Julie Leveritt asked me to speak at yesterday’s End-of-Life Conference sponsored by the St. Camillus Hospice, the Catholic Medical Association, Wisconsin Pro-Life and the Nazereth Project. It was held at St. Camillo Assisted Living center in Wauwatosa, WI. I spoke on the Oath of Hippocrates. Specifically the title was “Dusting off the Oath of Hippocrates in the 21st Century” with acknowledgement of John Patrick, MD, as I used some of his material in the talk.
It seemed well received. As a speaker, I never know quite how my words are viewed. Looking at the audience of about 220 people, I didn’t see anyone asleep, which is a good sign, but whether or not the talk has an impact on the listeners–no way for me to know. Several came up after to thank me, which was gratifying.
I didn’t mention that the talk was slightly shorter, but about the same as the talk I gave at Grand Rounds at Fairview Lakes in 2010, the talk that resulted in my dismissal.
Anyway, one person asked if I’d post the text on the internet. I gave her my blog address and what follows is more or less what I said yesterday. I edited the first talk I gave quite a little bit, because it needed editing. I’m a little better at that now.
Dusting off the Oath of Hippocrates in the 21st Century
First, I would like to credit John Patrick, MD for the inspiration for this talk, and, for some of the material I am using for this talk. Dr. Patrick is a now retired pediatrician from Ottawa, Canada who did research on pediatric nutrition for 25 years and is a gifted speaker. He is also the President of Augustine College in Ottawa, Canada. I’ve met him at a conference, though I doubt he would remember me. You can find him on the web at johnpatrick.ca.
The purpose of this talk is to inform you all about the Oath and why I think it is relevant even now, in the 21st century. Medicine, as I tell students and residents, is a glorious profession with a rich history. So my prayer is that you would have a grasp of how far we’ve come as a society and as a medical community, or maybe the more accurate word would be how far we’ve fallen as a society and medical community. If, as a result of this talk, you are more inspired to provide care for those people God places in your path, that would be a wonderful side benefit.
Who was Hippocrates? He was a Greek born about 460BC and died about 370BC. He is known as the Father of Medicine or the Father of Western Medicine and established the Hippocratic School of Medicine. His approach to medicine revolutionized medical care and separated it from other fields of study. He is the one who established medicine as a true profession unto itself. In addition to his contributions on many diseases, he probably wrote the Oath attributed to his name, the writing for which he is most famous.
First, the oath. I’ll read it to you.
I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:
To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.
I will prescribe regimens for the good of my patients according to my ability and my judgme-nt and never do harm to anyone.
I will not give a lethal drug to anyone if I am asked; nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.
But I will preserve the purity of my life and my arts.
I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.
In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.
All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.
If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.
Almost no new doctors recite the original oath which has some parts that were pertinent back then, but not so much now. Sadly though, most doctor’s oath do not even follow the main thrust of the original oath. Modern oaths add and subtract liberally from Hippocrates’s Oath. So, how have things changed? A study of 157 deans of medical and osteopathic schools in the US and Canada in 1993 found 43% promised to be accountable for their actions, 18% to do no mischief or harm, 14% included a prohibition against euthanasia, 11% invoked a deity, 8% foreswore abortion and 3% retained a ban against sexual contact with patients.
I’d like to now unpack the Oath briefly with a view of what I think may be less relevant in our day and age.
1) Teach the art to children of doctors.” Of course, that is no longer done. Medicine is taught to the best and brightest with consanguinity no longer a requirement. I’ll talk a little more about who gets taught medicine and who doesn’t a little later, because although consanguinity is not required, toeing the liberal line on abortion and euthanasia has become a defacto requirement. Regarding why Hippocrates put this requirement in, about only teaching medicine to children of doctors, my opinion on this—just an opinion—may be that he was emphasizing that students of medicine must be completely committed to medicine, as one may expect of a child of a physician.
