Swearing to care: the resurgence in medical oaths

Introduction

We are witnessing a resurgence of professional interest in medical oaths and codes of conduct. In the United Kingdom the General Medical Council has reissued its professional code and, together with the BMA, the royal colleges, and other organisations, has published a document on the “core values” of medical practice.1 2 There has been discussion of the role of oath taking at the end of medical training, and the BMA has drafted a new Hippocratic Oath on behalf of the World Medical Association (see third box).3 4 5 6 7 8 9 10 11 The American Medical Association has this year commemorated the 150th anniversary of its 1847 Code of Ethics with an extensive debate on the relevance of oaths and codes to modern practice.12 13 14

In many Western countries the process of refashioning health care to contain costs is precipitating rapid flux in the social relationships of medical practice. Doctors are no longer in a simple clinical relationship with patients: the structure of health services now involves them in many other tasks, some of which may entail conflicting responsibilities. Funding organisations and managers increasingly influence the nature and extent of the care which can be provided. At the same time, health care has become multidisciplinary in nature and multiagency in delivery. Scientific advances and new technological capabilities throw up difficult and sometimes bizarre moral predicaments. All these changes make for greater moral complexity in everyday practice.

The medical profession is being forced to face hard choices in patient care and to re-examine its own role in health care, causing it to look again at the nature of its own values. The Hippocratic Oath is being re-examined afresh for moral guidance. Traditionally a solemn promise invoking supernatural authority as witness, the oath entails making a covenant with other members of the profession to share knowledge freely, to respect one's teachers, and to behave towards patients according to the Hippocratic Code (box). There follows the conditional curse invoked upon transgressors, which includes censure by and exclusion from the profession and from human happiness.

The changing oath

Problems and controversies surround the textual authenticity and meaning of the original oath. It is not clear if or how much Hippocrates himself contributed to it, or how much it influenced health care in ancient Greece. It is probable that only a minority of doctors swore the oath. Some of its prohibitions seem to fly in the face of what is known about clinical practice in ancient Greece, which included surgery, abortion, and tolerance of infanticide.3 16 17

Those who have administered the oath during succeeding centuries have taken it on themselves to omit, add to, and change its clauses. For example, Elizabethan renditions required doctors to provide gratuitous care to the poor and not to flee from but to treat victims of plague.3 Present day versions tend to be agnostic on these matters.

A recent exegesis describes the oath as “a solemn promise: (a) of solidarity with teachers and other physicians; (b) of beneficence and non-maleficence towards patients; (c) not to assist suicide or abortion; (d) to leave surgery to surgeons; (e) not to harm, especially not to seduce patients; (f) to maintain confidentiality and never to gossip.”18 Tensions between the impetus of the original oath and the modern endeavour to ensure good practice according to bioethical principles are apparent in this text. Values a and d, which seek to foster an archaic professional exclusivity, sit uncomfortably with b, e, and f, which modern doctors would regard as fundamental principles: beneficence, non-maleficence, and confidentiality. Such incongruities point up the difficulties of applying the original oath to present day medical care. Many institutions bypass the problem altogether by administering oaths which are entirely modern in content, but which are titled Hippocratic.19

Who takes the oath?

Surveys show that about half of the medical schools in the United Kingdom and almost all of those in the United States administer an oath of some kind, mostly at graduation but occasionally earlier, a few at the outset of medical studies. Some use a modernised version of the Hippocratic Oath or of the Prayer of Maimonides, others use the Declaration of Geneva (box), and others still, their own institutional oath. The process of oath taking differs: some schools ask for graduands' affirmation by signature, in others the oath is read out or students recite it together during the graduation ceremony.6 9 19 The question of how voluntary such oath taking is has not been well documented. We have heard of no students who have opted out, or what would happen if they so chose.

