From an Exercise in Professional Etiquette to Society's Wish List?

The Council on Ethical and Judicial Affairs of the American Medical Association (AMA) recently published the 2002-2003 edition of The Code of Medical Ethics. This annotated version is published on a biennial basis and compiles the ethical position of the AMA on more than 175 specific issues, ranging from social-policy issues such as capital punishment, HIV testing, and multiplex genetic testing over interprofessional and hospital relations to opinions on practice matters (e.g., gifts to physicians or managed care).

The use of codes and guidelines to promote medical ethics is part of a long history that dates back to the Hippocratic tradition and its Oath of Hippocrates (probably fifth century B.C.). Today the use of codes is no longer self-evident. Many have questioned the kind of morality that is materialized through codes and guidelines. For a long period of time codes and professional guidelines fulfilled a specific function: they where levers of self-assertion for professional groups such as the medical profession. As such, codes of ethics seem to hold a promise of professional status (Darr 1997, 62). This promise is the rationale behind the recent movement of non- or semi-professions to elaborate codes of ethics. The increase in the number of occupations with full professional status indicates that the professional setting is changing.

An overview of the AMA Code of Ethics table of contents indicates a second, more fundamental change in today's professional setting. In comparison with classic codes of ethics (e.g., the Hippocratic tradition) in which the main focus was on intraprofessional relations and professional etiquette, contemporary codes of ethics display a remarkable openness. In this regard it is revealing that the list of opinions in the AMA Code of Ethics starts with about 50 positions that are brought together under the common denominator of "opinions on social policy issues." Codes of ethics are no longer the protective shields against external inferences from different sides as they have been identified before (Frankel 1989, 111). External elements such as economic and legal considerations are increasingly entering into the medical profession's morality. This development implies that the profession is no longer its own lawmaker, that instead the profession is determined from outside. For centuries, the establishment of a code of ethics was part of the elaboration of a professional structure in which the profession was the active pole. Individual members of the profession were then casted in a professional structure of duties and responsibilities set out by the profession itself. Today, the profession finds itself caught in a stringent web of duties and responsibilities in which responsibility toward society and its members is one of the central threads.

The structure of the opinions in the AMA Code of Ethics exemplifies this changed situation. Each opinion entails different components: the opinion itself and a list of annotations "reflecting citations in judicial rulings and the medical, ethical, and legal literature" (viii). In these annotations legal considerations take a prominent place. This signals the mentioned fundamental change in the professional setting: professions are no longer solely in control themselves but need to take into account an array of external moral elements in their own process of moral reasoning.

By presenting the positions and guidelines together with references to the medical, ethical, and legal literature, the AMA Code of Ethics partly overcomes two classic critiques on codes of ethics.

First, the inclusion of scientific literature in the opinions on specific issues prevents the Code of Ethics from being identified as too instructive and opposed to moral reasoning, as is often the case with code of ethics (Dawson 1994). The references to literature start and subsequently support a process of moral reasoning rather than obstructing this process with a disciplinarian attitude.

Second, the rich documentation provided with the different opinions weakens the common argument that a code of ethics is too vague (Limentani...