2) “To do no harm.” This is probably the most famous line in the Oath. But, all doctors do harm to patients every day. Surgeries have inherent risks of bad results, medicines have untoward side effects, vaccines can cause severe harm in a very small percentage of patients, and chemotherapies cause obvious harm. It is important we all intend no ultimate harm—I’ll say that again—it’s important we intend no ultimate harm, but we as doctor do perform surgeries and give medicine that may cause short term harm to a patient so they may benefit in the long term. We explain the risks and benefits of a procedure and, if the patient agrees to proceed, we proceed, even with the small risk of short term harm.
3) “I will not cut for stone and leave that for practitioners of this art.” Doctors did not do surgery back then, but left it to the barber-surgeon whose main surgery was for bladder stones. Since surgery was nearly universally fatal in 400BC, it’s easy to see why he put this into the Oath.
When you boil the Oath down, Oath advocates find six underlying fundamentals of the Oath of Hippocrates, four of which I intend to concentrate on today. The six are:
Transcendence or the recognition of God in the medical relationship.
Medicine as a Moral Activity Acknowledgment that medicine is a moral, not a primarily technical activity.
Life Not Death A commitment to not intentionally kill or do harm.
Covenant Covenantal relationship between practitioner and patient through illness until death.
Practitioner Integrity Honest interaction determined by medical judgment, conscience and faith
Collegiality Moral consensus and enduring collegiality amongst like-minded practitioners.
My presentation will concentrate on transcendence, medicine as a moral activity, life not death and practitioner integrity.
The Oath starts by swearing to the Gods; Apollo, Asclepius, Hygieia, and Panacea. Why swear to the Gods? Why does the oath start with this? Why not pledge to consecrate your life to the good of the humanity as in the Declaration of Geneva? Or “In the tradition of Hippocrates and the men and women through the ages who have dedicated their lives to the art and science of medicine” as in the recitation of the University of Minnesota medical graduates in 2009 or “vow to that which you hold dear”, or just “agree with the Principles of Code of Ethics of the AMA’”
This appeal to the Gods represents a concept called transcendence, which means being beyond the limits of all possible experience or knowledge, or, in other words, acknowledging God. Now, you and I would not swear to those Greek gods, but to our own God, the triune God; Father, Son and Holy Spirit.
The concept of God means that someone or some supreme being exists outside of ourselves, outside of humanity. A fundamental characteristic of God now and in Hippocrates time was judgment after death, the concept that God will one day judge us for our care of our patients. This concept is important because it means that the physicians will, first and foremost be accountable for the care of his or her patients to God and judgment by God is not to be taken lightly. Hippocrates knew that rationally, a patient was safer under the care of a doctor who feared judgment after death than a doctor who did not.
I can’t overstate the significance of this concept. It means that the Hippocratic physicians would be accountable to a being transcendent to this earth, transcendent to any person and transcendent to any cause or idea. Such a physician would answer for the care of his patients to God, not the one paying him the most money, not the state, not the corporation, not the licensing boards, not the medical societies, not peer pressure, not the hospital or clinic protocols and not the economist or bean counter.
In Hippocrates time, the doctors not only healed but also killed at the request of anyone with the money to pay. Patients could not trust their doctors to have their best interest in mind and Hippocrates wanted to change that.
As you all know, our modern medical secular ethics do not include answering to God. Our ethic is based, not on God and judgment, but on a biologic-psychologic-social world view or ethic. This bio-pyscho-social model is beholding to whom? Accountable to whom? Good question. This model is underpinned by first, the so-called ethical principle of utility, which means whatever gives the most good to the greatest number is OK as long as it increases happiness. And second by the so-called situational ethic, which says love is the only ethic, that love and justice are the same and that right and wrong are determined individually in each situation. In situational ethics, the end always justifies the means if it increases happiness. From this over-arching model, medicine has developed the six ethical pillars or principles by which we function in medicine today. Those six principles are patient autonomy, beneficence, non-maleficence, justice, dignity and honesty. But the foundation of these six principles rest on an unpredictable and changeable foundation as utilitarian and situational ethics tend to be. And, since this foundation is not transcendent, not fixed, and does not have any anchor outside itself, it becomes a shifting sand, a moving target. So these current six principles guiding medicine can change from day to day. As a result, one can never be sure that the patient is placed first when receiving care from a doctor. The economist could muscle in dictating medical decisions to promote rationing of care. The administrator could gain control with the manipulation of a doctor’s income based on doctor behavior. The committee that establishes protocols could influence patient care in a negative way. Even the doctor himself could put personal gain first in the medical equation, a concept similar to Hippocrates day when the patient could not be sure whose best interest was in the doctor’s mind.
