The Physician's Oath: Historical Perspectives

* Address for correspondence: Rachel Hajar, F.A.C.C., Sr. Consultant Cardiologist, Director of HH Publications and Executive Coordinator for Research, Director of Non-invasive Cardiology (1981-2014), Heart Hospital, Hamad Medical Corporation, Doha, Qatar. E-mail: moc.liamg@rajahlehcar

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INTRODUCTION

Doctor–patient relationship is the heart of medicine. It provides an important framework for the conduct of patients and physicians. The encounter has been the subject of considerable discussion and analysis throughout the centuries. Concepts covered range from matters of etiquette to profound questions of philosophical and moral conduct such as abortion, euthanasia, and end-of-life issues.

As a profession, medicine has dealt with these moral issues. The physician, because of his/her special status, acts for the good of the patient. The nature of the physician's job requires moral conduct and accountability. Our concepts of ethics have been derived from religions, philosophies, and cultures. The oaths or pledges that we take or swear allegiance to act as guidelines to a moral dilemma. The doctrines in the oaths allow doctors, patients, and families to generate a treatment plan without any conflict.

There are several codes of medical ethics that can be followed. In this article, we shall consider the history and evolution of the different oaths that we as physicians are bound to follow. Many medical schools administer these pledges upon graduation.

INFORMED MEDICAL CONSENT

In modern times, informed consent is central to the practice of medicine. It covers both health care and the law. There are so many issues related to informed consent that are beyond the scope of this article to discuss.

Doctors and lawyers deal with ethical issues and their life fascinates the public so that they are often the subject of movies or TV series. Currently, I am watching on Netflix “The Good Wife,” a title that intrigues me endlessly, but never mind. I am currently in Season 4. The Good Wife–a lawyer–went to work for a law firm after her husband–a public official–was forced to resign because of a sex scandal and was put in jail because of corruption. The wife had to go back to work, in a law firm, after being a homemaker for so many years. The law firm advises and represents clients, either individuals or corporations, about their legal rights. Of the many and varied cases, the firm represented were clients involved in health care. There were doctors acting as expert witnesses or being accused of causing an adverse reaction to a drug, and clients accusing doctors of a crime such as dishonesty or even murder. It was interesting to watch lawyers trying to manipulate or finding loopholes in the law to suit their case.

Today, hospitals and doctors get a patient to sign an informed consent form, especially before a procedure, to protect the hospital and doctors from law suits. Informed consent is so fundamental and important to modern medicine that we should all be familiar with its subtleties. At the heart of informed consent is respect for a person's dignity. It requires that the patient must have adequate reasoning and be in possession of all relevant facts about the proposed treatment.

If a patient is considered unable to give informed consent, another person is generally authorized to give consent on his/her behalf, for example, parents or legal guardians. Serious ethical issues come up if the patient is considered unable to give informed consent. There are also situations where a normal patient is provided insufficient information to form a reasoned decision so that lawyers step in. Examples are cases in clinical trials in medical research but these are usually anticipated and prevented by an ethics committee or institutional review board. In our institution, there is an ethics committee or medical review board who must consent to a research project. This is for the protection of the hospital, physicians, and patients.

WHAT IS INFORMED MEDICAL CONSENT?

Respect for a person's dignity has been indoctrinated in us since medical school. It is inculcated in us. Who can forget anatomy class? The anatomy professor indoctrinates all students to respect the dignity of the dead person–the corpse has to be treated with reverence and deference. The informed consent is the zenith of such dogma.

So, what exactly is it? It is a process of communication between a clinician and a patient that results in the patient's authorization or agreement to undergo a specific medical intervention. The patient signs a document of his/her agreement to the intervention and this is usually a sufficient evidence that serves to document the legal and ethical responsibility of the clinician and also of the patient. Hence, informed consent protects both the clinician and the patient.

