_Of Professional Conduct in Private or General Practice._
§ 1. The moral rules of conduct prescribed towards hospital patients
should be fully adopted in private or general practice. Every case
committed to the charge of a Physician or Surgeon should be treated with
attention, steadiness, and humanity; reasonable indulgence should be
granted to the mental imbecility and caprices of the sick; secrecy and
delicacy, when required by peculiar circumstances, should be strictly
observed; and the familiar and confidential intercourse, to which the
Faculty are admitted in their professional visits, should be used with
discretion, and with the most scrupulous regard to fidelity and honour.
§ 2. The strictest temperance should be deemed incumbent on the Faculty;
as the practice both of Physic and Surgery at all times requires the
exercise of a clear and vigorous understanding: and on emergencies, for
which no professional man should be unprepared, a steady hand, an acute
eye, and an unclouded head, may be essential to the well-being, and even
to the life, of a fellow-creature. Philip of Macedon reposed with entire
security on the vigilance and attention of his general Parmenio. In his
hours of mirth and conviviality he was wont to say, “Let us drink, my
friends; we may do it with safety, for Parmenio never drinks!” The moral
of this story is sufficiently obvious when applied to the Faculty; but it
should certainly be construed with great limitation by their patients[24].
§ 3. A Physician should not be forward to make gloomy prognostications;
because they savour of empiricism, by magnifying the importance of his
services in the treatment or cure of the disease. But he should not fail
on proper occasions to give to the friends of the patient timely notice
of danger when it really occurs, and even to the patient himself, if
absolutely necessary. This office, however, is so peculiarly alarming
when executed by him, that it ought to be declined whenever it can be
assigned to any other person of sufficient judgement and delicacy; for
the Physician should be the minister of hope and comfort to the sick,
that by such cordials to the drooping spirit he may smooth the bed of
death, revive expiring life, and counteract the depressing influence of
those maladies, which rob the philosopher of fortitude, and the Christian
of consolation[25].
§ 4. Officious interference in a case under the charge of another should
be carefully avoided. No meddling enquiries should be made concerning the
patient, no unnecessary hints given relative to the nature or treatment
of his disorder, nor any selfish conduct pursued, that may directly
or indirectly tend to diminish the trust reposed in the Physician or
Surgeon employed. Yet, though the character of a professional busy-body,
whether from thoughtlessness or craft, is highly reprehensible, there are
occasions which not only justify, but require, a spirited interposition.
When artful ignorance grossly imposes on credulity, when neglect puts
to hazard an important life, or rashness threatens it with still more
imminent danger, a Medical neighbour, friend, or relative, apprized of
such facts, will justly regard his interference as a duty. But he ought
to be careful that the information on which he acts is well founded,
that his motives are pure and honourable, and that his judgement of the
measures pursued is built on experience and practical knowledge, not
on speculative or theoretical differences of opinion. The particular
circumstances of the case will suggest the most proper mode of conduct.
In general, however, a personal and confidential application to the
gentleman of the Faculty concerned, should be the first step taken, and
afterwards, if necessary, the transaction may be communicated to the
patient or to his family.
§ 5. When a Physician or Surgeon is called to a patient who has been
before under the care of another gentleman of the Faculty, a consultation
with him should be proposed, even though he may have discontinued his
visits. His practice also should be treated with candour, and justified,
so far as probity and truth will permit: for the want of success in the
primary treatment of a case is no impeachment of professional skill or
knowledge; and it often serves to throw light on the nature of a disease,
and to suggest to the subsequent practitioner more appropriate means of
relief[26].
§ 6. In large and opulent towns the distinction between the provinces of
Physic and Surgery should be steadily maintained. This distinction is
sanctioned both by reason and experience. It is founded on the nature
and objects of the two professions; on the education and acquirements
requisite for their most beneficial and honourable exercise; and tends
to promote the complete cultivation and advancement of each. For the
division of skill and labour is no less advantageous in the liberal than
in the mechanic arts; and both Physic and Surgery are so comprehensive,
and yet so far from perfection, as separately to give full scope to
the industry and genius of their respective professors. Experience has
fully evinced the benefits of the discrimination recommended, which is
established in every well regulated hospital, and is thus expressly
authorized by the Faculty themselves, and by those who have the best
opportunities of judging of the proper application of the healing art. No
Physician or Surgeon, therefore, should adopt more than one denomination,
or assume any rank or privileges different from those of his order.
