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Codes of Ethics: Who Needs Them?

by Eric Matthews

A major research interest of mine is the philosophy and ethics of medicine and one of the most challenging and demanding pieces of work which I have been presented with in this area was the request that I should help to formulate a new oath or declaration to be taken by the medical graduands of the University of Aberdeen. Being faced with this task was challenging because it forced me to face up to the preliminary question of what the point of such a declaration or oath was, and why it seems to be only medical students who are required to make such a declaration at their graduation. (Until 1888, all those graduating at Aberdeen swore an oath.) So what is supposed to be so special about medical students? Indeed, is there anything special about them? Even if it was once true to say that there was something special about medicine, is it still true today, given the vast changes which have taken place both in the practice of medicine itself, and in the world at large, under the influence of technology and social development?

The first answer which springs to mind is that, in graduating MB, ChB, medical students are not simply, like other students, being confirmed as having achieved academic success in their examinations; they are also passing over the threshold from being students to being members of the medical profession. It is this entry into the profession which is symbolised by swearing an oath or affirming a solemn declaration, and that is what is special about medical graduations - their connection with the idea of medicine as a profession. A profession is supposed to be something more than a mere occupation, a way of making a living: it is supposed to have something solemn about it, symbolised by an oath or commitment to some special code of behaviour. Many people believe that all doctors in the Western tradition of medicine swear the famous 'Hippocratic Oath'. This does not seem to be universally so, but it is true that the centrality of the Hippocratic Oath in Western thinking about medicine is connected with the idea of medicine as a profession.

Thus, thinking about the point of a special oath or declaration for medical graduands leads naturally on to thinking about the idea of a profession. The concept of a 'profession' has come to be one of the key notions of our culture, though, like most such key notions, it remains vague and ill-defined. Other occupational groups besides medical practitioners have come to be described as 'professions' -- most obviously lawyers; and other occupational groups aspire to be recognised by this prestigious title -- managers, teachers, nurses, computer specialists, journalists. The list is almost endless. But medicine offers the 'paradigm case' of a profession -- the model of what we understand a profession to be, such that other groups can claim to be professions to the extent that they approximate to the condition of medicine. Medicine has this status in part because it can truly claim to be 'the oldest profession' (far more truly than the occupation which usually claims that title for itself!), and in turn this is partly due to the long-standing influence of the Hippocratic tradition, embodied in the oath.

Reflection on the nature of a profession, and what it takes to make an occupational group into a fully-fledged profession in its turn leads on to a much more fundamental and important question: what worthwhile role, if any, does that traditional concept of a profession have in a modern world of high technology, liberal democracy and market economics? Though my aim here is to provide an answer to this question which will apply, not only to medicine, but to other professions and candidates for professional status, it is still useful to start with the paradigmatic case of medicine.

The Hippocratic tradition in Western medicine, as I noted, is encapsulated in the 'Hippocratic Oath'. To understand the Oath, we need to place it in some kind of historical context. Relying here on secondary sources, the broad picture is that, in the world of Greece and Rome, medicine was not yet regarded as a profession in the modern sense. Having freed itself from its religious background, in which it was the preserve of priests, it was practised as a secular trade or skill, a means of earning one's living. There was no generally recognised, still less legally enforced, training for medical practitioners: anyone who wished could offer their medical services, and would be paid by results. The Hippocratic School, on the Greek island of Cos, stood aside from this general pattern: it was a 'School' in two senses - both in the sense of being a place where would-be doctors could be trained in the knowledge and skills which they would require, and in the sense of offering a distinctive way of thinking about health, illness and treatment. And it was a kind of guild, whose members were bound together by ties of loyalty to each other, to their teachers, and to the institution in which they had been trained.

This background explains some of the characteristic features of the Oath. First of all, it explains the fact that it is an Oath, a solemn binding commitment, sworn by the god Apollo the healer and all the other gods and goddesses, and so given religious sanction (note the last paragraph, with its rewards for fulfilment and punishments for transgression of the oath). The swearing of oaths, i.e. the making of solemn promises before God or the gods, is of course traditionally a way of marking the difference between the more relaxed commitments of everyday life and those which are binding because they concern more solemn and elevated areas of human existence: we make vows when getting married, or when entering the priesthood, or when about to give evidence in a court of law. The very fact that it is an Oath in itself, therefore, indicates a certain way of thinking about being a Hippocratic doctor: it is not just a way of earning a living, any more than being a priest is, but is being a member of a sacred grouping. And this is part of what was traditionally understood by a 'profession'.

