doctors we live in a difficult time. We are pulled in many different directions.
When I first started practice, (I finished my residency in 1981) it was far
easier to focus on the welfare of the patient. Since then doctors have been
encouraged to shift priorities.
For younger persons entering practice, family time and interests outside of
medicine take priority. They raise an interesting argument that the well
rounded, complete person makes the better doctor. Perhaps.
I''ve heard academic doctors say you don't get famous by seeing patients.
Maybe they will help a lot more people by discovering new things. Health systems
and doctors in practice need to make a profit. But fiscal goals often conflict
with ethical considerations.
I''ve heard academic doctors say you don't get famous by seeing patients. Maybe they will help a lot more people by discovering new things. Health systems and doctors in practice need to make a profit. But fiscal goals often conflict with ethical considerations.
most prominent conflict for the physician in practice is rising costs of
medical care and a system of rationing, some irrational rationing,
created by insurers, HMO’s and hospitals. If we follow the directives of
the insurers, the individual patient’s welfare is no longer is paramount.
Doctors, they tell us, need to be efficient providers of medical
care. It is more important that the patient or
"customer" as he or she is now called, feels satisfied, that he or
she has gotten a good deal, feels taken care of. In medical consumerism,
Customer perception takes precedence over reality. Health care is managed by
business types which morphs it into a
commodity. A patient encounter, even an operation or hospital stay, is no
more than an industrial product which can be made more or less efficiently -
what I call the widgetization (factory model) of medicine. T he
youthful doctor's clear eye gets a cataract, is jaundiced. Older doctors
however idealistic they might have been ionce,, battered by accountants and
lawyers are jaded rather than wise - in some, not all cases.
he youthful doctor's clear eye gets a cataract, is jaundiced. Older doctors however idealistic they might have been ionce,, battered by accountants and lawyers are jaded rather than wise - in some, not all cases.
If our time is spent away from the patient (e.g. peering into a computer) then patient will get less of what we have to give. "Document, Document Document," we are told by everyone. And we live in a medicolegal hell in which attorneys are turning patients and physicians into adversaries. Now, more than ever, it is important for the doctor examine who they are. Physicians must never lose sight of why it originally was they entered medicine and of the proud history and ideals of the profession. In other words integrity is more than ever critical for the physician.
At my own medical school, graduates recited the Hippocratic Oath. This is ancient, now outdated, and inconsistent with today's medical mores. Many medical schools no longer use these oaths at graduation, and for good reason. None is universally true or appropriate. I thought it might be fun to present a collection of a number of oaths, which serve to introduce young doctors into the profession. The oath that comes closest to my own ideals is that of the great physician Maimonides which I have placed last, below.
Since then I have tried to set down some of the ideals as I try to practice them, not in the form of an oath but as a set of expectations for patient care. I'm aware that a lot of people wouldn't agree with some of my own ideas. I also added some Principles of Practice from the American Medical Association. You'll find this below the last Oath and Prayer of Maimonides. See what you think.
- Charles Yanofsky
"I swear by Apollo the physician, and Æsculapius, and Hygeia, and Panacea, and all the gods and goddesses, that according to my ability and judgment, I will keep this oath and its stipulations -- to reckon him who taught me this art equally dear to me as my parents, to share my substance with him, and to relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art if they shall wish to learn it, without fee or stipulation, and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none other.
I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and holiness I will pass my life and practice my art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.
While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of this art, respected by all men, in all time. But should I trespass and violate this Oath, may the reverse be my lot."
World Medical Association, Declaration of
The World Medical Association is an association of national medical associations. This oath seems to be a response to the atrocities committed by doctors in Nazi Germany. Notably, this oath requires the physician to "not use [his] medical knowledge contrary to the laws of humanity." This document was adopted by the World Medical Association only three months before the United Nations General Assembly adopted the Universal Declaration of Human Rights (1948) which provides for the security of the body.
At the time of being admitted as a member of the medical profession:
God these things I do promise:
In the acceptance of my sacred calling,
I will dedicate my life to the furtherance of Jesus Christ's healing and teaching ministry.
I will give to my teachers the respect and gratitude which is their due. I will impart to those who follow me, the knowledge and experience that I have gained.
The wholeness of my patient will be my first consideration.
Acting as a good steward of the resources of society and of the talents granted me, I will endeavor to reflect God's mercy and compassion by caring for the lonely, the poor, the suffering, and those who are dying.
