THE DEVELOPMENT OF MEDICAL ETHICS

- A SOCIOLOGICAL ANALYSIS

by

IVAN WADDINGTON*

IT IS A curious fact that despite the rapidly growing volume of literature on the
professions, little work has been done by sociologists on the development of pro-
fessional ethics. This omission becomes doubly curious when one considers the central
importance attributed to professional ethics in much of the literature on professions;
given this situation one can hardly aspire to an adequate sociological analysis of the
development of professional occupations which does not include an analysis of the
development of professional ethics. This paper aims, in a modest way, to help fill
this gap by analysing the origins and early development of modem medical ethics.
The most famous of all codes of medical ethics is probably the Hippocratic Oath,
which Edelstein dates from the fourth century B.C." From time to time, slightly
modified forms of the oath were developed, for example to allow Christians to take
what was originally a pagan oath, and although there was no body which enforced
the ethical rules contained in the Hippocratic Oath, it appears to have had some
influence on medical practice. Thus Chauncey D. Leake has pointed out that prior
to the end of the eighteenth century, "the medical profession tried generally to
handle its ethical problems on the basis of the Greek tradition of good taste and
personal honor".2 However, if we wish to understand the development of specifically
modem codes of medical ethics, we must look not to ancient Greece, but to nineteenth-
century England, and in particular, to the work of Thomas Percival, whose Medical
ethics, published in 1803, marks an important break-point between ancient and
modem medical ethics. As Leake has pointed out, it was Percival who, more than
any other person, effected the "transition from the broad principles of Greek medical
ethics to the current complicated system".3
This view of Percival as the founder of modem codes of medical ethics is shared
by most medical men. Thus Forbes has referred to Percival's work as a "prominent
landmark in the progress and evolution of medical ethics", and adds that "No later
work has modified in any material degree the precepts and practice defined by Percival
for the conduct of a physician".4 Barton has written that Percival "compiled the
first modem code of medical ethics"," while McConaghey comments that the "rules
of conduct of modem times stem from the small book published in 1803 by Thomas
Percival".6
While it is difficult to over-estimate the importance of Percival's book, it would be
quite wrong to see it, in an almost asocial sense, purely as the work of a gifted indi-
vidual, for Percival's work is simply the most famous of a number of publications by
*Ivan Waddington, B.A., is Lecturer in Sociology, University of Leicester.
Medical History, 1975, vol. 19.
36

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press

 The development of medical ethics-a sociological analysis
English practitioners in the first half of the nineteenth century, all of which indicate
a major concern with ethical problems in the practice of medicine. These included
W. 0. Porter's Medical science and ethicks,7 published in 1837, and Abraham Banks'
Medical etiquette,8 published in 1839. This concern with ethical problems also found
expression in articles and editorials on medical ethics in all the major medical
periodicals, as well as in the considerable number of letters from readers dealing with
similar problems. Finally, mention must be made of associations, like the Manchester
Medico-Ethical Association,9 which were founded specifically to deal with ethical
problems, and of the development of medico-ethical committees in medical associa-
tions founded for more general purposes, such as the British Medical Association,
which set up its own medico-ethical committee in 1853.10
Thus Percival was not working alone, for his concern with medico-ethical problems
was shared by many of his contemporaries. Our problem, then, is to explain why
practitioners in England were concerned with medico-ethical problems at this time.
In general terms, the attempt to formulate codes of professional ethics, and to
establish institutions to enforce those codes, can be seen as an attempt, by professional
men themselves, to cope with certain recurrent problems with which they are faced
in the practice of their profession. These problems are not individual problems, but
problems which are shared by many members of the occupational group in question.
Thus, to ask why English practitioners were concerned with medical ethics at this
time, is to ask what sort of problems they habitually faced in the practice of medicine.
It is the task of this paper to answer this question.
Before, however, we come to this question, we must briefly analyse a precondition,
though by no means a sufficient condition, for the development of professional ethics,
namely the breakdown of the patronage system. The attempt to formulate and enforce
a code of professional ethics represents a development towards what has been termed
"colleague control"-that is, a form of social control in which the professional
activities of practitioners are regulated by the actions and sentiments of their pro-
fessional colleagues. Yet colleague control is only one of a variety of forms of occu-
pational control, and prior to the nineteenth century it was by no means the dominant
form of control of professional activities. Thus the eighteenth century was an age of
patronage, and patronage typically gives rise to a structure not of colleague control,
but of client control. Under patronage the aristocratic and wealthy client is the
dominant partner in the client-practitioner relationship; the client, by virtue of the
wider social bases of his power, is able to define both his own needs, and the manner
in which those needs are to be met. Moreover, the ties which bind the practitioner
to his patron or patrons are those of loyalty and personal subservience, and as Carr-
Saunders and Wilson have pointed out, "Men who are in that condition of personal
subservience do not easily associate with their fellows. Association might seem to
indicate a striving towards an independence that would be incompatible with the
relation of client to patron".11 A similar argument has been more recently expressed
by Johnson, who points out that patronage is associated with a fragmented, locally
oriented occupational group. Under patronage, the practitioner defers to and identi-
fies with his patron or patrons, rather than with his professional colleagues. Under
these conditions, the solidarity of the occupational group is relatively under-developed,
37

