IN DEFENSE OF THE
OATH
There can be a
reliable professional code, although we have none now.
Nathan Pollack, MD
OATH
"I
swear by Apollo Physician, by Asclepius, by Health, by Panacea and by all the
gods and goddesses, making them my witnesses, that I will carry out, according
to my ability and judgment, this oath and this indenture. To hold my teacher
in this art equal to my own parents; to make him partner in my livelihood; when
he is in need of money to share mine with him; to consider his family as my own
brothers, and to teach them this art, if they want to learn it, without fee or
indenture; to impart precept, oral instruction, and all other instruction to my
own sons, the sons of my teacher, and to indentured pupils who have taken the
physician's oath, but to nobody else. I will use treatment to help the sick
according to my ability and judgment, but never with a view to injury and wrongdoing.
Neither will I administer a poison to anybody when asked to do so, nor will I
suggest such a course. Similarly I will not give to a woman a pessary to cause
abortion. But I will keep pure and holy both my life and my art. I will not use
the knife, not even, verily, on sufferers from stone, but I will give place to
such as are are craftsmen therein. Into whatsoever houses I enter, I will enter
to help the sick, and I will abstain from all intentional wrong-doing and harm,
especially from abusing the bodies of man or woman, bond or free. And
whatsoever I shall see or hear in the course of my profession, as well as
outside my profession in my intercourse with men, if it be what should not be
published abroad, I will never divulge, holding such things to be holy secrets.
Now if I carry out this oath, and break it not, may I gain for ever reputation
among all men for my life and for my art; but if I transgress it and forswear
myself, may the opposite befall me. "
Trioi latroi
I. The
Procession of the Freshmen
Where are the living?
Where the life to which
they've gone?
Under the city?
Beyond the traffic, beneath
the grass?
No,
in vats
gregariously waiting for the coming fall.
Where are the deadly? They are coming
in linen labcoats,
stethoscopes aswinging,
to dissociate the living to
learn to treat the dead.
II. A Professional
Recession
This is the beginning of the
middle age of living.
I shall rediscover and resurrect
my youth.
Knowledge has no meaning.
Data flip, and flee me.
I shall give up healing,
abandon games of curing, relinquish
operations,
eschew
pat diagnoses, cease to write prescriptions,
and
learn to love the living.
Finally I worship the beauty
of the living.
I can aid the dying.
I can ease disease.
I shall be the living.
Maybe life
will free me
from the deathly bondage—
the
cold pedantic bondage, the outrage and the carnage
physicians
come to die in.
III. Ego
Hippocrates
at Cos
a fertile island
I learned to worship Aphrodite
and Asklepios
in the wholest holy way
learning flux of humors
interflux of vapors
chiasmata of physis
the nature of the whole
I have known you
man by the wall
and I have known your family
All night we have watched
you in fever
calmly trusting in the gods
in human love and wisdom
by day I have walked
through groves of olives
verdant vineyards
in dialogue with students
(sons of Asklepios)
in dialogue with teachers
(my fathers and their
fathers)
Cos is a silkmoth
perpetually emerging from
her chrysalic
medicine emerging into
daylight
into light and life and life.
***
There seem a variety of
interpretations of the clinical trust or contract. Why should it be so difficult for us to
describe the basic tasks of the clinician? Clinical work seems always and everywhere to
have been essential to human beings as individuals and societies , and despite
its many forms has basically stayed the same. But now and again we question and argue, with
no idea what direction to go.
Some argue that the forms and
functions of clinical work are not so clearly defined, that they are changing,
that in fact they must be changed drastically to meet overwhelming unmet
needs. It is so. Forms and functions
need greatly to change and grow. But
basic principles are unchanged (though our recognition of them is dim, and requires
constant refreshing).
The unchanging basic principles
are what tell us what it is to be a patient (which we are fairly willing to
acknowledge) , what it is to be a clinician (which we are reluctant to
scrutinize), and what the relationship between patient and clinician should be.
The clinician is a clinician only in
relation to the patient, but the patient is who he is without the clinician. (He is the sufferer, the afflicted, the one
who has need of care.) Let us make our
definitions in the simplest and most effective way. Given the person and needs of the patient, the
tasks of the clinician and the nature of the relationship are essentially
determined.
