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IN DEFENSE OF “THE OATH”
There can be a reliable professional code, although we have none now.

                                                                      OATH
"I swear by Apollo Physician, by Asclepius, by Health, by Panacea and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.  To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the physician's oath, but to nobody else.  I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing.  Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.  Similarly I will not give to a woman a pessary to cause abortion.  But I will keep pure and holy both my life and my art. I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein.  Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free.  And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.  Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I transgress it and forswear myself, may the opposite befall me."1

 

***

Trioi latroi2

I.  The Procession of the Freshmen

Where are the living?
Where the life to which they've gone?
Under the city?
Beyond the traffic, beneath the grass?
No,                                                      in vats
gregariously waiting  for  the coming fall.
Where are the deadly?  They are coming,
they are coming in linen labcoats, stethoscopes aswinging,
to dissociate the living to learn to treat the dead.

II.  A Professional Recession

This is the beginning of the middle age of living.
I shall rediscover and resurrect my youth.
Knowledge has no meaning.
Data flip, and flee me.
I shall give up healing, abandon games of curing, relinquish operations,
eschew pat diagnoses, cease to write prescriptions,
and learn to love the living.
Finally I worship the beauty of the living.
I can aid the dying.
I can ease disease.
I shall be the living.
Maybe  life  will  free  me  from  the deathly bondage—
the cold pedantic bondage, the outrage and the carnage
physicians come to die in.

III.  Ego Hippocrates

at Cos
a fertile island
I learned to worship Aphrodite
and Asklepios
in the wholest holy way
learning flux of humors
interflux of vapors
chiasmata of physis
the nature of the whole

I have known you
man by the wall
and I have known your family
All night we have watched you in fever
calmly trusting in the gods
in human love and wisdom

by day I have walked
through groves of olives
verdant vineyards
in dialogue with students
(sons of Asklepios)
in dialogue with teachers
(my fathers and their fathers)

Cos is a silkmoth
perpetually emerging from her chrysalic
medicine emerging into daylight
into light and life                          and life.

***

There seem a variety of interpretations of the clinical trust or contract.  Why should it be so difficult for us to describe the basic tasks of the clinician?  Clinical work seems always and everywhere to have been essential to human beings as individuals and societies, and despite its many forms has basically stayed the same.  But now and again we question and argue, with no idea what direction to go.

Some argue that the forms and functions of clinical work are not so clearly defined, that they are changing, that in fact they must be changed drastically to meet overwhelming unmet needs. It is so.  Forms and functions need greatly to change and grow.  But basic principles are unchanged (though our recognition of them is dim, and requires constant refreshing).

The unchanging basic principles are what tell us what it is to be a patient (which we are fairly willing to acknowledge), what it is to be a clinician (which we are reluctant to scrutinize), and what the relationship between patient and clinician should be.  The clinician is a clinician only in relation to the patient, but the patient is who he is without the clinician.  (He is the sufferer, the afflicted, the one who has need of care.)  Let us make our definitions in the simplest and most effective way.  Given the person and needs of the patient, the tasks of the clinician and the nature of the relationship are essentially determined.

Ideally the patient is motivated by self-interest directed toward his own health.  But (as I have shown in "To Be a Patient") when any of us becomes a patient gradually or abruptly, he or she becomes significantly irrational and dependent.  It is only if the process of clinical care goes well that the patient is enabled to judge and act better in her or his own behalf.

The clinician is who she or he is only in relation to the patient.  Perhaps that one could have an independent existence as an anthropologist or biologist or such, but then not as a clinician, merely interested in humans as one might be in bugs.  As an "objective" scientist she or he could not care essentially about this patient's welfare as a person—could not be κλινικος (klinikos), the one who comes to the sufferer at the bedside.

The clinical researcher is also no "coldly objective scientist," can no more afford to sever herself or himself apathetically from the patient than he or she would from humanity itself.  That person must possess in her or his reservoir somewhere care for all patients, and especially for the real ones she or he meets.

The student, perhaps yet afraid to take direct or total responsibility toward this patient, well might consider some future patient to be cared for by his yet-to-be-competent self.  She can share in her teacher's loyalty to the patient (and the teacher reciprocally can share in the student’s).

The teacher can show her own skill and loyalty to the student, and thereby reconfirm it in himself.  As she nurtures the student and other clinical staff they will be better able to care for the patient.  (Too often the "attending" physician attends neither patient nor student nor other professional staff, is as an absentee landlord whose name is stamped on documents.)