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press

 Ivan Waddington
while the "authority of the patron reduces the clear function of ethics and autonomous
disciplinary procedures".12
It is clear, then, that a well-developed patronage system is inimical to the develop-
ment of any form of colleague control, including professional ethics. The breakdown
of the patronage system, concomitant with the widening of the market for medical
services in the nineteenth century, can thus be regarded as a precondition for the
development of codes of medical ethics. It is, however, proper to regard this as a
precondition, rather than as a direct cause of the development of medical ethics, for
it does not, of itself, answer the question of why medical practitioners were con-
cerned with medico-ethical problems at this time. For an answer to this question, we
must look elsewhere.
Traditionally, sociologists have argued that the development of professional ethics
must be seen within the context of practitioner-client relationships. In 1933, Carr-
Saunders and Wilson suggested that "Just as the public may fail to distinguish between
competent and incompetent, so it may fail to distinguish between honourable and
dishonourable practitioners. Therefore the competent and honourable practitioners
are moved mutually to guarantee not only their competence but also their honour.
Hence the formulation of ethical codes."'3 A few years later, T. H. Marshall argued
that "Ethical codes are based on the belief that between professional and client
there is a relationship of trust, and between buyer and seller there is not."'14 Since
the time that Caff-Saunders and Wilson and Marshall wrote, the suggestion that
practitioner-client relationships are crucial to an understanding of professional
ethics- has become almost a sociological orthodoxy. Characteristically, those who
pursue this line of argument suggest that for a variety of reasons, but primarily because
of his ignorance, the client is unable to judge the quality of the professional services
which he receives. Consequently, the client is very vulnerable to exploitation by the
unscrupulous practitioner. The development of professional ethics is seen as a response
to this problem of social control. Thus the professional group itself undertakes to
guarantee the integrity of its members by the development and enforcement of codes
of professional ethics. In this way, the risk of exploitation of the client is minimized.'5
Specifically in relation to medical ethics, this type of explanation seems to be shared
by most medical historians and, not surprisingly, by medical practitioners themselves.
This approach, however, has been developed in the absence of any detailed empirical
investigation of the development of codes of professional ethics. How well, then,
does this approach enable us to understand the development of modern medical
ethics? If we examine Percival's Medical ethics carefully, we find little evidence that
Percival was concerned primarily with ethical problems in the doctor-patient relation-
ship. If we exclude Percival's last chapter, which is on medical jurisprudence rather
than medical ethics, we find that out of a total of forty-eight pages, only half-a-dozen
or so are devoted to a consideration of ethical problems in the doctor-patient relation-
ship. Moreover, his advice to practitioners on how to behave towards patients is,
for the most part, of a highly general kind, very much in keeping with the Greek
tradition; there is thus nothing specifically modern about it. Thus Percival advises
practitioners to "unite tenderness with steadiness", and "condescension with
authority".'6 All cases should be treated "with attention, steadiness and humanity".'7
38

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press

 The development of medical ethics-a sociological analysis
Percival gives little advice on how to cope with specific problems in the doctor-patient
relationship, although he does suggest that there should be no discussion of a case
before the patient,"8 that practitioners should observe "secrecy and delicacy" with
female patients,19 and that 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".20
If, however, comparatively little space is given to a consideration of ethical prob-
lems in doctor-patient relationships, a great deal of space is devoted to the establish-
ment of a set of rules for regulating the relationship between practitioners. Moreover,
the advice which Percival gives to practitioners in this context is much more concrete,
and more detailed. Consider, for example, his advice concerning the conduct of
consultations. "In consultations on medical cases", he says, "the junior physician
present should deliver his opinion first, and the others in the progressive order of
their seniority. The same order should be observed in chirurgical cases."'2' Even
more detailed is his advice on consultations between physicians and surgeons. Thus,
"In consultations on mixed cases, the junior surgeon should deliver his opinion first,
and his brethren afterwards in succession, according to progressive seniority. The
junior physician present should deliver his opinion after the senior surgeon and the
other physicians in the order above prescribed."22 Moreover, to resolve any uncertainty
arising in situations where the lines of seniority are not clearly defined, Percival even
sets out a method for assessing the relative seniority of practitioners engaged in
consultation with each other.a
The fact that Percival's book is concerned primarily with regulating relationships
between practitioners has been clearly pointed out by Leake, who makes a distinction
between medical etiquette and medical ethics. Medical etiquette, he suggests, "is
concerned with the conduct of physicians toward each other, and embodies the
tenets of professional courtesy. Medical ethics should be concerned with the ultimate
consequences of the conduct of physicians toward their individual patients and
toward society as a whole."24 He notes that "The term 'medical ethics', introduced
by Percival, is really a misnomer ... it refers chiefly to the rules of etiquette developed
in the profession to regulate the professional contacts of its members with each other".25
Nor is this surprising, for Percival's work was, in fact, written specifically in order to
resolve a purely intra-professional dispute. In 1789, an epidemic of typhoid or typhus
taxed the capacity of the Manchester Infirmary, and the trustees decided to double
the staff. The surgeons and physicians already on the staff took this as a reflection
upon their efforts, and resigned. In the confusion attending the change of staff,
there was apparently a good deal of friction between the practitioners attached to
the hospital, and Percival, who was physician extraordinary to the infirmary, was
asked to draw up a "scheme of professional conduct relative to hospitals and other
medical charities". The result was a small book which was printed for private distri-
bution in 1794, and which appeared in a revised form in 1803 as Percival's Medical
ethics.26 Leake has pointed out that "The circumstances under which Percival's
'Code' was written, made it necessary for him to place considerable emphasis on
medical etiquette",27 while Lester King has observed that the book was designed
"specifically to establish greater harmony among the physicians who had the care
39

