Following is the text of a grand rounds presentation I gave at my place of work. This is a long post because the talk lasted one hour. I do think this talk hits on areas of concern to all Christians since it gives corporate medicine’s views on current practices, many of which generate significant controversy. More information later. Maybe.
Matt Anderson, MD
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.
Second, I will be using the generic pronoun, “he”, for most of the talk when referring to physicians or others, but I define “he” as “he or she” when referring to those groups which would represent both sexes.
Third, my presentation today will involve no distractions, such as a cornucopia of colors, a dazzling display of fonts, a dizzying demonstration of moving pictures or a shameless spectacle of my computer skills. Instead, I will rely on three thousand years of evidence that the technique I’m using is effective in teaching students. It’s called lecture. And, if you wish to take notes with a pencil or pen, those are available. But, actually, the entire text of my talk will be posted on the web, so I would use the note pads to write down questions you may have and I’ll try to have a question and answer time after the talk. I’ll post the text on my seldom-read blog at mdviews.wordpress.com. You can’t access it from your computer here at work because it’s been blocked by my employer administration for its content. You can access it wirelessly here on the guest wireless if you have that ability or of course from your home computer.
Fourth, I don’t know if any of you are aware of this, but I do some free-lance writing and have been published in WORLD magazine six or seven times in the last year. You can access WORLD at worldmag.com.
Fifth, this talk is not a religious talk in any way and I’ve tried hard to make sure it is not, but it’s hard to separate religion from a talk about the Oath and how it relates to medicine in the 21st century, because the Oath talks about life issues and morality and God.
Finally, I’d like to thank Mike Dummer who is in charge of grand rounds for giving me this opportunity to present the Oath to you today. My talk is not scientific in any way, so you won’t increase your scientific medical knowledge or take home any juicy pearls of knowledge for your practice. But after some discussion, Mike graciously approved this topic, and I want to thank him publically.
Who was Hippocrates? He was a Greek born about 460BC and died about 370BC. He is known as the Father of Medicine and established the Hippocratic School of Medicine. His approach to medicine revolutionized the practice of medicine separating it from other fields of study. He is the one who established medicine as a profession. In addition to his contributions on many diseases, he 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 judgment 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.
Few new doctors recite the oath and I’m sure none of you doctors did. Modern oaths add and subtract liberally from Hippocrates’s Oath. If you want to see examples of other Oaths to see the differences through the years, you can grab a handout at the end of the talk.
Since the Oath is no longer used, how have things changed? A study of 122 deans of medical and osteopathic schools done in 2000 found that only one school used the text of the classical Hippocratic Oath. 48% reported they used other “versions” of the traditional oath, 21% used a modified Declaration of Geneva, 25% wrote their own and 15% were offered more than one oath. When researchers examined the contents of all oaths in use at that time, they discovered that 91% committed to privacy, 87% to teaching, 81% put the patients welfare first, 60% promised to be accountable for their actions, 18% to do no mischief or harm, 14% included a prohibition against euthanasia, 17% invoked a deity, 3% retained a ban against sexual contact with patients and 1% foreswear abortion.
Modern ethicists dislike the oath and view it has having no place in modern medical practice. One such ethicist is Dr. Sherwin Nuland, the author of the bestselling book How We Die and an internationally prominent physician and bioethicist from Yale University. Dr. Nuland advocates new doctors receive thorough training for euthanasia. Lobbying for this, he knew this was a clear violation of the Oath of Hippocrates, but dismissed the relevance of the Oath, writing:
[T]hose who turn to the oath in an effort to shape or legitimize their ethical viewpoints [against euthanasia], must realize that the statement has been embraced over approximately the past 200 years far more as a symbol of professional cohesion than for its content. Its pithy sentences cannot be used as all-encompassing maxims to avoid the personal responsibility inherent in the practice of medicine. Ultimately, a physician’s conduct at the bedside is a matter of individual conscience.
So if you look in the dust bin of history, you will find the Oath of Hippocrates.
I’d like to now unpack the Oath and go through it. I’ll list some of the lines in the Oath about which I’ve found objections or statements that are obviously not very relevant.
1) Teach the art to children of doctors. This implies doctor preference on learning medicine. Of course, that is no longer done and hasn’t been for centuries. Medicine is taught to the best and brightest with consanguinity no longer a requirement. I’ve thought about this, however, and 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 son of a physician.
2) “To practice and prescribe to the best of my ability for the good of my patients.” With managed care, rationing of care, cost-containment medicine and protocol medicine, this part of the oath is followed less and less. In fact, Ezekiel Emanuel, Rham Emmanuel’s brother, (the president’s chief of staff) who is a prominent physician at Harvard 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 doctors regarded the, “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. So, this statement seems more and more out-of- date.