There are many sites on the internet giving advice to clinicians on how to improve and obtain good communication with the patient. An important resource is “Interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures” by Kinnersley and published in Cochrane Database Syst Rev. 2013.[1]

The dialog of informed consent is used in both clinical and research settings. This process of informed consent may occur within one encounter or across multiple encounters.[2]

An informed consent has seven features:

Stating risks and benefits of the suggested treatment (and comparing them to the risks and benefits of alternatives)

Eliciting the patient's preference (and thereby consent).[3] Not every detail needs to be discussed, but all details needed for a “reasonable person” to make a decision must be provided.[4] Therefore, all risks of serious complications, even if they occur very rarely, need to be stated. Less serious risks need to be specified if they occur more commonly.[4]

Historical background

Informed consent was first used in court by the late attorney Paul G. Gebhard in a 1957 medical malpractice suit, Salgo v Leland Jr. University Board of Trustees[5] (Stanford University, California, USA). This case involved a patient named Martin Salgo who awoke paralyzed after aortography, having never been informed that such a risk existed. The defense argued that the doctor had been negligent in not warning Salgo that there was a risk of paralysis. The court ruled that “failure to disclose risks and alternatives was cause for legal action on its own.” This case helped to shape the patient–doctor relationship. It enabled patients to participate in their health care. In addition, the court stipulated that “the physician must seek and secure his patient's consent before commencing an operation or other course of treatment.

Respect for the patient's right of self-determination on a particular therapy demands a standard set by law for physicians rather than one which physicians may or may not impose upon themselves.”[6]

It is unthinkable nowadays to perform a medical procedure without a signed consent by the patient. Clinicians are required to inform patients what the procedure is all about as well as explain its potential risks.

It was not always so.

The notion of informed consent is relatively recent. Traditionally, the doctor–patient relationship has always been paternalistic, that is, the physician believes that he/she has the knowledge and expertise to understand the patient's condition and therefore only he/she knows what is good or best for the patient. To achieve a cure, it was widely felt that authority must be coupled with obedience. Traditionally, doctors have been under the impression that the patient does not understand very well his/her disease or his/her physical condition. Thus, it was deemed necessary that physicians make decisions for patients. This has been the old-style thinking in medicine, but this concept has changed with the advent of informed consent. Physicians felt that any disclosure of possible difficulties might erode patient trust. However, physicians are now required to disclose to the patient what the risks and adverse effects of a contemplated procedure or treatment plan.

Do physicians abide by an ethical code?

For thousands of years, the medical profession has regulated its conduct through the Oath of Hippocrates, a body of ethical statements developed primarily for the benefit of the patient. The oath has historically guided physician's professional conduct. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to the society, to other health professionals, and to self.

Physicians are respected for their knowledge and moral standing. New physicians take the Oath of Hippocrates which was adopted by the medical profession as a guide of professional conduct through the centuries. It is still being used today in graduation ceremonies of many medical schools. The oath was written over 2500 years ago. Although the oath bears the name of Hippocrates, there is no evidence that he wrote it. It is claimed that it was written 100 years after his death. No one knows who wrote it.[7]

In 1500, a German medical school (University of Wittenberg) incorporated taking the oath for its graduating medical students. However, it was not until the 1700s, when the document was translated into English that Western medical schools began regularly incorporating the oath in convocations. In 1948, it was adopted by the World Medical Association (WMA) based in Geneva, and in 1964, it was rewritten by Louis Lasagna (the then Dean of the Tufts University School of Medicine in Boston, Massachusetts, USA) and this version was adopted by many medical schools in the USA.[8] Its principles are held sacred by doctors to this day.

In its original form, the oath requires a new physician to swear, by a number of healing Gods, to uphold specific ethical standards. It is generally believed that the famous phrase, “ first do no harm” is contained in the original Hippocratic Oath but it was not, and it is believed that the motto is found elsewhere in Hippocrates' writings which states that “The physician must…have two special objects in view with regard to disease, namely to do good or to do no harm.”[8]

The original pledge (classical version) promised to “abstain from whatever is deleterious and mischievous,” to “give no deadly medicine to any one if asked,” and to “abstain from every voluntary act of mischief and corruption.”[8]

Physicians breathed the oath in their daily life: Treat the sick to the best of one's ability, preserve patient privacy, teach one's knowledge of medicine to the next generation, etc. These are lofty ideals. The oath is committed to doing what was best for the patient and ethically prohibits abortion, euthanasia (“administering poison”), and sexual relation with patients. These prohibitions make it clear that the physician is surrounded with certain moral standards which take precedence over the individual physician's judgment.[9]

There are two versions of the oath – classical and modern. These are reproduced here for comparison. The classical version of the oath is outdated. Most graduating medical school students swear to a modern version.

Hippocratic oath

The reproduction shown in Table 1 [10]and Table 2 is a translation from the Greek by Ludwig Edelstein, from The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943. It appears in many websites.

Table 1

The classical version of the Hippocratic Oath