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press

 Ivan Waddington
of the indigent sick, and was in no sense an attempt to explore any vague ethical
generalities".228
Despite the special circumstances under which Percival wrote, his book was by
no means unique, in terms of the kinds of problems with which it dealt, for Percival's
concern to regulate relationships between practitioners was shared by many of his
contemporaries. Thus Abraham Banks' Medical etiquette29 was, as the title suggests,
concerned almost entirely with intra-professional relationships. The only point at
which the doctor-patient relationship becomes problematic for Banks is when one
practitioner is called in to attend the patient of another practitioner, a situation
which only becomes problematic because another practitioner is involved in the
management of the case. A similar story is told by the letters to the Lancet, in which
allegations of unprofessional behaviour focus almost entirely around the conduct
of consultations and the poaching by one practitioner of the patients of another.30
Another major intra-professional problem, which was also dealt with by Banks31
concerned the division of fees in cases where the regular practitioner was unable to
attend and another practitioner was called in. In 1845, the Lancet reported that a
meeting had been called in London to establish some rules governing fee-splitting
in such cases. The Lancet commented that "Some general arrangements of this
nature had long been needed" and it went on to express the hope that such an arrange-
ment would help remove "the stigma cast upon the profession, that it displayed no
more cohesion than a 'rope of sand'."32
In fact, virtually all of the literature from this period supports the idea that re-
lationships between practitioners were much more sensitive, and much more in need
of regulation, than were relationships between practitioners and their patients.
Occasionally, the tensions between practitioners gave rise to open hostilities. Thus in
1837, the Lancet carried an editorial on a dispute between certain medical practi-
tioners in Newport and Monmouth. In the course of the dispute, which was publicized
in the Monmouthshire Merlin for 25 November, the practitioners involved took to
"placarding" one another, that is distributing bills critical of their opponents.33 In 1845,
the Lancet devoted another editorial to a conflict between two practitioners in Frome,
Somerset. This dispute, like many others at the time, arose as a result of a consultation
between the two practitioners, both of whom had published pamphlets criticizing the
other. The Lancet observed that one of the practitioners "heaps insult upon insult on
his opponent, on his opponent's brother-whose part in the case was merely that of a
spectator-and even attacks the entire medical profession of Frome".34
These well-publicized conflicts merely represented the tip of the iceberg however,
for conflicts between practitioners were endemic at this time, and it seems to have
been appreciated by practitioners themselves that the major problems with which
they had to contend arose from the internal divisions and tensions within the pro-
fession. Thus Abraham Banks referred to the "prevalence of illiberality in country
towns and villages; the jealousy existing between individual practitioners, who
frequently, under the mask of candour and professed friendship, undermine each
other's reputation, and never lose a chance of sinking one another in public estima-
tion, when this can be done with seeming good grace and kindness".35 That relation-
ships between provincial practitioners were often strained will come as no surprise
40

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press

 The development of medical ethics-a sociological analysis
to those who are familiar with Trollope's Doctor Thorne;3' it is, however, difficult to
see how they could be more strained than those between London practitioners when
the Lancet could refer to hospital consultants, and to those who controlled the Royal
Colleges as "crafty, intriguing, corrupt, avaricious, cowardly, plundering, rapacious,
soul-betraying, dirty-minded BATS".37 Clearly, however, Banks had this kind of
intra-professional conflict very much in his mind; his object, he said, was "to promote
concord and harmony amongst the several branches of the profession".38 A similar
point was made two years earlier by W. 0. Porter, in his Medical science and ethicks,
when he called upon doctors to follow the golden rule, "Do unto all men as you
would that they should do unto you".39 He hoped that we "should not then be
exposed to feel, or witness, or even hear of those feuds, which sometimes arise between
members of the profession, so injurious to the interests of all concerned, and so
derogatory to that high character, which it is our duty to preserve, and should be
our chief aim to raise in the estimation of the public".'0
This same point was repeated over and over again by those writing on medical
ethics. Thus in 1845, a correspondent of the Lancet called for the introduction of
"a standard or rule to guide doctors in their professional activities". However, he
went on in a somewhat despondent manner, "Or, is this subject too delicate, and
must we continue to live on, hoping for better feelings and deportment in those who
have hardly a fair word to use for their brother? Perhaps it is doubtful, after all,
whether any set of rules would unite a body so disaffected as ours"." Perhaps most
telling, however, are the comments of the author of a paper on medical ethics which
was published in the London Medical Gazette. The writer, W. B. Kesteven, pointed
to the "urgent need of a generally acknowledged principle whereon to base the rules
of medical ethics", and claimed that "it is doubtless the want of some such principle
that permits the jealousies, bickerings, and calumnies which distress and divide the
different branches and interests of the profession".'2 He then went on to ask "Is it
not an unenviable paradoxical notoriety, that a profession pre-eminently benevolent
and . . . eleemosynary to all beyond its own immediate sphere, should towards its
own members be proverbially uncharitable and litigious? Alas! will the time never
be that men shall apply to its members the eulogium so unwittingly extorted from
the pagans of old, 'See how these Christians love one another?' Or rather, how long
shall it be that the world shall continue to say, 'See how these doctors hate one
another?" 43
This argument is particularly telling, because it indicates quite unambiguously
that relationships between doctors and the wider society, including patients, were
characterized by benevolence and charity on the part of practitioners. The same point
was made in an editorial in the Lancet in 1842,44 and indeed, it seems to have been
a point on which the medical profession prided itself. The everyday problems facing
medical practitioners, it is clear, arose not in their relationships with their patients,
but in their relationships with their professional colleagues, relationships which all
too frequently were characterized by tensions, by hostilities, by accusations and
counter-accusations. The development of medical ethics, it is suggested, can best be
understood as an attempt to regulate these tension-ridden relationships so as to
reduce the amount of potentially very damaging intra-professional conflict.
41

