Ten Rules of Civility in Medicine: Reflections on Character and Moral Injury
“Labor to keep alive in your breast that little spark of celestial fire called conscience.”
— George Washington
As a young man, George Washington carefully copied a set of Rules of Civility in Conversation and Behavior. They were not written to enforce obedience, but to shape character—to cultivate restraint, humility, and attentiveness in one’s dealings with others. Long before Washington was entrusted with power, he was learning how power ought to be carried.
Medicine unfolds in a similar moral landscape. Each clinical encounter is more than an exchange of information; it is a meeting shaped by asymmetry—of knowledge, authority, and vulnerability. Illness is experienced not merely as pathology, but as disruption of identity, time, and control. The clinician enters that disrupted world briefly, yet decisively. How that presence is enacted matters.
Civility, in this sense, is not etiquette. It is an ethical posture—a way of being with another person under conditions of constraint. The following ten rules are not techniques to be executed, but orientations to be renewed.
1. Listen before speaking.
Listening allows the patient’s lived experience to emerge.
2. Apologize when appropriate.
An apology acknowledges harm at the level of experience, not blame.
3. Receive every question with seriousness.
To take a question seriously is to affirm the questioner’s dignity.
4. Attend to what is worthy of affirmation.
Recognition restores dignity where illness often erodes it.
5. Speak ill of no one.
Restraint preserves the ethical climate of care.
6. Extend equal concern to all.
Justice begins with vigilance toward one’s own partial vision.
7. Guard privacy in word and manner.
Respect is enacted as much as it is regulated.
8. Be present, however briefly.
Presence depends on attention, not time.
9. Exercise humility with humor.
Without shared meaning, levity may obscure seriousness.
10. Allow the patient to conclude the encounter.
Agency restores personhood where it is often diminished.
Increasingly, clinicians describe a form of distress not captured by the language of burnout. It arises when one is repeatedly unable to act in accordance with one’s moral understanding of care.
This moral injury stems not from indifference, but from sustained dissonance between professional ideals and daily realities.
In this context, civility serves not only the patient. It becomes a means of preserving the clinician’s own moral integrity. Small acts of attention and restraint remind us who we are trying to remain within systems that often make such remembrance difficult.
Washington’s rules endure because they recognize a timeless truth: where power exists, discipline of conduct is required.
Civility does not promise perfection. It asks for attentiveness—and attentiveness may be among the most ethical acts medicine still allows.