Doctors' status: changes in the past millennium
1999; Elsevier BV; Volume: 354; Linguagem: Inglês
10.1016/s0140-6736(99)90360-4
ISSN1474-547X
Autores Tópico(s)History of Medicine Studies
ResumoJosé Lázaro is professor of the history and theory of medicine at Universidad Autonoma de Madrid. He is in charge of the collection of classical psychiatry for the Fundación Archivos de Neurobiología, and is in charge of the medical humanities for the publishers Triacastela.In 1964, Pedro Laín Entralgo, a Spanish historian of medicine, published a book that soon became a classic: La relación médico-enfermo (The doctor-patient relationship). Laín analysed both what changed and what did not within the doctor-patient relationship from the Hippocratic era until the first half of the 20th century. He showed that, irrespective of the peculiarities of different historical epochs, many elements of this relationship had not changed during 25 centuries. There was something, however, which Laín Entralgo could not have guessed in 1964. Diego Gracia (Laín's succesor to the chair of the history of medicine in Madrid and author of a number of works which inspired this essay) squarely summarised it. In the last 35 years of the 20th century, the relationship between doctor and patient (and along with it the status of both) has changed more than during the preceding 25 centuries.At the beginning of our millennium, medical practice in Europe was essentially in the hands of clergymen, it was the so-called "monastic medicine", in direct continuity with the tradition of doctor-priests of primitive and archaic cultures.A physician and his servantView Large Image Figure ViewerDownload Hi-res image Download (PPT)In the 1lth century, at a time when the Church repeatedly prohibited monks from clinical practice, the first secular school of medicine of the Middle Ages developed in the Italian city of Salerno. This was the starting point of a long process of secularisation of the doctor's role, which became formally detached from that of the priest. Doctors assert their professional status. But what does "professional" mean?In its sociological meaning, a professional is traditionally a member of a privileged group who has accepted ("professed") by means of an oath a clear set of duties and rights, who follows a specific liturgy, keeps secret what he learns as a result of his activity, and enjoys judicial impunity because his conduct is governed by its own ethical code. Originally there were no more than three professions that expressed the only three forms of power. The priest who represented the power over the universe or macrocosmos. The ruler or judge who represented the power over the nation or mesocosmos. And the doctor who represented the power over the body or microcosmos. For this reason medieval universities had only three major disciplines: theology, law, and medicine.During the millennium that is now coming to an end, physicians stopped being priests and became professionals whose social role nevertheless kept similarities with that of the priest. Clergymen are called "father" by their faithful. For centuries doctors have treated their patients with strict paternalism. Just like a child had his father to take vital and difficult decisions on his behalf, the patient had a doctor who would decide with wisdom and prudence the best treatment. This traditional paternalistic version of the doctor-patient relationship, based on the principle of beneficence, dominated western medicine until 30 years ago. The doctor took decisions instead of his patient, for the patient's good. The patient's right to give his informed consent became established only during the last third of the 20th century. This meant turning the traditional, vertical beneficence relationship into the horizontal one that typically exists between two morally autonomous adults. Doctors' status was therefore radically transformed during the 20th century. The doctor stopped being a lonely professional and became a member of a health-care team. He stopped charging patients independently established honoraria, and became an employee tending services to people enrolled in collective care systems (public or private) within which confidentiality becomes blurred. The doctor no longer is the paternal, prestigious, and powerful person who decided what was best for his patient and child, he is now a technician informing his clients about the possible treatment options expecting him to choose one. The doctor is no longer judicially invulnerable, but increasingly summoned by judges to reply to the claims of unsatisfied patients. It may seem that the doctor no longer is a "second priest".However the doctor's priestly role is not gone, it has just changed, perhaps even been strengthened. Within increasingly secularised societies, values such as virtue and sin have been replaced by others such as health and harm. Many people who are not religious take the doctor's advice about what to eat or drink, about physical exercise, and sexual intercourse. Psychiatrists and psychoanalysts are called to listen to complaints that used to be addressed in churches. Judges rely upon medical forensic experts to make their verdicts.Doctors entered this millennium as priests and are leaving it transformed into a new sort of lay priest in the welfare state. For this reason perhaps, the emerging discipline of bioethics emphasises strongly the respect of the