PERCIVAL’S MEDICAL ETHICS.
_The Profits of this little work, if any, will be given to some Medical
Charity._
OXFORD:
PRINTED BY I. SHRIMPTON.
MEDICAL ETHICS;
OR, A CODE OF
INSTITUTES AND PRECEPTS,
ADAPTED TO THE
PROFESSIONAL CONDUCT
OF
PHYSICIANS AND SURGEONS.
BY THE LATE
THOMAS PERCIVAL, M.D., F.R.S.
_THIRD EDITION._
OXFORD:
JOHN HENRY PARKER.
LONDON: JOHN CHURCHILL, PRINCES STREET, SOHO.
M DCCC XLIX.
TO
STANLEY PERCIVAL, ESQ.,
OF BRIDGEFOOT, MIDDLESEX,
ONLY SURVIVING SON
OF DR. PERCIVAL,
THIS NEW EDITION
OF HIS FATHER’S LAST AND
MOST VALUABLE WORK
IS RESPECTFULLY OFFERED.
EDITOR’S PREFACE.
As the late Dr. Percival’s Code of Medical Ethics is commonly quoted as a
work of authority, not only in this country, but also in America[1], and
as the original edition[2] has now become somewhat scarce, it was thought
that it might be usefully republished.
The present edition is reprinted from that published by Dr. Percival
himself, (8vo. Manchester, 1803,) corrected occasionally by his
unfinished and unpublished edition[3], and also by the posthumous reprint
contained in vol. ii. of his collected “Works.” (4 vols. 8vo. Bath,
1807.) The references have been verified, and in several instances the
quotations have been corrected, but no other alteration has been made in
the _text_ of the work; as, even when the statements contained in it
were positively erroneous, the Editor preferred correcting them (where
necessary,) in a note[4]. Of the Notes and Illustrations added by Dr.
Percival several have been omitted, as being no longer wanted, as also
has the “Discourse on Hospital Duties” by his son.
By republishing Dr. Percival’s Code the Editor does not mean to imply
his agreement with all the opinions it contains, or his entire approval
either of the plan or the execution of the work. The want of a detailed
and scientific treatise on the subject of Medical Ethics, suited to
the present state of the Profession in Great Britain, (as M. Simon’s
admirable “Déontologie Médicale” is to France,) is beginning to be
universally felt. It has indeed long occupied the Editor’s thoughts,
and (as he has already ventured to intimate to the public[5],) he still
hopes, if life and leisure be allowed him, and if no abler writer step
forward to anticipate his design, to endeavour at some future time to
supply it.
_Sept. 11, 1849._
FOOTNOTES:
[1] In the Note prefixed by Dr. Hays to the “Code of Ethics of the
American Medical Association,” he writes as follows:—“On examining
a great number of Codes of Ethics adopted by different societies in
the United States, it was found that they were all based on that by
Dr. Percival, and that the phrases of this writer were preserved to a
considerable extent in all of them. Believing that language so often
examined and adopted, must possess the greatest of merits for such a
document as the present, clearness and precision, and having no ambition
for the honors of authorship, the Committee which prepared this Code have
followed a similar course, and have carefully preserved the words of
Percival, whenever they convey the precepts it is wished to inculcate.”
[2] A new edition was published in 1827, but the Editor’s notes are of
such a nature as to render the book absolutely mischievous.
[3] Of this rare volume the only copy that the Editor has seen or heard
of is in the library of the Manchester Royal Infirmary, and was given by
Dr. Percival himself. In the beginning there is the following Note in
his own hand-writing:—“The completion of the Medical Jurisprudence has
been long suspended; and it is uncertain when the undertaking will be
resumed. A title page; an introduction; a fifth and sixth section; and an
appendix, containing Notes and Illustrations, are wanting to finish this
little work.
_Manchester, March 17, 1794._”
It ends abruptly on p. 96, which terminates chap. iv. The text for the
most part agrees with that which was afterwards published, except that
this latter contains about twenty paragraphs that are not to be found
in the original sketch, and that great part of what forms Note XIV.
in the present edition is there found in the _text_. At the end of
the treatise there is the following Note, also in Dr. Percival’s own
hand-writing:—“Two sections wanting. Sect. V. On the Powers, Privileges,
Honours, and Emoluments of the Faculty. Sect. VI. On the Moral,
Religious, and Political Character of Physicians.”
[4] All the Editor’s additions are placed within brackets.
[5] In the Advertisement to Gisborne “On the Duties of Physicians.”
Nulla enim vitae pars, neque publicis neque privatis, neque forensibus
neque domesticis in rebus, neque si tecum agas quid, neque si cum altero
contrahas, vacare officio potest; in eoque colendo sita vitae est
honestas omnis, et in negligendo turpitudo.—(Cicero, _De Off._ i. 2.)
CONTENTS.
Page
Sketch of the Life of Dr. Percival 13
Author’s Dedication 17
Author’s Letter to E. C. Percival 19
AUTHOR’S PREFACE.
Origin of the work.—Suspension of it.—Farther progress of
it.—Addition of supplementary Notes and Illustrations 21
CHAPTER I.
_Of Professional Conduct relative to Hospitals, or other
Medical Charities._
§ 1. Duties of hospital Physicians and Surgeons.—Tenderness.—
Steadiness.—Condescension.—Authority 27
§ 2. Choice of their attendant Physician or Surgeon, how far
allowable to hospital patients ib.
§ 3. Feelings and emotions of patients, under critical
circumstances, to be duly regarded 28
§ 4. No discussion concerning the nature of their case to be
entered into before them ib.
