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Medical Ethics |

A Brief Historical and Theoretical Perspective on Patient Autonomy and Medical Decision Making: Part I: The Beneficence Model FREE TO VIEW

Jonathan F. Will, JD
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From the Bioethics and Health Law Center, Mississippi College School of Law, Jackson, MS.

Correspondence to: Jonathan F. Will, JD, MA, Bioethics and Health Law Center, Mississippi College School of Law, 151 E Griffith St, Jackson, MS 39201; e-mail: will@mc.edu


For editorial comment see page 488

Editor's note: This essay addresses the first topic in the Law and Medicine curriculum of the ongoing “Medical Ethics” series. To view all articles from the core curriculum, visit http://chestjournal.chestpubs.org/cgi/collection/medethics.

Constantine A. Manthous, MD, FCCP, Section, Editor, Medical Ethics

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(3):669-673. doi:10.1378/chest.10-2532
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As part of a larger series addressing the intersection of law and medicine, this essay is the first of two introductory pieces. This article explores the nature of the physician-patient relationship and of the practice of medicine dating from the Hippocratic tradition to the end of the 19th century, a period during which a beneficence-based medical ethic remained relatively stable. The medical literature dating from the Hippocratic texts to the early codes of the American Medical Association did not include a meaningful role for the patient in the decision-making process. In fact, the practice of benevolent deception—the deliberate withholding of any information thought by the physician to be detrimental to the patient’s prognosis—was encouraged. However, as philosophers identified an inherent value in respecting patient self-determination and the law imposed a duty on physicians to obtain informed consent, 2,400 years of relative stability under the beneficence model gave way to the autonomy model.

The practice of medicine today looks very different than it did 2,500 years ago, though interestingly, there has been greater change in the last 100 years or so than in the previous 2,400. This essay is the initial contribution to a larger series addressing the intersection of law and medicine, particularly with regard to the dynamics of the physician-patient relationship and decision making in medicine. This essay briefly explores the nature of the physician-patient relationship and of the practice of medicine, dating from the Hippocratic tradition to the end of the 19th century, a period during which a beneficence-based medical ethic remained relatively stable. A second essay (to be published in an upcoming issue of CHEST) will address when and how the shift occurred to the autonomy model at the turn of the 20th century and will also attempt to give some insight into why the shift occurred and took hold with the rise of the bioethics movement. The history provided by these introductory pieces is necessarily brief. For a more detailed account, see A History and Theory of Informed Consent1 and The Social Transformation of American Medicine2 referenced herein.

The shift from the beneficence model (characterized by maximum physician discretion) to the autonomy model (emphasizing increased patient involvement) paved the way for a new approach to decision making in medicine governed legally by the informed consent doctrine. If a patient must provide informed consent prior to the commencement of treatment, it follows that the patient can refuse the recommended treatment. Perhaps nowhere is this shift more apparent than in treatment at the end of life, where the goal of maintaining life, implicit in the practice of medicine, may give way to the preservation of patient self-determination, a right that is philosophically valued and legally recognized.

Following the brief synopsis outlined in these two introductory essays, the subsequent pieces in this series will more directly take up the role the law has played in shaping advance directives, surrogate decision making, and notions of assisted death within the health-care system. But to have an appreciation for the present, we must have an understanding of the past.

The Hippocratic Tradition

The beneficence model can be traced back to the Hippocratic Oath or, more precisely, to the texts making up the Hippocratic tradition.3 For instance, the oath itself provides that physicians will “apply dietetic measures for the benefit of the sick according to [their] ability and judgment; [and to] keep [the sick] from harm and injustice.”4 While it establishes a core set of physician responsibilities, notably absent is any language speaking to a meaningful role for the patient in the decision-making process.

Rather, the oath speaks of a group of high-minded, male individuals with specialized training, determined to keep their practice internal to a select group. Once within the group, physicians promised to keep those who taught them the art “equal to my parents” and to hold their teacher’s offspring “equal to my brothers in male lineage.”4 They further promised to teach the art only to their sons and their teacher’s sons and to pupils “who have signed the covenant and taken an oath according to medical law.”4 The medical profession was at once a male-dominated, exclusive club offering a special service, and it was determined to set itself apart from the quacks and charlatans of the day.