§ 7. Consultations should be promoted in difficult or protracted cases,
as they give rise to confidence, energy, and more enlarged views in
practice. On such occasions no rivalship or jealousy should be indulged:
candour, probity, and all due respect should be exercised towards the
Physician or Surgeon first engaged; and, as he may be presumed to be best
acquainted with the patient and with his family, he should deliver all
the medical directions agreed upon, though he may not have precedency
in seniority or rank. It should be the province, however, of the senior
Physician, first to propose the necessary questions to the sick, but
without excluding his associate from the privilege of making farther
enquiries, to satisfy himself, or to elucidate the case.
§ 8. As circumstances sometimes occur to render a special consultation
desirable, when the continued attendance of another Physician or Surgeon
might be objectionable to the patient, the gentleman of the Faculty whose
assistance is required, in such cases, should pay only two or three
visits, and sedulously guard against all future unsolicited interference.
For this consultation a double gratuity may reasonably be expected from
the patient, as it will be found to require an extraordinary portion both
of time and attention.
In Medical practice it is not an unfrequent occurrence, that a
Physician is hastily summoned, through the anxiety of the family or the
solicitation of friends, to visit a patient who is under the regular
direction of another Physician, to whom notice of this call has not been
given. Under such circumstances no change in the treatment of the sick
person should be made, till a previous consultation with the stated
Physician has taken place, unless the lateness of the hour precludes
meeting, or the symptoms of the case are too pressing to admit of delay.
§ 9. Theoretical discussions should be avoided in consultations, as
occasioning perplexity and loss of time; for there may be much diversity
of opinion concerning speculative points, with perfect agreement in those
modes of practice which are founded not on hypothesis, but on experience
and observation[27].
§ 10. The rules prescribed for hospital consultations may be adopted
in private or general practice[28]. And the seniority of a Physician
may be determined by the period of his public and acknowledged practice
as a Physician, and that of a Surgeon by the period of his practice as
a Surgeon, in the place where each resides. This arrangement, being
clear and obvious, is adapted to remove all grounds of dispute amongst
Medical gentlemen; and it secures the regular continuance of the order of
precedency established in every town, which might otherwise be liable to
troublesome interruptions by new settlers, perhaps not long stationary.
§ 11. A regular academical education furnishes the only presumptive
evidence of professional ability, and is so honourable and beneficial,
that it gives a just claim to pre-eminence among Physicians, in
proportion to the degree in which it has been enjoyed and improved.
Yet, as it is not indispensably necessary to the attainment of
knowledge, skill, and experience, they who have really acquired in a
competent measure such qualifications without its advantages, should
not be fastidiously excluded from the privileges of fellowship. In
consultations especially, as the good of the patient is the sole object
in view, and is often dependent on personal confidence, the aid of an
(_any?_) intelligent practitioner ought to be received with candour and
politeness, and his advice adopted, if agreeable to sound judgement and
truth[29].
§ 12. Punctuality should be observed in the visits of the Faculty, when
they are to hold consultation together; but, as this may not always be
practicable, the Physician or Surgeon who first arrives at the place
of appointment, should wait five minutes for his associate, before
his introduction to the patient, that the unnecessary repetition of
questions may be avoided. No visits should be made but in concert, or
by mutual agreement; no statement or discussion of the case should take
place before the patient or his friends, except in the presence of each
of the attending gentlemen of the Faculty, and by common consent; and
no prognostications should be delivered, which are not the result of
previous deliberation and concurrence.
§ 13. Visits to the sick should not be unseasonably repeated; because,
when too frequent, they tend to diminish the authority of the Physician,
to produce instability in his practice, and to give rise to such
occasional indulgences, as are subversive of all Medical regimen.
Sir William Temple has asserted, that “an honest Physician is excused
for leaving his patient, when he finds the disease growing desperate,
and can, by his attendance, expect only to receive his fees, without
any hopes or appearance of deserving them.” But this allegation is not
well founded; for the offices of a Physician may continue to be highly
useful to the patient and comforting to the relatives around him even in
the last period of a fatal malady, by obviating despair, by alleviating
pain, and by soothing mental anguish. To decline attendance under such
circumstances would be sacrificing to fanciful delicacy and mistaken
liberality that moral duty which is independent of, and far superior to,
all pecuniary appreciation.