This in turn explains another striking feature of the Hippocratic Oath namely, how much of it is concerned with the doctor's duties towards fellow-members of the guild. 'I will look upon him who taught me as a parent; I will regard his offspring as my own brothers and will teach them this art; I will teach this art to my own sons, to the sons of my teacher and to disciples bound by covenant and oath'. The sacred mysteries of Hippocratic medicine, in short, are not to be imparted to anyone who wants to know them, but only to those who are themselves members of the guild, 'bound by covenant and oath' or else blood-relatives of members. This idea of solidarity amongst fellow-practitioners is certainly one element in the traditional idea of a profession. In this regard, a profession is distinguished from a mere trade in that its members agree not to compete with each other, indeed to take each other's side when one member is attacked or criticised by a non-member. This is the idea of a profession as a kind of freemasonry. To many, myself included, this aspect of the traditional concept of a profession, at least as it has often expressed itself, seems thoroughly undesirable: not because there is anything wrong with being loyal to one's colleagues or with a belief in cooperation rather than competition, but because this mutual loyalty amongst professionals sometimes takes the form of sticking together against the interests of those whom the professionals are supposed to serve - in this case, the patients. For instance, when doctors, as sometimes happens, refuse to blow the whistle on incompetent or corrupt colleagues, we see the downside of this idea of medicine as a profession.

Fortunately, there is another aspect to the Hippocratic Oath, one which is ultimately inconsistent with the idea of the profession as a mutual-support society. This is the portion beginning with the words 'The regimen I adopt...' and ending with 'to be as sacred secrets'. The atmosphere here is totally different from that in the beginning and end of the Oath: it is not inward looking, to relations with fellow-professionals, but looks outward, to the doctor's duties to his patients - to work for their benefit, not to do them hurt, to give no deadly drug, not to procure an abortion, not to abuse one's position in order to harm patients, especially by sexual seduction, to keep patients' secrets, and so on. The notion of a profession here is not that of loyalty to one's colleagues, but that of service to one's clients, and so of having certain ethical obligations specific to one's occupation: this is the idea of a profession as a body governed by a code of ethics. The profession is seen as existing, not just for its own benefit, but also for the benefit of those to whom its skills and knowledge can be applied. It seems to have been the case that doctors belonging to the Hippocratic guild were required, very unusually in the ancient world, to be prepared to help patients without payment if necessary, and certainly to postpone discussions of their fee until after the treatment had succeeded, so as not to worsen the patient's condition by financial anxiety. This in itself indicates that the sense which is so evident in these sentences in the Oath, that patients' needs must be the first consideration of a doctor, was an established part of the Hippocratic attitude.

The other aspect of the idea of a profession which thus emerges from the Hippocratic tradition is therefore that a professional is someone who is bound by certain ethical standards, by a code of ethics which lays down how he or she ought to deal with clients, where these ways of dealing are governed by the interests of those clients rather than those of the professional. Being governed by a code of ethics in this way, rather than, for example, merely by legal sanctions, implies also that a profession is a self-regulating body, which administers its own code in ensuring that its members conform to appropriate standards. This self-regulation may, of course, be backed up ultimately by legal sanctions, but in its day-to-day operations it is administered by the profession itself: that is what makes it a code of ethics rather than a body of legal regulation.

But why should a code of ethics in this sense be so central to the idea of a profession? Clearly, because, as the Hippocratic case illustrates, it is felt that a profession ought not to be simply a commercial operation, conducted for personal profit in accordance with the usual rules of the market-place. People who operate in the market-place are, of course, subject to ethical requirements, the selfsame ethical requirements which apply to all of us as human beings: the butcher, the baker and the candlestickmaker are just as much under an obligation not to tell lies, to cheat, or to break promises in the conduct of their trades as we all are in our general dealings with each other. Just because these are universal human obligations, however, it would make no sense to ask a butcher, a baker or a candlestickmaker to swear a solemn oath to observe these ordinary moral rules in the practice of their trade, or to formulate them as an ethical code specific to just this occupational group. Such moral obligations are simply a restraint on misconduct by any human being, in any area of human life: there is no need to add anything to them to make them specific to this area of conduct or of relations between human beings.

