CHAPTER II.. _of Professional Conduct in Private or General Practice._

Of Professional Conduct in Private or General Practice.

§ 1. The moral rules of conduct prescribed towards hospital patients should be fully adopted in private or general practice. Every case committed to the charge of a Physician or Surgeon should be treated with attention, steadiness, and humanity; reasonable indulgence should be granted to the mental imbecility and caprices of the sick; secrecy and delicacy, when required by peculiar circumstances, should be strictly observed; and the familiar and confidential intercourse, to which the Faculty are admitted in their professional visits, should be used with discretion, and with the most scrupulous regard to fidelity and honour.

§ 2. The strictest temperance should be deemed incumbent on the Faculty; as the practice both of Physic and Surgery at all times requires the 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. Philip of Macedon reposed with entire security on the vigilance and attention of his general Parmenio. In his hours of mirth and conviviality he was wont to say, “Let us drink, my friends; we may do it with safety, for Parmenio never drinks!” The moral of this story is sufficiently obvious when applied to the Faculty; but it should certainly be construed with great limitation by their patients.

§ 3. A Physician should not be forward to make gloomy prognostications; because they savour of empiricism, by magnifying 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 judgement and delicacy; for the Physician should be 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 rob the philosopher of fortitude, and the Christian of consolation.

§ 4. Officious interference in a case under the charge of another should be carefully avoided. No meddling enquiries should be made concerning the patient, no unnecessary hints given relative to the nature or treatment of his disorder, nor any selfish conduct pursued, that may directly or indirectly tend to diminish the trust reposed in the Physician or Surgeon employed. Yet, though the character of a professional busy-body, whether from thoughtlessness or craft, is highly reprehensible, there are occasions which not only justify, but require, a spirited interposition. When artful ignorance grossly imposes on credulity, when neglect puts to hazard an important life, or rashness threatens it with still more imminent danger, a Medical neighbour, friend, or relative, apprized of such facts, will justly regard his interference as a duty. But he ought to be careful that the information on which he acts is well founded, that his motives are pure and honourable, and that his judgement of the measures pursued is built on experience and practical knowledge, not on speculative or theoretical differences of opinion. The particular circumstances of the case will suggest the most proper mode of conduct. In general, however, a personal and confidential application to the gentleman of the Faculty concerned, should be the first step taken, and afterwards, if necessary, the transaction may be communicated to the patient or to his family.

§ 5. When a Physician or Surgeon is called to a patient who has been before under the care of another gentleman of the Faculty, a consultation with him should be proposed, even though he may have discontinued his visits. His practice also should be treated with candour, and justified, so far as probity and truth will permit: for the want of success in the primary treatment of a case is no impeachment of professional skill or knowledge; and it often serves to throw light on the nature of a disease, and to suggest to the subsequent practitioner more appropriate means of relief.

§ 6. In large and opulent towns the distinction between the provinces of Physic and Surgery should be steadily maintained. This distinction is sanctioned both by reason and experience. It is founded on the nature and objects of the two professions; on the education and acquirements requisite for their most beneficial and honourable exercise; and tends to promote the complete cultivation and advancement of each. For the division of skill and labour is no less advantageous in the liberal than in the mechanic arts; and both Physic and Surgery are so comprehensive, and yet so far from perfection, as separately to give full scope to the industry and genius of their respective professors. Experience has fully evinced the benefits of the discrimination recommended, which is established in every well regulated hospital, and is thus expressly authorized by the Faculty themselves, and by those who have the best opportunities of judging of the proper application of the healing art. No Physician or Surgeon, therefore, should adopt more than one denomination, or assume any rank or privileges different from those of his order.

§ 7. Consultations should be promoted in difficult or protracted cases, as they give rise to confidence, energy, and more enlarged views in practice. On such occasions no rivalship or jealousy should be indulged: candour, probity, and all due respect should be exercised towards the Physician or Surgeon first engaged; and, as he may be presumed to be best acquainted with the patient and with his family, he should deliver all the medical directions agreed upon, though he may not have precedency in seniority or rank. It should be the province, however, of the senior Physician, first to propose the necessary questions to the sick, but without excluding his associate from the privilege of making farther enquiries, to satisfy himself, or to elucidate the case.

