Medical oaths and declarations
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7327.1440 (Published 22 December 2001) Cite this as: BMJ 2001;323:1440
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
k.sritharan@ic.ac.uk
PRHO Surgery, Charing Cross Hospital, London
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
Declaration of a New Doctor
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
Director
Competing interests: No competing interests