Doctor, heal thyself
Donald Gould
The British Medical Association has just published a revised edition of The Handbook of Medical Ethics, which is a 100-page guide to the way doctors should behave. The first edition of this comprehensive catalogue of professional 'dos' and 'don'ts' appeared only last year, and the fact that an amended version has been issued so soon, and that it is on offer not just to members of the healing trade but also the laity, is Symptomatic of a revolution which is currently remoulding Aesculapian affairs, and causing many an ancient medical brow to furrow, and the mind behind it to wonder what the world is coming to. It is a revolution more profound than that caused by the invention of anaesthetics, or the discovery of antibiotics, or the surgical adventurism of Professor Christiaan Barnard, for it concerns not the manner in which doctors treat disease, but the way in Which they treat their patients, and the role that they see for themselves in society.
The profession has always, of course, been regulated by codes of conduct, and everybody knows about the Hippocratic Oath, which is 2,500 years old. Most people believe that the oath is solemnly sworn by all young doctors when they graduate, and that it binds them to a lifetime of Christlike, selfless endeavour in the service of their patients, whose interests must always come first.
In fact, nobody swears the oath these days (except in some American medical schools, where a love of ceremony and a lust for tradition somewhat outweigh a sense of' the ridiculous), and a good thing too, because, when coolly examined, this sacred affirmation turns out to be no more than a set of rules for the protection of the trade.
It begins by demanding fealty to the professional top brass, the testifier promising `to reckon him who taught me this Art equally dear to me as my parents', and then seeks an undertaking that medical knowhow will only be passed on to the sons of existing members of the guild. Having secured the closed shop, it does then go on to prohibit doctors from conniving at murder CI will give no deadly medicine to anyone if asked . or procuring an abortion, or seducing women (or men, for that matter) met in the course of home visits, and it forbids the revelation of secrets learnt in the course of business, all of which may seem to be admirable precepts, propagated to protect the interests of the customer. But a cynic might see these strangely selected interdictions as no more than a PR exercise, designed to facilitate the free and welcome entry of physicians into households in pursuit of their fees, even when the paterfamilias happened to be away from home, fighting in Sardinia, or whatever. And until just recently, codes of professional medical conduct have remained very much the same. In this country the General Medical Council has had the power to persuade British doctors to behave 'ethically' since it was established, about 120 years ago. The council can strike a doctor off the register, effectively depriving him of his livelihood, if it finds him guilty of what used to be called 'infamous conduct in any professional respect', but is now less emotionally described as 'serious professional misconduct', or if it thinks he is unfit to practise by virtue of infirmity. Most of those bundled out of the medical club by the GMC during the past century have been found guilty of such heinous crimes as advertising, or making love to a patient, or associating with 'unqualified' providers of medical care, such as osteopaths. Doctors convicted by the courts are automatically reported to the council, and the majority of such unfortunates have been arrested for drunken driving (doctors rank equally with journalists amongst the occupational groups most likely to die from cirrhosis of the liver). These alcoholics have been commonly treated with indulgence by the council's disciplinary committee, perhaps being put 'on probation' to see Whether they can survive a 12-month period Without creating any further public scandal, and never mind the risk to patients posed by drink-befuddled brains. Hardly anybody has been arraigned for just plain, bad doctoring. The old-fashioned and restricted view of what constitutes good medical behaviour still survives. In the annual report of the GMC for 1980, Sir Robert Wright, the newly elected President, wrote: 'Proper professional conduct is based on an understanding and acceptance by doctors of good manners in professional relationships directed to the protection of mutual trust between doctor and patient — medical ethics' (my italics). In other words, the good 'ethical' practitioner is the one who sustains the public image of a profession within which all's for the best in the best of possible words, and who doesn't rock the boat.
The broader view of ethically sound and responsible professional attitudes involves something a great deal more important than 'good manners'. It is the concept that doctors should constantly assess the manner in which they use their considerable pri vileges and increasing ability to manipulate the minds and bodies of their fellow citizens. It is the demand that they should accept the necessity for the continuing exercise of a high degree of highly informed self-criticism, and that they should work hard at the task of demystifying their craft, and explaining what they are about, and how their minds are working, to the public they serve, in order that the public — the people on the receiving end — can play an intelligent part in deciding how the powerful tools of modern medicine should be employed.
This new insistence on the need to examine the role of medicine, and to accept the users of medical care as equal partners in the effort to create a healthier world, rather than being the passive recipients of whatever services the profession, in its superior wisdom, sees proper to provide, is resented by many members of the healing trade. Neither has it been generated primarily within the guild. It has been stimulated largely by outsiders, taking an objective and questioning view of the medical scene — people like Ivan Illich, and, most recently, Ian Kennedy in his Reith Lectures. But the movement has been well launched, and is now irresistible.
The BMA, a normally conservative body, and bastion of medical privilege, is to be congratulated and admired for its contribution to the debate in the form of the handbook now made available to all. The text deals with a wide range of 'ethical' issues, including the management of severely malformed infants, abortion, artificial insemination, the testing of new drugs on patients and special groups like prisoners, the handling of personal details stored in computers and on medical records, the duty of medical officials such as police surgeons toward the individual patient, and much else. Refreshingly, it also considers the responsibility of doctors in matters not commonly regarded as ethical issues, such as the need for clear and adequate communication, and the wise use of finite resources, and the folly of undertaking screening programmes for the discovery of conditions for which no adequate treatment can be offered.
It doesn't, of course, provide all the answers, but it acknowledges the need to ask the questions, and that is the important thing.
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