Ideally the patient is motivated
by self-interest directed toward his own health. But (as I have shown in "To Be a
Patient") when any of us becomes a patient gradually or abruptly, he or
she becomes significantly irrational and dependent. It is only if the process of clinical care
goes well that the patient is enabled to judge and act better in her or his own
behalf.
The clinician is who she or he is
only in relation to the patient. Perhaps
that one could have an independent existence as an anthropologist or biologist
or such, but then not as a clinician, merely interested in humans as one might
be in bugs. As an "objective"
scientist she or he could not care essentially about this patient's welfare as
a person—could not be "klinikos,"
the one who comes to the sufferer at the bedside.
The clinical researcher is also
no "coldly objective scientist," can no more afford to sever himself
apatheti-cally from the patient than he would from humanity itself. He must possess in his reservoir somewhere
care for all patients, and especially for the real ones he meets.
The student, perhaps yet afraid
to take direct or total responsibility toward this patient, well might consider
some future patient to be cared for by his yet-to-be-competent self. He can share in his teacher's loyalty to the
patient (and the teacher reciprocally can share in the student’s).
The teacher can show his own
skill and loyalty to the student, and thereby reconfirm it in himself. As he nurtures the student and other clinical
staff they will be better able to care for the patient. (Too often the "attending" physician
attends neither patient nor student nor other professional staff, is as an
absentee landlord whose name is stamped on documents.)
That we daily complain of callousness
from clinicians shows how sensitive we are as patients, how much we seek
reassuring attention. Clinicians often
become sensitive to clinical callousness because they know how uneconomical a
waste comes from distracting the patient with apparent lack of attention or concern.
Anyone who is a patient is easily
overpowered, vulnerable to hurt from disease and persons; the last thing he
needs is inattention or abuse from clinicians.
The patient needs an advocate in
the clinician. It is not paternalism to care for someone who needs care any
more than it is necessary for a parent to be patronizing to her or his child. Similar skills are required, similar
awareness, in being clinician and in being parent. To have more power than a relatively powerless
other can be a great help if it is clear you are on his side. To threaten, even inadvertently, to use it
against him will likely engender terror, evasion and passive-aggressive
resistance.
I have asserted that the
universal solvent for all apparent medical ethical dilemmas is the enhancement
of the autonomy of the patient (see "Medical Ethics--There are No
Dilemmas”). It is to be accomplished
especially (but not only) by skillful treatment of whatever disables the
patient, which must be based on accurate comprehensive assessment of the real
situation of the patient. One factor is
universally disabling to each patient--the predicament itself of being a
patient, no matter how temporary or mild the disease may seem.
Sensitivity to the patient may
depend on identification with the patient, but over-identification will only
enhance the patient's dependence. (Another
fine distinction! See "The Accomplished
Clinician" for more detail.)
It is clear no code of procedures
or policies can solve the multimyriad of clinical dilemmas. It is only by apprehending
basic principles we can have a way to discern what to do in any case, and these
principles most easily can be formulated in terms of simple clinical
relationships.
Doctor Pellegrino avers that
"the great deficiency of the Hippocratic Oath is its lack of attention to
the principle of autonomy." (1) I
can read the Oath with a measure of imagination, and in the context of the true
Hippocratic corpus I can read enhancement of autonomy. The value of the Oath today, even though it is
a late and poorly related extraction of true Hippocratic writings, is in its
serving to remind us there can be a code, that there need not be chaos or
ethical anarchy in our professions.
What we do properly cannot be
defined by legal limits for which there are formal punishments, nor by market
forces which assume what is valuable will be sought and bought. What we properly do must be contained within
basic principles of defined relationships and responsibilities which transcend
the meager legal requirements to do no punishable harm, or the hypothetical
economic proposition to do what the patient demands. There are more reliable roots, and they do
reside in the soul of the clinician. Clinical behavior without altruism is
dangerous and unreliable. (See Pellegrino and Thomasma, "Profession"
(2).)
