Acta Biomed 2018; Vol. 89, N. 3: 343-348 DOI: 10.23750/abm.v89i3.

7050 © Mattioli 1885

Debate

Thomas Percival. Discussing the foundation of Medical

Ethics
Sara Patuzzo1, Giada Goracci2, Rosagemma Ciliberti3
1
School of Medicine and Surgery, University of Verona, Verona, Italy; 2 Department of Foreign Languages and Literatures,
University of Verona, Verona, Italy; 3 School of Medicine and Surgery, University of Genova, Genova, Italy

Summary. Background and aim of the work: In 1803, the English physician Thomas Percival published Medical
Ethics, a work destined to become a milestone in the development of modern codes of medical ethics, starting
from the first edition of the American Medical Association’s ethical code. Notwithstanding the undeniable
influence that this book has exerted upon the codification of the principles of medical ethics, researchers and
experts foster different and opposing points of views on its real nature. They question whether Medical Eth-
ics truly belongs to the literary genre of codes of medical ethics or, better yet, to that of medical etiquettes.
Methods: This debate is crucial in the field both of medical history and of medical ethics, with regard not
only to Percival’s work, but also to the ethical value of the current codes of medical ethics and deontology.
Results: The lack of a rigorous philosophical-moral analysis of the current medical codification is reflected in
its mere loyalty to the legal regulation, in substantial continuity with the past. However, the constant chal-
lenges proposed by the biomedical development, require the need to rethink the traditional conceptual tools
of the current codes of medical ethics, with the purpose to achieve new schemes and innovative solutions.
Conclusions: On this perspective, when the codes of medical ethics are worked out by physicians, they could
be considered as wrongly titled medical etiquettes. This consideration could regard current codes of medical
ethics, that remain faithful to tradition and that would more probably be codes of medical etiquette with a
wrong title. (www.actabiomedica.it)

Key words: history of medicine, history of medical ethics, medical ethics, code of medical ethics, medical
etiquette

Introduction This notwithstanding, soon hospital institutions

turn out to be difficult to manage. The main causes
As the eighteenth century drew to an end, Eu- of the problem seem to stem from the medical prac-
rope experienced the effects of urbanisation as a conse- tice itself. The presence of compulsory regulations and
quence of the industrial revolution. A great part of the statutes, characterised by strict policies on available
population moves into big cities for economic oppor- resources undermines the prescriptive authority of
tunities, but they also often face diseases, misery and physicians and surgeons. Furthermore, several inner
indigence. Thanks to the doctrine of the Enlighten- contrasts overshadow the medical profession, which is
ment that breathes new life into the principle of toler- divided into three main groups: physicians, surgeons
ance, an emerging sense of help and support toward and pharmacists. Periodically, these tensions result in
lower classes starts to enliven the modernisation of hostilities and threaten the esprit de corps and unity of
hospitals, which are now seen as medical institutions the medical profession and as a consequence its stabil-
devoted to the social dimension of public health. ity and development.
344 S. Patuzzo, G. Goracci, R. Ciliberti

