The Hippocratic oath updated Could boost credibility of doctorsBMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6959.953 (Published 08 October 1994) Cite this as: BMJ 1994;309:953
- M P Ward Platt
EDITOR, - Eugene D Robin has done medicine a service by recasting the Hippocratic oath in a modern form.1 His suggestions tackle many of the ethical principles (respect for autonomy, beneficence, non- maleficence, justice, and scope) lucidly discussed by Raanon Gillon.1 I think, however, that two paragraphs are in danger of compromising the principle of autonomy - namely, the one relating to honesty with patients and the one starting, “I will do unto patients and their families only what I would want done unto me or my family.” This could be avoided by explicitly stating respect for autonomy in terms of imparting information and undertaking procedures.
I also believe that there should be explicit mention of the need to relieve pain. To some extent this is encompassed in the seventh paragraph by the words “to cure when possible but to comfort always.” However, as the provision of pain relief is still a large blind spot in medical practice, though central to the physicians's role, I suggest that this paragraph should finish, “I will strive to cure when possible, to comfort always, and to do my utmost to relieve pain and suffering.”
It would be a shame if Robin's suggestion remains only a box in a journal. Would the BMA or even the General Medical Council be interested in taking it up as a manifesto? At a time when patients' faith in their physicians is sometimes sorely tried it might give a much needed boost to doctors' credibility.
Surrogates' decisions in resuscitation are of limited value
- S Finner,
- N Theaker,
- R Raper,
- M Fisher
EDITOR, - Eugene D Robin's updated version of the Hippocratic oath contains much with which we would agree.1 In the fourth paragraph, however, he suggests that physicians should be bound by the wishes of their patients or, when the patient is incompetent to decide, the decision of family members.
We respect the right of patients to make informed decisions about their own care, but the degree to which that right should be transferred to surrogate decision makers is less clear. When patients have stated their wishes before becoming ill we will respect those wishes, but in Australia and the United Kingdom only a minority of patients will have made such a declaration. As doctors working in intensive care we are regularly confronted with the decision to withhold or withdraw life sustaining treatment, and whenever possible we discuss this with the patient. In most cases it is not possible to determine the patient's wishes, and we will then discuss the options openly and honestly with family members. We still strongly believe, however, that the ultimate decision to withdraw or withhold treatment lies with the medical and nursing staff caring for the patient, for two reasons. Firstly, the decision made by the surrogate is often the opposite of that which the patient would make.*RF 2-4*
Secondly, surrogate decision makers often feel that they have been asked to decide whether their loved ones should live or die; this burden should not be placed on the shoulders of someone who is already under great stress.
The line between granting patient autonomy and abrogating responsibility may be very fine. In some instances where continued treatment is clearly futile families will ask that “everything possible” be done. Leaving aside the issue of inappropriate use of scarce resources, we believe that it is wrong to continue treatment when the only realistic outcome is an undignified high technology death. In almost all cases further discussion, explanation, and independent second opinion, if necessary, and the passage of time allow the family to come to terms with the inevitability of death. On rare occasions we have had families demand that we continue treatment even to the point of performing cardiopulmonary resuscitation when we have believed that this course was futile and, as there was no possible benefit to the patient, might even constitute assault. When we have been unable to resolve our differences with the family in such cases we have done what we considered to be in the patient's best interests and allowed him or her to die. Fortunately, such extreme cases are rare, but they underline the fact that the ultimate responsibility is ours.