III. NINETEENTH CENTURY. A. EUROPE

In the course of the nineteenth century, medical ethics was profoundly transformed in European countries. Social, political, economic, professional, and scientific developments influenced the relationship of physicians to their patients, to their colleagues, and to the state. Focusing on continental Europe, this article first briefly characterizes medical ethics in the eighteenth century and then discusses its transformation after 1800, in connection with the evolution of the medical profession, public health and social medicine, and medical science. Most examples are drawn from Germany and France, where debates on ethical issues in medicine became particularly intense. The codification of medical morality was based on different models in these two countries. While in the German states (and to some extent also in Spain) medical ethics was clearly influenced by the early Anglo-American professional codes, in France national traditions of codes of honor in nineteenth-century bourgeois society appear to have shaped doctors' rules of conduct.

The Gentleman Doctor

Medical ethics in the eighteenth century was determined by the personal integrity and gentlemanly manners of the physician. His moral decisions were generally based, not on written rules of conduct of a college of physicians, nor directly on the Hippocratic code, but mainly on his medical knowledge, reasoning, and an internal code of honor. Enlightenment natural law theory, as developed by Samuel Pufendorf and Christian Thomasius, may have contributed to this approach. It encouraged a morality based upon rational reflection and individual conscience, rather than upon religious and ecclesiastical precepts (Geyer-Kordesch, 1993b). Eighteenth-century doctors usually treated only a small number of wealthy patients, leaving the majority of the population to the care of barber-surgeons (trained by apprenticeship), midwives, and diverse lay healers. Physicians, like their patients, felt bound to the traditional Platonic and Christian virtues of wisdom, moderation, courage, justice, and faith, hope, charity, as well as to bourgeois Enlightenment virtues like order, cleanliness, and industry (von Engelhardt, 1985).

In the German-speaking world of the eighteenth century, particularly in Prussia, modern professional ethics began to take shape within the academic discipline of medical jurisprudence. Physicians who were called on to give expert testimony on legal cases (e.g., consummation of marriage, paternity, infanticide, murder, poisoning, assault) were exhorted to build their statements truthfully on empirical findings, to admit uncertainty in medical evidence, and to behave with dignity (Geyer-Kordesch, 1993a, 1993b). At some universities, such as Halle and Göttingen, graduating physicians had to take vows of faithfulness to and respect for the academic institutions, careful and rational treatment of poor as well as rich patients, and medical confidentiality (Helm). Ethical demands like these helped physicians distinguish their conduct from that of quacks.

Social and Professional Change

The industrial revolution, urbanization, and pauperization shaped new forms of medical care during the late eighteenth and the first half of the nineteenth century. The migration of working people to the industrial regions led to an expansion of hospital medicine. Towns created publicly funded posts for physicians to treat the registered poor (i.e., those who were officially entitled to financial support from the municipal poor-relief fund). Accordingly, doctors were now confronted with a much broader range of patients, especially from the lower classes. At the same time, medical education began to require the acquisition of practical skills in surgery and obstetrics. Surgery was integrated as an academic discipline, and eventually the occupation of barber-surgeons was abolished.

Doctors became involved in public health through campaigns of smallpox vaccination, which was made compulsory in several European states as early as the first third of the nineteenth century, for example, in Bavaria (1807), Sweden (1816), and Württemberg (1818). Other states (e.g., France and Prussia) tried to support their national vaccination programs with a combination of encouragement (bonus paid to parents per vaccinated child, cash prizes and medals for vaccinators), constraint (refusal of welfare benefits to parents of unvaccinated children), and education (La Berge).

In France a public-health movement coalesced in the 1820s, in which "hygienists" of various professional backgrounds (physicians, pharmacist-chemists, engineers, veterinarians, and administrators) made efforts to solve common health problems by undertaking scientific investigations into their causes. Pioneering studies in occupational and industrial hygiene were carried out by the leaders of this movement, the physicians Alexandre Parent-Duchâtelet and Louis-René Villermé. Differential mortality studies by Villermé and the statistician Louis-François Benoiston de Châtauneuf further demonstrated a strong correlation between standard of living, and health and longevity. Following the model of the Paris health council (founded in 1802), conseils de salubrité were soon formed in other French cities and departments to advise prefects and mayors in regulating public health. Some hygienists, especially Villermé, saw themselves as moral reformers who would enable workers through better material and environmental conditions to emulate the values of the middle class (La Berge).

