New Doctors and the Hippocratic Oath

Excerpted by Elizabeth Hanink from article by Fritz Baumgartner MD, and Gabriel Flores MD.

 

Recently a member of the Scholl Advisory Board published a study in the Linacre Quarterly concerning the attitudes of future doctors with respect to the Hippocratic Oath. The Oath has been a guide to physicians for centuries, and the public often assumes that all graduating medical students make the classic promises enshrined in the document: to treat the ill to best of one’s ability, to give no deadly medicine to anyone if asked, nor suggest any such, and so forth.

But, as Fritz Baumgartner MD, and his colleague Gabriel Flores MD, point out in their article “Contemporary Medical Students’ Perceptions of the Hippocratic Oath,” today’s doctors quite possibly take a different oath. Adaptations eliminating the original’s prohibitions of abortion/euthanasia are common. What follows are excerpts from the article. Our thanks to Drs. Baumgartner and Flores for allowing the use of this study.

“The Hippocratic oath has achieved rightful stature as an ethical guide for physicians for millennia (Cameron 1991). Modern medical student’s views of the oath would seem important, considering health-care legislative changes mandating abortion/contraception coverage, efforts to limit conscientious objection, and legalizing euthanasia. Our study queried whether students view the original Hippocratic oath as relevant compared to modified forms, whether the original should be taught or recited at all, and whether students should be given a choice of version of the oath. We assessed students’ grasp of the actual contents of the original oath and its applicability to various ethical scenarios, with special consideration to the Nuremberg trials, physician-assisted suicide, and abortion.

“Students were. . . asked whether eleven specific events violated or exposed violations of the original oath. These included Salk polio vaccine trials (Meldrum 1998), Nuremberg medical trials (Ivy 1949), wrong-eye surgery and altered medical records (Harbin 2009), Kermit Gosnell abortion and infanticide murder trial (Friedersdorf 2013, Taranto 2013), Tuskegee syphilis experiments, (Meyer 1981), physician-assisted suicide (Physician-assisted Suicide 2013; Colbert, Schulte, and Adler 2013); California forced-sterilization practices in prisons and mental institutions (Stern 2005), withholding nutrition and hydration from patients in a chronic vegetative state (e.g., Terri Schiavo case; Fine 2005), unnecessary cardiac surgeries done on normal patients (Klaidman 2008), New York lawsuit detailing organ harvesting from patients not yet meeting the criteria of brain
death (Schram 2012), and China’s forced one-child limit family policy (Kane and Choi 1991).”

“How do modern medical students react to, interpret, and apply the Hippocratic oath? Our study is limited by the low (27 percent) response rate. Certainly, it is conceivable that the respondents themselves are a skewed subset of the overall student population. . .

Despite these limitations, some trends in medical-student thought processes regarding the oath can be gleaned from the study.

“Nearly a quarter of the responding students considered the original [oath] as not at all or not very relevant, and 13 percent felt medical schools should not even provide opportunities for students to learn about the original. Most considered the modified version as more applicable and disagreed with using the original at graduation. Although some comments left by students were supportive of the original, many were not, with some describing it as ‘archaic,’ ‘inapplicable,’ and having ‘flagrant sexism.’

“Our hypothesis was that increased knowledge of the contents of the original Hippocratic oath would correlate with an increased desire that it be used. The results showed the complete opposite. Those who felt that the original Hippocratic oath should not be used know the contents of the oath significantly better than those who felt that it should be used, and the difference was even more pronounced between those who strongly felt one way or another whether the original be used. Further, those students who did not desire that the original Hippocratic oath be used, especially those who felt strongly so, recognized the original’s stipulations against euthanasia and abortion significantly more often than those who desired that the original be used.

“These finds are concerning given that historically, the original Hippocratic oath has been an enduring ethical standard for physicians, not the least of which included being a yardstick by which were judged medical atrocities of the last century, including those revealed at the Nuremberg trials. It is possible that many modern medical students view the Hippocratic oath as an historical relic. They are not, however, willing to discard it  altogether, there remaining a sense that the oath, in some way, is vaguely relevant. The value of a nebulous Hippocratic oath remains, even if only for distant emotional, rather than acutely practical, purposes.

The doctors continue:

“Medical providers’ impression of the Hippocratic oath have practical importance, not only in case-specific and physician-specific instances but in
general health-care policy. A recent ‘Consensus Statement on Conscientious Objection in Healthcare’ by prominent bioethicists has argued that the legal protection of physicians who conscientiously object to euthanasia and abortion is ‘indefensible’ (Ballantyne et al. 2016). Doctors who refuse such procedure, they recommend, should be brought before ‘tribunals’ and forced ‘to compensate society and the health system for their failure to fulfill their professional obligation.’ Furthermore, medical students ‘should not be exempted from learning how to perform basic medical procedures they consider to be morally wrong.’ The signatories of the consensus statement were overwhelmingly bioethicists without medical
degrees, paralleling the spate of recent bioethics articles decrying conscientious objection by physicians. (Savulescu and Schuklenk 2016; Schuklenk 2015, Savulescu 2006). A statement from one article (Savulescu and Schuklenk 2016, 163) that the ‘scope of professional practice is ultimately determined by society,’ implies that the history and function of authentic medical practice as a learned profession with Hippocratic ethics has been usurped by regulatory decree. Genuine medical care, however, is not merely determined by the mandates of the powerful. Despite the lack of practical medical provider input, the specter of integration of these recommendations by international legislative bodies remains.

Baumgartner and Flores then conclude.

“Financial gain, power, and technology for its own end are ever-willing surrogates for a medicine severed from the Hippocratic tradition. Extreme ideologies of the last century have shown how quickly and easily it is to usurp a medicine separated from its moral roots. This is apt to be even more prevalent in the context of a relativistic culture whose moral foundations are in danger of asphyxiating. History has lessons to teach us and to relinquish a noble profession to a truncated paradigm of medicine devoid of Hippocratic principles hardly seems in the best interests of current or future patients. Our study raises the possibility that many medical students do not consider the Hippocratic oath as relevant to modern medicine. If such a void does exist, this then raises the question of what moral frameworks these new physicians utilize for the ethical practice of medicine and what authority such frameworks have.”