Question Seven: On the Obligations of Physicians

378. State of the question. - To physicians and surgeons there has been committed the office of protecting life and bodily health. Whence a) from justice they can be held to bodily care as from their proper office or from contract; - yet on the occasion of the exercise of this office, b) from charity they can be held to caring for the spiritual or temporal good of the sick, or also c) they can unjustly injure and damage in temporal things, namely by reason of expenses or harm. Concerning these things one must now speak specifically.

379. As regards bodily care, three principles must be attended to by physicians:

I. That they have sufficient skill in their art, at least ordinary skill, namely, for the cases which usually occur among them; otherwise they expose themselves to the danger of inflicting irreparable damage on the sick or wounded, and for that cause they can be obligated to restitution. From justice those are held to having knowledge and skill who have obligated themselves by a prior contract; but others are held not to exercise their art without sufficient skill, unless in a case of urgent necessity, when another is lacking.

Hence 1) physicians who wish to fulfill their office faithfully should not cease to apply themselves to study, because medical science and surgical art progress much.

2. In more difficult cases, if they doubt concerning their own skill, they ought to call in a more skilled physician, taking care that the sick person or his family consent to this; indeed even at their own expense, if it were necessary and he himself were ignorant of matters to be known by ordinary knowledge.

3. Those who lack sufficient knowledge are bound under grave obligation to acquire it, and meanwhile to abstain as far as possible from the exercise of the art, or to invoke the counsel of one more learned.

II. That they employ diligence proportionate to the gravity of the matter which is committed to their care. A physician who has been hired from contract or from a stipend accepted or promised is held from justice; otherwise he can be held from charity, even under grave obligation, in a case of grave necessity, if another is lacking and he himself can help without grave inconvenience; but if he undertakes the care, he is now held from justice, as from a contract tacitly entered into. And indeed:

1. He who has been hired by contract or stipend a) must hurry morally as soon as possible at any hour of day or night, even with grave inconvenience to himself, unless he certainly knows that from delay no damage will follow for the sick person; b) even in time of contagious disease he cannot desert the sick person.

2. He who has undertaken care of the sick person without a prior contract, a) is held to help the sick person in the better and more certain way in which morally he can; b) nor can he desert him, even if the disease becomes contagious, unless another is found who will take care of him.

3. He who, in employing ordinary diligence proportionate to the gravity of the matter, is notably negligent, sins against justice and is held concerning damages.

III. That they not use illicit means for procuring health. From justice safer remedies are to be employed, namely certain ones if they can be had; otherwise those which are more probably less dangerous and harmful, and more and more quickly profitable.

Hence 1) it is illicit, secure means having been left aside, to try uncertain ones.

2. When certain means are lacking, doubtful ones can be employed, provided that they are harmless; and they must be employed if the safety of the sick person is despaired of.

3. Indeed, when other means are lacking, remedies doubtfully harmful but probably profitable can be employed, if the safety of the sick person is despaired of; otherwise, lest death be accelerated, the matter is to be committed to nature, which by no means rarely lifts itself up. In these cases, namely, there must be proportion between the harm which is feared and the good which is hoped for; but even then a dangerous or extraordinary remedy generally is not to be employed without the consent of the sick person, at least presumed.

4. It is illicit to test a new remedy, even one that will profit others, with probable danger to health or life, not even with the consent of the sick person: for he is not lord of his life, nor are evils to be done so that goods may come to others. Unless perhaps there were only the danger of a lighter damage which could easily be repaired, and the consent of the sick person were added.

5. A physician must altogether abstain from illicit remedies and operations, of which kind are the direct procurement of abortion even to save the mother, - remedies of sterility even for preventing dangerous childbirth, - craniotomy, - the use of morphine, opium, cocaine, etc., in that way and degree in which these harm the body or mind, - imprudent or harmful use of hypnotism, - a dangerous operation done without a proportionately grave reason. In so great a proclivity as exists today rashly to perform whatever surgical operations and to employ doubtful and harmful remedies, especially in hospitals of the poor or of infants, physicians easily offend against justice, so that they are held to repairing damages.¹

¹ Noldin, Th. M. II, d. 744.

