Throwing the Hippocratic Oath in the trash

Throwing the Hippocratic Oath in the trashThrowing the Hippocratic Oath in the trash

An excerpt from The Demise of Medicine.

The Dalai Lama has once been quoted as saying, “Our prime purpose in this life is to help others. And if you can’t help them, at least don’t hurt them.”  In a nutshell, the Hippocratic Oath can be summarized in this one phrase: “Primum non nocere – above all, do no harm.” Amongst my many tattoos is that exact phrase and assuming I have a mirror or am feeling extra limber I look at it daily. It’s my mantra, my motto for daily living, and in general just a really good idea.

The Oath also has subsections which, while staying true to core concept of primum non nocere, apply to specific circumstances which are just as true now as they were in the 5th century BC. Unfortunately, it seems that in modern American medicine we have taken the Hippocratic Oath and summarily tossed it into the trash.

The first concept of the Oath is to respect those who taught us and teach future generations what we know. That’s pretty straightforward: Share your knowledge.  As a physician, it is my duty to teach. Most of what I do on a daily basis is teaching others. I teach patients about diet and nutrition. I teach about lifestyle choices. I teach about disease and disease prevention. I teach about medications and how they work. I teach nurse practitioner students and I teach medical students the hallowed art of my profession. Most of this is word of mouth. I do not write textbooks and I do not publish scientific journals. My charge is to educate about the core principles of medicine. Healthy choices, hygiene, lifestyle modification, and preventative medicine are staples. Having a discussion specifically about which chromosome the gene for breast cancer lies is not really relevant to my day. It may be important, but if that patient doesn’t do self-breast examinations or come in for mammograms it’s pretty pointless.

One would think that education and the dissemination of medical knowledge would be simple. However starting in the 1500s with royal grants given by Queen Elizabeth the concept of intellectual property was born. This idea really took off with the British Statute of Anne in 1710 and the Statute of Monopolies in 1623, which are the origins of copyrights and patents respectively.  Now it seems that just about everything medical is copyrighted, trademarked or patented, and usually marked up in price about 300% of what it’s really worth.

One day I found a medical supply catalog on my desk. It was big and bulky and reminded me some of the old Sears catalogs my parents used to get in the mail near Christmas that I would scour for things that I thought I wanted but could never afford. I flipped though this particular catalog and my eyes landed on the crash carts.

A crash cart is a wheeled cart that stores medicine and equipment used in medical emergencies. If I need to intubate someone because they have stopped breathing or shock their heart back into rhythm that’s the cart I go for. The price tags on these particular models were in the range of a thousand to two thousand dollars each. After all, they were made of high-grade steel with rolling wheels and a five-year warranty. Oddly to me, they also looked not so vaguely familiar. Also on my desk was a sale flyer for a local hardware store. They were selling a high grade steel tool box on wheels with a five-year warranty that looked familiar, no, exactly like, the “crash cart” that was in the other magazine. These were on sale for about forty dollars. When our office finally did buy a new “crash cart” box, it sold at a sporting goods store for about fifteen dollars. It was plastic but had a nice carrying handle. It also fits spinner-baits and assorted lures very nicely.

If the most basic and fundamental principles of medical knowledge were being discovered today, it would most certainly be restricted to the point of unavailability. Everything from medications to medical equipment, DNA, and even amino acids and their subsequent proteins are patented now.  Peer-reviewed medical journals in theory allow the exchange of new information and clinical research. However, even this is not free. The lack of adequate, and free, information will soon frustrate anyone trying to do research using PubMed. Expensive association fees or journal subscriptions ensure that someone is restricting widespread use, and I figure probably making a profit on, the exchange of medical information.

Unfortunately this is not limited to the medical profession as illustrated by the music industry’s lawsuit versus Napster. If there’s a buck to be made with intellectual property then we as Americans are after it. In this case I guess future generations of disenfranchised youth better pay up.