As the connection between bad living conditions and disease became more and more obvious—particularly after the onset of cholera epidemics in Europe beginning in the 1830s, and through the experience of the typhus epidemic in parts of Silesia in 1848—liberal physicians such as Rudolf Virchow argued for the social character of medicine and recognition of the doctor as an "advocate for the poor" (Ackerknecht).

In this period of social and professional change, physicians' concern about medical competition and secure incomes deepened. The breakdown of the so-called patronage system, in which a doctor's services were remunerated by the patient with a voluntary lump sum at the end of the year, raised debates about new models of payment that could maintain the dignity and independence of the physician and defuse competition. The concept that all practitioners should become medical officials (employees of the state)—an idea originating from reform proposals of the French Revolution—was discussed in France and Germany, and was temporarily implemented in the German duchy of Nassau (Brand). An 1823 proposal to found societies of physicians that would collect and redistribute fees, suggested by the Bonn clinician Christian Friedrich Nasse in a monograph Von der Stellung der Ärzte im Staate (On the Position of Physicians in the State), was apparently not realized (Nasse). Instead, Russia, Prussia, Hanover, and Bavaria instituted a policy of limiting the number of licensed physicians during the first decades of the nineteenth century. Some medical ordinances, for instance, those of Baden (1807) and of the canton of Zurich (1821), made licensing as a physician contingent on a number of ethical obligations, such as helping patients at any time irrespective of their social status, being discreet, and continuing one's medical education (Anner; Brand).

Duties and Rights

Increasingly, doctors wrote about the duties entailed by their profession, often using the expression deontology (science of duty), a title that is still sometimes found in European literature about medical ethics. In 1831 the Spanish physician Félix Janer published a book Elementos de moral médica, which dealt with the "dignity and importance" of the medical profession and examined the doctor's relations to the patient, within the profession and to other healers, and to the state and law. Being strongly influenced by the Lectures on the Duties and Qualifications of a Physician (1772) of the Edinburgh professor of medicine John Gregory, Janer adopted the Scotsman's demand that medical men show temperance, sobriety, firmness of character, humanity, and candor. Interestingly, he also extended these moral requirements to surgeons. These developments in Spain occurred in the context of arising competition and disputes over competence between traditional university-trained physicians (médicos puros) and new médicos colegiales, who from 1827 on began to graduate from colleges for medicine and surgery. These institutions granted the title médico-cirujano, which gave access to hospital positions. Janer himself was involved in teaching these future "medico-surgeons," eventually becoming director of the Barcelona College. Not surprisingly therefore, he defended the unity of medicine and surgery and pleaded for harmonious relations between the two types of medical practitioners (Ortiz Gómez et al.).

Other important examples of literature on medical deontology from the first half of the nineteenth century are Christoph Wilhelm Hufeland's "Die Verhältnisse des Arztes" ("The Relationships of the Physician," the last chapter of his authoritative manual of medical practice, Enchiridion medicum, 1836; ten editions until 1857; English, 1842) and Maximilien Armand Simon's Déontologie médicale (1845; Spanish, 1852). Like Janer, both these authors dealt with the relationships and ethical duties of the doctor to colleagues, to patients, and to society. Simon added a part on the moral rights of physicians, including a right to political activity, especially in the reform of laws pertaining to public health. Here Simon differed from Hufeland, who wanted to keep physicians out of any involvement in politics, permitting them only to educate the public on rational behavior in matters of health and disease. Both Hufeland and Simon described altruism as the central moral principle of the medical profession. For Simon, Christian faith formed the undisputable basis of this altruism and of all specific duties of the physician.

Both physicians' renewed admonition to care equally for the rich and the poor reflects the larger social spectrum of patients, as compared to the eighteenth century. Simon welcomed the "now multiplied" number of hospitals and dispensaries for the sick poor, yet warned his colleagues, as did Hufeland, not to abuse this group of patients for harmful scientific experiments. On the question of euthanasia, both physicians stressed that the sufferings of the dying should be alleviated, if necessary by a liberal use of opium, but that any life-shortening measures were strictly forbidden, even if the patient demanded them. Hufeland feared dire consequences for society if the physician once transgressed the line by judging the necessity of a human being's existence; Simon advanced the religious argument that man is not the master of his life. These statements were in keeping with those of the Göttingen professor of medicine Carl Friedrich Heinrich Marx, who had discussed the topic in detail in his inaugural lecture De euthanasia medica (1826). They expressed a general point of view within the medical profession that remained undisputed until the end of the nineteenth century.