The moral rules which apply to human beings as such by their very nature take no account of special relations in which one human being may stand to another. They are mainly negative - prohibitions against doing things in pursuit of one's own self-interest which may injure the legitimate interests of another human being. So they include rules like 'Don't tell lies', 'Don't break your promises', 'Don't use others merely as means to your own ends', and so on. They are, if you like, rules for dealings between strangers, people who have no special ties between them which might impose more positive requirements on their mutual dealings. They can, if appropriate, be formalised into terms of a contract imposing limitations on what one partner can do to another. In this, they are different from the moral ties which bind us to those with whom we do have special relationships - as friends, as parents to children or vice versa, as brothers and sisters, as husbands and wives or pairs of lovers. The general moral obligations of course apply in these special relationships too: we are certainly no more morally entitled to lie to our spouse than to the stranger we meet in the street. But these special ties impose moral requirements on us which, while not of course unlimited, go far beyond these universal moral obligations, and cannot be formalised in rules or contracts. What would we think of lovers or friends who thought of themselves as doing for each other only what is required by some sort of written contract between them?

Market relations between sellers and buyers are, of course, relations between strangers in the sense I have been suggesting. My butcher is not as such my friend (though he may be such contingently). His primary motive for selling meat to me and others is to make a living for himself, and morality comes into the relationship only in imposing constraints on what he can do in relation to me in the course of making that living for himself. The relationship is contractual or quasi-contractual. It is quite in order to say that a butcher has a moral obligation not knowingly to sell sub-standard meat to his customers (at least without their knowledge and at prices appropriate to high-quality meat). But it would be absurd to suggest that a butcher (as such, again) has a moral obligation to supply meat free of charge to customers who are too poor to pay the market price, especially if doing so would endanger his own livelihood. (The butcher who was a saint in that sense - a fairly bizarre notion in itself! - would not be a butcher in the ordinary sense, a practitioner in the meat trade.)

Human beings are such, and human society is such, that we feel the need for what I have called 'special relationships', marked off from the relationships of strangers because they meet certain fundamental human needs which such more distant relationships cannot supply - needs for intimacy, closeness, mutual help which goes beyond the bounds of mere social co-operation, and so on. I certainly do not want to suggest that the relationships between professionals and clients should be thought of as one example of such special relationships; but nor do I want to equate them with market relationships between tradespeople and their customers. My doctor is not (except contingently) my friend: but neither is he simply my supplier of medical services. What I want to suggest, as a result of my reflections on the Hippocratic tradition in medicine, is that the doctor-patient relationship, and the professional-client relationship more generally, as it has traditionally been thought of is distinct from both personal relationships and market relationships, but partakes in its own way of features which it shares with both: it has been seen as what might be called a 'quasi-personal' relationship.

What professional relationships are supposed traditionally to share with market relationships is that they are essentially relationships between strangers, relationships which can therefore be regarded as governed by rules or formalisable standards. My doctor is not as such my friend, and it would be absurd and inappropriate to expect him to care about me individually, and to go to great lengths in expressing such care, as I might hope my friends would do. What the professional relationship is supposed to have in common with personal relationships, however, and what is seen as differentiating it from market relationships is that the rules which govern it are not merely negative constraints on excessive selfishness, but embody positive obligations to serve the interests and needs of clients, even, if necessary, at some cost to those of the professional him- or herself. The existence of rules of conduct reveals that this is a relation between strangers: but the scope and positive nature of these rules differentiates it from that kind of relation between strangers which we find in the market place. Hence the idea of a code of professional ethics which, like the relevant part of the Hippocratic Oath, puts the needs and well-being of patients, rather than doctors, at the heart of the doctor's concerns.

