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Chapter 15 Images of the Healer William F. May Editor's Introduction In this essay on medical ethics, William F. May distinguishes a code (which gov­ erns practitioners' style of performance and technique, with little or no regard to ongoing personal relations) from a covenant (which focuses on the ongoing relationship and mutual obligation between covenant partners). Modern medical practice has opted for code as the ruling ideal in relation to patients. However, the Hippocratic oath contains two sets of obligations: not only to patients but also to benefactors who provided for the physician's training, the benefactors' progeny, and the physician's own students. These are covenant relations in that they are historically particular and involve an element of gratuitousness. May ar­ gues that relations with patients could better be conceived in covenantal terms, recognizing that the physician owes a debt of gratitude to society as a whole for education and for public support of the practice of medicine. The ideal of a covenant relation is also preferable to that of a contract, since the latter notion also suppresses the element of gift in human relations. How­ ever, the proper balance between duty and gift cannot be struck in a covenantal relation without reference to the original use of the term to describe the re­ lationship between God and Israel. "For the biblical tradition this transcendent was the secret root of every gift between human beings, of which the human order of giving and receiving could only be a sign." Although May's essay (first published in the Hastings Center Report in 1 975) predates the publication of Maclntyre's After Virtue, the language Macintyre de­ velops there can usefully be employed to redescribe May's arguments. Medicine is a practice; as such there must be rules setting boundaries within which the practice is possible (contracts), and technical skill (governed by codes) will be an important virtue. However, attention to these rules and techniques is not suffi­ cient for the flourishing of the practice. There is a virtue - the mean between a condescending philanthropy and a tit-for-tat orientation - that needs for its cul­ tivation an awareness of how the practice of medicine fits into the physician's own life story (a sense of her or his indebtedness to teachers and to society as a whole). But even more important for the development of this virtue is situating 3 2 4 Images of the Healer 3 2 5 the physician's life and the practice of medicine itself within the story of God and God's gratuitous blessings of life, well-being, and forgiveness. NANCEY MURPHY Code, Covenant, Contract, or Philanthropy Qyestions in medical ethics cannot be resolved apart from the professional ma­ trix in which most decisions are made. What is the nature of the relationship between physicians and their patients? How best can we conceptualize profes­ sional ethics and understand its binding power? The times press these questions, while tradition offers us several starting points, alternative ways of interpret­ ing professional obligations: the concepts of code and covenant, and the allied notions of philanthropy and contract. The Hippocratic oath, as Ludwig Edelstein notes in his unsurpassed study of that document,1 contains two distinct sets of obligations - those that pertain to the doctor's treatment of his patients and those that are owed his teacher and his teacher's progeny. Edelstein characterizes the first set of obligations, those owed patients, as an ethical code and the second set, those toward the professional guild, as a covenant. This distinction between code and covenant is extremely revealing and useful. Code itself, furthermore, may be divided into the unwritten codes of practical behavior, transmitted chiefly in a clinical setting from generation to generation of physicians, and into the written codes, beginning with the Hippocratic oath and concluding with the various revisions of the American Medical Association (AMA) codes that have had wide currency in this country. Technical proficiency is the prized ideal in the unwritten and informal codes of behavior passed on from doctor to doctor; the ideal of philanthropy (that is, the notion of gratu­ itous service to humankind) looms large in the more official engraved tablets of the profession. Then, the notion of covenant stands in contrast not only with the ideals of technical proficiency and philanthropy but also with the legal in­ strument of a contract to which, at first glance, a covenant seems so similar. With these distinctions, then, let us begin. The H ippocratic...


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