3) “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 harm, but no doctor can do no harm. So we as doctors are quite utilitarian in our ethic regarding “do no harm”. We explain the risks and benefits of a procedure and, if the patient agrees to proceed, we proceed, even with the small risk of harm.
4) “I will not give a lethal drug to anyone if I am asked nor will I advise such a plan.” With euthanasia now legal in many European countries and in Oregon, Washington and Montana in our own country, few doctors, probably, would swear to that and modern oaths that I’ve seen do not contain that admonition.
5) “I will not give a woman a pessary to cause abortion.” With legalized abortion, few doctors would agree with that, at least in OB/GYN. In fact, the condemnation of abortion in the oath is the main reason the oath is no longer used. Legalized abortion in 1973 purged that statement from the Oath overnight.
6) “I will keep myself far from all intentional ill-doing, including sex with women or men, be they free or slave.” Sex with patients is prohibited in the Oath, even with the slave who would have no say in the matter. The law and licensing boards in Iowa and Minnesota, I know, view sex with patients in a dim light. Sex with patients results in loss of your medical license. However, there are medical ethicists today who argue that the data on this blanket ban is lacking and sex with patients should be OK. Today, only about 3% of codes recited by new doctors specifically prohibit this.
7) “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. Probably Hippocrates was talking about bladder stones.
8) “I will keep the good of the patient the highest priority.” In this century, that is becoming increasingly difficult as there are now conflicting “good purposes” for medicine, especially cost-containment. Jim Sabin who teaches medical ethics at Harvard Medical School now argues that rationing is obviously necessary and mandatory for ethical health care in the 21st century. Peter Singer, the Princeton University ethicists who argues that killing a child in the first year of life should be legal if the child has serious disabilities, argues that health care rationing is desirable. It’s not hard to think of other “good purposes” which would conflict with the good of the patient, and there are many.
But, I contend today that the basic tenants of the Hippocratic Oath have value and meaning for today’s physicians, and, in fact, are necessary to practice good medicine.
There are six underlying fundamentals of the Oath of Hippocrates, four of which I intend to concentrate on today. The six are:
Recognition that transcendence is essential to medicine
Practitioner & patient each accountable to a higher authority
Medicine as a Moral Activity
Acknowledgment that medicine is a moral activity
Patients helped to decide what they ‘ought’ to do
Life Not Death
A commitment to not intentionally kill or do harm
A complete separation of killing and healing in society
Covenantal relationship between practitioner and patient
A professional relationship throughout illness until death
Informed by medical judgment, conscience and faith
Preserved by freedom to refuse treatment that is harmful
Moral consensus and enduring collegiality amongst like-minded practitioners
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 “To dedicate all my knowledge and strength to the preservation and improvement of the health of mankind and to the treatment and prevention of disease”, 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 agree with the Principles of Code of Ethics of the AMA from 1980 which says, ‘As a member of this profession, a physician must recognize responsibility not only to patients, but also to society, to other health professionals, and to self.’”
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, of course today, if we chose to swear to a God, we would not swear to those Greek gods, but to our own God. God means that someone outside of ourselves, outside of humanity. A fundamental characteristic of God now and in Hippocrates time was judgment, the concept that God will one day after our death, judge us for our care of our patients. But why is this concept important? Because it meant that the physician was, first and foremost accountable for the care of his patients to God. Judgment by God was not to be taken lightly. Doctors accountable to God feared the judgment of God after death. And 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. The significance of the invocation of the gods in the Oath of Hippocrates cannot be overstated. It meant 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. This Hippocratic 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.
You see, back when old Hippocrates practiced medicine, the doctor was beholding to no one but himself, or to someone who paid him more to do harm to the patient than the patient paid for healing. Patients could not trust their doctors to have their best interest in mind, could not count on doctors to heal them of their illness, could not rely on doctors to put their lives above other interests the doctor may have. Hippocrates wanted to change that.
Now we fast-forward to the 21st century. Our modern medical ethics do not include answering to God. So now, our medical view of the world holds, not to God, but to the biologic-psychologic-social view or ethic. This bio-pyscho-social model is beholding to whom? To whom is this model accountable? Good question. This bio-phsyco-social model is underpinned by first; the 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 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 pillars of accepted modern medical behavior, or six ethical principles by which we function in medicine today. Those six principles are patient autonomy, beneficence, non-maleficience, 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, not having any anchor outside itself, it becomes a shifting sand, a moving target. So these current six principles guiding medicine have as a foundation these utilitarian and situational ethics which are subject to change from day to day. As a result, one can never be sure the patient is placed first when receiving care from a doctor. The economist could muscle in dictating medical decisions, especially as rationing of care which is now front-burner and advocated by politicians. The administrator could gain control with the manipulation of income based on doctor behavior. The committee establishing the 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 mind.
Therefore, Hippocrates recognized the need for transcendence, because rationally, patients would be 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 opiodes 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.