Just as we mark out special or personal relationships from merely market or contractual relationships because they satisfy certain fundamental human needs which the market in principle could not satisfy; so we have come, in our culture at least, to mark out professional relationships from merely market relations because they satisfy certain needs which we do not think it morally right to leave to the market alone. Professions, I am suggesting, are those occupations which exist to provide certain kinds of goods which we regard as peculiarly essential to the possibility of a decent human life. Medicine is our paradigm of a profession because the good which it provides, health-care, seems to us, in our culture at least, above all necessary if someone is able to live the kind of life which we think worthy of a human being. To be healthy, as far as one's natural constitution allows, is seen as an essential part of the good life, the life that is more than a mere existence, because, while not absolutely necessary if we are to pursue characteristic human goals, it makes it considerably easier to do so. To care for and maintain health is thus to promote the good life for human beings.

To some extent, being as healthy as one can be is the responsibility of the individual him- or herself: but there are limits to the extent to which individuals can care for their own health. On the one hand, bad living conditions, caused by factors beyond one's own control, like lack of employment opportunities, can set limits to one's ability to maintain one's own health, and then it may be the responsibility of society as a whole to improve those conditions as far as possible. And on the other, the various contingencies of life - chance injuries, infections, inherited disorders - may affect one's health in ways which one can neither prevent nor cure by oneself, lacking medical knowledge and skill. Here is where professional health-care is needed if this component of the good life for human beings is to be supplied. Medicine is a profession because doctors are those who are educated and trained to supply this need.

The fact that this need is supposed to be a component of a life worthy of human beings is the main reason, I am arguing, why it cannot be supplied on a merely commercial or market basis: it cannot be regarded as a mere consumer good to be supplied to customers simply on the basis of their ability to pay. To deny someone health-care on the grounds of inability to pay would be seen as committing the injustice of treating them as unworthy because of their poverty alone of having access to one of the conditions for a decent human life. (Notice how, even in countries in which health care is generally provided on a market basis, it is still thought desirable that some form of health care should be available to those too poor to be able to afford it on such a basis - in charity hospitals, for instance, or by dedicated general practitioners working, if necessary, without fee.) And this in turn makes the relationship between doctors and patients (even when those patients can afford to pay for treatment) different in kind from that between butchers and their customers: on the doctors' side, it becomes one in which doctors are under an obligation to meet patients' needs, if necessary at the expense of their own; and on the patients' side, it makes it one in which the patients' must be able to trust their doctors to have their (the patients') needs in the forefront of their minds. Unlike the purely contractual relationship between sellers and buyers, it is thus an ethically-charged relationship creating obligations which go beyond the normal moral obligations which we all have to human beings as such.

If medicine is our paradigm of a profession, and if what I have just said is correct, then we can say that some of the essential features of a profession, as traditionally conceived at least, are the following. It is an occupation which, because it serves some central need for a life worthy of human beings, must be regulated primarily, not by the requirements of profit for the providers, or by ordinary market forces, or by legal contracts or stipulations, but by a code of ethics which goes beyond the ordinary obligations imposed on all human beings as such. This code of ethics will define these special obligations belonging to the particular relationship of service which is relevant in the profession in question. (Needless to say, the fact that profit for the providers should not be the primary motivation does not in any way entail that providers should be required to work for nothing, or for low pay: indeed, it might seem that society as a whole has a moral obligation to make sure that professionals do not suffer financially if they cannot participate freely in the market place in the same way as other occupations. Nor, to avoid misunderstanding, am I saying that medicine, or any other professional service, cannot be provided for payment by the recipient: only that, even where it is so provided, its provision cannot be governed only by the normal mechanisms and rules of the market, so that it needs to be regulated by other standards of an essentially ethical kind.)

In the light of this, we can think a little about other possible candidates for professional status. The practice of law has traditionally, as I said earlier, been regarded as almost as clear an example of a profession as medicine. So how does it fit the model I have outlined? We can identify the component of the good human life which it provides, perhaps, as the defence of justice and human rights and liberties. In our culture, it is thought that it would be impossible to live a life worthy of a human being if justice were not defended, if injustice were therefore not prevented, and if human beings were denied their legitimate liberties. The law is a profession to the extent that it meets that need and gives importance to it, rather than simply to the financial and other needs of lawyers. And the requirement to give that need priority is appropriately expressed in a code of ethics, which thus helps to define the status of the law as a profession.