§ 14. Whenever a Physician or Surgeon officiates for another who is sick
or absent during any considerable length of time, he should receive the
fees accruing from such additional practice; but, if this fraternal
act be of short duration, it should be gratuitously performed, with
an observance always of the utmost delicacy towards the interest and
character of the professional gentleman previously connected with the
family.
§ 15. Some general rule should be adopted by the Faculty in every town
relative to the pecuniary acknowledgements of their patients; and it
should be deemed a point of honour to adhere to this rule with as much
steadiness as varying circumstances will admit: for it is obvious that
an average fee, as suited to the general rank of patients, must be an
inadequate gratuity from the rich, who often require attendance not
absolutely necessary, and yet too large to be expected from that class of
citizens, who would feel a reluctance in calling for assistance without
making some decent and satisfactory retribution.
But in the consideration of fees, let it ever be remembered, that,
though mean ones from the affluent are both unjust and degrading, yet
the characteristical beneficence of the Profession is inconsistent with
sordid views and avaricious rapacity. To a young Physician it is of
great importance to have clear and definite ideas of the ends of his
Profession, of the means for their attainment, and of the comparative
value and dignity of each. Wealth, rank, and independence, with all the
benefits resulting from them, are the primary[30] ends which he holds
in view; and they are interesting, wise, and laudable: but knowledge,
benevolence, and active virtue, the means to be adopted in their
acquisition, are of still higher estimation; and he has the privilege and
felicity of practising an art, even more intrinsically excellent in its
mediate than in its ultimate objects. The former, therefore, have a claim
to uniform pre-eminence[31].
§ 16. All members of the Profession (including Apothecaries, as well as
Physicians and Surgeons,) together with their wives and children, should
be attended gratuitously by any one or more of the Faculty residing near
them whose assistance may be required; for, as solicitude obscures the
judgement, and is accompanied with timidity and irresolution. Medical
men, under the pressure of sickness, either as affecting themselves or
their families, are peculiarly dependent upon each other. But visits
should not be obtruded officiously; as such unasked civility may give
rise to embarrassment, or interfere with that choice on which confidence
depends. Distant members of the Faculty, when they request attendance,
should be expected to defray the charges of travelling; and, if their
circumstances be affluent, a pecuniary acknowledgement should not be
declined: for no obligation ought to be imposed, which the party would
rather compensate than contract.
§ 17. When a Physician attends the wife or child of a member of the
Faculty, or any person very nearly connected with him, he should
manifest peculiar attention to his opinions, and tenderness even to his
prejudices. For the dear and important interests which the one has at
stake, supersede every consideration of rank or seniority in the other;
since the mind of a husband, a father, or a friend, may receive a deep
and lasting wound, if the disease terminate fatally, from the adoption
of means he could not approve, or the rejection of those he wished to
be tried. Under such delicate circumstances, however, a conscientious
Physician will not lightly sacrifice his judgement; but will urge with
proper confidence the measures he deems to be expedient, before he leaves
the final decision concerning them to his more responsible coadjutor.
§ 18. Clergymen who experience the “res angusta domi” should be visited
gratuitously by the Faculty. And this exemption should be an acknowledged
general rule, that the feeling of individual obligation may be rendered
less oppressive. But such of the clergy as are qualified either from
their stipends or fortunes to make a reasonable remuneration for Medical
attendance, are not more privileged than any other order of patients.
Military or naval subaltern officers in narrow circumstances are also
proper objects of professional liberality.
§ 19. As the first consultation by letter imposes much more trouble and
attention than a personal visit, it is reasonable on such an occasion to
expect a gratuity of double the usual amount: and this has long been the
established practice of many respectable Physicians. But a subsequent
epistolary correspondence on the further treatment of the same disorder
may justly be regarded in the light of ordinary attendance, and may be
compensated as such according to the circumstances of the case or of the
patient.
§ 20. Physicians and Surgeons are occasionally requested to furnish
certificates, justifying the absence of persons who hold situations of
honour and trust in the army, the navy, or the civil departments of
government. These testimonials, unless under particular circumstances,
should be considered as acts due to the public, and therefore not to be
compensated by any gratuity. But they should never be given without an
accurate and faithful scrutiny into the case; that truth and probity
may not be violated, nor the good of the community injured, by the
unjust pretences of its servants. The same conduct is to be observed by
Medical practitioners when they are solicited to furnish apologies for
non-attendance on juries, or to state the valetudinary incapacity of
persons appointed to execute the business of constables, church-wardens,
or overseers of the poor. No fear of giving umbrage, no view to present
or future emolument, nor any motives of friendship, should incite to a
false, or even dubious declaration; for the general weal requires that
every individual who is properly qualified should deem himself obliged
to execute, when legally called upon, the juridical and municipal
employments of the body politic; and to be accessory by untruth or
prevarication to the evasion of this duty, is at once a high misdemeanour
against social order, and a breach of moral and professional honour.