I will maintain the utmost respect for human life. I will not use my medical knowledge contrary to the laws of humanity. I will respect the rights and decision of my patients.
I will hold in confidence all secrets committed to my keeping in the practice of my calling.
I will lead my life and practice my art with purity, and honor; abstaining from immorality myself, I will not lead others into moral wrong doing.
May God's kingdom, His healing power and glory be experienced by those whom I serve, and may they be made known in my life, in proportion as I am faithful to this oath."
The Oath of Amatus
by Amatus Lusitanus (1511-1568)
From "Jews and Medicine, Religion, Culture, and Science" (Jewish Publication Society). Also Aaron J. Feingold, M.D. from this book Three Jewish Physicians of the Renaissance. The Marriage of Science, and Ethics. Copyright 1994 by the American Friends of Beth Hatefutsoth.
"I swear by God the Almighty and Eternal (and by His most holy Ten Commandments given on Mount Sinai by Moses the lawgiver) that I never in my medical practice departed from what has been handed down in good faith to us and posterity; that I have never practiced deception, I have never overstated or made changes for the sake of gain, that I have ever striven that benefit might accrue to mankind; that I have praised non one nor censured anyone to indulge private interests, but only when truth demanded it. If I speak with falsehood, may God and His Angel Raphael punish me with Their eternal wrath and may on one henceforth place trust in me. I have not been desireful for he remuneration for medical services and have treated many without accepting any fee, but with none the less care. I have often unselfishly and firmly refused remuneration that was offered, preferring through diligent care to restore the patient to health, to being enrich3ed by his generosity. (I have given my services in equal manner to all, to Hebrews, Christians, and Muslims.) Loftiness of station has never influenced me and I have accorded the same care to the poor as to those of exalted rank. I have never produced disease. I have favored no druggist unless he excelled others in skill in his art and in character. In prescribing drugs I have exercised moderation guided by the physical condition of the invalid. I have never revealed a secret entrusted in me. I have never given a fatal draught. No woman has ever brought about an abortion with my aid. In short, I have done nothing which might be considered unbecoming an honorable and distinguished physician having always held Hippocrates and Galen before me as examples worthy of imitation and not having scorned the precepts of many other excellent practitioners of our art. I have endured the loss of private fortune, and have suffered frequent and dangerous journeys and even exile with calmness and unflagging courage, as befits a philosopher. The many students who have come to me have all been regarded a though they were my sons, I have used my best efforts to instruct them and to urge them to good conduct. I have published my medical works not to satisfy ambition, but that I might, in some measure, contribute to the furtherance of the health of mankind; I leave to others the judgment of whether I have succeeded; such at least has always been my aim and ever had the foremost place in my prayers."
Translated by Harry Friedenwald, Bulletin of the
MAIMONIDES (1135/38-1204) (in Hebrew: Rav or Rabbi
Moshe Ben Maimon, or "RaMBaM"
-- the acronym of his name), was the most important Jewish philosopher of the Middle Ages. Maimonides was born
in the Spanish city of
other works, Maimonides wrote "The Guide of the Perplexed,"
a treatment of several philosophical issues. His attempts to synthesize Jewish
revelation and Aristotelean philosophy influenced the
ideas of many Christian thinkers including
The "Daily Prayer Of A Physician" is attributed to Maimonides, but was probably written by Marcus Herz, a German physician, pupil of Immanual Kant, and physician to Moses Mendelssohn. It first appeared in print in about 1793.
THE OATH OF MAIMONIDES
"The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.
May I never see in the patient anything but a fellow creature in pain.
Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.
Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling."
THE PRAYER OF MAIMONIDES
"Almighty God, Thou has created the human body with infinite wisdom. Ten thousand times ten thousand organs hast Thou combined in it that act unceasingly and harmoniously to preserve the whole in all its beauty the body which is the envelope of the immortal soul. They are ever acting in perfect order, agreement and accord. Yet, when the frailty of matter or the unbridling of passions deranges this order or interrupts this accord, then forces clash and the body crumbles into the primal dust from which it came. Thou sendest to man diseases as beneficent messengers to foretell approaching danger and to urge him to avert it.
has blest Thine earth, Thy rivers
and Thy mountains with healing substances; they enable Thy creatures to
alleviate their sufferings and to heal their illnesses. Thou hast endowed man
with the wisdom to relieve the suffering of his brother, to recognize his
disorders, to extract the healing substances, to discover their powers and to
prepare and to apply them to suit every ill. In Thine
Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absent-minded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to preserve the lives and health of Thy creatures.