§ 5. Delicacy in many cases particularly required; and secrecy
sometimes to be strictly observed 29
§ 6. Moral and religious influence of sickness to be cherished
and promoted 29
§ 7. Propriety of suggesting to patients, under certain
circumstances, the importance of making their last will and
testament 30
§ 8. Parsimony in prescribing wine and drugs of high price
reprobated ib.
§ 9. Hospital affairs and occurrences not to be incautiously
revealed 31
§ 10. Professional charges to be made only before a meeting of the
Faculty ib.
§ 11. Proper discrimination between the Medical and Chirurgical
cases to be strictly adhered to 32
§ 12. What circumstances authorize new remedies and new methods of
Chirurgical treatment ib.
§ 13. Unreserved intercourse should subsist between the gentlemen
of the Faculty; and an account of every case or operation which
is rare, curious, or instructive, should be regularly drawn up
and preserved ib.
§ 14. Scheme for hospital registers 33
§ 15. Advantages arising from the scheme 34
§ 16. Close and crowded wards reprobated 35
§ 17. Establishment of a committee of the gentlemen of the
Faculty considered 36
§ 18. Importance of frequent consultations, and the mutual
assistance of the Physicians and Surgeons ib.
§ 19-22. Rules to be observed in consultations ib.
§ 23. Rules to be observed respecting operations 38
§ 24. Hospital consultations ought not to be held on Sundays,
except in cases of urgent necessity 39
§ 25. Stated days for operations often inconvenient and improper 39
§ 26. Dispensaries ib.
§ 27. Asylums for female patients labouring under syphilis.—Rules
to be observed in Lock Hospitals 41
§ 28. Asylums for insanity 43
§ 29. Modes of acquiring knowledge in the treatment of insanity
recommended 44
§ 30. Treatment of lunatics—tenderness—indulgence 45
§ 31. Boldness of practice sometimes required in cases of
mania.—Hospitals for small-pox—inoculation, &c. &c., require
no professional duties not already enumerated ib.
CHAPTER II.
_Of Professional Conduct in Private or General Practice._
§ 1. Moral rules of conduct, the same with those to be observed
towards hospital patients 47
§ 2. The strictest temperance required ib.
§ 3. Proper conduct to be observed respecting prognostications, and
the disclosure of circumstances to the friends of the patients 48
§ 4. Proper conduct respecting interference in cases under the
charge of another 49
§ 5. Conduct to be observed towards a Physician formerly employed
by the patient, but not now consulted 50
§ 6. Distinction between the provinces of Physic and Surgery to be
steadily maintained ib.
§ 7. Consultations to be promoted in difficult or protracted cases 51
§ 8. Special consultation.—Conduct of the Physician called in 52
§ 9. Theoretical discussions to be avoided in consultations 53
§ 10. Rules for consultations the same with those prescribed to
the Faculty attending hospitals.—Seniority, how determined ib.
§ 11. Education of Medical men—what influence it ought to have in
the consideration of their brethren ib.
§ 12. Punctuality in visits of consultation—further rules to be
observed 54
§ 13. Visits to the sick not to be unseasonably repeated 55
§ 14. Rules to be observed with regard to fees, when a Physician
officiates in the absence, or at the request, of another ib.
§ 15. Importance of adopting some general rule respecting
pecuniary acknowledgements 56
§ 16. Medical men and their families, when to be attended
gratuitously 57
§ 17. Peculiar delicacy and attention often required in attendance
upon them 58
§ 18. Attendance on clergymen in narrow circumstances ib.
§ 19. Consultation by letter 59
§ 20. Rules to be observed in furnishing certificates ib.
§ 21. Use of quack medicines to be discouraged 60
§ 22. The dispensing of nostrums reprobated 61
§ 23. Duty incumbent on individuals to promote the general
reputation of the Faculty collectively ib.
§ 24. Rule to be observed in professional controversy and contention 62
§ 25. Giving advice gratis ib.
§ 26. Rule to be observed in visiting the patient of another
Physician 63
§ 27. Another case of the same ib.
§ 28. Review of the treatment and progress of interesting cases
recommended ib.
§ 29. Moral and religious advice to patients 64
§ 30. Observance of the Sabbath by Medical gentlemen considered 65
§ 31. Co-operation of young and aged practitioners ib.
§ 32. Period of senescence in Physicians considered 66
CHAPTER III.
_Of the Conduct of Physicians to Apothecaries._
§ 1. Connection between the Apothecary and Physician 69
§ 2. The Apothecary often precursor to the Physician, and commonly
acquainted with the diseases of the family ib.
§ 3. Rule to be observed in the intercourse and co-operation of
the Physician and Apothecary 71
§ 4. Duty and responsibility of the Physician ib.
§ 5. Particular directions to be observed in visiting country
patients with the Apothecary 72
§ 6. Profits of Apothecaries 73
§ 7. Physicians visiting the patients of Apothecaries in their
absence, not approved of 74
§ 8. Duty of Apothecaries in recommending Physicians to families 75
§ 9. Establishment of funds for the benefit of the widows and
children of Apothecaries 76
CHAPTER IV.
_Of Professional Duties in certain Cases which require a
Knowledge of Law._
§ 1. Medical gentlemen exempt from serving on inquests, juries,
&c.; but frequently called upon to exercise duties which require
juridical knowledge 78
§ 2. Duty of Physicians in cases of last will and testament—knowledge
of law required 79
§ 3. Commissions of lunacy—appointment of a curator 83
§ 4. Treatment of lunatics as authorized by law 85
§ 5. Asylums for lunatics subject to strict regulations of law ib.