The fullness with which the Oath
can be read implies deep feeling for the patient, the society, medical traditions,
and for the divine power which underlies nature and healing. (3) It is fullness and deep feeling for basic principles
we need in a code, to meet the potential emptiness, pain and despair any
patient’s dilemma may invoke in us.
Consider some Hippocratic
statements and some commentaries on the Hippocratic ethic and tradition:
1. Primum non nocere
Medical teachers have used this
phrase longer than I can remember, giving the impression it is directly
Hippocratic. (It is not, if for no other
reason than it is Latin, a language in which Hippocrates never wrote. English-speaking professors ought not parade
their ignorance of tongues.)
2. As to diseases, make a habit of two things—to help, or at least to
do no harm (wfelein h mh blaptein).
Epidemics I, XI x.i (4)
This seems the valid source,
Epidemics being the valid Hippocratic work. The "constitutions" (specifically
historical ecologic descriptions) and the "cases" (unreconstructed
concrete observations) convince us of the honesty of the work. It Is the work of a clinician, not an
abstractor, based on the realities of discrete human experience.
3. I will use treatment to help the sick according to my ability and
judgement, but never with a view to injury and wrong-doing.
The Oath, Lines 16-18
This similar thought (even though
the Oath was not Hippocrates' own writing) is central to any strength of the
Oath. It describes the clinician's basic
relationship to each patient. There may
be other more ancient similar locutions, which only enhances the validity of
this basic principle. It is important
that the Oath specifies some other important relationships, whether or not we
agree with their details: relationship
of physician with teacher, student, offspring, parents, teacher's children,
and the gods. The crucial weakness is
not the prohibition of procedures, but the encouragement of withholding
information ("to impart precept... to nobody else" including the
patient (5)).
4. The course I recommend is to pay attention to the whole of the
medical art. Indeed, all acts that are
good or correct should be in all cases well or correctly performed; if they
ought to be done quickly, they should be done quickly, if neatly, neatly, if painlessly,
they should be managed with the minimum of pain; and all such acts ought to be
performed excellently, in a manner better than that of one's own fellows.
Regimen in Acute Diseases, IV (6)
This is good because it describes
action, goes beyond the mere avoidance of doing harm. Crucial is the exhortation to attend "the
whole of the medical art."
5. “…In the true Hippocratic
writing, Hippocrates does not swear, either by Apollo or anyone else. Least of
all would he have sworn by Asklepios and the latter's suppositious daughters,
Hygeia and Panacea. Hippocrates' doctrine
of rational medicine was the opposite of the Asklepian rites of magic and
dream-ritual, for which he had nothing but contempt... Similarly, all the
strong provisions in the Oath against surgery, therapeutic abortion, and so
forth are wholly in accord with Pythagorean doctrine, and wholly at variance
with the Hippocratic doctrine.
Dickinson W. Richards, M.D. "Hippocrates and History: The Arrogance of Humanism" (7)
Even though I grant his
criticisms, especially of swearing by minor gods, I can read into the Oath the
following valid principles: that the
relationship with the patient intends good and avoids harm, that some drastic
procedures are to be avoided, and that there is a special relationship also to
teachers, students and connected others.
6. Almighty God, Thou hast created the human body
with infinite wisdom...Thou hast blest Thine earth, Thy rivers and Thy
mountains with healing substances; they enable Thy creatures to alleviate their
sufferings and to heal their illnesses. Thou hast endowed man with the wisdom to
relieve the sufferings of his brother, to recognize his disorders, to extract
the healing substances, to discover their powers and to prepare and to apply
them to suit every ill. In Thine Eternal
Providence,
Thou hast chosen me to watch over the life and health of Thy creatures. I am now about to apply myself to the duties
of my profession. Support me, Almighty
God, in these great labours that they may benefit mankind, for without Thy help
not even the least thing will succeed.
Inspire
me with love for my Art and for Thy creatures. Do not allow thirst for profit, ambition for
renown and admiration, to interfere with my profession, for these are the
enemies of truth and of love for mankind and they can lead astray in the great
task of attending to the welfare of thy creatures. Preserve the strength of my body and of my
soul that they ever be ready cheerfully to help and support rich and poor, good
and bad, enemy as well as friend. In the sufferer let me see only the human
being. Illumine my mind that it may
recognize what presents itself and that it may comprehend what is absent or
hidden...