Within this difficult context, the English physi- Britain by Thomas Gisborne and Statuta Moralia by the
cian Thomas Percival conceived his Medical Ethics (1), Royal College of Physicians in London. Notwithstand-
that has successively inspired modern codes of medical ing this, Percival states that such works do not contain
ethics (the first example was the Code of ethics by the the specific references to the competences and tasks of
American Medical Association, dated 1847), which medical professionals. A gap that he wants to fill in by
organically collect the rules of conduct for physicians. detecting the rules of conduct directly within the field
However, another mainstream of thought states that it of medical practice, thus taking into consideration sev-
is not possible to address to Percival the foundation of eral medical statutes and regulations already existing.
medical ethics’ codification in Western society (2, 3). With the aim to create a work, which would have
If this second perspective would be the correct one, stuck to the real needs of physicians in their profes-
how could we qualify modern codes of medical ethics? sional practice, Percival has long discussions on its
Should these codes be discussed with regard to their main contents with friends and colleagues. On this
belonging to the field of medical ethics? Or differently purpose, in 1792 the first chapter of the book is pub-
to Percival’s code, modern codes should be treated as lished and in 1794 the entire work is edited for private
part of medical ethics on the basis of their upgrade? distribution. It is worth noting that the first draft of
In any case, Percival’s work is crucial both in the the work is titled Medical Jurisprudence, as it is origi-
field of study of history of medicine and in that of nally conceived as a neat collection of those regulations
medical ethics, in that it reconstructs the history of which are already ruling the medical conduct of the
the codification of medical ethics’ evolution. From this professionals who work at Manchester hospital. The
perspective, the recognition of its importance is widely title Medical Ethics appears only in 1803 with the fi-
shared, even if its knowledge within the field of history nal edition dedicated to his son who has decided to
of medicine, medicine and moral philosophy is, espe- undertake the medical profession. The choice of the
cially in Europe, not so widespread as it would deserve. title seems to be suggested by some friends, who may
have persuaded Percival to substitute the term “juris-
prudence” with that of “ethics”, as the latter mainly en-
1. Medical Ethics or Medical Jurisprudence? shrines the duty to respect both legal and ethical rules.
Anyway, the first title cannot go unnoticed, as it
Together with the problems that are oppressing introduces the controversy on the work’s real nature.
medical facilities, in 1789 Manchester is swept away Can the contents of Percival’s work be actually con-
by an epidemic of typhus, which seriously endangers sidered as the foundation of medical ethics and the
the operational efficiency of its hospital. related reflection on the principles of medical moral-
In order to solve the organisational problems, the ity? Or better yet, is the book just a collection of rules
managers of the hospital double the number of the of conduct, which comes into being and dies within
staff members. Unfortunately, the increasing number the mere practice of the physicians who worked in an
of the personnel causes several internal quarrels, which English hospital where the main problem was that of
in 1791, as the epidemic is still flaring up, lead even mutual respect and the living up to the medical profes-
to the closure of the ward dedicated to the care fever. sion’s good name?
The subsequent scandal forces the managers to desig- As a matter of fact, the formal office to which
nate one of the hospital’s most authoritative members, Percival was entrusted coincides with his declared pur-
Thomas Percival, to work out a code of conduct with pose: writing down a sort of guide for health profes-
the aim of disciplining the behaviours of the staff (4). sionals (physicians, surgeons, pharmacists) who work
Many similar works precede Thomas Percival’s in his hospital, which is first of all useful to define their
Medical Ethics. Amongst others: Lectures on the Duties roles and related responsibilities, together with the
and Qualifications of a Physician by John Gregory, “On rules of good fellowship. It is worth noting the wide
the Duties of a Physician” in Enquiry into the Duties of interest of this work in the legal aspects of medical
Men in the Higher and Middle Classes of Society in Great practice. In fact, the book devotes a whole chapter (the
Thomas Percival. Discussing the foundation of Medical Ethics 345

fourth) to the regulation of the physician’s behaviour in rope, these documents are called “codes of medical de-
the cases «which require a knowledge of law». ontology”, whilst in the Anglo-Saxon culture they are
Considering the task entrusted to Percival, his known as “codes of medical ethics” (7).
own purpose and the book’ broad interest in the legal The matter which is here called into question is
aspects, the first title (“Medical Jurisprudence”) could the attribution of modern medical ethics to Percival
apparently seem the most appropriate in order to de- and his work Medical Ethics.
fine the work. However, even if this book was specific First of all, the term itself “medical ethics” (or
part of the regulations issued for Manchester hospital, “professional ethics” or “practical ethics”) can not be
it cannot be included in the body of Manchester (or addressed to Percival. In fact, this expression existed in
England) health and medical laws. As a consequence, the English literature long before Percival’s work was
Percival’s friends were right to propose him to change published (8). Some examples could be the works by
the previous title “Medical Jurisprudence”. But was the Charles Davenant (9), David Fordyce (10), the above-
decision by Percival to substitute this title with that of mentioned Thomas Gisborne, who used the definition
“Medical Ethics” actually the correct one? of “applied moral philosophy” and David Hume who
analyses the notion of “practical morals” to distinguish
it from more abstract speculations.
2. Medical Ethics or Medical Etiquette? Beyond the question referring to the invention
of the definition “medical ethics”, it is worth noting
In the course of the eighteenth century, even the controversy, which derives from the interpreta-
though several physicians still inspire their profes- tions of the real nature of Percival’s work. The crucial
sional conduct to individual conscience and good sense point is whether it should be enlisted among the works
by following a personal “code of honour”, some efforts on medical ethics (defining Percival as a moral phi-
to systematise physicians’ duties and bans into specific losopher) and consider it as the first European code of
lists start to appear. These first approaches to the codifi- medical ethics (11), or appreciate it as a mere collec-
cation of what is fair and unfair in medical practice can tion of rules on medical etiquette.
be considered as evident examples of medical etiquette. As regards the substance, the basic difference be-
The literary genre of medical etiquette stems from the tween medical ethics and medical etiquette lays in the
reflection of a single physician, often famous and au- fact that the former concentrates on a wide-ranging
thoritative, who proposes himself as an ideal model for reflection, which covers various fields from the intra-
his readers. Hence, being it the result of a formulation, professional conduct to the doctor-patient and society
which is not shared by all colleagues, its guidelines do relationship. The latter merely regulates the behaviour
not provide sanctions in case of inobservance. among physicians, on the basis of the principle of mu-
Medical etiquettes seem to be inappropriate to tual courtesy.
face the new challenges brought about by the medical According to some researchers, Percival’s Medi-
profession, such as the struggle against several quack cal Ethics would be composed of sensitive and pro-
physicians and the social control of public health found reflections, which make it not only a timeless
through the claims of exclusive competences, the de- work amongst the greatest classics (12), but better yet
fence of dignity and unity of professional (5), the war- a milestone in Western medical ethics (13, 14). Behind
rant of a trusty relationship with untutored patients the misleading concept of professional decorum, in its
who are then unable to evaluate the services they re- innermost essence the work enshrines a solid and de-
ceive (6). In this light, to fulfil the task of working out finable moral theory, the ethical theory of virtue, chosen
shared documents, which are able to identify the pro- and applied by Percival to medicine after years of stud-
fession also from outside, the newly born medical asso- ies on moral philosophy (15, 16). Hence, Medical Eth-
ciations or Orders formulate for their subscribers some ics would have brought about a definitive separation
codes of conduct, which are occasionally endowed between the old Ippocratic ethics and modern ethics
with disciplinary enforceability. In mid-Southern Eu- (17, 18). becoming the first modern Code of medical
346 S. Patuzzo, G. Goracci, R. Ciliberti