principle of the patient's autonomy, to protect doctors from the authoritarian nature of every priestly status. José Lázaro is professor of the history and theory of medicine at Universidad Autonoma de Madrid. He is in charge of the collection of classical psychiatry for the Fundación Archivos de Neurobiología, and is in charge of the medical humanities for the publishers Triacastela. In 1964, Pedro Laín Entralgo, a Spanish historian of medicine, published a book that soon became a classic: La relación médico-enfermo (The doctor-patient relationship). Laín analysed both what changed and what did not within the doctor-patient relationship from the Hippocratic era until the first half of the 20th century. He showed that, irrespective of the peculiarities of different historical epochs, many elements of this relationship had not changed during 25 centuries. There was something, however, which Laín Entralgo could not have guessed in 1964. Diego Gracia (Laín's succesor to the chair of the history of medicine in Madrid and author of a number of works which inspired this essay) squarely summarised it. In the last 35 years of the 20th century, the relationship between doctor and patient (and along with it the status of both) has changed more than during the preceding 25 centuries. At the beginning of our millennium, medical practice in Europe was essentially in the hands of clergymen, it was the so-called "monastic medicine", in direct continuity with the tradition of doctor-priests of primitive and archaic cultures. In the 1lth century, at a time when the Church repeatedly prohibited monks from clinical practice, the first secular school of medicine of the Middle Ages developed in the Italian city of Salerno. This was the starting point of a long process of secularisation of the doctor's role, which became formally detached from that of the priest. Doctors assert their professional status. But what does "professional" mean? In its sociological meaning, a professional is traditionally a member of a privileged group who has accepted ("professed") by means of an oath a clear set of duties and rights, who follows a specific liturgy, keeps secret what he learns as a result of his activity, and enjoys judicial impunity because his conduct is governed by its own ethical code. Originally there were no more than three professions that expressed the only three forms of power. The priest who represented the power over the universe or macrocosmos. The ruler or judge who represented the power over the nation or mesocosmos. And the doctor who represented the power over the body or microcosmos. For this reason medieval universities had only three major disciplines: theology, law, and medicine. During the millennium that is now coming to an end, physicians stopped being priests and became professionals whose social role nevertheless kept similarities with that of the priest. Clergymen are called "father" by their faithful. For centuries doctors have treated their patients with strict paternalism. Just like a child had his father to take vital and difficult decisions on his behalf, the patient had a doctor who would decide with wisdom and prudence the best treatment. This traditional paternalistic version of the doctor-patient relationship, based on the principle of beneficence, dominated western medicine until 30 years ago. The doctor took decisions instead of his patient, for the patient's good. The patient's right to give his informed consent became established only during the last third of the 20th century. This meant turning the traditional, vertical beneficence relationship into the horizontal one that typically exists between two morally autonomous adults. Doctors' status was therefore radically transformed during the 20th century. The doctor stopped being a lonely professional and became a member of a health-care team. He stopped charging patients independently established honoraria, and became an employee tending services to people enrolled in collective care systems (public or private) within which confidentiality becomes blurred. The doctor no longer is the paternal, prestigious, and powerful person who decided what was best for his patient and child, he is now a technician informing his clients about the possible treatment options expecting him to choose one. The doctor is no longer judicially invulnerable, but increasingly summoned by judges to reply to the claims of unsatisfied patients. It may seem that the doctor no longer is a "second priest". However the doctor's priestly role is not gone, it has just changed, perhaps even been strengthened. Within increasingly secularised societies, values such as virtue and sin have been replaced by others such as health and harm. Many people who are not religious take the doctor's advice about what to eat or drink, about physical exercise, and sexual intercourse. Psychiatrists and psychoanalysts are called to listen to complaints that used to be addressed in churches. Judges rely upon medical forensic experts to make their verdicts. Doctors entered this millennium as priests and are leaving it transformed into a new sort of lay priest in the welfare state. For this reason perhaps, the emerging discipline of bioethics emphasises strongly the respect of the principle of the patient's autonomy, to protect doctors from the authoritarian nature of every priestly status.
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