This longish thoughtful response to my column on the Hippocratic Oath is worth posting on its own. This physician believes the Oath is a “living document,” that must change with the times. Well, doctors sure don’t swear by Apollo anymore, but I think this idea of a living Oath means that it can be deconstructed, which is precisely what is happening. In any event, here is the letter and my brief further response will follow:
“The oath is much more like a secret handshake than it is like the constitution of the United States. We look to it with reverence in that it reminds us that our duty to our patients is a sacred one. But it is not really possible to take it literally, unless you cherry pick. The oath forbids surgery and abortion. It enjoins us to teach our art to the sons of other practitioners (at no charge. Whatever you think of these strictures, you have to agree that they form no part of modern medical practice. Furthermore, the maxim “first do no harm” has a nice ring, but is not nearly as applicable to medicine today as the equally ancient and revered “you can’t make an omelet without breaking a few eggs”. We do a lot of harm with our surgery and chemotherapy. We do much more good, of course. The notion of avoiding all harm takes the life out of any possible risk/benefit approach to treatment.
I think that it is more realistic to view medical ethics as common law than as a compendium of defined, easily stated principles. We mostly learn it at the bedside, from our peers. Usually the lessons are dministered in medical school and residency by teachers and residents who are actually engaged in treating patients. It is absorbed through the skin, not memorized. Remarkably, most doctors end up with pretty much the same notions of what constitutes medical right and wrong. But the rules are not written in stone, and can be changed by societal pressures – not necessarily for the better. The notion that any form of euthanasia is unacceptable is still held by most of my colleagues, I think. It could change – it has, in some places. The idea that a doctor’s loyalty is to his patient before anything (no good stewards of society’s resources)is still almost universal among the people that I deal with.
The canon of medical ethics is a living “document” in exactly the way that the American constitution is not. The Hippocratic Oath is not our constitution.”
It seems to me that the Oath should be neither akin to a secret handshake or a viewed as a constitution. But it should be embraced as establishing principles that all doctors are honor-bound to follow, summarized as “always put your patient first” (with a few examples given). As to the surgery issue, my understanding is that the doctors practicing under the Hippocratic tradition used different techniques and thus foreswore surgery (imagine what surgery would mean then before anesthesia and an understanding of microbiology), but I was interested to note that Hippocratic physicians were to refer patients wanting surger to a different type of doctor qualified to perform it.
Viewing it as a “living document” grants a license to undermine it and even change its meaning 180 degrees. Moreover, from what I can tell, the current versions of the Oath are destroying it by turning it more into pabulum than core principles.