§ 6. Opinions given in cases of sudden death 87
§ 7. Justifiable homicide 88
§ 8. Excusable homicide 89
§ 9. Suicide 92
§ 10. Manslaughter—Murder 93
§ 11. Murder of bastard children 96
§ 12. Duelling 102
§ 13. Duty of Surgeons with respect to attending a duellist to
the field of combat 106
§ 14. Private and personal duty of Physicians with respect to
duel—true honour considered 108
§ 15. Homicide by poison—cases adduced 109
§ 16. Law in cases of rape 113
§ 17. Nuisances defined and considered 117
§ 18. Duty of Medical gentlemen when summoned to attend coroners,
magistrates, and judges 120
§ 19. Importance to gentlemen of the Faculty of settling their
opinions concerning the right of magistrates to inflict capital
punishment.—The limits prescribed to the exercise of the right;
and the duty of giving full efficiency to law 122
§ 20. Cautions relative to professional testimony in cases of
peculiar malignity 125
NOTES AND ILLUSTRATIONS.
Note
I. Caution or temerity in practice 129
II. Temperance of Physicians 130
III. A Physician should be the minister of hope and comfort to
the sick.—Enquiry, how far it is justifiable to violate truth
for the supposed benefit of the patient 132
IV. The practice of a prior Physician should be treated with
candour, and justified, so far as truth and probity will permit 141
V. Theoretical discussions should be generally avoided 142
VI. Regular academical education ib.
VII. Pecuniary acknowledgements 146
VIII. Public worship; scepticism and infidelity 150
IX. Union in consultation of senior and junior Physicians 166
X. [On Wills] 168
XI. Partial insanity, with general intelligence—Lucid interval 169
XII. [On the new Lunatic Act] 175
XIII. [Legal penalties on duelling] 181
XIV. Duelling.—Letter from Dr. Franklin ib.
XV. Punishment of the crime of rape 192
XVI. [Medical evidence at inquests] 194
SKETCH OF THE LIFE OF DR. PERCIVAL[6].
Thomas Percival was born at Warrington in Lancashire, Sept. 29, 1740.
When only three years old, he had the misfortune to lose both his
parents; and the care of his early education devolved upon his eldest
sister. When of proper age, he was placed at a private academy in the
neighbourhood of his native town; to the free grammar-school of which he
was subsequently removed.
In 1757 his name was enrolled as the first student at the Warrington
academy, then just instituted under the superintendence of Dr. Aikin.
After having acquired a high reputation for diligence in classical and
theological studies, he proceeded in 1761 to Edinburgh, where he applied
himself with great assiduity to medical pursuits. He would, it appears,
have gone either to Oxford or Cambridge, but for his scruples about
subscription to the Thirty-nine Articles. Whilst in Edinburgh he became
acquainted with Mr. Hume and Dr. Robertson; and during a visit to London
contracted a close intimacy with Lord Willoughby de Parham, who made him
his constant companion, and became his warmest friend and patron. He was
indebted to this nobleman for an early introduction to the most eminent
literary characters of the day; and through his recommendation became a
Fellow of the Royal Society in 1765.
In the same year he took his degree of M.D. at Leyden, and afterwards
visited Paris and Hamburgh. He then returned to Warrington; at which
place, after a residence of a few months, he married the daughter of
Nathaniel Bassnett Esq. In 1767 he settled at Manchester, where he passed
the remainder of his life.
Dr. Percival held a distinguished rank both as a literary character,
and a physician. In the latter capacity he displayed quick penetration,
discriminating judgement, patient attention, and above all, says
Abp. Magee, a deep sense of responsibility. As an author he obtained
considerable reputation in the philosophical and religious world,
particularly by his “Essays, Medical and Experimental,” and his last
work entitled, “Medical Ethics,” in which, it is said, while delineating
the requisites and qualifications of the medical practitioner, he has
unconsciously displayed the most exact portraiture of himself. His
other more important productions include “A Father’s Instructions;”
“Moral and Literary Dissertations,” (which have rarely been surpassed
by any didactic composition of a similar extent, for genuine feeling,
refined taste, purity of style or aptness of illustration;) and several
papers published in the Transactions of the Manchester Literary and
Philosophical Society, of which he was an original member, and continued
the president from its first foundation to the end of his life. He was
the first who attempted to establish public lectures on mathematics,
commerce, and the fine arts, in that town. In addition to his other
honours he was a fellow of the Royal Society of Edinburgh, and a member
of several foreign Societies. His correspondence was extensive, and
embraced a variety of subjects: among his epistolary friends, were
Archdeacon Paley, Dr. Priestley, Dr. Franklin, Dr. Beattie, and Hannah
More. In one of his letters to the first of these celebrated characters,
he avows himself a dissenter; but he rarely alludes to the fact
elsewhere, and he is known to have entertained a sincere respect for the
Church of England, of which his eldest son was a minister. He died at
Manchester Aug. 30, 1804, in the sixty-fourth year of his age. A Latin
epitaph by the Rev. Dr. Parr is inscribed on his tomb in the church at
Warrington; and over the president’s chair, in the hall of the Manchester
Philosophical Society, a mural tablet has been erected to his memory.
His works were collected and published in 4 vols. 8vo., 1807, with a
biographical memoir by his son Dr. Edward Percival, of Bath.
FOOTNOTES:
[6] Taken, with a few alterations, from “the Georgian Era,” vol. ii.
TO
SIR GEORGE BAKER, BART.,
PHYSICIAN TO THEIR MAJESTIES,
FELLOW OF THE ROYAL SOCIETY,
AND
LATE PRESIDENT OF THE COLLEGE OF PHYSICIANS, &c. &c.
THIS CODE OF
PROFESSIONAL ETHICS,
WHICH HE HAS
HONOURED WITH HIS SANCTION,
AND IMPROVED BY HIS COMMUNICATIONS,
IS GRATEFULLY AND RESPECTFULLY
INSCRIBED,
BY HIS
OBLIGED AND AFFECTIONATE FRIEND,
THE AUTHOR.