But I posit to you—Hippocrates got it right—transcendence is critically important, because rationally, patients are safer from harm.
This concept of transcendence has been echoed by others throughout the centuries. Thomas Sydenham, an English physician who lived in the 17th century is regarded as the Father of Modern Clinical medicine and also as the English Hippocrates. He lived during the English civil war and as a young man had a cavalier point a revolver at him at point blank range and fire. The revolver exploded, killing the cavalier, but not Mr. Sydenham. So he had a feeling his life had some purpose. He was the first to recommend cooling for the treatment of smallpox. He was the first to recognize the problem of pain and brought opioids to England. He used a quinine-containing bark to treat malaria and, of course, described Sydenham’s chorea. He recognized the importance of accurate clinical observations and patient history in treating disease. And, this giant of clinical medicine wrote the following oath.
IT BECOMES EVERY MAN WHO PURPOSES
To give himself to the care of others,
seriously to consider the four following things:
First, that he must one day give an account
to the Supreme Judge of all the lives
entrusted to his care.
Secondly, that all his skill, and knowledge, and energy
as they have been given him by God,
so they should be exercised for his glory,
and the good of mankind,
and not for mere gain or ambition.
Thirdly, and not more beautifully than truly,
let him reflect that he has undertaken
the care of no mean creature,
for, in order that he may estimate the value,
the greatness of the human race,
the only begotten Son of God became himself a man,
and thus ennobled it with his divine dignity,
and far more than this, died to redeem it.
And fourthly, that the doctor
being himself a mortal man, should be
Diligent and tender
in relieving his suffering patients,
inasmuch as he himself must one day be
a like sufferer.
— Thomas Sydenham, 1668
Ultimately, as Sydenham understood, it is only this transcendent commitment, this submission to God and God’s truths which protects patients.
Transcendence, in Hippocrates mind, was not just a good idea, but requirement for physicians to practice good medical care.
Medicine as a Moral Activity
Second, I would contend, as does the Oath, that, primarily medicine is not a technical activity, but a moral activity. When a patient comes in to your office, do they have to take your advice? No, of course not. So what you are doing is trying to convince them what they should do. Bp 170/110—you should take a high blood pressure medicine. Blood glucose 450? You should take insulin. When you move into the “should” aspect, you are defining “good”. And that is a moral activity. The Oath says, “I will prescribe regimens for the good of my patients according to my ability and my judgment.”
But where does that leave us with utilitarian and situational ethics? With managed care, corporate care, rationing of care, cost-containment medicine and protocol medicine, this part of the oath is followed less and less. In fact, Ezekiel Emanuel, an American bioethicist and fellow at the Center for American Progress and formerly a Harvard Associate Professor, sees the Hippocratic Oath as one factor driving “overuse” of medical care, and therefore what he sees as the excessive cost of medical care.
When he was a policy adviser in the Office of Management and Budget (OMB) in 2001, he argued that
“peer recognition [in medical training] goes to the most thorough and aggressive physicians.”
He lamented that doctor in training were rewarded for being meticulous and thorough. I’ll say that again. He lamented that doctors in training were rewarded for being meticulous and thorough.
I hardly know what to say to that. When I go to my doctor, I would much rather he or she be sloppy and superficial, not meticulous and thorough, wouldn’t you?
“Hippocratic Oath’s admonition to ‘use my power to help the patient to the best of my ability and judgment’ as an imperative to do everything for the patient regardless of the cost or effects on others.”
So, what he is saying is the best and brightest students, the most thorough, the most informed, the most able to reach a diagnosis, the ones who received the best grades were led or encouraged to achieve and do well because of the Oath of Hippocrates. Of course, that is what patients hope their doctor will do. But, he wanted to change that part of the oath to include cost containment. He advocated those students who demonstrate the best cost-containment medicine receive the highest grades, not the ones who are the most thorough. Many oaths now include such language, such as the Principles of Medical Ethics by the AMA.
