A Brief Introduction to the History of Clinical Ethics

Abstract

This brief introductory history traces the origins of Western clinical ethics from the Hippocratic Oath to the professionalization of clinical ethics consultation (CEC) in the 1970s. Modern CEC began in the early nineteenth century when English physician Thomas Percival’s developed professional rules for CEC in the newly emergent institution of the charity hospital to defuse intra-practitioner conflict and protect patients from abuse. In 1847 the American Medical Association (AMA) Americanized Percival’s ethics as a contractarian code of ethics that reconfigured Percival’s rules for consultation and patient protection in the context of a benignly paternalistic science-based medicine. As the AMA envisioned the clinical encounter, scientifically trained doctors would decide what was best for patients; and patients, in return, would obey doctors’ orders. This set the model for American clinical ethics until the 1970s when newly enacted civil rights, Medicaid, and Medicare laws entitled African Americans, the elderly, the poor, and women to move from charity, Negro, and women’s hospitals and wards into integrated ones. In this context the clinical ethics of science-based benign medical paternalism proved unable to respond to patients’ demands, or to challenges posed by emerging morally disruptive technologies (e.g., ventilators). A bioethical model of a multidisciplinary therapeutic partnership between clinician teams and patients’ autonomy-based rights emerged in response.

Although retaining traditional medical ethical ideals of beneficence and justice, bioethical CEC also stressed patient autonomy. Eventually bioethicists formed professional societies which developed codes of ethics for CEC, and the AMA and other professional societies revised their codes of ethics to accommodate bioethical ideas.