That we daily complain of callousness from clinicians shows how sensitive we are as patients, how much we seek reassuring attention.  Clinicians often become sensitive to clinical callousness because they know how uneconomical a waste comes from distracting the patient with apparent lack of attention or concern.  Anyone who is a patient is easily overpowered, vulnerable to being hurt from disease and callous persons; the last thing he needs is inattention or abuse from clinicians.

The patient needs an advocate in the clinician. It is not paternalism to care for someone who needs care any more than it is necessary for a parent to be patronizing to her or his child.  Similar skills are required, similar awareness, in being clinician and in being parent.  To have more power than a relatively powerless other can be a great help if it is clear you are on her side.  To threaten, even inadvertently, to use it against him will likely engender terror, evasion and passive-aggressive resistance.

I have asserted that the universal solvent for all apparent medical ethical dilemmas is the enhancement of the autonomy of the patient (see "Medical Ethics--There are No Dilemmas”).  It is to be accomplished especially (but not only) by skillful treatment of whatever disables the patient, which must be based on accurate comprehensive assessment of the real situation of this patient.  One factor is universally disabling to each patient--the predicament itself of being a patient, no matter how temporary or mild the disease may seem.

Sensitivity to the patient may depend on identification with the patient, but over-identification will only enhance the patient's dependence.  (Another fine distinction!  See "The Accomplished Clinician" for more detail.)

It is clear no code of procedures or policies can solve what seem a multimyriad of clinical dilemmas.  It is only by apprehending basic principles we can have a way to discern what to do in any case, and these principles most easily can be formulated in terms of simple clinical relationships.

Doctor Pellegrino avers that "the great deficiency of the Hippocratic Oath is its lack of attention to the principle of autonomy."3I can read the Oath with a measure of imagination, and in the context of the true Hippocratic corpus I can read enhancement of autonomy.  The value of the Oath today, even though it is a late and poorly related extraction of true Hippocratic writings, is in its serving to remind us there can be a code, that there need not be chaos or ethical anarchy in our professions. 

What we do properly cannot be defined by legal limits for which there are formal punishments, nor by market forces which assume what is valuable will be sought and bought.  What we properly do must be contained within basic principles of defined relationships and responsibilities which transcend the meager legal requirements to do no punishable harm, or the hypothetical economic proposition to do what the patient demands.  There are more reliable roots, and they do reside in the soul of the clinician.  Clinical behavior without altruism is dangerous and unreliable. (See Pellegrino and Thomasma on profession4).

The fullness with which the Oath can be read implies deep feeling for the patient, the society, medical traditions, and for the divine power which underlies nature and healing5.  What we need in a code is fullness and deep feeling for basic principles, to meet the potential emptiness, pain and despair any patient’s dilemma may evoke from us.

Consider some Hippocratic statements and some commentaries on the Hippocratic ethic and tradition:

1.  Primum non nocere

Medical teachers have used this phrase longer than I can remember, giving the impression it is directly Hippocratic.  (It is not, if for no other reason than it is Latin, a language in which Hippocrates never wrote.  English-speaking professors ought not parade their ignorance of tongues.)

2. As to diseases, make a habit of two things—to help, or at least to do no harm (ωΦελειν η μη βλαπτειν) [ophelayn hay may blaptayn].
                                                                                                                                                                Epidemics I, XI xi 6

This seems the valid source, Epidemics being the valid Hippocratic work.  The "constitutions" (specifically historical ecologic descriptions) and the "cases" (unreconstructed concrete observations) convince us of the honesty of the work.  It Is the work of a clinician, not an abstractor, based on the realities of discrete human experience.

3. I will use treatment to help the sick according to my ability and judgement, but never with a view to injury and wrong-doing.
                                                                                                                                                             The Oath, Lines 16-18

This similar thought (even though the Oath was not Hippocrates' own writing) is central to any strength of the Oath.  It describes the clinician's basic relationship to each patient.  There may be other more ancient similar locutions, which only enhances the validity of this basic principle.  It is important that the Oath specifies some other important relationships, whether or not we agree with their details:  relationship of physician with teacher, student, offspring, parents, teacher's children, and the gods.  The crucial weakness is not the prohibition of procedures, but the encouragement of withholding information ("to impart precept... to nobody else" including the patient7).

