MEDICAL 
ETHICS AND ETIQUETTE. 
THE CODE OF ETHICS ADOPTED BY THE 
AMERICAN MEDICAL ASSOCIATION, 
WITH COMMENTARIES 
BY 
AUSTIN FLINT, M. D. 
D. APPLETON AND COMPANY, 
NEWYORK: 
1, 8, AND 5 BOND STREET. 
1883. D. APPLETON AND COMPANY, 
COPYRIGHT BY 
1883. PREFACE. 
By the publication of the Code of Medical Ethics 
with brief commentaries, the writer of the latter car- 
ries out an intention formed many years ago. The 
publication at the present time, although perhaps ap- 
propriate on account of recent occurrences, is due 
to the fact that hitherto pressing engagements have 
led to its postponement. The writer had intended 
that the commentaries should appear without his 
name, thinking that to take upon himself the office 
of a commentator might be regarded as an immodest 
assumption. In not carrying out this intention he 
has yielded to the judgment of others. lie ventures 
to hope that the volume may be of use by inciting 
physicians to uphold the code, and also by con- 
tributing in some measure to diffuse a popular knowl- 
edge of it. MEDICAL ETHICS AND ETIQUETTE. 
INTRODUCTORY REMARKS. 
The objects of this volume are to present to the reader 
our National Code of Medical Ethics—in other words, the 
code adopted by the American Medical Association, as also 
by the State and local societies throughout our country—to 
submit in connection therewith brief commentaries; and to 
state certain rules of professional etiquette. 
A reader who has given to the subject little or no atten- 
tion may be supposed to ask, “ Wherefore the propriety 
of recognizing the principles of duty applied to medicine 
as constituting a distinct branch of ethical science ? ” “ Are 
not the rules in ethics which would govern the practition- 
er of medicine the same as in other applications ? ” There 
are certain fundamental truths which, of course, underlie 
all possible applications of ethics; but the adaptation to 
different conditions of human life call for separate con- 
sideration. Political ethics and social ethics are recog- 
nized different branches of ethical science. Ethics as ap- 
plied to the medical profession involves adaptations which 
require to be considered apart from the science as a 
whole. In various points of view, the practice of medicine, 2 
MEDICAL ETHICS AND ETIQUETTE. 
when contrasted with other pursuits, is peculiar. The 
medical practitioner does not deal with facts and laws hav- 
ing the exactness of those pertaining to physics. In em- 
ploying means for certain ends, he can not calculate results 
with mathematical precision. The problems of disease em- 
brace many aud varying elements, which can not always be 
estimated with absolute certainty. They offer a wide scope 
for the exercise of judgment in the practical applications of 
medical knowledge. It is by no means easy in all cases for 
the practitioner himself to judge correctly of the results of 
his practice ; and, for those who are not versed in the study 
of disease, this is an impossibility; hence, he is often 
blamed undeservedly, and as often, perhaps, he receives 
praise not strictly his clue. People can not form a true 
judgment of the merits of a physician by the character of 
his work, as can be done with reference to mechanical call- 
ings, and even the sister professions of law and theology. 
The choice of a family doctor is in many instances deter- 
mined by other circumstances than those which pertain to 
scientific knowledge or skill, and, as a rule, the relations be- 
tween the physician and his patients are not purely profes- 
sional, but involve the ties of friendship, and often affection. 
In no other profession or calling are extrinsic means availa- 
ble for competition to the same extent as in the practice of 
medicine, and in no other pursuit are the opportunities so 
great for ungenerous or unscrupulous advantages. Under 
these circumstances it is not to be wondered at that physi- 
cians are peculiarly sensitive respecting their professional 
relations and rival practitioners. 
Peculiar responsibilities pertain to the practice of medi- 
cine, aside from those involved in the treatment of cases of 
disease. In the exercise of his profession, the physician 
becomes intimately acquainted with the private character 
of his patients. Weaknesses, faults, vices, can not be con- INTRODUCTORY REMARKS. 
3 
cealed, if not confessed. He can not escape, if he would, 
knowledge of family secrets. He is exposed to peculiar 
temptations. Other responsibilities relate to the honor and 
purity of the profession, the promotion of medical knowl" 
edge, the prevention of diseases, and the protection of the 
public health. The charitable gift of professional services 
to institutions and to individuals is an obligation which, with 
certain limitations, is inseparable from the medical profes- 
sion. Important obligations arise from the opportunities 
afforded by the relations of physician and patient for advice 
and aid in overcoming injurious and immoral habits. There 
are duties connected with the expression of opinions con- 
cerning the nature, the probable cause, and the termination 
of diseases to patients and their friends, with communica- 
tions respecting the diseases of patients to others, and with 
testimony given in courts of law. Finally, moral obliga- 
tions to society are to be fulfilled by the members of the 
medical profession, individually and collectively, with refer- 
ence to irregular practitioners, secret nostrums, and all the 
multitudinous forms of quackery. 
The rules of conduct adapted to the peculiarities of medi- 
cine constitute medical ethics. These rules have a moral 
weight. Medical etiquette, on the other hand, consists of 
the forms to be observed in professional intercourse. These 
are conventional. They have not the binding force of eth- 
ical rules; nevertheless, they claim observance. The medi- 
cal profession receives not a little ridicule for observing rules 
of etiquette, but their observance is a protection against 
not only embarrassment and confusion, but misapprehen- 
sions and dissensions, injurious alike to physicians and pa- 
tients. 
If there be ground for a distinct system of ethics applied 
to medicine, the rules of conduct which the system requires 
should be codified. A code of ethics adopted by the pro- 4 
MEDICAL ETHICS AND ETIQUETTE. 
fession represents the views held by the majority of its 
members, and is, therefore, binding on all. It is indispen- 
sable for the sake of reference whenever differences of opin- 
ion arise. It indicates the proper course to those whose 
moral perceptions may be defective. It may prove a safe- 
guard against the bias of personal interests. It thus con- 
tributes to the purity and dignity of the medical profession. 
Much would be gained in the popular respect for the pro- 
fession were the public better acquainted than they are with 
the ethical rules by which its members assume to be gov- 
erned. It is, perhaps, a common impression that the ob- 
jects of a code of medical ethics have exclusive reference 
to the interests of the medical profession. So far from this, 
the objects are of far more importance to the public welfare 
than to physicians. The truth of this statement will be 
apparent, without argument, to any who will take the trouble 
to become acquainted with the provisions of the code. The 
writer may add that, in preparing these articles, he has been 
actuated by the hope that they may do something in the 
way of a general diffusion of knowledge on subjects which 
they who are not members of the medical profession are apt 
to think do not in the least concern them. These remarks, 
having reference to the ethics of medicine, will apply meas- 
urably to the rules of professional etiquette. 
Prior to 1847 the codes of medical ethics which existed 
in this country were instituted by State or local societies? 
and in many, probably in most, of the States of the Union 
there were none. At the convention which resulted in the 
organization of the American Medical Association, in 1847, 
a committee, of which the late Isaac Hays was chairman, 
were instructed to report a code of ethics. This committee 
reported a code which was adopted unanimously, and from 
that date it has been recognized as the National Code 
throughout the whole country. With the single exception of INTRODUCTORY REMARKS. 
5 
a recent action by the New York State Medical Society, this 
code has remained without any material additions or modi- 
fications. It has had, therefore, the approval of the medical 
profession of the United States for a period of over thirty- 
five years. It is but justice to the memory of an excellent 
English physician to state that the American code is based 
on that prepared by Thomas Percival, and published in 
1803. Credit to Percival was given by Hays, in a note 
accompanying his report, as follows: “On examining a 
great number of codes of ethics adopted by different so- 
cieties in the United States, it was found that they were 
all based on that by Dr. Percival, and that the phrases of 
this writer were preserved to a considerable extent in all 
of them. Believing that language so often examined and 
adopted must possess the greatest of merits for such a docu- 
ment as the present—clearness and precision—and having no 
ambition for the honors of authorship, the committee which 
prepared this code have followed a similar course, and have 
carefully preserved the words of Percival whenever they 
convey the precepts it is wished to inculcate.” Percival’s 
code of ethics was prepared for a son who was about to 
engage in medical practice, and who died before its publi- 
cation. It was dedicated to another son who was engaged 
in the study of medicine. In its composition, as he says in 
the dedication, his thoughts were directed to his son, “ with 
the tenderest impulse of paternal love, and not a single 
moral rule was framed without a secret view to his designa- 
tion, and an anxious wish that it might influence his future 
conduct.” The following is another quotation from the dedi- 
cation : “ The relations in which a physician stands to his 
patients, to his brethren, and to the public, are complicated 
and multifarious, involving much knowledge of human na- 
ture and extensive moral duties. The study of professional 
ethics, therefore, can not fail to invigorate and enlarge your 6 
MEDICAL ETHICS AND ETIQUETTE. 
understanding, while the observance of the duties which 
they enjoin will soften your manners, expand your affec- 
tions, and form you to that propriety and dignity of con- 
duct which are essential to the character of a gentleman.” 
The code of the American Medical Association will form 
the basis of this work. The arrangement of topics adopted 
in that code will be followed, namely: Ist. The duties of 
physicians to their patients, and the obligations of patients 
to their physicians. 2d. The duties of physicians to each 
other and to the profession at large. 3d. The duties of the 
profession to the public, and the obligations of the public to 
the profession. A chapter will be devoted to each of these 
three divisions. The three chapters will embrace the entire 
code, with such comments as may suggest themselves. In a 
few instances the writer will venture upon critical remarks. 
In connection with topics which belong to medical ethics 
will be introduced remarks upon etiquette. CHAPTER I. 
THE DUTIES OF PHYSICIANS TO THEIR PATIENTS, AND THE 
OBLIGATIONS OF PATIENTS TO THEIR PHYSICIANS. 
The plan which will be pursued, as regards the code and 
the commentaries, is the introduction of a portion of the code 
to serve as the text for the comments which will follow. 
The latter will be distinguished by a difference in print, 
and will therefore not require a distinctive heading. It 
would be easy for a writer full of admiration of the code to 
amplify largely upon it; but, appreciating the importance of 
having the volume of small size, the commentaries will be 
brief. The code offers very little opportunity for controver- 
sial discussion; all who have studied it must admit the diffi- 
culty of taking exceptions to its ethical rules. 
Section 1. A physician should not only he ever ready to 
obey the calls of the sick, but bis mind ought also to be imbued 
with the greatness of his mission, and the responsibility he ha- 
bitually incurs in its discharge. These obligations are the more 
deep and enduring, because there is no tribunal other than his 
own conscience to adjudge penalties for carelessness or neglect. 
Physicians should, therefore, minister to the sick with due im- 
pressions of the importance of their office, reflecting that the 
ease, the health, and the lives of those committed to their 
charge depend on their skill, attention, and fidelity. They 
Art. I.—Duties of Physicians to their Patients. 8 
MEDICAL ETHICS AND ETIQUETTE. 
should study, also, in their deportment, so to unite tenderness 
with firmness, and condescension with authority, as to inspire 
the minds of their patients with gratitude, respect, and confi- 
dence. 
The sentiments so admirably expressed in the foregoing 
first paragraph of the code need no arguments for their 
support, nor any comments to increase their force. They 
antagonize undue influences arising from self-conceit, an 
irritable temper, indolence, devotion to pleasure or to occu- 
pations which divert from professional duties, and all mer- 
cenary considerations. At the same time, they do not con- 
travene self-respect and a proper regard for personal interests. 
It is not to be assumed that the practice of medicine is a 
sacred calling in the sense in which this expression is ap- 
plied to the clerical profession, nor that it is adopted for 
purely benevolent or philanthropic purposes. The medical 
profession holds out to its candidates the inducements of an 
honorable pursuit, studies which are not only attractive, but 
afford ample scope for the mental faculties, labors which 
may carry with them the satisfaction of saving life and re- 
storing health, but, conjoined with these, an expectation of 
gaining a livelihood, together with means for the enjoy- 
ment of the pleasures of domestic and social life, a fair 
prospect for acquiring a competency, and, with prudence 
and perseverance, even wealth. The last of these induce- 
ments are by no means necessarily inconsistent with the 
higher sentiments which should govern the conduct of phy- 
sicians. Self-abnegation is a noble trait, not infrequently 
exemplified in the lives of members of the medical pro- 
fession, but communities have no more right to demand it 
of them than of those in other callings, and indifference to 
their own worldly interests and the claims of their families 
is not to be enjoined upon them more than upon those en- 
gaged in other pursuits. This principle is one to be under- DUTIES OF PHYSICIANS TO THEIR PATIENTS. 
9 
stood both by physicians and the public. Writers of fiction 
and dramatists have depicted lives devoted to the duties of 
medical practice purely as works of charity.* These de- 
lineations have their analogues in real life. On the other 
hand, there are those whose absorbing aim is to acquire 
either distinction or pecuniary gain. Without undertaking 
to interfere with motives and objects, for which every one 
must be responsible to his own conscience, the code of 
ethics places before the mind of the physician sentiments 
peculiarly applicable to the exercise of the medical profes- 
sion. 
Sec. 2. Every case committed to the charge of a physician 
should be treated with attention, steadiness, and humanity. 
Reasonable indulgence should be granted to the mental imbe- 
cility and caprices of the sick. Secrecy and delicacy, when re- 
quired by peculiar circumstances, should be strictly observed ; 
and the familiar and confidential intercourse to which physi- 
cians are admitted in their professional visits should be used 
with discretion, and with the most scrupulous regard to fidelity 
and honor. The obligation of secrecy extends beyond the period 
of professional services; none of the privacies of personal and 
domestic life, no infirmity of disposition or flaw of character 
observed during professional attendance, should ever be divulged 
by the physician except when he is imperatively required to do 
so. The force and necessity of this obligation are indeed so 
great that professional men have, under certain circumstances, 
been protected in their observance of secrecy by courts of jus- 
tice. 
Most persons, of “ all sorts and conditions,” regard phy- 
sicians Avith respect in consideration of their calling. Even 
they who are notoriously rough and uncivil in their inter- 
course with others are often gentle and courteous to those 
from whom they expect to receive medical aid in sickness. 
As a rule, the physician, in his visits to his sick patients, re- 
* E. g., “Le medecin de campagne,” by Balzac. 10 
MEDICAL ETHICS AND ETIQUETTE. 
ceives kindness and confidence. It may, however, be other- 
wise as a consequence of the influence of disease upon the 
mind. Disease not infrequently renders persons impatient, 
querulous, irritable, distrustful, suspicious, and these morbid 
mental conditions may manifest themselves in language and 
manner, perhaps, much at variance from the traits of char- 
acter belonging to the same persons when well. Both pro- 
priety and policy dictate the utmost forbearance under these 
circumstances, on the ground that one is not to be held re- 
sponsible in sickness for utterances and conduct which in 
health might properly involve accountability. The physi- 
cian does not compromise his self-respect by submitting pa- 
tiently to rudeness, or even insults, from a sick patient, to 
which he would be by no means bound to submit quietly if 
the patient were well. This ethical rule is not, at least to 
the same extent, applicable to the friends of patients. But 
here allowance is often to be made for the disturbance of 
mind arising from anxiety and apprehensions. Less allow- 
ance is due to officious visitors and acquaintances. For- 
bearance toward these is not always to be embraced within 
the scope of medical ethics. Prudence and tact are to be 
exercised according to the circumstances in particular in- 
stances. 
On the part of the physician, it is a gross impropriety 
to require the forbearance of his sick patients and their 
friends. For him there is not the excuse which the latter 
may fairly claim. Roughness and the lack of courtesy on 
his part are the more inexcusable for the reason that patients 
and their friends are, in 'a measure, at his mercy. They 
have a right to expect from him kindness and patience, and, 
if he be lacking therein, he is not entitled to the indulgence 
which is due to them, if they be deficient in these regards. 
Brutality toward patients or their friends is a grievous of- 
fense against the medical profession. It is especially repre- DUTIES OF PHYSICIANS TO THEIR PATIENTS. 
hensible toward hospital patients, or those from whom no 
pecuniary recompense is expected. Private patients in good 
circumstances can elect and change physicians. This is a 
privilege denied to those who seek relief in public institu- 
tions, or to whom medical services are gratuitously rendered; 
hence, it is taking a mean advantage not to treat such pa- 
tients with attention and humanity. 
The binding force of secrecy as regards all information 
obtained in connection with professional relations, whenever 
it is desired, or is desirable, on the part of patients or their 
friends, that the information should not be communicated 
to others, is not sufficiently appreciated by many members 
of the medical profession, and still less is it appreciated by 
the public. Weaknesses, foibles, and vices, perhaps unsus- 
pected by others, become known to the physician. He can 
not help knowing them if he would. No one but himself is 
to be the wiser for this knowledge. Physical ailments and 
defects which the physician must discover, he has no right 
to speak of. Confidential communications by patients re- 
lating to themselves, their families, or their progenitors, arc 
to be held as a sacred trust. 
Physicians should be reserved, and exercise judgment 
in speaking of the ailments of those under their care. 
Many ailments are of a nature that most persons desire to 
conceal, and they should not be deprived of the right of 
concealment. It can not, for example, be agreeable to a 
young woman for her acquaintances to know that she is 
troubled with a tapeworm. Other affections of a much 
more delicate nature might be cited as examples. The 
right of concealment by no means belongs exclusively to 
the female sex. Moreover, a patient may have a serious dis- 
ease, of which, in order to spare family and friends anxiety, 
or for other reasons, concealment is desired. The physician 
is bound to respect this desire. A physician who appreci- 12 
MEDICAL ETHICS AND ETIQUETTE. 
ates fully the duty of secrecy can not but feel that it is a 
reflection upon his professional character when, as often 
happens, he is requested by a patient to observe this duty. 
It is true that some patients are not sensitive on this sub- 
ject, and they may even desire that others may know of the 
nature of their maladies. Under these circumstances the 
physician is, of course, absolved from the duty of secrecy. 
He is not, however, to act upon his own presumption in 
the matter, when the feelings of his patients can be readily 
ascertained. 
A more judicious reserve than is now practiced by not 
a few physicians would soon lead to a better understanding 
of the ethical duty of secrecy on the part of the public. 
How common is it for a practitioner to be asked, “ What is 
the matter with Mr. , or Mrs. , or Miss ? ” 
The answer is expected to embrace the nature and seat of 
the disease, the symptoms which are present, and, perhaps, 
all the details of the sick-room. If a patient happen to be 
a person of note, the attending physician is liable to be 
called upon by an interviewer, who expects to get the diag- 
nosis, the symptomatic history, the prognosis, and the treat- 
ment, for publication in a newspaper. Now, the ground is 
by no means to be taken that nothing is to be communi- 
cated to friends, acquaintances, or the public respecting 
cases of disease. It would be simply absurd to take this 
ground. The condition of a patient in respect of danger, 
and, in some instances, the probable duration of disease, may 
properly he made known to those who are interested in the 
patient’s welfare. It is sometimes proper and sometimes 
not to state the nature of the disease. It may not be prop- 
er to go further. Of this, the physician must he the judge. 
It should he left to his judgment and sense of propriety 
or duty how much should be told of details belonging to 
the privacy of the sick-room. Intelligent, well-bred per- DUTIES OF PHYSICIANS TO THEIR PATIENTS. 
13 
sons, who have reflected upon the duty of a physician in 
respect of secrecy, will never place him in the unpleasant 
position of declining to answer questions relating to his 
patients. 
Physicians have to deal with malingering. When called 
upon to decide whether or not persons are malingerers in 
prisons, in the army and navy, in hospitals, and other public 
institutions, and when impostors undertake to deceive the 
public by feigning diseases, either for gain, sympathy, or 
notoriety, there can be no question as to the duty of expos- 
ure. In private practice the duty will vary according to 
the circumstances in individual instances. The duty then 
points to the course which will be most productive of good, 
and with regard to this the physician is to exercise his 
judgment. In an instance like the following it seems plain 
that secrecy would have been improper: A young man, the 
son of a wealthy father, feigned paroxysms of intense pain 
and convulsions, and at times unconsciousness. He had 
imposed upon a medical adviser so far as to obtain from the 
latter a written statement that he would probably never re- 
cover, and was liable to die in one of the paroxysms. When 
he had reason to know that his deception was discovered 
by another physician, he became abusive in the extreme, 
instead of asking for concealment, with a promise that the 
malingering should cease. Under these circumstances, the 
diagnosis was stated to the parents, and the case relin- 
quished. Secrecy outside of the family in such an instance 
would be proper, provided the diagnosis was not kept by 
them a secret, and the physician was not called upon to 
defend its correctness. There are instances, however, the 
object being to awaken interest or affection, in which ex- 
posure is not the physician’s duty, inasmuch as it will not 
do good and may do much harm. It may be a question 
whether the physician should ever dissimulate so as to ap- 14 
MEDICAL ETHICS AND ETIQUETTE. 
pear to Tbe himself deceived. Policy may seem to dictate 
this course. As a rule, it is more consistent with profes- 
sional character to undeceive the malingerer at a proper 
time and in a proper way; otherwise, the physician be- 
comes an accomplice in the fraud. With regard to secrecy 
beyond this, there can be no better rule than to pursue the 
course which will do the least harm or the most good to all 
concerned. 
In respect of the knowledge of criminal acts, the physi- 
cian is not to play the part of a detective or an informer. 
