Thursday, July 7, 2011

Physician Oaths and Social Responsibility


Most people are familiar with the existence, if not the content, of Hippocratic Oath taken by physicians on graduation from medical school. Whether this was originally written by that Greek “founder of Medicine” or not, it is very old, and has been updated often to be relevant to modern practice. Most medical schools do recite some modification of this oath at graduation, although some use the Oath of Maimonides, written by Moshe ben Maimon, a 12th century Jewish physician from Spain and North Africa. All are focused on the role of the physician and his or her commitment and implicit pact with his/her patients, including using healing and confidentiality. There is also a fair amount of veneration of teachers. The Declaration of Geneva adopted by the World Medical Association in 1948 after the horrific acts of Nazi doctors were revealed in the Nuremberg trials, and revised many times since then, adds some acknowledgment that the physician also has responsibility to society; it now includes the phrase “will not use my medical knowledge to violate human rights and civil liberties, even under threat”.  

This, I think, is a step forward. In the time of Hippocrates and later Maimonides, there were great limits to what physicians could do as healers. Surgery only became something people regularly survived after the invention of ether as anesthesia and the recognition of the importance of antisepsis (even hand-washing) in the late 19th century. In his graduation speech to the Harvard Medical School, Cowboys and Pit Crews (which I have cited earlier EMRs and Primary Care: The good, the bad, and the challenges, June 11, 2011), Dr. Atul Gawande refers to Dr. Lewis Thomas describing the work of an intern as recently as 1937 in his book “The Youngest Science” [1]. Those interns worked hard in order to make sure they didn’t miss one of the treatable conditions, because “There were only a few. Lobar pneumonia could be treated with antiserum, an injection of rabbit antibodies against the pneumococcus, if the intern identified the subtype correctly. Patients in diabetic coma responded dramatically to animal-extracted insulin and intravenous fluid. Acute heart failure patients could be saved by bleeding away a pint of blood from an arm vein, administering a leaf-preparation of digitalis, and delivering oxygen by tent. Early syphilitic paresis sometimes responded to a mix of mercury, bismuth, and arsenic. Surgery could treat certain tumors and infections. Beyond that, medical capabilities didn’t extend much further.”

The huge explosion of treatments, and often cures, both medical and surgical, that occurred during the 20th century far exceeds all that came before. There is an extraordinary amount that we, as physicians, can do for all sorts of conditions as well as much more effective treatments for the conditions Gawande lists above. When I trained in the 1970s, we could do things scarcely dreamed of when Thomas was an intern in 1937, and what we can do today makes the 1970s look like ancient history. We continue to see in the 21st century explosions of new therapies, some good, some not-so-good, and many unproven before they are released on the market. Our incredibly enhanced understanding of science, such as the human genome, and the amazing engineering capabilities of our technology, make it seem as if nothing is unachievable.

But because we can do things for certain diseases, because we can utilize certain technologies, doesn’t mean that we always should. Even the treatments Gawande describes above, limited as they were, often had devastating side effects that killed when they did not cure. Now we have more treatments that can be absolutely wonderful for some people in some circumstances, but not for everyone in every circumstance. [2] The complexities of these interventions make it even more important to have a physician’s ethic that understands context, understands public as well as individual health, and most important understands the contribution of food, housing, education and other social basics to health.

The “Declaration of Professional Responsibility: Medicine’s Social Contract With Humanity”, adopted by the American Medical Association (AMA)’s House of Delegates in 2001, is a more recent effort to summarize the obligations of the physician. Its title itself understands the role of the physician as more than a commitment to the individual patient but, in fact, a social contract with humanity, to the interconnectedness of all people. Its 9 points re-state many of the basic principles of the Hippocratic and Maimonides Oaths; it then adds several additional critical concepts. These include, in particular, commitments to:

“VI. Work freely with colleagues to discover, develop, and promote advances in medicine and public health that ameliorate suffering and contribute to human well-being.
VII. Educate the public and polity about present and future threats to the health of humanity.
VIII. Advocate for social, economic, educational, and political changes that ameliorate
suffering and contribute to human well-being.”

This is a very big and important step. It is even more important when not just the individual physicians, but the institutions of which they are a part, commit to core social values. Recently, WONCA, the World Council of Family Doctors, convened a conference, in East London, South Africa in October2010, to look at the Social Accountability of Medical Schools. Its final report, issued in December 2010, “Global consensus for social accountability of medical schools”, addresses 10 major areas:

&Area 1: Anticipating Society’s Health Needs
&lArea 2: Partnering With The Health System And Other Stakeholders
&Area 3: Adapting To The Evolving Roles Of Doctors And Other Health Professionals
&Area 4: Fostering Outcome-Based Education
&Area 5: Creating Responsive And Responsible Governance Of The Medical School
&Area 6: Refining The Scope Of Standards For Education, Research And Service Delivery
&Area 7: Supporting Continuous Quality Improvement In Education, Research And Service Delivery
&Area 8: Establishing Mandated Mechanisms For Accreditation
&Area 9: Balancing Global Principles with Context Specificity
&Area 10: Defining The Role Of Society

Each of these has several points listed under it, which are goals/directions for medical schools to achieve. People, and the societies that they comprise, invest heavily in medicine and medical education because they value health, and see this investment as a way to achieve health. But as the cost of medical care rises, absorbing more and more of our GDP and that of the world, it has the opposite effect. As it begins to squeeze out necessary spending on infrastructure, on education, on housing, on nutritious food, it degrades health.

While WONCA represents only family doctors/general practitioners, it is an important international organization and its recommendations will be taken seriously by medical schools around the world. To the extent that they are, it would be a good thing, because medical schools, like the physicians that they educate, need to be much clearer on how they fit into the society that produced and supports them.

Physicians and other health professionals cannot see themselves only as technicians with a bag of tools to use on the sick; they must be the custodians of health, the enablers of health, the advocates for the necessary components of healthy people and a healthy society. The Preamble to the “Declaration of Professional Responsibility” ends with this simple reminder:
Humanity is our patient.”

[1] Thomas L, The Youngest Science: Notes of a Medicine Watcher, Viking, 1983.
[2] And this does not even touch on the issue of financial cost.

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