[1803.]
Quicquid dignum sapiente bonoque est.
(Horace, _Ep._ i. 4. 5.)
TO E. C. PERCIVAL[7].
Permit me, my dear Son, to offer to your acceptance this little manual
of MEDICAL ETHICS. In the composition of it, my thoughts were directed
towards your late excellent brother[7], with the tenderest impulse of
paternal love; and not a single moral rule was framed without a secret
view to his designation, and an anxious wish that it might influence his
future conduct.
To you, who possess in no inferior degree my esteem and attachment,
who are prosecuting the same studies, and with the same object, my
solicitudes are naturally transferred: and I am persuaded, these united
considerations will powerfully and permanently operate upon your
ingenuous mind.
It is the characteristic of a wise man to act on determinate principles;
and of a good man to be assured that they are conformable to rectitude
and virtue. The relations in which a Physician stands to his patients,
to his brethren, and to the public, are complicated and multifarious;
involving much knowledge of human nature, and extensive moral duties. The
study of professional Ethics, therefore, cannot fail to invigorate and
enlarge your understanding; whilst the observance of the duties which
they enjoin, will soften your manners, expand your affections, and form
you to that propriety and dignity of conduct, which are essential to the
character of a gentleman. The academical advantages you have enjoyed at
Cambridge, and those you now possess in Edinburgh, will qualify you,
I trust, for an ample and honourable sphere of action. And I devoutly
pray, that the blessing of GOD may attend all your pursuits, rendering
them at once subservient to your own felicity, and the good of your
fellow-creatures.
Sensible that I begin to experience the pressure of advancing years, I
regard the present publication as the conclusion, in this way, of my
professional labours[8]. I may, therefore, without impropriety, claim the
privilege of consecrating them to you, as a paternal legacy. And I feel
cordial satisfaction in the occasion of thus testifying the esteem and
tenderness, with which, whilst life subsists, I shall remain,
Your affectionate friend,
THOMAS PERCIVAL.
_Manchester, Febr. 20, 1803._
FOOTNOTES:
[7] [See below, p. 22.]
[8] [This anticipation was correct: Dr. Percival died in the following
year, Aug. 30, in the sixty-fourth year of his age.]
AUTHOR’S PREFACE.
The first chapter of the following work was composed in the spring of
1792, at the request of the Physicians and Surgeons of the Manchester
Infirmary: and the substance of it constitutes the code of laws, by
which the practice of that comprehensive institution is now governed.
The Author was afterwards induced, by an earnest desire to promote the
honour and advancement of his Profession, to enlarge the plan of his
undertaking, and to frame a general system of Medical Ethics; that the
official conduct and mutual intercourse of the Faculty might be regulated
by precise and acknowledged principles of urbanity and rectitude. Printed
copies of the scheme were therefore distributed amongst his numerous
correspondents, by most of whom it was warmly encouraged, and by many of
them was honoured with valuable suggestions for its improvement.
Whilst the Author was thus extending his views, and carrying on his
work with ardour, he lost the strongest incentive to its prosecution,
by the death of a beloved son[9], who had nearly completed the course
of his academical education, and whose talents, acquirements, and
virtues, promised to render him an ornament to the healing art. This
melancholy event was followed, not many years afterwards, by a second
family loss equally afflictive[10]; and the design has ever since been
wholly suspended. The Author now resumes it, animated by the hope that
it may prove beneficial to another son[11], who has lately exchanged the
pursuits of general science at Cambridge, for the study of Medicine at
Edinburgh. He feels at the same time impressed with the conviction that
the languor of sorrow becomes culpable, when it obstructs the offices of
an active vocation. “I hold every man,” says Lord Bacon[12], “a debtor
to his profession; from the which as men of course do seek to receive
countenance and profit, so ought they of duty to endeavour themselves, by
way of amends, to be a help and ornament thereunto. This is performed
in some degree by the honest and liberal practice of a profession,
when men shall carry a respect not to descend into any course that is
corrupt and unworthy thereof, and preserve themselves free from the
abuses wherewith the same profession is noted to be infected: but much
more is this performed if a man be able to visit and strengthen the
roots and foundation of the science itself; thereby not only gracing
it in reputation and dignity, but also amplifying it in profession and
substance.”
It was the Author’s original intention to have treated of the powers,
privileges, honours, and emoluments of the Faculty. But he now conceives
that this would lead him into a field of investigation too wide and
digressive; and therefore chooses to confine himself to what more
strictly belongs to Medical Ethics.
To these institutes he has annexed an Anniversary Discourse, delivered
by the late Rev. Thomas Bassnett Percival, LL.B., before the President
and Governors of the Infirmary at Liverpool[13]. As it is an address to
the gentlemen of the Faculty, the officers, the clergy, and the trustees
of the charity, on their respective hospital duties, by one competent to
the subject from his early studies, it cannot but be deemed sufficiently
appropriate to the present work, exclusively of a father’s claim to the
privilege of its insertion.
The aphoristic form of this code of Medical Ethics, though adapted
to such an undertaking, forbids in a great measure all digression,
and even precludes the discussion of many interesting points nearly
connected with the subject. Supplementary Notes and Illustrations,
therefore, are necessary to the completion of the Author’s plan: and
he trusts the candid reader will grant him the liberty of thus stating
his opinions more at large; of rectifying misconceptions, to which the
brevity essential to the work may give rise; and of correcting whatever
subsequent reflection, or the judicious observations of his friends, may
discover to be erroneous.
A considerable portion of these sheets was communicated to the Rev.