It is less traditional to regard teaching (at schools or universities) as a profession, but there is good argument for treating it in this way, since once again teaching is the provision of a good which is central to our conception of a life worthy of human beings, namely, knowledge, understanding and an appreciation of cultural values, and a growth in personal maturity insofar as that depends on knowledge, understanding and appreciation of cultural values. Because of this centrality, it does not seem that education (as opposed to vocational training) ought to be regarded as a mere consumer good, to be provided on a merely commercial or market basis, but as a service to the students or pupils (and through them to society at large). This requirement to regard teaching as the provision of a service, as well as the means of earning a living, is, again, properly expressed in the form of codes of ethics, defining those obligations of teachers to students which go beyond the universal moral obligations binding on human beings as such, and which reflect the specific character of the relationship between teachers and their students.

Many other occupational groups, as I said at the beginning, nowadays aspire to the status of professions, since being a 'profession' has come to have a particular prestige in our culture. But in order to justify such a claim, at least if the term 'profession' was being used in the traditional sense which I have tried to analyse, they would, above all, have to show one thing. They would have to show that the good which their occupation characteristically provides was central enough to what is required for a life worthy of a human being to transform their relationship with their clients. It would have to be something which could not be seen merely as a relation between sellers and customers, engaged in primarily in order to make a living. Instead, it would have to be possible to consider it as one in which what was provided was a genuine service to clients, something in which the good of the clients was at least as important as the need of the providers to make a living. In the context of that relationship, the ethical obligations imposed on the providers would go beyond the normal moral demands which we all have to accept, and could reasonably therefore be expressed in a special ethical code.

I have an open mind about the claims of various non-traditional occupations, like journalism, computing or management, to professional status in this sense, but one thing is worth saying at this point: the concept of a 'profession' under scrutiny here is very definitely a traditional concept, and there is no reason why these new occupations could not be regarded as 'professions' in some other, non-traditional, sense. It is always open to us to revise the concept of a profession: so we do not have to retain the kind of paradigm which is embodied in the Hippocratic Oath.

Having said that, let us now consider the question posed in the title of this paper. Do we need, is it good for us to retain, the traditional concept of a profession which I have described, with its associated code of ethics and quasi-personal relationships between professional and client? One way to get into this discussion is to return to my starting-point, the task of devising a new graduation declaration for medical students. Here is that declaration.

I SOLEMNLY DECLARE THAT, AS A GRADUATE IN MEDICINE OF THE UNIVERSITY OF ABERDEEN, I WILL EXERCISE MY PROFESSION TO THE BEST OF MY KNOWLEDGE AND ABILITY FOR THE GOOD OF ALL PERSONS WHOSE HEALTH MAY BE PLACED IN MY CARE, AND FOR THE PUBLIC WEAL; THAT I WILL HOLD IN DUE REGARD THE HONOURABLE TRADITIONS AND OBLIGATIONS OF THE MEDICAL PROFESSION AND WILL DO NOTHING INCONSISTENT THEREWITH AND THAT I WILL BE LOYAL TO THE UNIVERSITY AND ENDEAVOUR TO PROMOTE ITS WELFARE AND MAINTAIN ITS REPUTATION.

It is worth observing that this is a declaration, rather than an oath and that there were reasons for this. One reason was that it was intended to be used by graduands coming from many different cultural backgrounds, in some of which there is an objection to swearing oaths of any kind, and in many of which there might be an understandable objection to swearing an oath by the Christian God (Jews, Muslims, Hindus, Buddhists, Sikhs, etc.) or by any God at all (atheists and humanists). A bland oath by (for instance) 'all that I hold most dear' might solve part of the problem, but not all of it, and would anyway reduce the whole procedure to banality. So it had to be a solemn declaration, affirmed rather than sworn.