The language of the oath creates the impression that physicians (unlike others) have a superior knowledge that makes them capable of diagnosing illness, which carries with it the responsibility to offer treatments for the benefit of the sick. Indeed, the beneficence model is premised on the notion not only that physicians in the practice of their trade should avoid causing harm (exemplified by the principle of nonmaleficence), but also that they should affirmatively attempt to prevent harm, remove harm, and promote good.1 In short, the Hippocratic tradition stands for the proposition that physicians have an ethical obligation to act, to the best of their judgment, for the medical benefit of their patients. Physicians had the responsibility, therefore, to conduct their behavior in such a way as to comply with this obligation.

Implicit in this traditional duty, however, was that physicians, and physicians alone, had the knowledge and skill necessary to know what would benefit their patients. Thus, physicians historically relied almost exclusively on their own judgments as to what was best for their patients. Hippocratic texts often portrayed physicians as the ones “who command and decide,” while patients “must place themselves fully in physicians’ hands and obey commands.”1 This practice, which equated overall benefit with medical benefit, emphasized the provision of treatments and general physician behavior that were thought to promote the medical interests of patients.

Ethics, Etiquette, and Authority

The physicians’ ancient duty to act for the benefit of their patients is supported by the ethical principle of beneficence and survives today. Beyond this, however, medical codes dating to antiquity read as much (and probably more) like manuals on etiquette than ethics.5 Early rules for physician behavior focused on appearance and dress as well as speech, mannerisms, and interprofessional conduct.1 The reason for this stems from the realities of medical practice during those times.

To act beneficently, the Hippocratic tradition taught physicians to exercise authority over obedient patients. However, as Princeton sociologist Paul Starr2 notes, “Authority, in its classical sense, signifies the possession of some status, quality, or claim that compels trust or obedience.” Given the nature of primitive treatments, physician authority and patient obedience were far from foregone conclusions. In times when the medical outcomes for the most well-respected blood-letter were likely not measurably better than those for the quack down the street, patient perception of physician behavior was of utmost importance. Because early physicians could not necessarily rely on competence and skill to legitimate their claims to authority, behavior and etiquette that cultivated a sense of respect and propriety were the keys to a physician gaining a positive reputation through which increased patient trust and obedience would follow.1

The importance of instilling patient trust and confidence led to the accepted and, indeed, encouraged practice of benevolent deception. A concept that today would accurately be labeled medical paternalism, benevolent deception was premised on the idea that any information that might adversely impact patient health should be withheld, even to the point of outright lying if necessary. Benevolent deception was consistent with the beneficence model under the theory that to the extent the truth would compromise the patient’s faith in the cure and, thus, the overall medical prognosis, the truth should not be revealed.1

Under this model, there was no room in the medical literature for discussion of informed decision making by patients. Instead the Corpus Hippocraticum advises of the “wisdom of ‘concealing most things from the patient, while you are attending to him . . . turning his attention away from what is being done to him; . . . revealing nothing of the patient’s future or present condition.’”1 This ethic had not changed during the medieval period, when Henri de Mondeville, consistent with the Hippocratic tradition, advised his colleagues, “‘[P]romise a cure to every patient, but . . . tell the parents or the friends if there is any danger,’” and, “The surgeon must not be afraid to lie if this benefits the patient.”1

With little modification, the Hippocratic tradition and its ideal of the authoritative physician and the obedient patient carried through to the 18th century and the Enlightenment. The evidence of such historical physician behavior can be gleaned from the directives set forth in the contemporary medical codes, from early medical journals and correspondence between physicians, and also from what limited records physicians traditionally kept and passed through the ages.1 The longevity and stability of the Hippocratic tradition were due in no small part to the fact that writings on medical ethics were monopolized by those practicing the profession and not philosophers, theologians, lawyers, and the like.5