Some may consider it a strong assertion that a physician is 
under an ethical bond of secrecy when, through his profes- 
sional intercourse, he may have ascertained that his patient 
is an escaped convict, a thief, a robber, a forger, or even a 
murderer. No matter how heinous the crime, the wretched 
criminal has a right to medical services in sickness. Who 
can tell how important it may be that his health should be 
restored and his life prolonged by these services, albeit in 
the light of human judgment it might seem better that he 
remain prostrated by disease or die. The duty of the phy- 
sician in such instances relates exclusively to the patient. 
He would be debarred from medical services were it under- 
stood that physicians are to play the part of detectives and 
informers. It may be said that a distinction should be 
made as to the nature and degree of crimes which patients 
have committed. But where is the line to be drawn ? It 
is not for the physician to exercise a judicial discretion on 
that point. The ethical rule is without exceptions. Medi- 
cal men do not always appreciate the binding force of this 
rule, and disastrous effects sometimes follow its non-observ- 
ance. The following recital is in illustration: 
An unfortunate young woman had sought to escape the 
disgrace of maternity, and is a victim of malpractice. A 
physician is called to attend her in her extremity. He DUTIES OF PHYSICIANS TO THEIR PATIENTS. 
15 
recognizes tlie nature of the case and the dangerous condi- 
tion of the patient. He demands, in the cause of justice, 
to know the name of the author of her trouble, and of the 
one who had undertaken a criminal interference. An officer 
of justice is summoned to receive her testimony. The 
woman dies. The newspapers give publicity to the case, 
with all its details. The physician acted from his sense of 
duty, his object being the punishment of the offenders against 
the law. As results of his action, the moral effect of the 
steps taken in behalf of justice may have contributed to the 
death of the patient, and, at least, it is fair to conclude that 
the misery of her last hours was thereby increased; she left 
a dishonored memory ; disgrace was brought upon the rela- 
tives of both parties, he being a husband and the father of a 
family. After all, the surviving offenders eluded punish- 
ment. This is not a hypothetical case. It is left to the 
reflections of the reader, with but brief comment. In no 
point of view was the action of the physician to be justi- 
fied, although taken with good intentions. Knowledge of 
the fact of malpractice was essential to a proper appreciation 
of the case. Further knowledge was not essential, and it 
was taking an ungenerous and improper advantage to de- 
mand it. Compliance with the wishes of the patient, vol- 
untarily and deliberately expressed, could afford the only 
ground for excuse in the non-observance of secrecy. 
The duty of the physician in giving testimony as a 
medical witness may be regarded from two points of view, 
namely: medical ethics, and existing laws relating to the sub- 
ject. As regards the former, he must be himself the judge; 
in the latter, he will be instructed by legal advisers and the 
courts. It may happen that there is not agreement in these 
two points of view; in other words, he may be required to 
give testimony respecting matters which, in his judgment, 
are in the category of professional secrets. He must decide 16 
MEDICAL ETHICS AND ETIQUETTE. 
in such a case whether he will act in opposition to his 
convictions of ethical duty, or refuse to testify and accept 
the consequences, whatever they may be. One who has 
confidence in his own interpretation of duty, and holds the 
dictates of conscience to be above all other considerations, 
will refuse to testify, provided he have firmness enough to 
take that position. On the other hand, a refusal will not 
come from those who are distrustful of their ability to judge 
correctly of ethical duty, or from those who believe that in 
a conflict between the dictates of conscience and the inter- 
pretation of existing laws the latter should prevail; or, 
again, from those who would rather yield than submit to the 
consequences of not yielding. 
The section of the code of ethics prefixed to these re- 
marks is definite and comprehensive as to the duty and the 
scope of professional secrecy. Aside from the sense of 
honor and humanity, this portion of the code affects prac- 
titioners of medicine merely in relation to policy. The 
interests of the public, much more than those of physicians, 
are involved in this portion of the code. But, in view of 
these interests, it should be an object with members of the 
medical profession to secure the enactment of laws which 
are in full agreement with the letter and the spirit of the 
code. Testimony which involves a violation of medical 
ethics should not only be not required, but prohibited. For 
declining to give testimony, a declaration under oath that 
it would be a dereliction of the duty of secrecy should suf- 
fice. 
In the laws of the State of New York there is a statute 
which is in harmony with the code of medical ethics. It is 
headed “ Physicians not to disclose Professional Informa- 
tion,” and reads as follows: “ A person duly authorized to 
practice physic or surgery shall not be allowed to disclose 
any information which he acquired in attending a patient in DUTIES OE PHYSICIANS TO THEIR PATIENTS. 
17 
a professional capacity, and which was necessary for him to 
act in that capacity.” 
A summary of the New York cases, and examples drawn 
therefrom, may he of interest to the reader.* 
“ It must be assumed,-from the relationship existing, that 
the information would not have been imparted except for 
the purpose of aiding the physician in prescribing for the 
patient. Information means not only communications re- 
ceived from the lips of the patient, but such knowledge as 
may be acquired from the patient himself, from the state- 
ments of others who surround him, or from observations of 
his appearance and symptoms.” Edington vs. Mutual Life 
Insurance Company, 5 Hun., 1. 
“But communications made to persons in attendance at 
the office of a physician during his absence, and not shown 
to have been made as the basis of a prescription, are not 
privileged.” Kendall and Gray, 2 Hill, 300. 
“ Nor does the statute preclude the physician from tes- 
tifying to the nature of the disease and the character of the 
treatment when he sues to recover for his services.” Ken- 
dall and Gray, 2 Hill, 300. 
“ But whenever a visit is regarded and acted upon as 
professional, the statute applies; as, for example, when a 
wounded man accused of murder was visited by two physi- 
cians at the request of the coroner, held on the trial that 
the physicians could not as witnesses disclose the informa- 
tion that they acquired on such visits, as the prisoner knew 
them to be physicians, and submitted to questions for that 
reason.” People vs. Stout, 3 Park. Cr., 670. 
“ In an action for divorce, the physician can not be re- 
quired to testify to conversations which were held with him 
in his professional capacity, although these conversations 
* Furnished by a legal friend, Edward H. Strobel, Esq. 18 
MEDICAL ETHICS AND ETIQUETTE. 
tended to establish adultery.” Hume vs. Hume, IN. Y. 
Sup., 499. 
“Nor can a physician be required to testify whether a 
person had venereal disease when under his care.” Sloan 
vs. N. Y. C. R. R., 45 N. Y., 125. 
“ There seem to be the two following exceptions to the 
statute: An application to a physician for means of procur- 
ing an abortion, accompanied by a disclosure of the female’s 
name, is not privileged, the ground of the decision being 
that it was doubtful whether such a communication should 
be considered as made while consulting the physician pro- 
fessionally, and that the information was not essential to 
enable him to prescribe.” Hewitt vs. Prince, 21 Wend., 79. 
“ The statute creates merely a privilege in favor of the 
patient, and there is no person, after the patient’s death, 
entitled to assert it. Hence, the statute has no application 
when a physician is called, in probate of a will, to testify 
touching the capacity of the deceased patient,” Allen vs. 
Public Administrator, 1 Bradf., 21. 
“ Both these exceptions are doubted in Edington vs. Life 
Insurance Company, on appeal to Court of Appeals, 67 N. 
Y., 185. The latter exception was virtually overruled in 
that case, it being held that the protection which the law 
gives to professional confidence does not cease upon the 
death of the party ; the seal which the law fixes upon such 
communications remains unless removed by the party him- 
self or his legal representative.” 
“ It must be understood that the privilege is that of the 
party and not of the witness. The testimony of a physician, 
if not objected to by the patient, is admissible. If the 
party interested waive his right, the physician may be ex- 
amined.” Johnson vs. Johnson, 14 Wend,, 637. 
A statutory law substantially the same as in the State of 
New York exists in the following States of the Union : Mis- DUTIES OF PHYSICIANS TO THEIR PATIENTS. 
19 
souri, Wisconsin, lowa, Indiana, Michigan, Arkansas, and 
California. 
The law in England makes the divulging of professional 
secrets compulsory. “In the case of the Duchess of King- 
ston, it was decided that in a court of justice medical men 
are hound to disclose these secrets when required to do so. 
Lord Mansfield said on that occasion, ‘lf a medical man 
voluntarily revealed these secrets, to he sure he would he 
guilty of a breach of honor and of great indiscretion, but 
to give that information which by the law of the land he is 
hound to do will never he imputed to him as any indiscre- 
tion whatever.’ In that case Sir C. Hawkins, who had at- 
tended the Duchess as a medical man, was compelled to 
disclose what had been communicated to him in confidence. 
This is the leading case in England, and fixes the law in 
that country; or, in better words, it is the common law rule.” 
It will he noted that the decision referred to takes cogni- 
zance only of the rights of the medical man, not those of 
his patients. 
The law in France recognizes fully the obligation for 
secrecy on the part of physicians, as appears from the fol- 
lowing citation: “ Obligation des medecins envers les par- 
ticuliers qu’ils traitent. 
“ Comme un medecin est souvent dans I’occasion de 
connaitre les secrets de ses malades, soit par la confiance 
qu’on pent avoir en lui, soit par les conjoncturcs qui rendent 
sa presence necessaire, lorsqu’il est question de quelque 
affaire secrete, il est de son devoir de ne point abuser de 
ce qui est venu a sa connaissance, et de garder a cet egard 
un secret inviolable. Ce secret est ordonne par un article 
des statuts de la faculte de medecine, qui portc: Aegrorium 
arcana, visa, audita, intellecta, nemo eliminet—Merlin, 
“ Repertoire de jurisprudence,” tome 20, titre, “ Medecin,” 20 
MEDICAL ETHICS AND ETIQUETTE. 
It is incumbent on physicians to decide beforehand upon 
the action which they will take in cases involving a question 
of professional confidence. Penalties incident to the convic- 
tion that the requirements of professional confidence should 
be inviolable are to be accepted as conducive to the honor of 
the profession and to humanity. 
Section 8. Frequent visits to the sick are in general requi- 
site, since they enable the physician to arrive at a more perfect 
knowledge of the disease—to meet promptly every change 
which may occur, and also tend to preserve the confidence of 
the patient. But unnecessary visits are to be avoided, as they 
give useless anxiety to the patient, tend to diminish the author- 
ity of the physician, and render him liable to be suspected of 
interested motives. 
It is generally left to the physician to judge of the fre- 
quency of visits which cases require. He is asked by pa- 
tients, or their friends, much oftener to increase than to 
diminish the number of his visits. Not infrequently he is 
asked to make the number greater than, in his judgment, 
the case requires. Patients who are able and willing to in- 
cur the expense of superfluous visits are entitled to them, if 
professional attendance necessary in other cases be not 
thereby prevented. But it is fair, both to the physician 
and patient, to state that a certain proportion of visits 
made at the request of the latter are not required by the 
circumstances of the case. In this way useless anxiety on 
the part of the patient from unnecessary visits is avoided. 
Physicians, naturally, are sensitive respecting an imputation 
of making more visits than cases require, and, for this rea- 
son, they may make fewer than are advisable. Young prac- 
titioners, who are known to be struggling for a livelihood, 
are especially apt to be sensitive on this point. Owing to 
the infrequency of visits in consequence of this sensitive- 
ness, they may appear not to be sufficiently interested in a DUTIES OF PHYSICIANS TO THEIR PATIENTS. 
21 
case, or not to attach to it sufficient importance. It is al- 
ways better to mate too many than too few visits. The 
former error is easily corrected, hut the latter does not ad- 
mit of correction. The instances must be extremely rare 
in which physicians multiply visits beyond the requirements 
of a case for the purpose of pecuniary gain. Instances are 
much more frequent in which they fail to do justice, both 
to their patients and themselves, in this regard. 
Section 4. A physician should not he forward to make gloomy 
prognostications, because they savor of empiricism, by magnify- 
ing the importance of his services in the treatment or cure of 
the disease. But he should not fail, on proper occasions, to 
give to the friends of the patient timely notice of danger when 
it really occurs; and even to the patient himself, if absolutely 
necessary. This office, however, is so peculiarly alarming when 
executed by him that it ought to be declined whenever it can 
be assigned to any other person of sufficient judgment and deli- 
cacy. For the physician should he the minister of hope and 
comfort to the sick; that, by such cordials to the drooping 
spirit, he may smooth the bed of death, revive expiring life, and 
counteract the depressing influence of those maladies which 
often disturb the tranquillity of the most resigned in their last 
moments. The life of a sick person can be shortened not only 
by the acts, but also by the words or the manner of a physician. 
It is, therefore, a sacred duty to guard himself carefully in this 
respect, and to avoid all things which have a tendency to dis- 
courage the patient and to depress his spirits. 
It is a mild expression to say that gloomy prognostica- 
tions made in order to magnify the importance of medical 
services savor of empiricism. Whenever made with that 
intent, they denote nothing less than downright charlatanry. 
The facility with which patients are led to an exaggerated 
estimate of medical services, and the disposition often, of 
their own accord, toward such an estimate, offer, in many 
instances, a strong temptation. Physicians not over scru- 22 
MEDICAL ETHICS AND ETIQUETTE. 
pulous as to the means of obtaining a popular reputation 
for professional skill are likely to yield to the temptation. 
A well-educated physician must know that he can rarely 
assume to have warded off an impending disease. The 
statement to a patient that he has barely escaped an attack 
of pneumonia, typhoid fever, apoplexy, or other diseases 
which might he included in this category, is either evidence 
of ignorance on the part of the physician who makes the 
statement, or it is a gross violation of medical ethics. It is 
a popular error that most diseases can he foreseen by skilled 
observers, and prevented by skillful measures. The truth 
is, this can properly he said of but few diseases. The pub- 
lic are also equally in error in regard to the management of 
diseases. Certain diseases are controllable by known thera- 
peutical agencies. Many, however, in the present state of 
our knowledge, can not be controlled; that is, arrested and 
brought at once, or speedily, to a favorable termination. 
In a considerable proportion the tendency is to end favora- 
bly, and this tendency might suffice, irrespective of any ac- 
tive treatment. The management of the diseases which 
are not controllable consists in close observation and watch- 
ing for complications or untoward events, meeting indications 
as they arise in particular cases, palliating symptoms, re- 
lieving pain or distress, and sustaining the powers of life, 
thus endeavoring to promote a favorable termination, to 
diminish suffering, and, perhaps, shorten the duration of the 
disease. 
It is, of course, dishonest, and, therefore, a violation of 
medical ethics, for a physician to claim more credit than 
that to which he is entitled in controlling diseases or in 
their management. A better understanding than now gener- 
ally exists in the popular mind of the nature and scope of the 
offices of the physician, in these regards, will tend to place 
the medical profession in a better light before the public. DUTIES OF PHYSICIANS TO THEIR PATIENTS. 
Forwardness in gloomy prognostications is not always 
evidence of a desire to magnify the importance of medical 
services. It may proceed from a mental tendency thereto. 
Some minds are so constituted that there is a constant dis- 
position to loot on the dark side and anticipate the worst. 
This is a misfortune in the practice of medicine, alike for 
the physician and his patients. The physician loses a po- 
tential factor in the management of diseases, and the pa- 
tient suffers a corresponding disadvantage. Some physi- 
cians are over-sanguine in prognosis, and fail to appreciate 
fully the condition of patients in respect of danger. A 
juste milieu is desirable; but, if there must be error in either 
direction, it is far better to err by looking on the bright 
side. 
Undue solemnity, anxiety, and apprehension in the 
looks, manner, or words of a medical attendant on the 
sick, are extremely unfortunate—they discourage patients, 
whereas, on the other hand, a cheerful mien, calmness of 
deportment, and verbal assurances, sometimes accomplish 
more than drugs. Patients often declare that they are con- 
scious of deriving benefit from the visits of a physician ir- 
respective of his prescriptions, but the manifest effect is 
sometimes quite the reverse. It is a duty always to encour- 
age patients as much as the circumstances of the case will 
allow. The encouraging features of a malady should be 
dwelt upon, and not those of an opposite character. Un- 
favorable events which may be apprehended should not 
be referred to in the hearing of the patient, although it may 
be judicious to mention them to friends, in order that they 
be not taken by surprise, and attach blame to the physician 
for concealment. 
Patients, when seriously ill, do not often ask for explicit 
information as to the existence or the degree of danger. If 
the question be asked, it must, of course, be answered. MEDICAL ETHICS AND ETIQUETTE. 
The answer, with rare exceptions, should he so worded as 
not to exclude hope, hut without deceiving the patient by 
holding out false assurances of recovery. To tell a patient 
that within a fixed period death is certain is not only a 
brutal violation of propriety, hut such a belief is seldom 
warranted by actual knowledge. The writer of these com- 
mentaries has in several instances sat by the bedside await- 
ing the last breath in cases which have ended in recovery. 
It may be a duty for the physician, of his own accord, to 
intimate, or cause to be intimated, to the patient that the 
disease is not without danger. It seems hardly right that 
persons should die from disease without having had any sus- 
picion of danger; but this not infrequently happens. There 
may be important matters to be attended to in preparation 
for death. Last wishes and words are often of great com- 
fort to surviving relatives and friends. As stated in the 
code, it is more appropriate for communications having 
reference to danger and death to be made by some one 
other than the medical attendant; but often others shrink 
from this painful duty, and, moreover, many are not com- 
petent to perform the duty with judgment and delicacy; 
hence, it falls upon the physician, and, under those circum- 
stances, he should not decline it. 
Section 5. A physician ought not to abandon a patient because 
the case is deemed incurable, for his attendance may continue to 
be highly useful to the patient, and comforting to the relatives 
around him, even in the last period of a fatal malady, by alle- 
viating pain and other symptoms, and by soothing mental an- 
guish. To decline attendance under such circumstances would 
be sacrificing to fanciful delicacy and mistaken liberality that 
moral duty which is independent of and far superior to all 
pecuniary consideration. 
Instances are not extremely rare in which recovery from 
disease takes place when there had seemed to be little or DUTIES OF PHYSICIANS TO THEIR PATIENTS. 
25 
no ground for hope. This fact renders it injudicious for the 
physician to pronounce a positively fatal prognosis even in 
cases which are apparently hopeless. There is no need 
of saying that death is certain, inasmuch as the statement 
of extreme danger answers every purpose as regards duty 
toward the relatives or friends, and, also, the patient. The 
physician should avoid committing his own mind to a fatal 
prognosis whenever there is the slightest foundation for 
hope, because the effect will he relaxation of his medical 
efforts. The effect of an abandonment of all hope on the 
minds of nurses, relatives, and friends, is bad. Their co- 
operative efforts are thereby relaxed, and not infrequently, 
as a desperate alternative, the patient is given over to ex- 
perimentation with some irregular methods of practice. 
It is trying to a physician to continue to visit patients 
when he feels that the resources of medicine are powerless, 
and to witness the closing scenes of life. But there is room 
for his good offices under those circumstances, and he should 
not withhold them. He can often do much toward lessen- 
ing pain or discomfort—mental and physical; he can con- 
tribute to euthanasia, and he can comfort those who sur- 
round the bed of death by assurances that in the “last 
agony,” as it is miscalled, these manifestations of distress are 
usually unattended by conscious suffering. 
Section 6. Consultations should be promoted in difficult or 
protracted cases, as they give rise to confidence, energy, and 
more enlarged views in practice. 
Erroneous views respecting consultations prevail largely 
in the public mind, and, to a considerable extent, among 
members of the medical profession. A request for a con- 
sultation is often considered as implying lack of confidence 
in the attending physician. It is not an uncommon notion 
that the function of a consulting physician is to judge con- 26 
MEDICAL ETHICS AND ETIQUETTE, 
cerning the practice which has been pursued, and announce 
his decision to the patient and friends. Some persons have 
the idea that the physician in consultation assumes entire 
control of the case, and that he is entitled to whatever 
credit may pertain to the management. It is not to be 
wondered at that, recognizing and perhaps sharing in these 
erroneous popular views, practitioners are anxious to dis- 
pense with consultations, if they can be avoided, and con- 
sent with reluctance when they are proposed. It is highly 
important that the public should have correct views of the 
proper objects of consultations. These objects are : co-opera- 
tion in the management of cases of disease, a division of 
responsibility, and the satisfaction of patients and those in- 
terested, by enabling them to feel that, whatever may be the 
result', they have done all that lies in their power to secure 
the best resources of medicine. A medical consultation 
should not necessarily imply that the consulting physician 
has more knowledge and skill than the physician in attend- 
ance. The advantage is in having two or more heads in- 
stead of one head. Life and health are certainly of suffi- 
cient importance to claim the judgment of more than one 
person. Questions in law, or of the affairs of business, or 
of comparatively unimportant matters relating to rules of 
conduct, are often deemed of sufficient consequence to ob- 
tain collective opinions. How inconsistent, therefore, to rely 
upon a single mind in cases of disease which may lead, if 
not to death, to a permanent impairment of the mental or 
physical powers! Consultations, when their true objects 
are recognized by all parties, are of great comfort to 
an attending physician. Undoubtedly, a reason for their 
being distasteful to him often is a want of full confi- 
dence in the honor of the consulting physician. Hence, 
it is important that physicians comply conscientiously 
with the rules laid down by the code in respect of con- DUTIES OF PHYSICIANS TO THEIR PATIENTS. 
sultations. These rules will be considered under another 
heading. 
Section 7. The opportunity which a physician not unfrequent- 
ly enjoys of promoting and strengthening the good resolutions 
of his patients, suffering under the consequences of vicious con- 
duct, ought never to be neglected. His counsels, or even re- 
monstrances, will give satisfaction, not offense, if they be prof- 
fered with politeness, and evince a genuine love of virtue, 
accompanied by a sincere interest in the welfare of the person 
to whom they are addressed. 