But there was another reason for choosing a declaration, which is perhaps more relevant to our present theme. One of the objections I had to the Hippocratic Oath was precisely the element of entry to a closed fraternity or freemasonry which I have referred to already. Swearing an oath by God or the gods inevitably, as it seemed to me, introduces this element of a spurious sacredness into the proceedings. I emphasis that word 'spurious': where there is a genuine sacredness, as in entry to the priesthood or a monastic life, no one could sensibly object to the solemnity of marking that by a vow. But it seems to me unhealthy, for reasons I mentioned earlier, to regard medical practitioners as some kind of sacred guild, bound together by special obligations to each other: and to retain the idea of an oath is strongly to suggest, as I thought, the continuation of that unhealthy view of medicine. That is different from saying that there is a need to have some elevation of tone in such a declaration, to express and communicate to the graduands the sense that medicine is an occupation which makes special moral demands on them, that medicine is not simply a way of making a living but involves a service to humanity, and that need is one that I sought to achieve, as far as I was able, by the particular register of language which I tried to use throughout the declaration.

The change from an Oath by Apollo the Healer to a solemn commitment thus symbolises a change from the idea of profession as a sacred fraternity, devoted to helping each other, to the idea of a profession as a group of people pursuing an occupation which exists at least as much to promote the good of its clients as to secure the interests of its practitioners: from an inward-looking to an outward-looking conception of a profession. In some ways, this amounts to retaining the second half of the Hippocratic Oath and abandoning the first. But the Hippocratic Oath, of course, is a whole: the second half, shorn of the first, takes on a different character, and I would want to say one more suited to the circumstances of the modern world than the original Hippocratic Oath could ever be.

For it can hardly be doubted that the situation of the medical profession, and of the professions in general, in the late twentieth century is, and must be, radically different from what they were in Hippocrates' day, or at any time even up until the quite recent past. Sticking only to the example of the medical profession, because I know it better than any other (except my own), I can suggest numerous ways in which its position has changed. First of all, and very important, the old Hippocratic idea that doctors should not always charge fees for their services has been superseded in most modern countries by the idea that health care should be publicly provided, free (or almost so) at the point of delivery - whether that public funding takes the form, as in this country and in Scandinavia, of a national health service paid for out of general taxation, or, as in some other European countries, of a system of state health insurance. Even in relatively backward countries, like the United States, in which the bulk of provision is private, there are public schemes for veterans, the elderly and other groups (not to mention health care provided by private charity). The change from the doctor's being a provider of health care who depends on fee income for a living to being a practitioner who receives his or her income from the state must necessarily affect our conception of what it means to call medicine a 'profession'.

Secondly, medicine, at all levels, is nowadays much more of a team activity than it ever was before. Even general practitioners tend to work increasingly in teams, in group practices with practice nurses and other associated professions; and in hospital medicine, this is even more evident. One result of this is that the relationship between individual doctors and individual patients inevitably becomes less personal than it used to be. Except in some rural practices, it is no longer as common as it used to be for doctors to have a personal knowledge of most of their patients, the details of their lives and their family relationships, so that the doctor can think of the patients as 'my patients' and the patient can think of the doctor as 'my doctor'. This necessarily makes it more difficult (to put it mildly) to think of the doctor-patient relationship as a 'quasi-personal' relationship in the sense which I tried to outline earlier. The doctor becomes much more the impersonal provider of a service.

Part of the reason for the growth in team-working (as well as social and economic factors) is the increasingly technological character of modern medicine, and that is important, too, in other ways in changing the character of medicine as a profession. Pre-technological, or even low-tech, medicine is essentially the delivery of a personal service, in which the personal character of the doctor and the way in which he (and it almost always was a he) relates personally to the patient play a crucial role. The old ideas of the 'bedside manner', of 'doctor's orders' and of medical paternalism all embody this notion that health care depended above all on the qualities of the doctor as a wise and caring individual, rather than any of the instruments, pills or other impedimenta that the doctor might have at his disposal (which were largely useless, anyway). And along with this went a conception of health itself as a state of 'being as well as could be expected', ticking over in a condition normal for most people of one's age, and living what was then considered to be a normal lifespan. Compare this with modern 'hi-tech' medicine, in which what can be offered is an extension of the lifespan and a life from which many of the normal limitations of human existence have been removed, and in which the personal character of the doctor is often much less important than the properties of the technology which the doctor (or the medical team) operate. Once again, the notion of the doctor-patient relationship as quasi-personal is undermined.