Should
those who are wiser than I wish to improve and instruct me, let my soul
gratefully follow their guidance...
Imbue
my soul with gentleness and calmness...
Let
me be contented in everything except the great science of my profession. Never allow the thought to arise in me that I
have attained to sufficient knowledge, but vouchsafe to me the strength, the
leisure, and the ambition ever to extend my knowledge. For Art is great, but the mind of man is ever
expanding.
Almighty
God! Thou has chosen me in Thy mercy to
watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may
benefit mankind, for without Thy help not even the least thing will succeed.
Maimonides (8)
Maimonides’ Prayer is more simple
and to the point than the pseudo-Hippocratic Oath. It acknowledges that the benefit is the
patient’s, the power is already present in nature, and that therfore the goal
cannot be for the welfare or recognition of the physician. That leaves only altruistic motives as valid
and only humility and assiduous study as tools of the trade.
7. I am asserting that what has
come to be called the system of medical care may be better understood as a
series of contracts or understandings rather than an array of facilities,
trained professionals and instruments...My own view is that the two-party contract
wherein two individuals negotiate an agreement about what is wrong and what is
to be done, remains central in medical care and is essential to its regular
effectiveness.
Richard M. McGraw, M.D. "Social and Medical Contracts Explicit and
Implicit" (7)
Whatever elaborations and
qualifications we impose on the clinical relationship, it must irreducibly be
equivalent to a two-party contract, because the patient must be one real
person, and the clinical agent (whether a single person, a team, an institution,
or whatever) must relate to the patient as if another person. The relationship must be personal.
8. AMA: Principles of Medical Ethics 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 not only to patients, but
also 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.
I. A physician shall be
dedicated to providing competent medical service with compassion and respect
for human dignity.
II. A physician shall deal honestly
with patients and colleagues, and strive to expose those physicians deficient
in character or competence, or who engage in fraud or deception.
III. 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.
IV. A physician shall respect
the rights of patients, of colleagues, and of other health professionals, and
shall safeguard patient confidences within the constraints of the law.
V. A physician shall continue to
study, apply and advance scientific knowledge, make relevant information
available to patients, colleagues and the public, obtain consultation, and use
the talents of other health professionals when indicated.
VI. 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 services.
VII. A physician shall recognize
a responsibility to participate in activities contributing to an improved
community.
The deficit here is that no relationship
is well defined. Each statement is
diversely qualified. Certainly the impact is not patient-centered,
nor is there any acknowledgement of the autonomy of the patient. There is no coherence. This
is of little value. (8)
9. University of Colorado School of Medicine—Honor Code Pledge Card
The Honor Code of the University of Colorado School of Medicine states that students will
behave in an ethical and honest way at all times. When any student or faculty member observes or
knows about dishonorable conduct any kind, he should discuss it with the person
who has behaved in an unethical way. In
addition, that behavior must be reported to the Honor Council or any of the
five class representatives. Failure to
report dishonest behavior is also a violation of the Honor Code. Honor Code violations are investigated by
the Honor Council, which consists of one class representative from the
freshman, sophomore, and junior classes, and two from the senior class, as well
as two ex-officio faculty members. The
Honor Council makes the recommendations for disciplinary action to the
Executive Committee, which consists of the Department Chairmen and the Dean of
the School of Medicine.
I, the undersigned, pledge that I will uphold and support the Honor
Code of the University of Colorado School of Medicine as described above.
Date_______S i g n a t u r e___________________
No behavior or principle of
behavior is specified. The "constitution" which underwrites this
pledge denies the possibility or necessity to "designate or categorize
conduct with reference to whether it is honorable or dishonorable..." The
unfairness to the student coerced to sign this pledge is evident, but also
unnecessary, since we can take hold of a more comprehensive professional code,
whether we choose the arcane old one (traditional if not legitimate ) or
generate a new one. There is no
advantage to anyone in imposing on students something less lofty than the most
ambitious of codes; and if the most ambitious is appropriate to the novice, the
teacher will easily adopt it for himself.