§ 8. As circumstances sometimes occur to render a special consultation desirable, when the continued attendance of another Physician or Surgeon might be objectionable to the patient, the gentleman of the Faculty whose assistance is required, in such cases, should pay only two or three visits, and sedulously guard against all future unsolicited interference. For this consultation a double gratuity may reasonably be expected from the patient, as it will be found to require an extraordinary portion both of time and attention.

In Medical practice it is not an unfrequent occurrence, that a Physician is hastily summoned, through the anxiety of the family or the solicitation of friends, to visit a patient who is under the regular direction of another Physician, to whom notice of this call has not been given. Under such circumstances no change in the treatment of the sick person should be made, till a previous consultation with the stated Physician has taken place, unless the lateness of the hour precludes meeting, or the symptoms of the case are too pressing to admit of delay.

§ 9. Theoretical discussions should be avoided in consultations, as occasioning perplexity and loss of time; for there may be much diversity of opinion concerning speculative points, with perfect agreement in those modes of practice which are founded not on hypothesis, but on experience and observation.

§ 10. The rules prescribed for hospital consultations may be adopted in private or general practice. And the seniority of a Physician may be determined by the period of his public and acknowledged practice as a Physician, and that of a Surgeon by the period of his practice as a Surgeon, in the place where each resides. This arrangement, being clear and obvious, is adapted to remove all grounds of dispute amongst Medical gentlemen; and it secures the regular continuance of the order of precedency established in every town, which might otherwise be liable to troublesome interruptions by new settlers, perhaps not long stationary.

§ 11. A regular academical education furnishes the only presumptive evidence of professional ability, and is so honourable and beneficial, that it gives a just claim to pre-eminence among Physicians, in proportion to the degree in which it has been enjoyed and improved. Yet, as it is not indispensably necessary to the attainment of knowledge, skill, and experience, they who have really acquired in a competent measure such qualifications without its advantages, should not be fastidiously excluded from the privileges of fellowship. In consultations especially, as the good of the patient is the sole object in view, and is often dependent on personal confidence, the aid of an (any?) intelligent practitioner ought to be received with candour and politeness, and his advice adopted, if agreeable to sound judgement and truth.

§ 12. Punctuality should be observed in the visits of the Faculty, when they are to hold consultation together; but, as this may not always be practicable, the Physician or Surgeon who first arrives at the place of appointment, should wait five minutes for his associate, before his introduction to the patient, that the unnecessary repetition of questions may be avoided. No visits should be made but in concert, or by mutual agreement; no statement or discussion of the case should take place before the patient or his friends, except in the presence of each of the attending gentlemen of the Faculty, and by common consent; and no prognostications should be delivered, which are not the result of previous deliberation and concurrence.

§ 13. Visits to the sick should not be unseasonably repeated; because, when too frequent, they tend to diminish the authority of the Physician, to produce instability in his practice, and to give rise to such occasional indulgences, as are subversive of all Medical regimen.

Sir William Temple has asserted, that “an honest Physician is excused for leaving his patient, when he finds the disease growing desperate, and can, by his attendance, expect only to receive his fees, without any hopes or appearance of deserving them.” But this allegation is not well founded; for the offices of a Physician 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 obviating despair, by alleviating pain, and by soothing mental anguish. 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 appreciation.

§ 14. Whenever a Physician or Surgeon officiates for another who is sick or absent during any considerable length of time, he should receive the fees accruing from such additional practice; but, if this fraternal act be of short duration, it should be gratuitously performed, with an observance always of the utmost delicacy towards the interest and character of the professional gentleman previously connected with the family.