Contemporary problems involving competition among doctors are reflected in Hufeland's strong plea for cooperative conduct—"Disparaging a colleague means disparaging the art and oneself!" (p. 906)—and in his discussion of proper behavior during joint consultations, a topic treated in 1798 by the Hanoverian court physician Johann Stieglitz in a monograph Über das Zusammenseyn der Ärzte am Krankenbett (On the Meeting of Doctors at the Bedside). In cases of malpractice, however, Hufeland exhorted his profession to set greater store by the "saving" of the patient than by consideration for the colleague. Difficulties with the transition of medical practice from a gentlemanly calling to a modern, economically oriented profession are evident in Simon's energetic defense against the reproach that doctors were guided by commercial interests.

Codification and Control

For physicians in the states of the North German Confederation, and soon for those of the whole German Empire, the trade ordinance of 1869 became an important step in that transition. It defined medical practice as a trade that anyone could exercise (Kurierfreiheit), yet granted legal protection of the title Arzt (physician). It abolished the doctor's duty to help any patient in case of "urgent danger," which had been included in the Prussian penal code in 1851 and was regarded by many physicians as a coercion to provide treatment. The trade ordinance intensified the resolve of academic, state-certified physicians to distinguish themselves from lay healers by establishing professional societies.

In 1873, two years after the foundation of the German Empire, an association of German societies of physicians (Deutscher Ärztevereinsbund) was formed. Its main activities consisted of representing professional and economic interests. Many societies of physicians had codes of appropriate conduct, some of which were modeled directly on the code of ethics of the American Medical Association (AMA) of 1847, and thus basically on Thomas Percival's Medical Ethics of 1803. The disciplinary powers of those societies were limited to their own members, however.

In contrast to this, the so-called chambers of physicians (Ärztekammern), founded in German states beginning in the mid-1860s, formed state-controlled medical courts of honor, which were given authority to punish professional misconduct by all physicians in the respective district (except army doctors and medical officials, who were under the direct control of the state). Once created, the medical courts of honor seem to have been very active. It has been estimated that they engaged in more than 3,000 proceedings between 1904 and 1909 in Prussia, which at this time had about 15,000 physicians who were not employed by the state or the army. Most proceedings dealt with charges of misconduct in medical competition, such as unlawful advertising, underbidding other doctors, disparaging colleagues in the presence of laypeople, and unauthorized use of specialist titles (Huerkamp).

This German path toward well-organized intraprofessional self-control, authorized by the state, contrasted with developments in France. Here, the formation of medical professional organizations was hindered by postrevolutionary legislation that followed the principle of liberal individualism. The Le Chapelier law of 1791 prohibited members of the same occupation from forming organizations that would promote their common interests, and in 1810 associations of more than twenty people formed without approval of the government were forbidden. Physicians were subject to legal responsibility for malpractice: Harm to a patient was a tort, as defined by the civil code of 1803, and was also punishable as a criminal offense under some articles of the penal code of 1810 (Ramsey).

The "medical marketplace" of early-nineteenth-century France, however, led to proposals for additional disciplinary provisions. Legislation in 1803 had established the first uniform licensing system for medical practitioners in the whole of France, distinguishing "doctors of medicine" and "doctors of surgery," officiers de santé (health officers), and certified midwives. While the doctors were required to have studied at least four years at a medical school, health officers could qualify after three years' study but also by serving six years under a doctor or five years in a hospital. Unlike doctors, the officiers, destined to provide constant medical care for the rural population, were permitted to work only within the département that had given them license to practice. On the one hand, these legal requirements drew a sharp line between regular, licensed practitioners and irregular healers, such as itinerant quacks, sedentary empirics (vendors of special remedies), and folk healers, who could now be prosecuted for illegal medical practice. On the other hand, the institution of health officers, who represented a class of less-well-trained physicians, created fears of a lapse in standards and professional decline among doctors. Moreover, economic need caused many regular practitioners to collaborate with unqualified empirics, to promote their own proprietary medicines, or to offer special cures. In these circumstances, medical reform commissions from 1812 onward repeatedly suggested the establishment of "chambers of discipline" or "medical councils," whose jurisdiction would include both illegal practice and professional misconduct. None of these proposals was put into action, however, partly because they were linked to the controversial question of reforming the institution of health officers, and partly because many doctors did not wish any further intervention by the state. In 1892 legislation abolished the title of officier de santé, as well as that of "doctor of surgery" (Ramsey).