10. "A Physician's
Affirmation" by Fredrick R.
Abrams (9)
In order to be worthy of self-respect, I pledge to respect others who
place their trust in me as a professional in the healing arts . Therefore:
I will practice my art and my science to benefit my patients. I will disclose to my patients that which I
know of their disease, and any hazards of the remedies I might suggest, that I
may guide them to choose the course that suits them best.
I will offer care and comfort when they are ill, and when death becomes
inevitable, I will ease their way as best I can in keeping with their expressed
plan.
I will recognize their right to self-determination, and if conflict
should arise with my own ethical restraints, make them aware without judging
wherein we differ, that they should consider seeking help elsewhere for their
complaints.
I will intercede in their behalf within the scope of my authority if I
perceive they are being treated without regard for their humanity. I will hold in confidence that which is seen
or heard in my role as a physician.
I will ever be a student to sharpen my skills and further my knowledge
that I may be a better clinician. If I act in this way I may aspire to join men
and women who, through the ages, have approached the loftiest ideals of the
healing mission, for I will have earned the faith and trust which is the
strongest tie in the bond between patient and physician.
My respected colleague has
captured a great deal of what a professional code should include. He has made
clear the responsible relationships to which he aspires: relationship to patients respecting their
autonomy, hopes for self, and honor for those who share his profession in the
past, present and future.
11. This emphasis on the physician doing what he or she thinks will
benefit the patient even in the face of the patient's contrary desires is
classical Hippocratic professional ethics.
It is oblivious to broader ethical requirements, independent of
consequences, including notions of patient's rights.
Robert Veatch "Professional Ethics: New Principles for
Physicians?" The Hastings Center Report, June 1980
Patients are always dependent because
of their afflictions. To acknowledge
this reality can lead, rather tha to paternalism, to effective enhancement of
the patient's autonomy. To help the sick
to the best of one's ability and judgement is not an evil, nor does it require
one to ignore the patient’s choices. (Quite the opposite). Veatch's A Theory of Medical Ethics
(10) deserves a response.
I thought Robert Veatch would
likely treat problems of medical ethics from a formal contractual viewpoint,
that I would come away from reading his book with the vague impression he had
never been a clinician or patient. I
know he is a teacher in relation to students, that he must have been a patient,
and that he has had extensive clinical experiences, but I do not read his
personal experiences between his lines. I do not sense his "subjective"
experience as a person involved in the clinical relationship. I read only his "objective"
experience as a critic.
I thank him for having carefully
outlined an apparently rational basis for understanding three levels of moral
contract which illuminate the clinical relationship: (1) the basic social contract incumbent upon
all members of society; (2) the general role-defining contract between society
and the professional group; and (3) the specific agreement between a clinician
and a patient as equal contractors, which can take place under the aegis of the
two broader contracts.
There is strength and value in
this apparently rational approach, but it withholds itself from the realm in
which real clinical encounters occur. Its
weakness is the same as the weakness of the law, whose admitted limitation is
that it cannot surely identify the exact principles the ideal
"reasonable" person would use in every case. There is a reality and a measure of
universality in clinical phenomena, and these do not clash with Dr. Veatch's
work, but there must also be a way to integrate clinical reality with social
theory. We certainly agree there is an
apprehensible standard far more reliable than the mere consensus of a
self-interested professional group.
A crucial area to scrutinize is
Dr. Veatch's detailed strong criticism of "the Hippocratic
Principle," the major elements of which he identifies as consequentialism, paternalism and individualism.
We always seem to agree the patchwork
which has come to us as "Hippocrates" is imperfect, but it draws us
to use it ever again as the soil in which we are rooted. "…(T)he Hippocratic ethic is dead,"
Veatch says (p. 170), and I will gladly help him bury it as soon as I am
convinced it is more dead than God used to be. Like Veatch, I also have struggled with
Hippocrates, but have found him an ally, not an adversary.