Thomas Gisborne, M.A.[14], whilst engaged in the composition of his
“Enquiry into the Duties of Men,” a work that reflects the highest
honour on the abilities and philanthropy of the author, and which may
be justly regarded as the most complete system extant of practical
ethics. The chapter concerning Physicians[15] contains a reference to
these institutes, expressed in the most gratifying terms of friendship;
and it treats so largely of the duties of the Faculty, as to seem,
at first view, to supersede the use of the present manual. But the
two publications differ not only in their plan, but in many of their
leading objects; and it may be hoped they will rather illustrate than
interfere with each other. The same remarks may be applied to the
excellent “Lectures” of Dr. Gregory[16]. Even the “Statuta Moralia” of
the College of Physicians[17], whatever merit or authority they possess,
are not sufficiently comprehensive for the existing sphere of Medical and
Chirurgical duty; and by the few regulations which they establish, they
tacitly sanction the recommendation of a fuller and more adequate code of
professional offices.
Copies of the former unfinished impression of this work have been
transmitted to the libraries of several infirmaries in different parts of
the kingdom; and the Author has reason to hope that they have contributed
to excite attention to the subject of hospital police. Amongst other
pleasing proofs of this truth, he refers with peculiar satisfaction to
the late publications of his friends, Sir G. O. Paul, Bart., and Dr.
Clark[18], of Newcastle-upon-Tyne.
This work was originally entitled “Medical Jurisprudence;” but, some
friends having objected to the term _Jurisprudence_, it has been
changed to _Ethics_. According to the definition of Justinian, however,
Jurisprudence may be understood to include moral injunctions as well as
positive ordinances:—“Juris praecepta sunt haec; honeste vivere, alterum
non laedere, suum cuique tribuere.” (_Instit._ i. 1. § 3.)
_Manchester, Febr. 15, 1803._
FOOTNOTES:
[9] [James Percival, who died Febr. 25, 1793, in the twenty-fourth
year of his age, of a malignant fever, which he had contracted while
prosecuting his medical studies at Edinburgh. See _Memoirs of Dr.
Percival_, prefixed to his “Works,” p. clxxix.]
[10] [The death of his eldest son the Rev. Thomas Bassnett Percival, in
the thirty-second year of his age, May 27, 1798. See _Memoirs &c._ p.
ccii.]
[11] [Edward Cropper Percival, the editor of his father’s collected
Works, and author of “Practical Observations on Typhous Fever,” 8vo.
1819; who settled first at Dublin, and afterwards at Bath, where he died,
1819, at the age of 36.]
[12] In the preface to his _Elements of the Common Laws of England_.
(_Works_, vol. iv. p. 9.)
[13] [This Sermon is omitted in the present edition.]
[14] [The author of numerous religious works; born Oct. 31, 1758, died
March 24, 1846. See _Gent. Mag._ for June 1846.]
[15] [The twelfth chapter, which has been extracted, and reprinted in a
separate form, 1847, Oxford, 16mo.]
[16] [Dr. John Gregory’s well-known “Lectures on the Duties and
Qualifications of a Physician.”]
[17] [“Statuta Moralia Collegii Regalis Medicorum Londinensium,” 1722,
8vo. pp. 16.]
[18] [Author of “Observations on Fevers,” &c. 1780, 8vo., and other
works.]
MEDICAL ETHICS;
_&c. &c._
CHAPTER I.
_Of Professional Conduct, relative to Hospitals, or other Medical
Charities._
§ 1. Hospital Physicians and Surgeons should minister to the sick with
due impressions of the importance of their office; reflecting that the
ease, the health, and the lives of those committed to their charge
depend on their skill, attention, and fidelity. They should study,
also, in their deportment, so to unite tenderness with steadiness, and
condescension with authority, as to inspire the minds of their patients
with gratitude, respect, and confidence.
§ 2. The choice of a Physician or Surgeon cannot be allowed to hospital
patients, consistently with the regular and established succession of
medical attendance. Yet personal confidence is not less important to
the comfort and relief of the sick poor, than of the rich under similar
circumstances; and it would be equally just and humane to enquire
into and to indulge their partialities, by occasionally calling into
consultation the favourite practitioner. The rectitude and wisdom of
this conduct will be still more apparent, when it is recollected, that
patients in hospitals not unfrequently request their discharge on a
deceitful plea of having received relief, and afterwards procure another
recommendation, that they may be admitted under the Physician or Surgeon
of their choice. Such practices involve in them a degree of falsehood,
produce unnecessary trouble, and may be the occasion of irreparable loss
of time in the treatment of diseases.
§ 3. The feelings and emotions of the patients, under critical
circumstances, require to be known and to be attended to, no less than
the symptoms of their diseases: thus, extreme timidity with respect to
venesection contra-indicates its use in certain cases and constitutions.
Even the prejudices of the sick are not to be contemned, or opposed with
harshness; for, though silenced by authority, they will operate secretly
and forcibly on the mind, creating fear, anxiety, and watchfulness.
§ 4. As misapprehension may magnify real evils, or create imaginary
ones, no discussion concerning the nature of the case should be entered
into before the patients, either with the House-Surgeon, the pupils of
the hospital, or any medical visitor.
§ 5. In the large wards of an infirmary the patients should be
interrogated concerning their complaints in a tone of voice which cannot
be overheard. Secrecy, also, when required by peculiar circumstances,
should be strictly observed. And females should always be treated with
the most scrupulous delicacy. To neglect or to sport with their feelings
is cruelty; and every wound thus inflicted tends to produce a callousness
of mind, a contempt of decorum, and an insensibility to modesty and
virtue. Let these considerations be forcibly and repeatedly urged on the
hospital pupils.
