Trusting Doctors: The Decline of Moral Authority in American Medicine

Trusting Doctors: The Decline of Moral Authority in American Medicine

by Jonathan B. Imber
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Princeton University Press


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Trusting Doctors: The Decline of Moral Authority in American Medicine

For more than a century, the American medical profession insisted that doctors be rigorously trained in medical science and dedicated to professional ethics. Patients revered their doctors as representatives of a sacred vocation. Do we still trust doctors with the same conviction? In Trusting Doctors, Jonathan Imber attributes the development of patients' faith in doctors to the inspiration and influence of Protestant and Catholic clergymen during the nineteenth and early twentieth centuries. He explains that as the influence of clergymen waned, and as reliance on medical technology increased, patients' trust in doctors steadily declined.

Trusting Doctors discusses the emphasis that Protestant clergymen placed on the physician's vocation; the focus that Catholic moralists put on specific dilemmas faced in daily medical practice; and the loss of unchallenged authority experienced by doctors after World War II, when practitioners became valued for their technical competence rather than their personal integrity. Imber shows how the clergy gradually lost their impact in defining the physician's moral character, and how vocal critics of medicine contributed to a decline in patient confidence. The author argues that as modern medicine becomes defined by specialization, rapid medical advance, profit-driven industry, and ever more anxious patients, the future for a renewed trust in doctors will be confronted by even greater challenges.

Trusting Doctors provides valuable insights into the religious underpinnings of the doctor-patient relationship and raises critical questions about the ultimate place of the medical profession in American life and culture.

Product Details

ISBN-13: 9780691135748
Publisher: Princeton University Press
Publication date: 08/25/2008
Edition description: New Edition
Pages: 296
Product dimensions: 6.30(w) x 9.30(h) x 1.00(d)

About the Author

Jonathan B. Imber is the Class of 1949 Professor in Ethics and professor of sociology at Wellesley College. He is the author of Abortion and the Private Practice of Medicine.

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Trusting Doctors The Decline of Moral Authority in American Medicine

By Jonathan B. Imber Princeton University Press
Copyright © 2008
Princeton University Press
All right reserved.

ISBN: 978-0-691-13574-8

Chapter One Protestantism, Piety, and Professionalism

Whether trusted or not, doctors have used the Hippocratic oath for two thousand years as the equivalent of a social contract between the medical profession and the public, administered in modern times at graduation from medical school. Even though the legacy of that contract may now seem to raise more questions than it answers about the physician's duties, the original oath has been described as "the Medical Decalogue [equivalent to the Ten Commandments], universally accepted as such."

That original, as translated by Ludwig Edelstein in his book The Hippocratic Oath: Text, Translation, and Interpretation (1943), reads as follows:

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art-if they desire to learn it-without fee and covenant; to give ashare of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

A more contemporary adaptation was written in 1964 by Louis Lasagna (1923-2003), who was for many years the academic dean of Tufts University Medical School. As an introduction to the central concerns of this book, it is worth comparing the two.

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

Lasagna's updated pledge is a recasting to accommodate to more modern times: the Greek gods are no longer invoked, the language no longer refers to male family lineages or "pupils who have taken an oath" only, and the dismissal of "the knife" has been changed to acknowledge that surgery is often a key component of medical treatment.

Today, however, even relatively contemporary formulations like Lasagna's or an earlier one adopted in Geneva in 1948 by the Second General Assembly of the World Medical Association might seem dated. In fact, according to a recent graduate of Harvard Medical School, her class wrote its own, even newer pledge. Much has changed with regard to the moral and ethical challenges today's doctors face-and with regard to the implications of those challenges for the bond of trust between physician and patient. What has not changed is that within the profession of medicine the tradition of making a solemn commitment to adhere to certain standards of character and morality endures. And even in times that present them with many new dilemmas, fledgling doctors still vow to uphold those parts of the ancient oath that are seen as timeless. Respect for one's teachers; cooperation with one's colleagues; and above all, the protection of patients' interests, including a promise of confidentiality-these assurances are deeply embedded in the institutional foundations of what it means to be and act as a physician.

These foundations do not, for our purposes here, determine what a physician actually does; rather they represent a key to understanding the historical belief in the United States that doctors are worthy of our trust. The Hippocratic oath was the first rhetorical foundation of that trust, the pagan halo under which all subsequent collective efforts to stipulate the physician's duties emerged. And the sacred nature of that pledge, in all its contemporary variants and in the broadest sense of the word "sacred," still resonates in American society-despite an erosion of personal and public trust in doctors in recent decades-because of the historical connections between religious beliefs, religious establishments, and the medical profession.