While it is true that some physicians were also members of the clergy and that many were well-read in the popular philosophers of their time, their writings in medical ethics came almost exclusively from a secular perspective. During the Enlightenment then, physicians did not bring about a wholesale change within the ethics of medicine, but their interest in human reason and progress did lend itself to a new discussion about the importance of such things as truth telling within the physician-patient relationship.1

Benevolent Deception and the Ethics of the Enlightenment

During the Enlightenment, certain physicians wrote extensively on the nature of physicians’ duty to patients. Perhaps most notable of these were Benjamin Rush, an American Revolutionary who received much of his medical training in Europe, and John Gregory, a well-known physician from Scotland and an educator of Rush. Influenced by such philosophers as Francis Bacon, René Descartes, and John Locke, Gregory and Rush advocated truthfulness and disclosure to patients.1 Interestingly, such duties were still attributable to and did not suggest a departure from the beneficence model.

As an important figure in the American Revolution, Rush agreed with the philosophical notion that freedom and independence were part of good health. He believed that increasing patient understanding would lead to improved medical outcomes, and he warned of the dangers attendant to blind adherence to the Hippocratic tradition and its emphasis on physician authority and deception. To be clear, however, even Rush did not speak in terms of respecting patient decision making. He specifically acknowledged the importance of physicians maintaining an “‘inflexible authority over [patients] in matters that are essential to life,’” and he noted that a patient should “‘never oppose his own inclinations nor judgment to the advice of his physician,’” and importantly, Rush conceded that deception was necessary, especially for the unenlightened patient.1

Consistent with the beneficence model, therefore, Rush advocated truth telling and disclosure, but really only insofar as he believed that rational patients would be enlightened by such information. He presumed that these enlightened patients would appreciate the wisdom of their physicians and graciously comply with the physician orders. It was this ability to share in the physician’s wisdom that was thought to contribute to overall medical prognosis and thus to be beneficial.

Among the ranks of physicians, Rush and Gregory, with their emphasis on truth telling, were likely ahead of their time, and their views did not garner wide support. Rush was perhaps too much of an American Revolutionary for the likes of European physicians, and so it was another of Gregory’s students, the British physician Thomas Percival,6 whose writings in medical ethics would carry the beneficence model into the modern age. Percival’s magnum opus, Medical Ethics,7 was published in 1803 and was consistent with the Hippocratic tradition in its admonition that physician action and etiquette be directed to promote patients’ best medical interests.1

Similar to earlier rhetoric on physician behavior, Percival focused as much on medical etiquette as ethics, emphasizing gentlemen-like conduct and offering suggestions regarding fees, consultation, and interprofessional relations (including notions of physician seniority for dispute resolution). Also, like earlier writings, Percival makes no real mention of seeking consent from patients or of any duty to respect patient decision making.1 Indeed, Percival was a major proponent of benevolent deception. He acknowledged the virtue of physicians being truthful to patients, but between veracity and the physician’s duty to act beneficently, beneficence clearly trumped. Percival went as far as to suggest that a physician “does not actually lie in acts of deception and falsehood, as long as the objective is to give hope to the dejected or sick patient.” Above all for Percival, the role of physician is to “‘be the minister of hope and comfort.’”1

Whereas Rush embraced the Enlightenment views on human reason and rationality in his writings on truth telling and disclosure within the physician-patient relationship, Percival seemed to distance himself from those precepts. Percival questioned patients’ capacity for such reason and rationality, given their dependence on physicians and the physicians’ superior knowledge as to what information would be detrimental to the patients’ health. Although Percival struggled with what the appearance of lying would mean to the profession (it not being gentlemen-like), he was not convinced by claims that truth telling itself promoted health and, therefore, had no trouble justifying benevolent deception. Rush and Percival were contemporaries, and at the time, Percival’s views as to the empirical value of truth telling triumphed. This dispute would, of course, see resurgence in 20th-century America.

