In his relatively brief discussion of the subsequent growth and impact of bioethics on medical trust, Imber argues that Catholic moral theology and notions of pastoral medicine inspired early work in bioethics by Callahan and others on topics such as abortion, medical paternalism, and genetic intervention.
Religious and theological views on medical and reproductive ethics were also targeted by secular bioethicists in the US. For some bioethicists saw the prevalence of unjustifiable medical paternalism as a symptom of the insularity of professional role-based ethical standards themselves.
That is, codes of medical ethics in America, which had supported attitudes of medical condescension and made no mention of respecting patients, were attacked as self-serving and outdated, and as lacking adequate moral authority. Robert Veatch, for example, urged doctors to reject a professionally-generated ethic altogether and rely solely for guidance on broad-based ethical theories such as Kantianism or Utilitarianism:.
The real problem is the use of professional ethical standards rather than those rooted in some more universally accessible source of morality. This appeal to broad-based ethical theories was quite independent of any religiously-inspired challenges to medical authority. Many bioethicists subsequently came to see this rejection of a professionally-generated medical ethic as an overreaction. Instead, they argued that an appropriate conception of the internal morality of medicine could be legitimately invoked by doctors without condoning the unethical behaviour of the past.
The revival of a distinctive medical ethic also paved the way for applications to medicine of an approach known as virtue ethics, according to which actions are right if they are what a person with a virtuous character would do in the circumstances. Imber analyses the rise of bioethics as a broad social movement and as a fundamentally equalising force, challenging the dominance of doctors and clergy over moral questions regarding health and reproduction. The development of health consumer groups over the last 40 years, and their insistence on the importance of informed consent in clinical practice, has also helped reshape community expectations of doctor-patient relationships.
Medical ethics teaching also changed significantly as a result of these demands for more patient involvement in decision-making and better accountability, and doctors were taught to develop greater humility and to become less judgmental towards their patients. American medical practice is now notorious for its litigiousness, and Imber provides a plausible explanation for how this came about:.
The increase in malpractice suits during the s and s reflected the distrust of the profession as well as the demands for even higher levels of quality in medical care. These demands were the consequence of the increase in medical specialties and subspecialties, creating more insistence on effective treatment and less tolerance for error p. However, the development of bioethics and the renewed interest in virtue ethics have led many medical educators to return to more rounded and less narrowly technical notions of professional character and competence, which offer hope for alleviating this poisonous trend.
Trusting Doctors is a well-researched and absorbing account of how American medicine gained and then lost its social cachet.
What of the medical profession in Australia? The more scientific approaches to medicine being developed in the early 20th century clearly boosted the reputations of doctors in Australia, as in America and Great Britain. The various Australian state branches of the British Medical Association BMA were federated in , when a unified code of professional ethics, dealing mainly with the regulation of advertising and etiquette toward patients, was introduced Armit ; Egan Following World War I, Australian medical schools began to include brief instruction in the ethical obligations of physicians, and there was public discussion of issues such as abortion, methods of birth control, and confidentiality in relation to patients with sexually transmitted diseases.
However, religion exercised less influence on medical ethics and conceptions of professional character in Australia than it did in the United States. Australian doctors carrying out research found themselves under more scrutiny from , when the first recorded institutional research ethics committee was set up at the Royal Victorian Eye and Ear Hospital in Melbourne McNeill While the regulation of biomedical research in Australia was less reactive than it was in the United States, which had witnessed some well-publicised scandals in the s, the development of the concept of informed consent in research also helped Australian patients gain recognition of the importance of this concept in the context of clinical practice.
Australian doctors also found their moral authority being challenged by the widespread social changes of the s.
However, litigation against doctors has been a less significant factor in this country than in the United States. Also, here as in the United States, dissatisfaction with entrenched medical paternalism led some patients to turn away from conventional medical practitioners in favour of complementary medicine Clark-Grill Like many of their overseas counterparts, several Australian medical schools began to strengthen their teaching of ethics to medical students in the s and s. And, after the National Inquiry into Medical Education, all Australian medical schools began to include a substantive medical ethics component in their undergraduate programs Oakley Today much more is expected of doctors than in the past.
Medical graduates are required to be effective communicators and to have a much better understanding of ethical principles and practice than their predecessors, and the unstoppable medical transparency movement places doctors under unprecedented public scrutiny. But where such trust was often taken for granted in the past, patients now commonly expect doctors to earn their trust, and to maintain it through demonstrating good evidence-based practice in what they do see, for example, Lupton This change is not to be lamented.
Trust is enhanced when we know that doctors and the profession are performing well, and are upholding the priorities that the community entrusted them to have when granting their monopoly of expertise in the first place. The medical profession has lost the elevated social standing it once had.
Armit, H. Bentley, A. Churchill, L. Clark-Grill, M.
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