Fundamentally, in my mind and in my practice, and, also, what I try to teach students and residents, is that medical care is fundamentally a relationship with the patient and the doctor. If the patient leaves your office or exam rooms and believes in his or heart that you truly care about that patient, they will come back. One of the main pillars of caring is prescribing for the good of your patient, the one in the room with you, based on your best knowledge and judgment because it generates trust.
I’ll say that again. When a doctor prescribes medical care based on his or her best judgment, it generates trust. And trust is crucial. But modern medicine is doing everything they can, it seems to thwart this trust. One way is check box medicine or protocol medicine, which means practicing medicine based on what is good for a group instead of what may be best for the patient sitting in front of you. I means leaving your best judgement at the door and following a check list. The pressure on doctors to follow these protocols gets stronger each day. Hospitals and clinics carry a big stick to get doctors to comply. The insurance companies insist on them, the government wants them in place and ultimately the insurance companies and government want to base a doctor’s pay on how well they follow these medical cookbooks. Doctors employed where I used to work now have 60% of their income determined by their work product and 40% determined by pay-for-performance, or how well they follow the protocols. The State of Minnesota publishes data on how every clinic in the state meets the protocols it assigns. It’s what Obamacare wants to do. And heaven help you as a doctor if you step off the cookbook plantation.
However, these checklists mean the patient may get testing or medicines which are not needed in the doctor’s judgment or, worse, the patient may be denied needed care based on the doctor’s judgment. I believe in my heart that protocol medicine will be the horse rationing rides in on, and no one will complain. Why? Because they’ll call it a “best practice,” a protocol the doctors must follow. It’s how the death panels will work. They will be called a “best practice.” The checklist may say the patient is too old for treatment, not cost effective. Or too disabled for treatment. Nothing exists in modern medical ethics to prevent any of this. Our 21st century shift to utilitarian, situation ethics means physician behavior will be dictated by the pronouncements of those with political power.
Now I wonder if I’ve caught a few of you physicians by surprise because many of you may see “best practices” as a good thing, a desired thing. You may not believe that protocol medicine designed to improve care for a group of patients, could have negative consequences or undermine patient trust. But, I would ask you to explain this system to a lay person and see what reaction you get. Whenever I explain the motivations behind protocol medicine which designs treatments based on what is best for a group of patients instead of the doctor’s best judgment for that patient, in the room, with that particular problem, I am met with near universal anger that a doctor would do this. Try it. Tell a married woman in a stable relationship that she must have STD testing because the doctor will lose income if he or she doesn’t test enough women her age, regardless of whether or not she needs the test. Try telling a mom with an 8 month old who has a fever of 104 degrees and is pulling at his ear that the ear infection isn’t serious and the child doesn’t need an antibiotic because if the doctor prescribes too many antibiotics, his or her income will be decreased. My wife already tried that. Her parents never took her in. She’s deaf in her left ear from chronic untreated ear infections as a child in spite of three surgeries as an adult. See for yourself if this system increases trust or undermines trust.
Can protocol medicine run even further amok? Of course. In England, there is the Marie Curie Institute which oversees the National Institute for Clinical Excellence (NICE), an irony not missed on you fans of C. S. Lewis. This NICE group developed an end-of-life protocol, or best practice. This best practice said that when the doctor determined the patient had less than 24 hours to live, the protocol would kick in. This protocol meant stopping all fluids and food (IV’s, tube feedings) and sedating the patient. And, guess what. They all died. Everything was good until two palliative care doctors—not religious folks—published an article critical of the protocol. They found that many on the protocol, when removed from the protocol, lived for quite some time. This created a public stir when families realized Uncle Joe was ushered out of this life prematurely. About 23% of the dying patients in UK were following this protocol. Since it was a best practice, it was not regarded as euthanasia and still is not regarded as euthanasia. Last I looked the protocol had been modified, but was still defended by NICE. That’s just one of the more egregious examples.
