth and early twentieth centuries advocated a professional morality that would judge physicians in terms of their skillful application of specialized scientific knowledge in caring for the sick and the healthy. This new moral philosophy of medicine gradually became institutionalized in some medical schools and societies between 1870 and 1900.

The more progressive schools established teaching and research laboratories, and hundreds of North American practitioners journeyed to the laboratories and clinics of Europe for instruction in the basic sciences, especially microbiology and pathology, and in the clinical specialties, especially the surgical ones. Between 1864 and 1894, American physicians organized more than a dozen national societies for medical specialists (e.g., pediatrics, obstetrics, urology).

These groups did not adopt written codes of ethics. Instead they proclaimed—by word and deed—the values of a liberal premedical education and a thorough education in the medical sciences, allegiance to the experimental method as the proper approach to truths about health and disease, and a strong belief in research and continuing education.

These doctors espoused the rightness of their values as dogmatically as those who believed in the AMA code. Physicians and patients knew of numerous practitioners who did not accept the code but were reputable as persons and successful as healers. The same could not be said for doctors who ignored the bacteriological discoveries, the vaccines, the antiseptic principles, the improvements in diagnostic technology, the pharmacological therapeutics—all based on the methods of experimental science and clinical trials. Good doctors were those who competently and humanely applied this medical science.

These values led to numerous reforms in North American medical education, facilitated and sanctioned by the reestablishment of licensure policies in all of the United States by 1898. In 1902 the Medical Council of Canada became the central licensing agency for the provinces. These new licensure approaches not only sanctioned the reform measures adopted by the progressive American and Canadian medical schools but also upheld obedience to law as an important measure of professional virtuosity.

The physicians who supported these laws and schools recognized that the AMA code said nothing about the more technically proficient environments of the modern hospitals emerging after 1870. To provide competent surgical care, doctors needed instruments and assistants. By the late 1890s, scientific practitioners needed X-ray equipment and laboratory machines that could not be carried in black bags. Technically imprecise care was immoral to these doctors.

Technically adequate care, especially surgical care, required the services of trained nurses. As hospitals became cathedrals of applied science, doctors supported the training schools for nurses initiated by London's Florence Nightingale in 1860. At least fifteen of these schools existed in North America by 1880 (Rosenberg, p. 219). The ethical values espoused by these professional nurses encompassed certain cultural ideals about women, as well as specific norms about knowledge and obedience. Women were believed to be the moral standard-bearers of Victorian society. Those who chose to become nurses were special women who sacrificed much for the glory of God and the needs of the sick. Soldiers in the fight against disease, these nurses organized militaristic training schools that prepared women, attired in starched and pressed white uniforms, to assist physicians obediently in applying scientifically derived medical knowledge.

The AMA code had said nothing about nurses or women or blacks. Physicians and patients welcomed trained nurses who were social products of a new moral philosophy of medicine that assigned special values to some women. Overcoming objections by most males, other women became doctors. Nearly 400 women physicians practiced in 21 states by 1881 (Burns, 1988). Excluded from the AMA, black physicians adapted to the segregationist culture of their era by organizing the National Medical Association in 1895. The AMA codifiers made no revisions to accommodate these scientific, professional, and social changes.

The most significant change involved the transformation of the hospital into a powerful institution that incorporated the moral values of religious charity, scientific excellence, specialized patient care, and social justice. The number of hospitals in North America grew from about 300 in the 1870s to more than 4,000 by 1910. These hospitals became arenas for moral confrontations between medical practitioners and nonprofessional administrators and other laypersons. They fostered the emergence of new healthcare workers and professionals, including laboratory technicians, nurses, occupational and physical therapists, social workers, and hospital chaplains. Each group forged its particular ethical agenda. Hospitals also supported the rapidly expanding urge for specialty differentiation among physicians. At the turn of the twentieth century, hospitals became the interpersonal crucibles that sustained and transformed the legacies of North American medical ethics.

Conclusion

Before 1900, North American physicians were morally acceptable if they cherished dominant religious ideals, behaved as gentlepersons, learned the fundamentals of medical science, revered a code of professional ethics, and abided by the laws of their communities. Professional virtuousness was measured by the extent of allegiance to the cultural and professional traditions of the West, as those traditions had been adapted to North American conditions. During the last quarter of the nineteenth century, a small group of doctors began to challenge some of the value claims for professional orthodoxy. They believed that favorable results in curing and preventing specific diseases in particular humans made possible by the technically proficient behaviors of skilled professionals applying scientifically derived knowledge were more important than the status-seeking rituals of AMA codifiers or the religious beliefs of the professionals. Yet, the conservative tendencies were so tenacious that the majority of practitioners, at the opening of the twentieth century, still believed in codification as the primary method for establishing professional ethics and still displayed loyalty to the values of one association's code even though major changes in the cultural, scientific, technological, and institutional legacies had changed the nature of the quest for professional ethics.

chester r. burns (1995)

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