IX.

American Medical Association, Principles of Medical Ethics, 1903

Preface

At the annual meeting of the American Medical Association, held in New Orleans, the

House of Delegates unanimously adopted, on May 7, 1903, the “Principles of Medical

Ethics” recommended by its committee, and ordered that the following extract from the

report of the Special Committee on Revision of the Code of Medical Ethics be printed as

an explanatory preface to these “Principles”:

“The caption ‘Principles of Medical Ethics’ has been substituted for ‘Code of

Medical Ethics.’ Inasmuch as the American Medical Association may be conceived to

hold a relation to the constituent state associations analogous to that of the united States

through its constitution to the several states, the committee deemed it wiser to formulate

the principles of medical ethics without definite reference to code or penalties. Large

discretionary powers are thus left to the respective state and territorial societies to form

such codes and establish such rules for the professional conduct of their members as they

may consider proper, provided, of course, that there shall be no infringement of the

established ethical principles of this Association.”

The American Medical Association promulgates as a suggestive and advisory

document the following:

Chapter I. The Duties of Physicians to Their Patients

The Physician’s Responsibility

Section 1. Physicians should not only be ever ready to obey the calls of the sick

and the injured, but should be mindful of the high character of their mission and of the

responsibilities they must incur in the discharge of momentous duties. In their

entrusted to their care depend on skill, attention and fidelity. In deportment they should

unite tenderness, cheerfulness and firmness, and thus inspire all sufferers with gratitude,

respect and confidence. These observations are the more sacred because, generally, the

only tribunal to adjudge penalties for unkindness, carelessness or neglect is their own

conscience.

Humanity, Delicacy, and Secrecy Needed

Sec. 2. Every patient committed to the charge of a physician, should be treated

with attention and humanity, and reasonable indulgence should be granted to the caprices

of the sick. Secrecy and delicacy should be strictly observed; and the familiar and

confidential intercourse to which physicians are admitted, in their professional visits,

should be guarded with the most scrupulous fidelity and honor.

Secrecy to Be Inviolate

Sec. 3. The obligation of secrecy extends beyond the period of professional

services; none of the privacies of individual or domestic life, no infirmity of disposition

or flaw of character observed during medical attendance, should ever be divulged by

physicians, except when imperatively required by the laws of the state. The force of the

obligation of secrecy is so great that physicians have been protected in its observance by

courts of justice.

Frequency of Visits

Sec. 4. Frequent visits to the sick are often requisite, since they enable the

physician to arrive at a more perfect knowledge of the disease, and to meet promptly

every change which may occur. Unnecessary visits are to be avoided, as they give undue
anxiety to the patient; but to secure the patient against irritating suspense and

disappointment the regular and periodical visits of the physician should be made as

nearly as possible at the hour when they may be reasonably expected by the patient.

Honesty and Wisdom in Prognosis

Sec. 5. Ordinarily, the physician should not be forward to make gloomy

prognostications, but should not fail, on proper occasions, to give timely notice of

dangerous manifestations to the friends of the patient; and even to the patient, if

absolutely necessary. This notice, however, is at times so peculiarly alarming when

given by the physician, that its deliverance many often be preferably assigned to another

person of good judgment.

Encouragement of Patients

Sec. 6. The physician should be a minister of hope and comfort to the sick since

life may be lengthened or shortened not only by the acts, but by the words or manner of

the physician, whose solemn duty is to avoid all utterances and actions having a tendency

to discourage and depress the patient.

Incurable Cases Not to be Neglected

Sec. 7. The medical attendant ought not to abandon a patient because deemed

incurable; for continued attention may be highly useful to the sufferer and comforting to

the relatives, even in the last period of the fatal malady, by alleviating pain and by

soothing mental anguish.

Judicious Counsel to Patients

Sec. 8. The opportunity which a physician has of promoting and strengthening the

good resolutions of patients suffering under the consequences of evil conduct ought never
to be neglected. Good counsels, or even remonstrances, will give satisfaction, not

offense, if they be tactfully proffered and evince a genuine love of virtue, accompanied

by a sincere interest in the welfare of the person to whom they are addressed.

Chapter II. The Duties of Physicians to Each Other and to the Profession at Large

Article I. –Duties for the Support of Professional Character

Obligation to Maintain the Honor of the Profession

Section 1. Everyone on entering the profession, and thereby becoming entitled to

full professional fellowship, incurs an obligation to uphold its dignity and honor, to exalt

its standing and to extend the bounds of its usefulness. It is inconsistent with the

principles of medical science and it is incompatible for physicians to designate their

practice as based on an exclusive dogma or sectarian system of medicine.

