Book Review

The Codification of Medical Morality: Historical and Philosophical Studies of the Formalization of Western Medical Morality in the Eighteenth and Nineteenth Centuries

N Engl J Med 1994; 331:686September 8, 1994

Article

The Codification of Medical Morality: Historical and Philosophical Studies of the Formalization of Western Medical Morality in the Eighteenth and Nineteenth Centuries
Vol. 1. Medical ethics and etiquette in the eighteenth century. (Philosophy and Medicine. Vol. 45.) Edited by Robert Baker, Dorothy Porter, and Roy Porter. 230 pp. Boston, Kluwer Academic, 1993. $87. ISBN: 0-7923-1921-4

The literature of the history of medicine contains relatively few serious studies of the formation of ethical standards for medical practice. Consequently, this collection of essays comes as a welcome addition. This book, the first of two planned volumes, explores various aspects of the formalization of medical ethics in the modern English-speaking world. Coedited by a philosopher and two historians, the book is a scholarly yet accessible introduction to the historical background of modern medical ethics. The essays represent mature scholarship in this area of study, and several of the contributors have themselves previously written substantial studies of the development of medical ethics. The present volume focuses largely on the social and philosophical context of the two principal documents relating to medical ethics in the 18th century, John Gregory's Lectures on the Duties and Qualifications of a Physician (1772; Philadelphia: M. Carey and Son, 1817) and Thomas Percival's Medical Ethics (1803; Huntington, N.Y.: R.E. Krieger, 1975).

The book has three sections. The first deals with the social context of the development of formal codes of medical ethics in the 18th century, the second with the philosophical background of that century, and the third with the formalization of codes of ethics during this period, particularly the works of Gregory and Percival. In several of the essays the authors use case histories to examine how professional decorum and the manners of the 18th century evolved into a system of ethics embodied in formal standards and reflecting the physician's duty to the patient and the profession.

The first section of the book describes the professional chaos that characterized the practice of medicine in the 18th century. In the book's first essay, Mary E. Fissell discusses the transition of medical standards of behavior from the focus on gentlemanly behavior and professional decorum, a standard adopted because it was most likely to attract prominent patients and bring generous fees, to more formalized expectations of professional behavior rooted in a professional ethic. Two other essays present the cases of specific doctors, Henry Bracken and Thomas Beddoes, who epitomized particular aspects of the ethical situation. Bracken was a “man-midwife” and author of several medical works, who advocated high standards of medical practice, though he himself was accused of various kinds of misbehavior, including forgery and libel. The author of this chapter, David Harley, uses Bracken's own attempt to maintain high medical standards and the personal and professional attacks levied against him as a means of understanding the professional ferment that led to the establishment of formal ethical codes. Roy Porter, coeditor of the book and a prolific medical historian, uses the writings of Beddoes, a physician and social critic, to highlight the corrupt nature of elite medicine of the time. Beddoes questioned the dominance of decorum as the determinant of professional behavior among his contemporaries.

The second part of the book lays out the philosophical background of the late-18th-century approach to medical ethics, which was rooted in the philosophical ferment of the Scottish Enlightenment. Here a secular basis for medical ethics emerged, which served as a basis for the ethical codes that were beginning to be developed. The section on the philosophical background of the major codes of the 17th century describes in some detail the moral philosophy of the Scottish Enlightenment and the forces at play in the development of formal codes of ethics later in the century. John Gregory, a friend of the philosopher David Hume, grounded his ethical writings in the concept of sympathy. The final section of the book examines specifically the works of Gregory and Percival, and the way in which these works came to be the standards for physicians' behavior in the decades to come.

The essays in this book are well written and generally soundly argued, though one chapter contains the dubious insight that Gregory's view of sympathy was “feminist,” whereas Adam Smith's was “sexist.” This anachronism notwithstanding, the essays adopt a sophisticated approach to the complex nature of the development of medical ethics. This collection of essays represents medical history and philosophy at their best. It illuminates the process by which contemporary standards of medical ethics evolved and aids our understanding of how we came to think the way we do about our responsibility as physicians to our patients and our society.

Samuel B. Thielman, M.D., Ph.D.
St. Joseph's Hospital, Asheville, NC 28801