Veatch quotes Edelstein's translation,
"I will follow that system...which according to my ability and judgement I
consider for the benefit of the sick." (11) Jones says, "I will use treatment to help
the sick according to my ability and judgement." (5) The problem I have in digesting Veatch's
criticism of the Hippocratic Principle comes partly from his having
"divided to conquer." He
properly identifies the inherent focus on outcomes (and displays the variety of
interpretations of "to help, or not to harm" versus "primurn non
nocere") but does not integrate that focus on outcomes with the
"paternalism" of the Hippocratic Principle. He does not integrate paternalism with
individualism. The lack of integration I
sense in Veatch's book is equivalent to an ignoring of clinical phenomena. Robert Veatch is the rational analyst, taking
apart the living experience, abstracting it too distantly. Consequentialism, paternalism and
individualism are all implications of the Hippocratic Principle, but they come
as a package, the results of practical experience; they have some value as truisms
when seen in context, in relation to each other.
The central phenomenon of the
clinical relationship is dependence of the real individual patient on the real
individual clinician. It is not his
autonomy which characterizes the patient, but exactly his lack of autonomy. To emphasize the autonomy of the patient in
medical ethics is utterly important because given the initial dependence of each
patient the clinician too easily can perpetuate dependence and inhibit autonomy,
consciously or inadvertently. I beg
clinicians to use much of their energies to enhance autonomy. Autonomy is the goal (coherent with health),
but it is not the condition of the patient as the clinical relationship begins.
We do not often get the opportunity to
treat persons through their health, but usually because of their disease.
Accepting Veatch's analysis of
the Hippocratic Principle, that it consists of consequentialism, paternalism
and individualism, I will show how taken together they are coherent, productive
of good, and valuable as a basis for a code for the clinician (although not the
basis of a code for patients or third parties).
Attending to consequences in each
individual case for the sake of that real person is the essential orientation
of the personal clinician. (Other clinicians
may have proper focuses elsewhere--in community health, research, et
cetera--but they are acting somewhat differently.) Consequentialism and individualism need not be
problematic. It is paternalism which is
hard to swallow. Why need clinicians
seem paternalistic? (It is the
paternalism of the Hippocratic Principle which has caused concern for Edmund
Pellegrino and other clinical ethicists, and seems anathema to Veatch.)
If the benefit to the individual
patient is to be considered, Veatch asks why all benefits to the patient not be
considered, not only physical and psychological. But he says, "Physicians seem to be in no
position to assess them since they have no particular expertise in economic,
spiritual, aesthetic, intellectual, or other non-medical dimensions of benefit
to the patient." (p.148) Shall we
have a committee of consultants for each citizen in need?
Whether expert or not, physicians
often are trusted to help in all these areas, and have developed some capacity
to help. Physicians also participate in
formal legal responsibility beyond the physical and psychological. Even if the clinician is not ideally expert,
why should he not consider all benefits for each individual? If we emphasize the consequentialist aspect of
the Hippocratic Principle, then we must carefully consult each individual
patient in detail about what his proper individual needs and desires may be. Concern for the outcome is bound inextricably
with individualization and necessitates communication with the individual who
is involved. Paternalism may be implied,
but not lack of communication with the patient.
Veatch so narrowly considers
"my ability and judgement" that he jumps to the conclusion the
clinician will somehow manipulate the patient utterly without the patient's
consent or participation. Such unilateral
manipulation and exploitation of human persons has never been proper clinical
behavior, nor will it ever be.
The statement of the Hippocratic
Principle is clinician-centered because the clinician's behavior can be submitted
to standards, can be programmed and controlled.
The patient's behavior cannot be standardized. The patient is bound by no rules.
There can be no "contract
between equals" here, because the parties are not equal. The autonomy of the patient is not a given,
but it certainly is the central goal of the entire clinical process. There can be a series of understandings, but
they must continually be changing to suit the changing situation of the
patient, the changing clinical relationship. Whether the outcome of the clinical process
goes well or ill, the status of the patient is continually changing, but not so
the status of the clinician. The
clinician's role can be standardized and codified because his responsibility to
the patient is constant. The patient is
obligated only loosely to one thing--concern for self.