Members of the medical profession, as such, are not 
called upon to be expounders of doctrines of morals, still 
less partisans of any particular form of religious faith. The 
tendency of that knowledge of human character which is 
incident to the practice of their profession is to make phy- 
sicians charitable, and tolerant of diversities of opinion in 
relation to ethics and religion. Seeing, as they can not fail 
to do, all that lies beneath the surface in the different sta- 
tions and varied conditions of human life, they know that 
the worst traits of character may be found in the highest, 
and the best in the lowest, of the conventional grades of 
society. Owing to the intimate and unreserved relations of 
the physician to his patients, he can often do much toward 
carrying out the injunctions of that portion of the code 
which is prefixed to these remarks. It is undoubtedly true 
that persons will often listen more considerately to counsels 
or remonstrances from a medical adviser than to those of 
relatives, friends, and neighbors, or even to the admonitions 
of the clergy. It is, perhaps, true that most persons are in- 
fluenced more by considerations which have reference to 
life and health than to those which appeal directly to the 
moral nature. The evils resulting from the abuse of al- 
cohol, the dangers connected with the habitual use of 
opium, chloral, and other drugs, and the consequences of MEDICAL ETHICS AND ETIQUETTE. 
28 
licentiousness, may, in not a few instances, be pointed out 
more effectively by a physician who has the confidence of 
his patients than by any one else. It is clearly his duty 
not to forego any opportunity of “ promoting and strength- 
ening the good resolutions of his patients.” 
Art. II.— Obligations of Patients to their Physicians. 
There are several reasons why this portion of the code 
calls for but little in the way of commentary. In the first 
place, the commentator being a member of the medical pro- 
fession, it is a matter of delicacy not to dilate too largely on 
the obligations of patients to their physicians. In the second 
place, although in the preparation of these commentaries 
the hope is entertained that they will have interest for non- 
medical readers, there is probably little ground for the ex- 
pectation that they will have an extensive popular circula- 
tion. In the third place, a large proportion of patients are 
fully sensible of their obligations to their physicians; 
and, lastly, the portion of the code which defines the obli- 
gations of patients to their physicians is so clear and com- 
prehensive as not to offer much scope for addition or eluci- 
dation. For these reasons, instead of making each subdivi- 
sion a separate heading for comments, the entire article 
Avill be first given, and, afterward, brief remarks on the 
topics which it embraces, following the order in which they 
are presented in the code. 
Section 1. The members of the medical profession, upon 
whom is enjoined the performance of so many important and 
arduous duties toward the community, and who are required to 
make so many sacrifices of comfort, ease, and health for the 
welfare of those who avail themselves of their services, certainly 
have a right to expect and require that their patients should 
entertain a just sense of the duties which they owe to their 
medical attendants. OBLIGATIONS OF PATIENTS TO PHYSICIANS. 
29 
Section 2. The first duty of a patient is to select as his medi- 
cal adviser one who has received a regular professional educa- 
tion. In no trade or occupation do mankind rely on the skill of 
an untaught artist; and in medicine, confessedly the most difficult 
and intricate of the sciences, the world ought not to suppose that 
knowledge is intuitive. 
Section 3. Patients should prefer a physician whose habits 
of life are regular, and who is not devoted to company, pleasure, 
or to any pursuit incompatible with his professional obligations. 
A patient should, also, confide the care of himself and family, 
as much as possible, to one physician; for a medical man who 
has become acquainted with the peculiarities of constitution, 
habits, and predispositions of those he attends, is more likely to 
be successful in his treatment than one who does not possess 
that knowledge. 
A patient who has thus selected his physician should always 
apply for advice in what may appear to him trivial cases, for the 
most fatal results often supervene on the slightest accidents. It 
is of still more importance that he should apply for assistance in 
the forming stage of violent diseases; it is to a neglect of this 
precept that medicine owes much of the uncertainty and imper- 
fection with which it has been reproached. 
Section 4. Patients should faithfully and unreservedly com- 
municate to their physician the supposed cause of their disease. 
This is the more important, as many diseases of a mental origin 
simulate those depending on external causes, and yet are only to 
be cured by ministering to the mind diseased. A patient should 
never be afraid of thus making his physician his friend and ad- 
viser; he should always bear in mind that a medical man is 
under the strongest obligations of secrecy. Even the female 
sex should never allow feelings of shame or delicacy to prevent 
their disclosing the seat, symptoms, and causes of complaints 
peculiar to them. However commendable a modest reserve 
may be in the common occurrences of life, its strict observance 
in medicine is often attended with the most serious conse- 
quences, and a patient may sink under a painful and loathsome 
disease which might have been readily prevented had timely 
intimation been given to the physician. MEDICAL ETHICS AND ETIQUETTE. 
Section 5. A patient should never weary his physician with 
a tedious detail of events or matters not appertaining to his dis- 
ease. Even as relates to his actual symptoms, he will convey 
much more real information by giving clear answers to inter- 
rogatories than by the most minute account of his own fram- 
ing, Neither should he obtrude upon his physician the details 
of his business nor the history of his family concerns. 
Section 6. The obedience of a patient to the prescriptions of 
his physician should be prompt and implicit. He should never 
permit his own crude opinions as to their fitness to influence his 
attention to them. A failure in one particular may render an 
otherwise judicious treatment dangerous, and even fatal. This 
remark is equally applicable to diet, drink, and exercise. As 
patients become convalescent, they are very apt to suppose that 
the rules prescribed for them may be disregarded, and the con- 
sequence, but too often, is a relapse. Patients should never 
allow themselves to be persuaded to take any medicine what- 
ever that may be recommended to them by the self-constituted 
doctors and doctresses who are so frequently met with, and who 
pretend to possess infallible remedies for the cure of every dis- 
ease. However simple some of their prescriptions may appear 
to be, it often happens that they are productive of much mis- 
chief, and in all cases they are injurious, by contravening the 
plan of treatment adopted by the physician. 
Section T. A patient should, if possible, avoid even the 
friendly visits of a physician who is not attending him; and, 
when he does receive them, he should never converse on the sub- 
ject of his disease, as an observation may be made, without any 
intention of interference, which may destroy his confidence in 
the course he is pursuing, and induce him to neglect the direct 
tions prescribed to him. A patient should never send for a 
consulting physician without the express consent of his own 
medical attendant. It is of great importance that physicians 
should act in concert; for, although their modes of treatment 
may be attended with equal success when employed singly, yet 
conjointly they are very likely to be productive of disastrous 
results. 
Section 8. When a patient wishes to dismiss his physician, OBLIGATIONS OF PATIENTS TO PHYSICIANS. 
31 
justice and common courtesy require that he should declare his 
reasons for so doing. 
Section 9. Patients should always, when practicable, send for 
their physician in the morning, before his usual hour of going 
out; for, by being early aware of the visits he has to pay during 
the day, the physician is able to. apportion his time in such a 
manner as to prevent an interference of engagements. Patients 
should also avoid calling on their medical adviser unnecessarily 
during the hours devoted to meals or sleep. They should always 
he in readiness to receive the visits of their physician, as the 
detention of a few minutes is often of serious inconvenience to 
him. 
Section 10. A patient should, after his recovery, entertain a 
just and enduring sense of the value of the services rendered 
him by his physician; for these are of such a character that 
no mere pecuniary acknowledgment can repay or cancel 
them. 
The demands for medical services are so irregular, oc- 
curring at all times of both day and night, that a physician 
in full practice can not systematize his work. He must 
often forego periods of study, sleep, and needed rest, meals 
at stated times, social enjoyments, and recreation. The de- 
mands frequently can not be deferred, and the services per- 
haps can not be performed by a substitute, even if one be 
available. These are not trifling hardships, but of greater 
weight are the peculiar anxieties and responsibilities per- 
taining to the practice of medicine. The pressure of these 
is felt as a heavy burden by most physicians, although it 
may be concealed by calmness, cheerfulness, and either 
brusque or jovial manners. 
Notwithstanding its arduous duties and the many sacri- 
fices which it involves, the medical profession does not lack 
members, and in many places it is overcrowded. There are 
but few communities in which patients have not a choice 
among a considerable number of practitioners. In selecting 32 
MEDICAL ETHICS AND ETIQUETTE. 
a medical adviser or a family physician, most patients are 
influenced not a little by external appearances and by feel- 
ings of friendly interest. It can not be expected that they 
can judge critically of professional attainments. To form 
any accurate judgment of skill in therapeutics is by no 
means always easy for the medical observer, and it is simply 
impossible for those who are not versed in medical knowl- 
edge to decide how much to attribute to nature and how 
much to art in recovery from disease. True it is that very 
many believe themselves fully warranted in assuming to 
determine in individual cases whether a practitioner de- 
serves credit or blame; but this belief is no evidence of the 
correctness of the assumption. Many do not hesitate to 
decide as to the relative merits of what is known as the 
regular practice and the various systems which appeal to 
popular favor on the ground of having originated in ad- 
vanced views of medicine. This fact is proof of credulity 
in matters pertaining to the practice of medicine; for sure- 
ly no one can claim that the decisions often so readily formed 
have any logical foundation. Undoubtedly a pleasing ad- 
dress, together with good judgment and tact in matters not 
strictly connected with medical services, often goes far toward 
obtaining and preserving the confidence of patients. There 
is nothing wrong in this; but it need not be argued that to 
deserve confidence something more than these recommenda- 
tions is requisite. It follows from what has been stated 
that the evidence of having received a good medical educa- 
tion is not to be overlooked in selecting a medical adviser. 
Of this evidence every one can form an opinion. Aside 
from official testimony, the good sense which a physician 
shows in matters not connected with medicine is to be 
taken into account, and the esteem in which he is held by 
his professional brethren. The importance of a discrimina- 
tion among physicians according to their educational rec- OBLIGATIONS OF PATIENTS TO PHYSICIANS. 
33 
ommendations does not relate exclusively to the interests of 
patients in selecting medical advisers. Such a discrimina- 
tion is likely to have not an inconsiderable influence on the 
promotion of medical education. 
Intemperance is a calamity as great in the practice of 
medicine as in any other calling. There are few spectacles 
more painful than a drunken doctor at the bedside of a pa- 
tient affected with a disease involving immediate danger to 
life. Such a spectacle happily is rare. It can not be said 
that intemperance is largely prevalent in the medical pro- 
fession. There is no need of impressing upon patients the 
fact that a physician devoted to drinking-saloons, the bill- 
iard-table, horse-racing, and other kindred pleasures so 
called, or to the gayeties of fashionable life, is not to be pre- 
ferred to one of different habits and tastes. This is well 
enough understood. The acquaintances which a doctor 
makes in frivolous or low associations do not prefer him as 
their medical adviser. In like manner the public is suffi- 
ciently alive to the damaging effect on the professional 
character of the medical practitioner by an unduly absorb- 
ing interest in art, literature, or pursuits of any kind which, 
although in themselves worthy, direct the attention from 
the duties of his profession. 
It is wise to select a medical adviser when in health. 
Ho one should be uncertain upon whom to call for profes- 
sional services. The selection, if deferred in case of illness 
until a time when these services are needed, perhaps sud- 
denly, can not be deliberate, and must often be determined 
by accident. A patient under those circumstances is liable 
to be placed in a situation of much embarrassment; the 
physician accidentally in charge may not prove acceptable, 
but it is painful to make a change. The responsibility in 
cases of disease should be concentrated upon one person. 
It is unwise to have several medical advisers—one for dis- 34 
MEDICAL ETHICS AND ETIQUETTE. 
eases of the chest, another for nervous diseases, etc. The 
interests of patients are best subserved by having those who 
are distinguished as specialists always act in concert with 
the one who stands in the relation of medical adviser. It 
is the duty of the latter to decide whether certain ailments 
are trivial, or whether they betoken an important malady; 
hence, the importance of consulting him at once, wherever 
there are any symptoms of disease. Patients who have a 
proper degree of confidence in their physicians will be un- 
reserved in their communications, thus giving every oppor- 
tunity of judging respecting the agencies which may be 
involved in producing or maintaining the conditions of dis- 
ease. A physician never considers anything to savor of in- 
delicacy which may have a bearing on the knowledge of 
the case which he is called upon to treat. On the other 
hand, the patience of physicians is sometimes sadly tried by 
needless details. After a brief account, a competent physi- 
cian understands vastly better than the patient the differ- 
ent directions in whicli it is desirable to push inquiries. 
Lengthened descriptions of morbid sensations or feelings 
are not only needless and tiresome, but confusing. Above 
all, patients should forbear writing out a full history of their 
subjective symptoms. 
There is a class of patients much dreaded by physicians, 
namely, those who insist upon being taken into a medical 
consultation with regard to the treatment. Such patients 
desire not only to know what medicines are prescribed, but 
to discuss the reasons therefor; they are not content with- 
out exercising their own judgment concerning therapeutic 
indications and the means of fulfilling them. Still more, 
they sometimes undertake to dispense with or to modify 
the directions of the physician in his absence, according to 
their own ideas or modes of reasoning. It is not only very 
unsatisfactory to treat such patients, but they are likely to OBLIGATIONS OF PATIENTS TO PHYSICIANS. 
35 
fail to receive the full benefit of judicious treatment. If a 
patient has full confidence in his physician, he should fol- 
low strictly, without contention or distrust, all medical di- 
rections. If a patient has not full confidence in his physi- 
cian, it is best for all concerned that another be substituted. 
The impropriety of professional conversations with phy- 
sicians not in charge of a case should be understood by 
patients as well as physicians. A proper sense of propriety 
will deter the latter from making any inquiries as to the 
symptoms and treatment, or offering any observations. To 
act according to the advice of different physicians, the lat- 
ter being in ignorance of the fact, is not only dishonorable, 
but prejudicial to the welfare of the patient. If the advice 
of more than one be desired, the proper way to obtain it is 
by a professional consultation, which no physician should 
ever decline, provided the one proposed to be called in con- 
sultation be acceptable to him. To request the services of 
a consulting physician without the knowledge and consent 
of the physician in charge is a gross discourtesy, and, if 
done under circumstances which imply lack of confidence, 
the latter is fully justified in relinquishing the case. 
Patients Avho have lost confidence in their physicians 
should request discontinuance of their services. So essen- 
tial is full confidence in the treatment of cases of disease 
that it is a false delicacy to conceal the want of it. It is 
best for both the patient and the physician that there be a 
change. The code states that common courtesy and justice 
require that, when a physician is dismissed, the reasons 
should be disclosed. But the loss of confidence is in itself 
a sufficient reason, no matter how unreasonable the loss 
may be. A high-minded physician can not wish to con- 
tinue in charge if he can not have the confidence of the 
patient. He should take the initiative in the relinquish- 
ment of the case whenever he is satisfied that confidence is 36 
MEDICAL ETHICS AND ETIQUETTE. 
lost. The reasons for the loss of confidence in some in- 
stances may be as indefinite as in the following familiar 
lines: 
“ I do not like thee, Dr. Fell; 
The reason why I can not tell; 
But this I know, and that full well, 
I do not like thee, Dr. Fell.” 
Now, under such circumstances, Dr. Fell should be satisfied 
with the information conveyed by these lines, and retire 
from the case. 
The inability to systematize his work is a great draw- 
back to the comfort of the medical practitioner. Patients 
can do not a little toward relief in this regard by observing 
the injunctions contained in the ninth section of the article 
of the code now commented upon. This reference suffices 
for that section. The tenth and last section of the article 
expresses a truth which, for the majority of patients, need 
not have been expressed. The feelings of a patient at the 
time of recovery from disease, as contrasted with those at 
a later period, have furnished a subject for jests and humor- 
ous illustrations; but “ a just and enduring sense of the 
value of the services rendered him by his physician ” is felt 
by the patient as a rule, and the degree of grateful appre- 
ciation of these services by the many more than compen- 
sates for a lack of this appreciation by the few. CHAPTER 11. 
OF THE DUTIES OF PHYSICIANS TO EACH OTHER AND TO 
THE PROFESSION AT LARGE. 
Art. I.—Duties for the Support of Professional Character. 
Section 1. Every individual, on entering the profession, as 
he becomes thereby entitled to all its privileges and immunities, 
incurs an obligation to exert his best abilities to maintain its 
dignity and honor, to exalt its standing, and to extend the 
bounds of its usefulness. He should, therefore, observe strictly 
such laws as are instituted for the government of its members; 
should avoid all contumelious and sarcastic remarks relative 
to the faculty as a body; and, while by unwearied diligence 
he resorts to every honorable means of enriching the science, 
he should entertain a due respect for his seniors, who have, by 
their labors, brought it to the elevated condition in which he 
finds it. 
Section 2. 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 physician owes alike to his pro- 
fession and to his patients. It is due to the latter, as without it 
he can not command their respect and confidence, and to both, 
because no scientific attainments can compensate for want ot 
correct moral principles. It is also incumbent upon the faculty 
to be temperate in all things, for the practice of physic requires 
the unremitting exercise of a clear and vigorous understanding; 
and, on emergencies, for which no professional man should be 
unprepared, a steady hand, an acute eye, and an unclouded head 
may be essential to the well-being, and even to the life, of a 
fellow-creature. 38 
MEDICAL ETHICS AND ETIQUETTE. 
Section 3. It is derogatory to the dignity of the profession 
to resort to public advertisements, or private cards, or handbills, 
inviting the attention of individuals affected with particular 
diseases—publicly offering advice and medicine to the poor 
gratis, or promising radical cures; or to publish cases and 
operations in the daily prints, or suffer such publications to be 
made ; to invite laymen to he present at operations, to boast ot 
cures and remedies, to adduce certificates of skill and success, 
or to perform any other similar acts. These are the ordinary 
practices of empirics, and are highly reprehensible in a regular 
physician. 
Section 4. Equally derogatory to professional character is 
it for a physician to hold a patent for any surgical instrument 
or medicine; or to dispense a secret nostrum, whether it he the 
composition or exclusive property of himself or of others. For, 
if such nostrum be of real efficacy, any concealment regarding 
it is inconsistent with beneficence and professional liberality; 
and if mystery alone give it value and importance, such craft 
implies either disgraceful ignorance or fraudulent avarice. It is 
also reprehensible for physicians to give certificates attesting the 
efficacy of patent or secret medicines, or in any way to promote 
the use of them. 
The late Alexander 11. Stevens, in his acknowledgment 
of the honor of an election to the presidency of the Ameri- 
can Medical Association, at its first annual meeting in 1848, 
spoke of the profession of medicine in the following terms : 
“ Our profession, gentlemen, is the link that unites Science 
and Philanthropy. It is one of the strongest ligaments 
that binds together the elements of society. It teaches the 
rich their dependence, and elevates the poor to a sense of 
the innate dignity of their nature. Its aim is to add to the 
comfort and duration of human life. In a country where 
population is not crowding on the means of subsistence, and 
where every individual has the largest opportunity of pro- 
moting his own happiness and of perpetuating it in his pos- 
terity, the medical profession, entirely philanthropic in its DUTIES OF PHYSICIANS TO EACH OTHER. 
39 
objects, more intimately connected with the pursuits of 
science than the other learned professions, and not over- 
shadowed by an hereditary aristocracy, enjoys pre-eminent- 
ly a high social position, and, for all legitimate objects, a 
commensurate influence.” Eulogiums equally glowing, in 
view of its beneficent objects, have come from speakers and 
writers not of the medical profession. It is not a small 
thing to belong to a profession so much honored, and plain- 
ly it is the duty of its members to do nothing to impair, 
but everything to sustain and promote, its honorable char- 
acter. It may be said that the sentiments expressed in re- 
lation to the “ duties for the support of professional charac- 
ter,” contained in the two first sections under this head, are 
mere truisms and platitudes. This may be said with regard 
to any collection of ethical principles for the regulation of 
human conduct. Experience shows the importance of the 
embodiment in language of moral principles pertaining to 
other of the relations of life, and there is reason to believe 
that this portion of the code has had not an inconsiderable 
influence upon the character of the profession by inciting 
its members to become worthy of it, and to render it still 
more worthy of the estimation in which it is generally held 
by the public. 
There can be no difference of opinion in the minds of 
worthy physicians as to the acts which in the third section 
of this article are specified as derogatory to the dignity of 
the profession. But the propriety of the interdiction of 
these acts by the code is not always appreciated by the 
public. As a reason for their being interdicted as “ highly 
reprehensible in a regular physician,” it suffices to say that 
“ they are the ordinary practices of empirics.” The public 
should understand that these practices are criteria of irregu- 
lar or unworthy practitioners. With this understanding, if 
persons consent to be influenced by such acts, the responsi- 40 
MEDICAL ETHICS AND ETIQUETTE. 
bility for consequences lies with themselves. The credulity 
in regard to therapeutics which is inherent in the minds of 
many will doubtless always afford encouragement for a con- 
tinuance of the various meretricious methods of obtaining 
credit for superior medical or surgical skill. 
There are certain conventional rules, differing in differ- 
ent places, which come under the head of etiquette rather 
than ethics. In the city of New York it would be deemed 
unbecoming to insert a card with residence and office hours, 
or a notice of removal, in a medical journal, and still more 
in a newspaper or any non-medical periodical. But in some 
other cities such notices in a medical journal are not looked 
upon as improper, and in some parts of the country even 
advertisements in newspapers by physicians, stating that 
they are candidates for practice, are not objected to. In 
Paris a professional cloor-plate is a deviation from propriety. 