ethics (19, 20), whose precepts would have remained overseas, in particular in the United States, where sev-
unchanged up to the present (21). eral professional bodies based their own ethical codes
After all, according to other authors, it seems on Percival’s work, even sometimes copying word by
more convincing the stance of those who state that word some procedures contained in the book, as in the
Percival’s work merely represents a set of maxims and case of the Boston Medical Society. Moreover, in 1847,
aphorisms of intra-professional etiquette, which aims a group of American physicians, amongst others Ben-
only at regulating good fellowship (22). In the work, jamin Rush and Isaac Hays, took Percival’s Code as
there is no evidence of moral-philosophical analyses, the backbone for the development of the ethical code
which aim at exploring the general aspects of ethics, of the newly born American Medical Association, which
since the main purposes of the book are only those of had been crafted one year before by Nathan Smith
perpetuating the paternalistic spirit of medicine and Davis with the purpose of promoting high levels of
propagandizing the monopolistic tendency and coop- quality in medical education and professional practice.
erative system of the medical profession (13). Because As a result of such influence that Percival had on
of its being “withdrawn”, this book seems to side with modern codes of medical ethics, we should legitimate-
a corporatist sense with the main purpose to safeguard ly expect a certain continuity between Percival’s book
the medical team’s interests. In fact, we should not for- and modern codes. But if, as we have already pointed
get that Percival, as a conservative man, wrote his work out, Percival’s Code is a work of medical etiquette,
in a time in which the English medical corporations, how is it possible that modern codes are documents of
that had an elitist structure, were undergoing a demo- medical ethics?
cratic strike, especially by the liberal economic concep- One could say that current codes, even if they are
tion. To face it, he opposed a model of profession as a based upon the (togliere) Percival’s work, show evident
whole of unity and integrity in front of society. differences to it. In particular, they would reflect the
To sum up, unless we do not opt for a special moral maturation of contemporary society, by mark-
meaning of “ethics”, such as that of «morally permis- ing the conversion from the Hippocratic approach,
sible standards of conduct governing members of a steeped in medical paternalism and corporatism, to
group simply because they are members of that group» contemporary medical ethics that recognizes the pa-
(23), Percival’s book cannot be evaluated as a work of tient’s central value in the care relationship.
medical ethics. But, if we agree that Medical Ethics is a Indeed, Percival’s work just represents the ump-
wrongly titled work of medical etiquette, how should teenth effort to reassess the Ippocratic medical ethics
we assess modern codes of medical ethics, which have (25), as it lacks in significant originality if compared to
their background in Percival’s book? In fact, if that of its original source (17). Indeed, Percival’s perspective
Percival is not a work of medical ethics, how could cur- is evidently conservative with regard to the traditional
rent codes on medical ethics be considered as such? ethical paradigm, which he however tries to adapt to
the hospital practice of his times (26), with the prin-
cipal aim to maintain the classical division into physi-
3. Medical Ethics or Paternalistic Medical Ethics? cians, surgeons, and pharmacists to stress the duty of
mutual respect of their own competences and related
Come abbiamo detto, Medical Ethics’ wide hierarchical roles.
spreading, that exceeded the expectations of its Au- However, is it also true that modern codes have
thor, is undeniable (24). In the decades following the outdated the Hippocratic and paternalistic tradition,
publication of Medical Ethics, both in England and in showing a full sensitivity towards medical behaviour
Scotland several hospitals and medical associations, which aims at safeguarding not only professionals, but
amongst which the Manchester Medico-Ethical Associa- also patients?
tion and the British Medical Association, take inspira- In order to answer this question, we look at what
tion from its language and contents to self-regulate the happens when the principles of medical ethics are rec-
medical profession. The fame of Medical Ethics spread ognised by and translated into Codes of conduct, which
Thomas Percival. Discussing the foundation of Medical Ethics 347