§ 21. The use of quack medicines should be discouraged by the Faculty, as
disgraceful to the Profession, injurious to health, and often destructive
even of life. Patients, however, under lingering disorders, are sometimes
obstinately bent on having recourse to such as they see advertised or
hear recommended with a boldness and confidence which no intelligent
Physician dares to adopt with respect to the means that he prescribes. In
these cases, some indulgence seems to be required to a credulity that
is insurmountable; and the patient should neither incur the displeasure
of the Physician, nor be entirely deserted by him. He may be apprized of
the fallacy of his expectations, whilst assured at the same time that
diligent attention should be paid to the process of the experiment he
is so unadvisedly making on himself, and the consequent mischiefs, if
any, obviated as timely as possible. Certain active preparations, the
nature, composition, and effects of which are well known, ought not to be
proscribed as quack medicines.
§ 22. No Physician or Surgeon should dispense a secret nostrum,
whether it be his invention, or exclusive property; for, if it be of
real efficacy, the concealment of it is inconsistent with beneficence
and professional liberality; and if mystery alone give it value and
importance, such craft implies either disgraceful ignorance or fraudulent
avarice.
§ 23. The _esprit du corps_ is a principle of action founded in human
nature, and, when duly regulated, is both rational and laudable. Every
man who enters into a fraternity engages by a tacit compact not only
to submit to the laws, but to promote the honour and interest, of the
association, so far as they are consistent with morality and the general
good of mankind. A Physician, therefore, should cautiously guard against
whatever may injure the general respectability of his Profession; and
should avoid all contumelious representations of the Faculty at large,
all general charges against their selfishness or improbity, and the
indulgence of an affected or jocular scepticism concerning the efficacy
and utility of the healing art.
§ 24. As diversity of opinion and opposition of interest may in the
Medical, as in other professions, sometimes occasion controversy and
even contention; whenever such cases unfortunately occur, and cannot be
immediately terminated, they should be referred to the arbitration of a
sufficient number of Physicians or of Surgeons, according to the nature
of the dispute; or to the two orders collectively, if belonging both to
Medicine and Surgery. But neither the subject matter of such references,
nor the adjudication, should be communicated to the public; as they may
be personally injurious to the individuals concerned, and can hardly fail
to hurt the general credit of the Faculty.
§ 25. A wealthy Physician should not give advice gratis to the affluent,
because it is an injury to his professional brethren. The office of
Physician can never be supported but as a lucrative one, and it is
defrauding in some degree the common funds for its support, when fees
are dispensed with, which might justly be claimed.
§ 26. It frequently happens that a Physician, in his incidental
communications with the patients of other Physicians or with their
friends, may have their cases stated to him in so direct a manner, as
not to admit of his declining to pay attention to them. Under such
circumstances his observations should be delivered with the most delicate
propriety and reserve: he should not interfere in the curative plans
pursued, and should even recommend a steady adherence to them, if they
appear to merit approbation.
§ 27. A Physician, when visiting a sick person in the country, may be
desired to see a neighbouring patient who is under the regular direction
of another Physician, in consequence of some sudden change or aggravation
of symptoms. The conduct to be pursued on such an occasion is to give
advice adapted to present circumstances, to interfere no farther than
is absolutely necessary with the general plan of treatment, to assume
no future direction unless it be expressly desired, and, in this case,
to request an immediate consultation with the practitioner antecedently
employed.
§ 28. At the close of every interesting and important case (especially
when it hath terminated fatally,) a Physician should trace back in calm
reflection all the steps which he had [_has?_] taken in the treatment of
it. This review of the origin, progress, and conclusion of the malady,
of the whole curative plan pursued, and of the particular operation of
the several remedies employed, as well as of the doses and periods of
time in which they were administered, will furnish the most authentic
documents on which individual experience can be formed. But it is in
a moral view that the practice is here recommended; and it should be
performed with the most scrupulous impartiality. Let no self-deception
be permitted in the retrospect; and, if errors either of omission or
commission are discovered, it behoves that they should be brought fairly
and fully to the mental view. Regrets may follow, but criminality
will thus be obviated; for good intentions, and the imperfection of
human skill which cannot anticipate the knowledge that events alone
disclose, will sufficiently justify what is past, provided the failure
be made conscientiously subservient to future wisdom and rectitude in
professional conduct.