If all this is true, is there still any place for the idea of 'medical ethics', of professional codes of ethics, of medicine as a 'profession' at all? Should I have bothered to devise a new declaration at all, or, even if I did, should I have tried to give it such a solemn and elevated tone? I think there was some point in my task, and I think that not simply because I do not want to feel that I have simply been wasting my time, but because I consider that there is still a place in the modern world for some sort of conception, perhaps updated, of a profession. What remains of the old conception of a profession, I want to argue, is just the notion that the service which a profession supplies is one which is central to what Aristotle called 'the good for man', to what makes a life worthy of human beings. Such a 'good' need not be equated with what is 'morally' good, in the modern, post-Kantian, sense of 'moral': it is simply a component of human well-being or eudaimonia. Kant himself denied that health was morally good, since healthy people could well be immoral just because of the pride engendered by their bodily health. But most of us would agree that, on the whole and other things being equal, a life in which one is healthy is a better life for a human being in some sense of 'better'. (I have to express such claims in terms like 'most of us would agree', since there is always the possibility of disagreement about the components of human well-being).

And if health is such a central component of well-being, then caring for health must have a different character from providing for the satisfaction of a desire which some people have, but others do not, or which some people place higher in their scale of preferences than others. The latter can be described as consumer goods, to be provided for those who want them and are prepared to pay for them; goods like health care, however, are goods to which human beings have a moral entitlement, regardless of their ability to pay - they are 'good for' the recipient, not merely 'good in his or her eyes'.

But in a society such as our own, as I said earlier, health care at least is provided for everyone independently of their ability to pay, out of general taxation. The moral requirement, if it is one, to provide health care is therefore met by the state. What room, then, is left for the idea of the actual providers, the doctors, nurses and other health care workers, as 'professionals', subject to a code of professional ethics? I would suggest it is this: even if the funding is provided by the state, the provision of such a central human good requires a sense of dedication, of moral seriousness, on the part of the providers if it is to be of a quality worthy of the role which it plays in the recipients' lives. The providers have to regard what they are doing, not simply as a means of making a living for themselves (though it must of course be in part that), but as a service given to humanity. Hence the code of ethics which they subscribe to must lay upon them obligations great, and different in kind, from those to which the providers of other, less central, goods are subject; and these obligations must be to concern themselves primarily with the well-being of patients, rather than with their own self-interest. In that light, one can understand many of the clauses in the declaration which I drafted.

How far what I have said about medicine can be applied to other candidates for professions is something I must leave to those who know more about those occupations than I do. But perhaps I can close by making a few remarks about one profession which I know more about than I do about medicine - my own profession of university teacher. Many of the things I have said about medicine, of course, are specific in their particular form to that profession. But university teaching too has changed, often in comparable ways to medicine, from what it used to be, under the pressures of the modern world. A mass higher education system cannot be the same as one which catered, as it used to when I first entered the profession, for the most part to a small elite. It is necessarily less personal: there is no possibility any more of the kind of one-to-one tutorials which used to exist, or of knowing all the members at least of the Honours class individually - not only knowing their names (even that becomes more difficult nowadays) but knowing a great deal about their lives and circumstances. The opportunities to make teaching a conversation or dialogue between individuals grow constantly less, and the pressure to make it the simple impersonal transmission of information constantly increase. The role of technology in teaching becomes concomitantly more important. If university teaching is to continue to regard itself as a profession, therefore, rather than simply as a particular group of technicians, it can only be as long as what it provides is, not a mere consumer good, but a component of the good life for human beings. Vocational training, as I said earlier, can be regarded as a consumer good in that sense: people's preferences for the kind of job they wish to do, and the extent of training which they want to have for doing it, vary from one individual to another. But the cultivation of the mind, through increasing knowledge and understanding and the development of mental capacities, could well be argued to be more than that, to be in fact a component of human well-being. To say this is not in any way to deprecate vocational training, or to deny its importance to society: but the case for vocational training is, anyway, well-established and generally accepted. What it is to say is that a society in which provision was made for vocational training, but not for the cultivation of the mind, would be one which did not care about the good for man; and that university teachers who provide only vocational training, of however high a level, and do not dedicate themselves with a sense of vocation to the cultivation of the mind, have no right to the title of a profession. Maybe we too need a code of ethics: and perhaps that might be another job for me.

Eric Matthews is Professor of Philosophy at the University of Aberdeen. He is currently Visiting Professor at Wooster College

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