Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Stop this nonsense now!
- William T Stevenson (24 December 2001)
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Hippocrates and modern Declarations
- John H Scotson (24 December 2001)
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Close but no cigar
- Stephan N Larsson (25 December 2001)
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medical principles istated in bland language.
- NANCY K OCONNOR (27 December 2001)
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Time for doctors to commit to human rights
- Peter L Hall (4 January 2002)
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Author reply
- Kaji Sritharan (23 April 2002)
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A deficient declaration
- John Grimley Evans (25 April 2002)
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Medical oaths are now redundant
- William D H Carey (26 April 2002)
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Declaration of a New Doctor
- FREDERICK F. FENECH, 117, St. Paul Street, Valletta, VLT 07, MALTA (25 June 2002)
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William T Stevenson, Consultant Radiologist Burnley
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Lest it take on a life of it’s own, like Motherhood immune to question, it is necessary to declare that this Declaration is nonsense. Scarcely excelled in foolishness even by the 1978 WHO Alma-Ata Declaration, this new example of meaningless waffle has an equally negligible chance of effecting any benefit to mankind. The statement that a professor of medical ethics was involved engenders about as much confidence in the value of the declaration as if it contained the words ‘holistic’, ‘empowerment’ or ‘audit’. Like Christianity, the stated ideals are impossible to attain, and only those with an inability to examine themselves would even aspire to them. The first hurdle is downed on the first line and it is hardly worth reading further: "to the best of my ability serve humanity". When in imminent danger of parting company with a rockface, it is indeed possible to hang on "to the best of my ability", but it can’t be done for very long. Do these authors have no sense of the ridiculous, or are they evidence of the rebirth of the previous incarnation of the WHO? Spokesmen for Christianity counsel against letting the perfect be the enemy of the good, in the sense of making the best use of the Christian principles which are already well known. This is no excuse for the deliberate introduction of a new set of aims which are plainly unachievable from the outset. Even the drafting is faulty: "I shall never intentionally do or administer anything to the overall harm of my patients". What about intentionally administering thrombolysis after MI? Some of those patients will have strokes, and some of them will not derive any cardiac benefit from the thrombolysis. We know that before we start, but we hope that the numbers come out right in the end. ‘I shall not do or administer anything to my patient with the intent of overall harm’ would be better, but such tinkering cannot restore this document to sense. Put ye not your faith in medical ethicists. When you are dealing with real patients in the middle of the night they won’t be there; they will be ‘on the Box’ affecting to agonise over difficulties while secure in the knowledge that they won’t have to deal with them. You will be the one who administers the thrombolysis that ‘strokes’ the patient, who performs the operation that turns out badly or who fails to report the x-ray correctly. The retrospective study will be difficult to do well, but I suggest that adverse events, culpable or otherwise, in medicine will be no less (and, to be fair, no more) likely when the practitioner has made this Declaration. The Hippocratic Oath, like much in our national life, displayed the merits of traditional ceremony which was not expected to mean anything and was rarely employed. The credulous are now exhorted by example to institute this silly public declaration, for fear of seeming deficient in ‘caring and sharing’ credentials. Those familiar with Heller’s ‘Catch-22’ will recall "The Great Loyalty Oath Crusade", a fad which was only abandoned when someone realised that this ‘Emperor does indeed wear no clothes’. I urge the next House to reject this Notion. This is all you really need to swear to yourself: ‘I promise to try reasonably hard to do a reasonably good job’. But you have to mean it. |
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John H Scotson, Retired GP
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The “Declaration of a new doctor” as set out in the editorial “Medical Oaths and Declarations” is to be welcomed. This declaration calls to mind the original Hippocratic Oath and these words from the Oath “ I will not give a fatal draught to anyone if I am asked; nor will I suggest any such thing. Neither will I give a woman means to procure an abortion.” Now that euthanasia is more widely practised and abortion has become legalised and regarded by many as an acceptable surgical procedure it would behove us all to be reminded that what has now become commonplace was throughout the centuries regarded as an abhorrent crime and such it remains from a moral and ethical point of view. Because killing, whether by abortion or euthanasia, can have no part in the practice of civilised medicine I consider the dictum of the Oath outlawing any form of killing in medicine by doctors should be retained in any future Oaths or Declarations. To those who would be reluctant to include these prohibitions because of present day medical practice I would reply that Declarations and Oaths tell us what should be done rather than what is being done. |
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Stephan N Larsson, Radiation Oncologist Vancouver Island Cancer Centre, 2410 Lee AvenueVictoria, BC,Canada
