Hippocrates is considered to be the father of medicine. Before being taught medicine, his disciples were made to swear an oath to the Gods of healing of Greek pantheon: Apollo, Asclepius, Hygeia, and Panacea. This was to help them understand the gravity of their situation and what is expected from their conduct as healers. The oath has been in existence from 400 BC. Hippocrates was a philosopher as much as a physician. He considered healing to be a scientific art. The oath sets the standards of conduct at a time when healers were considered near divine and no laws or litigations existed. The oath became universal only toward the early 19th century. Before that, different cultures had their own oaths. In India, Charaka Samhita had a physician oath. In it, physicians can refuse to treat people who were not favored by the king. This shows that oaths were a product of the sociocultural factors of the times they were created. It seems difficult to follow the same oath without keeping in touch with changing times.
OATH VS BIOETHICS
If the Hippocratic oath is seen through the prism of changing times, swearing to ancient Greek Gods seems a little redundant in this multiethnic, multicultural, and pluralistic world. In the time of Hippocrates, women were not allowed to become physicians. It has long since been a matter of contention for many female physicians to take an oath which was meant exclusively for male physicians. Medical education was just imparted to a few selected disciples, free of cost, in that time. This seems impossible in modern times, where the government may not be able to continue medical education for thousands of graduates without even a nominal fee structure. While the oath prohibits abortion and euthanasia, abortion up to 20 weeks is legal according to the Medical Termination of Pregnancy Act and euthanasia is legal in selected countries. The oath has not taken into consideration the vegetative states, unnecessary suffering, pain, and the rights of the patients to live with dignity. These issues probably were nonexistent in ancient Greece. These issues show that the original oath has a limited role in modern sociocultural and bioethical complexities.
The oath asks the physician to treat the patient according to his best ability and judgment. It gives utmost importance to beneficence. Patient autonomy and justice, which are now considered the cornerstones of bioethical principles, have not been discussed in the oath. This renders the oath paternalistic. In the modern history, particularly in the Nazi era, scientists of the Schutzstaffel conducted experiments without informed consent. These doctors acted “according to the best of their ability and judgement.” This led to a review of the oath following Second World War during the Nuremberg Trial, and new ethical principles for research, called the Nuremberg code, were proposed, as the court recognized the limitations of the Hippocratic oath in the modern era bioethics.
When the oath was formulated, there existed only a tripartite relationship in medicine: between the patient, physician, and illness. This harmony was disrupted by the advent of health insurance, malpractice issues, technology, and pharmaceutical companies. The recent increase in government regulation, the proliferation of the third-payer system, and the democratization of medical knowledge all place pressures on physicians that are new to the last 40 years; their ethical implications are not satisfactorily addressed by the modern Hippocratic oath. Doctors may not be able to prescribe the best possible treatment for their patients due to economic restraints. Universal healthcare coverage is a state responsibility only in a few developed countries. The intrusion of health insurance providers and corporate hospitals affect the physician treatment paradigm, thus affecting the physicians’ autonomy in treatment.
The treatment strategy is also affected by patients’ choices. Due to the advent of Google and the availability of medical research articles in the public forum on the Internet, the patient has become a voracious consumer of medical data. Patients consult doctors with semi-literate opinions regarding diagnosis and treatment options. The physician has to act accordingly, keeping not only beneficence in mind but also patient autonomy or risk of suffering legal consequences.
Physicians are no more healers, and healing is no longer an art, but it is just a service rendered. Medicine, a once noble and holy profession, has been defined as “services rendered” under the Consumer Protection Act. Physicians are vulnerable to multiple civil litigations. The image of the Hippocratic gentleman is no more and has been replaced by that of a harassed general practitioner.
The oath is also seen to promote physician burnout. A recent survey showed that at least one-third of the physicians polled (i.e., 34% of 2600 doctors), agreed that the oath promotes burnout. The oath, which advocates putting patients’ interests first, always leads to a denial of personal and professional limitations.
When its relevance in modern psychiatry is assessed, the oath seems to be in conflict with the existing laws. The oath assures blanket confidentiality. In the case of child sexual abuse, where the child and the family do not want to divulge information, if the psychiatrists follow the letter of the oath and keep it a secret, they would find themselves at the risk of being imprisoned. According to the Protection of Children against Sexual Offences Act, information regarding child sexual abuse should be immediately informed to respective authorities, and withholding such information may result in fine and imprisonment up to 6 months. Administering covert medication, keeping in mind the patient's beneficence, might assuage the doctor's conscience but leaves him/her vulnerable to litigations. It is considered overriding patient's autonomy and is against the new Mental Healthcare Act. The doctor might agree to provide teleconsultations for minor issues, keeping in mind the patient's beneficence. This might be moral and ethical, but the law advocates against it.
The debate regarding the relevance of the oath, and whether to follow the oath or the law, is nothing new. Its relevance in modern medicine has long since been a topic of debate, with many arguments for both sides. In 1973, the US Supreme Court rejected the oath as a guide to medical ethics and practice by stating that the oath is incapable of covering the latest developments and methods of medical practice and research. Veatch, a prominent ethicist, claimed that the oath promotes traditional paternalistic values. Despite this, studies have shown that 62 of 122 medical schools in the United States administered the Hippocratic oath or a modified version of it. Several countries have come up with their own version of the oath suitable to their cultural needs. The Hippocrates oath is used out of context by lay people and mass media to emphasise that “patients interests are above everything else to a doctor”.
The oath is not legally binding. It is more of an ethical signpost. However when doctors were protesting violence against doctors, the high court reprimanded the doctors that they were neglecting their duties which was akin to criminal negligence, quoting the Hippocrates oath in its judgement. It is probably this level of importance and universality which confuses young physicians, about to take critical decisions, on whether to uphold the oath or the law.
In regard to ethics and morals, Karl Menninger said: “When in doubt, be human.” But, when facts change, our opinions should change. In this era of litigations, it is best to remember: “When in doubt, be rational and follow the law.” Ethical violations may incur minor punishments or fees, but violating the law will lead to imprisonment and an indelible mark on our careers. People who choose medicine usually have a strong sense of ethics and a higher purpose. Very few people take medicine to earn money. For medical students who arrive at the college with a strong sense of ethical values, the oath is redundant. For those who lack these values, the oath is just an exercise in hypocrisy.
There is no arguing the fact that Hippocratic oath embodies the principles of beneficence, gratitude, confidentiality, and humility. In a recent study, 59% of the physicians polled said that the oath was very meaningful to them. It imbued in them a sense of brotherhood, gratitude, and pride about their chosen profession. This does not alter the fact that the oath lacks the nuances of modern bioethics and is in direct contradiction of the existing laws at times. It is certainly difficult to give up on an idea which has been acculturated into the branch of medicine for nearly 2000 years. But, nothing is permanent except change. Hence, it is time the medical fraternity took stock of the situation. Medicine will never give up on the spirit of the oath. No physician is suddenly going to care less about a patient's benefit because they are no longer taking an oath. Physicians should keep in mind that any oath needs constant review and re-evaluation keeping with the constant changes of the society. We should acknowledge that upholding the oath does not protect us from any legal difficulties. We should follow the existing laws until laws and ethics are no longer at loggerheads with each other.
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