Beginning in the 1850s, the number of physicians relative to the population grew steadily in France, leading to still fiercer competition and precarious incomes. In addition, legislation between 1874 and 1905 imposed new duties on French doctors, such as treating poor patients in return for a moderate state remuneration, testifying as experts in courts, and surveying the standards of public health (e.g., quality of water supply, housing conditions). In the 1880s, in response to these developments, doctors began to form medical unions (syndicats) to promote their professional interests. Initially illegal but tolerated, the syndicats were legally recognized in 1892. The ultimate aim of their most radical members was to create an obligatory Ordre des Médecins, analogous to the Ordre des Avocats for lawyers (founded in 1810). Such an order did not emerge; Both the government and a majority within the medical profession opposed it. But in an attempt to set ethical standards for doctors, to regulate intraprofessional relationships, and to form a unified front toward the public, the medical syndicates adopted deontological statutes that were binding on their membership.

These syndical deontologies were modeled upon the male honor codes of bourgeois social and recreational societies (cercles or sociétés à plaisance), which flourished in mid-nineteenth-century France (Nye, 1993b). Like these societies, the syndicates regarded the personal honorability (honnêteté) of their members as essential and had a policy of solving internal conflicts intra muros (i.e., without recourse to the courts). Members were obliged to report cases of malpractice to the syndicat, which had the right to withdraw membership. In this context, the old idea of "chambers of discipline" was taken up again, for example, by the medical syndicate of the arrondissement of Avesnes, which prescribed the formation of such a "tribunal of honor" in its statutes of 1910 (Nye, 1993a). Generally, however, the disciplinary powers of French professional organizations remained relatively weak throughout the nineteenth century, compared to those of their counterparts in Germany, Britain, and the United States (Ramsey).

In 1900 the Paris medical syndicate organized an international congress on "professional medicine and medical deontology," at which key speakers proposed that the problems created by overcrowding and competition should be solved through "confraternity" and "the force of moral law." Many French treatises on medical deontology, published around the time of the congress, reflected the same demands. They furthermore insisted on medical confidentiality to protect not only the privacy of the patient but also the reputation of the profession. Accordingly, the medical syndicates in the 1890s resisted requirements of the public-health legislation to divulge the names of patients with contagious diseases, whereas doctors in the first half of the nineteenth century had done so freely during smallpox and cholera epidemics (Nye, 1993a).

Controversial Issues

In the second half of the nineteenth century, ethical issues arising from developments in preventive medicine, medical science, and hospital medicine became topics of intraprofessional as well as public debate in several European countries. Following the introduction of compulsory smallpox vaccination in the German Empire in 1874, the many newly established antivaccination societies agitated intensely until World War I. Refusal to have one's children vaccinated was based mainly on reasons of conscience resulting from individual weighing of benefits and risks. In part, the reasons also reflected a protest against the restriction of personal freedom in matters of health (Maehle, 1991). This aspect had surfaced as a problem already around 1800, when Johann Peter Frank, then director general of public health of Lombardy (Cisalpine Republic), proposed universal state-controlled health care in his System einer vollständigen medicinischen Polizey (Haun). Antivaccinationism was basically a medical lay movement. Societies against vaccination were guided by academics and few physicians, who were influenced by ideas of natural healing (through water cures, diet, exercise, sun, and fresh air) and social hygiene. The same was true for the organized antivivisection movement (Maehle, 1993), which emerged as a result of the increasing scientific use of animals associated with the rise of experimental physiology (Claude Bernard, Carl Ludwig), pathology (Virchow), and bacteriology (Louis Pasteur, Robert Koch). Antivivisectionist activities, imported from Britain in the 1860s, were particularly strong in Tuscany, Germany, Switzerland, and Sweden (Rupke). A general antiscientific and antimaterialistic attitude was often behind the overt argument that animal experiments were useless cruelties (Maehle, 1993).

The growing importance of hospital medicine, reflected in the large clinics of Vienna and Paris in the first half of the nineteenth century, combined with the progress in medical science, brought the ethical problems of human experimentation into the foreground. In 1880 the courts of Bergen, Norway, sentenced Gerhard Armauer Hansen, the discoverer of the leprosy bacillus, for inoculating a female hospital patient suffering from a particular type of leprosy with leprous material from another patient (with a different type of the disease) without prior information or consent (Vogelsang). Albert Neisser, professor of dermatology in Breslau, was fined in 1900; hoping to induce immunity against syphilis, he had injected syphilitic blood serum into eight uninformed female hospital patients (three children and five prostitutes) in 1892. These and other cases stimulated intensive public debate, which—like the vivisection controversy—often had antiscientific and anti-Semitic undercurrents. Prevented from careers in the German civil service, Jews were strongly represented in the so-called free professions, such as medicine or law. In medical university careers, doctors of Jewish origin tended to concentrate in the experimental disciplines (physiology, pharmacology, immunology) and the new specialty of dermatology and venereology, because they could hardly find entry to the prestigious "classic" professorships in internal medicine and surgery. Anti-Semites advanced propaganda arguments that animal and human experimentation was an expression of "Jewish materialism" (Elkeles).

