The Hippocratic oath - WMDs and alcohol – dilemmas for doctors

A blog from winter 2010 – still relevant to WMD and to the minimum pricing for alcohol debate

Friday, 12 November 2010

The Hippocratic oath – old and new

I have been aware of the existence of the Hippocratic Oath for most of my life, have probably glibly referred to it on occasion, but until last night, I have never actually read it or understood its exact place in modern medicine.

Events in the Scottish Parliament this week led me to find out a bit more about it, and I now realise that most of what I believed was based on various misconceptions.

1. I believed that it had existed in an unchanged form since Hippocrates – the father of modern medicine - first set it down several hundred years before the birth of Christ. It hasn’t,  and in fact Hippocrates may have had little to do with it …

2. I believed that every medical practitioner was obliged to take the Hippocratic oath. They are not, at least not in recent years …

In fact, the wording of the original Oath, in translation, astonished me. I had hoped to find something in it that would help me to understand what influence, if any, it might have on medical doctors who get involved in politics – say, Dr. Liam Fox, for example. (You may be able to think of others.)

Would anything in the Oath, in its original form or in the more modern principles favoured by the BMA, that try to hold on to some of the essential sense and principles of the original act as any guide to the ethical and moral behaviour of a doctor involved in the pragmatic and often dirty business of politics?

How, for example, could Liam Fox interpret his responsibilities under the oath when acting as a Defence Minister, commissioning weapons of death and mass destruction, and sending young men and women to kill other human beings, and perhaps to be killed or maimed themselves?

Would he take the ethical position that, since he was not practising medicine in this role, the oath was irrelevant? After all, doctors are not like priests, claiming to draw their authority from their god – they are high-level professionals, with high ethical standards, but ordinary mortals nonetheless.

No answer there – the question is beyond my philosophical and analytical abilities.

But how about, say for example, a doctor/politician who in his or her role is obliged to bring medical knowledge specifically to bear on decisions affecting the health of the population?

Say, over egregious abuse of alcohol in a society?

A thorny question also, but perhaps more amenable to Hippocratic analysis, but certainly not hypocritical consideration.

Doctors, like scientists, often reach different conclusions faced with the same facts, the same evidence: doctors debate, discuss, in fact in recent months, I’ve heard them doing it many times at the end of my beds in St. John’s and the RIE, and at the beds of other critically ill patients. It struck me as a vital dialogue - not always between equals, because the medical profession is hierarchical in the extreme - but one where every view is invited, heard and weighed.

Back to the Hippocratic Oath …

I’ll take the classic version rather than the original, which frankly sounds more than a little odd to a modern ear. (It’s also a little odd in the classic version.)

It’s hard to seize on anything relevant to a modern topic such as, say, dealing with the enormous harm to the health, wellbeing, safety and economic strength of an entire nation because of abuse of a legal and freely available dangerous drug – alcohol.

“I will apply dietic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.”

I couldn’t find dietic in my Oxford dictionary, so I presume it means dietetic – relating to diet, i.e. the nature of food and drink ingested.

Alcohol, misused, clearly does harm, and undoubtedly causes injustice, in its supply to people who are by age, immaturity or predisposition to addiction and excess vulnerable to this drug, and to others, who are harmed by violence, by disturbance in public places, in the home, by the overstretching of the caring and public order services, by economic factors – the list is a long one.

Keeping them all from harm and injustice due to alcohol abuse seems to me an appropriate interpretation of the Hippocratic Oath.

“I will neither give a deadly drug to anybody if asked for it, nor will I make suggestion to this effect.”

A difficult one to interpret in the context of a licensed drug and a licensed trade, especially when that drug forms a central part of the economy of my country. One might reasonably expect a doctor to recognise that the drug is only deadly under certain circumstances, and consumed in moderation may actually be beneficial, but to look long and hard at it becoming available too cheaply and too easily to vulnerable groups especially the young and immature.

But where there is a widespread consensus, in the society of which that doctor is a part, by virtually all doctors, the professional association that represents doctors, by the police force of that society, by the established Church of that society, by health workers, addiction workers, careworkers in that country, one might reasonably expect that a doctor/politician would tend to follow that consensus, a consensus of his or her peers and virtually every authoritative voice.

Of course, one must allow for the fact the majority are not always right; that lone voices, driven by burning personal conviction, must follow their consciences, and speak out against the majority if necessary. Such men and women have rendered invaluable service to their profession and to society at great personal cost on occasion.

It would of course be unthinkable that anyone would be influenced significantly or even totally by purely political considerations in going against that consensus, would it not? Let’s hope it never happens …

Well, I am not a doctor, but I owe my life to the medical profession in Scotland, not once, but several times over the last year, and I experienced their dedication,  professionalism and deep humanity at first hand. I also saw how the abuse of alcohol in Scottish society overstretched them, consumed an inappropriate amount of scarce resources, and exposed them personally to violence and intimidation.

So in that respect at least, I feel that I have a right – and a duty - to speak.

The Hippocratic Oath for medically - qualified politicians

It occurred to me that I should offer my own version of the Hippocratic Oath for modern career politicians who are also medically qualified: there are many of them in the UK and worldwide. At the moment, such professionals face an intolerable conflict between the ancient high standards of ethics in their profession and the pragmatic realities of politics today.

I’ve tried to keep it simple -

“I will strive to preserve life and the quality of life, not only for my patients but for any human being upon affected by my actions and decisions, except where it conflicts with the order of my party whip and/or my political career and advancement.

I will not knowingly support any action, or measure, or decision that will harm a human being, nor will I impede any measure, action or decision that protects human beings from harm, except where it conflicts with the order of my party whip and/or my political career and advancement.”

I feel this simple oath will give the necessary get-out clauses to any medically qualified politician who finds the conflict between political career and medical ethics intolerable. I accept that my experience has been confined to business and commercial ethics, which tend to have a high degree of elasticity, especially where the maximisation of profit and volume sales are concerned.

Business and commercial professionals also have the convenient theory and practice of externalisation to distance themselves from the often inconvenient aspects of ethics, whereby untidy matters of principle can either be outsourced or laid at the door of government. This flexibility has unfortunately been denied to medical professionals – and to some degree members of the legal profession – when facing similar ethical and moral dilemmas, especially in the matter of wars, the rationale for going to war, conflicts, weaponry, WMDs, and measures to protect the health of the population. (Accountants and bankers have long since cracked this thorny problem, as many large corporate audit practices and investment houses regularly demonstrate across the globe.)

 The legal profession, however, are well equipped to look after themselves, especially when the blunt instrument of UK libel law is so readily available to them.

Perhaps my little contribution may go some way to promoting a debate that will lead to solutions for hard-pressed politicians, still reeling from the disgraceful press, public opinion and legal attacks on their traditional privileges, in relation to expenses, house flipping, revolving doors to industry, non-executive directorships and consultancy contracts, etc.