one should not forget, are worked out by medical associ- spired on the one hand to the method of positive law
ations composed almost exclusively by physicians. So far, and, on the other hand to the principles, which could
the noble moral reflection on the ethical implications of be also religious, of traditional ethics. Its twofold pur-
medical practice is often replaced by a list of behaviours pose is to establish harmony among the conflicting
according to which the hierarchy relating to the good of factions at the hospital of Manchester and defend the
the patient (and society) and the good of physicians (and corporatist interests of the medical profession. To this
their category) is not always clear. Besides, as we have extent, amongst the various literary genres to which
seen, the main historical reason which leads to the for- the codes of conduct for physicians could be attribut-
mulation of codes of medical ethics is not the defence of ed, the one that better fits Percival’s work is the medi-
a person’s interests, but rather the will to create a kind of cal etiquette. Anyway, Medical Ethics has undoubtedly
“internal contract”, however recognised at a social level, left an indelible mark in the history of medical ethics,
aimed at claiming and defending the medico-centric as well as in the history of medicine, and it should be
perspective of the healthcare organisation, together with considered as a fundamental reference for those who
the monopolistic interest and paternalistic model of the study this subject. Again, this aspect reinforces the dif-
profession. Then again there is a conflict of interests, ob- ference between medical ethics and its related codifi-
viously: if this is really about reaching a new foundation cation by a medical hand.
of medical ethics on a social basis, the authors of the Reflections on medical ethics have no bounda-
professional regulations should not be exclusively physi- ries. The subject is stimulated from within by several
cians. They should pretty include representations of pa- moral theories and paradigms, which are developed on
tients, or at least provide a consultation with associations the basis of issues evaluated by rational justifications.
of health care services’ consumers. Medical ethics is moral philosophy when it exam-
In addition to the presence of a practical “open- ines every sensitive issue that is directly or indirectly
ness” to the external dimension (that should not be raised by medicine from its focal nucleus: the patient
only stated by general principles, but also achieved not only as an object but also as a subject of medical
within the rules of conduct), one thinks to what other care (27). In the age of Percival, it is worth mention-
fundamental features are needed to identify a code of ing John Gregory (28), whose reflection, based on the
conduct as a document of medical ethics. These fea- moral philosophy of David Hume, stems from the idea
tures emphasise, on the one hand, the presence of a that the doctor-patient relationship should be the core
conscious and organic moral-philosophical reflection interest of medical ethics, and that society should be
on the ethical theory choosen the code, and, on the free to decide for its own good-health, even though
other hand, the use of a method of rational justifica- that means to discourage the privileges of the medical
tion for the selection of the rules of conduct. class. Alternatively, we could hold up as an example
In the long run, also these features will not be part Rev. Thomas Gisborne (29), whose work, less fortu-
of modern codes of medical ethics. In order to fill this nate than those of Percival and Gregory, aims at giving
gap, experts in moral philosophy (at present a small part priority to patients, rather than to physicians.
of the commissions responsible for the elaboration of The codification of medical ethics consists in
codes, should be included among the codes’ authors. the declension of the principles of medical ethics by
To conclude, we argue that if the critical overview self-regulating the medical conduct in which, to every
set on Percival’s work is correct, the same logic should professional duty corresponds a right. In this light, it
be applied to current codes of medical ethics. is more likely that the codes of medical ethics remain
faithful to tradition, instead of accepting new moral
interpretations, according to which a patient increas-
Conclusion ingly gains a central role (30). In other terms, if the
codes of medical ethics are worked out by the bod-
Percival’s Medical Ethics is not a work on moral ies, which represent the profession rather than soci-
philosophy applied to medicine, but rather a book in- ety, these would more probably be codes of medical
348 S. Patuzzo, G. Goracci, R. Ciliberti

etiquette with wrong titles. This is exactly the case of 16. Pellegrino ED. Percival’s Medical ethics. The Moral phi-
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Forward to Percival Thomas. Medical ethics or a Code of School of Medicine and Surgery, University of Verona,
Institutes and Precepts adapted to the professional conduct Verona, Italy
of physicians and surgeons. Birmingham: Ala, 1985. E-mail: sara.patuzzo@univr.it