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Why the Hippocratic ideals are dead

BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7351.1463 (Published 15 June 2002) Cite this as: BMJ 2002;324:1463
  1. Imre Loefler (loefler{at}swiftkenya.com), surgeon
  1. Nairobi, Kenya

    Medical ethics in Western medicine have traditionally concerned six major principles, all of which are in the Hippocratic oath: reverence for our teachers and consideration towards our colleagues; the command “first, do no harm”; absolute regard for life; restriction to field of expertise; abuse of privilege; and respect for privacy. In addition Hippocratic medicine is pious, serene, and centres solely on the individual.

    Modern medicine lacks piety and serenity

    Contemporary medicine places much less emphasis on reverence for the teachers, if for no other reason than because a doctor has limited exposure to his or her teachers: there are too many of them. Obligations towards the family of the deceased teacher, if they exist at all outside the sphere of emotion, are rarely financial.

    Consideration towards colleagues is still an important part of medical ethics, although the practice of treating colleagues and their families for free has decreased greatly. The bad mouthing of colleagues, however, has always been commonplace.

    The command “do no harm” has become increasingly difficult to observe. In contemporary medicine, with its array of powerful interventions, some harm is almost always done. The choice of therapeutic measures depends on comparisons between the amount of harm that an intervention may cause and the natural history of a disease. In the process doctors make value judgments that are necessarily prone to ideological influences. Also harm may not be immediately apparent—if it follows the intervention with some delay, a causal relationship may be difficult to prove.

    The most emphatic principle in Hippocratic medicine, the absolute respect for life, has been subject to fundamental modifications: in contemporary medicine life is clearly not held in absolute regard. Abortion is commonplace, euthanasia and assisted suicide are becoming acceptable, and “no resuscitation” policies are part of everyday practice.

    The demand that a medical practitioner restricts himself to his field of expertise is seen as being just as crucial today as it was in Hippocrates's day. However, as more and more subspecialties and even sub-subspecialties emerge, the relationship between what a doctor has actually learnt to do, what he or she is supposed to do, what he or she is actually doing, and what he or she is capable of doing is not straightforward.

    The prohibition against abuse of privilege, particularly with regard to sexual relationships between doctors and their patients, still stands. However, it is only enforced in the starkest of cases. Countless doctors have married their patients and the number of doctors who date their patients or members of patients' families is inestimable.

    To “abstain from every voluntary act of corruption and mischief” is still considered an important tenet of medicine. However, it is generally understood only to apply to individual relationships between doctors and their patients. When it comes to clinical trials, particularly trials involving drug or machinery manufacturers, corruption and mischief are rampant.

    The respect for privacy has also become a casualty of modern medicine. Nowadays, it would appear that those who foot the bill for medical care—insurance companies, for example—have gained the right to know every detail. Laws relating to notifiable diseases, immunisation, and certification of death have also eroded privacy.

    Modern medicine lacks piety and serenity. The single greatest difference between Hippocratic medicine and modern medicine is that the former focused solely on the relationship between the individual doctor and the individual patient, whereas the latter also takes the concerns of society at large into consideration. The emphasis is shifting increasingly toward the concerns of society. This shift, which began 200 years ago with the issue of public health, is utilitarian. Aiming to achieve the maximum benefit for the greatest number has necessarily interfered with the Hippocratic ideal of medicine.

    Craving for the nobility and the relative simplicity of Hippocratic medicine is just pointless nostalgia. Hippocratic ethics are the ethics of a time when medical interventions had little impact on people's lives. But although Hippocratic medicine had little impact on survival rates, its values were important in the face of severe disease and threatening death. Modern medicine, however, is potent. While people are not necessarily healthier, even those with lethal conditions are living longer because modern technology can prolong their lives.

    The Hippocratic ethics take no account of the impact of modern medicine. This is why the Hippocratic oath, particularly in respect to its three most essential principles—the sanctity of life, the privacy of patients, and the “do no harm” command—is increasingly subverted, ignored, altered, reinterpreted.

    The Hippocratic ethics do not tally any more with the realities of modern society. Whether this is regrettable or not, doctors and society must get to grips with the ethical consequences of the medical revolution.

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