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.” It also says, “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.” The Oath continues with, “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.”
These moral concepts: Always prescribing or treating patients for their good based on the doctors ability and judgment, never engaging in intentional immoral behavior with men or women patients and keeping all patient information private constituted a huge advance in medical care.
Physicians, then as now, were in a powerful position, one in which the patient was subordinate and at a disadvantage. This prohibition against sex with patients continues today in our laws and rules from the state medical boards, in spite of attempt to change it. And yes, there are attempts to change it, believe it or not. Some now say the issue has not been studied, therefore no one knows if sex with patients impacts patients or doctors or the health care system negatively. I hardly know what to say about that. When doctors follow such a ban against sex with patients as is written in the Hippocratic Oath, patients of both sexes can safely receive care from doctors of both sexes without fear of sexual contact in spite of the vulnerable position in which they are placed. To me, this is a priceless trust and needs no randomized controlled trial.
Prescribing for the good of patients based on knowledge and judgment also generates trust. This concept is challenged in several ways. 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 challenges the individual judgment of physicians. And, of course, our motivation to practice in this way comes from three fronts: strong peer pressure (the whole clinic has to meet the goal or no one benefits), extra money for compliance with the protocols and quotas and even employment requirements (comply or be disciplined).
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. What if the checklist says the patient is too old for treatment? (Not cost effective, a term we will be hearing more and more as rationing becomes a reality) Or too disabled for costly treatment. (a situation now occurring in England) Nothing exists in modern medical ethics to prevent any of this. Our 21st century allegiance has shifted to a mushy, squishy, moving target of physician behavior which depends on the de rigueur (or in style) pronouncements of those in power.
Now, probably most of you physicians here don’t really believe that, that protocol medicine, which may 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 discuss it. When I do, when I explain the motivations behind protocol medicine (more money, pressure from administration, pressure from peers and what will soon be pressure from the government), medicine which treats based on what is best for a group of patients instead of the doctor’s best judgment, 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. See for yourself if this system increases trust or undermines trust.
Can protocol medicine run 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 was still defended by NICE. That’s just one of the more egregious examples.
Regarding 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. The HIPAA rule, finalized in 2003 and amended in 2008 allows access to your patient’s patient-identifiable medical record by a staggering number of organizations, individuals and the government without your patient’s consent, including, but not limited to, billing clearing houses, insurance companies and their employees, many outside vendors hired by your insurance company, some employers under a self-insurance plan, many researchers, organ donor groups, and, yes, even marketers. (You see your pediatrician and get an ad for disposable diapers in the mail two weeks later.) And the government has even more authority to see individual records. No consent from your patient is needed for quality, regulatory and compliance auditing, public health or fraud and abuse investigations. The police can see individual records without a court order if they have any suspicion of domestic or child abuse. Some judicial proceedings need no court order. Workers comp, national security and the military are exempt from consent. There are even instances in which the government can access mental health record, the most sensitive record of all.
And those are the legal violations of privacy.
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. Already, I could log on to EPIC and call up a chart from a variety of my employer hospitals and clinics and alter a record or just snoop. I would be fired, of course, but could do it. How hard is it to steal a logon name or password? First, I know nearly all your logon names. Second, they now make a pen with a small camera and flash drive which can record real time. The password you use could be easily stolen at a visit. If I were to steal a logon name and password and altered a medical record, no one would even suspect me and the poor schmuck doctor from whom I stole the password would be fired. 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 politician running for office, say Michelle Bachman to use an example? One week before the voting, a doctor zealot from the other party accesses her record and alters it to say she had two abortions when speaking against abortion, that she admitted to being a closet alcoholic, that she had schizophrenia and was controlled on meds. The record could be printed and given the Star-Tribune. By the time the dust settled the election would be over and she 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? Already I have had a patient insist I make a paper chart for her to keep in my file cabinet because she had sensitive information she did not want in the EMR. 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, rationally, Muslims have a problem because their concept of “En shala”, the will of Allah. The will of Allah, en shala, is much stronger than the Judeo-Christian view of the will of God. You know that when a Muslim dialysis technician throws up his hands and says En shala when the dialysis machine stops working while everyone else is scurrying around to find the fuse. 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. And, as you know, if you were to ask, about 90% of the patients you see in your office would identify themselves as Christian. In order to be culturally relevant, then, we should be familiar with the tenants of Christianity. Arguably, the Sermon on the Mount, given by Jesus, is the most famous part of the Bible. So how many of you who attend church less than once a month can tell me what is in the Sermon of the Mount? So, for most of you, you see almost all self-identified Christians in your office but have only kindergarten knowledge of Christianity and are culturally illiterate of their belief system. Such ignorance is surely a violation of my employer’s goal of cultural relevance. I know for myself, if 90% of my patients were Muslim, I’d be reading the Koran to find out what they believe and why they do what they do.