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Sir, The new Imperial College Medical Oath described by Sritharan et al (BMJ 2001;323:1440-1441 ( 22-29 December )) was actually quite good in that it outlined much of the ethical and moral basis of medicine without descending too far into the syrupy abyss of Political Over-correctness. However, I was disappointed to see the clause beginning "I will not permit considerations of gender, race, religion,...." Gender is a quality of parts of speech, not people. "Considerations of sex,........" is the correct term. |
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NANCY K OCONNOR, Pawhuska Indian Health Center Pawhuska OK 74056 USA
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The language used in the oath is not universal or timeless, but clearly influenced by the agenda oriented language of modern medical ethics. One suspects that fifty years from now, that this oath will be considered dated and passe. What it lacks is hard to define, but perhaps can be hinted at in Paul Woodruff's recent book on Reverence: "Reverence begins," he writes, "in a deep understanding of human limitations; from this grows the capacity to be in awe of whatever we believe lies outside our control - God, truth, justice, nature, even death." The chief emotions arising from reverence, aside from awe, are respect and shame: "Respect is for other people, shame is over one's own shortcomings, and awe is usually felt toward something transcendent." The object of our reverence may be holy or secular, may be a moral cause or an ideal, may be the universe itself, but whatever the object, it dwarfs us, keeps us open to new guidance, teaches us humility and restraint." Without reverence, the flat, theoretical language of the oath can quickly degenerate. Perhaps we no longer believe in Apollo, but at least our Hippocratic oath reminds us to remember our human limitations, and places us in a company of physicians that date back twenty five hundred years. |
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Peter L Hall, Chair, Physicians for Human Rights-UK West Herts Hospitals
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The public declaration committing newly qualified Imperial College medical graduates to practise medicine ethically, incorporates a welcome recognition of the importance of human rights(1). The doctors' admirable aim is supported by a BMA working party's conclusion that public declarations strengthen a doctor's resolve to behave with integrity (2). Ethical codes play an important role as frameworks upon which to practise medicine, yet they are governed by principles best particularised in human rights treatises. Perhaps then it is to human rights that the medical profession should turn to find a widely acceptable canon. Discussing medical oaths in 1997 Jennifer Leaning wrote, What is missing in these commitments, and what the Universal Declaration of Human Rights (UDHR) provides, is a recognition of the separate, inviolate nature of the individual person who will face that young doctor in the casualty area, the examination room, the office, the conference room (3). From the opening statement in article 1, that every human being is born free and equal in dignity and rights, the document enumerates the critical freedoms that fill the space surrounding every man, woman, and child on earth (http://www.unhchr.ch/udhr/lang/eng.htm). Human rights also have a direct impact on health, the most striking example being the extent to which their neglect or promotion has a major influence on the distribution of HIV infection within a population, and the speed with which infection progresses to AIDS and death (4). Although the UDHR refers to health, the foremost legal source for the international human right to the highest attainable standard of health is Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR), ratified by the UK in 1976 (http://www.unhchr.ch/html/menu3/b/a_cescr.htm). Doctors recently acquired authoritative guidance on the meaning of the right to health. The General Comment on Article 12 provides a comprehensive explication of contemporary standards of not only healthcare provision, including the right of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalised groups, but also the essential prerequisites for health, for example food and nutrition, (http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000 .4,+CESCR+General+comment+14.En?OpenDocument). Surely it would be better for doctors to commit directly to honouring rights inhered in every individual at birth - such as striving to apply those principles within the UDHR pertinent to medical practice, and to promoting the right to the highest attainable standard of health. 1. Sritharan K, Russell G, Fritz Z, Wong D, Rollin M, Dunning J, Morgan P, Sheehan C. Medical oaths and declarations. BMJ 2001; 323: 1440-1441 ( 22-29 December ) 2. BMA. Medicine betrayed. London: Zed Books, 1992. 3. J Leaning. Human rights and medical education. BMJ 1997;315:1390-1391 4. UNAIDS, June 2000 Report on the global HIV/AIDS epidemic. What makes people vulnerable? http://www.unaids.org/epidemic_update/report/Epi_rep ort_chap_vulnerable.htm Dr Peter Hall MBBS, MRCPI, DGM Chair, Physicians for Human Rights-UK |
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Kaji Sritharan, PRHO in Surgery Charing Cross Hospital, London, W6 8RF