Grant that my patients have confidence in me and my art and follow my directions and my counsel. Remove from their midst all charlatans and the whole host of of ficious relatives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes of our art and often lead Thy creatures to their death.
Should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance; for vast is the extent of our art. Should conceited fools, however, censure me, then let love for my profession steel me against them, so that I remain steadfast without regard for age, for reputation, or for honor, because surrender would bring to Thy creatures sickness and death.
Imbue my soul with gentleness and calmness when older colleagues, proud of their age, wish to displace me or to scorn me or disdainfully to teach me. May even this be of advantage to me, for they know many things of which I am ignorant, but let not their arrogance give me pain. For they are old and old age is not master of the passions. I also hope to attain old age upon this earth, before Thee, Almighty God!
Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding.
Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed."
Preamble: The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility not only to patients, but also to society, to other health professionals, and to self. The following Principles adopted by the [AMA] are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.
II. A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception.
III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
IV. A physician shall respect the rights of patients, of colleagues, and of other health professionals, and shall safeguard patient confidences within the constraints of the law.
V. A physician shall continue to study, apply and advance scientific knowledge, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
VI. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services.
VII. A physician shall recognize a responsibility to participate in activities contributing to an improved community.
A Personal Perspective
Modern medical practice has raised new concerns and makes conflicting demands on the practicing physician. There are pressures from third party payers and HMO’s who do not have the patient’s welfare as their primary concern. We have futile treatments that increase patient suffering prolonging insensate dependence instead of useful life as in the persistent vegetative state. We're pressured by licensing bureaus and puritanical groups that penalize physicians for prescribing the most effective pain reducing medicine. Religious groups attempt to influence personal decisions for everybody according to the dictates of their own faith. Law enforcement, insurance carriers, employers and a host of others seek patient’s personal information for their own ends. Attorneys try to bend medical opinion to win their cases, and drive away brilliant and compassionate physicians, things that Maimonides, Osler, Hippocrates, never dreamed of. Perusing the above oaths and considering ramifications of the long-term practice of medicine, admitting that I tend to be a practical straight forward twenty-first century person, eschewing the superfluity of flowery language and supplications, it is possible to come through with some “reasonable expectations.” These are some of the principles that I personally feel are important. I realize that not every person would agree with all of them. I’m well aware that no one is perfect or can always live up to the lofty and idealistic standards set forth below. But given these understandings the patient has a right to expect from his or her physician that: (Please excuse me for using “he” to mean “he or she” and “his” for “his or her” to save space.)
I. The patient’s health is always the first concern. The doctor’s job is to prevent, cure and treat disease, to alleviate pain and suffering and disability. The doctor strives to minimize the effect of personal feelings, inconvenience and discomfort, financial considerations, influence of others such as third party payers and entrepreneurs threatening to deflect the true physician from placing the patient’s welfare above all other considerations. All comers no matter what their background, are viewed as equals, when it comes to a doctor-patient relationship.
II. The physician should not violate the patient’s trust. Honesty and forthrightness are expected in all dealings. Openness is the first rule of medical practice. The patient will be justifiably fearful if he suspects the doctor is being less than honest or holding back. The physician should see himself as an educator, always striving to inform and teach, above all to outline the risks and benefits of treatments. The patient or his agent will make the final informed choice regarding medical treatments according to capacity. Anything else would constitute assault. The physician should make every effort to expose fraudulent practices and products that have proliferated on the market which make exaggerated claims and should never knowingly involve himself with such products or treatments.
III. No information should be released to any party without the express permission of the patient or his agent. Employers, insurers and third parties are pressing physician’s offices for results of HIV studies, genetic profiles and other medical tests. This information should not be used against the patient.
IV. Medical opinions are made on the basis of the best facts and reasoning and not according to the influence of outside parties such as entrepreneurial groups or attorneys.
V. Any doctor who does not have a special reverence for life should quit practice. Generally he will choose life over death except under limited circumstances may include:
A. Ending one person’s life to save another.
B. Futile care: In situations where care only serves to increase pain and suffering or where there is no reasonable hope of return of sapience (awareness) i.e. prolonged coma or persistent vegetative state.
