Seabrook Island resident and guest columnist continues his series of blog posts on critical issues in the practice of modern medicine. —Tidelines Editors
A Practical Adaptation of an Ancient Oath in Search for Modern Relevance
Times are changing = the understatement of the year, and hardly a surprise! It’s probably safe to say that this cliché is especially applicable to what we euphemistically call the American Medical System. In January, when I departed somewhat from the usual style of this blog, I promised to come back to cancer related issues in the future, and I will – but not just yet.
Other things have been on my mind as of late, and I want to explore several contemporary medically related topics for the next several blogs; however not in the usual way that concerns the mechanics of the system – Medicaid, Medicare, Obamacare, etc. Instead I want to discuss certain behavioral matters from an historical and ethical perspective, hopefully catalyzing thought and discussion about topics that often stimulate strong individual feelings. The reader should think of this as food for thought and discussion, and in no way advocacy or opposition on my part. Let’s go back in time for the foundation for this discussion.
In antiquity, the practice of medicine was based on magic and astrology, rather than on any semblance of science. Hippocrates of Cos, who lived between the fourth and fifth centuries BC, was probably the first to address both the scientific and the ethical aspects of medicine. It would, in fact, be inaccurate to think that the Hippocratic Oath as we know it represented Greek medical practice of the time. The Hippocratic thinking actually more resembled later Judeo-Christian principles than the flexible Hellenistic practices of Hippocrates’ time, in which infanticide, abortion, and suicide were condoned, and perhaps even encouraged. It is thought, therefore, that Hippocrates essentially founded a new ethical way that earned him the title of father of the profession.
Legend has it that he proposed an oath that would be a nonbinding pledge of intent for ethical behavior in the practice of medicine. For many years, that Oath has been recited by graduating medical students during commencement exercises; in fact, I have a vivid memory of the excitement I felt when my first act after receiving the medical diploma was to recite the Oath with my classmates. The recitation of the Hippocratic Oath is, admittedly only a formality today, and it’s done sporadically among institutions – like prayer and the Pledge of Allegiance, such rituals are thought by some to be politically inappropriate.
Still the allure lingers, and many references are made to it, despite the fact that most patients and even some physicians have no idea what Hippocrates actually said. I suspect that most people and many doctors think of the Oath as being of historic interest only—a writing that symbolizes a traditional rite of passage rather than a functional document. One of the liberties of the aging process is being dogmatic, and in this writing by using that self-granted privilege, I seek to negate this idea about the Oath. In point of fact, much of this ancient but surprisingly precocious rule book is relevant and workable in today’s practice of medicine— perhaps more so than in antiquity.
Despite all secular and progressive pressures of the contemporary times, I believe there is an imperative for doctors to rescue the remnants of moral integrity from an unpromising climate. Because of my belief in the high ideals outlined in the Hippocratic Oath, and since I am concerned about physician behavior, ethics and their relative morality, it is worth examining not only the oath’s original content, but also some of the modifications that have been made in a search for modern relevance.
The medical schools that administer the Oath usually tailor it to bypass the original wording, which forbade abortion and euthanasia, and furthermore it admonished physicians against performing surgery. It should be made clear, however, that the exclusion of statements on abortion and euthanasia from modern versions does not represent a de facto endorsement of either. The absence of the wording is meant to allow legal flexibility, as well as debate and disagreement among members of the profession.
In fact, there is currently much vigorous dialogue within academic and legal circles on these matters. The issues of abortion and euthanasia in particular, and one other that relates to special surgical training, are actually within the dominion of my discussion. In this essay, therefore, I will seek to weave the applicability of these topics into the reader’s considerations without taking sides or endorsing a specific view.
Obviously, other complex ethical issues that are associated with recently acquired knowledge are not in the original Oath—cloning and other genetic engineering, stem cell research, and others—all of which are appropriately of great interest to physicians and ethicists. However, a discussion that includes all necessary adaptations of the Oath is beyond the scope of these blogs. Almost certainly, as scientific knowledge grows, new topics will arise that theoretically challenge ethicists, and on a practical level, challenge physicians who administer patient care. As this intellectual discourse evolves, the medical profession will almost certainly interact with, agree and disagree with, and oppose or acquiesce to the intellectual machinations of social anthropologists.
Because physician behavior is a recurrent theme throughout much of my writings, I would like to examine Hippocrates’s original document and spell out how it has been modified in search for modern applicability. In doing this, I have addressed only those changes I think are most relevant to our world. For example, certain adaptations, such as the Oath’s restriction of abortion is contentious today and warrants discussion, but for our purposes, only in limited fashion. My personal opinions might be obvious by way of anecdote, but they are not meant to challenge the reader’s own beliefs. Hence, guidance in thoughtfulness rather than dictum is offered. To delve into the general discussion of abortion would be presumptuous on my part and moreover would risk political polarization and dilution of the thoughts that are essential to the literary purpose of this essay.