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Dr Stevenson in his letter(1) attacking the Declaration of a New Doctor(2) misses the point entirely, and makes a number of baseless, glib comments in an attempt to rubbish the concept. Values and morals are instilled throughout life and not conjured out of thin air. Moreover, to be maintained they rely on active reinforcement and such arrogance in assuming intent in medical practice is dangerous. The Hippocratic oath amongst other texts referenced in the construction of the Declaration contains a wealth of wisdom that should not, through complacency, be lost to the history books. An 'affirmation' makes NO claim to guarantee morality but merely reinforces an ethical code of conduct and importantly provokes doctors into more actively considering their undertaking. In this era of 'doctor-bashing' we are made all too aware that professional status is not an inherent right, but a privilege granted by society. It's preservation hinges on trust and meeting societal obligations and expectations (3,4). It is therefore a fragile, constantly evolving concept that needs updating. The Declaration of a New Doctor took over 7 months of debating and deliberating to compose and was certainly not a task undertaken lightly. Transparency of conduct and solidarity in affirming professional values should not be mistaken for paternalism and to condemn this process of reflection in medical practice will be a step backward in securing public faith in the profession. Dr Stevenson remarks that the 'stated ideals of the declaration… are impossible to attain,' but fails to substantiate the claim with any coherency. The declaration appeals only that we serve 'to the best of (our) ability' and makes no unreasonable or unobtainable demand. Should we then reject the Geneva Convention on Human Rights or any struggle for World peace on the same grounds? The declaration states 'I shall never INTENTIONALLY do or administer anything to the overall harm of my patients,' and Dr Stevenson argues that the use of thrombolytic drugs after myocardial infarction and the complication of stroke contravene this. However, the overall INTENTIONAL benefit derived from treatment outweighs any risk which is UNintentional. The backing of an entire year of newly qualified doctors and the more recent support lent by the Royal College of Physicians(5) is surely sufficient reassurance that such a Declaration is of benefit. Moreover, that there is a role for medical ethics within medicine. Finally, the suggestion that perhaps we ought simply to 'promise to try reasonably hard to do a reasonably good job,' is about as passion inspiring and pride evoking as watching paint dry! Dr Kaji Sritharan
1. Stevenson WT (letter). BMJ 2002;324:851 2. Sritharan K, Russell G et al. Medical Oaths and Declarations. BMJ 2001;323:1440-41. 3. Creuss SR & Creuss RL. Professionalism must be taught. BMJ;1997:315:1674-77. 4. Calman K. The Profession of Medicine. BMJ 1994;309:1140. Alberti G. Professionalism - Time for a New Look. Clinical Medicine |
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John Grimley Evans, Professor of Clinical Geratology University of Oxford, Radcliffe Infirmary, Oxford OX2 6HE
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Sir, As I share the view, attributed by Shakespeare to Marcus Junius Brutus, that oaths are only for people that no one is going to trust anyway [1], I did not pay deep attention to the Imperial College updating of Hippocrates in your Christmas 2001 edition [2]. It has now been republished in the Journal of Medical Ethics [3] and is seemingly in danger of becoming widely endorsed. Age is conspicuously absent from the list of factors that the oath giver undertakes not to allow to influence his or her duty of care. I am worried both by this omission and by the absence of protest from your subsequent correspondents. Ageist practice by doctors is widely documented, has no ethical or biological justification, and is condemned in the National Service Framework for Older People [4]. Clearly we must advise older members of the public that if attended by a medical graduate of Imperial College they must always demand a second opinion from a doctor of more liberal provenance. John Grimley Evans 1] Shakespeare W. Julius Caesar 1599; Act II Scene 1. 2] Sritharan K, Russell G, Fritz Z et al. Medical oaths and declarations. BMJ 2001;323:1440-1. 3] Gillon R. In defence of medical commitment ceremonies. J Medical Ethics 2002;28:7- 9. 4] Department of Health. National Service Framework for older people. London: DoH, 2001. http://www.doh.gov.uk/nsf/olderpeople.htm |
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William D H Carey, Clinical Pharmacologist Hammersmith Medicines Research, Central Middlesex Hospital, London NW10 7NS
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Editor - Medical oaths were introduced in an attempt by the ancient Greek public to try and ensure that doctors would always do their best for patients. Nowadays the public relies on the GMC and doctors being struck off if found wanting, audit and the courts. Today, therefore, medical oaths are redundant. An engineer does not take an oath, yet any failing could lead to a much geater loss of life than a doctor. Priests take oaths, but they do not work as we see in the current paedophile scandal. The courts are going to achieve much more in curtailing that abuse. Yours faithfully William D H Carey |
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FREDERICK F. FENECH, Director International Institute on Ageing, United Nations - Malta, 117, St. Paul Street, Valletta, VLT 07, MALTA
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Dear Sir, I have just seen the “Declaration of a New Doctor” made by the graduating year of 2001 from Imperial College of Medicine in London which was published n the British Medical Journal 2001; 323; 1440 – 41. I would like to congratulate the students for producing a modern version of the Oath of Hippocrates. At a time when there is still a lot of unwritten discrimination vis-à-vis the elderly, could I suggest that, in the statement in which they state: “I must not permit consideration of gender, race, religion, political affiliation, sexual operation, and nationality ors social standing to influence my duty of care”, they should add, among these cases also AGE. In the Plan of Action 2002 approved by Governments at the Second World Assembly on Ageing, organised by the United Nations and held in April 2002 in Madrid, among a number of central themes running through the Plan of Action was the importance of having universal and equal access to health services. Yours sincerely, Prof. Frederick F. Fenech
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