Professor Holger Maehle's latest book, A Short History of British Medical Ethics (Ockham Publishing, 2021), challenges established understandings in Bioethics of the traditional ethics of doctors.
In the context of current bioethics, the traditional ethics of doctors are often seen as dominated by etiquette and concern for professional interests rather than patient interests. In my new book, A Short History of British Medical Ethics (Ockham Publishing, 2021), I show that this assessment is wrong. Exploring medical ethics in Britain from the late eighteenth to the early twentieth century, i.e. the period in which the modern medical profession was formed, I illustrate how the doctors of this period faced difficult issues of medical practice. In making judgements about their options and actions, not only concerns about professional reputation but also about patients’ welfare and the public good played an important role.
I review key works of British medical ethics from the 1770s to the early 1900s, to show what authors of this period themselves thought to be the most important ethical issues, and what conceptions of a good medical practitioner they developed. The literature reflects an interest in the relationships between professional sub-groups, i.e. between physicians, surgeons, and apothecaries, and later between specialist consultants and general practitioners. However, the authors also reflect on a broad range of patient-related matters, including compassion, confidentiality, mutual trust and obligations, clinical experimentation, and doctors’ continuing duty to the dying and their families.
A particular fruitful source is the documentation arising from disciplinary actions of the General Medical Council, the regulatory body for medical practitioners in Britain. I study a range of controversial behaviours, from matters of personal and sexual conduct to professional issues such as medical advertising and the ‘covering’ of unqualified assistants. I argue that the protection of patients and of a wider public interest in responsible medical practice were essential considerations in the GMC’s disciplinary proceedings.
Subsequently, I explore nineteenth-century doctor-patient relations, questioning to what extent doctors sought their patients’ consent to treatments and how well patients were informed by their medical attendants. I focus in particular on the legal case Beatty vs Cullingworth 1896, in which a doctor was accused by his patient of having removed her ovaries without valid consent. Dr Cullingworth had beforehand discussed the operation with Miss Beatty, who was a nurse: there was a large ovarian tumour on one side and possibly a smaller one on the other side. Miss Beatty, who was engaged to be married, said that if both ovaries were found to be diseased, she wanted neither of them removed. Cullingworth asked her to leave the matter in his hands. On finding during the operation cysts in both ovaries, he took a paternalistic view and extirpated both ovaries, thus making her infertile. While he was acquitted in the subsequent legal proceedings, the case showed that full information and written consent would have been desirable, as the British Medical Journal commented in 1896. Issues of gender, professional ethics, and law, as well as the historical development of gynaecological surgery, came into this particular case. In more general terms it demonstrates how doctors’ paternalistic attitudes and their tradition of restricted truth-telling in the patient’s presumed interest had become a problem by the turn to the twentieth century.
Finally, I turn to situations in which nineteenth-century medical practitioners had to make hard moral choices. For example, I examine how they dealt with desperate cases of severely obstructed labour where the baby could neither be delivered manually, nor by using the forceps. Practitioners then had to decide whether they should sacrifice the life of the unborn child through craniotomy in the hope of saving the mother, or risk the woman’s life in daring to perform a Caesarean section, which at the time had a very high mortality. British obstetricians usually decided for foetal craniotomy, but in Catholic countries doctors were more willing to risk the Caesarean operation, if the woman consented to it, in order to preserve the chance of delivering a living baby that could then be baptised. Other moral choices concerned confidentiality in cases of illegal abortion and venereal diseases. Here, doctors grappled with the question of disclosure without the patient’s consent in the interest of the public or a third party. They had to balance their commitment to the individual patient, which called for strict confidentiality, with wider legal and social expectations of their role. This might include reporting a case of criminal abortion to the police, especially if the woman was dying from the intervention, or warning contact persons of patients infected with a venereal disease. This also involved doctors’ situation as witnesses in court, when they were required to reveal private information about their patients.
Professor Andreas-Holger Maehle, Director of the Centre for the History of Medicine and Disease, Deaprtment of Philosophy, Durham University