In New York a door-plate or sign, modest in its proportions 
as in other regards, is the rule. But in some places the 
traditional “ doctor’s shingle ” is a board which, in size and 
conspicuousness, would answer for a drug-shop, with, per- 
haps, an arrangement for illumination at night. In these 
and other matters falling in the category of conventional 
rules, it is, to say the least, not in good taste for any one to 
go beyond the limits which custom defines. 
The grounds for the injunction not to patent remedies 
or surgical instruments, and not to dispense secret nostrums, 
are not always appreciated by the public. Some appear to 
think that it is dictated by jealousy or professional preju- 
dice. The reasons are concisely but clearly stated in the 
code. Imagine Jenner to have applied for a patent giving 
exclusive property in vaccination, or keeping it a secret! 
How different would the names of those identified with the 
discovery and introduction of anaesthesia in surgical and 
medical practice appear in history had the attempt not DUTIES OF PHYSICIANS TO EACH OTHER. 
41 
been made to withhold from the profession and the public 
the agent employed, and to secure a proprietary interest 
therein ! Here, as in all other instances, the restrictions of 
the code of ethics have reference to the welfare of the com. 
munity, and not to the selfish interests of the medical pro- 
fession. 
Aet. ll.—Professional Services of Physicians to each other. 
Section 1. All practitioners of medicine, their wives, and 
their children while under the paternal care, are entitled to the 
gratuitous services of any one or more of the faculty residing 
near them, whose assistance may be desired. A physician afflict- 
ed with disease is usually an incompetent judge of his own case; 
and the natural anxiety and solicitude which he experiences at 
the sickness of a wife, a child, or any one who, by the ties of 
consanguinity, is rendered peculiarly dear to him, tend to ob- 
scure his judgment, and produce timidity and irresolution in his 
practice. Under such circumstances, medical men are peculiarly 
dependent upon each other, and kind offices and professional aid 
should always be cheerfully and gratuitously afforded. Visits 
ought not, however, to be obtruded officiously, as such unasked 
civility may give rise to embarrassment, or interfere with that 
choice on which confidence depends. But if a distant member 
of the faculty, whose circumstances are affluent, request attend- 
ance, and an honorarium be offered, it should not be declined ; 
for no pecuniary obligation ought to be imposed which the 
party receiving it would wish not to incur. 
Proper delicacy as regards visiting their brethren in 
sickness is not always observed by medical men. From the 
best of motives, the professional friends and neighbors of a 
sick physician are apt to call upon him, inquire into his 
case, proffering their opinions and advice, without any con- 
cert between them, and the result is that a medical patient 
may receive no systematic treatment; he is more poorly 
cared for in this respect than the poorest of non-medical 
patients. He often can not, without much embarrassment, MEDICAL ETHICS AND ETIQUETTE. 
42 
exercise the privilege of the latter in selecting the advisers 
whom he would prefer. He should not be deprived of this 
privilege, and the greatest care should be taken to secure it 
for him. Except in cases where close intimacy dictates a 
deviation from the rule, a physician should not ask to see 
another physician in illness until requested to do so. The 
manifestation of interest and sympathy should be limited to 
kind messages and inquiries through others. It is as im- 
portant to a physician who is sick as to others, to have a 
regularly selected physician in attendance, and consulta- 
tions, if desired, should be had in the same way as in other 
cases. 
Naturally and properly, medical services rendered to 
members of the profession should be gratuitous. The rule 
with regard to an honorarium, however, is a sound one in 
this application: namely, one has no right to impose a pecu- 
niary obligation when it is distinctly against the wishes of 
the party receiving the services. This rule is applicable 
here as in other cases. A request to present a bill for ser- 
vices, however, should never be made. Such a request im- 
plies an expectation that it will not be complied with. Any 
pecuniary acknowledgment by a member of the profession 
for medical services should be made strictly as an honora- 
rium. 
Aet. lII. Of the Duties of Physicians as respects Vicarious 
Offices. 
Section 1. The affairs of life, the pursuit of health, and the 
various accidents and contingencies to which a medical man is 
peculiarly exposed, sometimes require him temporarily to with- 
draw from his duties to his patients, and to request some of his 
professional brethren to officiate for him. Compliance with 
this request is an act of courtesy, which should always be per- 
formed with the utmost consideration for the interest and char- 
acter of the family physician, and, when exercised for a short DUTIES OP PHYSICIAN'S TO EACH OTHER. 
43 
period, all the pecuniary obligations for such service should be 
awarded to him. But if a member of the profession neglect his 
business in quest of pleasure and amusement, he can not be con- 
sidered as entitled to the advantages of the frequent and long- 
continued exercise of this fraternal courtesy without awarding 
to the physician who officiates the fees arising from the dis- 
charge of his professional duties. 
In obstetrical and important surgical cases, which give rise 
to unusual fatigue, anxiety, and responsibility, it is just that the 
fees accruing therefrom should be awarded to the physician who 
officiates. 
The code of ethics defines the line of conduct in many 
instances of which it may be said that a proper courtesy and 
sense of honor should suffice without formal ethical rules. 
Assuming that an adequate degree of courtesy and sense of 
honor belong to members of the medical profession in general, 
to assume this for all members would be to claim for medicine, 
in a moral point of view, a position far above that of any 
other pursuit. Ethical rules, therefore, are needed for a 
greater or less number of physicians. But, irrespective of 
any question of moral delinquency, rules are useful by indi- 
cating precisely what is to be done under certain circum- 
stances, thus preventing embarrassment and saving the 
trouble of discussion in particular instances. It is to some 
extent a popular impression that the feelings of physicians 
toward each other are rather repellent than attractive. This 
impression is groundless. There is no class of men among 
whom fraternal sentiments prevail more than among practi- 
tioners of medicine. Personal antipathies from local jeal- 
ousies, and, occasionally, incident to differences in opinion 
concerning questions which are considered as involving im- 
portant interests of the profession, do not invalidate the 
correctness of this statement. Requests for vicarious offices, 
as well as other services for professional brethren, are usually 
cheerfully complied with. 44 
MEDICAL ETHICS AND ETIQUETTE. 
Vicarious offices offer an opportunity for one deficient 
in a proper sense of honor to undermine the confidence of 
patients in their physicians. This may be done, not openly, 
hut insidiously, by questions, expressions of surprise, over- 
assiduous attentions, etc. It will do much toward neutraliz- 
ing such violations of honor if the public be made ac- 
quainted with the article of the code which relates to these 
offices. Patients will be led to understand the motive 
which prompts such dishonorable efforts, and, so far from 
accomplishing the objects, they will justly react upon un- 
worthy members who act in opposition to the spirit of the 
code. It sometimes happens that a patient placed under 
the care, temporarily, of a practitioner, prefers that the sub- 
stitute should continue permanently in charge. A patient 
may express a wish to that effect from a feeling that it is 
an act of courtesy to do so, at the same time, perhaps, be- 
ing anxious that the family physician should resume his 
services. In order to avoid all difficulties, the physician 
who has performed vicarious offices in any case should re- 
linquish the case, as soon as these offices are no longer 
needed, into the hands of the physician for whom he has 
acted, without any explanation or discussion with the pa- 
tient or friends. If requested to remain in charge, he should 
positively decline. The family physician, after having been 
reinstated, is then, of course, free to act in conjunction with 
the wishes of the patient and friends, as regards the con- 
tinued attendance of his substitute, either in consultation 
or in charge of the case. 
The rules in regard to fees being clearly stated, there 
need be no embarrassment nor discussion on this score in 
particular cases. DUTIES OF PHYSICIANS TO EACH OTHER, 
Art. IV.— Of the Duties of Physicians in Regard to Con- 
sultations. 
Section 1. A regular medical education furnishes the only 
presumptive evidence of professional abilities and 
and ought to he the only acknowledged right of an individual 
to the exercise and honors of his profession. Nevertheless, as 
in consultations the good of the patient is the sole object in 
view, and this is often dependent on personal confidence, no in- 
telligent regular practitioner, who has a license to practice from 
some medical board of known and acknowledged respectability, 
recognized by this association, and who is in good moral and 
professional standing in the place in which he resides, should be 
fastidiously excluded from fellowship, or his aid refused in con- 
sultation, when it is requested by the patient. But no one can 
be considered as a regular practitioner or a fit associate in con- 
sultation whose practice is based on an exclusive dogma, to the 
rejection of the accumulated experience of the profession, and 
of the aids actually furnished by anatomy, physiology, pathology, 
and organic chemistry. 
The foregoing section has of late been made the subject 
of much discussion. Of the entire code this section alone 
has occasioned dissension. The writer of these remarks is 
one of many who think that the code is here open to objec- 
tion, not, however, in spirit or intent, but in phraseology. 
The last sentence is the part concerning which an objection 
may fairly be raised. At the time when the code was 
adopted by the American Medical Association, the irregular 
practitioners, so-called, were, for the most part, uneducated 
men, whose practice was not only based on an exclusive dog- 
ma, but, professedly, to the “ rejection of the accumulated ex- 
perience of the profession, and of the aids actually furnished 
by anatomy, physiology, pathology, and organic chemistry.” 
They were “steam doctors,or Thomsonians,” “botanical or 
herb doctors,” “ eclectics,” and the like. A system of prac- 
tice based on the dogmas of Hahnemann had not then ac- 46 
MEDICAL ETHICS AND ETIQUETTE. 
quired a hold on popular favor. A considerable number of 
those who became homoeopathic practitioners, as they are 
termed, were from the ranks of the medical profession, and 
had received a regular medical education. Since the adop- 
tion of the code, this system has obtained a legal recogni- 
tion. It has its societies, colleges, and journals. The 
homoeopathic practitioners are an organized class, distinct 
from the regular profession. They are candidates for prac- 
tice on the ground of a radical distinction in their thera- 
peutical system, and it is on this ground that patients elect 
their services. Meanwhile, other systems in antagonism to 
the regular profession are comparatively insignificant as 
regards the number of practitioners and of patients. 
It is fair to conclude that the framers of the code had 
no feeling of illiberality, and no intention to interfere with 
the practice of medicine, under any circumstances, in the 
cause of humanity. The code declares explicitly that “in 
consultations the good of the patient is the sole object in 
view,” and enjoins against declining consultations on the 
score of fastidiousness. The restrictions of the code are 
in no wise inconsistent with the demands of humanity in 
cases of emergency. In saying that certain practitioners 
are not to be considered as regular or fit associates in con- 
sultation, it is neither said nor implied that a physician 
should not see a patient even with these practitioners when 
humanity requires him to do so. The tenor and spirit of 
the code throughout are opposed to any act of professional 
inhumanity. Moreover, in particular cases, the physician 
must be the judge of his duty in this regard. Practically, 
there need be no difficulty in deciding how to obey the 
dictates of humanity, and, at the same time, conform to the 
code, under the guidance of a conscientious regard for both. 
The objectionable point in the code is that which makes 
“a practice based on an exclusive dogma” the ground of a DUTIES OF PHYSICIANS TO EACH OTHER. 
47 
refusal to meet practitioners in consultation. This is not a 
valid objection. Any physician has a right either to origi- 
nate or adopt an exclusive dogma, however irrational or 
absurd it may he. Dogmas have prevailed more or less in 
the past history of medicine. If in a consultation there be 
lack of agreement respecting either diagnosis or treatment, 
the code indicates in another article precisely the course 
to be pursued. The true ground for refusing fellowship in 
consultations, as in other respects, is a name and an organi- 
zation distinct from and opposed to the medical profession. 
Whenever practitioners assume a distinctive appellation, 
thereby assuming to represent an essentially distinct system 
of practice, taking an attitude of antagonism to the regular 
profession, seeking popular favor on the ground that they 
belong to a “ new school ” based on truth and productive 
of good, whereas the regular profession belong to an “ old 
school ” based on error and productive of harm—how can 
there be fellowship either in consultations or in other re- 
spects ? If they who thus assume an attitude of antagonism 
to the medical profession conscientiously hold to the dis- 
tinctive tenets which, as they profess, are the ground of their 
antagonism, how can they consistently desire to meet mem- 
bers of the latter in consultation, and, with opposing views 
of therapeutics, how could such consultations accomplish 
“ the sole object in view,” namely, “ the good of the pa- 
tient ” ? If, as is asserted, homoeopathy has practically been 
abandoned by most of those who practice under this name, 
or so modified that the modes of treatment in cases of dis- 
ease are not essentially different from those of the regular 
protession, why retain the separate organization and the 
name, which imply to the public a radical therapeutic dis- 
tinction ? If the assertion be true, the name and the or- 
ganization being retained, professional fellowship is rendered 
thereby immoral on the ground of complicity in a fraud 48 
MEDICAL ETHICS AND ETIQUETTE. 
upon the public. It is to be hoped that the body from 
which the code emanated—namely, the American Medical 
Association—will adopt such modifications in the phraseolo- 
gy of this section as will place restrictions on consultation, 
not on the ground of doctrines or forms of belief, but on 
separation from and avowed antagonism to the medical pro- 
fession. Under no circumstances can there consistently be 
fellowship with any class of practitioners who adopt a dis- 
tinctive title as a trade-mark, and who are banded in’ order 
to impair the confidence of the public in the medical pro- 
fession,* To take the ground that, because the Legislature 
of a State has placed on an equal legal footing different 
classes of practitioners, those of one class can not refuse 
to consult with those of another class, is as absurd as to 
* The action of the British Medical Association is in accordance 
with this view. The two following resolutions are quoted from a seines 
adopted by that body: 
“Resolved, That homoeopathic practitioners, through the press, the 
platform, and the pulpit, have endeavored to heap contempt upon the 
practice of medicine and surgery, as followed by members of this asso- 
ciation, and by the profession at large. 
“ Resolved, That for these reasons it is derogatory to the honor of 
members of this association to hold any kind of professional inter- 
course with homoeopathic practitioners.”—Vide “British Medical 
Journal,” June 10, 1882, 
In these resolutions the repudiation of homoeopathic piactitionera 
is based on their attitude toward the practice of medicine as followed 
by the profession at large, and not on the dogmas which they profess, 
although in another resolution the latter are characterized as “utterly 
opposed to science and common sense, as well as completely at vari- 
ance with the experience of the medical profession.” Another resolu- 
tion is, “ That there are three classes of practitioners who ought not to 
be members of this association [British Medical] : 1. Real homoeopathic 
practitioners; 2. Those who practice homoeopathy in combination with 
other systems of treatment; and 3. Those who under various pretences 
meet in consultation, or hold professional intercourse with those who 
practice homoeopathy.” DUTIES OF PHYSICIANS TO EACH OTHER. 
49 
assert that a Jewish rabhi is bound to exchange pulpits 
with Christian ministers, or the latter to affiliate with Mor- 
mon elders for the reason that, in the eye of the law, in this 
country, all religious denominations have equal rights. The 
people demand of their legislators the enactment of laws 
for the protection of life, liberty, and property, but they do 
not look to them for the institution or the interpretation of 
codes of ethics. If homoeopathic practitioners abandon the 
organization and the name, provided they have received a 
“ regular medical education,” there need be no restrictions 
on consultations other than those belonging to other portions 
of the code, whatever therapeutical doctrines they may hold. 
There are many, not of the medical profession, who 
have been led to believe that its members are bound to 
uphold antiquated traditional doctrines. Many seem to 
think that the “ old-school practitioners,” as they are deri- 
sively called, are committed to a system of practice expressed 
by the term allopathy. All medical men know that, so far 
from these popular notions being true, they are quite the 
reverse of truth. The term allopathy originated with 
Hahnemann, and was intended to denote a doctrine the op- 
posite to homoeopathy. It is simply a term of reproach. 
It has no pertinency as applied to the medical profession- 
As is well known by all conversant with the history of medi- 
cine, doctrines and practice undergo changes in proportion 
to the advancement in the several branches of medical 
knowledge and accumulated experience. The tendency, cer- 
tainly, within the last half century has been to adopt new 
views too readily, not heeding sufficiently the restraint of a 
rational conservatism. It is desirable that the public should 
understand that the medical profession is in no sense a sect, 
as implied by the name allopathy. It allows the utmost lati- 
tude of opinion. The sectarians in medicine are those who 
have professed faith in tenets to which they are bound, at 50 
MEDICAL ETHICS AND ETIQUETTE. 
least ostensibly, to adhere. Opinions held by members of 
the regular profession, however at variance with those gen- 
erally entertained, and however absurd, may fairly give rise 
to criticism, and ridicule, but they can not be made occa- 
sions for professional discipline. With a proper understand- 
ing of the reasons which actuate members of the medical pro- 
fession in declining to meet irregular practitioners, their 
action can not be attributed to either jealousy or prejudice. 
Their action, indeed, may involve the sacrifice of personal 
interests, and it concerns the public welfare not less than the 
dignity and honor of the profession. Let the statement be 
repeated, until no longer necessary for the information of the 
public, that there are no allopathic practitioners of medicine. 
A regular member of the medical profession should never 
even tacitly admit the propriety of this designation. Let 
it be understood by the public, as well as by the profession, 
that there is no necessity for a schismatic separation from 
the regular profession on account of any peculiarity of doc- 
trine. Such a separation is not from necessity, hut for the 
purpose of obtaining practice. That it is successful for 
that end, observation shows. Why it is so is a question in 
psychology, the discussion of which would be out of place 
here. 
Section 2. In consultations, no rivalship or jealousy should 
be indulged; candor, probity, and all due respect should be 
exercised toward the physician having charge of the case. 
Section 7. All discussions in consultation should be held as 
secret and confidential. Neither by words nor manner should 
any of the parties to a consultation assert or insinuate that any 
part of the treatment pursued did not receive his assent. The 
responsibility must be equally divided between the medical at- 
tendants—they must equally share the credit of success as well 
as the blame of failure. 
Section 10. A physician who is called upon to consult 
should observe the most honorable and scrupulous regard for DUTIES OF PHYSICIANS TO EACH OTHER. 
51 
the character and standing of the practitioner in attendance; 
the practice of the latter, if necessary, should he justified as 
far as it can be consistently with a conscientious regard for 
truth, and no hint or insinuation should be thrown out which 
could impair the confidence reposed in him, or atfect his repu- 
tation. The consulting physician should also carefully refrain 
from any of those extraordinary attentions or assiduities which 
are too often practiced by the dishonest for the base purpose of 
gaining applause* or ingratiating themselves into the favor of 
families and individuals. 
These three sections of Article IY, although not occur- 
ring consecutively in the code, are here collocated because 
they contain ethical rules which have reference to the rela- 
tions of consulting with attending physicians. 
Reference may be made again to the popular errors con- 
cerning consultations Avhich prevail to some extent among 
members of the medical profession. One of these errors 
is that a consultation, when requested by patients or their 
friends, implies, as a matter of course, dissatisfaction with 
the services of the physician in attendance. The request 
should never be considered in that light. Connected with 
this error is another, namely, that it is the office of a con- 
sulting physician to pronounce a judicial decision respect- 
ing the treatment which has been pursued, or which is 
being pursued, by the physician with whom he is requested 
to consult. This is not the office of a consulting physician. 
He should be reserved in forming an opinion as to past 
treatment, inasmuch as the case was not under his observa- 
tion, and it would be unfair to judge of circumstances which 
he had not observed; hence, an opinion unfavorable to the 
past treatment, if indiscreetly formed and still more indis- 
creetly uttered to any but the attending physician, might 
do the latter great injustice. Whatever judgment he may 
form respecting the treatment which is being pursued, is 
for the physician in attendance, and for no one else. Still 52 
MEDICAL ETHICS AND ETIQUETTE. 
another error is to assume that a physician in consultation 
has more knowledge or skill than the attending physician, 
and that, consequently, the latter is to be subordinate to 
the former in the management of a case. A consulting 
physician may or may not be the superior in knowledge or 
skill. Not infrequently a physician is called in consulta- 
tion for the reason that he has given special attention to 
the disease from which the patient is suffering; but, exclu- 
sive of these instances, a consultation should by no means 
imply, as a matter of course, a superiority of the consulting 
physician. These errors, prevailing somewhat in the pro- 
fession, have a much larger popular prevalence. It is owing 
to their prevalence that medical consultations are not more 
frequent. Patients and their friends often hesitate to pro- 
pose a consultation from a desire not to imply want of con- 
fidence in the attending physician. The physician is often 
reluctant to propose it lest the proposal be considered as a 
confession of deficient self-confidence, or because he is dis- 
trustful of the one who is likely to be called in consultation, 
and who is, perhaps, his rival or competitor in practice. Let 
these errors in the profession and in the public mind be re- 
moved, and consultations will be much more frequent than 
they now are. So far as the physician is concerned, a con- 
sultation with those whom he can conscientiously meet on 
terms of fellowship, and in whose honor he can trust, is a 
source of much relief and comfort. Aside from any assist- 
ance which he may derive from it, the responsibility of the 
case is divided, and his hands are strengthened by the in- 
creased confidence of those most interested. Moreover, 
rightly conducted consultations tend to enhance popular 
regard for the medical profession; hence, it is much to be 
desired that the public should have correct ideas on this 
subject. 
The true ground for a medical consultation is the bene- DUTIES OF PHYSICIANS TO EACH OTHER. 
53 
fit which may be derived by bringing the judgment of two 
or more minds to bear upon a case. There are few things in 
human life which are generally considered more precious 
than health, and there are few calamities which, in the*minds 
of most persons, it is more desirable to postpone than death. 