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press

 Ivan Waddington
In order to understand the reasons for this endemic conflict within the medical
profession, we must have some understanding of the rapidly changing structure of
medical practice at this time. Traditionally the law had recognized only three types
of medical practitioners: physicians, surgeons, and apothecaries. These three groups
were organized in a hierarchical structure, with physicians forming the "first class of
medical practitioner in rank and legal pre-eminence".4 By the Statute of 32 Henry 8,
physicians were allowed to practise physic in all its branches, among which surgery
was included. However, the disdain which physicians, as a body of learned men, felt
for manual work, had led to a contraction in their duties, and by the eighteenth century,
the practice of the physician was held to be properly confined to prescribing of drugs
to be compounded by the apothecary, and in superintending operations performed
by surgeons in order to prescribe what was necessary to the general health of the
patient, or to counteract any internal disease. The controlling body for physicians
was the Royal College of Physicians of London, a small and exclusive body, very
conscious of the necessity to maintain the high status which physicians had long
enjoyed.
In sharp contrast to physicians, surgeons had long been regarded as craftsmen
rather than gentlemen. The surgeons had been united with the barbers in the Company
of Barber-Surgeons until 1745, in which year they formed a separate organization,
the Company of Surgeons, which subsequently became the Royal College of Surgeons
of London in 1800. The proper sphere of practice of the surgeon was held to consist
generally in the cure of all outward diseases, and in the use of surgical instruments
in all cases where this was necessary."
The lowest order of the medical profession, the apothecaries, had been organized
in the Society of Apothecaries since 1617. The charter of the Society required seven
years' apprenticeship to a member as an essential qualification for admission to the
freedom of the Company, and stated that at the end of seven years "every such
apprentice ... shall be examined, proved, and tried concerning the preparing, dis-
pensing, handling, commixing and compounding of medicines".47 However, by the
early part of the eighteenth century, the apothecaries had successfully grafted medical
on to pharmaceutical practice, and had won legal recognition of their right to
"administer medicine of their own authority, and without the advice of a physician"."
This tripartite structure was enshrined not only in the internal institutional structure
of the profession-in the sense that there were separate licensing bodies for physicians,
for surgeons and for apothecaries-but also in the legal system. Thus the "orders"
of the profession were hierarchically ranked, and each grade of practitioner had
privileges which were legally defined. The general concept of the qualified or registered
practitioner had no place in English law prior to the Medical Act of 1858; instead
there were separate laws relating to physicians, to surgeons, and to apothecaries.
If, however, this tripartite structure was more or less clear in formal terms, it had
become, by the beginning of the nineteenth century, anything but clear in practice.
The social and economic changes associated with the agricultural and industrial
revolutions-too complex to be gone into here-had not only expanded the demand
for medical care, but had also created demands for a new type of medical care. Under
the impact of these new demands the divisions between physicians, surgeons, and
42

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press

 The development of medical ethics-a sociological analysis
apothecaries were steadily breaking down. Thus, from 1750 onwards, a rapidly
growing number of practitioners were combining the practice of medicine, surgery,
midwifery and pharmacy to form a quite new professional role, that of the general
practitioner. By the 1830s, general practitioners were by far the most numerous
class of medical men, probably providing some ninety per cent of the qualified
medical care in England. Numerous witnesses who gave evidence before the Select
Committees of both 183449 and 18474850 testified to the fact that there were hardly
any practitioners, even in London, who could confine their practice to pure medicine
or surgery.51
Not all medical men were engaged primarily in general practice, however, for the
growth of hospitals in the eighteenth and nineteenth centuries had given rise to a
much smaller, but very important, class of consulting physicians and surgeons who
owed their positions as consultants primarily to their hospital appointments.52 Thus
in the period 1750-1850 the traditional tripartite structure was being steadily eroded
and replaced by the emergence of the modem structure of medical practice, based on
the differentiation between general practitioners and the hospital-based consultants.
While the traditional tripartite structure was clearly breaking down, however, an
institutional structure appropriate to this new professional differentiation was slow
in developing. This resulted in a very confused situation, in which definitions of roles
and statuses within the medical profession were very unclear. As a correspondent
of the Lancet pointed out in 1841, "Everything connected with our profession is, at
present, in a state of disorder and uncertainty; its laws are in abeyance; and young
men, about to commence their medical studies, are quite at a loss what to expect,
or what plan of education to pursue".53 The medical profession in the first half of
the nineteenth century was, as Leake has bluntly but accurately characterized it, "a
mess", and within this ambiguous and fluid situation, different types of practitioners
"jockeyed for positions of prestige and power".54
This jockeying for position was related to the prevailing confusion surrounding
the division of labour within the profession, a problem which was intimately related
to the different statuses attributed to different kinds of medical work. Thus the role
of the general practitioner cut across the traditional tripartite division of labour,
since it necessarily combined the practice of medicine, surgery, pharmacy, and mid-
wifery. A number of practitioners however-particularly the consulting physicians
and surgeons-were bitterly opposed to the incorporation of what they regarded as
purely manual or trading activities into the doctor's role, for they feared that such a
development threatened the high status which physicians had long enjoyed, and
which surgeons had recently attained. Thus the Royal Colleges of Physicians and
Surgeons, which were dominated by the consultants, adopted a variety of policies
designed to maintain the purity of medicine and surgery undiluted by manual and
trading operations, and to stem the rise of the general practitioner. Among other
things, they refused to broaden the scope of their examinations to cover anything
other than pure medicine and surgery respectively,55 and to allow general practi-
tioners on to their governing councils." The general practitioners in turn resented
what they saw as an attempt to deny them their proper place within the profession
and to condemn their characteristic mode of earning a livelihood as a low-status
43