4. The course I recommend is to pay attention to the whole of the medical art.  Indeed, all acts that are good or correct should be in all cases well or correctly performed; if they ought to be done quickly, they should be done quickly, if neatly, neatly, if painlessly, they should be managed with the minimum of pain; and all such acts ought to be performed excellently, in a manner better than that of one's own fellows.
                                                                                                                                              Regimen in Acute Diseases, IV 8

This is helpful in a practical way because it describes action, goes beyond the mere avoidance of doing harm.  Crucial is the exhortation to attend "the whole of the medical art."

5.  “…In the true Hippocratic writing, Hippocrates does not swear, either by Apollo or anyone else. Least of all would he have sworn by Asklepios and the latter's suppositious daughters, Hygeia and Panacea.  Hippocrates' doc­trine of rational medicine was the opposite of the Asklepian rites of magic and dream-ritual, for which he had nothing but contempt... Similarly, all the strong provisions in the Oath against surgery, therapeutic abortion, and so forth are wholly in ac­cord with Pythagorean doctrine, and wholly at variance with the Hippocra­tic doctrine.
                                            Dickinson W. Richards, M.D. "Hippocrates and History:  The Arrogance of Humanism" 9

Even though I grant his criticisms, especially of swearing by minor gods, I can read into the Oath the following valid principles:  that the relationship with the patient intends good and avoids harm, that some drastic procedures are to be avoided, and that there is a special relationship also to teachers, students and connected others.

6.  Almighty God, Thou hast created the human body with infinite wisdom...Thou hast 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 sufferings 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 Eternal Providence, Thou hast chosen me to watch over the life and health of Thy creatures.  I am now about to apply myself to the duties of my profession.  Support me, Almighty God, in these great labours that they may benefit mankind, for without Thy help not even the least thing will succeed.
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 cheerfully to 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 may recognize what presents itself and that it may comprehend what is absent or hidden...
Should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance...
Imbue my soul with gentleness and calmness...
Let me be contented in everything except 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 has 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.
                                                                                                                                                                          Maimonides 10

Maimonides’ Prayer is more simple and to the point than the pseudo-Hippocratic Oath.  It acknowledges that the benefit is the patient’s, the power is already present in nature, and that therefore the goal cannot be for the welfare or recognition of the physician.  That leaves only altruistic motives as valid and only humility and assiduous study as tools of the trade. 

7.  I am asserting that what has come to be called the system of medical care may be better understood as a series of contracts or understandings rather than an array of facilities, trained professionals and instruments...My own view is that the two-party contract wherein two individuals negotiate an agreement about what is wrong and what is to be done, remains central in medical care and is essential to its regular effectiveness.
                                                        Richard M. McGraw, M.D. "Social and Medical Contracts Explicit and Implicit" 11

Whatever elaborations and qualifications we impose on the clinical relationship, it must irreducibly be equivalent to a two-party contract, because the patient must be one real person, and the clinical agent (whether a single person, a team, an institution, or whatever) must relate to the patient as if another person.  The relationship must be personal.

8.  AMA:  Principles of Medical Ethics 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 American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.
I.  A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity.
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 services.
VII.  A physician shall recognize a responsibility to participate in activities contributing to an improved community.

The deficit here is that no relationship is well defined.  Each statement is diversely qualified.   Certainly the impact is not patient-centered, nor is there any acknowledgement of the autonomy of the patient.  There is no coherence.  This is of little value12.

9.  University of Colorado School of Medicine—Honor Code Pledge Card
The Honor Code of the University of Colorado School of Medicine states that students will behave in an ethical and honest way at all times.  When any student or faculty member observes or knows about dishonorable conduct any kind, he should discuss it with the person who has behaved in an unethical way.  In addition, that behavior must be reported to the Honor Council or any of the five class representatives.  Failure to report dis­honest behavior is also a violation of the Honor Code.  Honor Code violations are investigated by the Honor Council, which consists of one class representative from the freshman, sophomore, and junior classes, and two from the senior class, as well as two ex-officio faculty members.  The Honor Council makes the recommendations for disciplinary action to the Executive Committee, which consists of the Department Chairmen and the Dean of the School of Medicine.
I, the undersigned, pledge that I will uphold and support the Honor Code of the University of Colorado School of Medicine as described above.
Date_______S i g n a t u r e___________________13

No behavior or principle of behavior is specified.  The "constitution" which underwrites this pledge denies the possibility or necessity to "designate or categorize conduct with reference to whether it is honorable or dishonorable..." The unfairness to the student coerced to sign this pledge is evident, but also unnecessary, since we can take hold of a more comprehensive professional code, whether we choose the arcane old one (traditional if not legitimate ) or generate a new one.  There is no advantage to anyone in imposing on students something less lofty than the most ambitious of codes; and if the most ambitious is appropriate to the novice, the teacher will easily adopt it for himself.

