May 1998

Page 3 Healers or Killers?

Although Hippocrates is remembered primarily for his oath, his purpose in formulating it was to separate the healers from the killers. Before his time, physicians performed two functions for their patients; one was to cure but the other was to kill. Medicine man, witch doctor or shaman were some of the titles used; varying degrees of magic, potions or prayers were the means to establish the cure. But the same physician could use similar magic to cast an evil spell on you and might even invoke the spirits to kill you. Those who have practised in Africa will remember the inexplicable deaths of certain patients whom the juju man had so condemned. So, for all our benefits, Hippocrates said that henceforth a doctor will only cure and left us with the noble phrase primum non nocere 'first, do no harm'. Perhaps, in the current debate on euthanasia, we are seeing the re-emergence of the killers?

The oath has suffered many indignities over the years' not least from being largely ignored in medical schools: but also the famous punchline 'I will give no deadly medicine to anyone, if asked, nor suggest such counsel, and in like manner 1 will not give a woman a pessary to produce an abortion' has frequently been savaged in many international declarations. Willke points out that the American Medical Association, after abortion was legalised following the Roe v. Wade decision, deleted the phrase and substituted the equivalent of 'I will do nothing illegal'¹ Modern scholarship appears to have decided that the great body of writings bearing his name should better be known as the Hippocratic Corpus, having been written over at least 70 years by many different hands, none of them definitely Hippocrates. Doubtless that makes it easier to add a little mitigation here and there.

Oaths are certainly not fashionable nowadays; "they were formerly written in blood and involved the supernatural which is unlikely to invest them with supermarket appeal. Professional core values are now the vogue, together with outline duties and responsibilities. The medical profession has be- come more diverse, for doctors come now from various cultural, ethnic and economic backgrounds: as its activities involve close co-operation with other health carers, perhaps a pan-professional oath (or shared ethical code) should be created?

It is interesting that, in the Annual Report of Council, 1996-97, of the BMA, is included a 'Draft revision of the Hippocratic Oath'. Fortunately it is only a draft, for a revision of something with such an ancient lineage deserves very special scrutiny. Naturally, it is a comprehensive attempt and contains much that is admirable. But there is evasion and some confusion about issues fundamental to the practice of medicine.

On abortion it says: 'Where abortion is permitted, 1 agree that it should take place only within an ethical and legal framework'. Surely the oath (or core value) is a profession of basic ethical obligations which a doctor publicly acknowledges and pledges himself to uphold? As such it is intended to make clear the moral duties of doctors. The most fundamental of these obligations is never intentionally to seek to end the life of a human being. That the State or legislative action permits or encourages behaviour contrary to the profession of medicine is no reason for ignoring the sanctity of life.

Again no attempt is made to define the 'ethical framework' within which it is to be conducted. On euthanasia, the oath is conspicuously and, one fears, ominously silent.

Given the increasing role of medical research in the activities of doctors, it is highly regrettable that the draft revision contains no commitment to ensure that in scientific research 'concern for the interests of the subject will always prevail over the interests of science and society' (As in the Declaration of Helsinki).

A truly professional oath will express not only recognition of those fundamental requirements of justice which a doctor may be tempted to ignore, but, in expressing a commitment to serve the good of health in the lives of patients, will recognise some limits to what is to count as the good of health. Instead, in para 5, the emphasis falls on patient autonomy: 'I will ensure that patients receive the information and support they want to make about disease prevention and improvement of their health.' Surely this respect for the patient is limited not so much by a shared understanding of the good of the profession i.e. a body of skilled practices, informed by specialist knowledge and governed by a distinctive ethic designed to promote human good, as by the individual outlook of each doctor. Professions are responsible for the ethical and technical criteria by which their members are evaluated: they have the exclusive right and duty to discipline unprofessional conduct.

It is to be hoped that the forthcoming ARM of the British Medical Association will seriously debate these issues.

1. Willke, JC. Assisted Suicide and Euthanasia, Hayes Publishing Co.,lnc., 6304. Hamilton Avenue, Cincinnati, 0H45224.