§ 6. The moral and religious influence of sickness is so favourable to
the best interests of men and of society, that it is justly regarded
as an important object in the establishment of every hospital. The
institutions for promoting it should therefore be encouraged by the
Physicians and Surgeons, whenever seasonable opportunities occur; and,
by pointing out these to the officiating clergyman, the sacred offices
will be performed with propriety, discrimination, and greater certainty
of success. The character of a Physician is usually remote either from
superstition or enthusiasm; and the aid, which he is now exhorted to
give, will tend to their exclusion from the sick wards of the hospital,
where their effects have often been known to be not only baneful, but
even fatal.
§ 7. It is one of the circumstances which softens the lot of the poor,
that they are exempt from the solicitudes attendant on the disposal of
property. Yet there are exceptions to this observation; and it may be
necessary that an hospital patient, on the bed of sickness and death,
should be reminded by some friendly monitor of the importance of a last
will and testament to his wife, children, or relatives, who otherwise
might be deprived of his effects, of his expected prize-money, or of
some future residuary legacy. This kind office will be best performed
by the House-Surgeon, whose frequent attendance on the sick diminishes
their reserve, and entitles him to their familiar confidence. And he will
doubtless regard the performance of it as a duty; for whatever is right
to be done, and cannot by another be so well done, has the full force of
moral and personal obligation.
§ 8. The Physicians and Surgeons should not suffer themselves to be
restrained by parsimonious considerations from prescribing wine, and
drugs even of high price, when required in diseases of extraordinary
malignity and danger. The efficacy of every medicine is proportionate
to its purity and goodness; and on the degree of these properties,
_caeteris paribus_, both the cure of the sick and the speediness of
its accomplishment must depend. But, when drugs of inferior quality
are employed, it is requisite to administer them in larger doses, and
to continue the use of them a longer period of time; circumstances
which probably more than counterbalance any savings in their original
price. If the case, however, were far otherwise, no economy of a fatal
tendency ought to be admitted into institutions, founded on principles
of the purest beneficence, and which, in this age and country, when well
conducted, can never want contributions adequate to their liberal support.
§ 9. The Medical gentlemen of every charitable institution are in some
degree responsible for, and the guardians of, the honour of each other.
No Physician or Surgeon, therefore, should reveal occurrences in the
hospital, which may injure the reputation of any one of his colleagues;
except under the restriction contained in the succeeding article.
§ 10. No professional charge should be made by a Physician or Surgeon,
either publicly or privately, against any associate, without previously
laying the complaint before the gentlemen of the Faculty belonging to the
institution, that they may judge concerning the reasonableness of its
grounds, and the measures to be adopted.
§ 11. A proper discrimination being established in all hospitals between
the Medical and Chirurgical cases, it should be faithfully adhered to by
the Physicians and Surgeons on the admission of patients.
§ 12. Whenever cases occur, attended with circumstances not heretofore
observed, or in which the ordinary modes of practice have been attempted
without success, it is for the public good, and in an especial degree
advantageous to the poor, (who, being the most numerous class of society,
are the greatest beneficiaries of the healing art,) that new remedies
and new methods of Chirurgical treatment should be devised. But in the
accomplishment of this salutary purpose the gentlemen of the Faculty
should be scrupulously and conscientiously governed by sound reason,
just analogy, or well authenticated facts. And no such trials should be
instituted without a previous consultation of the Physicians or Surgeons,
according to the nature of the case.
§ 13. To advance professional improvement, a friendly and unreserved
intercourse should subsist between the gentlemen of the Faculty, with
a free communication of whatever is extraordinary or interesting in
the course of their hospital practice. And an account of every case or
operation, which is rare, curious, or instructive, should be drawn up
by the Physician or Surgeon to whose charge it devolves, and entered in
a register kept for the purpose, but open only to the Physicians and
Surgeons of the charity.
§ 14. Hospital registers usually contain only a simple report of
the number of patients admitted and discharged. By adopting a more
comprehensive plan they might be rendered subservient to Medical science
and beneficial to mankind. The following sketch is offered with deference
to the gentlemen of the Faculty. Let the register consist of three
tables: the first specifying the number of patients admitted, cured,
relieved, discharged, or dead; the second, the several diseases of the
patients, with their events; the third, the sexes, ages, and occupations
of the patients. The ages should be reduced into classes; and the tables
adapted to the four divisions of the year. By such an institution, the
increase or decrease of sickness; the attack, progress, and cessation of
epidemics; the comparative healthiness of different situations, climates,
and seasons; the influence of particular trades and manufactures
on health and life; with many other curious circumstances, not more
interesting to Physicians than to the community, would be ascertained
with sufficient precision.
§ 15. By the adoption of the register recommended in the foregoing
article, Physicians and Surgeons would obtain a clearer insight into the
comparative success of their hospital and private practice; and would be
incited to a diligent investigation of the causes of such difference.
In particular diseases it will be found to subsist in a very remarkable
degree: and the discretionary power of the Physician or Surgeon in
the admission of patients, could not be exerted with more justice or
humanity, than in refusing to consign to lingering suffering and almost
certain death a numerous class of patients, inadvertently recommended
as objects of these charitable institutions. “In judging of diseases
with regard to the propriety of their reception into hospitals,” says
an excellent writer, “the following general circumstances are to be
considered:—
“Whether they be capable of speedy relief; because, as it is the
intention of charity to relieve as great a number as possible, a quick
change of objects is to be wished; and also because the inbred disease
of hospitals will almost inevitably creep in some degree upon one who
continues a long time in them, but will rarely attack one whose stay is
short.
“Whether they require in a particular manner the superintendence of
skilful persons, either on account of their acute and dangerous nature,
or any singularity or intricacy attending them, or erroneous opinions
prevailing among the common people concerning their treatment....
“Whether they be contagious, or subject in a peculiar degree to corrupt
the air and generate pestilential diseases....
