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The mandate that healers act in the best interests of their patients was first codified in Mesopotamia in 1754 BC and enacted by Hammurabi (1810 BC – 1750 BC), the sixth Babylonian king. The Code of Hammurabi included sliding scale prices for treatment based on the patient’s wealth and punishment for maiming or causing death, ranging from a fine (for slaves) to losing one’s fingers or hands (for rich patients). The Hammurabian mechanics of medical morality were extended a millennium later by the Hippocratic Oath, which added an ethical compass by which physicians are meant to practice. Reciting the Oath* en masse is a long-standing tradition for students upon graduation from medical school, which puts newly minted doctors on notice that more is expected of them than the average Joe.
Hippocrates of Kos
*Or a version thereof. Whilst the Oath has been attributed to Hippocrates of Kos (460-370 BC, see bust), the Father of Medicine, it is more likely an amalgam of related works, linked by Ludwig Edelstein (1902-1965), a classic Greek scholar, to the Pythagoreans.
The original Oath is a quaint anachronism with references to the Greek gods, maintaining a monastic lifestyle, forbidding abortions, and referring patients with (kidney) stones to surgeons. In 1964, the academic dean at the Tufts School of Medicine, Louis Lasagna, rewrote the Oath to reflect modern practice. The modified Oath is the version recited by most American medical students upon graduation. All of the Oaths—the Oath of Maimonides, Osteopathic Oath, Declaration of Geneva, Good Medical Practice (from the General Medical Council in the UK), whether recited or written and signed—share a common thread of ethics, trustworthiness and professionalism*.
*These same principles are expected of scientists, for which a parallel Hippocratic Oath for Scientists was proposed by Nobelist Joseph Rotblat.
Several of the core principles of Hippocratic medical ethics have been questioned or frankly discarded, including the prohibition of abortion and assisted death in the terminally ill; the circumventing of consent to medicate psychotic patients who are dangerous to themselves and others; the prohibition of romantic relationships with former and current* patients; and the breaching of patient confidentiality when the physician–especially a psychiatrist, has the slightest soupçon of suspicion that a patient plans dastardly deeds, a response to the decision in Tarasoff v Regents of the University of California.
Cynics will argue that once a group such as physicians “adjust” their ethics, they’re on the slippery slope and will be more willing in the future to compromise previously sacrosanct values. One needn’t look too far to see examples of healers turned to the proverbial dark side:
• Farid Fata–a US oncologist sentenced to 45 years behind bars for Medicare fraud, money laundering and, most outrageously, treating hundreds of patients for cancer they didn’t have.
• (Sir) Roy Meadow–a UK paediatrician whose testimonies in multiple trials in High Court led to the false conviction and imprisonment of several mothers for allegedly killing their children, one of whom later drank herself to death.
• Ian Paterson–a UK breast surgeon sentenced to 20 years in HM Prisons for mutilating patients, breach of trust and abuse of power.
• Carmen Puliafito–dean of the University of Southern California School of Medicine, who made a name for himself by smoking methamphetamine, consorting with addicts and criminals and frequenting prostitutes.
• Harold Shipman–a GP in the UK who topped over 200 of his patients for money.
• Andrew Wakefield–a UK physician struck from the GMC register for fraudulent research that falsely linked MMR vaccines to autism, which led to a marked drop in MMR vaccinations and an increase in measles, mumps and rubella in unvaccinated children.
The above physicians’ breaches were egregious enough to garner the wrong kind of headlines. The rhetorical question is, are these bad actors the tip of the iceberg or just statistical outliers?
Fortunately, if public opinion matters, then most people trust health professionals far more than lawyers, law makers and used car salesmen. According to the latest Gallup poll, 60% to 84% of those surveyed rate the honesty and ethics of health professionals (nurses, pharmacists, medical doctors, and dentists, in descending order) as very high or high. As physicians, we must remain vigilant and not compromise our values and squander the trust placed in us by our patients and society. If we don’t like the headlines that could result from one or more misstep or series of bad choices ranging from over-billing, and unbundling various procedures to shoplifting and physical relationships with vulnerable patients…perhaps we shouldn’t do them.
We would all do well to remember the words of Edmund D Pelligrino in his 1989 essay on ethics in the professions, A virtuous professional, then, is one who can be expected with reasonable certainty to exhibit as one of his traits of character, altruistic beneficence construed as effacement of self-interest. It is the medical professionals’ generic ability to efface self-interest for the good of our patients that distinguishes us from other professionals who are long on words but short on deeds.
Edmund D. Pellegrino, Character, Virtue and Self-Interest in the Ethics of the Professions, 5 J. Contemp. Health L. & Pol’y 53 (1989). Available at: http://scholarship.law.edu/jchlp/vol5/iss1/7