The next concept of the Oath is to practice medicine in accordance with your ability and judgment, which translates to “don’t do things beyond your scope of practice.”  In other words, to be perfectly blunt if you don’t know what you’re doing, don’t do it. Dr. Conrad Murray was the physician convicted of involuntary manslaughter in the 2009 death of Michael Jackson.  This is not an isolated incident. Increasingly, physicians are being criminally prosecuted for medical care.

Examples of these prosecutions include at least three obstetricians convicted of manslaughter or second-degree murder, a Colorado anesthesiologist convicted of reckless manslaughter, an anesthesiology resident charged with involuntary manslaughter, and an Oklahoma surgeon convicted of involuntary manslaughter.   Medical malpractice has now crossed over into the criminal court system.

If one of my patients has a bad outcome and there is an untimely death, not only do I have to worry about a malpractice suit, I now have to consider that there may be criminal charges pressed.  I could actually be charged with murder. With that thought in the back of my mind, I sometimes find making the hard decisions that I need to make very difficult.

Andrew Morton is a physician and the author of The Demise of Medicine.

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  • doc99

    Farewell and adieu to Ye fair Spanish ladies
    Farewell and adieu Ye ladies of Spain.
    For we received orders to sail back to Boston
    And nevermore will we see you again.

    Fair Spanish Ladies – modified in the film Jaws

    • SteveCaley

      I hope the ABA paid for product placement (i.e. the Shark.)

  • guest

    How about financial toxicity we cause to our patients. No one talks about these things. There is fear among doctors. No one is speaking up about this. Unnecessary procedures, overtesting to rule out things in case of a lawsuit, billing and coding nonsense. I understand student loans have to be paid off. Had I known all this I would have passionately not chosen medicine as a career. It has absolutely nothing to do with helping people and everything to do with stealing money from people, doctors and patients.

    • DeceasedMD

      You must work in a large hospital setting maybe academic? I have seen some pretty awful stuff myself. I have seen unnecessary uncomfortable tests that are done when the specialist definitely knows before hand it was useless. In fact my pt, said that the specialist never went over the results of the test and had to be reminded. It’s egregious. Also as you say not enough is talked about financial costs that are left uncontained and still pts sign up and have clue what the cost is. And by passively complying, as you say it is actually harming pts. But I don’t think the physicians that practice like that, see it that way.

    • SteveCaley

      I like the turn of phrase, “Had I known all this I would have passionately not chosen medicine as a career.” It speaks to me. To be human, to be passionate – to defend the weak, helpless and needy – is what humans are for, and for many of us, it burns like a passion. I also am considering my passions in relieving myself of the burden of medicine as it is now.

  • Eric Strong

    I’m afraid I don’t agree with some of the above.

    1. The oft quoted version of the Hippocratic Oath – “above all, do no harm” – simply makes no logical sense. It’s just an older version of the Precautionary Principle, in which any intervention with any possible chance of harm is avoided until the chance of harm can be proven to be zero. Under this logic, doctors should avoid prescribing any medication that has a risk of side effects, and should avoid performing surgery with any risk of significant harm. In reality, of course, doctors use risk/benefit analysis (usually subconsciously, or at least, informally) to decide whether the benefit of a treatment outweighs risk of harm. However, the silly Oath still persists in American medical culture. I have even heard trainees and faculty alike, literally quote the Oath when trying to defend an illogical conclusion regarding most appropriate course of treatment (e.g. denying potentially life-saving surgery for a high risk patient who has an even greater chance of dying without the surgery). We need to replace the Oath with another statement, equally catchy, that actually better reflects the complexity of decision-making in the modern world.

    2. I appreciate the example of the ridiculous markup of the crash cart. I also think it’s amazing how much medical equipment is marked up – from stethoscopes to portable ultrasound machines. However, one aspect of medicine which is dramatically improving in the free dissemination of medical knowledge is the FOAM movement (Free Open Access Medical Education). To see examples of how open-access is increasingly trumping copyright and profit concerns, check out: http://lifeinthefastlane.com/foam/ or alternatively, my YouTube channel: https://www.youtube.com/user/drericstrong

  • James O’Brien, M.D.

