When Dr Daniel Sokol, medical ethicist at St George’s, University of London, Director of the Applied Clinical Ethics (ACE) programme at Imperial College and a columnist for the British Medical Journal (‘Ethics Man’), asked his medical students to name famous doctors in the history of medicine:
- Their fist answer was Harold Shipman, the GP who murdered hundreds of patients. (Upon hearing, he nearly swallowed his tongue.
- Their second answer was House, the fictional doctor from the American TV series. (Tears of frustration welled up in his eyes knowing the fact that their second attempt was no where near what he anticipated.)
- Their third answer was Hippocrates, presumed author of the Hippocratic Oath. (He breathed a sigh of relief finally.)
1. Respect for patient autonomy
Autonomy (literally self-rule) is the capacity to think, decide, and act on the basis of such thought and decision, freely and independently. Respect for patient autonomy requires health professionals (and others, including the patient’s family) to help patients to come to their own decisions (e.g. by providing important information) and to respect and follow those decisions (even when the health professional believes that the patient’s decision is wrong).
2. Beneficence: the promotion of what is best for the patient
This principle emphasises the moral importance of doing good to others and, in particular in the medical context, doing good to patients. Following this principle would entail doing what was best for the patient. This raises the question of who should be the judge of what is best for the patient. This principle is often interpreted as focusing on what an objective assessment by a relevant health professional would determine as in the patient’s best interests. The patient’s own views are captured by the principle of respect in patient autonomy.
The two principles, autonomy and beneficence, conflict when a competent patient chooses a course of action which is not in his or her best interests.
3. Non-maleficence: avoiding harm
This principle is the other side of the coin of the principle of beneficence. It states that we should not harm patients. In most situations this principle does not add anything useful to the principle of beneficence. The main reason for retaining the principle of non-maleficence is that it is generally thought that we have a prima-facie duty not to harm anyone, whereas we owe a duty of beneficence to a limited number of people only.
There are four components to this principle: distributive justice; respect for the law; rights; and retributive justice.
With regards to distributive justice: first, patients in similar situations should normally have access to the same healthcare; and second, in determining what level of health care should be available for one set of patients we must take into account the effect of such a use of resources on other patients. In other words, we must try to distribute our limited resources (time, money, intensive care beds) fairly.
The second component of justice is whether the fact that some act is, or is not, against the law is of formal relevance. Whilst many people take the view that it may, in some situations, be morally right to break the law, nevertheless if laws are made through a reasonable democratic process they have moral force.
The types and status of rights are much disputed. The fundamental idea is that if a person has a right it gives her a special advantage – a safeguard so that her right is respected even if the overall social good is thereby diminished.
Retributive justice concerns the fitting of the punishment to the crime. In the medical context this issue is sometimes raised when a person with mental disorder commits a crime.
One sentence from the original Hippocratic Oath reads as, “In a pure and holy way, I will guard my life and my art and science” – is a call for professional integrity. Doctors should refrain from immoral behaviour and resist the temptations that accompany their privileged position (today, from drug companies offering generous gifts, for example).
Dr Daniels Sokol’s view of the contemporary core medical principles in light of the Hippocratic Oath continues to the penultimate section of the original Hippocratic Oath deals with confidentiality and reads: “And about whatever I may see or hear in treatment, or even without treatment, in the life of human beings, I will remain silent, holding such things to be unutterable.”
As today, patients in ancient times shared deeply personal information with doctors on the assumption that their details would not be revealed to others. Without this trust, patients may withhold facts that would help the doctor make an accurate diagnosis. The text ends with the rewards that await those who respect the Oath (“the benefits both of life and of art and science, being held in good repute among all human beings for time eternal”) and the punishment of those who do not (“if, however, I transgress and swear falsely, the opposite of these”).
In an age of technological developments, cosmetic surgery, complementary medicine, drug companies, and many other temptations for patients and doctors alike, the spirit of the Oath is as relevant as ever.