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press

 Ivan Waddington
medical occupation, unfit for gentlemen. From the second half of the eighteenth
century the general practitioners launched a campaign for the democratic reform of
the medical corporations, for the reform of medical education and licensing, for the
abolition of the divisions between physicians, surgeons, and apothecaries, and for
the recognition of general practice as a legitimate and honourable professional
activity.57 This campaign, which lasted for a hundred years, was bitterly fought, and
gave rise to extremes of vituperation and personal insult, in which the Lancet in
particular excelled, and occasionally it gave rise to the use of physical violence by one
section of the profession against another.58 The widely held picture of a profession
as a harmonious community is not one which can readily be applied to the medical
profession in the nineteenth century.
This analysis provides a major key to the understanding of why ill feeling and
disharmony so often characterized relationships between practitioners. It also helps
us to understand why the problem of defining what kinds of activities should be
undertaken by what kinds of practitioners figured prominently in the literature on
medical ethics. Thus only in these terms, it is suggested, can we understand Percival's
lengthy discussion of the relationships which ought to prevail between the different
"grades" of practitioners. Of Percival's three chapters on medical ethics, the whole of
the third chapter is devoted to a discussion "Of the Conduct of Physicians towards
Apothecaries", while other statements on the relationships between physicians,
surgeons and apothecaries are scattered liberally throughout his work. Thus in his
advice on the conduct of mixed consultations, cited earlier, Percival showed a clear
understanding of the nice status distinctions between physicians and surgeons in his
recommendation that the most junior physician present should deliver his opinion
after the most senior surgeon had delivered his.
On issues of this kind, Percival was a conservative-according to Sir George
Clark, "the best conservative opinion" of his time59-and accordingly he advised his
fellow practitioners to maintain the traditional division of labour within the pro-
fession. Thus in his chapter on hospitals, he advised that "A proper discrimination
being established, in all hospitals between the medical and chirurgical cases, it should
be faithfully adhered to by the physicians and surgeons on the admission of patients".'0
Similarly, in the chapter on private practice, he recommended that "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.... Experience has fully evinced the benefits of the discrimination recom-
mended, 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."61 Similarly, in his chapter on the relationships
between physicians and apothecaries, he suggests that physicians should refuse a
request to visit the patients of an apothecary, in the latter's absence. "Physicians",
he argued, "are the only proper substitutes for physicians; surgeons for surgeons;
and apothecaries for apothecaries."62 Thus Percival tried to present guidelines which
would prevent the continual disputes over the division of labour within the profession;
44

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press

 The development of medical ethics-a sociological analysis
his solution, as we have seen, was to call for the maintenance of the traditional
divisions within the profession.
While most practitioners seem to have agreed that the breakdown of the traditional
tripartite division of labour was a major cause of the jealousies and tensions within
the profession, few were willing to go along with Percival's conservative remedy.
The radicals' position was clearly set out in a long paper on medical ethics by Thomas
Laycock, which was published anonymously in the British and Foreign Medico-
Chirurgical Review in 1848. Laycock pointed out that the profession "seems little
better than a chaos; the whole mass is upheaving; decomposition and recomposition
are going on; but we can discern no great principles by which coherence and strength
may be given to the discordant elements. It is quite impossible that the intelligent
lay public will notice the professional desire for organization and legislation, so long
as the impelling motives are nothing more dignified than sectional interests, grade
prejudices, or interested clamours in a pecuniary sense".63 "How", he asked, "can
members of Parliament and the educated classes esteem a profession, the members of
which mutually disparage each other?""4 Laycock then went on to examine the
squabbles over the division of labour within the profession. "All bodies of men" he
argued, "are intolerant of any departure from principles and practices that have
become conventional. Although such departure may have nothing whatever in it
morally wrong, yet it is visited 'with the utmost rigour of the law'-that may have
been conventionally established. Thus physicians fully engaged in practice will
bitterly regard the young physician who, feeling the pressure of the res augusta domi,
may exercise any surgical talent he may possess, or who, suspecting that his
medicamina are not well compounded, or of a spurious quality, may look to the
manufacture of his powder, or point his own guns."65 He pointed out that even though
all types of practitioners co-operated harmoniously in organizations like the Royal
Medico-Chirurgical Society, the educational institutions continued to "raise their
Shibboleth before the public, before Parliament, and in the profession, and establish
their differences where there is hardly any distinction". The leading men in the
College of Surgeons treated medical cases as frequently as surgical ones. "To all
purposes, and in every way, the surgeon is a physician, with the ability to operate
chirurgically superadded to his medical acquirements, and is conventionally permitted
to operate, prescribe, and receive his fee, so long as he calls himself 'surgeon'. But
led him add M.D. to his name, and conventionalism forthwith binds up his right
hand, severs him from his College, and circumscribes the sphere of his usefulness."
Laycock added that "if it could be proved that this line of demarcation, already
obliterated in the voluntary associations, is of any use whatever to either the pro-
fession or the public when drawn between two classes of practitioners, in which the
difference of education and attainments is now at least really but nominal, we would
acquiesce at once in the arrangement. But it has yet to be shown that a union of
these two educational institutions, and a reorganisation on a broad base of ethical
principles, would either render the surgeon less skillful, or the physician less educated
or intellectual. The whole matter is indeed hardly capable of serious argument."
Thus Laycock called for the abolition of those professional divisions which Percival
had defended in 1803. Only by taking such a step, argued Laycock, could the intra-
45