But many modern ethicists see no problem with calling a spade a spade. Why call it a “best practice?” Call it rationing. Rationing is good. It should be embraced openly. James Sabin who teaches medical ethics at Harvard Medical School argues that rationing is obviously necessary and mandatory for ethical health care in the 21st century. He concludes, however, that “there’s no way that the need for rationing could have been part of the federal health reform process. We’re not yet mature enough as a body politic to deal with that piece of reality without going ballistic about “death panels.” But wishful thinking and political immaturity don’t change the fact that rationing happens now, will have to be acknowledged in the future, and is an ethical requirement, not an abomination.”
So Mr. Sabin thinks you are politically immature and engaged in wishful thinking if you oppose the death panels.
I can’t discuss morality in medicine without discussing the covenant of privacy. The Oath covenants a doctor to keep private all he knows about his patient. Privacy, however, is out the window, both legally and illegally in this 21st century. Today, I want to touch on the illegal violations of patient privacy, almost exclusively because of the electronic medical record.
As you all know, a computer terminal and a password are now the gate to unlock every patient’s record in what used to be called the medical records department. With the EMR, the government intends cross-platform access so every record in the country could be accessible to every medical care provider in the country. Now that takes a lot of trust. How hard is it to steal a logon name or password? They now make a pen with a small camera and flash drive which can record real time video and sound. The user name and password you use could be easily stolen at a visit. In California, a hospital fired many employees who accessed the record of a celebrity and sold the information to a tabloid. A medical transcriptionist in India hired by Stanford for medical transcription tried to blackmail Stanford for money by threatening to put all her transcriptions on the internet. Conceivably, your entire record could end up on the internet.
What if you were a pro-life politician running for office? One week before the voting, a doctor zealot from the other party accesses your record and alters it to say you’ve had two abortions all the while speaking against abortion. The record could be printed and given the local newspaper. By the time the dust settled the election would be over and you would lose. What about probate and a challenged will? The record of the deceased could be altered just prior to death to include a diagnosis of early Alzheimer’s. What about child custody and parental fitness? The list of serious harm from this lack of privacy chills my medical soul.
All of these instances violate the privacy charge of the Oath. Do patients care about privacy? When I worked for a large health care corporation, I had patients request I keep their records on paper in my office because of privacy issues. The EMR violates the Oath and undermines trust.
This concept, trust, is not a scientific or technical concept. In fact, all the concepts in life that are most important to us are not scientific or technical. They are moral. Concepts such as love, fidelity, courage, trust, loyalty, justice, honesty, truth and others. Hippocrates recognized that and made it clear in his Oath that medicine was indeed a moral activity and this moral activity garnered trust. Science, of course, has nothing to say about these moral concepts that are so important to us. But if these important concepts come from if they do not come from science? Well, these important concepts come from one of the religions or societal codes found in the world, including the ancient Greeks. Of course all societies from every continent and all the multitudes of people groups in each continent have rules and morality specific to their group. Although these rules of morality differ from society to society, all societies have them. A society cannot function without them.
But, we can say about medicine through the centuries, no moral code or ethic has influenced medicine more than that of the Jews and Christians. We are the product of Greek and Hebrew thought modified by the Christian church. This ethic derived from Jews and Christians has been the dominant guide for medicine throughout the centuries. Our care, to treat patients, is based on that. And it is this moral code that has allowed medicine to advance to where it is today. Why? Why did this Jewish and Christian moral ethic allow or encourage advancement in medicine? Because Jews and Christian believe in the fall of man into sin, that man is inherently sinful and in need of redemption. And the redeemer, their God, has commanded these Jews and Christians to care for the poor, the sick, the traveler and the disabled and relieve suffering on this earth. And it is this ethos has allowed for medicine to progress to its current state today. Other moral systems tend to have problems for medicine. For instance, they may have a fatalistic ethos, one which does not recognize a God of order. That ethos, a fatalistic ethos, and in fact any fatalistic ethos, rationally prevents advancement in medicine and is unacceptable to us.
