For the first time since graduation from medical school, stirred by the courage of my colleagues in the ICUs and emergency rooms during the COVID pandemic, I looked back at the Hippocratic oath to reassess its charge to physicians. My wife and I, both doctors, studied and trained for a long time, and we considered the years spent and the effort put forth to be a calculated sacrifice. But amidst the pandemic, that tabulation changed. Risking personal harm was an aspect of medicine I scarcely considered but, in retrospect, probably should have. So I went back to the most concise expression of our mandate to see if I’d missed something.
In its modern permutation, the Hippocratic oath extols deference to science, humility in the face of expansive knowledge, and compassion to a suffering human. It warns us against employing futile treatments and violating patient privacy. An ounce of prevention is worth a pound of cure, it reminds us. Then there’s this more enigmatic admonition:
I will remember that I remain a member of society, with special
obligations to all my fellow human beings, those sound of mind
and body as well as the infirm.
Why do I need reminding that I “remain a member of society” at large, and what are my “special obligations?” And while the charge of the oath to practice compassionately while mindful of special obligations might be construed to mean risking personal safety, this certainly isn’t explicitly stated.
However, the American Medical Association’s Declaration of Professional Responsibility makes the imperative stark.
We, the members of the world community of physicians, solemnly
commit ourselves to apply our knowledge and skills when needed,
though doing so may put us at risk.
There it is. Clear as day. But while most physicians might intuit their professional responsibility to stick around when their personal safety is imperiled, I doubt many could reference this codified source.
As it turns out, actually, the AMA’s code of ethics has waxed and waned on obligating practitioners to treat through personal endangerment. The first version, authored in 1847, rendered unequivocal the physician’s duty to treat in times of ‘pestilence,’ whereas the revamped code in 1957 offered more interpretive wiggle room. Infectious disease was ubiquitous in and before 1847. On-the-job exposure simply came with the territory, the responsibilities obviated by the pervasiveness of incurable infections. Like a fireman fights fires, when you became a doctor in 1847, you were going to risk becoming infected, so if you couldn’t handle it, you better find something else to do. In the latter half of the 20th century, however, vaccines and antibiotics vanquished many deadly maladies, and practice expectations changed accordingly. Personal risk was no longer a given.
COVID — at least the highly transmissible, lethal, and unpredictable initial strains — brought this issue to the fore once again. Do health care workers have a duty to treat those at risk of personal harm? Is there a collective, self-abnegating professional obligation, and if so, what is its basis?
The late physician-philosopher, Dr. Edmund Pellegrino, asserted that self-effacement lies inherent to the moral nature of healing. Three characteristics of medicine differentiate it from other professions and oblige its members to disavow self-interest. First, the vulnerability and helplessness of the sick place a moral claim on the doctors equipped to care for them. Second, medical knowledge is not proprietary to the clinician but rather held “in trust for the good of the sick.” Physicians are beholden to those who enabled the acquisition of professional expertise by permitting invasions of privacy, experimentation on human subjects, and subsidizing medical education. Finally, an oath publicly avows fidelity to patients akin to a marriage. The oath states Pellegrino, even more so than the degree, confers entrance into the profession of medicine, characterizing the doctor-patient relationship as covenantal rather than contractual.
That might be what the oath means when it directs graduating medical students to remember that they remain members of society” with “special obligations.” It tells us that doctors’ professional identity transcends the walls of a hospital or clinic. Obligations don’t stop when the white coat comes off, and the shift ends. Professional and personal identities coalesce, resulting in an indiscriminate obligation to broader humanity that is setting agnostic. Doctors can’t flee patients in the face of danger anymore so than a policeman or fireman because doing so would be to “abnegate what is essential to being a physician.”
The vivid professional selflessness of our colleagues over the past several years should have all of us reflecting on whether contracts and codes delineate profession-wide standards or whether the very moral nature of medical work inherently prescribes those parameters. The COVID pandemic affords the chance to replace the hollow formality of the oath with genuine reflection on what it means to be a doctor and what it takes to uphold the profession’s highest standards.
David Shafran is a pediatrician.
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