It is, therefore, a singular anomaly that conferences on mat- 
ters of far less importance than those relating to health and 
life, such as business interests, politics, social life, etc., are 
more frequent than medical consultations. In cases of dis- 
ease, these are frequently delayed until the condition of the 
patient is hopeless, and when no real benefit can possibly be 
derived from them. Not only should they be had earlier, 
but they should not be limited to cases in which there is 
more or less immediate danger. The fact that they are apt 
to be thus limited renders them a source of apprehension to 
patients, and, for this reason, they are sometimes delayed. 
The public should understand it to be a point of honor 
with honorable members of the profession to hold every- 
thing which takes place in consultation as secret and con- 
fidential. It should be understood that it is improper to 
ask such questions of the attending physician as “ What did 
the physician in consultation say?” “Did he make any 
change in the treatment ? ” etc.; or of the consulting phy- 
sician, “ Does the attending physician understand the case ? ” 
“ Has he treated it properly ? ” etc. Sometimes friends of a 
patient, who are not members of the medical profession, 
wish to be present at a consultation. This is never allowa- 
ble. As it may be a matter of delicacy for the attending 
physician to request them to retire, this should, if omitted 
by him, always be done by the physician in consultation. 
A consulting physician is placed in a most constrained situ- 
ation if, as is sometimes done, the physician in attendance 
requests friends of the patient to be present. The request 
should not be acceded to. If the attending physician ask MEDICAL ETHICS AND ETIQUETTE. 
of the consulting physician, in the presence of patients or 
friends, if there he agreement, the answer should he frank 
and positive. The consulting physician may sometimes 
make this statement of his own accord, hut it is gratuitous, 
and may he offensive if made without any intimation of a 
want of confidence in the attending physician, or in an as- 
suming, patronizing manner. Unless there he a difference 
of opinion, which is provided for in another section of this 
article of the code, an imperative duty of a consulting phy- 
sician is to sustain and promote confidence in the attending 
physician. In this way, as well as hy any suggestions which 
he may have made in relation to treatment, he contributes 
to the “ good of the patient.” 
Section 3, In consultations, the attending physician should 
be the first to propose the necessary questions to the sick, after 
which the consulting physician should have the opportunity to 
make such further inquiries of the patient as may be necessary 
to satisfy him of the true character of the case. Both physicians 
should then retire to a private place for deliberation; and the 
one first in attendance should communicate the directions agreed 
upon to the patient or his friends, as well as any opinions which 
it may be thought proper to express. But no statement or dis- 
cussion of it should take place before the patient or his friends, 
except in the presence of all the faculty attending, and by their 
common consent; and no opinions or prognostications should be 
delivered which are not the result of previous deliberation and 
concurrence. 
Section 4. In consultations, the physician in attendance 
should deliver his opinion first; and, when there are several con- 
sulting, they should deliver their opinions in the order in which 
they have been called in. No decision, however, should restrain 
the attending physician from making such variation in the 
mode of treatment as any subsequent unexpected change in the 
character of the case may demand. But such variation and the 
reasons for it ought to be carefully detailed at the next meet- 
ing in consultation. The same privilege belongs also to the DUTIES OF PHYSICIANS TO EACH OTHER. 
55 
consulting physician if he is sent for in an emergency, when 
the regular attendant is out of the way, and similar explana- 
tions must be made by him at the next consultation. 
Section 5. The utmost punctuality should be observed in the 
visits of physicians when they are to hold consultation together, 
and this is generally practicable, for society has been consider- 
ate enough to allow the plea of a professional engagement to 
take precedence of all others, and to be an ample reason for 
the relinquishment of any present occupation. But, as profes- 
sional engagements may sometimes interfere, and delay one of 
the parties, the physician who first arrives should wait for his 
associate a reasonable period, after which the consultation 
should be considered as postponed to a new appointment. If 
it he the attending physician who is present, he will, of course, 
see the patient and prescribe; but, if it be the consulting one, 
he should retire, except in case of emergency, or when he has 
been called from a considerable distance, in which latter case he 
may examine the patient, and give his opinion in writing, and 
under seal, to be delivered to his associate. 
The above rules relate to etiquette in consultations, as 
distinct from ethics. Of less importance than the latter, 
they are, nevertheless, important. As it is an essential part 
of the office of a physician in consultation to co-operate in 
all regards with the physician in attendance, and to pro- 
mote the confidence of the patient, he should take pains to 
treat the latter with becoming consideration and respect. 
The physician in consultation is supposed to be present at 
the instance of the physician in attendance; he should cer- 
tainly decline to be present if not with the full consent of 
the latter, lie is, in the first place, to listen to a recital of 
the history of the case by the attending physician. This 
may be given in the presence of the patient, or not, as the 
attending physician may deem advisable. Going*into the 
sick-chamber, the attending physician should take prece- 
dence, and, if there be more than one physician in consulta- 56 
MEDICAL ETHICS AND ETIQUETTE. 
tion, they should follow in the order in which they have been 
invited to consult in the case. Following this rule without 
any formal demonstrations will spare occasions for observ- 
ers to remark how elaborately polite doctors are to each 
other in consultations. The attending physician should al- 
ways he the first to approach the bedside and examine the 
patient, no matter how intimate may be the friendly rela- 
tions of the latter to the physician in consultation. It is a 
gross breach of propriety for a physician in consultation to 
go to the bedside at once and proceed to an examination, 
as if there were no attending physician in the case, lie is 
to await a request of the attending physician to examine the 
patient. His examination should, of course, be sufficiently 
extended, but not beyond the data requisite for forming his 
opinion. Asking superfluous or irrelevant questions and 
carrying the examination into needless details belong in the 
category of “ those extraordinary attentions or assiduities 
which are too often practiced by the dishonest for the base 
purpose of gaining applause, or ingratiating themselves into 
the favor of families and individuals.” On the other hand, 
a very cursory examination may give the impression that 
the consulting physician is able to see at a glance what the 
attending physician has failed to comprehend, perhaps after 
much painstaking investigation. Whatever may be the 
social relations of the consulting physician to the patient, it 
is but decorous that in the sick-room he should be reserved 
in both manner and conversation. It is a breach of pro- 
priety to be particularly demonstrative or loquacious. To 
the attending physician belongs the most prominent role in 
the sick-room, without regard to differences in age, expe- 
rience, or position. Answers to questions by the patient or 
surrounding friends, addressed to the consulting physician, 
prior to the consultation, as to the nature of the malady, the 
gravity of the case, etc., are to be courteously waived. DUTIES OF PHYSICIANS TO EACH OTHER. 
57 
The attending physician in the consultation-room should 
have the opportunity of first stating his views concerning 
the case, if he have not done so already in the recital of the 
history. He may, however, desire to waive this privilege, 
and request the views of the consulting physician before 
stating his own. If he have full confidence in the honor of 
the physician whom he meets in consultation, he will be 
unreserved, stating frankly his difficulties and doubts, if he 
have had any, in the diagnosis and management of the case. 
The consulting physician, if he find occasion to differ in 
opinion, should always give due consideration to the fact 
that the attending physician has had a better opportunity 
for the study of the case than he can have at a single visit. 
Allowance is also to be made for changes which are liable 
to take place in the course of a disease. It is needless to 
say that any difference of opinion should be stated with 
respectful courtesy. It is his duty to state any difference 
of opinion, and he need not feel undue delicacy in so doing, 
knowing, as he should know, that the difference, if it be not 
irreconcilable as regards the bearing on the treatment, will 
never be mentioned by himself outside of the consultation- 
room. There is a good reason, when two or more consult- 
ing physicians are present, for the attending physician to 
call first for the views of the youngest, and afterward in the 
order of juniority. The reason is that the younger will be 
likely to express his views with more freedom before than 
after the views of his seniors have been expressed. More- 
over, if there be difference of views, it is more decorous for 
the dissent to come from the older than from the younger of 
those in consultation. In the great majority of the instances 
in which there are differences in opinion they relate to 
points in pathology or etiology, and not to the diagnosis or 
treatment. There may be wide divergencies of opinion 
concerning the interpretation of the facts in a case, with 58 
MEDICAL ETHICS AND ETIQUETTE. 
complete agreement in respect of the practical points. As 
regards the latter, in most of the instances in which differ- 
ent views are expressed, they relate to the means of accom- 
plishing certain objects, there being unanimity as regards 
these. Consultations should not be unduly protracted; if 
so, patients or their friends are apt to imagine that there is 
either lack of agreement or some unusual obscurity in the 
case. 
It is the office of the attending physician to communi- 
cate to patients or their friends the result of a consultation 
as regards the nature of the case, the prognosis, and the 
treatment. He may, however, prefer that this be done by 
a physician in consultation. If done by the attending 
physician, it is generally best for the consulting physician 
or physicians to be present; otherwise, suspicious minds 
may conjecture that the views of the latter have not been 
fully or correctly stated. It should be considered a matter 
of courtesy for the attending physician to ask the consult- 
ing physician or physicians if he have stated accurately the 
result of the consultation, and to invite questions addressed 
to the latter. Often patients or their friends are not satis- 
fied without some conversation with physicians in consulta- 
tion. The conversations, however, should always take place 
in the presence of the attending physician, except the latter 
desires it to be otherwise. If there exist that entente cor- 
diale between the consulting and the attending physician 
which is desirable in consultations, the latter may request the 
former to converse with a patient or his friends by himself. 
Assurances and encouragement may in this way sometimes 
be more effectual than when given more formally by either 
when both are present. It should be considered as an in- 
sult, except that no improper reflection is intended, when 
the friends of a patient, after a consultation, seek a private 
interview with a consulting physician, in order to ascertain DUTIES OF PHYSICIANS TO EACH OTHER. 
59 
whether he really entertained the views which he had ex- 
pressed or to which he had ostensibly assented. A certain 
measure of resentment, as well as reserve, under such cir- 
cumstances, tends to impress upon the public the ethical 
rule of secrecy as regards the details of medical consulta- 
tions. 
Unessential changes in the treatment of a case should 
not directly follow a consultation. Inasmuch as the fact 
that the changes are not essential is not likely to be appre- 
ciated, they are apt to be misinterpreted, to the prejudice 
of the attending physician. Whenever there is agreement 
as to the treatment which is being pursued, it should, of 
course, be continued. It should by no means be considered 
that, as a matter of course, other or additional therapeutical 
measures are to be suggested by a physician in consultation. 
A consulting physician sometimes has unmerited credit in 
consequence of some trivial modification of the treatment, 
which is attributed to him. Simple justice to the attending 
physician dictates great delicacy and circumspection in the 
suggestion of measures of treatment which are not of imme- 
diate importance. It is needless to add that suggestions 
made for the purpose of giving the impression of a change 
in treatment are in the highest degree dishonorable. 
It may seem a small matter to enjoin punctuality in a 
code of ethics, but, in reality, the matter is of much im- 
portance. Failure to keep an appointment, or tardiness, in 
the first place, is apt to occasion annoyance to a patient, 
who may be awaiting the consultation with great anxiety. 
In the second place, the detention of the one who is punc- 
tual may upset all his arrangements for the remainder of 
the day. There are few engagements with reference to 
which a prompt fulfillment is of greater importance than 
medical consultations and other professional visits on the 
sick. It must, however, sometimes happen that the emer- 60 
MEDICAL ETHICS AND ETIQUETTE. 
gencies of medical practice prevent the fulfillment of en- 
gagements. Whenever practicable, the parties interested 
should he seasonably notified of the inability to fulfill them. 
On the other hand, it is a breach of etiquette for a consult- 
ing physician to arrive at the house of a patient much be- 
fore the time appointed for a consultation. This is not 
always easily avoided. If it so happen, he should invari- 
ably await the arrival of the attending physician without 
entering the sick-room; and he should decline to receive a 
history of the case until he can hear it from the lips of the 
physician in attendance. In observing these rules of etiquette* 
he avoids the suspicion of unprofessional conduct by taking 
a dishonorable advantage of the absence of the physician in 
charge. Here, as in other instances, the rules by which 
members of the medical profession are governed should be 
clearly stated, in order to endeavor to popularize them, and 
do away with the remark, so often made by those who are 
not members of the profession, to the effect that they are 
not acquainted with the requirements of medical etiquette. 
How long shall a consulting physician wait for the ar- 
rival of an attending physician ? The answer to this ques- 
tion will differ in different places. It is desirable that in 
each place there be some conventional rule in relation to 
the matter. In the city of New York, about fifteen min- 
utes is considered to be a proper period. At the end of 
this period, the physician is to decide whether it is advisa- 
ble to leave and arrange for another appointment, or to see 
the patient, and leave his views in a sealed note addressed 
to the attending physician. His decision must depend on 
the urgency of the case and other circumstances. In every- 
thing relating to rules of ethics and etiquette, the dictates 
of humanity are to be considered as paramount. When- 
ever the condition of a patient is such as to require imme- 
diate measures for relief, a consulting physician, in the ab- DUTIES OF PHYSICIANS TO EACH OTHER. 
sence of tlie attending physician, is to proceed as if the 
case were in his charge, giving an account of what he has 
done, either in a sealed note or subsequently by word of 
mouth, to the attending physician. It is superfluous to say 
that, under these circumstances, the character and the inter- 
ests of the attending physician are to be carefully and ten- 
derly considered. 
Section 8. Should an irreconcilable diversity of opinion 
occur when several physicians are called upon to consult to- 
gether, the opinion of the majority should he considered as de- 
cisive; but if the numbers be equal on each side, then the 
decision should rest with the attending physician. It may, 
moreover, sometimes happen that two physicians can not agree 
in their views of the nature of a case and the treatment to be 
pursued. This is a circumstance much to be deplored, and 
should always be avoided, if possible, by mutual concessions, 
as far as they can be justified by a conscientious regard for the 
dictates of judgment. But, in the event of its occurrence, a 
third physician should, if practicable, be called to act as umpire; 
and, if circumstances prevent the adoption of this course, it 
must be left to the patient to select the physician in whom he 
is most willing to confide. But, as every physician relies upon 
the rectitude of his judgment, he should, when left in the minor- 
ity, politely and consistently retire from any further deliberation 
in the consultation, or participation in the management of the 
case. 
Section 9. As circumstances sometimes occur to render a 
special consultation desirable, when the continued attendance of 
two physicians might be objectionable to the patient, the mem- 
ber of the faculty whose assistance is required in such cases 
should sedulously guard against all future unsolicited attend- 
ance. As such consultations require an extraordinary portion 
both of time and attention, at least a double honorarium may 
be reasonably expected. 
The disagreement of doctors has long been proverbial. 
Without entering into any discussion of the grounds for 62 
MEDICAL ETHICS AND ETIQUETTE. 
the popular impression that physicians are more apt to dis- 
agree than those engaged in other pursuits, it is certain that 
in medical consultations a diversity of opinions calling for 
the measures which are enjoined in the ethical code is ex- 
tremely rare. • The writer of these commentaries, during a 
long experience, has known of but very few instances. In 
the event of a diversity of opinion relating to the nature of 
the case and the treatment to be pursued, the “ good of the 
patient ” is generally better consulted by mutual concessions 
than by resorting to the measures just alluded to. The 
concessions should be mutual; that is, neither the attending 
nor the consulting physician has a right to expect that on 
his side nothing is to be conceded. The consulting physi- 
cian is to consider that the attending physician has had the 
advantage of having observed the case from the commence- 
ment, and generally, also, of a better acquaintance with the 
previous history of the patient. On the other hand, it 
often happens that the attending physician is bound to rec- 
ognize a larger experience on the side of the consulting 
physician, and, perhaps, the advantage of his having given 
special study to the disease from which the patient suffers. 
These are grounds for concession on either side. If, how- 
ever, a diversity of opinion be so great as not to be recon- 
ciled by mutual concessions, to agree seemingly, but not in 
reality, would plainly be in violation of truth and justice. 
The measures inculcated by the code, under these circum- 
stances, must commend themselves as proper, in view of the 
feelings and interests of all concerned. 
Whether consultations are to be repeated or not, and 
how frequently they are to be repeated, should be deter- 
mined by the circumstances in particular cases. When de- 
sired by patients or their friends, it is unwise for the physi- 
cian in charge to oppose their repetition on the ground that 
they are not necessary. Whether necessary or not, patients DUTIES OF PHYSICIANS TO EACH OTHER. 
63 
or their friends are entitled to have their wishes gratified in 
this regard, especially if the additional expense be under- 
stood. If their wishes be thwarted by the physician in 
charge, he may afterward have occasion for regrets. The 
consulting physician has his rights in this matter, inasmuch 
as he has assumed a part of the responsibility of the case. 
It is not, therefore, improper for him, in certain cases, to 
request additional consultations. On the other hand, he 
may be invited to repeat the consultation merely as an ex- 
pression of politeness or respect, and it may be becoming 
in him to say that he considers a repetition unnecessary. 
In general, the propriety of the rule respecting “ unsolicited 
attendance” is sufficiently obvious. The exceptional in- 
stances are those in which the consulting physician feels 
unwilling to assume a share of the responsibility without 
further observation, and those in which he has reason to 
believe that the limited means of the patient constitute 
the sole ground for not soliciting a continuance of his 
services. 
There are some points relating to the ethics and eti- 
quette of consultations which are not touched upon in the 
code. One of these is the duty of a consulting physician 
who may be asked to take the place of the attending physi- 
cian in a case while it is in progress. It may happen that 
there is dissatisfaction with the services of the attending 
physician, of which the consulting physician may not have 
been aware, and it is proposed that the former relinquish 
the case into the hands of the latter. This transfer of a 
case is justifiable on but one ground—namely, that it is in 
accordance with the wishes of the attending physician. The 
consulting physician should satisfy himself on this score. 
It is not enough that the attending physician consent. He 
will, of course, do so if requested. If not in accordance 64 
MEDICAL ETHICS AND ETIQUETTE. 
with liis wishes, the transfer should be positively declined 
by the consulting physician. 
Another point relates to subsequent attendance by the 
consulting physician. After a case is ended, in another ill- 
ness the patient may request his services as an attending 
physician. There may be exceptional instances, but, as a 
rule, such a request should be declined. If acceded to, it 
should be after a full understanding with the physician pre- 
viously in attendance. This and the preceding rule are 
essential in order that consultations may be held without 
risk of injury to the feelings and interests of attending phy- 
sicians. A physician in consultation, if actuated by proper 
delicacy and a sense of honor, will, of course, sedulously 
guard against the possibility of his services being preferred 
to those of the attending physician. 
Another point may be referred to. It sometimes hap- 
pens that a change of an attending physician is made 
while another physician is associated in consultation. Shall 
the latter remain in consultation with the successor of the 
former ? As a rule, certainly not. If the change has been 
made on account of dissatisfaction with the medical treat- 
ment, the consulting physician is as responsible for this as 
the attending physician, and he should decline to remain in 
consultation. If other reasons have led to the change, 
there are obligations of courtesy which are not to be ignored. 
There should be a full understanding with the attending 
physician who is superseded. The “ good of the patient ” 
is, of course, a primary consideration. The action must be 
determined by the circumstances proper to each case. 
There may be circumstances which should properly lead 
a consulting physician to decline further association with an 
attending physician, although no disagreement in consulta- 
tion had occurred. If the attending physician fail to carry 
out measures agreed upon, either intentionally or from in- DUTIES OF PHYSICIANS TO EACH OTHER. 
65 
efficiency, it is not just for the consulting physician to he 
held to an equal responsibility in the case. It is the duty 
of an attending physician to carry out faithfully the course 
of treatment decided upon, and, if he persistently fail in so 
doing, the consulting physician is justified in declining to 
he longer associated with him. 
Akt. Y.—Duties of Physicians in Gases of Interference. 
Section 1. Medicine is a liberal profession, and those ad- 
mitted into its ranks should found their expectations of prac- 
tice upon the extent of their qualifications, not on intrigue or 
artifice. 
Section 2. A physician, in his intercourse with a patient 
under the care of another practitioner, should observe the strict- 
est caution and reserve. No meddling inquiries should be made 
—no disingenuous hints given relative to the nature and treat- 
ment of his disorder; nor any course of conduct pursued that 
may directly or indirectly tend to diminish the trust reposed in 
the physician employed. 
Section 3. The same circumspection and reserve should be 
observed when, from motives of business or friendship, a phy. 
sician is prompted to visit an individual who is under the direc- 
tion of another practitioner. Indeed, such visits should be 
avoided, except under peculiar circumstances; and, when they 
are made, no particular 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 cir- 
cumstances will admit. 
Section 4. A physician ought not to take charge of or pre- 
scribe for a patient who has recently been under the care of 
another member of the faculty in the same illness, except in 
cases of sudden emergency, or in consultation with the physi- 
cian previously in attendance, or when the latter has relin- 
quished the case, or been regularly notified that his services are 
no longer desired. Under such circumstances, no unjust and 
illiberal insinuations should be thrown out in relation to the 
conduct or practice previously pursued, which should be justi- 66 
MEDICAL ETHICS AMD ETIQUETTE. 
fied as far as candor and regard for truth and probity will per. 
init; for it often happens that patients become dissatisfied when 
they do not experience immediate relief, and, as many diseases 
are naturally protracted, the want of success, in the first stage 
of treatment, affords no evidence of a lack of professional knowl- 
edge and skill. 
Section 5. When a physician is called to an urgent case, be- 
cause the family attendant is not at hand, he ought, unless his 
assistance in consultation be desired, to resign the care of the 
patient to the latter immediately on his arrival. 