As a sidelight, when it comes to medicine, physicians only respect the opinions of other physicians or physician researchers and generally pride themselves on their medical knowledge. Of the patients who walk into a doctor’s office today, depending on location and practice type, most doctors would have patients who would self-identify themselves as Christian. So a doctor to be culturally relevant, should understand the basic tenants of Christianity. Jesus is the central figure of the new Testament and the Sermon on the Mount is probably Jesus most famous sermon. Yet, if you as a physician what’s in the Sermon on the Mount, few can tell you anything about it. So our emphasis on cultural relevance breaks down when physicians have only a kindergarten knowledge of Christianity.
Protection of Life
Another important concept of the oath was the protection of life. The Oath says, “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.” It is this sentence more than any other that has led to the Oath’s disuse since about 1973 when abortion was legalized. So you can see, abortion and euthanasia are not new concepts and are as old as medicine itself.
But why did Hippocrates include this prohibition? Why was this important? Well, to understand that, as I mentioned earlier, you have to understand medicine in Hippocrates time. Since the sorcerer and the physician were often the same person, he could kill as well as heal. You never knew if someone had paid more for your death than you had paid for your life. Hippocrates wanted to change that. He wanted patients to recognize that there would be a group of doctors, Hippocratic doctors, who would never kill and always try to heal. He knew that rationally, patients would trust doctors who valued life more than those who did not. This safety has been recognized by Margaret Mead, the anthropologist. She wrote.
For the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with power to kill had power to cure, including specially the undoing of his own killing activities. … With the Greeks, the distinction was made clear. One profession, the followers of Asclepius, were to be dedicated completely to life under all circumstances, regardless of rank, age, or intellect – the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child. . . . [T]his is a priceless possession which we cannot afford to tarnish, but society always is attempting to make the physician into a killer – to kill the defective child at birth, to leave the sleeping pills beside the bed of the cancer patient. . . . [I]t is the duty of society to protect the physician from such requests.
But society does push us to kill. Abortion has been legal in the US since 1973. Euthanasia is legal in many European countries and also in Oregon, Washington and Montana. And even if you are not in one of these states, euthanasia goes on. As you all know, doctors can kill patients with the greatest of ease. And can do it without detection by the most astute forensic pathologist. You may know of doctors whose old and sick patients seem to die earlier than you would expect. And killing can be addicting. The British GP, John Bodkin Adams, in the 1940’s and 1950’s killed 160 of his patients with medicines and 132 left him money in their wills. He became the richest GP in England, quite famous, and treated the nobility of the day. He was finally caught, but was acquitted at trial of murder. The Dutch now have legal euthanasia. But the government can’t get a handle on the numbers of euthanized patients. They surveyed doctors and more than half of the time, doctors do not report euthanasia because of the paper work hassle. Who would have thought that the Dutch physicians who gave their lives under the Nazi rule in WW2 rather than euthanize those with disabilities would have developed the Groningen Protocol which contains directives with criteria under which physicians can kill disabled infants, infants in no danger of imminent death, infants whose lives fit a protocol, or best practice, (which determines their lives are not worth living), all without the threat of legal prosecution or punishment.
Peter Singer, the Princeton University ethicist and atheist, argues that killing a child in the first year of life should be legal if the child has serious disabilities and also argues that health care rationing is desirable. Of course, he also sees no differences between humans and animals and that sex with animals should be fine if it doesn’t hurt the animal.
I think I can illustrate this concept of safety for patients whose doctors value life. Suppose you are dying of cancer and I am your doctor, and unknown to anyone else, I have the cure for your cancer in my pocket. What should I do? Give the cure. But suppose you are very rich and have made me heir to your money when you die. And, I am a committed social Darwinian, situational ethicist who determines right and wrong on the fly, one who does not follow any transcendent law or code, one with no commitment to life. What should I do then? Of course. Keep it in my pocket. Therefore, when you die, I collect my winnings, and then can market my cure for great monetary gain. I could even dedicate the cure to you, my dear friend. You see, one can’t say it is right to give you the cure unless one can say that saving life is good. And that’s the problem. We now think that only saving some life is good.
Physician Integrity and Conscience
Finally, the Oath speaks to the concept of practitioner integrity, or conscience. The oath says, “I will preserve the purity of my life and my arts.” What that means, I think, is that the doctor will not violate his or her purity of conscience in life and in medicine. In other words, be true to conscience at all times. What does that mean and why is it significant? It means that a doctor has to know the difference between right and wrong and has to do what is right. That is the true basis of the rights of conscience. Where are the attacks coming? Mostly on the right to life issue. They want doctors to do abortions, refer for abortion, or perform or refer for euthanasia.
