Medical Ethics or, A Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons by Thomas Percival, MD, The Classics of Medicine Library, Gryphon Editions, New York, Birmingham 1985, 246 pages, $49

Critics declare the whole notion of professional ethics, not just in medicine, morally suspect and self-serving. The very nature of the patient-physician relationship is being variously reinterpreted. Some see it as a contract or a commodity transaction, others as an exercise in applied biology, and still others as a semi-sacred covenant. Medicine is being subjected to the rules of the marketplace so that altruism and economic self-interest oppose each other. Lawyers, economists, and sociologists doubt whether physicians, or any other group in our society, can be trusted to act in other than their own self-interest. The Federal Trade Commission increasingly comes to regard professional ethics as monopolistic and in restraint of competition. It has now been a decade since the Presidentís Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research completed their voluminous reports. It extended further into social ethics, resource allocation, access, and availability of health and medical care. It placed emphasis for the first time on self-determination and autonomy of patients in making clinical choices. Because our society has become more diverse in its moral beliefs which makes moral consensus more difficult, the Classics of Medicine Library felt compelled to examine and understand the ethics of our professional forebears.

Thomas Percivalís Medical Ethics, with Oath and Deontological books of the Hippocratic Corpus, remains one of the most influential documents in Anglo-American medical ethics and its spirit has shaped our professional mores. The Classics of Medicineís reprint volume is a facsimile of the first edition published at Manchester in 1803. In the preface to the first American edition in 1927, Chauncey Leake took note of the "considerable interest in the moral problems of medical practice." He stated that economic pressures, a "floating population," and experiments in group practice, health insurance, and state medicine were altering the "close relationship which formerly existed between physicians and patients." Fifty years later in his preface to the second American edition, Leake listed a different set of problems: abortion, contraception, euthanasia, human experimentation, truth telling, the right to die, and pharmaceutical and genetic manipulations."

Percivalís now classic work owes its birth to a territorial dispute among physicians during the typhus and typhoid epidemic in the Manchester Infirmary in 1789. Percival was asked to draw up a scheme of professional conduct that might provide guidance for resolving the dispute. To be chosen by the two factions is evidence that Percival occupied a position of unusual trust among his colleagues. He completed the first chapter in 1792 which was printed privately under the heading "Medical Jurisprudence" and circulated to an impressive list of prominent personages, including physicians, clergymen and barristers. Percival was encouraged during the intervening decade by their responses and suggestions and completed the four chapters that now comprise his Medical Ethics.

The four chapters deal with the conduct of physicians I) in hospital practice, II) in private practice, III) in relation to apothecaries, and IV) in cases that may require a knowledge of law. Percival stated that his Medical Ethics "constitutes the code of laws, by which the practice of [the Manchester Infirmary] is now governed." Percivalís Medical Ethics soon became the foundation for medical ethics in the English-speaking world. It was introduced in America by Samuel Brown, the first medical professor of Transylvania University, and adopted in substantially unchanged form by the New York State Medical Society becoming the foundation of the first code of the AMA.

The relevance ethics of nearly two centuries ago can be overviewed with his topical lines: "Physicians & surgeons should not ... be restrained ... from prescribing wine and drugs even of high price when required in diseases of extraordinary malignity and danger... Consultations should be encouraged... Officious interference, in a case under the charge of another, should be carefully avoided... Patients should be interrogated concerning their complaints in a tone of voice which cannot be overheard. Secrecy, also, when required. . . should be strictly observed... Females should always be treated with the most scrupulous delicacy... To neglect their feelings is cruelty... A physician should not... make gloomy prognostications... magnifying the importance of his services... "

These rules of conduct, if implemented, would improve our profession and the practice of medicine which is under increasing attack.