Often people boil medical ethics down to a saying: “First, do no harm,” and attribute that to the Hippocratic Oath. For those who love Latin, that phrase is Primum non nocere. In fact, Hippocrates never said that.
“First do no harm” makes a nice sound bite, but is as limited as the treatments that Hippocrates had for his patients. Physicians have evolved thinking about medical ethics much beyond a phrase. The reason is this: we know that treatments can cause harm. Because we know that treatments can cause harm we must balance that with the good that they do.
The “oath of Hippocrates” has changed from its original text. So when someone asks, “Did you even take the Hippocratic oath?” the answer is “no.” My medical school class did not swear this oath because it is out-of-date and out-of-touch with modern medicine. Certainly surgeons cannot use the oath, as the phrase, “I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.”
Here is the “classic” version of the Hippocratic Oath:
I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:
To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art—if they desire to learn it—without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.
I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.
I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.
I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.
Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.
What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.
If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.
Four Pillars of Modern Medical Ethics
Today, the ethics of medicine are built on four foundations- and these pillars of ethical medicine have come about because of the horrors of Nazi Germany, the Tuskegee Syphilis Study, and modern transplantation surgery. We have had to build these ethics to not only encompass medicine, how we practice it, but how we conduct research with our patients.
Those four pillars are autonomy, nonmaleficence, beneficence, and justice.
As a physician we have ethical obligations, and expectations to our patients of autonomy – people are truly free to choose their treatment, but must have the information that is required to make a choice. It is the patient who has the choice- even if we think we know what is good for the patient; it is not up to us to make that choice for them.
But the physician also has autonomy. The physician can choose to not treat a particular patient. Sometimes our ethics come into conflict with that of a patient, and it is our choice to not treat them.
A key tenet for physicians is nonmaleficence – to not use our skill and knowledge to harm a patient. Deliberate harm would be to put a patient at risk for a treatment we know doesn’t work. Risk associated with procedure does not count as “doing harm” unless the procedure has no hope of benefit.
When non-physicians offer treatment that they state “has no harm” they would be violating medical ethics. Many non-medical treatments have not been tested, so we do not know how they would compare to traditional treatments. When “Traditional Chinese medicine” offers a tea that ultimately causes kidney failure, they have violated ethics that a modern physician would lose their license over: the treatment was not tested, and when it was found to cause harm, they didn’t ask for it to be removed.
We know conventional chemotherapy has the potential to cause illness, and even death – I know this personally because my brother died four years ago after his first dose of chemotherapy put his frail body into septic shock, from which he did not recover. Some suggested that because my brother had metastatic lung cancer that the chemotherapy robbed him of the few months he had- and therefore the physician went against nonmaleficence by administering a therapy that would not do benefit. But that chemotherapy was not to prolong Jimmy’s life- certainly there were no illusions that it would cure him – but he was suffering horribly, and it was hoped a reduction of the tumor burden would give him some relief.
This is the tenet that as a physician it is our duty to act in the best interest of the patient. This means to directly intervene, if possible, for the comfort and well-being of our patient. The key is that we are not the ones who judge this- it is the patient, and not the physician, that determines this – and involves other aspects besides health and survival. As a physician we must be trusted, we must be truthful, and we must respect confidentiality of our patients above all else. It is our goal to ease pain and suffering- and not cause it. And while not all providers and patients weigh this the same- this is not judged by the physician, only by the patient.
This is not judgment- this is the concept of fairness to all. While there are limited resources- we must find a way to make these resources to our patients in a fair manner. The transplant world deals with this in how organs are distributed among those in need.
For research patients, this means that we ensure that reasonable, non-exploitative procedures are administered fairly, that there is a distribution of costs and benefits to potential research subjects.
Application to non-physicians
As physicians, we take on these ethics. We are held accountable to them by our state medical boards in the US. But not all who claim to treat people abide by these.
As a foundation of these, we trust that the medicines and the treatments we prescribe will be beneficial to our patients, and as a result, we demand that these medicines be tested. This is not so with supplements.
When an herbal tea given by people who practice “Chinese traditional medicine” caused patients to have kidney failure and some to die, the tea was pulled from the market. However, in the United States, supplements do not fall under the FDA. Our ethic would demand that this “medicine” be tested, and that there be a place where adverse events related to the tea could be accumulated as an early warning system. But the traditional Chinese Medicine have no such ethic – nor do they care to have their supplements tested.
When a medical device, or a drug, is recalled by the FDA, or voluntarily recalled by the manufacturer, it is proof that our system is working. Like many systems, it will not be 100 per cent – and there are sad stories of drug companies that have withheld information from the FDA and publications. Thankfully, that is in the minority.
I’ve been involved in FDA studies, and every adverse outcome from any patient is reported. That is the standard that the FDA demands. We may not see the connection to the device, but if an adverse event continues to occur then the FDA investigates quickly. In contrast, adverse events with supplements occur without any oversight by any authority. There is no central place where all adverse events are recorded.
When a non-physician states that a particular ailment can be cured by “food” – there is often no proof other than anecdotal proof. Meaning, someone thought they improved after changing foods, or diet. These people will often quote Hippocrates, “let food be thy medicine, and medicine be thy food.” Since Hippocrates lived in the 5th Century BC he had no modern medicine to compare anything to, nor did they have the scientific method established to treat patients. Hippocrates did not even want his physicians to practice surgery.
Treating people with “diet” when that is not tested or proven is not ethical – but more about that later.