But the worst thing you can be or say in this multicultural age is that you know what is right and what is wrong, because that undermines the foundation of the so-called utilitarian ethic and the situational ethics. Right and wrong are supposed to depend on where you sit, what your viewpoint is. What is right for you may not be right for me. What is good for you may not be good for me. Right and wrong, like beauty, are in the eyes of the beholder. All views are supposed to have validity.
But in practice, we all live as though objective right and wrong exists. Example: A student wrote an essay on existentialism which made the point that there is no absolute right or wrong. When the student handed in his excellent paper, the professor gave him a C. The incensed student returned to argue for a better grade, to which the professor gave his reason for the C. He didn’t like blue folders. To make a point, the professor’s individual preference defined right and wrong. The student got the point. So you can see, for justice to exist for that student, an ethic beyond individual preference must exist. If preference determines justice, political power will remove the blindfold from lady justice. And justice is critical to medicine.
To illustrate this further, I’ll tell you about Arthur Leff, a Yale law school professor, who died in 1981, wrote an essay entitled, “Unspeakable Ethics, Unnatural Law”. He was worried about this problem or right and wrong and how it applied to the law. And in this article, he starts with this:
“I want to believe – and so do you – in a complete, transcendent, and immanent set of propositions about right and wrong, findable rules that authoritatively and unambiguously direct us how to live righteously. I also want to believe – and so do you – in no such thing, but rather that we are wholly free, not only to choose for ourselves what we ought to do, but to decide for ourselves, individually and as a species, what we ought to be. What we want, Heaven help us, is simultaneously to be perfectly ruled and perfectly free, that is, at the same time to discover the right and the good and to create it.”2
Leff states that absent an ultimate authority figure (i.e. God) handing down moral laws from on-high there is no reason for any person to prefer one set of behavior identified as “moral” to another. Leff terms this “the Grand Sez Who.”
The conclusion of Leff’s essay lands wrongly but dramatically illustrates the dilemma.
“All I can say is this: it looks as though we are all we have. Given what we know about ourselves and about each other that is an extraordinarily unappetizing prospect; looking around the world, it appears that if all men are brothers the ruling model is Cain and Abel. Neither reason, nor love nor even terror, seems able to make us good, and worse than that there is no reason why anything should. Only if ethics is something unspeakable by us could law be unnatural and therefore unchallengeable. As things stand now everything is up for grabs.
Nevertheless napalming babies is bad, starving the poor is wicked, buying and selling each other is depraved. There is in this world such a thing as evil.”
But I would ask, would you want a doctor with moral integrity or without moral integrity providing your care? If a doctor caved on his strongly held belief just so he could make money, or keep his job, or maintain medical prominence, or be on the “in group” of his doctor peers, what would you think? Would this be a doctor you would seek out to provide your care—someone you know will compromise if the need is great enough? Would he cover up a medical error he made? Would he lie about what constituted the best treatment when he knew it was not? I know who I would want and it would not be the compromiser. So the conscience of physicians, their moral integrity, is under assault, to medicines detriment. Hippocrates knew that, and insisted on moral integrity, on the purity of the physician’s life of art.
What the Hippocratic Oath gave us was a vision of doctors with moral character and high ethical standards who deserved trust.
So that is my take on the Oath of Hippocrates. This Oath provides safety for patients from a doctor’s other allegiances; provides dignity to patients in the medical encounter; fosters confidence to patients, knowing their very personal and private information will be safely held by their doctor; and enables trust to develop, knowing that their doctor’s morality and ethics are based on the hard truth of principles which have stood the test of time, not the soft sincerity of recent conventions, conventions with no anchor, conventions beholding to those in power, conventions which, in my mind, have been weighed in the balance and found wanting. The Hippocratic Oath, taken seriously, places us in a timeless framework in which we can practice medicine with the most benefit to our patients.
Matt Anderson, MD