    Conrad Murray was criminally negligent and not just incompetent. I am surprised he has defenders other than his lawyers. Gosnell was a monster. Doctors are not foreign diplomats immune from homicide prosecution.

    • querywoman

      I have said it before. Criminal law covers really harmful conduct from doctors. Harold Shipman was a notorious example.
      Doctors can be prosecuted for intentional misconduct under criminal law in any country.
      Medical malpractice is a complex, civil issue. Malpractice is vague, broad, and hard to prove.

  • Thomas D Guastavino

    How about when a hospital demands that you follow a protocol that you know adds no additional benefit but actually causes your patients harm?

    • DeceasedMD

      Maybe we just need a good lawsuit

    • Suzi Q 38

      Warn the patient.
      The patient can refuse any hospital protocol or bogus treatment.
      I would want to be warned, and I would keep it confidential.

      i would tell you “Thank you!.”

      • Thomas D Guastavino

        Oh, I have no problem ignoring the protocol but that does not stop the hospital demands.

  • Alan Wartenberg

    Not sure why it has gained so much currency, but Primum Non Nocere is NOT part of the Hippocratic Oath, and never was. In fact, it really doesn’t even make sense in the modern world. Hippocrates may have recognized that a large number of interventions in his day not only did no good, but they did harm. Avoiding those to prevent harm was at no cost since the interventions COULDN’T do any good. If we stopped treating cancer because the treatment itself hurts a small percentage of those treated, we would be doing a great deal of harm. In short, we CANNOT do good without at least the potential of doing some harm. Informed consent, wise patient selection and careful treatment are our options.

    • SteveCaley

      You are right – it is an associated aphorism that it not even in the language of Hippocrates. Galen is a better example for this sort of thought. He taught that “there is a methodological difference between taking account of the patient in front of you in all of the patient’s particularity and, instead, understanding the patient in front of you as representing an instance of a general rule of biomedical science.” Dance to that, rock stars.

      The term “harm” does better in the current legal language – J. Olivera writes on John Stuart Mill’s ideas on Liberty:

      Mill refers to conduct harmful as well as ‘hurtful to others’, that ‘produce’ or ‘cause evil’ to others, that result in ‘definite damage, or a definite risk of damage’ to them, as action which ‘affects prejudicially the interests of others’, ‘directly, and in the first instance’, that is injurious to ‘certain interests, which… ought to be considered as rights’

      Mill, again, quoted: ‘Encroachment on their rights; infliction on them of any loss or damage not justified by his own rights; falsehood or duplicity in dealing with them; unfair or ungenerous use of advantages over them; even selfish abstinence from defending them against injury—these are fit objects of moral reprobation, and, in grave cases, of moral retribution and punishment. And not only these acts, but the dispositions which lead to them, are properly immoral, and fit subjects of disapprobation which may rise to abhorrence’ (LIV6).

      It would more strongly reach out to things done with wrong intent, rather than undesired effect; things ‘of bad mind.’
      I do not think that the aphorism is “silly,” as others have attributed it to be; it is often incorrectly associated with Hippocrates, which is an error, although a trivial one.

  • Suzi Q 38

    Doctors adhering to the “Hippocratic oath??”
    What fake world are people living in?
    I am sure the good exist, but there are not enough of those.
    I will admit that most of my doctors are good and have a conscience.
    The remainder are liars and truly do not care.
    To them, we are one of many, and they do not want to take the time to truly know us and treat us medically and socially in the manner to which is humane and is expected by us.

    I say, beware that these doctors exist, and AVOID THEM.
    They have the ability to hurt you, and hope that you don’t figure it out.
    Run, do not walk, away as quickly as possible from these doctors.

    Your health depends on it.

  • querywoman

    Research the Hippocratic Oath online. It’s contradictory, and not required of modern medical students.
    Personal ethics are within one’s soul, as in the normal criminal standard for insanity is knowing right from wrong.
    I have been to umpteen doctors who thought preventive medicine was the gold standard and couldn’t treat illnesses with real symptoms. I consider that malpractice, but the medical authorities don’t always agree with me.