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March 2001
Volume 65 |
Number 3
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Code of Conduct |
R. Dennis Bastron,
M.D.
Robert J. McQuillan, M.D.
Committee on Ethics
Statements of ethical behavior have been a part of medical practice
for some 4,000 years, beginning with the Code of Hammurabi, circa
2,000 B.C.E., which established fees for medical practitioners
and penalties for bad outcomes. These statements may take the
form of prayers, oaths, creeds, declarations or institutional
directives. The Oath of Hippocrates, 4th century B.C.E., is the
most famous example in Western medicine. This oath stems from
a highly developed system of moral belief probably Pythagorean
and indicates that to be a good physician, one must first be a
good and kind person.
Modern American codes of ethics began with the writings of John
Gregory and Thomas Percival, both Scottish physicians. In 1794,
Percival was asked to mediate a dispute among surgeons, physicians
and apothecaries at the Manchester Infirmary. His manuscript,
published as Medical Ethics in 1803, was more popular in the United
States than Europe and was the model for the 1809 Boston Medical
Police, written by John Warren, Lemuel Hayward and John Fleet
for the Association of Boston Physicians. Medical Ethics was also
the model for the 1847 Code of Ethics for the newly formed American
Medical Association. This was the first national code of professional
ethics in the world.
Codes of medical ethics are valuable and necessary because of
the nature of physician-patient relationships. The predominant
characteristic of the covenantal relationship is the vulnerability
of the patient. Anesthesiologists' patients are especially vulnerable.
Depriving patients of their consciousness and protective reflexes
heightens our level of responsibility and duties to them. This
has been termed by some to be an existential vulnerability because,
should their trust be misused or abused, devastating consequences
can occur. This level of professional responsibility has historically
been attributed to four professions: medicine, clergy, teaching
and law. Existential vulnerability is at the heart of why these
professions must have professional codes that maintain the trust
of those they strive to serve.
Ethics always has been a part of the practice of anesthesiology.
Crawford W. Long, M.D., received permission to administer ether
to James Venable; and William T.G. Morton, asked the permission
of Gilbert Abbott before administering Letheon (a term used by
Dr. Morton to disguise the identity of ether). Moreover, John
Collins Warren, M.D., who operated on Mr. Abbott, refused to allow
Morton to administer Letheon at the Massachusetts General Hospital
until he divulged the active ingredients. Morton finally admitted
that it was sulfuric ether, and he administered an anesthetic
for the first major operation under ether. The surgery was performed
by George Hayward, M.D. It seems that the Boston Medical Police
(written by the fathers of these two surgeons) proscribed the
use of nostrums medicines with secret ingredients.
The problem of increased vulnerability of anesthetized patients
was recognized soon after the public demonstration of ether, even
by proponents of painless surgery. Apparently their fears were
justified. Within months, sexual assaults on etherized females
were reported in France, New York City and Philadelphia. Fifteen-year-old
Hannah Greener became the first anesthetic fatality in January
1848. Furthermore, prominent surgeons soon began to applaud anesthesia
for allowing them to perform involuntary surgical procedures to
circumvent the opposition of the timid and unruly; and placing
the patient in a passive condition gives the surgeon a control
over him which could not possibly obtain in any other manner.
It is no small wonder that ASA places so much emphasis on ethical
behavior as espoused in its Guidelines for the Ethical Practice
of Anesthesiology!
ASA first promulgated its ethical guidelines in 1967, and it
endorsed and incorporated the American Medical Association's Principles
of Medical Ethics. At the August 1997 Board of Directors meeting,
ASA District Director Peter L. Hendricks, M.D., a U.S. Navy veteran
familiar with the development of the 1955 Code of Conduct for
members of the U.S. Armed Forces, responded to an anecdotal reporting
of unethical behavior of anesthesiologists. He proposed that ASA
develop its own code of conduct. The Board of Directors referred
this matter to the Committee on Ethics, which after two years
of discussion determined that the Guidelines for the Ethical Practice
of Anesthesiology, originally constructed as a guide to ethical
behavior, already served the purpose of a Code of Conduct.
The 1999 House of Delegates adopted the Committee's recommendation
that every ASA member, in order to be a member in good standing,
should sign their membership card as a yearly affirmation that
they are bound to abide by the guidelines. In fact, the ethical
guidelines are the only such binding ASA document. As a result,
the membership card now contains the following statement above
the signature line: As a member in good standing of the American
Society of Anesthesiologists, I agree to the ASA Guidelines for
the Ethical Practice of Anesthesiology. Moreover, the annual
dues invoice states that Membership in good standing of the American
Society of Anesthesiologists requires adherence to the ASA Guidelines
for the Ethical Practice of Anesthesiology.
It is hoped that the prominence of these statements will enhance
members’ awareness of their ethical obligations and encourage
them to study the Guidelines for the Ethical Practice of Anesthesiology.
The authors wish to thank Stephen H. Jackson, M.D., Chair of
the Committee on Ethics, for his helpful suggestions.
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R.
Dennis Bastron, M.D. is Professor of Anesthesiology, Professor
and Head, Department of Humanities in Medicine, Texas A&M
University System Health Sciences Center College of Medicine.
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Robert
J. McQuillan, M.D., is Chair, Department of Anesthesiology
and Associate Professor of Anesthesia and Clinical Ethics,
Creighton University Medical Center, Omaha, Nebraska. |
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