§ 29. The opportunities 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. And his counsels, or even remonstrances, will give
satisfaction, not disgust, if they be conducted with politeness, and
evince a genuine love of virtue, accompanied by a sincere interest in the
welfare of the person to whom they are addressed.
§ 30. The observance of the Sabbath is a duty to which Medical men are
bound, so far as is compatible with the urgency of the cases under their
charge. Visits may often be made with sufficient convenience and benefit,
either before the hours of going to church, or during the intervals of
public worship; and in many chronic ailments the sick, together with
their attendants, are qualified to participate in the social offices of
religion, and should not be induced to forego this important privilege by
the expectation of a call from their Physician or Surgeon[32].
§ 31. A Physician who is advancing in years, yet unconscious of any
decay in his faculties, may occasionally experience some change in the
wonted confidence of his friends. Patients, who before trusted solely to
his care and skill, may now request that he will join in consultation,
perhaps with a younger coadjutor. It behoves him to admit this change
without dissatisfaction or fastidiousness, regarding it as no mark of
disrespect, but as the exercise of a just and reasonable privilege in
those by whom he is employed. The junior practitioner may well be
supposed to have more ardour than _he_ possesses in the treatment of
diseases, to be bolder in the exhibition of new medicines, and disposed
to administer old ones in doses of greater efficacy. And this union of
enterprise with caution, and of fervour with coolness, may promote the
successful management of a difficult and protracted case. Let the Medical
parties, therefore, be studious to conduct themselves towards each other
with candour and impartiality; co-operating by mutual concessions in the
benevolent discharge of professional duty[33].
§ 32. The commencement of that period of senescence, when it becomes
incumbent on a Physician to decline the offices of his profession, it
is not easy to ascertain; and the decision on so nice a point must be
left to the moral discretion of the individual. For, one grown old in
the useful and honourable exercise of the healing art, may continue
to enjoy, and justly to enjoy, the unabated confidence of the public;
and, whilst exempt in a considerable degree from the privations and
infirmities of age, he is under indispensable obligations to apply his
knowledge and experience in the most efficient way to the benefit of
mankind: for the possession of powers is a clear indication of the will
of our Creator concerning their practical direction. But in the ordinary
course of nature the bodily and mental vigour must be expected to decay
progressively, though perhaps slowly, after the meridian of life is
past. As age advances, therefore, a Physician should from time to time
scrutinize impartially the state of his faculties, that he may determine
_bona fide_ the precise degree in which he is qualified to execute the
active and multifarious offices of his profession; and, whenever he
becomes conscious that his memory presents to him with faintness those
analogies on which Medical reasoning and the treatment of diseases are
founded, that diffidence of the measures to be pursued perplexes his
judgment, that, from a deficiency in the acuteness of his senses, he
finds himself less able to distinguish signs or to prognosticate events,
he should at once resolve (though others perceive not the changes which
have taken place,) to sacrifice every consideration of fame or fortune,
and to retire from the engagements of business. To the Surgeon under
similar circumstances this rule of conduct is still more necessary; for
the energy of the understanding often subsists much longer than the
quickness of eye-sight, delicacy of touch, and steadiness of hand, which
are essential to the skilful performance of operations. Let both the
Physician and Surgeon never forget that their professions are public
trusts, properly rendered lucrative whilst they fulfil them, but which
they are bound by honour and probity to relinquish as soon as they find
themselves unequal to their adequate and faithful execution.
FOOTNOTES:
[24] See Notes and Illustrations, No. II.
[25] See Notes and Illustrations, No. III.
[26] See Notes and Illustrations, No. IV.
[27] See Notes and Illustrations, No. V.
[28] See above, chap. i. §§ 19-21.
[29] See Notes and Illustrations, No. VI.
[30] [The word _primary_ is omitted in ed. 1807.]
[31] See Notes and Illustrations, No. VII.
[32] See Notes and Illustrations, No. VIII.
[33] See Notes and Illustrations, No. IX.