The following is the full Hippocratic Oath that was originally translated from Greek:
“I swear by Apollo, Asclepius, Hygeia, 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.
- 1. 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.
- 2. I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.
- 3. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan. Similarly I will not give a woman a pessary* to cause an abortion.
- 4. I will preserve the purity of my life and my art.
- 5. 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, specialist of this art.
- 6. 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, especially from the pleasures of love with women or men, be they free or slaves.
- 7. 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.
- 8. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men in all times; but if I swerve from it or violate it, may the reverse be my lot.
The first part of the original Hippocratic Oath that referred to the pagan gods is of course absent from modern day versions. Also different is the first paragraph that addresses “teaching medicine to the sons of my teachers.” This section refers to the perpetuation of the guild of medicine in which the sons of physicians often followed in the family tradition. Until recent times, medical schools generally gave preferential consideration to the male children of physicians. The demography of medicine has, however, changed substantially— slowly in the 1970s, but dramatically in the last twenty to thirty years, so that now the selection process for medical school is largely based on a system of meritocracy, and as a result, at least half of the typical incoming classes are women.
As the medical profession assumes more and more of a bi-gender personality, doctor/patient interactions – empathy, patience etc.- undoubtedly will change somewhat. As with all parts of the “work force,” the ramifications of this trend in terms of behavior provide fertile ground for discussion, which I happily leave to the social anthropologists and other scholars in behavioral biology. Thus, this part of the Oath no longer can be applied in the literal manner.
The section of the Oath that speaks of “never cutting for stone” (part 5) literally refers to the surgery that was done for kidney and bladder stones. This restriction was predicated on the fact that physicians of that time compromised their status in society if they did surgery, which was left to other “less serious” individuals. Surgical tasks were left largely to barbers. This is adaptable to contemporary times by interpellation and application. In effect this can be used for the restriction of surgery to those properly trained to do it.
Taking this one step further in the discussion of cancer, one of the points I have discussed in a previous blog was that in this day of very sophisticated cancer care, the multidisciplinary team of cancer specialists is the norm rather than the exception. As an integral part of that team, the surgical oncologist (i.e., the tumor surgeon) is key. Essentially, there is no place in cancer surgery for a surgeon with marginal training or one who does only occasional tumor surgery. In smaller communities, this issue creates much practical difficulty for both patients and local physicians, and when patients in smaller communities cannot or will not go to a cancer center, it can create a difficult dilemma for the local doctors. The day of ultra sub-specialization is based on this prophetic section of the Oath.
Parts 2 and 3 of the Oath concern what is referred to in the modern parlance of bioethicists as “patient beneficence,” or what might be loosely defined as that which is in a patient’s best interest. “To prescribe regimens for the good of my patients . . . and never do harm to anyone” and “never give a lethal drug” are directives clear in their intent. This is the section of the Oath most relevant to the care of today’s cancer patients. Death and dying, physician-assisted dying, physician-assisted suicide, and euthanasia are important and often contentious issues that fall within this category.
A substantive discussion of cancer care must involve these matters, and members of the cancer team should attempt to understand their own feelings regarding these sober issues. I compare this self-appraisal of the cancer doctor to the development of a psychiatrist, who is required to undergo personal therapy/analysis time as a patient with a psychiatric colleague. By undergoing this “analysis,” they hopefully better understand how their own psychic strengths and limitations intersect those of their psychiatric patients. A comparable concept and dynamic are at work in oncology.
Only after the physician has defined his or her own thoughts on death and dying should such a dialogue begin with a patient. Patients are often frightened of such a discussion and will not broach the subject. The possibility of death is at least a subliminal part of what lurks in the mind of most cancer patients, and when indicated, no one should be better able than an oncologist to delve into this. The avoidance of this uncomfortable discussion leads to misunderstandings, false assumptions and expectations, as well as a flawed approach to the patient’s illness. Ideally, the effectiveness of the physician’s communicative skills should mitigate the negativity of this sober topic. I plan to write in later blogs about this subject, and will even tie this into our discussion of the hottest topic of the day – doctor assisted suicide; i.e. euthanasia.
Part 3 of the Oath that prohibits the induction of an abortion is deleted from the modern versions, not because the American medical profession endorses or condones the practice but in order to allow a discussion of this very contentious matter. In fact, the practice, while legal, is neither prohibited nor encouraged by the current guidelines of the profession. The subject deserves targeted discussion, and will be the topic of next month’s blog.
• Pessary – a device worn in the vagina to support the uterus, but was used by ancients to induce an abortion
—Roy B. Sessions, MD, FACS
Seabrook Island, SC