From accountants to zookeepers, professionals of all sorts seem to have a code of ethics these days. It was not always so. Until about 1800, ethics, especially professional ethics, was about character, honor and dishonor, virtue and vice. Ethics had nothing to do with formal codes of conduct. A true professional, being a gentleman, needed no written instruction in how to behave.

The First Code of Ethics
Thomas Percival (1740-1804) of Manchester, England, first proposed a code of ethics for physicians and surgeons in a pamphlet published in 1794. The expanded version (1803) coined the expressions "professional ethics" and medical ethics".

Percival's proposal for a code of medical ethics had resonance in America. The Boston Medical Society had such a code by 1808. Percivalean codes thereafter slowly supplanted the ethics of honor in the U.S. By 1847, the newly-formed American Medical Association adopted a Percivalean "Code of Ethics", the first code of ethics adopted by any national professional society anywhere, and the first to be denominated a "code of ethics". By the beginning of the twentieth century, codes had become the dominant form of professional ethics in the U.S. Today, a formal code of ethics is the hallmark of professionalism for professionals everywhere.

This crude history describes how codes supplanted the earlier ethics of gentlemanly honor, but the interesting question is why they supplanted them. Codes of ethics differ from their precursor, "the code of honor", most noticeably in format, their "codification". The word "codification" was coined by Percival's contemporary, the English philosopher Jeremy Bentham (1748-1832), for the standardization he was trying to bring to British law.

At the time, British law was primarily "case law", the legal judgments of judges. Statutes were %pecial law", generally adopted in response to a specific problem the judges had not resolved as Parliament liked. Text books had to provide any system the law had. Bentham wanted to replace judgemade law with statutes bringing system to entire legal subjects, such as criminal law or evidence. Medical ethics, which Percival originally called "medical jurisprudence", was an analogous attempt to bring system to the individual moral judgments of medical professionals.

To appreciate the importance of Percival's innovation, one needs to understand how individualistic medical ethics had been.

Oaths
The word "profession" is Latin for "bound by an oath." In Roman times, one's "profession" was the occupation one declared to a tax collector under oath. About 100 AD, a Greek Physician, Scribonious Largus, redefined the "medical profession" in terms of the Hippocratic oath. In medicine at least, the term .1 profession" thereafter identified an occupation whose members had special obligations to those whom they served.

Veneration for the Hippocratic "corpus" (the collected works of Hippocrates and his followers) was part of the Renaissance rediscovery of classical texts. In 1525 and 1526, authoritative Latin and Greek versions of the Hippocratic corpus were published, and academic medical institutions began to teach Hippocratic moral precepts, in particular the oath, thereby cementing the identification of medical professionalism with fiduciary obligations to the sick. Shortly thereafter, some academic institutions resurrected the practice of having entrants swear a version of the Hippocratic oath. In medicine, therefore, being a member of a "liberal profession", that is, a profession that demanded literacy and thus some form of education, was identified with the idea of taking on (by oath) moral obligations beyond those of an ordinary gentleman.

From the Renaissance through the Enlightenment, ideals of gentlemanly honor infused the "Hippocratic oaths" sworn by medical practitioners, not only in Europe, but in European settlements in the new world. As late as 1807, the Medical Society of the State of New York required practitioners to sign the following oath upon admission to the society (an admission carrying with it the right to practice medicine in the state):

I do solemnly declare, that I will honestly, virtuously, and chastely conduct myself in the practice of physic and surgery, with the privileges of exercising which profession I am now to be invested; and that I will, with fidelity and honor, do everything in my power for the benefit of the sick committed to my charge.

If we scrutinize professional oaths like this one, we find their language to be highly subjective. They use the first person singular. They are activated by the performative "I swear" (or, in this case, "I declare"). They commit the oath- to general ideals couched in inspiring language, and subject to personal interpretation. The original Hippocratic oath committed the swearer to act in the best interests of the sick "according to my ability and judgment". The New York oath requires practitioners to practice "honestly, virtuously, and chastely" and to act with "fidelity and honor"-ideals far too general to provide much guidance.

