Should doctors be held to higher moral standards than others?

By Daniel Sokol

In a highly publicised case, Dr Arora  – a general practitioner – was suspended for a month after the Medical Practitioners Tribunal deemed her dishonest for telling a medical colleague that she had been promised a laptop when no such promise had been made.  The Tribunal noted that Dr Arora’s exaggeration brought the medical profession into disrepute and that anything short of suspension would fail to promote and maintain proper standards of conduct for doctors.

As well as raising concerns about gender and racial bias – Dr Arora was a female, ethnic minority doctor – the case prompted many in the profession to wonder whether the moral standards expected of doctors were too high.  Should the medical profession be held to a loftier standard than ordinary people?

The irony is that these standards were not set by society but by doctors.

The term ‘medical ethics’ first emerged in the medical literature in Thomas Percival’s eponymous text, published in 1803Percival, an English doctor, wrote in the Dedication addressed to his son ‘the study of professional ethics…will soften your manners, expand your affections, and form you to that propriety and dignity of conduct, which are essential to the character of a gentleman.’  He instructed doctors to ‘cautiously guard against whatever may injure the general respectability of the profession’.

Al Jonsen, in his Short History of Medical Ethics, remarked that ‘the serious efforts of physicians such as …Percival to improve the manners and morals of the profession attest to the sorry state of the profession in their days.’  The vast majority of doctors did not enjoy high status and pay.  An old lady in Somerset Maugham’s Of Human Bondage, published in 1915, recounted how in her youth in the 1850s no gentleman’s son would consider a career in medicine.

The historian Edward Shorter in Bedside Manners wrote that, around the turn of the 20th century, when medicine became more scientific and it began to be harder to get into medical school, ‘the modern doctor began to think increasingly well of himself’.  Doctors sought to act like English gentlemen, joining prestigious clubs and becoming pillars of society.  Harley Street, in central London, housed 36 doctors in 1873.  By 1900, it was close to 150.  The social and economic status of all doctors rose dramatically in the course of the 20th century.  This brought with it some therapeutic benefits, particularly in improving the mental health of patients.  Shorter argued that ‘once medical men began imagining themselves to be socially a notch or two above everybody else, their ability to cure psychological disease increased correspondingly.’

In 1958, Stephen Hadfield, a surgeon and Assistant Secretary of the British Medical Association, wrote in Law and Ethics for Doctors:

‘They [doctors] should at all times so conduct themselves as to justify an implicit trust and respect on the part of their patients.  Such trust and respect will be vitiated by any doubtful or improper conduct outside the professional sphere as well as within.’

Doctors lamenting the high standards of conduct expected of them therefore have their predecessors to blame.  If here today, what would these august doctors say in their defence?

They would say that lowering the expectations of good conduct may save the skin of some doctors who would otherwise have been sanctioned or erased from the register, but that may in the fullness of time have knock-on effects on the medical profession and the health of patients.  They would offer arguments based on self-interest and altruism.

In terms of self-interest, they would point out that establishing and maintaining a high standard raised the status and income of the medical profession, reminding today’s doctors reaping the rewards of past generations that it was not always so.  It is possible, they might say, that lowering the standard may similarly reduce the social status of doctors and eventually their income.  If so, fewer bright young men and women would choose a career in medicine.

In terms of altruism, they would point to the greater trust, faith and respect that most patients have in a profession held to very high standards of conduct and how this is likely to raise the confidence of patients in doctors’ advice and improve their adherence to treatment.  Lowering the standards – an event which may attract considerable press attention – could reduce this all-important trust and respect, and damage the health of patients.

Finally, they might argue that the requirement for high standards of conduct forms part of the fabric of medical practice and that it is no coincidence that its origins can be traced back to Hippocrates and beyond.  It is based, they might say, on the profound trust held by patients and society that doctors be not only competent but of good character.  Without such trust, how can patients be satisfied that doctors will not take advantage of their vulnerability and the inequality of power.  The erosion of this image of the trustworthy and morally upstanding doctor, so long in the making, may damage the relationship between doctor and patient and between doctor and society.

Whatever the plausibility of these arguments and, in my opinion, the extreme harshness of Dr Arora’s sanction (which is under appeal at the time of writing), the medical profession must consider with care the consequential effects, good and bad, of any proposal to alter expected standards of conduct on both the profession itself and on the health of the public.

 

Author: Daniel Sokol

Affiliation: Barrister and Medical Ethicist, 12 King’s Bench Walk

Competing interests: None declared

Social media accounts:

Twitter – @DanielSokol9

Webpage – www.medicalethicist.net

 

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