§ 15. Some general rule should be adopted by the Faculty in every town relative to the pecuniary acknowledgements of their patients; and it should be deemed a point of honour to adhere to this rule with as much steadiness as varying circumstances will admit: for it is obvious that an average fee, as suited to the general rank of patients, must be an inadequate gratuity from the rich, who often require attendance not absolutely necessary, and yet too large to be expected from that class of citizens, who would feel a reluctance in calling for assistance without making some decent and satisfactory retribution.

But in the consideration of fees, let it ever be remembered, that, though mean ones from the affluent are both unjust and degrading, yet the characteristical beneficence of the Profession is inconsistent with sordid views and avaricious rapacity. To a young Physician it is of great importance to have clear and definite ideas of the ends of his Profession, of the means for their attainment, and of the comparative value and dignity of each. Wealth, rank, and independence, with all the benefits resulting from them, are the primary ends which he holds in view; and they are interesting, wise, and laudable: but knowledge, benevolence, and active virtue, the means to be adopted in their acquisition, are of still higher estimation; and he has the privilege and felicity of practising an art, even more intrinsically excellent in its mediate than in its ultimate objects. The former, therefore, have a claim to uniform pre-eminence.

§ 16. All members of the Profession (including Apothecaries, as well as Physicians and Surgeons,) together with their wives and children, should be attended gratuitously by any one or more of the Faculty residing near them whose assistance may be required; for, as solicitude obscures the judgement, and is accompanied with timidity and irresolution. Medical men, under the pressure of sickness, either as affecting themselves or their families, are peculiarly dependent upon each other. But visits should not be obtruded officiously; as such unasked civility may give rise to embarrassment, or interfere with that choice on which confidence depends. Distant members of the Faculty, when they request attendance, should be expected to defray the charges of travelling; and, if their circumstances be affluent, a pecuniary acknowledgement should not be declined: for no obligation ought to be imposed, which the party would rather compensate than contract.

§ 17. When a Physician attends the wife or child of a member of the Faculty, or any person very nearly connected with him, he should manifest peculiar attention to his opinions, and tenderness even to his prejudices. For the dear and important interests which the one has at stake, supersede every consideration of rank or seniority in the other; since the mind of a husband, a father, or a friend, may receive a deep and lasting wound, if the disease terminate fatally, from the adoption of means he could not approve, or the rejection of those he wished to be tried. Under such delicate circumstances, however, a conscientious Physician will not lightly sacrifice his judgement; but will urge with proper confidence the measures he deems to be expedient, before he leaves the final decision concerning them to his more responsible coadjutor.

§ 18. Clergymen who experience the “res angusta domi” should be visited gratuitously by the Faculty. And this exemption should be an acknowledged general rule, that the feeling of individual obligation may be rendered less oppressive. But such of the clergy as are qualified either from their stipends or fortunes to make a reasonable remuneration for Medical attendance, are not more privileged than any other order of patients. Military or naval subaltern officers in narrow circumstances are also proper objects of professional liberality.

§ 19. As the first consultation by letter imposes much more trouble and attention than a personal visit, it is reasonable on such an occasion to expect a gratuity of double the usual amount: and this has long been the established practice of many respectable Physicians. But a subsequent epistolary correspondence on the further treatment of the same disorder may justly be regarded in the light of ordinary attendance, and may be compensated as such according to the circumstances of the case or of the patient.

§ 20. Physicians and Surgeons are occasionally requested to furnish certificates, justifying the absence of persons who hold situations of honour and trust in the army, the navy, or the civil departments of government. These testimonials, unless under particular circumstances, should be considered as acts due to the public, and therefore not to be compensated by any gratuity. But they should never be given without an accurate and faithful scrutiny into the case; that truth and probity may not be violated, nor the good of the community injured, by the unjust pretences of its servants. The same conduct is to be observed by Medical practitioners when they are solicited to furnish apologies for non-attendance on juries, or to state the valetudinary incapacity of persons appointed to execute the business of constables, church-wardens, or overseers of the poor. No fear of giving umbrage, no view to present or future emolument, nor any motives of friendship, should incite to a false, or even dubious declaration; for the general weal requires that every individual who is properly qualified should deem himself obliged to execute, when legally called upon, the juridical and municipal employments of the body politic; and to be accessory by untruth or prevarication to the evasion of this duty, is at once a high misdemeanour against social order, and a breach of moral and professional honour.