Section 6. It often happens in cases of sudden illness, or of 
recent accidents and injuries, owing to the alarm and anxiety of 
friends, that a number of physicians are simultaneously sent for. 
Under these circumstances, courtesy should assign the patient 
to the first who arrives, who should select from those present 
any additional assistance that he may deem necessary. In all 
such cases, however, the practitioner who officiates should re- 
quest the family physician, if there be one, to be called, and, 
unless his further attendance be requested, should resign the 
case to the latter on his arrival. 
Section 7. When a physician is called to the patient of an- 
other practitioner, in consequence of the sickness or absence of 
the latter, he ought, on the return or recovery of the regular at- 
tendant, and with the consent of the patient, to surrender the case. 
[The expression, “patient of another practitioner,” is under- 
stood to mean a patient who may have been under the charge 
of another practitioner at the time of the attack of sickness, or 
departure from home of the latter, or who may have called for 
his attendance during his absence or sickness, or in any other 
manner given it to be understood that he regarded the said phy- 
sician as his regular medical attendant.] 
Section 8. A physician, when visiting a sick person in the 
country, may be desired to see a neighboring patient who is 
under the regular direction of another physician, in consequence 
of some sudden change or aggravation of symptoms. The con- 
duct to be pursued on such an occasion is to give advice adapted 
to present circumstances; to interfere no further than is abso- 
lutely necessary with the general plan of treatment; to assume DUTIES OF PHYSICIANS TO EACH OTHER. 
67 
no future direction, unless it be expressly desired; and, in this 
last case, to request an immediate consultation with the practi- 
tioner previously employed. 
Section 10. When a physician who has been engaged to at- 
tend a case of midwifery is absent, and another is sent for, if 
delivery is accomplished during the attendance of the latter, he 
is entitled to the fee, but should resign the patient to the prac- 
titioner first engaged. 
The foregoing sections of the code embrace points in 
ethics and etiquette the propriety and importance of which 
no member of the medical profession will undertake to deny. 
Their observance is essential to the harmony, good fellow- 
ship, and mutual co-operation of practitioners of medicine, 
thereby contributing to the honorable character of the pro- 
fession, to public confidence in regard to it, and to its use- 
fulness in the cause of humanity. The question, however, 
may be raised, Is it necessary to embody these points in 
ethics and etiquette in formal rules; that is, would not 
physicians regulate their conduct equally well without the 
latter ? The affirmative answer to this question would imply 
that all those admitted to the ranks of the medical profes- 
sion found “ their expectations of practice upon the extent 
of their qualifications, and not on intrigue or artifice.” 
No one will venture to claim for all members of the profes- 
sion that purity and high moral tone which are implied in 
the affirmative answer to the question. It must be admitted 
that these rules are not infrequently violated. Does it fol- 
low that the rules are useless ? Certainly not. The fact 
only proves that knowledge of rules does not always secure 
their observance. This is true, not alone in medical ethics, 
but in theology, law, and every department of morals. That 
prescribed rules of medical ethics influence more or less the 
conduct of physicians can not be doubted. This is true as 
regards other duties, else, wherefore the propriety of such 68 
MEDICAL ETHICS AND ETIQUETTE. 
rules applied, not only to tlie higher moral relations of 
human life, hut to those of minor importance, and even the 
trivialities of social intercourse. To do away with ethical 
rules for the reason that they are not always observed would 
be in opposition to human experience and conducive to 
anarchy. Prescribed rules of conduct are of use by giving 
distinctness and force to popular sentiment. Moreover, the 
knowledge of rules affects the conduct of those who, not 
devoid of rectitude, pursue the wrong because they do not 
know the right. Rules thus tend to nullify the tempta- 
tions and the specious pleadings of apparent self-interest. 
It has been argued for the inutility of rules in medical 
ethics, that penalties for their non-observance are with diffi- 
culty instituted and enforced. This argument is as illogical 
as in its application to all other moral duties. It is a fea- 
ture of the code of medical ethics that it takes no cognizance 
of penalties for violations of its requirements. It appeals 
solely to the judgment and conscience. Measures for the 
enforcement of its rules are left entirely to the discretion of 
local associations. These measures admit of discussion and 
differences of opinion. They may be injudicious in respect 
of undue laxity on the one hand, and, on the other hand, 
of over-strictness. In either case, the propriety and the 
importance of the rules remain unaffected. Whether viola- 
tions of ethical rules shall be silently passed by, or occasion 
only personal expostulation, or be met by the tacit disap- 
probation of professional brethren, and under what circum- 
stances they call for disciplinary measures, together with 
the forms of discipline called for in particular cases, are 
questions the consideration of which does not fall within 
the scope of these commentaries. 
Reference has repeatedly been made in the course of 
these commentaries to the importance of popularizing 
knowledge of medical ethics and etiquette. This is espe- DUTIES OF PHYSICIANS TO EACH OTHER. 
69 
cially desirable with respect to the “ duties of physicians in 
cases of interference.” Recognizing the propriety of the 
rules laid down in the code, knowledge of them would lead 
to co-operation on the part of the public in securing their 
observance. It is a common impression that, intrinsically, 
the ethical rules have no binding force; that they are re- 
strictive without regard to individual rights and the claims 
of humanity. The observance of rules of etiquette is re- 
garded as a frivolous formality. Let the rules of ethics and 
etiquette be understood by those without, as well as by 
those within, the profession, and deliberate violations of 
professional duty and propriety will be likely to fail in their 
objects. Public opinion will concur to render disreputable 
those who are guilty of unprofessional conduct. 
Section- 9. A wealthy physician should not give advice gratis 
to the affluent; because his doing so is an injury to his profes- 
sional brethren. The office of a physician can never be sup- 
ported as an exclusively beneficent one; and it is defrauding, in 
some degree, the common funds for its support, when fees are 
dispensed with which might justly be claimed. 
For two reasons this section of the code has a limited 
application. In the first place, the number of wealthy phy- 
sicians is small; in the second place, most physicians who 
are wealthy are as willing to accept fees as they who are in 
moderate circumstances. The rule was doubtless intended 
to apply to instances in which a wealthy physician gives 
out, or has it understood, that his services are free to those 
who can afford proper remuneration as well as to the poor. 
The intent could not have been to enjoin it as a duty to 
receive fees in every instance from the affluent. There are 
circumstances under which, from delicacy or other motives, 
physicians are unwilling to he paid for their services, irre- 
spective of the pecuniary ability of the patient. No one has 
a right to judge of these circumstances but the physician 70 
MEDICAL ETHICS AND ETIQUETTE. 
himself. Offenses against the intent of this rule must he 
extremely rare. As a measure of policy, with a view to 
obtain and retain practice, it would not be likely to succeed. 
With some exceptions, patients able to pay for medical ser- 
vices would not consent to continue long to receive them 
gratuitously. As an illustration, a medical friend of the 
writer, whose practice was largely among the affluent, kept 
no regular books, and sent no bills for fifteen years. The 
explanation which he gave was that he did not need any in- 
come from his practice, and he was too indifferent thereto 
to incur the trouble of making charges and collecting ac- 
counts. As a result, the greater part of his patients left 
him, preferring the services of those whose practice was on 
a business basis. 
Persons who have relinquished medicine for other pur- 
suits, and those who have pursued a partial course of medi- 
cal study, are sometimes fond of playing the part of a dilet- 
tante practitioner. Except in cases of emergency, this is an 
impropriety which does injustice to the medical profession, 
to say nothing of the risk of injury to patients. An illus- 
tration of this risk, at the time of writing these remarks, 
has fallen under the writer’s notice. An English clergyman, 
who had given some attention to the study of medicine as 
an amateur, was arrested and committed for trial on the 
charge of having caused the death of a young girl by ad- 
ministering oil of bitter almonds. There was no evil intent 
in giving the remedy, but, from ignorance, it was given in 
a poisonous dose. The counsel of the accused admitted the 
case to be one of “ homicidal misadventure.” The London 
“Lancet” concludes a notice of the case by saying : “We 
may hope that Eev. Mr. T.’s ample admissions and benevo- 
lent career will simplify and shorten a trial which, however, 
ought to serve as a warning to clergymen to remember that 
the weapons of their warfare are not medical.” DUTIES OF PHYSICIANS TO EACH OTHER. 
71 
Complaint is often made of tlie injustice done by dis- 
pensaries and clinics on tlie same ground as that of gratui- 
tous advice to the affluent. The complaint is a valid one, 
in so far as these institutions furnish gratuitously medical 
and surgical aid to those who have no right to assume the 
claims of poverty. It is difficult in the administration of 
medical charities to escape imposition. To do so, as far as 
practicable, is plainly a.duty, not alone to the medical pro- 
fession, but to those by whom the charities are maintained, 
and to those for whose relief they are instituted. 
Aet. Yl.—Of Differences between Physicians. 
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 cases unfor- 
tunately occur, and can not be immediately terminated, they 
should be referred to the arbitration of a sufficient number of 
physicians, or a court-medical, or, where both parties are mem- 
bers of the medical society of their county, to the censors. 
Section 2. As peculiar reserve must be maintained by phy- 
sicians toward the public in regard to professional matters, and 
as there exist numerous points in medical ethics and etiquette 
through which the feelings of medical men may be painfully as- 
sailed in their intercourse with each other, and which can not 
be understood or appreciated by general society, neither the 
subject-matter of such differences nor the adjudication of the 
arbitrators should be made public, as publicity in a case of this 
nature may be personally injurious to the individuals concerned, 
and can hardly fail to bring discredit on the faculty. 
“ A doctors’ quarrel ” is an expression often made use 
of in a way to imply an event of common occurrence. It 
may be affirmed that doctors are not more given to quarrel- 
ing than those engaged in other pursuits. Indeed, the 
mental influence of their professional duties is in an oppo- 
site direction. The occasions, however, of controversy and 72 
MEDICAL ETHICS AND ETIQUETTE, 
contention among medical men are apt to be not under- 
stood and appreciated by others. This is implied in the 
often-repeated saying, “ Who shall decide when doctors dis- 
agree.” Hence it is that the controversies and contentions 
of physicians are regarded as denoting a quarrelsome ten- 
dency. 
Contentions among physicians for the most part are 
brought about by gossiping busybodies and go-betweens. 
Some persons seem to think that they can not compliment 
a physician more highly than by disparaging his competi- 
tors. Certain of his friends are not content with the ordi- 
nary manifestations of friendship, but they feel it incumbent 
upon them to depreciate as much as possible the merits of 
others. His partisans seek to draw from him expressions 
derogatory to the character or practice of the practitioners 
to whom they are opposed. His words are misinterpreted, 
and his silence may be misconstrued. Tale-bearers are ready 
to carry offensive reports to those to whom they refer. Re- 
sentment and retorts naturally follow. Thus it is that they 
who should be brethren are at sword-points. Now, gener- 
ally this result might be prevented by a very simple pro- 
cedure. Let any one who is led to impute a grievance to 
another practitioner at once seek an explanation in a spirit 
of kindness and charity. The result will be, in nine cases 
out of ten, that either the imputation is without foundation, 
or a satisfactory apology will be obtained. Such an ex- 
planation may tend to produce mutual confidence and ce- 
ment friendships. 
Harmony among physicians is most desirable, not alone 
for the comfort of those concerned, but as conducive to the 
honor and usefulness of the medical profession. It is essen- 
tial to co-operation in medical consultations, in measures for 
public health, etc. For the maintenance of harmonious re- 
lations, local associations are important. In places of small DUTIES OF PHYSICIANS TO EACH OTHER. 
73 
or moderate size, these associations should embrace all the 
members of the profession of the community who are in 
good standing. In this -way are avoided the evils of cliques, 
which are to be deprecated. The local associations should 
have more or less of a social character. They afford oppor- 
tunities for intimate acquaintance, for the explanation of 
misunderstandings and for their prompt adjustment. Ob- 
servation will show that, in the places in which such associa- 
tions exist, much more harmony and good fellowship pre- 
vail than in the places in which physicians are not brought 
together in social intercourse. Controversies and conten- 
tions, however, can not always be avoided. They will be 
terminated with the more difficulty the longer they con- 
tinue. The code of ethics, therefore, judiciously instructs 
that, if not terminated immediately, they are to be adjusted 
by arbitration. The method to be preferred is for the par- 
ties to select disinterested and unprejudiced persons as 
arbitrators, having previously agreed to abide by their de- 
cisions. In this way publicity may be avoided. But, if a 
supposed grievance involve a question of flagrant unprofes- 
sional conduct, there may be no alternative beyond a formal 
complaint to and an adjudication by an organized society, 
embracing among its powers regulations for investigation 
and discipline in such cases. The code instructs that the 
censors of a county society are to adjudicate. This, evi- 
dently, should be left to the action of the society, which 
may refer these matters to a special committee on ethics, or 
to committees appointed for the purpose in particular cases. 
Here, as elsewhere, the code takes no cognizance of the 
modes of discipline. Each society may determine these 
without regard to the action of other societies. The rea- 
sons for secrecy as regards the subject-matter of the adjudi- 
cation of differences among physicians are succinctly but 
amply set forth in the code. Secrecy, however, can hardly 74 
MEDICAL ETHICS AND ETIQUETTE. 
be expected when expulsion from societies and exclusion 
from professional fellowship are the penalties inflicted. 
Nor, with a view to a salutary moral effect, would secrecy, 
under these circumstances, he desirable, were it practicable. 
Aet. YII.— Of Pecuniary Acknowledgments. 
Some general rules should be adopted by the faculty, in every 
town or district, relative to pecuniary acknowledgments from 
their patients; and it should be deemed a point of honor to ad- 
here to these rules with as much uniformity as varying circum- 
stances will admit. 
By no process of distortion can this article of the code 
be made to inculcate a combination, after the manner of 
trades-unions, to establish and enforce a certain rate of 
wages for medical services. The article applies fully as 
much to exorbitant as to inadequate pecuniary acknowledg- 
ments. It is plainly important, for the convenience of pa- 
tients, as well as of physicians, that in every community 
there should be an understanding as to the customary fees 
for the different kinds of service which medical men are ex- 
pected to render. It would be extremely incongruous in 
ordinary practice for the physician, before giving advice or 
making a professional visit, to state the amount of compen- 
sation which he will require, although, in certain cases, to 
do so is not only proper but advisable; nor, as a rule, should 
patients be expected, whenever a physician is summoned, 
to inquire respecting his fee, albeit, under certain circum- 
stances, this is both decorous and desirable. Exclusive of 
exceptional instances, which will be presently referred to, 
the adoption of some general rules, and their recognition 
within and without the profession, obviate the necessity of 
questions, explanations, and discussions, which are often em- 
barrassing and disagreeable. 
The poor policy of under-bidding other physicians, for DUTIES OF PHYSICIANS TO EACH OTHER. 
75 
the sake of gaining practice, would probably deter those 
from pursuing it who might he so inclined. The adage, 
“ dear at any price,” would be applicable to physicians rely- 
ing on this policy. This is well understood by the public. 
Few patients are disposed to select a medical adviser be- 
cause he places a low pecuniary valuation on his services. 
Necessity alone would dictate a choice on this ground; and 
it is rarely the case that inability to pay the customary fees 
prevents patients from having the services of those whom 
they prefer. The code by no means interdicts deviations 
from the general rules according to varying circumstances. 
It is to the honor of the profession that the instances are 
few in which efforts for the relief of suffering and the pres- 
ervation of life are withheld on account of inability to make 
an adequate pecuniary acknowledgment. The circumstances 
which lead physicians from sympathy to deviate from the 
general rules are often not apparent to others. Few persons 
outside of the medical profession are aware of the extent 
to which the services of its members are freely rendered, 
with but little or no compensation; hence, one reason for 
an exaggerated estimate of the incomes of those largely en- 
gaged in practice, and for the fact that the majority of 
practitioners, after a long professional career, leave but lit- 
tle property. The physician, from his intimate relations 
with his patients, comes to know often their limited re. 
sources, of which, perhaps, others are ignorant; how can he 
add to their embarrassment and anxiety by exacting full 
payment for his services? A considerable proportion of 
those to whom these services are gratuitously rendered do 
not come to him in forma pauperis, but silently appeal to 
his benevolence. While it can not be assumed as a prin- 
ciple that the remuneration received from the affluent 
should be sufficient to compensate for services to those un- 
able to make pecuniary acknowledgments, the fact that these 76 
MEDICAL ETHICS AND ETIQUETTE. 
services are rendered in the cause of humanity should be 
considered as a reason for the ready and cheerful payment 
of fees by patients who have no claims on the charity of 
the profession. 
A demand for exorbitant fees is not in accordance with 
this article of the code. When based on an assumption of 
extraordinary knowledge or skill, it is an imposition, and it 
is, of course, fraudulent if services have been falsified. An 
exorbitant fee can not he claimed on the score of the wealth 
of a patient. Such a patient may add to the fee an hono- 
rarium which, considering the services rendered by a physi- 
cian to those unable to make pecuniary acknowledgments, 
may he accepted without compromising self-respect. Ex- 
traordinary services rightfully claim deviations from the gen- 
eral rules in respect of fees. Detentions or constant at- 
tendance, involving sacrifice of interests, unusual fatigue, or 
impairment of comfort, and visits requiring traveling and 
absence from home, are in this category. No one hut the 
physician himself can place a valuation on such services, 
and it is his right to do this, provided there he an under- 
standing before the services are rendered. If the expense 
of certain services he stated beforehand, patients or their 
friends can have no occasion for complaint, and thereby the 
risk of unpleasant feelings, and, it may he, a suit at law, 
will he avoided. 
Inasmuch as it is the custom in this country, after medical 
services have been rendered, either for the patient to request 
to know the amount of indebtedness, or, if not requested, for 
a hill to be presented, it is unbecoming to leave the amount 
of pecuniary compensation to be determined by the party 
who has received the services. It is to be assumed that the 
services have a certain valuation, varying, of course, accord- 
ing to circumstances in particular cases. To decline to fix 
on any valuation, provided patients be affluent, is virtually DUTIES OF PHYSICIANS TO EACH OTHER. 
77 
to appeal to their generosity, and this is certainly undigni- 
fied. If the valuation hy patients he higher than that of 
the physician, the difference is easily made up hy an hono- 
rarium. The exceptions to the rule that the physician 
should determine the value of his services are in some in- 
stances in which the pecuniary resources of the patients are 
either unknown or known to he limited. For a physician 
to keep no account of medical services, relying on the volun- 
tary contributions of his patients for his support, is not only 
unseemly, hut derogatory to the profession. Medical as 
well as other services are entitled to compensation, when- 
ever they are not charitably bestowed, and it is disreputable 
to place pecuniary acknowledgments in the light of a gra- 
tuity. CHAPTER 111. 
OF THE DUTIES OF THE PROFESSION" TO THE PUBLIC, AND OF 
THE OBLIGATIONS OF THE PUBLIC TO THE PROFESSION. 
Section 1. As good citizens, it is the duty of physicians to 
be ever vigilant for the welfare of the community, and to bear 
their partln sustaining its institutions and burdens; they should 
also be ever ready to give counsel to the public in relation to 
matters especially appertaining to their profession, as on sub- 
jects of medical police, public hygiene, and legal medicine. It 
is their province to enlighten the public in regard to quarantine 
regulations—the location, arrangement, and dietaries of hos- 
pitals, asylums, schools, prisons, and similar institutions—in re- 
lation to the medical police of towns, as drainage, ventilation, 
etc.—and 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, even at the jeopardy of their 
own lives. 
Art, I.—Duties of the Profession to the Public. 
Section 2. Medical men should also be always ready, when 
called on by the legally constituted authorities, to enlighten 
coroners’ inquests and courts of justice on subjects strictly 
medical—such as involve questions relating to sanity, legiti- 
macy, murder by poisons or other violent means, and in regard 
to the various other subjects embraced in the science of medi- 
cal jurisprudence. But in these cases, and especially where 
they are required to make a post-mortem examination, it is just, 
in consequence of the time, labor, and skill required, and the DUTIES OF THE PROFESSION TO THE PUBLIC. 
79 
responsibility and risk they incur, that the public should award 
them a proper honorarium. 
Section 3. There is no profession by the members of which 
eleemosynary services are. more liberally dispensed than by the 
medical, but justice requires that some limits should be placed 
to the performance of such good offices. Poverty, professional 
brotherhood, and certain of the public duties referred to in the 
first section of this article, should always be recognized as pre- 
senting valid claims for gratuitous services; but neither institu- 
tions endowed by the public or by rich individuals, societies for 
mutual benefit, for the insurance of lives or for analogous pur- 
poses, nor any profession or occupation, can be admitted to 
possess such privilege. Nor can it be justly expected of phy- 
sicians to furnish certificates of inability to serve on juries, to 
perform militia duty, or to testify to the state of health of per- 
sons wishing to insure their lives, obtain pensions, or the like, 
without a pecuniary acknowledgment. But to individuals in in- 
digent circumstances such professional services should always 
be cheerfully and freely accorded. 
Laudation of the medical profession by physicians for 
the public may not always be consistent with a proper de- 
gree of modesty, but laudation of the profession for its 
members is not only admissible, but it has a salutary influ- 
ence. The more physicians are led to regard medicine in 
its humane and noble aspects, the more they are reconciled 
to its hardships, and the more they are incited to do all in 
their power to maintain its character and usefulness. The 
feeling that honor is reflected by membership of a profes- 
sion which professes to be governed by the code of medical 
ethics conduces to a high moral tone, and it is in this way 
that the code is of great service. It is a beautiful feature 
of the code that it aims solely at the influence of its ethical 
rules on the mind, irrespective of any penalties. It is based 
on the principle that moral rectitude is promoted more 
by fostering upright sentiments than by the punishment of 
offenses. 80 
MEDICAL ETHICS AND ETIQUETTE. 
