Throwing 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 I do not write textbooks and I do not publish scientific journals.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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