As the New York oath attests, in the era of gentlemanly honor, ethics focused on the character of the practitioner (especially, his honesty, chastity, and virtue). Since character was the chief guarantor of the integrity of professional conduct, even a hint that a professional's character was less than honorable was a serious matter. Indeed, stains on character tended to be irreparable. Individuals therefore went to extraordinary lengths to preserve their "good name and reputation." They brought law suits, engaged in "pamphlet wars" (exchanges of hostile pamphlets), and even fought duels.

Dangers of Honor
The need to guard personal honor zealously may have helped to preserve professional standards among solo practitioners, but it also tended to undermine the largescale cooperation that characterizes modern professional institutions (law and medical schools, law firms and medical hospitals, and so forth). For professionalism to assume its modern form, some alternative conception of "professional morality" was required.

Thomas Percival seems to have been the first person to appreciate this point - and thus the first to propose writing a code of professional ethics. A practicing physician, a leader of the Manchester Philosophical Society, an anti-slavery activist, and a world- author of moral parables for children (such as A Father's Instructions to His Children, 1775), Percival came to doubt the ethics of character only reluctantly, after a spectacular breakdown in professional morality at his own hospital, the Manchester Infirmary.

In 1792, a festering dispute, exacerbated by a pamphlet war, erupted into a work stoppage by surgeons that coincided with the outbreak of an epidemic. Hospital trustees were outraged that desperate patients were being turned away from the hospital because of a dispute between surgeons. They called upon Percival to lead a committee to draft rules to prevent any recurrence of this fiasco. The committee drafted the needed regulations, which were promptly implemented. Then, two years later, for reasons unknown to us (most of Percival's personal papers were destroyed during the bombing of Manchester in World War 11, Percival published Medical Jurisprudence or a Code of Ethics and Institutes' Adapted to the Professions of Physic and Surgery. Nine years later he issued the revised pamphlet as a book, Medical Ethics.

Percival's Innovations
Percival's code of ethics was unlike anything published before. It banished the first person singular, the language of oath, subjectivity, and idiosyncrasy, replacing it with the second and third person plural. Standards of conduct were formulated in numbered "duties". The duties, some quite detailed, were justified by the medical profession's core collective responsibility to care for the sick. As is typically the case with professional ethics, in affirming this core responsibility, Percival also asserted the moral authority and independence of medical professionals, especially, their authority over the hospital trustees who were their nominal employers.

Percival knew from personal experience that the lay trustees of eighteenth -century hospitals, rather like the trustees of some twentiethcentury managed care organizations, were not always trustworthy guardians of the profession's fiduciary responsibility to serve "the ease, the health, and the lives of those committed to their charge." Trustees were sometimes tempted to overcrowd words or use "drugs of inferior quality". Noting that such cost- strategies were typically counterproductive, Percival stated that, even if they were not, physicians and surgeons had a professional obligation "not [to) suffer themselves to be restrained by parsimonious considerations from prescribing .... drugs [since] .... no economy of a fatal tendency ought to be admitted into institutions founded on the principles of purest beneficence".

Percival's code of ethics thus gave medical professionals a moral mandate to appraise the conduct, not only of fellow professionals, but of their nominal superiors and employers, hospital administrators, managers, and trustees.

Percival drafted the first code of professional ethics in response to a particular crisis arising from the mismatch between the personalized ethics of individual honor and the requirements for standardization inherent in a modern institution, the hospital. Modern professions adopted his innovation, codes of ethics, because they needed its fundamental elements: a) common standards (to support extensive cooperative endeavors); b) the minimization of the interpersonal strife that the emphasis on individual honor encourages; and c) a framework of Weals that permits professionals to assert their independence of their nominal employers in the name of service to others.