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press

 Ivan Waddington
professional squabbling and bickering be ended. Thus he concluded his paper by
calling on enlightened provincial practitioners to place the organization of the
profession on "its proper basis", or else the profession would remain "as it is-a
chaos of confficting elements".66
Shortly afterwards, the Lancet gave Laycock's paper its "warmest approbation".
Quoting extensively from the article, the Lancet said "there are no passages in the
article. . . with which we more cordially agree than those which describe the unworthy
jealousies which rise between some among the different classes of the profession, when
any man dares to step out of his proper line; when the physician or surgeon, for
instance, trenches upon the province of the general practitioner; when the general
practitioner aspires to the work of the surgeon or physician; or when the physician
and surgeon dare to defy artificial distinctions, and pass from one department to the
other." The Lancet added "how constantly have we dwelt on the meretricious separa-
tion, the unworthy caste-division, which seeks to make the highest surgeon lower
than the physician, and the highest general practitioner lower than both".67 The
Lancet, of course, had, since its foundation in 1823, campaigned consistently for the
abolition of the tripartite structure, and by the middle of the century there was
widespread agreement amongst doctors that there could be no end to the disharmony
and tensions within the profession as long as the tripartite structure remained. It is
hardly surprising that this issue should have figured prominently in the literature on
medical ethics.
As the tripartite structure was steadily being eroded, so the modern structure of
medical practice, based on the differentiation between consultants and general
practitioners, was beginning to emerge; indeed, these were, in reality, different aspects
of the same process. But just as the breakdown of the tripartite structure gave rise to
problems, so too did the emergence of the consultant-general practitioner relationship.
As the hospitals developed, so they gave rise to a class of consulting physicians and
surgeons, and the practice of calling in a consultant to help in the management of
particularly difficult or ambiguous cases became increasingly common. Relationships
between general practitioners and consultants were frequently characterized by
hostilities and tensions however, for both roles were, in a real sense, new roles, and
as such, they had not yet, at this period, become as clearly differentiated and insti-
tutionalized as they are today. In particular, there was one critical area of overlap
between the role of the consultant and the role of the general practitioner, an area of
overlap which not only differentiates the nineteenth-century consultant from the
present-day consultant, but which was also at the root of much of the conffict which
characterized consultations in the nineteenth century.
This critical area of overlap arose because consultants did not then-as they do
now-confine their practice to consulting work, but also normally acted as general
practitioners to small numbers of wealthy clients. In addition there were a large
number of practitioners-particularly in the provinces, where consulting work was
normally less readily available-who derived the major part of their income from
general practice, but who also occasionally acted as consultants within their own
locality. The result was that consultations were normally held between two practi-
tioners, both of whom, to some extent, were in general practice; thus there was a real
46

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press

 The development of medical ethics-a sociological analysis
element of competition involved, particularly for wealthier clients. Within this situa-
tion, mutual suspicion and hostility between consultants and general practitioners
were common. Allegations by general practitioners that consultants were trying to
poach their patients, either by calling on the patient a second time without the
knowledge of the regular attendant, or by implicitly or explicitly criticizing the therapy
recommended by the latter, were common. From the 1830s onwards, the Lancet
published numerous letters from practitioners alledging breaches of professional
etiquette, the most common complaints being those which related to the conduct of
consultations and the poaching of patients. In 1849, W. B. Kesteven referred to the
"censurable condemnation of a professional brother, whether of a higher or lower
grade, by looks, gestures, innuendos, etc. For example, a physician called in con-
sultation takes occasion in the absence of the general practitioner to hint that a
different treatment should have been adopted; or by indirect means, such as friendly
visits, etc., supplants the ordinary attendant, or destroys his patient's confidence".68
In 1854, the Association Medical Journal, in reply to a correspondent who complained
of the conduct of a consultant, agreed that it was easy for a consultant to:
Convey a censure in a frown,
And wink a reputation down.
The Association Medical Journal went on to point out that "extreme watchfulness
and honesty of act and feeling are essential requisites in this class of practitioners".69
The conflict between general practitioners and consultants-which was in effect a
demarcation dispute-smouldered on throughout the nineteenth century, and towards
the end of the century, in 1886, the lines of conflict were more clearly articulated than
ever before with the foundation of the Association of General Practitioners. The
Association, which was founded with the aim of forcing consultants to confine their
activities to consulting practice, would have nothing to do with "so-called consultants
who practised as general practitioners.... It will not seek to discredit them, nor will
its members refuse to meet them when required to do so; but it will exert all its
individual and collective influence in favour of those who act as consultants as the
term is understood by this Association".70
Given this situation, it is hardly surprising that a number of writers, from Percival
onwards, should see consultations and the poaching of patients as major areas re-
quiring regulation by a code of medical ethics. Percival's advice on these points is
quite detailed. Thus we have seen that Percival not only lays down the order in
which parties to a consultation should deliver their opinion, but also suggests a way
of calculating the seniority of the respective practitioners involved. Punctuality should
be observed in consultations, and "No visits should be made but in concert, or by
mutual agreement"'.7 When consultations are held, "no rivalship or jealousy should
be indulged. Candour, probity and all due respect should be exercised towards the
physician or surgeon first engaged."72 "Officious interference, in a case under the
charge of another, should be carefully avoided."73 If a practitioner is called to a
patient under the care of another practitioner, he should always observe "the utmost
delicacy towards the interest and character of the professional gentleman, previously
connected with the family".74 The practitioner should "interfere no farther than is
47
D