C. Where an informed competent patient or trusted agent of a patient refuse medical treatment.
D. Issues of life and death should be settled according to ethical principles of beneficence on an individual basis and cannot be resolved in blanket fashion by religious fiat.
E. The patient is the final arbiter of his or her medical treatment. This applies to ongoing care and decisions to terminate futile medical care. Where the patient is unable to express an opinion, life and death choices should be in accord with a previously expressed opinion or may be made by previously written document such as a Living Will or by Decisions of a Durable Power of Attorney for Health Care. Even when a decision is made to end conventional medical care, every effort should be made to preserve dignity and minimize pain and suffering as in judicious use of narcotic and sedative medication. It is permissible to end life sustaining treatment under limited circumstances of futile care in accordance of previously expressed wishes of the patient or officially designated surrogate.
VI. Doctors have been recruited agents of state sponsored torture, murder and “experimentation.” and other heinous crimes. A physician who participates in such acts of his own free will, in direct violation of his duty to preserve life and decrease suffering, is a criminal. What is a worse crime than harnessing the advances in knowledge and science for evil purposes? And just as the mentally incompetent person may be held not responsible for a crime, the educated highly cognizant physician with evil intent is more guilty of transgression. Corollaries: (post-Nuremburg) A. All medical interventions should be undertaken with express informed consent and to help and never harm the patient. B. Physician behavior needs to be monitored by outside agencies.(The profession has not adequately policed itself) C. Physicians ought never participate in executions, or torture or harm (understanding that there might be mitigating circumstances for such participation in certain limited instances for example to save other lives.)
(United Nations Principles Of Medical Ethics: “UN Principles state as an absolute rule that health personnel, particularly physicians, may not “engage, actively or passively, in acts which constitute participation in, complicity in, incitement to, or attempts to commit torture or other cruel, inhuman or degrading treatment or punishment” and further illuminate the ethical obligations in the interrogation of prisoners or detainees. In particular, the UN principles hold that it is unethical for health care personnel, particularly physicians, to engage in any professional relationships with detainees other than to evaluate protect or improve their physical or mental health.” From Rubenstein, L et al Coercive US Interrogation Policies: A Challenge to Medical Ethics. JAMA 294: 1544-1549, 2005.)
VII. The doctor is duty bound to stay abreast in his field and continue his medical education. However, all he can be expected to do is put forth his best effort at all times for the welfare of his patient. The doctor is not perfect or infallible. Error is a fact of life. The doctor is expected to perform according to the standards of his specialty, and make reasonable judgments based on the information at hand. All fields of human endeavor are fraught with inevitable human error. The moral imperative is to practice in good faith. Doctors need to be allowed to be allowed to research practice strategies which have empirically been shown to decrease medical error, the only intervention shown to improve patient welfare. We ought to emphasize research on diminishing medical errors, not penalizing doctors who make mistakes. Our current malpractice tort system results in net harm and suffering for patients. The physician is in a bind, but considers it a special challenge to find a way work for the benefit of his patient despite obvious corruption and greed and ignorance.
VIII. The best doctors strive to live an upright life in one's family and/or community. He should set an example. He should not shrink from helping others and expressing compassion for those not as well off and those who live in poverty and other difficulties. The true practice of medicine is always humbling, engendering in the practitioner, reverence for life and special empathy for persons less well-off. But the doctor needs to make his own effort to maximize his own physical and mental well-being, realizing that we all have limitations and in the end are subject to the same forces and misfortunes. The doctor is part of the human family. More than that, the experience in medicine ought to have instilled a special appreciation of what it means to be a person. Above all a doctor should have a love of learning and must always be honest in all of his own dealings be mindful of his own character inside and outside the clinic.
IX. Physicians are duty bound to end practice if they are impaired, addicted or incompetent and to stop other doctors who are dangerous or incompetent. If you are jaded, have lost their enthusiasm, optimism, idealism then you may consider leaving the practice of medicine outright or at least move away from direct patient care.
X. Above all the patient should expect empathic compassionate care in a health system where they can be assured their own welfare is the top priority. The modern physician is a compassionate applyer of scientific principles. A doctor who encourages less than scientific patent or mountebank type alternative practices, particularly for their own gain, is working below ethical standards of the profession.
(C) 2007 Charles Yanofsky