“Whether a fresh and pure air be peculiarly requisite for their cure, and
they be remarkably injured by any vitiation of it[19].”
§ 16. But no precautions relative to the reception of patients who labour
under maladies incapable of relief, contagious in their nature, or liable
to be aggravated by confinement in an impure atmosphere, can obviate
the evils arising from close wards, and the false economy of crowding
a number of persons into the least possible space. There are inbred
diseases which it is the duty of the Physician or Surgeon to prevent, as
far as lies in his power, by a strict and persevering attention to the
whole medical polity of the hospital. This comprehends the discrimination
of cases admissible, air, diet, cleanliness, and drugs; each of which
articles should be subjected to a rigid scrutiny at stated periods of
time.
§ 17. The establishment of a committee of the gentlemen of the
Faculty, to be held monthly, would tend to facilitate this interesting
investigation, and to accomplish the most important objects of it. By the
free communication of remarks, various improvements would be suggested;
by the regular discussion of them, they would be reduced to a definite
and consistent form; and by the authority of united suffrages, they would
have full influence over the governors of the charity. The exertions
of individuals, however benevolent or judicious, often give rise to
jealousy, are opposed by those who have not been consulted, and prove
inefficient by wanting the collective energy of numbers.
§ 18. The harmonious intercourse which has been recommended to the
gentlemen of the Faculty will naturally produce frequent consultations,
viz. of the Physicians on Medical cases, of the Surgeons on Chirurgical
cases, and of both united in cases of a compound nature, which, falling
under the department of each, may admit of elucidation by the reciprocal
aid of the two professions.
§ 19. In consultations on Medical cases the junior Physician present
should deliver his opinion first, and the others in the progressive
order of their seniority. The same order should be observed in
Chirurgical cases; and a majority should be decisive in both: but if the
numbers be equal, the decision should rest with the Physician or Surgeon
under whose care the patient is placed. No decision, however, should
restrain the acting practitioner from making such variations in the mode
of treatment, as future contingencies may require, or a farther insight
into the nature of the disorder may shew to be expedient.
§ 20. In consultations on mixed cases the junior Surgeon should deliver
his opinion first, and his brethren afterwards in succession, according
to progressive seniority. The junior Physician present should deliver his
opinion after the senior Surgeon, and the other Physicians in the order
above prescribed.
§ 21. In every consultation the case to be considered should be concisely
stated by the Physician or Surgeon who requests the aid of his brethren.
The opinions relative to it should be delivered with brevity, agreeably
to the preceding arrangement, and the decisions collected in the same
order. The order of seniority among the Physicians and Surgeons may be
regulated by the dates of their respective appointments in the hospital.
§ 22. Due notice should be given of a consultation, and no person
admitted to it except the Physicians and Surgeons of the hospital,
and the House-Surgeon, without the unanimous consent of the gentlemen
present. If an examination of the patient be previously necessary, the
particular circumstances of danger or difficulty should be carefully
concealed from him, and every just precaution used to guard him from
anxiety or alarm.
§ 23. No important operation should be determined upon, without a
consultation of the Physicians and Surgeons, and the acquiescence of
a majority of them. Twenty-four hours notice should be given of the
proposed operation, except in dangerous accidents, or when peculiar
circumstances occur which may render delay hazardous. The presence of
a spectator should not be allowed during an operation, without the
express permission of the operator. All extra-official interference in
the management of it should be forbidden. A decorous silence ought to
be observed. It may be humane and salutary, however, for one of the
attending Physicians or Surgeons to speak occasionally to the patient,
to comfort him under his sufferings, and to give him assurance (if
consistent with truth,) that the operation goes on well, and promises a
speedy and successful termination[20].
As a hospital is the best school for practical Surgery, it would be
liberal and beneficial to invite in rotation two Surgeons of the town,
who do not belong to the institution, to be present at each operation.
§ 24. Hospital consultations ought not to be held on Sundays, except
in cases of urgent necessity; and on such occasions an hour should be
appointed which does not interfere with attendance on public worship.
§ 25. It is an established usage in some hospitals to have a stated day
in the week for the performance of operations. But this may occasion
improper delay, or equally unjustifiable anticipation. When several
operations are to take place in succession, one patient should not
have his mind agitated by the knowledge of the sufferings of another.
The Surgeon should change his apron, when besmeared; and the table or
instruments should be freed from all marks of blood, and every thing that
may excite terror.
§ 26. Dispensaries afford the widest sphere for the treatment of
diseases, comprehending not only such as ordinarily occur, but those
which are so infectious, malignant, and fatal, as to be excluded from
admission into infirmaries. Happily also they neither tend to counteract
that spirit of independence which should be sedulously fostered in the
poor, nor to preclude the practical exercise of those relative duties,
“the charities of father, son, and brother,” which constitute the
strongest moral bonds of society. Being institutions less splendid and
expensive than hospitals, they are well adapted to towns of moderate
size; and might even be established without difficulty in populous
country districts. Physicians and Surgeons in such situations have
generally great influence; and it would be truly honourable to exert it
in a cause subservient to the interests of Medical science, of commerce,
and of philanthropy.
The duties which devolve on gentlemen of the Faculty engaged in
the conduct of Dispensaries, are so nearly similar to those of
hospital Physicians and Surgeons, as to be comprehended under the
same professional and moral rules. But greater authority and greater
condescension will be found requisite in domestic attendance on the
poor; and human nature must be intimately studied, to acquire that full
ascendancy over the prejudices, the caprices, and the passions of the
sick and of their relatives, which is essential to Medical success.