So the modern ethic, the modern morality of this squishy, shifty, bio-psycho-social model of medicine, this subjective, utilitarian situational ethic has another important implication and that is the inability to make a distinction between right and wrong. These modern ethical views contend that right and wrong 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 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 Arther Leff, a Yale law school professor, who, in 1979 spoke at Duke and 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
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.”
What the Hippocratic Oath gave us was a vision of doctors with moral character and high ethical standards who deserved trust.
The third 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. (1)
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 when he persuaded a patient to change her will in the morning and killed her in the afternoon. He was out of jail in a few years. 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.
I think I can illustrate this concept of safety for patients whose doctors value life by using a member of the audience. Suppose _____ is dying of cancer and I am his doctor, and unknown to anyone else, I have the cure for his cancer in my pocket. What should I do? Give the cure. But suppose ________ is very rich and has made me heir to his money when he dies. 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 he dies, I collect my winnings, and then can market my cure for great monetary gain. I could even dedicate the cure to my dear friend __________. You see, you can’t say it is right to give him the cure unless you can say that saving life is good. And that’s the problem. We now think that only saving some life is good.
In our day and age, as Dr. Patrick contends, it would have been better if the medical community had resisted entry into the profession of abortion and euthanasia from a philosophical stand point so that this dedication to life could have continued. We live in a pluralistic society in which abortion and euthanasia will always be with us. It was in Hippocrates time and still is. So I see no danger of either going away. But abortion is not a difficult procedure to teach. A physician is not needed. Likewise, euthanasia. We could have abortionists and euthanists without any difficulty. That way one group would not be tainted with death. One group, physicians, would be known to always protect life. They would be prohibited from causing death. Patients could know they would always be safe. Of course, that will never happen now. Abortion and euthanasia are deeply embedded in the medical community.
But there are doctors now who want to change that and want physicians again to be the ones protecting life. There is a group of physicians now who follow the main tenants of the Oath of Hippocrates, including respect for life. They are Jews, Muslims, Christians, Hindus and others who have formed a Hippocratic Registry of Physicians. This registry, this group, should it become large enough, could even become a competing medical system of Hippocratic medicine. Should that happen, people again could vote with their feet. I think ultimately, such a system would become dominant in the end. It may take a couple of centuries as it did in Hippocrates time, but I think it would become dominant because patients would be safer. If interested, you can find the Hippocratic Registry of Physicians at www.hippocraticregistry.com.
Finally, number four, is 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? Because rights of conscience, the rights of a doctor to preserve this purity, is being challenged. Already, ACOG has issued an ethical opinion, #385 which says OB/GYN physicians should either perform abortion or refer for abortion regardless of their belief about life, or move close to an abortionist so his or her patients have ready access to abortion and if these physicians do not do that, they are unethical. About two months after that came out; the ABOG stated that to be board certified, an OB/GYN had to adhere to the ethics of the college. So OB/GYN board certification could become dependent of compliance with the ethics of the abortion community. The Secretary of HHS at the time, Mr. Leavit challenged the OB/GYN board and received assurances from the Board that they had no intention of making such a requirement for certification. However, the Board did not change any of the written requirements for certification. Because of that action by ACOG and the OB/GYN board, HHS specifically made a rule that no physician could be made to perform or refer for abortion against his or her conscience. President Obama has promised to rescind that rule.
During the public comment time when this rule was offered for consideration, a Christian Medial Association polled pro-life physicians to see if they had been harassed for their beliefs. 39% of pro-life physicians experienced coercion to violate their consciences during their medical education by faculty and administration, with 23 percent experiencing such discrimination in the application process alone. And 32 percent experienced coercion to participate in or refer for procedures that violate their conscience during their professional careers. Hundreds of medical students, residents and practicing physicians including yours truly submitted their stories of discrimination because of their beliefs during the comment time of the HHS rule, stories that I find unbelievable in this so-called multicultural, tolerate-everyone’s-beliefs day and age.
As an example of modern tolerance, the department of education at the University in British Columbia proposes that no one should be admitted to medical school who will not agree to perform abortions. Such a rule would effectively eliminate practicing Jews, conservative Christians, devout Muslims, many Mormons, and some Hindus— basically, anyone who would not agree to do abortions. Now there’s an inclusive multicultural maneuver—eliminate those applicants who come from cultures with whom you disagree.
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.
So that is the Oath of Hippocrates. Now you know some of the parts that do not apply to us in this day and age, but you also know the main tenants of the Oath, transcendence, medicine as a moral activity, life not death, practitioner integrity, covenant and collegiality. It is my belief that these tenants, these timeless concepts recognized by Hippocrates and included in the Oath that served medicine well for 2,500 years, are of value to us today. 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.