The Protestant Vision of Medicine as a Sacred Vocation

During the nineteenth century, formal codes of guidance for physicians in the United States were the direct inheritance of the work of three British physicians, John Gregory (1724-1773), Thomas Percival (1740-1804), and Michael Ryan (1800-1841). In particular, Percival's Medical Ethics, or a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons (1803) was the principal source for the "Boston Medical Police," a code of conduct promulgated by members of the Boston Medical Association in 1808. Medical societies in eleven other states adopted some version of this code in subsequent years, and on May 6, 1847, the American Medical Association approved the first national code of medical ethics at a gathering of physicians in Philadelphia.

Echoing the Hippocratic oath, these various codifications of expectations about medical conduct included specific directives about the duties of physicians to their patients (and vice versa), the obligations of physicians to one another, and the obligations of the profession to the public (and vice versa). The principle of reciprocity between physician and patient and between profession and public, as the late historian of medical ethics Chester Burns noted, was exemplified in the work of one American physician, Worthington Hooker, who published the only full-length study of medical ethics to be brought out in the nineteenth century. In writing about Hooker and his time, Burns concluded,

No American claimed that codes guaranteed medical righteousness. Codes simply provided physicians with some knowledge of the difference between right and wrong professional conduct. Without some ideals and some means of institutionalizing them, there would be little chance to alter professional evils anywhere.

As the medical profession continued to evolve in this country, "righteousness" was indeed an issue, and the question of whether the meaning of this word relates to religion, to morality and character, or to strictly secular standards of conduct is central to the broader question of trust. Historians of nineteenth-century medicine in the United States have long taken for granted its white, Protestant character, so much so that one key to understanding the nature of the public's almost universal trust in medicine, beginning in the middle of the nineteenth century and lasting until the middle of the twentieth, was the near uniformity of its practitioners not only in terms of their race, class, and gender, but also in terms of the kinds of cultural expectations that pertained to how they should act with respect to society, colleagues, and their patients.

In his book The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1820-1885, John Harley Warner writes,

In a commencement address to Cincinnati medical students in 1877 on "the dignity and sanctity of the medical profession," the speaker asserted that "its chief excellence is not that it is scientific, but that it is redemptive."

To understand and explain illness were important parts of the physician's task, but they did not constitute the whole of it. The physician was more than a natural scientist; he was also a healer. Warner goes on to argue that the commencement speaker, Nathaniel West, was dissenting from the "still novel view that professional identity in medicine should be defined chiefly by science," and in an article titled "Science, Healing and the Physician's Identity," he interprets the "redemptive" dimension of medicine as being the humane impulse to act, whether or not the action taken had been scientifically proven to be therapeutically efficacious. It is significant, however, that the speaker Warner chose to quote on this point was not a physician, although his talk was entitled "The Medical Science and Profession," but rather a Presbyterian minister.

The Reverend Nathaniel West Jr. (1824-1906) graduated from the University of Michigan and the Western Theological Seminary, and served in pulpits in Pittsburgh, Cincinnati, Brooklyn, and St. Paul. In the clerical tradition of working through the relation of revealed truth to practical conduct, West followed the general practice of many other ministers who used the occasion of a commencement speech to put forth their own views about what was at stake in the fledgling physician's obligations to patients and profession.

Quoting Ovid, "Non est in Medico semper relevetur ut aeger" (The cure of the patient is not always in the physician's power), West remarked,

If any one, therefore, will seek the true occasion of the rise of the medical profession, he will find no sufficient explanation of this in science itself, but in an historic fact antecedent to all science, the first violation of moral laws imposed upon man by his Creator. It involves questions which do not belong to medical science, as such, but to a totally different department of investigation-none the less important on this account, but all the more worthy of moral consideration, as throwing a peculiar sacredness around the profession itself.

The "peculiar sacredness" West attributed to medicine was his way of acknowledging that, far from being hostile to science, the theological beliefs of enlightened Protestants encouraged an examination and justification of how the clerical and medical professions were engaged in a common pursuit of both physical and spiritual well-being.

West insisted that his remarks should not be interpreted as sanctioning all practices alleged to be medical. Charlatans were present in both the medical and clerical professions, he noted. He did not describe in any detail who, in his opinion, walked on the right side and who did not, but he did convey an overall view to his audience similar to that expressed several years earlier by Oliver Wendell Holmes Sr., who concluded in 1869 that although improvements had occurred in the relations between clergymen and physicians, "Whether the world at large will ever be cured of trusting to specifics as a substitute for observing the laws of health, and to mechanical or intellectual formulae as a substitute for character, may admit of question. Quackery and idolatry are all but immortal."