6. Finally, a physician sins gravely who, without true necessity or manifest utility, inspects or touches the genital organs, especially of women, because he abuses his office; he also sins more gravely who gives to the sick counsels which are directly opposed to the law of chastity, such as of performing onanism, pollution, fornication.

380. As regards the spiritual or temporal good of the sick: By natural law and by the grave precept of charity, the physician is held, either by himself or through another, to warn a sick person in danger of death concerning the sacraments to be received at an opportune time and concerning temporal affairs to be arranged, at least if the warning is necessary: for from charity he is held to remove grave evil from his neighbor, if he can without grave inconvenience.

Hence 1) if others could not or would not warn the sick person, or if the sick person would not believe them warning him concerning the danger, the physician himself by himself is held to warn him.

2. Yet he would be excused from warning if he knew with moral certainty that the sick person was in the state of grace and already had arranged temporal affairs, or was so hardened in impiety that even warned he would not wish to be converted: this can only very rarely be affirmed with certainty.

3. The physician also ought to warn the family, so that provision may be made more safely for the spiritual and temporal good of the dying person.

Formerly by ecclesiastical law, namely by decree of Lateran Council IV (1215), afterwards again confirmed by Pius V (8 Mar. 1566), it was prescribed to physicians that they should not undertake the care of one dangerously lying sick unless by warning him concerning confession to be made, and, if he had not confessed within three days, they should abstain from visiting. Yet the law was never received everywhere, and where it was received, it is now abrogated.

381. As regards expenses: From justice the physician is held to beware of useless expenses and of excessive stipends to be demanded.

A stipend, according to justice, must not only be sufficient so that according to his condition the physician who exercises his art and gives his powers for the greater part to medical care can live; but it can be rather great, as is clear from the importance and utility of those things concerning which he has care, from the breadth of the knowledge and skill required which is acquired only by longer study and great expenses, from the great responsibility at the same time and the dangers to which he is sometimes exposed. But the stipend can be increased when an accidental circumstance is given: a) by reason of greater distance, longer time, multiplied visitation, or special care or operation; b) by reason of more excellent or extraordinary skill, which is not usually acquired except by increased studies and expenses; c) by reason of special danger, to which, in a more difficult case, the reputation of the physician is exposed.

But in determining the stipend, a double measure can be attended to of itself: for either the common estimation can establish it proportionately to services furnished according to those things which we have handed down here; or also it could have it not as compensation according to equality, but as a contribution to the honorable support of the physician, so that for the same care less would be paid by persons of lesser condition, more proportionately by those who are of better condition. Now even according to this measure a stipend is justly established, provided, however, that a price excessive is not demanded from the rich, nor the salary according to the other measure defined by an association of physicians or by common estimation: for no one is judged to wish to grant a price greater than is customary.

Hence 1) the physician sins who for the sake of gain institutes useless visits or prescribes superfluous remedies, unless the sick person desires it or it is necessary for procuring health by such suggestion; who without necessity calls in other physicians or prolongs treatment longer; who performs useless or too dangerous operations for the sake of gain; or demands too great a stipend.

2. A physician cannot demand a stipend greater than ordinary, with the circumstances of places and persons considered. But if extraordinary services are sought from him, such as a difficult surgical operation which supposes singular skill, he cannot demand whatever price according to his pleasure, but that which, with account taken of labor, difficulty, etc., has proportion with the stipend which the most skilled are accustomed to demand.

3. From charity he ought to care gratis for the poor constituted in necessity, namely, in extreme necessity even with grave inconvenience; in grave necessity without grave inconvenience; in common necessity, if he conveniently can, at least when others are lacking.

It is better that a physician abstain from all means little worthy or less right, which smell of cupidity, and easily furnish occasion for abuse.²

² He who desires more on these arguments should consult Salsmans, Geneeskundige Plichtenleer, deontologie medica, in which various practical cases are considered.