Perspectives in Biology and Medicine

Perspectives in Biology and Medicine 44.1 (2001) 148-152

Book Review

The American Medical Ethics Revolution: How the AMA's Code of Ethics Has Transformed Physicians' Relationships to Patients, Professionals and Society

Whether the Code of Ethics adopted by the fledgling American Medical Association in 1847, and its several successors, have in fact "transformed physicians' relationships," as the subtitle of this book claims, remains a point for debate. However, the book itself leaves little question that investigation and contemplation of the Code provide a strong stimulus for creative thought and conversation. Based on the example of the many and varied arguments displayed here, perhaps it would even be fair to say that discussion of the Code has the potential to transform the debates of contemporary biomedical ethics. This is an exceptionally good book, not because its contributors' conclusions are unassailable, but precisely because together they raise the right questions and keep the debates open and active. More than many other books about the ethics of medical practice and of health care generally, this one engenders the desire to know more, to think harder and in new ways about lingering conflicts and the assumptions that underlie them.

Harmon Smith and Larry Churchill, in their 1986 monograph about the ethics of primary care practice, explicitly place their proposals for enhancing practitioners' moral imaginations "beyond decorum." In doing so, they--like many others over the past 150 years, as this book makes clear--dismiss the AMA Code as dealing with little but professional etiquette (Smith and Churchill 1986, p. 3). In contrast, the opening essay of this book, by Chester R. Burns, brings to mind the traditional meaning of decorum, a much more positive connotation than is implied by references to "mere" etiquette.

Through most of the history of ethics, decorum has designated the outward evidence, in proper conduct, of an inwardly ordered and virtuous soul. That [End Page 148] descriptions of the decorous man have traditionally included details of dress and gait reflects less an excessive pride in external bearing than a pre-Cartesian belief that physical deportment reliably mirrors and communicates moral goodness. ¹ Dr. Burns makes clear that Benjamin Rush, the 18th-century Philadelphia physician, philosopher, and intellectual forerunner of the 1847 Code, was one who understood decorum in its ancient meanings: "Rush forged a rigorous causal reciprocity between ideals and conduct, ethics and etiquette. Honoring the ideals produced virtuous behaviors, which, in turn, validated the ideals." The Code's provisions may now often be construed as nothing more than etiquette but, from what this book teaches us of the history of thought that underlies them, it is doubtful they were intended to be either so lacking in moral substance or so artful as that disparagement implies.

In the second essay, bearing the same title as the book, Robert B. Baker presents a very rich picture of the development of the AMA Code, with fascinating insight into the interplay of British and American thought and mores, the influence of both traditional moral philosophy and the burgeoning American entrepreneurial spirit. He argues the thesis of the book's title--that the 1847 Code was revolutionary--clearly and forcefully, although not, I think, entirely conclusively. The claim that the Code's authors made a significant alteration to the work of Thomas Percival, the British physician whose writings on medical ethics some 50 years earlier formed the basis of the Code, by featuring physicians' duties to patients is well-supported; it is a fertile base for speculation on both the reasons for and the consequences of that change. However, it is less clear that "revolution" is an apt label, if the term entails the claim of transformative power made in the subtitle...