§ 21. The use of quack medicines should be discouraged by the Faculty, as disgraceful to the Profession, injurious to health, and often destructive even of life. Patients, however, under lingering disorders, are sometimes obstinately bent on having recourse to such as they see advertised or hear recommended with a boldness and confidence which no intelligent Physician dares to adopt with respect to the means that he prescribes. In these cases, some indulgence seems to be required to a credulity that is insurmountable; and the patient should neither incur the displeasure of the Physician, nor be entirely deserted by him. He may be apprized of the fallacy of his expectations, whilst assured at the same time that diligent attention should be paid to the process of the experiment he is so unadvisedly making on himself, and the consequent mischiefs, if any, obviated as timely as possible. Certain active preparations, the nature, composition, and effects of which are well known, ought not to be proscribed as quack medicines.

§ 22. No Physician or Surgeon should dispense a secret nostrum, whether it be his invention, or exclusive property; for, if it be of real efficacy, the concealment of 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.

§ 23. The esprit du corps is a principle of action founded in human nature, and, when duly regulated, is both rational and laudable. Every man who enters into a fraternity engages by a tacit compact not only to submit to the laws, but to promote the honour and interest, of the association, so far as they are consistent with morality and the general good of mankind. A Physician, therefore, should cautiously guard against whatever may injure the general respectability of his Profession; and should avoid all contumelious representations of the Faculty at large, all general charges against their selfishness or improbity, and the indulgence of an affected or jocular scepticism concerning the efficacy and utility of the healing art.

§ 24. As diversity of opinion and opposition of interest may in the Medical, as in other professions, sometimes occasion controversy and even contention; whenever such cases unfortunately occur, and cannot be immediately terminated, they should be referred to the arbitration of a sufficient number of Physicians or of Surgeons, according to the nature of the dispute; or to the two orders collectively, if belonging both to Medicine and Surgery. But neither the subject matter of such references, nor the adjudication, should be communicated to the public; as they may be personally injurious to the individuals concerned, and can hardly fail to hurt the general credit of the Faculty.

§ 25. A wealthy Physician should not give advice gratis to the affluent, because it is an injury to his professional brethren. The office of Physician can never be supported but as a lucrative one, and it is defrauding in some degree the common funds for its support, when fees are dispensed with, which might justly be claimed.

§ 26. It frequently happens that a Physician, in his incidental communications with the patients of other Physicians or with their friends, may have their cases stated to him in so direct a manner, as not to admit of his declining to pay attention to them. Under such circumstances his observations should be delivered with the most delicate propriety and reserve: he should not interfere in the curative plans pursued, and should even recommend a steady adherence to them, if they appear to merit approbation.

§ 27. A Physician, when visiting a sick person in the country, may be desired to see a neighbouring patient who is under the regular direction of another Physician, in consequence of some sudden change or aggravation of symptoms. The conduct to be pursued on such an occasion is to give advice adapted to present circumstances, to interfere no farther than is absolutely necessary with the general plan of treatment, to assume no future direction unless it be expressly desired, and, in this case, to request an immediate consultation with the practitioner antecedently employed.

§ 28. At the close of every interesting and important case (especially when it hath terminated fatally,) a Physician should trace back in calm reflection all the steps which he had [has?] taken in the treatment of it. This review of the origin, progress, and conclusion of the malady, of the whole curative plan pursued, and of the particular operation of the several remedies employed, as well as of the doses and periods of time in which they were administered, will furnish the most authentic documents on which individual experience can be formed. But it is in a moral view that the practice is here recommended; and it should be performed with the most scrupulous impartiality. Let no self-deception be permitted in the retrospect; and, if errors either of omission or commission are discovered, it behoves that they should be brought fairly and fully to the mental view. Regrets may follow, but criminality will thus be obviated; for good intentions, and the imperfection of human skill which cannot anticipate the knowledge that events alone disclose, will sufficiently justify what is past, provided the failure be made conscientiously subservient to future wisdom and rectitude in professional conduct.