Comments on the duties of physicians, as good citizens, 
to the public may fairly furnish an occasion for laudatory 
reflections. In all measures relating to the health and wel- 
fare of communities, physicians have been foremost. They 
have always been found ready to devote knowledge, time, 
and efforts to these objects. Most medical associations are 
formed in great part for the purpose of considering and 
carrying out measures for the promotion of public health. 
“ The American Public Health Association,” which was 
formed in 1872, has for its sole objects “the advancement 
of sanitary science and the promotion of organizations and 
measures for the practical application of public hygiene.” 
Members of this association, from all the States of the 
Union, are, for the most part, medical men. They attend 
annual meetings, prepare papers which are published in an 
annual volume of Transactions, and contribute funds for all 
the expenses of the association. Voluntary local associa- 
tions, sustained by the medical profession, for the same ob- 
jects, exist in different parts of the Union. There are not 
a few medical men in this country whose professional labors 
are devoted especially, or chiefly, to sanitary science or hy- 
giene, with no expectation of compensation except the satis- 
faction of having contributed to the promotion of public 
health or the welfare of the communities in which they 
live. May we not claim that for these things the medical 
profession is deserving of praise ? 
In claiming for the profession praise for the performance 
of duties to the public, it is not intended in the least to de- 
preciate the binding force of these duties as such. They 
are so recognized. Within late years, to the study of sani- 
tary science and hygiene has been allotted a distinct depart- 
ment of medicine. Preventive medicine, as this depart- 
ment is called, now holds a prominent place in medical 
literature, as well as in the labors of medical men. Recent DUTIES OF THE PROFESSION TO THE PUBLIC. 
81 
developments in etiology have already led to most impor- 
tant results as regards the prevention of diseases, and there 
is reason to believe that these developments are the earnest 
of those still more important. Few, if any, of those who 
have given attention to the subject will doubt that in the 
medicine of the future more is to he expected from the ap- 
plication of knowledge to prophylaxis than to therapeutics. 
It is needless to add that physicians are morally bound to 
become acquainted with important facts and laws relating 
to sanitary science and hygiene as they are developed, in 
order thereby to be able to fulfill properly their duties to 
the public. They who are engaged in investigations re- 
lating to etiology and pathology are bound to consider and 
follow out, as far as practicable, the bearings of these on 
the health and welfare of communities. 
It may be said, in the way of laudation, that there are 
very few instances in which members of the medical profes- 
sion desert the post of duty in consequence of the danger 
which may be therewith connected. They generally “ face 
the danger,” whether it be on the field of battle or when 
a pestilence prevails. The profession is entitled to what- 
ever of praise belongs to courage in the performance of 
professional duty, albeit the courage has no recompense 
beyond the satisfaction of having followed the dictates of 
duty. The physicians’ roll of honor is the list of those 
who have died in the performance of professional duty. 
The history of every epidemic disease furnishes such a list. 
The risk of life was simply a duty, but who will refuse to 
accord to it nobleness ? Who would remove from the code 
that portion which enjoins upon physicians that, when pes- 
tilence prevails, “it is their duty to face the danger, and to 
continue their labor for the alleviation of the suffering, even 
at the jeopardy of their own lives ” ? 
A broad distinction, in respect of pecuniary acknowledg- 82 
MEDICAL ETHICS AND ETIQUETTE. 
ments, exists between tbe duties which every physician owes 
to the public in behalf of matters embraced in preventive 
medicine and the duties connected with the legal adminis- 
tration of justice. Whenever called upon by legally con- 
stituted authorities to give advice or expert testimony at 
coroners’ inquests or in courts of justice, in relation to 
medical questions, physicians should be paid for their ser- 
vices, In view of the services rendered to the public with- 
out compensation, for those just referred to there should 
be adequate pecuniary acknowledgments. Investigations in 
cases of supposed insanity, of homicide by poisons or other 
means, etc., and post-mortem examinations, made under in- 
struction by authorities, claim ample remuneration. There 
is no good reason for physicians being expected to perform 
these duties gratuitously. Much injustice is often done to 
the medical profession in regard to these duties. Physi- 
cians should not fail, from a false sense of delicacy, to assert 
their rights in this regard, and they should endeavor to lead 
the public to recognize the propriety of so doing. 
The foregoing remarks concerning those duties to the 
public for which physicians should receive adequate re- 
muneration will apply equally to certain professional ser- 
vices rendered to institutions and to individuals. These ser- 
vices are referred to in the third section of the article of 
the code which relates to the duties of the profession to 
the public. That these services should be rendered gratui- 
tously seems to be expected, because those which are purely 
eleemosynary are recognized as such by the profession. 
Now, this is a good reason for not rendering the services 
without payment. They are in no sense eleemosynary in 
their character. It should be generally understood by mem- 
bers of the profession, as well as by the public, that they 
are to receive pecuniary acknowledgment. A reform in this 
regard would be of not a little importance to physicians, DUTIES OF THE PROFESSION TO THE PUBLIC. 
83 
and the burden on the public would be light. The qualifi- 
cation relating to individuals in indigent circumstances 
divests the rule of any objection on the score of liberality, 
and is in accordance with the spirit of beneficence which 
pervades the entire Code of Ethics. 
Section 4. It is the duty of physicians, who are frequent 
witnesses of the enormities committed by quackery, and the in- 
jury to health, and even destruction of life, caused by the use of 
quack medicines, to enlighten the public on these subjects, to 
expose the injuries sustained by the unwary from the devices 
and pretensions of artful empirics and impostors. Physicians 
ought to use all the influence which they may possess, as pro- 
fessors in colleges of pharmacy, and by exercising their option 
in regard to the shops to which their prescriptions shall be sent 
to discourage druggists and apothecaries from vending quack or 
secret medicines, or from being in any way engaged in their 
manufacture and sale. 
Empiricism, in the popular sense of this term—in other 
words, charlatanry or quackery—has hitherto abounded, 
and will, doubtless, continue to abound. Its success, de- 
pending, as it does, on a peculiarity of certain mental con- 
stitutions, is the same at the present time as in the past, 
and as it will be in the future. The forms of empiricism 
change with different periods, but the underlying credulity 
remains unchanged. This credulity has no necessary con- 
nection with intellectual endowments, special talents, or 
extensive acquirements in other branches of knowledge than 
medicine. Hence, the judgment of those distinguished in 
law, art, theology, letters, or in business operations, is of no 
more, and, indeed, of less value than that of persons hav- 
ing good common sense in the middle walk of life. 
To enlighten the public on subjects which may be em- 
braced under the name popular medical delusions is not 
easy. There are difficulties not readily overcome. In the 84 
MEDICAL ETHICS AND ETIQUETTE. 
first place, persons fall into tliese delusions from an intrinsic 
proclivity thereto, and not as a result of investigation or a 
logical process of reasoning. Arguments, however cogent, 
and evidence, however strong, are, therefore, often of no avail. 
In the second place, efforts to enlighten the public on these 
subjects by physicians are met by a belief that they are 
prejudiced and interested parties. In the third place, 
whenever one has committed himself to an empirical doc- 
trine or system of practice, the feelings of egotism and pride 
are powerful obstacles in the way to a conviction of error. 
The mind strives to find support in the opinions which have 
been adopted, and resists proof against their validity. 
Hence, in order to gain strength thereby in their opinions, 
they endeavor to make proselytes. For those who are open 
to a fair consideration of these subjects, it would seem that 
the following points should be conclusive: It can hardly be 
denied that educated medical men are the most competent 
to form correct judgments concerning questions which re- 
late to etiology, pathology, and therapeutics. If there be 
truth in any assumed discovery or improvement in these 
branches of knowledge, it is plainly for the interest of medi- 
cal men to adopt them. Sooner or later physicians must 
accept real discoveries or improvements. Is it not, there- 
fore, the safest policy to be governed by the verdict of the 
medical profession? 
The position taken by the medical profession in regard 
to secret remedies is not generally understood by the 
public. It is simply this: If these remedies be really valu- 
able, they should be made known for the benefit of all man- 
kind. They should not be kept secret or patented for per- 
sonal gain. There should be no mystery connected with 
them. Surely this position is disinterested, and in accord- 
ance with the dictates of humanity. The action advised 
by the code in regard to druggists and apothecaries who DUTIES OF THE PROFESSION TO THE PUBLIC. 
85 
prepare or vend secret nostrums is one which, it would be 
well for physicians to adhere to more strictly than is usu- 
ally done—namely, to discriminate, in sending their pre- 
scriptions, in favor of the shops which have nothing to do 
with these nostrums. In this way their sale can be dis- 
couraged, and something accomplished toward directing 
the attention of the public to the subject from a proper 
point of view. 
Within late years a custom has arisen and become 
largely prevalent among pharmaceutists which should he 
discountenanced by the medical profession. Reference is 
had to the diversity of medicinal preparations compounded 
of different drugs, and extensively advertised for the use of 
physicians and the public. These are now known as “ pro- 
prietary medicines.” A legal right of proprietorship is se- 
cured and held by vending them under a trade-mark. The 
custom is objectionable for several reasons. It encourages 
a popular use of drugs without medical advice. The use 
of these medicinal compounds interferes with combina- 
tions by physicians in adaptation to indications in individ- 
ual cases of disease. Their use interferes with accurate 
observations of the effects of particular drugs. Finally, 
there can be no guarantee that the preparations are what 
they purport to he. As a rule, the best policy with refer- 
ence to the welfare of patients and to experience in thera- 
peutics is to prescribe potential remedies separately, rather 
than in combination, and, when prescribed in combination, 
to give preference to officinal preparations. It is not de- 
nied that some of the so-called proprietary remedies are 
useful, and it is not intended by these remarks to imply 
that new remedies are not to be properly tested by clinical 
observations. There is a manifest impropriety in giving 
certificates recommending any of the multitudinous pharma- 
ceutic .compounds with which the country is flooded. If a 86 
MEDICAL ETHICS AND ETIQUETTE. 
physician have beenled by his experience to form a favor- 
able opinion of any one of these, or of a new remedy, the 
proper channels of communication with the profession are 
through the medium of medical hooks or journals. Com- 
munication with the public by certificates or articles in 
newspapers is in violation of the Code of Ethics. 
Aet. ll. Obligations of the Public to Physicians. 
Section 1. The benefits accruing to the public, directly and 
indirectly, from the active and unwearied beneficence of the 
profession, are so numerous and important that physicians are 
justly entitled to the utmost consideration and respect from the 
community. The public ought likewise to entertain a just ap- 
preciation of medical qualifications; to make a proper discrimi- 
nation between true science and the assumptions of ignorance 
and empiricism—to afford every encouragement and facility for 
the acquisition of medical education—and no longer to allow 
the statute-books to exhibit the anomaly of exacting knowledge 
from physicians, under a liability to heavy penalties, and of 
making them obnoxious to punishment for resorting to the only 
means of obtaining it. 
The claims of the medical profession to the considera- 
tion and respect of the community have been already com- 
mented on sufficiently in connection with other portions of 
the Code of Ethics. A just appreciation of medical qualifi- 
cations by the public is desirable as an incentive to mem- 
bers of the profession to aim at these, and as a reward for 
their possession. In these points of view, it is discouraging 
to the votaries of true science for the assumptions of igno- 
rance and empiricism to be successful in obtaining popular 
distinction. The public can not be expected always to 
judge correctly between real qualifications and false assump- 
tions. True distinction in medicine, therefore, must be 
based on the opinions of unbiased medical men. 
The apathy and indifference on the part of the public to OBLIGATIONS OF THE PUBLIC TO PHYSICIANS. 
87 
medical education is a singular incongruity, in view of the 
immense importance of well-educated physicians to every 
community. The interests of medical education are left al- 
most wholly to physicians, whereas these interests concern 
the public vastly more than the medical profession. If the 
public could be made to see this subject in a proper light, there 
would be no lack of accommodations, provisions, and appli- 
ances for all the departments of medical instruction. The 
last sentence of the Code of Ethics refers especially to the 
absence of legal enactments in behalf of the practical study 
of anatomy. Since the adoption of the code in 1847, much 
has been accomplished, chiefly by the efforts of physicians, 
in the legalization of this study and the provisions for ob- 
taining subjects for dissection. In many parts of the Union, 
however, much is yet to be accomplished. Let the public 
consider that, if adequate laws be enacted, there will be no 
occasion for occurrences which naturally and properly shock 
the feelings of a community. Let it also be considered that 
the public welfare is promoted by affording all proper facili- 
ties for clinical study and teaching, by encouraging patho- 
logical investigations, by refusing sympathy with the pseudo- 
humanitarians who would interdict experimental researches 
upon the lower animals, and by bestowing honorable distinc- 
tion on those who are justly deserving of it. The public 
welfare is promoted just in proportion as thereby medical 
science is advanced and medical education improved. The 
time will come when not only public authorities will appre- 
ciate the importance of co-operating with the medical pro- 
fession in behalf of the interests of medical science and 
education, but private munificence will take this direc- 
tion. For the cause of humanity, as well as the honor 
of the profession, a full recognition of the obligations of 
the public to physicians is a “ consummation devoutly to 
be wished.” 88 
MEDICAL ETHICS AND ETIQUETTE. 
Concluding Remarks. 
The proposal to write commentaries on our National 
Code of Ethics may have conveyed to the minds of many 
an idea of presumption. The writer of the foregoing com- 
mentaries indulges the hope that their perusal has not sus- 
tained this idea, inasmuch as he has not ventured to take 
issue with the code on any important point except one— 
namely, the ground for refusing medical consultations. Nor 
has he assumed to he an expounder of the code, hut only 
to supplement comments in conformity with the spirit which 
pervades it. In fact, a leading motive has heen to excite 
the attention of medical, and, perhaps, also, to some extent, 
non-medical readers, to the code itself. There are many 
members of the medical profession who have never read 
the code with that degree of interest which it claims, and 
there are some who have never read it. These assertions 
are based on information obtained by personal inquiries. 
It is safe to say of the public that not one in a thousand 
knows anything of its character and provisions. If the 
publication of the code in connection with the commen- 
taries may lead in any measure to the diffusion of a better 
knowledge of it, the writer would have the gratification of 
feeling that he had done a good work. When it is con- 
sidered that this ethical code was adopted by the American 
Medical Association thirty-six years ago without a dissenting 
voice, that it has remained without any alteration by the 
association up to the present time, and that it has been ac- 
cepted without any modification by every medical organi- 
zation which has adopted any code throughout our country, 
how can any one doubt that it must be remarkably free 
from objectionable features! Were it otherwise, such an 
extraordinary unanimity of approval for so long a period CONCLUDING REMARKS. 
89 
would have been impossible. But the code in itself affords 
the best evidence of its intrinsic excellence. It is a col- 
lection of ethical principles and rules which can not but 
commend themselves to the approbation of every one. 
Their excellence has never been questioned. No one can 
doubt that complete conformity to them would secure for 
the medical profession, in the highest degree, purity, human- 
ity, and universal respect. 
The writer is not one of those who apparently have a 
fondness for disparaging the medical profession of this 
country. He believes that a large proportion of the mem- 
bers of the profession are desirous of conforming to the 
Code of Ethics. He believes, moreover, that, from the 
standpoint of the observance of medical ethics, the profes- 
sion of America will compare favorably with that of any 
other country. If this view be correct, much is to be at- 
tributed to the influence of our national code, and it is a 
rational conclusion that this influence will be increased by 
a more general knowledge of its teachings and requirements. 
For this end, knowledge of the code should be made a part 
of medical education. Schools of medicine should not as- 
sume that, as a matter of course, graduates will make them- 
selves acquainted with it. It should be brought to the at- 
tention of medical students, and its precepts inculcated by 
their teachers. Conformity to it should be embraced in 
the obligations formally acknowledged when the doctorate 
is conferred. Recent events, which are now to be referred 
to, will, it is hoped, be ultimately productive of good by 
directing greater attention to the code, and enhancing its 
importance in the minds of the profession. 
The New York State Medical Society, at its annual meet- 
ing in February, 1882, adopted, as a substitute for the Na- 
tional Code of Ethics, the following: 90 
MEDICAL ETHICS AND ETIQUETTE. 
CODE OF MEDICAL ETHICS. 
I. The Relations of Physicians to the Public. 
11. Rules governing Consultations, 
111. The Relations of Physicians to Each Other. 
I.—The Relations of Physicians to the Public. 
It is derogatory to the dignity and interests of the profession 
for physicians to resort to public advertisements, private cards? 
or handbills, inviting the attention of individuals affected with 
particular diseases, publicly offering advice and medicine to the 
poor without charge, or promising radical cures; or to publish 
cases or operations in the daily prints, or to suffer such publica- 
tions to be made; or, through the medium of reporters or inter- 
viewers or otherwise, permit their opinions on medical and sur- 
gical questions to appear in the newspapers; to invite laymen 
to be present at operations; to boast of cures and remedies; to 
adduce certificates of skill and success, or to perform other simi- 
lar acts. 
It is equally derogatory to professional character, and op- 
posed to the interests of the profession, for a physician to hold 
a patent for any surgical instrument or medicine, or to prescribe 
a secret nostrum, whether the invention or discovery or exclu- 
sive property of himself or others. 
It is also reprehensible for physicians to give certificates at- 
testing the efficacy of patented medical or surgical appliances, 
or of patented, copyrighted, or secret medicines, or of proprie- 
tary drugs, medicines, wines, mineral waters, health resorts, etc. 
Members of the Medical Society of the State of New York, 
and of the medical societies in affiliation therewith, may meet in 
consultation legally qualified practitioners of medicine. Emer- 
gencies may occur in which all restrictions should, in the judg- 
ment of the practitioner, yield to the demands of humanity. 
II.—Rules governing Consultations. 
To promote the interests of the medical profession and of the 
sick, the following rules should be observed in conducting con- 
sultations: CONCLUDING REMARKS. 
91 
The examination of the patient by the consulting physician 
should he made in the presence of the attending physician, and 
during such examination no discussion should take place, nor 
any remarks as to diagnosis or treatment be made. When 
the examination is completed, the physicians should retire to a 
room by themselves, and, after a statement by the attending 
physician of the history of the case and of his views of its diag- 
nosis and treatment, each of the consulting physicians, begin- 
ning with the youngest, should deliver his opinion. If they ar- 
rive at an agreement, it will be the duty of the attending physi- 
cian to announce the result to the patient, or to some responsi- 
ble member of the family, and to carry out the plan of treat- 
ment agreed upon. 
If in the consultation there is found to be an essential differ- 
ence of opinion as to diagnosis or treatment, the case should be 
presented to the patient, or some responsible member of the 
family, as plainly as possible, to make such choice, or pursue 
such course as may be thought best. 
In case of acute, dangerous, or obscure illness, the consulting 
physician should continue his visits at such intervals as may be 
deemed necessary by the patient or his friends, by him, or by 
the attending physician. 
The utmost punctuality should be observed in the visits of 
physicians when they are to hold consultations, but, as profes- 
sional engagements may interfere or delay one of the parties, 
the physician who first arrives should wait for his associate a 
reasonable period, after which the consultation should be con- 
sidered as postponed to a new appointment. If it be the attend- 
ing physician who is present, he will, of course, see the patient 
and prescribe ; but, if it be the consulting physician, he should 
retire, except in an emergency, or when he has been called from 
a considerable distance, in which latter case he may examine 
the patient, and give his opinion in writing, and under seal, to 
be delivered to his associate. 
All practitioners of medicine, their wives, and their children 
while under paternal care, are entitled to the gratuitous services 
111.—The Relations of Physicians to Each Other. MEDICAL ETHICS AND ETIQUETTE. 
92 
of any one or more of fhe faculty residing near them, whose 
assistance may he desired. 
Gratuitous attendance can not, however, be expected from 
physicians called from a distance, nor need it he deemed obliga- 
tory when opposed by both the circumstances and the prefer- 
ences of the patient. 
The affairs of life, the pursuit of health, and the various ac- 
cidents and contingencies to which a medical man is peculiarly 
exposed may require him temporarily to withdraw from his 
duties to his patients, and to request some of his professional 
brethren to officiate for him. Compliance with this request is 
an act of courtesy, which should always be performed with the 
utmost consideration for the interests and character of the family 
physician, and, when exercised for a short period, all the pecun- 
iary obligations for such service should be awarded to him. 
But if a member of the profession neglect his business in ques- 
of pleasure and amusement, he can not he considered as enti- 
tled to the advantages of the frequent and long-continued exert 
cise of this fraternal courtesy without awarding to the physi- 
cian who officiates the fees arising from the discharge of his 
professional duties. 
In obstetrical and important surgical cases, which give rise 
to unusual fatigue, anxiety, and responsibility, it is just that the 
fees accruing therefrom should be awarded to the physician who 
officiates. 
Diversity of opinion and opposition of interest may, in the 
medical as in other professions, occasion controversy, and even 
contention. Whenever such cases unfortunately occur, and can 
not be immediately terminated, they should he referred to the 
arbitration of a sufficient number of physicians before appeal- 
ing to a medical society, or the law, for settlement. 