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press

 Ivan Waddington
absolutely necessary with the general plan of the treatment; to assume no further
direction, unless it be expressly desired; and, in this case, to request an immediate
consultation with the practitioner antecedently employed."75 Abraham Banks deals
with many similar problems, advising consultants not to call on patients without the
general practitioner being present,76 giving advice on how to divide the fee when two
practitioners consult," on how to act when a second party is called in to decide upon
the treatment of another practitioner,78 and on what to do (and what not to do)
when one practitioner is sent for to the patient of another practitioner.79 In W.
Fraser's "Queries in medical ethics", a series of questions and answers on ethical
problems published in the London Medical Gazette in 1849, no less than fourteen of
the twenty-seven queries deal with consultations, and with taking over the manage-
ment of a case from another practitioner.80
Medical practitioners, it is clear, were no more given than any other section of
the educated classes to the consideration of abstract philosophical principles. Rather,
their concern with medical ethics was a practical concern, arising from certain re-
current problems with which they were faced in the day-to-day practice of their
profession. In this paper it has been suggested that these practical problems arose
primarily within the context of relationships between practitioners, as a result of
certain structural tensions within the profession. The commonly held view that
professional ethics develop primarily in order to regulate relationships between
practitioners and their clients finds little support from an analysis of nineteenth-
century writings on medical ethics, in which ethical problems in the doctor-patient
relationship occupy only a minor place.
It is not suggested, of course, that an understanding of practitioner-patient re-
lationships is irrelevant to an understanding of medical ethics, for there are clearly
passages in Percival's work, as in the work of other writers, which relate to the
doctor-patient relationship. What is suggested is that the importance of the doctor-
patient relationship for an understanding of medical ethics has been very considerably
overstated, and that the development of medical ethics may be much more closely
related to the need to regulate relationships between practitioners than has com-
monly been held.
Nor is it claimed that this analysis is equally applicable to the development of
codes of professional ethics in all professional occupations at all times, for the signi-
ficance of colleague relationships, as well as the potentiality for intra-professional
conflict, are likely to vary according to different structural conditions. Nevertheless,
the analysis might well be applicable to other occupations which emerged as modern
professions in the nineteenth century, for the changing pattern of demand for pro-
fessional services during that period produced some similar changes, resulting in
similar tensions, within other professional groups.8' However, the structural con-
ditions under which many new occupations-including many para-medical occupa-
tions-are today striving for professional status, are quite different, and it would be
foolish to expect them to follow the characteristic nineteenth-century pattern of
professional development.
However, the case of medicine is an important test case, if only because the medical
profession has so frequently been used as the prototypical profession, on the basis of
48

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press

 The development of medical ethics-a sociological analysis
which a number of models of the professions have been constructed by sociologists.
The conventional explanation of the development of professional ethics is not valid,
it is suggested, even for the prototypical profession, and it is perhaps time that
sociologists took a harder, more critical look at the conditions under which profes-
sional ethics develop, and at the functions which they perform. It would seem that
for too long sociologists have accepted on trust the bland assurances of the pro-
fessionals themselves that codes of ethics develop purely in order to protect clients.
If sociology is, as Berger suggests, the art of mistrust,82 then it is perhaps time that
we were a little less trusting.
ACKNOWLEDGEMENTS
I wish to thank the Research Board of the University of Leicester for providing financial assistance
which enabled me to undertake the research on which this paper is based. My thanks are also due to
my colleagues, especially Professor Ilya Neustadt, Professor Joe Banks, Terry Johnson, and Cheryl
Knowles, for their comments on an earlier draft of this paper.

REFERENCES
1. Ludwig Edelstein, 'The Hippocratic Oath: text, translation and interpretation', Bull.
Hist. Med., Baltimore, Johns Hopkins Press, 1943, supplement no. 1.
2. Chauncey D. Leake (ed.), Percival's medical ethics, Baltimore, Williams & Wilkins,
1927, p. 36.
3. Ibid., pp. 23-24.
4. Robert Forbes, 'A historical survey of medical ethics', St. Bart's Hosp. J., 1955, 59:
282-286, 316-319.
5. Richard Thomas Barton, 'Sources of medical morals', J. Am. med. Ass., 1965, 193:
133-138.
6. R. M. S. McConaghey, 'Medical ethics in a changing world', J. Coll. Gen. Practnrs,
1965, 10: 3-17.
7. William Ogilvie Porter, Medical science and ethicks: an introductory lecture, Bristol,
W. Strong, 1837.
8. Abraham Banks, Medical etiquette, London, Charles Fox, 1839.
9. The rules and bye-laws of the Manchester Medico-Ethical Association were published
in 1848, and reviewed in an anonymous article entitled 'Medical ethics', Brit. For.
med.-chir. Rev., 1848, 2: 1-30.
10. Ernest Muirhead Little, History of the British Medical Association 1832-1932, London,
British Medical Association [n.d.], p. 288. In 1853 the Association was, of course,
still known as the Provincial Medical and Surgical Association. It became the British
Medical Association in 1855.
11. A. M. Carr-Saunders and P. A. Wilson, The professions, London, Oxford University
Press, 1933; reprinted London, Frank Cass, 1964, p. 300.
12. Terence J. Johnson, Professions and power, London, Macmillan, 1972, pp. 68-69.
13. Carr-Saunders and Wilson, op. cit., note 11 above, p. 302.
14. 'The recent history of professionalism in relation to social structure and social policy',
in T. H. Marshall, Sociology at the crossroads and other essays, London, Heinemann,
1963, pp. 150-170. This essay was originally published in the Canad. J. Econ. polit. Sci.,
1939, 5: 325-334.
15. For a statement of this position see, for example, William J. Goode, 'Community
within a community: the professions', Am. sociol. Rev., 1957, 22: 194-200, and
Barrington Kaye, The development of the architectural profession in Britain, London,
Allen & Unwin, 1960, pp. 11-21.
16. Leake, op. cit., note 2 above, p. 71.
49