Veatch comes to the formulation,
"The physician should benefit the patient according to the most objective
judgement available unless the patient autonomously chooses some other course,
provided the physician's own conscience is not violated beyond limit." (p.
149) This complex standard implies the
greatest validity is in the "most objective judgement available,"
modified by subjective vetoes from the patient or the clinician. In fact, proper clinical decisions are made
in a dialogue between clinician and patient which involves each party
subjectively and objectively, with a
shared assumption that the benefit of the patient is the central goal. Difficult situations may bring in other
parties, but the proper nature of the process is not changed thereby, only
confused often. (This is the dangerous
rationale which is used to support irrational programs like DRG's.)
What if the patient wants something
not in his own or society's interest? Some
decision will be made, even if it is for inaction. When the clinician makes a decision
"according to my ability and judgement" he takes responsibility for
his assessment, recommendations and action. The clinician takes responsibility to the
patient and to the community, not from self-interest but from duty attached to
his role, defined (imperfectly) by his code. The clinician professes responsibility for the
outcome, but it is the patient who must ultimately take the responsibility, for
he directly suffers the consequences.
The difference between the actual
and the ideal is great, but the clinician is closer to being able honestly to
contract than is the patient. Cultural changes
may be bringing the patient-consumer closer to the ability to contract openly
and honestly, but it must always be so that the clinical process will begin
with a relatively anxious and incompetent patient and (I hope) a relatively
competent and calm clinician. The ideal
process immediately begins to enable the patient, to bring him closer to the
autonomy Veatch posits hypothetically at the beginning.
Veatch proposes a three-level contract.
The first two levels might be achieved,
never perfectly (the social contract and the contract of the professional
group). The third, the concrete contract
between clinician and patient, cannot be had as he wishes. It is the result,
not the beginning of the clinical relationship.
Perhaps there is a way to
formulate the three-level contract Veatch seeks, but it will always be a
lop-sided agreement. The patient's part
of the agreement is simple, something like, "I depend on you to help me
become more autonomous (more able, more healthy), and I will honestly try to
participate in my own behalf." The
burden on the patient is his responsibility for his own life in all its ramifications.
He is not intrinsically burdened within
the clinical relationship.
The clinician is bound in the contract
by something like this: "I will
follow that system...which according to my ability and judgement I consider for
the benefit of the sick" because I am the one who takes responsibility
until the patient can take more full care of himself; and I will relinquish
power over him from the beginning and throughout our relationship according to
his current ability to take responsibility for himself; and I will participate
in an ongoing dialogue with him as to how well and able he feels; and I will
always be ready to err on the side of promoting his autonomy, at the potential
risk of his other goods, because the patient is a person with rights to choose,
and I am neither omniscient nor omnipotent.
1. Personal communication from Edmund Pellegrino,
January
12 , 1982.
2. Pellegrino and Thomasma, A Philosophical
Basis of Medical Practice (New York:
Oxford University Press, 1981).
3. A sentiment expressed by Leon K . Kass, M.D.
in his lecture given November 12, 1980 at the University of Chicago, "The
Hippocratic Oath: Thoughts on Medicine
and Ethics."
4. Hippocrates, translated by W. H Jones,
Loeb Classical Library, Vol. 1, p. 165, Harvard/Heinemman, 1972.
5. Op. cit., Vol. I, p. 299.
6. Op. cit., Vol. II, p. 65.
7. Bulger, Roger J., Hippocrates
Revisited: A Search for Meaning, Medcom,
New York, 1973.
8. Abraham
Joshua Herschel, Maimonides, (translated by Joachim Neugroschel), London, Faber, 1982.
9. Detailed criticisms may be found in Pellegrino
and Thomasma, A Philosophical Basis of Medical Practice and in Veatch’s A
Theory of Medical Ethics.
10. Abrams, F.R., "Social Needs and the
Physician’s Duties: A Physician’s
Affirmation,” People and Policy, 1979, 1; 18-21.
11. Veatch, Robert M., A Theory of Medical
Ethics, New York, Basic Books, 1981.
12. Edelstein, Ludwig, Ancient Medicine, Baltimore, Johns Hopkins, 1967.
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