10.   "A  Physician's  Affirmation"  by Fredrick R. Abrams 14
In order to be worthy of self-respect, I pledge to respect others who place their trust in me as a pro­fessional in the healing arts . Therefore:
I will practice my art and my science to benefit my patients.  I will disclose to my patients that which I know of their disease, and any hazards of the remedies I might suggest, that I may guide them to choose the course that suits them best.
I will offer care and comfort when they are ill, and when death becomes inevitable, I will ease their way as best I can in keeping with their ex­pressed plan.
I will recognize their right to self-determination, and if conflict should arise with my own ethical restraints, make them aware without judging wherein we differ, that they should consider seeking help elsewhere for their complaints.
I will intercede in their behalf within the scope of my authority if I perceive they are being treated with­out regard for their humanity.  I will hold in confidence that which is seen or heard in my role as a physician.
I will ever be a student to sharpen my skills and further my knowledge that I may be a better clinician. If I act in this way I may aspire to join men and women who, through the ages, have approached the loftiest ideals of the healing mission, for I will have earned the faith and trust which is the strongest tie in the bond between patient and physician.

My respected colleague has captured a great deal of what a professional code should include. He has made clear the responsible relationships to which he aspires:  relationship to patients respecting their autonomy, hopes for self, and honor for those who share his profession in the past, present and future.

11. This emphasis on the physician doing what he or she thinks will benefit the patient even in the face of the patient's contrary desires is classical Hippocratic professional ethics.  It is oblivious to broader ethical requirements, independent of consequences, including notions of patient's rights15.

Patients are always dependent because of their afflictions.  To acknowledge this reality can lead, rather than to paternalism, to effective enhancement of the patient's autonomy.  To help the sick to the best of one's ability and judgment is not an evil, nor does it require one to ignore the patient’s choices.  (Quite the opposite.)  Veatch's A Theory of Medical Ethics deserves a response.16

I thought Robert Veatch would likely treat problems of medical ethics from a formal contractual viewpoint, that I would come away from reading his book with the vague impression he had never been a clinician or patient.  I know he is a teacher in relation to students, that he must have been a patient, and that he has had extensive clinical experiences, but I do not read his personal experiences between his lines.  I do not sense his "subjective" experience as a person involved in the clinical relationship.  I read only his "objective" experience as a critic.

I thank him for having carefully outlined an apparently rational basis for understanding three levels of moral contract which illuminate the clinical relationship:  (1) the basic social contract incumbent upon all members of so­ciety; (2) the general role-defining contract between society and the professional group; and (3) the specific agreement between a clinician and a patient as equal contractors, which can take place under the aegis of the two broader contracts.

There is strength and value in this apparently rational approach, but it withholds itself from the realm in which real clinical encounters occur.  Its weakness is the same as the weakness of the law, whose admitted limitation is that it cannot surely identify the exact principles the ideal "reasonable" person would use in every case.  There is a reality and a measure of universality in clinical phenomena, and these do not clash with Dr. Veatch's work, but there must also be a way to integrate clinical reality with social theory.  We certainly agree there is an apprehensible standard far more reliable than the mere consensus of a self-interested professional group.

A crucial area to scrutinize is Dr. Veatch's detailed strong criticism of "the Hippocratic Principle," the major elements of which he identifies as consequentialism, paternalism and individualism.  We always seem to agree the patchwork which has come to us as "Hippocrates" is imperfect, but it draws us to use it ever again as the soil in which we are rooted.  "…(T)he Hippocratic ethic is dead," Veatch says (p. 170), and I will gladly help him bury it as soon as I am convinced it is more dead than God used to be.  Like Veatch, I also have struggled with Hippocrates, but have found him an ally, not an adversary.