§ 27. Hospitals appropriated to particular maladies are established
in different places, and claim both the patronage and the aid of the
gentlemen of the Faculty. To an asylum for female patients labouring
under syphilis it is to be lamented that discouragements have been too
often and successfully opposed. Yet whoever reflects on the variety
of diseases to which the human body is incident, will find that a
considerable part of them are derived from immoderate passions and
vicious indulgences. Sloth, intemperance, and irregular desires are the
great sources of those evils which contract the duration and imbitter
the enjoyment of life. But humanity, whilst she bewails the vices of
mankind, incites us to alleviate the miseries which flow from them. And
it may be proved that a Lock Hospital is an institution founded on the
most benevolent principles, consonant to sound policy, and favourable to
reformation and to virtue. It provides relief for a painful and loathsome
distemper, which contaminates in its progress the innocent as well as
the guilty, and extends its baneful influence to future generations.
It restores to virtue and to religion those votaries whom pleasure has
seduced or villany betrayed, and who now feel by sad experience that
ruin, misery, and disgrace are the wages of sin. Over such objects
pity sheds the generous tear, austerity softens into forgiveness, and
benevolence expands at the united pleas of frailty, penitence, and
wretchedness[21].
No peculiar rules of conduct are requisite in the Medical attendance on
Lock Hospitals: but, as these institutions must from the nature of their
object be in a great measure shut from the inspection of the public,
it will behove the Faculty to consider themselves as responsible in an
extraordinary degree for their right government; that the moral, no less
than the Medical purposes of such establishments may be fully answered.
The strictest decorum should be observed in the conduct towards the
female patients; no young pupils should be admitted into the house; every
ministering office should be performed by nurses properly instructed; and
books adapted to the moral improvement of the patients should be put into
their hands, and given them on their discharge. To provide against the
danger of urgent want, a small sum of money and decent clothes should at
this time be dispensed to them; and, when practicable, some mode should
be pointed out of obtaining a reputable livelihood.
§ 28. Asylums for insanity possess accommodations and advantages, of
which the poor must in all circumstances be destitute; and which no
private family, however opulent, can provide. Of these schemes of
benevolence all classes of men may have equal occasion to participate the
benefits; for human nature itself becomes the mournful object of such
institutions. Other diseases leave man a rational and moral agent, and
sometimes improve both the faculties of the head and the affections of
the heart. But lunacy subverts the whole rational and moral character,
extinguishes every tender charity, and excludes the degraded sufferer
from all the enjoyments and advantages of social intercourse. Painful is
the office of a Physician, when he is called upon to minister to such
humiliating objects of distress; yet great must be his felicity, when he
can render himself instrumental, under Providence, in the restoration of
reason and in the renewal of the lost image of GOD. Let no one, however,
promise himself this divine privilege, if he be not deeply skilled in
the philosophy of human nature; for, though casual success may sometimes
be the result of empirical practice, the _medicina mentis_ can only be
administered with steady efficacy by him, who, to a knowledge of the
animal economy and of the physical causes which regulate or disturb its
movements, unites an intimate acquaintance with the laws of association,
the control of fancy over judgement, the force of habit, the direction
and comparative strength of opposite passions, and the reciprocal
dependences and relations of the moral and intellectual powers of man.
§ 29. Even thus qualified with the pre-requisite attainments, the
Physician will find that he has a new region of Medical science to
explore; for it is a circumstance to be regretted both by the Faculty
and the public, that the various diseases which are classed under the
title of insanity remain less understood than any others with which
mankind are visited. Hospital institutions furnish the best means of
acquiring more accurate knowledge of their causes, nature, and cure;
but this information cannot be attained, to any satisfactory extent, by
the ordinary attention to single and unconnected cases. The synthetic
plan should be adopted; and a regular journal should be kept of every
species of the malady which occurs, arranged under proper heads, with
a full detail of its rise, progress, and termination; of the remedies
administered, and of their effects in its several stages. The age, sex,
occupation, mode of life, and (if possible,) hereditary constitution
of each patient should be noted; and, when the event proves fatal, the
brain and other organs affected should be carefully examined, and the
appearances on dissection minutely inserted in the journal. A register
like this in the course of a few years would afford the most interesting
and authentic documents, the want of which on a late melancholy
occasion[22] was felt and regretted by the whole kingdom.
§ 30. Lunatics are in a great measure secluded from the observation of
those who are interested in their good treatment; and their complaints of
ill-usage are so often false or fanciful, as to obtain little credit or
attention, even when well founded. The Physician, therefore, must feel
himself under the strictest obligation of honour, as well as of humanity,
to secure to these unhappy sufferers all the tenderness and indulgence
compatible with steady and effectual government.
§ 31. Certain cases of mania seem to require a boldness of practice,
which a young Physician of sensibility may feel a reluctance to adopt. On
such occasions he must not yield to timidity, but fortify his mind by the
councils of his more experienced brethren of the Faculty. Yet, with this
aid, it is more consonant to probity to err on the side of caution than
of temerity[23].
Hospitals for the small-pox, for inoculation, for cancers, &c. &c., are
established in different places; but require no professional duties,
which are not included under, or deducible from, the precepts already
delivered.
FOOTNOTES:
[19] See Aikin’s _Thoughts on Hospitals_, p. 21.
[20] The substance of the five preceding articles (§§ 19-23) was
suggested by Dr. Ferriar and Mr. Simmons, at the time when I was desired
by them and my other colleagues to frame a code of rules for the
Manchester Infirmary. The additions now made are intended to adapt them
to general use.
[21] See two Reports, intended to promote the establishment of a Lock
Hospital at Manchester, in the year 1774, inserted in the Author’s
_Essays Medical, Philosophical, and Experimental_, vol. ii. p. 263.
(_Works_, vol. iv. p. 203.)
[22] [Alluding to the case of George III.]
[23] See Notes and Illustrations, No. I.