Intended for healthcare professionals

Education And Debate

Internal and external morality of medicine: lessons from New Zealand

BMJ 2000; 320 doi: (Published 19 February 2000) Cite this as: BMJ 2000;320:499
  1. Charlotte Paul, associate professor of epidemiology (
  1. Department of Preventive and Social Medicine, University of Otago Medical School, PO Box 913, Dunedin, New Zealand
  • Accepted 7 October 1999


It has been claimed that the Bristol case will kill internal self regulation.1 The New Zealand experience should serve as a warning against believing that internal self regulation by the medical profession is useless and should be discarded. After the report of the New Zealand cervical cancer inquiry 11 years ago,2 which has similarities with the Bristol case, many new rules were made, some of which have the status of legal regulations, governing both research and medical practice. Yet these apparent improvements in ethical standards represent an unbalanced concentration on an external morality for medicine. Over the same time internal morality, though it had a key role in limiting the harm done to patients in the cervical cancer study, has been thoroughly neglected.

Henk ten Have has described internal morality as those values, norms, and rules that are intrinsic to the practice of medicine.3 Internal morality arises from within a community of practitioners—doctors, nurses, teachers—and it is based on how one should behave in one's daily work. These are shared values that are learnt from one another and may or may not be written down. External morality is the view from outside, reflecting the ethos of the wider society. The recent discipline of bioethics has grown up largely outside medicine and has developed principles of its own. Rules drawn from principles in bioethics and from other ethical doctrines in society are often codified into laws.

The best known written code for practitioners, drawn up by insiders, is the Hippocratic oath.4 A central statement is: “I will use my power to help the sick to the best of my ability and judgment; I will abstain from harming or wronging any person by it.” The code is written in the first person—a moral agent is envisaged. The most …

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