Oaths, charters, and our professional ethos
A re-examination of the Hippocratic Oath leads to questions of ethics, professionalism, and a more modern code that physicians can follow.
Have you looked at the Hippocratic Oath recently? I had not actually read it since my medical school graduation 32 years ago, and I must admit it is quite dated in its precepts. Yet Hippocrates' words are frequently held up as the standard by which physicians should be behaving. There is indirect reference to principles of beneficence, the duty to promote good and act in the best interest of the patient, and nonmaleficence, the duty to do no harm to the patient. But those statements are not explicitly present in that oath.
It seems every week there is another sensational story about fraud or wrongdoing in our health care system, whether it be corporate entities like insurance or pharmaceutical companies or individual doctors. With these news stories, is it any wonder why a recent Gallup poll found that only 65% of Americans say medical doctors' honesty and ethical standards are “very high or high”? (It is 85% for nurses.)
Are these poll statistics consistent with our real-life experiences interacting with our own patients? Do our patients read news stories about misbehavior, conflicts of interest, and even fraud in health care and not trust us, or other parts of “the system,” as a result? Clearly how they sometimes can view the profession of medicine distinctly differs from their views of their own personal physicians.
What really determines how we behave with our patients? We typically enter medicine because we are interested in helping people. As internal medicine specialists, whether in primary care general internal medicine or as subspecialists managing chronic diseases, we enjoy the privilege of long-term close relationships with patients, helping them navigate illness and life stresses and frequently sharing in their joys as well. These relationships are intensely gratifying and frequently the highlight of our busy days.
As we scurry between office visits or hospital rooms, do we ever ask ourselves, “What would Hippocrates do?” Of course not. The very nature of our physician-patient relationship with its inherent trust determines our responsibilities and subsequent behaviors in the context of the vulnerability of illness. We don't think about the Hippocratic Oath or any “physician social contract” in most of our work. It is the sacrosanct physician-patient relationship that drives us.
Principles of the Hippocratic Oath were transitioned into a more modern world with the AMA's Code of Ethics in 1847. The medical profession was in a very different cultural place than now, trying to evolve from a guild, and there was a logic to using a social contract framework at that time. Such a contract implied certain societal expectations (caring and compassionate treatment from doctors, promotion of the public good, prioritization of the patient and not physician self-interest, medicine as a profession setting adequate standards for education, training, and practice) in return for medicine's expectations (autonomy to self-regulate and to act in the best interests of patients). The code made reference to “duties,” but we do not explicitly think about those duties as we deliver patient care.
Our role as physicians has many philosophical and practical considerations, and ACP entered this area with the first edition of the ACP Ethics Manual in 1984. As the complexity of our health care systems and interactions among physicians, individual patients, and society have evolved, updates brought us to the most recent edition of the ACP Ethics Manual, the seventh, released in 2019. This excellent document warrants some review for those who haven't yet done so. Many of these issues are frequently framed within “professionalism.”
In 2002, the ACP Foundation, in partnership with the ABIM Foundation and the European Federation of Internal Medicine, released “Medical Professionalism in the New Millennium: A Physician Charter.” This succinct document is as pertinent now as it was almost 20 years ago. Have you read it, or even heard of it? Starting with the three fundamental principles—primacy of patient welfare, patient autonomy, and social justice—the Physician Charter outlines 10 professional responsibilities, all categorized as “commitments.”
These various oaths, codes, and charters are not foremost in our mind while seeing patients. But they are important in helping to frame the implicit social contract that we do indeed have. They are good educational tools for those entering our profession, and we should think of them when we reflect on what we do and why in an ever-challenging health care world.
Social contract theory is based on our social relationships, which in our profession's case are with our patients individually and with our society. We are given certain unique responsibilities and privileges, such as prescribing medications that are potentially dangerous and even illegal for people to have in their possession improperly and providing “excuses” for our patients to miss work, avoid jury duty, and obtain special right to use disability-reserved parking spaces, all of which carry legitimacy once finalized with our magical signatures.
In return, society expects us to act responsibly and to provide medical care to patients competently, keeping the patient foremost in our concern. Being part of the medical profession brings this social contract. It is assumed we will abide by the contract and simultaneously provide the best care to our patients while also recognizing those areas where we have a responsibility to society at large to be stewards of “doing the right thing.” The World Medical Association's Declaration of Geneva is considered to be a modernized version of the Hippocratic Oath, first adopted in 1948 and most recently amended in 2017. It outlines well foundational principles that we live and breathe.
Yet our patients do not trust us merely because we have taken the Hippocratic Oath or Declaration of Geneva “Physician's Pledge” at medical school graduation or because they understand this implicit social contract. It is the patient-physician relationship that is intensely personal and is central to a patient's ability to confide in a physician about the deepest and most intimate feelings or concerns. The emotional involvement and gratification from those relationships are the greatest parts of what we do. It's not an oath or a code that makes us behave in “professional” ways; it is our desire to aid and comfort a fellow person who comes to us vulnerable and in need of our help. Sure, the oaths and codes and charters outline what professional behavior should be and serve as our necessary guardrails in areas of ethical uncertainty, but those documents are not the essence of what we do.
The sacrosanct physician-patient relationship contains its own inherent ethos. In today's technology-driven world, relationships do not provide the rapid informational analysis of evolving artificial intelligence. But relationships offer the foundation in which to provide comfort, understand uncertainty, and hopefully experience healing where possible.
As Sir William Osler said, “The good physician treats the disease; the great physician treats the patient who has the disease.” Our patients want to be treated as people, not as mere collections of physiologic and pathologic phenomena. The essence of what physicians do combines knowledge and technical expertise with the human touch of caring and compassion in a relationship.