It seems clear that even while admonishing students about the limits and temptations of their vocation, West hoped to join the "scientific" with the "redemptive" in order to secure both a scientific basis for medicine and a theological guide for physicianhood. His long encomium to medicine was not nostalgic but rather intended to reinforce the idea that the new methods of scientific investigation were confirming of, rather than destructive to, Christian truths:

The skillful anatomist will cut away a whole hemisphere of the brain, slice by slice, and find the Apostle's Creed or the Ten Commandments, faith in God and hope of immortality, with all the mental faculties, just as strong as before the chloroform and knife began their work. The living spirit is the same, its creed the same. Its ethereal essence survives the knife, the martyr's flame, the tomb!

In an age of rapid change and development, conflict among physicians about the therapeutic efficacy of differing approaches to disease and treatment did influence clergymen's opinions of the medical profession. But their central concern was contained in the advice they gave to physicians about their moral responsibilities, advice that was intended, at least in part, to define new strategies for professing and promoting Christian faith and values in an era rapidly substituting scientific agnosticism for divine revelation. And in the end, modern codes of medical professionalism owe as much to this professing as to any advances in therapeutic technique. How ministers communicated the importance of specifically Protestant Christian piety in this context can be seen in a literature of preaching that was directed at medical students and, presumably, their teachers. Both Nathaniel West and Charles Quintard (whose pronouncements we will quote later) were among those ministers who used the occasion of a commencement ceremony to outline Christian ideals as they pertained to medical practice. It is difficult to reconstruct completely who was asked to deliver such addresses, and the vast majority of them, in any case, were not published. But extant versions of speeches, sermons, and eulogies, a list of which is contained in appendix 1, provide ample illustrations of how Protestant clergymen approached the vocation of medicine during the greater part of the nineteenth century. (Clergy asked to deliver commencement addresses to medical students during the second half of the century were overwhelmingly Protestant and male, although Lucretia Mott [1793-1880], the Quaker abolitionist and participant at Seneca Falls, made a speech to medical students in 1849 in Philadelphia, and rabbis delivered several addresses that survive. Catholic priests, however, were virtually invisible in such quasi-public ceremonies.)


Excerpted from Trusting Doctors by Jonathan B. Imber
Copyright © 2008 by Princeton University Press. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents

Preface: A Sociological Perspective xi

Introduction xvii

Part One: Religious Foundations of Trust in Medicine

Chapter 1: Protestantism, Piety, and Professionalism 3

Chapter 2: The Infl uence of Catholic Perspectives 22

Chapter 3: The Scientifi c Challenge to Faith 43

Chapter 4: Public Health, Public Trust, and the Professionalization of Medicine 65

Part Two: Beyond the Golden Age of Trust in Medicine

Chapter 5: The Growth of Popular Distrust in Medicine 107

Chapter 6: The Evolution of Bioethics 130

Chapter 7: Anxiety in the Age of Epidemiology 144

Chapter 8: Trust and Mortality 167

Acknowledgments 197

Appendix 1: Extant Addresses, Sermons, and Eulogies by Clergymen 201

Appendix 2: Philadelphia Medical Sermons 208

Appendix 3: Long Island College Hospital Commencements, 1860-1899 210

Notes 213

Index 265

What People are Saying About This

Peter Conrad

Trusting Doctors is a major book, a benchmark on medical morality and trust, and an exemplar of religion's impact on medicine.
Peter Conrad, Brandeis University

Richard John Neuhaus

Doctors and people who have no choice but to trust doctors--which means all of us--need to read this book. With both sympathy and uncompromising honesty, Jonathan Imber traces the frequently troubled history of a medical profession that needs to attend to its increasingly fragile moral authority.
Richard John Neuhaus, editor in chief of the journal "First Things"

Daniel Callahan

Jonathan Imber's Trusting Doctors is an important, interesting, and readable book. We all know that our modern doctors do not have the social aura they once did. Imber effectively tells us the eye-opening story of why that change has happened.
Daniel Callahan, cofounder of the Hastings Center

De Vries

This important book challenges many ideas that have long been taken for granted in medical sociology and the history of medicine: ideas about the work of bioethics and epidemiology, as well as the relation between religion and medicine.
Raymond G. De Vries, University of Michigan

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