Observation of Professional Rules

Sec. 2. The physicians should observe strictly such laws as are instituted for the

government of the members of the profession; should honor the fraternity as a body;

should endeavor to promote the science and art of medicine, and should entertain a due

respect for those seniors who, by their labors, have contributed to its advancement.

Duty to Join Medical Organization

Sec. 3. Every physician should identify himself with the organized body of his

profession as represented in the community in which he resides. The organization of local

or county medical societies, where they do not exist, should be effected, so far as

practicable. Such county societies, constituting as they do the chief element of strength in

the organization of the profession, should have the active support of their members and

should be made instruments for the cultivation of fellowship, for the exchange of
professional experience, for the advancement of medical knowledge, for the maintenance

of ethical standards, and for the promotion in general of the interests of the profession

and the welfare of the public.

County Societies to Affiliate with Higher Organizations

Sec. 4. All county medical societies thus organized ought to place themselves in

affiliation with their respective state association, and these, in turn, with the American

Medical Association.

Purity of Character and Morality Required

Sec. 5. There is no profession from the members of which greater purity of

character and a higher standard of moral excellence are required than the medical; and to

attain such eminence is a duty every physicians owes alike to the profession and to

patients. It is due to the patients, as without it their respect and confidence can not be

commanded; and to the profession, because no scientific attainments can compensate for

the want of correct moral principles.

Temperance in All Things

Sec. 6. It is incumbent on physicians to be temperate in all things, for the practice

of medicine requires the unremitting exercise of a clear and vigorous understanding; and

in emergencies – for which no physicians should be unprepared – a steady hand, an acute

eye, and an unclouded mind are essential to the welfare and even to the life of a human

being.

Advertising Methods to Be Avoided

Sec. 7. It is incompatible with honorable standing in the profession to resort to

public advertisement or private cards inviting the attention of persons affected with
particular diseases; to promise radical cures; to publish cases or operations in the daily

prints, or to suffer such publication to be made; to invite laymen (other than relatives who

may desire to be at hand) to be present at operations; to boast of cures and remedies; to

adduce certificates of skill and success, or to employ any of the other methods of

charlatans.

Patients and Secret Nostrums

Sec. 8. It is equally derogatory to professional character for physicians to hold

patients for any surgical instruments or medicines; to accept rebates on prescriptions or

surgical appliances; to assist unqualified persons to evade legal restrictions governing the

practice of medicine; or to dispense, or promote the use of, secret medicines, for if such

nostrums are of real efficacy, any concealment regarding them is inconsistent with

beneficence and professional liberality, and if mystery alone give the public notoriety,

such craft implies either disgraceful ignorance or fraudulent avarice. It is highly

reprehensible for physicians to give certificates attesting the efficacy of secret medicines,

or other substances used therapeutically.

Article II. –Professional Services of Physicians to Each Other

Physicians Dependent on Each Other

Section 1. Physicians should not, as a general rule, undertake the treatment of

themselves, nor of members of their family. In such circumstances they are peculiarly

dependent on each other; therefore, kind offices and professional aid should always be

cheerfully and gratuitously afforded. These visits should not, however, be obtrusively

made; as they may give rise to embarrassment or interfere with that free choice on which

such confidence depends.

Sec. 2. All practicing physicians and their immediate family dependents are

entitled to the gratuitous services of any one or more of the physicians residing near

them.

Compensation for Expenses

Sec. 3. When a physician is summoned from a distance to the bedside of a

colleague in easy financial circumstances, a compensation, proportionate to traveling

expenses and to the pecuniary loss entailed by absence from the accustomed field of

labor, should be made by the patient of relatives.

One Physicians to Take Charge

Sec. 4. When more than one physicians is attending another, one of the number

should take charge of the case, otherwise the concert of thought and action so essential to

wise treatment can not be assured.

Attention to Absent Physician’s Patients

Sec. 5. The affairs of life, the pursuit of health, and the various accidents and

contingencies to which a physician is peculiarly exposed, sometimes require the

temporary withdrawal of this physician from daily professional labor and the

appointment of a colleague to act for a specified time. The colleague’s compliance is an

act of courtesy which should always be performed with the utmost consideration for the

interest and character of the family physician.

Article III. –The Duties of Physicians in Regard to Consultations

Section 1. The broadest dictates of humanity should be obeyed by physicians

whenever and wherever their services are needed to meet the emergencies of disease or

accident.

Consultations Should Be Promoted

Sec. 2. Consultations should be promoted in difficult cases, as they contribute to

confidence and more enlarged views of practice.

Punctuality in Consultations

Sec. 3. The utmost punctuality should be observed in the visits of physicians whey

they are to hold consultations, and this is generally practicable, for society has been so

considerate as to allow the plea for a professional engagement to take precedence over all

others.