The United States: Physician Status and a Little Bit of History Repeating

Percivallian principles, with their continuation of Hippocratic notions of the authoritarian physician and the obedient patient, were roundly accepted by early-American physicians. The first codes adopted by the American Medical Association (AMA) were largely based on Percival’s model, with many passages taken verbatim.1 In fact, the Percivallian language would remain in the AMA codes until amendments were adopted in 1980 in response to changes brought about by the bioethics movement. That said, while American physicians readily championed Percival’s approach to medical practice, early-American patients were not so easily convinced of physician claims of status and authority, and the profession struggled to gain legitimacy.

As a British physician, Percival had the benefit of operating within a system in which many physicians had attained a level of status supported by over 2,000 years of tradition and the development of formalized education. Though not members of the aristocracy themselves, elite European physicians had attained a level of privileged status by the 18th century through the treatment of and association with aristocratic patients.2 American physicians training in Europe got a taste for this status and hoped to bring it back to the United States.

At the risk of over-simplification, perhaps the three largest stumbling blocks faced by early-American physicians claiming such status were their arsenal of treatments with questionable efficacy, the general ideology upon which the United States was founded, and the lack of unification and formalized education.2 Prior to the 19th century, medical treatments had not progressed all that much. Early-American physicians, much like their ancient predecessors, could not rely on skill and competency to justify their claims of authority and status. Therefore, they focused on cultivating an image of respectability and propriety, when in fact they often had little to no education or formal training at all.2 This reliance on gentlemanly behavior had proven effective in establishing legitimacy for European physicians; however, it did not work as well in America.

The philosophers, notably John Locke, who influenced Rush’s writing (and his emphasis on truth telling and disclosure) also provided the foundation for the general American ideology of the time. The emphasis on liberty, individualism, and self-sufficiency encouraged the lay populace to be skeptical of any group making self-interested claims of status and authority, particularly when there appeared to be no legitimate basis for such claims. Indeed, in its extreme forms, the physician practice of benevolent deception would include withholding information about the physician’s lack of qualification for fear that it would compromise the patient’s faith in the cure.

It was this foundational American ideology that would end up solidifying the autonomy model in the middle of the 20th century; though even by the end of the 18th century, the domestic medicine movement8 decried the need for physicians to treat most illnesses and offered medical manuals to lay people, suggesting that “every thing valuable in the practical part of medicine is within the reach of common sense.”2 As a result, early-American physicians who had adopted the Percivallian ethic and who longed to attain the level of legitimacy achieved by their European counterparts struggled in the face of an American populace skeptical of unsubstantiated claims to authority.

A turning point came in France early in the 19th century, when physicians, through empirical investigation, determined that many of the accepted medical treatments of the time had limited to no therapeutic value. With this revelation, however, came an increased emphasis on disease prevention and on developing alternative treatments with scientifically measurable efficacy. The reliance on science effectively changed the nature of the medical profession, with scientific and technologic advances leading to greater complexity and the acknowledgment that the practice of medicine was beyond the skill of lay people.2 As such, Locke’s ideology, with its emphasis on self-sufficiency for Americans as individuals, seemed less tenable for Americans as patients.

The increasing complexity also demanded that medical education and the profession itself become more formalized and unified. Hearkening back to the Hippocratic tradition, the AMA, which was established around 1846, identified as one of its primary objectives “to bear emphatic testimony against quackery in all its forms.”1 Soon, American medical education became standardized. While the first medical schools were opened in Philadelphia and Boston during the latter half of the 18th century, by the end of the 19th century there were over 130 medical schools, and 96% of them required three or more years of training.2 Beyond formalized education, individual states imposed their own licensing requirements on physicians. Thus, the American physician, licensed by the state and holding a reputable medical degree, could now legitimize his claim to authority. Because of this, toward the end of the 19th century, even American patients, with their liberal-individualistic ideals, were willing to submit to the authority of, and be obedient to, their trusted physicians.5 At that point, American physicians attained the status that seemed to be promised by Percivallian ethics and that was essential to the survival of the beneficence model.

Conclusion: Consent vs Informed Consent

The principles of the Hippocratic tradition, as modernized by Percival, had survived remarkably unscathed for over two millennia, and throughout, the physician-patient relationship was marked by the authoritative physician and the trusting, obedient patient. While early claims to such authority were founded upon questionable legitimacy, physicians were consistent in maintaining an ethical duty to act to the best of their judgment for the medical benefit of their patients. By the end of the 19th century, medicine had become sufficiently complex to permit even American patients with their liberal ideals to accept their role of obedience.