Veatch quotes Edelstein's translation, "I will follow that system...which according to my ability and judgement I consider for the benefit of the sick.”17  Jones says, "I will use treatment to help the sick according to my ability and judgement.”18  The problem I have in digesting Veatch's criticism of the Hippocratic Principle comes partly from his having "divided to conquer."  He properly identifies the inherent focus on outcomes (and displays the variety of interpretations of "to help, or not to harm" versus "primum non nocere") but does not integrate that focus on outcomes with the "paternalism" of the Hippocratic Principle.  He does not integrate paternalism with individualism.  The lack of integration I sense in Veatch's book is equivalent to an ignoring of clinical phenomena.  Robert Veatch is the rational analyst, taking apart the living experience, abstracting it too distantly.  Consequentialism, paternalism and individualism are all implications of the Hippocratic Principle, but they come as a package, the results of practical experience; they have some value as truisms when seen in context, in relation to each other.

The central phenomenon of the clinical relationship is dependence of the real individual patient on the real individual clinician and the clinical context in all its awesome magnitude and intricacy.  It is not his autonomy which characterizes the patient, but exactly his lack of autonomy.  To emphasize the autonomy of the patient in medical ethics is utterly important because given the initial dependence of each patient the clinician too easily can perpetuate dependence and inhibit autonomy, consciously or inadvertently.  I beg clinicians to use much of their energies to enhance autonomy.  Autonomy is the goal (coherent with health), but it is not the condition of the patient as the clinical relationship begins.  We do not often get the opportunity to treat persons through their health, but usually because of their disease.

Accepting Veatch's analysis of the Hippocratic Principle, that it consists of consequentialism, paternalism and individualism, I will show how taken together they are coherent, productive of good, and valuable as a basis for a code for the clinician (although not the basis of a code for patients or third parties).

Attending to consequences in each individual case for the sake of that real person is the essential orientation of the personal clinician.  (Other clinicians may have proper focuses elsewhere--in community health, research, et cetera--but they are acting somewhat differently.)  Consequentialism and individualism need not be problematic.  It is paternalism which is hard to swallow.  Why need clinicians seem paternalistic?  (It is the paternalism of the Hippocratic Principle which has caused concern for Edmund Pellegrino and other clinical ethicists, and seems anathema to Veatch.)

If the benefit to the individual patient is to be considered, Veatch asks why all benefits to the patient not be considered, not only physical and psychological.  But he says, "Physicians seem to be in no position to assess them since they have no particular expertise in economic, spiritual, aesthetic, intellectual, or other non-medical dimensions of benefit to the patient." (p.148)  Shall we have a committee of consultants for each citizen in need?

Whether expert or not, physicians often are trusted to help in all these areas, and have developed some capacity to help.  Physicians also participate in formal legal responsibility beyond the physical and psychological.  Even if the clinician is not ideally expert, why should he not consider all benefits for each individual?  If we emphasize the consequentialist aspect of the Hippocratic Principle, then we must carefully consult each individual patient in detail about what his proper individual needs and desires may be.  Concern for the outcome is bound inextricably with individualization and necessitates communication with the individual who is involved.  Paternalism may be implied, but not lack of communication with the patient.

Veatch so narrowly considers "my ability and judgement" that he jumps to the conclusion the clinician will somehow manipulate the patient utterly without the patient's consent or participation.  Such unilateral manipulation and exploitation of human persons has never been proper clinical behavior, nor will it ever be.

The statement of the Hippocratic Principle is clinician-centered because the clinician's behavior can be submitted to standards, can be programmed and controlled.  The patient's behavior can­not be standardized.  The patient is bound by no rules.

There can be no "contract between equals" here, because the parties are not equal.  The autonomy of the patient is not a given, but it certainly is the central goal of the entire clinical process.  There can be a series of understandings, but they must continually be changing to suit the changing situation of the patient, the changing clinical relationship.  Whether the outcome of the clinical process goes well or ill, the status of the patient is continually changing, but not so the status of the clinician.  The clinician's role can be standardized and codified because his responsibility to the patient is constant.  The patient is obligated only loosely to one thing--concern for self.

Veatch comes to the formulation, "The physician should benefit the patient according to the most objective judgement available unless the patient autonomously chooses some other course, provided the physician's own conscience is not violated beyond limit." (p. 149)  This complex standard implies the greatest validity is in the "most objective judgement available," modified by subjective vetoes from the patient or the clinician.  In fact, proper clinical decisions are made in a dialogue between clinician and patient which involves each party subjectively and objectively, with a shared assumption that the benefit of the patient is the central goal.  Difficult situations may bring in other parties, but the proper nature of the process is not changed thereby, only confused often.  (This is the dangerous rationale which is used to support irrational programs like DRG's.)