§ 29. The opportunities which a Physician not unfrequently enjoys, of promoting and strengthening the good resolutions of his patients suffering under the consequences of vicious conduct, ought never to be neglected. And his counsels, or even remonstrances, will give satisfaction, not disgust, if they be conducted 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.

§ 30. The observance of the Sabbath is a duty to which Medical men are bound, so far as is compatible with the urgency of the cases under their charge. Visits may often be made with sufficient convenience and benefit, either before the hours of going to church, or during the intervals of public worship; and in many chronic ailments the sick, together with their attendants, are qualified to participate in the social offices of religion, and should not be induced to forego this important privilege by the expectation of a call from their Physician or Surgeon.

§ 31. A Physician who is advancing in years, yet unconscious of any decay in his faculties, may occasionally experience some change in the wonted confidence of his friends. Patients, who before trusted solely to his care and skill, may now request that he will join in consultation, perhaps with a younger coadjutor. It behoves him to admit this change without dissatisfaction or fastidiousness, regarding it as no mark of disrespect, but as the exercise of a just and reasonable privilege in those by whom he is employed. The junior practitioner may well be supposed to have more ardour than he possesses in the treatment of diseases, to be bolder in the exhibition of new medicines, and disposed to administer old ones in doses of greater efficacy. And this union of enterprise with caution, and of fervour with coolness, may promote the successful management of a difficult and protracted case. Let the Medical parties, therefore, be studious to conduct themselves towards each other with candour and impartiality; co-operating by mutual concessions in the benevolent discharge of professional duty.

§ 32. The commencement of that period of senescence, when it becomes incumbent on a Physician to decline the offices of his profession, it is not easy to ascertain; and the decision on so nice a point must be left to the moral discretion of the individual. For, one grown old in the useful and honourable exercise of the healing art, may continue to enjoy, and justly to enjoy, the unabated confidence of the public; and, whilst exempt in a considerable degree from the privations and infirmities of age, he is under indispensable obligations to apply his knowledge and experience in the most efficient way to the benefit of mankind: for the possession of powers is a clear indication of the will of our Creator concerning their practical direction. But in the ordinary course of nature the bodily and mental vigour must be expected to decay progressively, though perhaps slowly, after the meridian of life is past. As age advances, therefore, a Physician should from time to time scrutinize impartially the state of his faculties, that he may determine bona fide the precise degree in which he is qualified to execute the active and multifarious offices of his profession; and, whenever he becomes conscious that his memory presents to him with faintness those analogies on which Medical reasoning and the treatment of diseases are founded, that diffidence of the measures to be pursued perplexes his judgment, that, from a deficiency in the acuteness of his senses, he finds himself less able to distinguish signs or to prognosticate events, he should at once resolve (though others perceive not the changes which have taken place,) to sacrifice every consideration of fame or fortune, and to retire from the engagements of business. To the Surgeon under similar circumstances this rule of conduct is still more necessary; for the energy of the understanding often subsists much longer than the quickness of eye-sight, delicacy of touch, and steadiness of hand, which are essential to the skilful performance of operations. Let both the Physician and Surgeon never forget that their professions are public trusts, properly rendered lucrative whilst they fulfil them, but which they are bound by honour and probity to relinquish as soon as they find themselves unequal to their adequate and faithful execution.

FOOTNOTES:

See Notes and Illustrations, No. II.

See Notes and Illustrations, No. III.

See Notes and Illustrations, No. IV.

See Notes and Illustrations, No. V.

See above, chap. i. §§ 19-21.

See Notes and Illustrations, No. VI.

See Notes and Illustrations, No. VII.

See Notes and Illustrations, No. VIII.

See Notes and Illustrations, No. IX.