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press

 Ivan Waddington
17. Ibid., p. 90.
18. Ibid., p. 72.
19. Ibid., p. 73.
20. Ibid., p. 90.
21. Ibid., p. 80.
22. Ibid., p. 81.
23. Ibid., p. 96.
24. Ibid., p. 2.
25. Ibid., p. 1.
26. Ibid., pp. 30-32.
27. Ibid., p. 37.
28. Lester S. King, 'Development of medical ethics', New Eng. J. Med., 1958, 258: 480-486.
29. Banks, op. cit., note 8 above.
30. See, for example, Lancet, 1839-40, ii: 875; 1839-40, ii: 942; 1840-41, i: 68-69; 1841-42,
i: 549; 1847, ii: 266-267; 1848, ii: 538; 1850, ii: 186-187; 1850, ii: 249; 1850, ii:
489-490; 1850, ii: 621.
31. Banks, op. cit., note 8 above, pp. 1-4.
32. Lancet, 1845, ii: 492.
33. Lancet, 1837-38, i: 346-347.
34. Lancet, 1845, i: 657-658.
35. Banks, op. cit., note 8 above, p. 39.
36. Trollope's Doctor Thorne was written in 1857-58 and published in the latter year.
37. Lancet, 1831-32, i: 2.
38. Banks, op. cit., note 8 above, p. 57.
39. Porter, op. cit., note 7 above, p. 29.
40. Ibid., p. 29.
41. Lancet, 1845, ii: 687.
42. W. B. Kesteven, 'Thoughts on medical ethics', London med. Gaz., 1849, n.s. 9: 408-414.
43. Ibid., p. 414.
44. Lancet, 1841-42, ii: 728-731.
45. John William Willcock, The laws relating to the medical profession, London, 1830, p. 30.
This outline of the legal status of medical practitioners is based on the work of
Willcock, who was an authority on these matters.
46. This is a very general outline of a rather complex legal situation. For a more detailed
examination of the legal status of the surgeon, see ibid., pp. 56-58.
47. Quoted in Rachel E. Franklin, 'Medical education and the rise of the general practi-
tioner', Ph.D. thesis, University of Birmingham, 1950, p. 112.
48. Willcock, op. cit., note 45 above, p. 67.
49. Report from the select committee on medical education, 1834 (602-1) Part I, (602-Il)
Part II, (602-III) Part III.
50. Report from the select committee on medical registration, 1847, (602); First and second
reports from the select committee on medical registration and medical law amendment,
1847-48, (210); Third report from the select committee on medical registration and
medical law amendment, 1847-48, (702).
51. The evidence of the breakdown of the tripartite structure, and of the emergence of the
general practitioner, has been well summarized elsewhere by Holloway, and there is
neither the time nor the necessity to argue the point in detail again here. See S. W. F.
Holloway, 'Medical education in England, 1830-1858: A sociological analysis',
History, 1964, 49: 299-324.
52. Thomas McKeown, 'A sociological approach to the history of medicine', Med. Hist.,
1970, 14: 342-351.
53. Lancet, 1840-41, Hi: 107-108.
54. Chauncey D. Leake, 'Percival's Medical Ethics: promise and problems', Calif. Med.,
1971, 114: 68-70.
50

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press

 The development of medical ethics-a sociological analysis
55. For the College of Physicians, see the Report from the select committee on medical
education, 1834, (602-1) Part I, Qs. 2025-2027, 2568. For the College of Surgeons,
see the First and second reports from the select committee on medical registration and
medical law amendment, 1847-48, (210), Q. 804.
56. In the College of Surgeons, general practitioners were excluded from the Council
under a bye-law of 7 April 1748. See the First and second reports from the select com-
mittee on medical registration and medical law amendment, 1847-48, Q. 11. In the
College of Physicians they were excluded under bye-laws of 1771, described in Sir
George Clark, A history of the Royal College of Physicians, Oxford, Clarendon Press
for the Royal College of Physicians, 1964-66, 2 vols., vol. 2, p. 566.
57. For an analysis of one of the early reform movements see I. Waddington, 'The struggle
to reform the Royal College of Physicians, 1767-1771: A sociological analysis',
Med. Hist., 1973, 17: 107-126.
58. Physical violence was used, for example, by the licentiates of the Royal College of
Physicians in their attempt to reform the College in the period 1767-1771. For a
detailed analysis, see ibid.
59. Clark, op. cit., note 56 above, vol. 2, p. 613.
60. Leake, op. cit., note 2 above, p. 76.
61. Ibid., pp. 93-94.
62. Ibid., pp. 117-118.
63. 'Medical ethics', Brit. For. med.-chir. Rev., 1848, 2: 1-30.
64. Ibid., p. 24.
65. Ibid., p. 27.
66. Ibid., p. 30.
67. Lancet, 1848, ii: 44-45.
68. Kesteven, op. cit., note 42 above, p. 412.
69. Ass. med. J., 1854, 2: 1085-1086.
70. Br. med. J., 1886, i: 1124.
71. Leake, op. cit., note 2 above, p. 97.
72. Ibid., p. 94.
73. Ibid., p. 92.
74. Ibid., p. 98.
75. Ibid., p. 106.
76. Banks, op. cit., note 8 above, p. 10.
77. Ibid., pp. 5-9.
78. Ibid., pp. 54-59.
79. Ibid., pp. 43-47.
80. W. Fraser, 'Queries in medical ethics', London med. Gaz., 1849, n.s. 9: 181-187, 227-232.
81. The most striking similarities are, perhaps, to be found in the legal profession in the
nineteenth century. As Carr-Saunders and Wilson have noted, the development of both
professions "was anything but smooth.... On reflection it appears that what hap-
pened in both cases was the early segregation of practitioners, advocates, and physi-
cians, whose function at a later date was realized to be specialist. But the associations
of these specialists, having attained great power and prestige, attempted to inhibit
the development of general practitioners of law and medicine of whose services the
public had need. When they could not prevent their appearance, they tried to keep
them subservient, and the history of both professions is largely concerned with the
problems so brought about." See Carr-Saunders and Wilson, op. cit., note 11 above,
p. 304. In the legal profession the general practitioners were, of course, solicitors.
82. Peter L. Berger, Invitation to sociology, Harmondsworth, Penguin, 1966, p. 42.

51

https://doi.org/10.1017/S002572730001992X Published online by Cambridge University Press