Necessary Delays

Sec. 4. As professional engagement may sometimes cause delay in attendance, the

physician who first arrives should wait for a reasonable time, after which the consultation

should be considered as postponed to a new appointment.

Good feeling and Candor in Consultations

Sec. 5. In consultations no insincerity, rivalry or envy should be indulged; candor,

probity and all due respect should be observed toward the physician in charge of the case.

Unauthorized Statements of Discussions

Sec. 6. No statement or discussion of the case should take place before the patient

or friends, except in the presence of all the physicians attending, or by their common
consent; and no opinions or prognostications should be delivered which are not the result

of previous deliberation and concurrence.

Attending Physicians May Vary Treatment

Sec. 7. No decisions should restrain the attending physicians from making such

subsequent variations in the mode of treatment as any unexpected change in the character

of the case may demand. But at the next consultation reasons for the variations should be

stated. The same privilege, with its obligation, belongs to the consultant when sent for in

an emergency during the absence of the family physician.

Attending Physicians to Prescribe

Sec. 8. The attending physician, at any time, may prescribe for the patient; not so

the consultant, when alone, except in a case of emergency or when called from a

considerable distance. In the first instance the consultant should do what is needed, and in

the second should do no more than make an examination of the patient and leave a

written opinion, under seal, to be delivered to the attending physician.

Discussions in Consultation Confidential

Sec. 9. All discussions in consultation should be held as confidential. Neither by

words nor by manner should any of the participants in a consultation assert or intimate

that any part of the treatment pursued did not receive his assent.

Conflicts of Opinion

Sec. 10. It may happen that two physicians can not agree in their views of the

nature of a case and of the treatment to be pursued. In the event of such disagreement, a

third physician should, if practicable, be called in. None but the rarest and most
exceptional circumstances would justify the consultant in taking charge of the case. He

should not do so merely on the solicitation of the patient or friends.

Consultant to Scrupulously Regard Rights of Attending Physician

Sec. 11. A physician who is called in consultation should observe the most

honorable and scrupulous regard for the character and standing of the attending

physician, whose conduct of the case should be justified, as far as can be, consistently

with a conscientious regard for truth, and no hint or insinuation should be thrown out

which would impair the confidence reposed in the attending physician.

Article IV. –Duties of Physicians in Cases of Interference

Qualifications the Only Basis of Practice

Section 1. Medicine being a liberal profession, those admitted to its ranks should

found their expectations of practice especially on the character and extent of their

medical education.

Intercourse with Patients of Other Physicians

Sec. 2. The physician, in his intercourse with a patient under the care of another

physician, should observe the strictest caution and reserve; should give no disingenuous

hints relative to the nature and treatment of the patient’s disorder, nor should the course

of conduct of the physician, directly or indirectly, tend to diminish the trust reposed in the

attending physician.

Circumspection as Regards Visits

Sec. 3. The same circumspection should be observed when, from motives of

business or friendship, a physician is prompted to visit a person who is under the

direction of another physician. Indeed, such visits should be avoided, except under
peculiar circumstances; and when they are made, no inquiries should be instituted relative

to the nature of the disease, or the remedies employed, but the topics of conversation

should be as foreign to the case as circumstances will admit.

Duty as to Calls to patients of Other Physicians

Sec. 4. A physician ought not to take charge of, or prescribe for, a patient who has

recently been under the care of another physician, in the same illness, except in case of a

sudden emergency, or in consultation with the physician previously in attendance, or

when that physician has relinquished the case of has been dismissed in due form.

Criticisms to Be Avoided

Sec. 5. The physician acting in conformity with the preceding section should not

make damaging insinuations regarding the practice adopted, and, indeed, should justify it

if consistent with truth and probity; for it often happens that patients become dissatisfied

when they are not immediately relieved, and, as many diseases are naturally protracted,

the seeming want of success, in the first stage of treatment, affords no evidence of a lack

of professional knowledge of skill.

Emergency Cases

Sec. 6. When a physician is called to an urgent case, because the family attendant

is not at hand, unless assistance in consultation is desired, the former should resign the

care of the patient immediately on the arrival of the family physician.

Duty When Called with Other Physicians

Sec. 7. It often happens, in cases of sudden illnesses, and of accidents and injuries,

owing to the alarm and anxiety of friends, that several physicians are simultaneously

summoned. Under these circumstances, courtesy should assign the patient to the first who
arrives, and who, if necessary, may invoke the air of some of those present. In such case,

however, the acting physician should request that the family physician be called, and

should withdraw unless requested to continue in attendance.

Cases to Be Relinquished to Regular Attendant

Sec. 8. When a physician is called to the patient of another physician during the

enforced absence of that physician the case should be relinquished on the return of the

latter.