A concrete consequence of the debate on human experiments was a decree by the Prussian Ministry of Education in 1900 that required informed consent of the research subjects and prohibited scientific experimentation on minors and other persons who were not fully competent (Grodin).

New ethical challenges also emerged with the passage in the German Empire of the Health (1883), Accident (1884), and Retirement and Disability (1889) Insurance Acts; the scheme was soon copied by Austria (1888), Hungary (1891), Luxembourg (1901), and Switzerland (1911). The task of certifying sickness and disability placed physicians between the often conflicting interests of patients and insurance companies. Medical insurance tended to strengthen the patient's position; doctors began to complain that patients behaved as if they were their employers (Brand). On the other hand, insurance companies owned by factories could serve as a means for the social control of working-class patients (Frevert). For physicians the insurance scheme created hopes of economic improvement. In the long run, however, it heightened medical competition by drawing an increasing number of individuals into the profession.

Teaching Medical Ethics

Against this background, the proposal to include medical ethics in the curriculum for medical students was debated in Germany during the 1890s. At an 1898 conference on internal medicine at Wiesbaden, those who argued that an ethical attitude must be inculcated by the family, not at the university, and that ethics could not be subdivided according to the different professions, won the day. Yet the debate generated a spate of books that advocated the teaching of medical ethics. The Berlin medical historian Julius Pagel published a Medicinische Deontologie for prospective medical practitioners in 1897 (Pagel), the Wiesbaden physician Oswald Ziemssen, cousin of the renowned clinician Hugo von Ziemssen, a monograph Die Ethik des Arztes als medicinischer Lehrgegenstand (The doctor's ethics as a medical teaching subject) in 1899. Pagel gave a great deal of space to cooperative behavior among medical colleagues, demanded solidarity in cases of professional error, and advised doctors to act with self-confidence when seeing patients. Furthermore, the doctor should take care not to speak familiarly with members of the lower classes. Ziemssen built his book on codes of German societies of physicians and above all on Jukes de Styrap's A Code of Medical Ethics of 1878 (de Styrap). To some extent, he also drew on German philosophical traditions, arguing that the ethics of the physician were based on a combination of Immanuel Kant's categorical imperative, Arthur Schopenhauer's voice of feeling, and Johann Friedrich Herbart's practical judgment.

Contemporary philosophers, such as Friedrich Paulsen and Max Dessoir, also acknowledged the importance of teaching medical ethics with books and lectures. Paulsen pointed to the growing importance of medicine for modern society (von Engelhardt, 1989). Dessoir wanted the profession to compensate for a loss of ethical values in depersonalized doctor–patient relationships that resulted from specialization and the influence of medical science. Accordingly, he suggested a teaching program that would cover not only the "profession and character of the physician" and his "relationship to colleague and to the public" but also "vivisection and human experimentation" and "ethical principles in general" (p. 382).

Dessoir also served as an adviser to the Berlin neurologist Albert Moll, who provided the most significant contribution of this period with his 650-page Ärztliche Ethik. Moll argued that concern for medical ethics had concentrated on the physician's duties to colleagues and the profession (i.e., on medical etiquette), rather than on duties to the patient. He therefore put particular emphasis on ethical problems of medical practice, such as the doctor's refusing and breaking off treatment, euthanasia, deceiving the patient, advising extramarital sexual intercourse (e.g., in neurasthenia due to sexual abstinence, or in impotence), cosmetic surgery, and abortion. Moll devoted much attention to the issue of human experimentation, quoting numerous examples from the scientific literature. He oriented medical ethics to the well-being of the individual patient, not to the general welfare. Explicitly renouncing any basis in theological or philosophical systems of morality, he defined the doctor–patient relationship in legal terms, as a contract. This implied the physician's duty to fulfill the contract and the patient's obligation to respond by paying the fee. With this positivist approach, Moll reflected a general intellectual tendency of his time. In its comprehensiveness, his book provides a good overview of ethical issues in late-nineteenth-century European medicine.

Summary

In the nineteenth century there was a significant shift from reliance on largely implicit and nonsystematic notions concerning the gentleman doctor to written codes of professional etiquette and to a growing body of literature and theoretical perspectives concerning specific issues in medical ethics. In this century many of the concerns and methods now employed in medical ethics were first articulated.

andreas-holger maehle (1995)

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