An excerpt from chapter 8, Is there a Medical Ethic?

: The Hippocratic Oath and the Sources of Ethical Medicine, of Towards a More Natural Science, by Leon R. Kass, M.D. Why the Hippocratic Oath Of the numerous oaths and codes articulating principles of medical practice, the Hippocratic Oath is both the oldest and the most well known. Its authorship is unknown, and also its age scholarly proposals for its source ranging anywhere from the sixth century B.C. to the first century A.D. For many centuries the Oath was taken as the very model of medical conduct; it informed the attitude of generations of physicians. Indeed, until the present generation, it was sworn to by students of many if not most of our nations medical schools on the occasion of completing their studies and entering their chosen profession. Yet its very antiquity is now increasingly a reason for its declining importance among us. Given the contemporary historicist prejudice, that is, given our belief that truths are simply relative to time-and-culture, and therefore, that old documents bespeak and reflect only old cultures and beliefs, we increasingly regard the Oath merely historically, that is to say, not seriously. Not only our ideology, but also our changed circumstances contribute to our not taking the Oath seriously. Medicine has changed tremendously in our century. The institutions in which it is taught and practiced, the tools of diagnosis, the modes of treatment, even the principles for understanding the basic mechanisms of diseaseall these would overwhelmingly surprise a nineteenth-century physician, alone poor Hippocrates. To these changes in medical practice must be added changes in mores and beliefs in the community at large. For all these reasons, the Hippocratic Oath might seem to be an unlikely source of useful wisdom. Yet even if our circumstances are inhospitable to the Oaths teachings, we should be wary of dismissing a document held by thoughtful men over many centuries to the embodiment of medical wisdom. With this as my defense for doing so, I turn to the Oath itself. I hope to show that it is internally coherent and comprehensive in its scope, that its various parts flow naturally from a profound understanding of what medicine is and must essentially be, and that it therefore stands as an expression of the medical ethic in which the medical and ethical are as hard to separate as the concave and the convex. [Kass proceeds to divide the Oath into eight parts: the oath proper (paragraph one), rules for conduct with respect to teachers and students (paragraph two), conduct with respect to patients and their households (paragraphs three to seven), and a prayer (paragraph eight). The translation Kass cites of the Oath itself is reprinted on the last page.]

The new Principles of Ethics recently adopted by the American Medical Association [last page] do in fact omit several of these subjects and add others. They contain no statement of the end of medicine, saying only that a physician shall be dedicated to providing competent medical service, nowhere defining or delimiting the goal being served. Moreover, the AMA Principles speak neither to limits on technique nor to duties to teachers or students. Instead, the new AMA Principles deal with the physician relations with society: respect for law, coupled with a responsibility to seek changes in laws bad for patients; respect for rights within constraints of law; and social responsibility of a physician to participate in activities contributing to an improved community. I grant that these subjects are important, and despite my serious reservations about the particulars, I have no quarrel with appending principles on the subject of relations with society to a statement of professional principle. But they are at most peripheral. They are in themselves neither essentially medical nor essential to medicine. Moreover, those in AMA Principles are peculiar to the relation of medicine to a modern, liberal, legalisticsociety. They would not accurately describe, much less constitute, medicine in traditional or premodern societies. However important, such politically determined principles must be foreign to medicine, if medicine as medicine is essentially the same, independent of regime. To make more plausible the suggestion that the Hippocratic Oath bespeaks the universal core of medicine, we must try to show not only that the subjects treated in the Oath exhaust the pertinent domain, but also that the content of each provision is not only defensible, but even somehow essential to, or constitutive of, the nature and meaning of the healing art. The Content of the Oath: The Treatment Paragraphs Let us begin, not illogically, with the passage that states the physicians main business: I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice. This states unequivocally that it is sick individuals, not society or mankind or some abstract idea, who are the beneficiaries of the physicians activity. Moreover, the sick qualify for his services because they are sick, not because they have claims, desires, wishes, demands, or rights. The healer works with and for those who need to be healed, those who are not whole. I mean to emphasize the Hippocratic Oaths tacit assertion that medicine is a cooperative rather than a transforming art, and that the physician is but an assistant to nature working within, the body having its own powerful tendencies toward healing itself (e.g., wound healing and other regenerative activities, or the rejection of foreign bodies and the immune response). Though our current technological prowess tends to make us forget these matters, does not the Oath speak truly? The inherent tendencies toward wholeness are much more precarious in human beings than in our animal friends and relations. Our dietary habits are not given by instinct but by convention, habit, and choice. Man is the animal most likely to make himself sick, in the very act whose purpose is to nourish and sustain. Sometimes we eat ourselves sick through ignorance of what is good for us, sometimes through incontinence and lack of self-restraint in the face of knowing better. In both these ways, we do ourselves unwitting harm and even injustice; that is, we treat

ourselves unfittingly and worse than we deserve. The physician, according the Oath, is not only one who brings a corrective diet to the already sick. He is also the one who seeks to prevent the ignorant and the self-indulgent from harming themselves. He has the knowledge needed to direct and inform the otherwise dangerously open and uninformed human appetites. It may at first seem strange to think that we human beings need such knowledgeable outsiders or that we do not know what is good for us, all the more so on the premise that our body is the primary healer and the doctor but the physicians assistant. But a body possessed of the power of reason, and hence also of choice, is a body whose possessor may lead it astray, owing to ignorance or wayward impulse. The physician, the ally of our body and of those inner powers working toward our own good, supplies needed knowledge, advice, and exhortation. He seeks to keep us from self-harm and injustice. The Oaths little paragraph on dietetics, properly unpacked, reveals the core of medicine. The mention of the injustice that a person can do to himself becomes the link to the next provision, the one that forswears giving deadly drugs or abortifacients. This provision, I have already suggested, wisely implies that the true physician will not use his available means indiscriminately, to promote alien ends. The physician is no mere technician, selling his services on demand. But what is a proper and what an alien end? If the goal is to benefit the sick, what are the limits of benefit? The present passage shows us how to think about this, for the limits on the use of technique are derived from an understanding of the essence of the healing activity.

I swear by Apollo Physician and Asclepios and Hygeia and Panacea and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant: To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else. I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice. I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art. I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work. Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves. What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about. If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

Preamble The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility to patients first and foremost, as well as to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician. Principles of medical ethics A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. A physician shall, while caring for a patient, regard responsibility to the patient as paramount. A physician shall support access to medical care for all people.