If medical controversies are brought before the public in 
newspapers or pamphlets by contending medical writers, and give 
rise to or contain asssertions or insinuations injurious to the per- 
sonal character or professional qualifications of the parties, the 
effect is to lower in the estimation of the public not only the 
parties directly involved, but also the medical profession as a 
whole. Such publications should, therefore, be brought to the CONCLUDING REMARKS. 
93 
notice of the county societies having jurisdiction, and discipline 
inflicted, as the case may seem to require. 
In justice to the medical profession of the State of 
New York, the number of votes by which the foregoing 
new code,” as it is called, was substituted for the national 
code, should he stated and kept in mind. The substitu- 
tion was carried by 62 ayes against 18 nays. A two-thirds 
majority of seventy persons thus decided to substitute a 
code in which a large part of the national code is abrogated, 
and to insert in the portions retained a modification which, 
as will presently be seen, is of great importance, thereby 
severing fellowship, by means of representation, of the State 
society and of county societies with the American Medical 
Association, as well as with societies in other States.* Those 
of the medical profession of the State of New York who 
had no expectation of such changes in the national code, and 
who were taken by surprise at the action of the State soci- 
ety, seemed to think that, as a matter of course, the action 
would be reversed at the next annual meeting. But, to 
complete the history, at the meeting in February, 1883, a 
motion for a reversal was lost, 99 voting for and 105 
* The following is the ninth by-law of the American Medical Asso- 
ciation: “No State or local medical society, or other organized institu- 
tion, shall be entitled to representation in this association that has not 
adopted the Code of Ethics, or that has intentionally violated or disre- 
garded any article or clause of the same.” In accordance with this by- 
law, the Judicial Council of the association, at the annual meeting in 
1882, decided as follows: “ Having carefully examined the Code of 
Ethics adopted by the New York State Medical Society at its annual 
meeting in February, 1882 (or furnished by the secretary of said soci- 
ety), the Judicial Council find in said code provisions essentially differ- 
ent from and in conflict with the Code of Ethics of this association ; 
and, therefore, in accordance with the provisions of the ninth by-law of 
the American Medical Association, they unanimously decide that the 
said New York State Medical Society is not entitled to representation 
by delegates in this association.” 94 
MEDICAL ETHICS AND ETIQUETTE. 
against it. Thus, at the present time, the New York State 
Society and the affiliated county societies in the State are 
ostensibly committed to the adoption of the new code. 
The New York Academy of Medicine, which has no con- 
nection with the State society except that it is empowered to 
send delegates to that body, retains the national code in its 
by-laws, and the fellows of the academy are therefore bound 
to it as fully as hitherto. It is not proposed to engage here 
in a controversial discussion of the reasons assigned for the 
action of the State society respecting the ethical code, and 
still less to inquire into personal motives. Some remarks, 
however, offered in a spirit of courtesy, may not be out of 
place. 
Why more than one half of the national code was left 
out of the new code has not, so far. as the writer knows, 
been explained. The omitted portion embraces the “ duties 
of physicians to their patients,” the “ obligations of patients 
to their physicians,” the “ duties for the support of profes- 
sional character,” and the “obligations of the public to phy- 
sicians.” Certainly the duties and obligations as specified 
in the omitted portions of the code can not be objected to. 
It can do no harm to specify them. They do not occupy 
so large a space in print that it was advisable to eliminate 
them in order to curtail the length of the code. The only 
conceivable explanation of their omission is that they were 
considered as superfluous. But it may be that they who 
voted for their elimination judged incorrectly, however natu- 
rally, from their own consciousness. A personal sense of 
rectitude is not always a safe guide in judging of the im- 
portance of ethical rules for self-government in others. 
There are many persons who are not liable to the tempta- 
tion to steal or commit murder, but no one will probably 
contend that, for this reason, the commandments relating to 
these offenses should be dropped from the decalogue. CONCLUDING REMARKS. 
95 
The important modification in the portion of the na- 
tional code which is retained in the new code is in this 
sentence : “ Members of the medical society of the State of 
New York, and of the medical societies in affiliation there- 
with, may meet in consultation legally qualified practitioners 
of medicine.” Since the discussions to which the substitu- 
tion of a new code has given rise relate almost exclusively 
to this sentence, it is fair to conclude tbat herein is the gist 
of the matter. The point is tbat a legal qualification ren- 
ders consultations permissible. Narrowing further the ob- 
ject of the modification, the practitioners of homoeopathy 
have hitherto been excluded from consultations by an inter- 
pretation of the Code of Ethics; they are legally qualified 
practitioners, and, at the present time, they constitute the 
great majority of those with whom consultations have been 
considered as interdicted by the code. The question, there- 
fore, now at issue in the State of New York is simply this ; 
Shall consultations with homoeopathic practitioners be per- 
mitted ? The affirmative answer to this question is based 
chiefly on two reasons—namely, first, the requirements of 
humanity; and, second, the legal status of homoeopathic 
practitioners. These reasons are specious but invalid. It 
is a gratuitous reflection on the National Code of Ethics to 
imply that it interdicts professional services under any cir- 
cumstances in which they are required by humanity. It 
was quite unnecessary to introduce into the new code the 
following sentence : “ Emergencies may occur in which all 
restrictions should, in the judgment of the practitioner, 
yield to the demands of humanity,” To intimate that this 
rule of action is in violation of the national code is a mon- 
strous injustice to it and to the medical profession. As re- 
gards the legal status of homoeopathic practitioners, this has 
nothing to do with the question at issue. It would be 
strange indeed if a State Legislature should undertake to 96 
MEDICAL ETHICS AND ETIQUETTE. 
regulate tlie professional etliics of physicians. This has 
never been attempted, and it probably never will be. The 
argument that a legal status affects in any measure the 
status as regarded from the standpoint of medical ethics 
seems to the writer too trivial to call for refutation. It will 
be time enough to consider seriously this argument when 
fellowship with all classes of practitioners is made compul- 
sory by statute, and this is equivalent to an indefinite post- 
ponement. 
The true ground for declining professional fellowship with 
any class of practitioners has been considered in the com- 
mentaries on that portion of the national code which relates 
to consultations. This ground is not a professed belief in 
the vagaries of Hahnemann, or in any other dogmas. It 
is the adoption of the names homoeopathic, eclectic, botanic, 
etc., as a trade-mark; the formation of a sectarian school of 
practice, announced to the public as such, and the endeavor, 
in divers ways, to bring the regular medical profession into 
popular disrepute. The physicians who became the early 
disciples of Hahnemann were not driven out of the ranks 
of the profession; they made haste to go out of their own 
accord, and to announce to the public their secession. 
Then, as now, it suited their ends not to be regarded as 
simply practitioners of medicine. Then, and ever since, 
they have sought for popular patronage as a sect detached 
from the regular profession. Their success in obtaining 
practice is due to the belief entertained by their patrons 
that they have had sagacity and independence enough to 
break away from antiquated doctrines and traditional rules 
of therapeutics, supplanting these by the great discoveries 
of the founder of the sect. Under these circumstances, 
can members of the medical profession, imbued with a 
proper sense of professional honor, do any act which in- 
volves affiliation with homoeopathic practitioners? The CONCLUDING REMARKS. 
97 
danse in the new code which sanctions consultations with 
them is a concession of honor, and a concession which has 
been publicly treated by them with scorn. Moreover, the 
concession implies a confession of error in the past; for, if 
the recent action of the State Medical Society be right, the 
medical profession has been in the wrong for the past thirty- 
six years! 
The action which substituted a new code for our time- 
honored National Code of Ethics has brought upon the 
profession of the State of New York a great disaster. It 
has substituted for harmony, dissension, with all the evils 
flowing therefrom—evils affecting not only the profession, 
but communities. Has this result been sufficiently consid- 
ered? Granting honesty of purpose to those who origi- 
nated and who have carried on with persistent efforts the 
movement against the national code, is it not the part of 
wisdom to pause and reflect upon these evils ? Should not a 
measure fraught with such consequences command, to say 
the least, a large majority in its favor? Would it not be 
becoming in the ardent advocates of the measure to recog- 
nize the propriety of some approach to unanimity of opinion, 
and for this end be content to await the result of a fuller 
discussion and a longer period of deliberation ? Finally, 
if the national code need revision, it is desirable that what- 
ever changes are made should be uniform throughout the 
country, not differing in the different States of the Union. 
Therefore, in closing these remarks, the writer earnestly 
appeals to those who advocate the new code, and to those 
who are in favor of no code, to join hands with those who 
uphold the national code in submitting all questions con- 
cerning professional ethics to the American Medical Asso- 
ciation, and to abide by the decisions of that body. 
THE END. WORKS OF AUSTIN FLINT, Jr„ M. D. 
The Physiology of Man; designed to represent the 
Existing State of Physiological Science, as applied to the Punctions 
of the Human Body. Complete in 5 vols., Bvo. Cloth, $22.00; 
sheep, $2'7.00; or, per volume, cloth, $4.50; sheep, $5.50. 
Vol. I. Introduction; Tub Blood; Circulation; Respiration. 
Vol. 11. Alimentation; Digestion; Absorption; Lymph and Chyle. 
Yol. 111. Secretion; Excretion; Ductless Glands; Nutrition; Animal 
Heat; Movements; Voice and Speech. 
Vol. IV. The Nervous System. 
Vol. Y. Special Senses; Generation. 
General Index to the Work. 
“The work is free from technicalities and purely professional terms, and, 
instead of only being adapted to the use of the medical faculty, will he found of 
interest to the general reader who desires clear and concise information on the 
subject of man physical.”—-Yew) York Evening Post. 
The Physiological Effects of Severe and Pro- 
tracted Muscular Exercise j with Special Reference to its 
Influence upon the Excretion of Nitrogen. 1 vol., 12mo. Cloth, $l.OO. 
A Text-book of Human Physiology; designed 
for the Use of Practitioners and Students of Medicine. Illustrated 
by three Lithographic Plates, and three hundred and thirteen Wood- 
cuts. 1 vol., imperial Bvo. Cloth, $6.00; sheep, fLOO. 
On the Source of Muscular Power. Arguments 
and Conclusions drawn from Observations upon the Human Subject, 
under Conditions of Rest and of Muscular Exercise. 1 vol., 12mo. 
Cloth, $l.OO. 
D. APPLETON & CO., Publishers, 1, 3, & 5 Bond Street, New York. THE 
POPULAR SCIENCE MONTHLY. 
This magazine draws from the intellectual resources of all nations, 
and is now recognized as the most successful scientific periodical in the 
world. 
Appealing to no one class, it is patronized by intelligent readers of 
every class all over the country. It is widely taken by the cultivators of 
science in all branches, and by physicians, engineers, scientific farmers, 
and those pursuing the mechanical and manufacturing arts. Thoughtful 
clergymen find it indispensable, and are extensively enumerated among 
its subscribers. Teachers, finding its discussions of the scientific prin- 
ciples of education invaluable, are among its most liberal supporters. It 
has a large clientage among the lawyers, and it is not easy to find an hon- 
est and independent student of politics that does not read it. 
‘ The reason of this is, that our best minds are getting tired of the 
shallow frivolities of sensational literature, and demand a magazine that 
elevates the standard of popular reading in this country. Science is the 
great agency of improvement in this age, private and public, individual, 
social, professional, and industrial. In its irresistible progress it touches 
everywhere, and affects everybody. It gives law to the material inter- 
ests of the community, and modifies its ideas, opinions, and beliefs, so 
that all have an interest in being informed of its advancement. Those, 
therefore, who desire to know what is going on in the world of thought 
in these stirring times, when new knowledge is rapidly extending, and 
old errors are giving way, will find that they can only keep informed by 
subscribing for The Popular Science Monthly. 
Terms : $5.00 per annum, or 50 cents a number; cloth covers for the 
volumes, 50 cents each. 
The volumes begin with May and November of each year, and sub- 
scriptions may begin at any time. 
A club of five will be supplied for |20.00 per annum. 
New York: D. APPLETON & CO., 1, 3, & 5 Bond Street. A NEW WEEKLY JOURNAL. 
THE 
MW YORK IEDIOAL JOURNAL, 
A Weekly Review of Medicine. 
Beginning with the number for Saturday, January 6,1883, the “New 
York Medical Journal” became a weekly instead of a monthly. The fre- 
quent publication of LECTURES is now made a prominent feature, and 
pains are taken to choose such as will prove valuable to the reader. At the 
same time care is taken not to lessen the variety and value of the more 
formal articles known as ORIGINAL COMMUNICATIONS. In accepting 
articles of that class, regard is had more particularly to the wants of the 
general practitioner, and all the special branches of medicine are duly rep- 
resented. 
In the matter of BOOK NOTICES, publishing more frequently, we are 
able to avoid delays. Formerly a great deal of contemporary literature was 
kindly sent to us in the reasonable expectation that it would be noticed in 
our pages—and yet we were obliged to pass it by. Much of this matter is 
of such a nature that, if noticed at all, it should be noticed wit hout delay. 
The columns of the weekly now enable us to do justice to the literature of 
the day, and to keep our readers fully and promptly informed of its scope 
and character. 
CLINICAL REPORTS will hereafter be a regular feature of the weekly 
Journal, embracing clinical records from the various hospitals and clinics, 
not only of New York, but of various other cities, together with clinical 
contributions from private practice. 
The EDITORIAL ARTICLES will be more numerous, and we shall be 
able to give more timely consideration to passing events. It is in this de- 
partment especially that frequency of issue adds to the interest of a journal. 
SOCIETY PROCEEDINGS will be given more promptly than before, 
and those of a greater number of societies will figure. 
The REPORTS ON THE PROGRESS OF MEDICINE—a feature of 
the Journal which we have reason to think has been highly valued by our 
readers—will not be curtailed in their scope. On the contrary, an addi- 
tional quarterly report will be published on Preventive Medicine and Medi- 
cal Jurisprudence. All the reports will be given quarterly, so that upon 
each of the departments of medicine formerly covered by them (anatomy 
and physiology; materia mcdica, therapeutics, and toxicology; general 
medicine; surgery; orthopaedic surgery and diseases of the joints; obstetrics 
and gynaecology; ophthalmology and otology; cutaneous and venereal dis- 
eases ; and psychological medicine), as well as the new topic mentioned 
above, a report will appear four times a year. 
Under the head of MISCELLANY we shall include matters of news, 
correspondence, etc.—the varied items that one expects to find in a weekly 
paper. 
Terms, $5.00 per annum (postage prepaid by the Publishers); single copies, 12 cents. 
New York: D. APPLETON & CO., 1, 3, & 5 Bond Street, NOW READY, A NEW EDITION OF 
Lectures on Orthopedic Surgery and 
Diseases of the Joints. 
LEWIS A. SAYRE, M. D., 
Professor of Orthopedic Surgery and Clinical Surgery in Bellevue Hospital Medi- 
cal College; Consulting Surgeon to Bellevue Hospital, Charity Hospital, 
St. Elizabeth’s Hospital, Northwestern Dispensary, etc,, etc. 
Illustrated with 324 Engravings on Wood. 1 vol., Bvo. Cloth, 
$5.00; sheep, $6.00. 
“This edition has been thoroughly revised and rearranged, and the subjects 
classified in the anatomical and pathological order of their development. Many 
of the chapters have been entirely rewritten, and several new ones added, and 
the whole work brought up to the present time, with all the new improvements 
that have been developed in this department of surgery. Many new engravings 
have been added, each illustrating some special point in practice.”—Author. 
“ The name of the author is a sufficient guarantee of its excellence, as no man 
in America or elsewhere has devoted such unremitting attention for the past 
thirty years to this department of surgery, or given to the profession so many 
new truths and laws as applying to the pathology and treatment of deformities.” 
Western Lancet. 
“Dr. Sayre has stamped his individuality on every part of his book. Post 
sessed of a taste for mechanics, he has admirably utilized it in so modifying the 
inventions of others as to make them of far greater practical value. The care, 
patience, and perseverance which he exhibits in fulfilling all the conditions 
necessary for success in the treatment of this troublesome class of cases are 
worthy of all praise and imitation.”—Detroit Review of Medicine. 
“Its teaching is sound, and the originality throughout very pleasing; in a 
word, no man should attempt the treatment of deformities of joint affections 
without being familiar with the views contained in these lectures.”—Canada 
Medical and Surgical Journal. 
NOTICES OF FORMER EDITIONS. 
RECENTLY ISSUED, A NEW EDITION OF 
A Practical Manual on the Treatment 
of Club-Foot 
Professor of Orthopedic Surgery in Bellevue Hospital Medical College; Surgeon 
to Bellevue and Charity Hospitals, etc. 
LEWIS A. SAYRE, M. D., 
Fourth edition, enlarged and corrected. 1 vol., 12mo. Illustrated. 
Cloth, $1.25. 
“The object of this work is to convey, in as concise a manner as possible, all 
the practical information and instruction necessary to enable the general practi- 
tioner to apply that plan of treatment which has been so successful in my own 
hands.”—Preface. 
“ The book will very well satisfy the wants of the majority of general practi- 
tioners, for whose use, as stated, it is intended.”—New York Medical Journal. 
New York: D. APPLETON & CO., 1, 3, & 5 Bond Street. In one Bvo volume, of nearly 7SO pages. 
A TREATISE ON INSANITY, 
IN' ITS MEDICAL RELATIONS. 
WILLIAM A. HAMMOND, M.D., 
Surgeon-General U. 8. Army (retired list); Professor of Diseases of the Mind and 
Nervous System in the New York Post-Graduate Medical School; 
President of the American Neurological Association, etc. 
In this work the author has not only considered the subject of Insanity, 
but has prefaced that division of bis work with a general view of the mind 
and the several categories of mental faculties, and a full account of the vari- 
ous causes that exercise an influence over mental derangement, such as 
habit, age, sex, hereditary tendency, constitution, temperament, instinct, 
sleep, dreams, and many other factors. 
Insanity, it is believed, is in this volume brought before the reader in an 
original manner, and with a degree of thoroughness which can not but lead 
to important results in the study of psychological medicine. Those forms 
which have only been incidentally alluded to or entirely disregarded in the 
text-hooks hitherto published are here shown to be of the greatest interest 
to the general practitioner and student of mental science, both from a 
normal and abnormal stand-point. To a great extent the work relates to 
those species of mental derangement which are not seen within asylum 
walls, and which, therefore, are of special importance to the non-asylum 
physician. Moreover, it points out the symptoms of Insanity in its first 
stages, during which there is most hope of successful medical treatment, 
and before the idea of an asylum has occurred to the patient’s friends. It is 
believed that the issue of this work will constitute an era in the progress of 
the study of Insanity. 
New York: D. APPLETON & CO., Publishers, 1, 8, & 5 Bond Street. Treatise on Chemistry 
A 
H. E. ROSCOE, F. R. S., and 
BY 
Professors of Chemistry in the Victoria University, Owens College, Manchester. 
C. SCHORLEMMER, F. R. S., 
ILLUSTRATED. 
INORGANIC CHEMISTRY. Bvo. 
Yol. I.— Non-Metallic Elements. Price, $5.00. 
Vol. ll.—Part I.—Metals. Price, $3.00. 
Yol. ll.—Part ll.—Metals. Price, $3.00. 
ORGANIC CHEMISTRY. Bvo. 
Vol. lll.—Part I.—The Chemistry of the Hydrocarbons and their 
Derivatives. Price, $5.00. 
Yol. lll.—Part ll.—Completing the work. (Inpreparation.) 
“Of the 695 pages constituting this first moiety of the third and last volume 
of Roscoe and Schorlemmer’s new chemical text-book no less than 190 are occu- 
pied with the discussion of the methods and the philosophy of the subject. The 
tystematic description of individual organic compounds—their occurrence, their 
production, their properties, and their reactions—begins with the methyl group, 
and then proceeds through nineteen sections, or 270 numbered paragraphs. In 
these we are presented with well-digested accounts of bodies containing from 
one to twenty-four atoms of carbon ; the aromatic series, and those compounds 
which have, up to the present time, eluded classification, partially or wholly, 
being reserved, we presume, for the second and concluding portion of the final 
installment of the work before us. It is difficult to praise too highly the selec- 
tion of materials and their arrangement, or the wealth of illustrations which ex- 
plain and adorn the text. Moreover, it is most satisfactory to find that the 
progress of this valuable work toward completion is so rapid, that its beginning 
will not have become antiquated before its end has been reached—no uncom- 
mon occurrence with elaborate treatises on natural science subjects.”—London 
Academy. 
‘.‘The authors are evidently bent on making their book the finest systematic 
treatise on modern chemistry in the English language, an aim in which they are 
well seconded by their publishers, who spare neither pains nor cost in illustrat- 
ing and otherwise setting forth the work of these distinguished chemists.”— 
London. Athenaeum. 
“It has been the aim of the authors, in writing their present treatise, to 
place before the reader a fairly complete and yet a clear and succinct statement 
of the facts of Modern Chemistry, while at the same time entering so far into a 
discussion of chemical theory as the size of the work and the present transition 
state of the science will permit. 
“ Special attention has been paid to the accurate description of the more im- 
portant processes in technical chemistry, and to the careful representation of 
the most approved forms of apparatus employed. 
“Much attention has likewise been given to the representation of apparatus 
adopted for lecture-room experiment, and the numerous new illustrations re- 
quired for this purpose have all been taken from photographs of apparatus act- 
ually in use.”—Extract from Preface. 
For sale by all booksellers ; or sent by mail, post-paid, to any address in the 
United States, on receipt of price. 
New York: D. APPLETON & CO., 1, 8, & 5 Bond Street