Oaths and ethics

To the extent that oaths indicate a commitment to firm moral parameters, their affirmation may strengthen doctors' resolve to behave with integrity in extreme circumstances. This was the finding of a BMA working party investigating medical involvement in and resistance to human rights abuses. This group recommended that “medical schools incorporate medical ethics into the core curriculum, and that all medical graduates make a commitment, by means of affirmation, to observe an ethical code.”21

LEE STANNARD

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In the United Kingdom the GMC's code Duties of a Doctor has evolved over time in response to alleged breaches of its guidance, changes in the organisation of health care, new law, and changing mores in society.22 Since it has a statutory basis and carries great professional authority, what could swearing an oath add to it?

We have not located any studies which examine whether oath taking affects doctors' competence to deliberate effectively on ethical matters. The main intention of a medical oath seems to be to declare the core values of the profession and to engender and strengthen the necessary resolve in doctors to exemplify professional integrity, including traditional moral virtues such as compassion and honesty. Oaths also provide moral orientation through rule-like precepts and prohibitions, from which generalities the practitioner is left to infer or extrapolate to the specifics of everyday practice. Medical codes on the other hand seek to clarify the means by which such moral ends can be achieved, by offering guidance for everyday practice, outlining applicability in exemplary cases together with grounds for identifying exceptions. Affirmation of an ethical code by means of an oath therefore permits the oath to contain within its remit a supplementary field of guidance.

Others at the bedside

All the medical oaths and codes we have considered are traditionally viewed as relating only to doctors, although there is a suggestion that the Hippocratic Oath was originally designed to be taken by doctors' assistants and associates.23 But many of the moral difficulties in present day health care arise in the context of complex organisations in which other members of the healthcare team are bound by different codes of conduct (or by none at all), perhaps with conflicting responsibilities and obligations. Some of these people have the power to influence clinical decisions since they represent and are answerable to powerful third parties (government, insurance companies, NHS trusts, health maintenance organisations) which have determinative influence on the care doctors can provide.

More than one medical commentator has used parody to predict the impotence of any new Hippocratic oath in these circumstances:

“Whatsoever I shall see or hear of the lives of men that is not fitting to be spoken, I shall document fully in their charts so that complete, problem-oriented records may be available for any insurers, legal counsellors, or government agencies that may become involved … I will exercise my art not solely for the cure of my patients but will take into account the return-on-investment, the cost-benefit ratio … since, in the overall picture society will benefit, even though an individual patient may suffer some hardship or relapse.”24

A pan-professional oath?

Such problems are clearly not for doctors alone to resolve. The American Academy of Arts and Sciences has recently instigated a transatlantic initiative to create a shared ethical code for health carers (see editorial in this issue by Berwick et al). It outlines a number of serious dilemmas which require the concerted attention of all healthcare professions and which would benefit from open public debate. Is it ethical to exclude specific treatments from healthcare coverage or service packages? Is it ethical to keep information secret which might benefit all patients everywhere but which provides an organisation with a competitive advantage? Can it be ethical to care selectively for less sick patients instead of more sick ones because of political or financial imperatives?

If a pan-professional oath were to be established it could engender a positive degree of moral cohesion between all caring professions, across institutional boundaries, influencing perhaps even the organisation of health care. This is the lesson to be drawn from the American Medical Association's recent attack on the ethical impropriety of so called gag clauses, which seek to place contractual constraints on doctors' freedom of speech. After the association's intervention, several health plans in the United States immediately removed such clauses, and more than 100 submitted their contracts to the association for ethical review.25

The hope is that a single oath for all health care professions could heal split loyalties and ameliorate existing moral tensions in health care. The intention is honourable, and no one should underestimate the difficulty of the task. A comparison of existing codes for non-doctors and the recent BMA draft revision of the Hippocratic Oath (box) might serve as a good starting point for exploring common ground. It bodes well, we think, that, like the doctors' oath, the conduct codes of nurses and managers place patients' welfare paramount.26 27 The challenge, then, may not be one of agreeing ends, but means. Agreeing on such an oath would provide an inclusive opportunity for healthcare workers from different walks of life to speak with one voice for the benefit of patients.