Emergency Attention and Advice

Sec. 9. A physician, while visiting a sick person in the country, may be asked to

see another physician’s patient because of a sudden aggravation of the disease. On such

an occasion, the immediate needs of the patient should be attended to and the case

relinquished on the arrival of the attending physician.

Substitute Obstetric Work

Sec. 10. When a physician who has been engaged to attend an obstetric case is

absent and another is sent for, delivery being accomplished during the vicarious

attendance, the acting physician is entitled to the professional fee, but must resign the

patient on the arrival of the physician first engaged.

Article V. –Differences between Physicians

Arbitration of Differences

Section 1. Diversity of opinion and opposition of interest may, in the medical as in

other professions, sometimes occasion controversy and even contention. Whenever such

unfortunate cases occur and can not be immediately adjusted, they should be referred to

the arbitration of a sufficient number of impartial physicians.

Sec. 2. A peculiar reserve must be maintained by physicians toward the public in

regards to some professional questions, and as there exist many point in medical ethics

and etiquette through which the feelings of physicians may be painfully assailed in their

intercourse, and which can not be understood or appreciated by general society, neither

the subject-matter of their differences nor the adjudication of the arbitration should be

made public.

Article VI. –Compensation

The Limits of Gratuitous Service

Section 1. By the members of no profession are eleemosynary services more

liberally dispensed than by the medical, but justice requires that some limits should be

placed to the performance. Poverty, mutual professional obligations, and certain of the

public duties named in Sections 1 and 2 of Chapter III, should always be recognized as

presenting valid claims for gratuitous services; but neither institutions endowed by the

public or the rich, or by societies for mutual benefit, for life insurance, or for analogous

purposes, nor any profession occupation, can be admitted to possess such privilege.

Certifying or Testifying to Be Paid For

Sec. 2. It can not be justly expected of physicians to furnish certificates of

inability to serve on juries, or to perform militia duty; to testify to the state of health of

persons wishing to insure their lives, obtain pensions, or the like, without due

compensation. But to persons in indigent circumstances such services should always be

cheerfully and freely accorded.

Sec. 3. Some general rules should be adopted by the physicians in every town or

district relative to the minimum pecuniary acknowledgment from their patients; and it

should be deemed a point of honor to adhere to these rules with as much uniformity as

varying circumstances will admit.

Giving or Receiving of Commissions Condemned

Sec. 4. It is derogatory to professional character for physicians to pay or offer to

pay commissions to any person whatsoever who may recommend to them patients

requiring general or special treatment or surgical operations. It is equally derogatory to

professional character for physicians to solicit or to receive such commissions.

Chapter III. The Duties of the Profession to the Public

Duties as to Public Hygiene, etc.

Section 1. As good citizens it is the duty of physicians to be very vigilant for the

welfare of the community, and to bear their part in sustaining its laws, institutions and

burdens; especially should they be ready to cooperate with the proper authorities in the

administration and the observance of sanitary laws and regulations, and they should also

be ever ready to give counsel to the public in relations to subjects especially appertaining

to their profession, as on questions of sanitary police, public hygiene and legal medicine.

Enlightenment of Public on Sanitary Matter. Duties in Epidemics

Sec. 2. It is the province of physicians to enlighten the public in regard to

quarantine regulations; to the location, arrangement and dietaries of hospitals, asylums,

schools, prisons and similar institutions; in regard to measures for the prevention of
epidemic and contagious diseases; and when pestilence prevails, it is their duty to face

the danger, and to continue their labors for the alleviation of the suffering people, even at

the risk of their own lives.

Physicians as Witnesses

Sec. 3. Physicians, when called on by legally constituted authorities, should

always be ready to enlighten inquests and courts of justice on subjects strictly medical,

such as involve questions relating to sanity, legitimacy, murder by poison or other violent

means, and various other subjects embraces in the science of medical jurisprudence. It is

but just, however, for them to expect due compensation for their services.

Enlightenment of the Public as to Charlatans

Sec. 4. It is the duty of physicians who are frequent witnesses of the great wrongs

committed by charlatans and of the injury to health and even destruction of life caused by

the use of their treatment, to enlighten the public on these subjects and to make known

the injuries sustained by the unwary from the devices and pretensions of artful impostors.

Relations to Pharmacists

Sec. 5. It is the duty of physicians to recognize and y legitimate patronage to

promote the profession of pharmacy, on the skill and proficiency of which depends the

reliability of remedies, but any pharmacist who, although educated in his own profession,

is not a qualified physician, and who assumed to prescribe for the such, ought not to

receive such countenance and support. Any druggist or pharmacist who dispenses

deteriorated or sophisticated drugs or who substituted one remedy for another designated

in a prescription ought thereby to forfeit the recognition and influence of physicians.