What if the patient wants something not in his own or society's interest?  Some decision will be made, even if it is for inaction.  When the clinician makes a decision "according to my ability and judgement" she takes responsibility for her assessment, recommendations and action.  The clinician takes responsibility to the patient and to the community, not from self-interest but from duty attached to her role, defined (imperfectly) by her code.  The clinician professes to care about the outcome, but it is the patient who must ultimately take the responsibility, for he directly suffers the consequences.

The difference between the actual and the ideal is great, but the clinician is closer to being able honestly to contract than is the patient.  Cultural changes may be bringing the patient-consumer closer to the ability to contract openly and honestly, but it must always be so that the clinical process will begin with a relatively anxious and incompetent patient and (I hope) a relatively competent and calm clinician.  The ideal process immediately begins to enable the patient, progressively to bring him closer to the autonomy Veatch posits hypothetically at the beginning.

Veatch proposes a three-level contract.  The first two levels might be achieved, never perfectly (the social contract and the contract of the professional group).  The third, the concrete contract between clinician and patient, cannot be had as he wishes.  It is the result, not the beginning of the clinical relationship.

Perhaps there is a way to formulate the three-level contract Veatch seeks, but it will always be a lop-sided agreement.  The patient's part of the agreement is simple, something like, "I depend on you to help me become more autonomous (more able, more healthy), and I will honestly try to participate in my own behalf."  The burden on the patient is his responsibility for his own life in all its ramifications.  He is not intrinsically burdened within the clinical relationship.

The clinician is bound in the contract by something like this:  "I will follow that system...which according to my ability and judgement I consider for the benefit of the sick" because I am the one who takes responsibility until the patient can more fully care for himself; and I will relinquish power over him from the beginning and throughout our relationship according to his current ability to take responsibility for himself; and I will participate in an ongoing dialogue with him as to how well and able he feels; and I will always be ready to err on the side of promoting his autonomy, at the potential risk of his other goods, because the patient is a person with rights to choose, and I am neither omniscient nor omnipotent.

___________________________________________________

1 This translation of the “Hippocratic Oath” which we shall discuss here is from the Loeb Classical Library Hippocrates, volume I, page 299, translated by W.H.S. Jones.

2 In medical school in the late 1960’s I reached with some depth of feeling for a personal essence of each physician, looking to a communal character shared with my father; my friend Norman Singer the first physician to be killed in the war in Viet Nam; my teacher Ernst Lachman who first told me Norman had been killed (which gave me the last line of the second part, the last line yet to be written that day “the outrage and the carnage physicians come to die in”); and the teacher of all of us, Hippocrates whose honesty and altruism represent the physician in all of us.

3 Personal communication from Edmund Pellegrino, January 12 , 1982.

4 Pellegrino and Thomasma, A Philosophical Basis of Medical Practice (New York:  Oxford University Press, 1981).

5 A sentiment expressed by Leon K . Kass, M.D. in his lecture given November 12, 1980 at the University of Chicago,  "The Hippocratic Oath:  Thoughts on Medicine and Ethics".

6 Hippocrates, translated by W. H Jones, Loeb Classical Library, Vol. 1, p. 165, Harvard/Heinemman, 1972.

7 Op. cit., Vol. I, p. 299.

8 Op. cit., Vol. II, p. 65.

9  Bulger, Roger J., Hippocrates Revisited:  A Search for Meaning, Medcom, New York, 1973.

10 Abraham Joshua Herschel, Maimonides, (translated by Joachim Neugroschel), London, Faber, 1982.

11  Detailed criticisms may be found in Pellegrino and Thomasma, A Philosophical Basis of Medical Practice and in Veatch’s A Theory of Medical Ethics.

12 This version of the AMA principles was in use when I jotted these notes.  Earlier and later ones are similar, so far as I can see.

13 Again, this is the old reality, which I trust has been improved in the past three decades.  It is not so important what those dear deans of the medical school had done before that day, but that Jock Cobb and the rest of us were having a seminar among us at breakfast to improve on the status quo.

14 Abrams, F.R., "Social Needs and the Physician’s Duties:  A Physician’s Affirmation,” People and Policy, 1979, 1; 18-21.

15 Veatch, Robert M., A Theory of Medical Ethics, New York, Basic Books, 1981.

16 And I am thankful for his response to me which was (in essence) the familiar message:  You are dead wrong, but I will defend to the death your right to be so.

17 Edelstein, Ludwig, Ancient Medicine,  Baltimore, Johns Hopkins, 1967.

18 Op. cit. (Hippocrates), Vol. I, p. 299.

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