The prevailing medical literature, which supported the beneficence model and its emphasis on promoting medical benefits to be determined unilaterally by physicians using their specialized training, did not include a meaningful role for the patient in the decision-making process.9,10 That said, it should not be implied that physicians never obtained patient consent, because of course they did. However, to the extent that consent was obtained, it had little if anything to do with respecting patient decision making. Rather, consent seeking had more to do with practical concerns relating to the necessity of patient cooperation with a given procedure or maintaining the reputation of the given physician or the medical profession generally.1

Further, to the extent information was disclosed to patients, it was not done in connection with any recognizable purpose of respecting patient autonomy as an end in itself. Rather, information would be disclosed if such disclosure was thought to contribute to the overall medical benefit of the patient, consistent with the beneficence model.

The golden age of medicine in the United States existed under the umbrella of the beneficence model, but it would be short lived. The next essay in this series will pick up with the changes occurring around the turn of the 20th century and continuing through the bioethics movement that would call into question patient trust of and obedience to physicians. As philosophers identified an inherent value in respecting patient self-determination and the law imposed a duty on physicians to obtain informed consent, 2,400 years of relative stability under the beneficence model gave way to the autonomy model.

Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: Special thanks to Dr Constantine Manthous for organizing this series of articles and to Professor Kathy Cerminara for her guidance. Thanks also to Mississippi College School of Law for the continued support.

Faden RR, Beauchamp TL. A History and Theory of Informed Consent. 1986; New York, NY Oxford University Press:53-113
 
Starr P. The Social Transformation of American Medicine. 1982; New York, NY Basic Books:33-115
 
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 2009;6th ed. New York, NY Oxford University Press:149
 
Edelstein L. The Hippocratic Oath: Text, Translation, and Interpretation. 1943; Baltimore, MD The Johns Hopkins University Press
 
Rothman DJ. Strangers at the Bedside. 1991; New York, NY Aldine Transactions:102-103
 
Leake CD. Percival’s Medical Ethics. 1975; Huntington, NY Robert E. Krieger Publishing Company:1-229
 
Percival T. Medical Ethics; or a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons. 1803; Manchester, England S. Russel
 
Buchan W. Domestic Medicine, or the Family Physician. 1791;2nd ed Philadelphia, PA John Dunlop
 
Katz J. The Silent World of Doctor and Patient. 1984; New York, NY Free Press, Macmillan Inc
 
Pernick MS. The Patient’s Role in Medical Decisionmaking: A Social History of Informed Consent in Medical Therapy, Included in the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. 1982;Vol 3 Washington, DC US Government Printing Office:3
 

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Tables

References

Faden RR, Beauchamp TL. A History and Theory of Informed Consent. 1986; New York, NY Oxford University Press:53-113
 
Starr P. The Social Transformation of American Medicine. 1982; New York, NY Basic Books:33-115
 
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 2009;6th ed. New York, NY Oxford University Press:149
 
Edelstein L. The Hippocratic Oath: Text, Translation, and Interpretation. 1943; Baltimore, MD The Johns Hopkins University Press
 
Rothman DJ. Strangers at the Bedside. 1991; New York, NY Aldine Transactions:102-103
 
Leake CD. Percival’s Medical Ethics. 1975; Huntington, NY Robert E. Krieger Publishing Company:1-229
 
Percival T. Medical Ethics; or a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons. 1803; Manchester, England S. Russel
 
Buchan W. Domestic Medicine, or the Family Physician. 1791;2nd ed Philadelphia, PA John Dunlop
 
Katz J. The Silent World of Doctor and Patient. 1984; New York, NY Free Press, Macmillan Inc
 
Pernick MS. The Patient’s Role in Medical Decisionmaking: A Social History of Informed Consent in Medical Therapy, Included in the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. 1982;Vol 3 Washington, DC US Government Printing Office:3
 
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