Ideals and the Hippocratic Oath

Hippocrates was a Greek philosopher and physician who lived from 460 to 377 BC. He is known as the 'father of modern medicine'.¹ His work included the Hippocratic Oath which described the basic ethics of medical practice and laid down a moral code of conduct for doctors. The classical Hippocratic Oath has been translated and interpreted.² However, modern versions have also been proposed, using much of the basic principles of the original.³

Many people think that doctors still swear the Hippocratic Oath. It is not compulsory but in fact many medical schools now hold a ceremony where graduating doctors do swear an updated version. The British Medical Association has drafted a new Hippocratic Oath on behalf of the World Medical Association.⁴ The General Medical Council has also reissued its professional code and has published a document on the 'core values' of medical practice.⁵

There is a separate article that discusses Medical Ethics.

The classical Hippocratic Oath has been summarised as:

'A solemn promise:

• Of solidarity with teachers and other physicians.
• Of beneficence (to do good or avoid evil) and non-maleficence (from the Latin 'primum non nocere' or 'do no harm') towards patients.
• Not to assist suicide or abortion.
• To leave surgery to surgeons.
• Not to harm, especially not to seduce patients.
• To maintain confidentiality and never to gossip.'

The General Medical Council (GMC) is charged with the supervision of the conduct of the medical profession. This includes educational standards, ethics and behaviour. The extent to which the GMC should question personal ethics and behaviour if they do not impinge on medical practice may be debated.

The booklet 'Good Medical Practice'⁵ is sent to all doctors and is also available on-line. It discusses the duties of a doctor registered with the General Medical Council. This covers many of the principles of the original Hippocratic Oath. These duties are summarised below.

Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and you must:

• Make the care of your patient your first concern.
• Protect and promote the health of patients and the public.
• Provide a good standard of practice and care:
  • Keep your professional knowledge and skills up to date.
  • Recognise and work within the limits of your competence.
  • Work with colleagues in the ways that best serve patients' interests.
• Treat patients as individuals and respect their dignity:
  • Treat patients politely and considerately.
  • Respect patients' right to confidentiality.
• Work in partnership with patients:
  • Listen to patients and respond to their concerns and preferences.
  • Give patients the information they want or need in a way they can understand.
  • Respect patients' right to reach decisions with you about their treatment and care.
  • Support patients in caring for themselves to improve and maintain their health.
• Be honest and open and act with integrity:
  • Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk.
  • Never discriminate unfairly against patients or colleagues.
  • Never abuse your patients' trust in you or the public's trust in the profession.

You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions. Some of these points are worthy of further discussion below.

Make the care of your patient your first concern

• Our first duty is to our patients, not to the Trust, the NHS, or to Society. Society, preferably with the guidance of NICE, may make decisions about the validity and cost-effectiveness of certain types of treatments. Care for our patients does not mean resuscitating the terminally ill but we need to act with care and compassion in the interest of our patient.

Provide a good standard of practice and care

• Keep your professional knowledge and skills up to date:
  • Medicine is changing rapidly and we cannot do what is best for our patients if we are out of date. Keeping up to date is no longer an optional extra but is required for revalidation. We should try to practice evidence-based medicine where it exists.
• Recognise and work within the limits of your competence:
  • The Hippocratic Oath refers to physicians opting out of surgery in favour of those more adept in that work. One of the great attractions of General Practice is the breadth of practice but we must acknowledge our limitations. Within Secondary Care specialist centres and specialist surgeons get better results than generalists. We must do what is in the best interests of our patients.
• Work with colleagues in the ways that best serve patients' interests:
  • We are all part of a multi-disciplinary team and the aim of us all is to serve the interests of our patients.

Treat patients as individuals and respect their dignity

• Treat patients politely and considerately:
  • Complaints and even litigation are often precipitated by attitudes rather than the belief that a mistake has been made. All patients should be treated politely and considerately. Some people, particularly the elderly, like to be addressed more formally than others. Not everyone likes a stranger to greet them by their Christian name. However fraught you might feel never let go of basic civility.
  • Be sensitive and discreet in what you say or do. A light-hearted air of informality can be valuable but it may also be misinterpreted. Give patients somewhere private to disrobe. Ask permission before doing things, including before inviting a student or registrar to examine the patient.
  • For intimate examination chaperones should be offered and used.
• Respect patients' right to confidentiality:
  • This is also a reflection of the Hippocratic Oath.
  • As the care team becomes wider, the question of who should be entitled to share information becomes more complicated.
  • A court can compel a doctor to divulge confidential information but due consideration will be given.
  • Guidance states that a doctor should breach confidentiality if it relates to a serious crime.⁷ The problem is what constitutes a serious crime? If in doubt seek advice first.
  • A doctor is also under obligation to breech confidence if the welfare of children is at stake.⁸
  • The balance of best interest in terms of confidentiality and disclosure can be very difficult.
  • Confidentiality must also be respected when talking to relatives. They do not have an automatic right to know. If feasible, ask permission from the patient first.
  • Teenagers must also know that they can approach health care professionals in confidence.

Work in partnership with patients

• Listen to patients and respond to their concerns and preferences:
  • Communication is a two-way process. In a free society everyone is entitled to their beliefs and opinions. Reason by all means but ultimately the autonomy of the individual is paramount. A sane adult is permitted to refuse effective treatment. Be careful to respect people's religious beliefs.
  • The patient may simply be expressing fear or misunderstanding. Be caring and helpful in your approach, not confrontational. You may explain the lack of evidence and potential dangers of alternative therapies but avoid being dogmatic yourself. The patient makes the final decision.
• Give patients information in a way they can understand:
  • Consent can only be informed if the patient understands what they has been told. Avoid jargon, technical terms and abbreviations. When explaining risks, people of low education may not understand percentages.
  • The problem of informed consent, whether for a procedure or a drug, is to decide what is relevant. If a list of every possible complication were to be recited it is unlikely that anyone would ever take any drug or submit to any procedure. A list gives no indication of risk. It is a difficult balance to decide what to tell and what to omit. A very low risk may be omitted but it becomes more important if the adverse consequences are serious or fatal.
• Respect patients' right to reach decisions with you about their treatment and care:
  • Not everyone may want this but as far as possible it is good practice to involve your patients in making decisions about their management.
  • When the GMC relaunched 'Good Medical Practice' in 2006, "partnership with patients" was an important issue.

Be honest and open and act with integrity

• Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk:
  • A doctor who is not fit to practise from mental or physical illness must not do so. It is a demanding profession and we do our patients no service if we are not up to the requirements for whatever reason. If a colleague appears unfit to practise then action should be swift, appropriate and discrete. One may need to approach the colleague, the PCT or other employing Trust. Never denigrate a colleague publicly or to patients. Approach the correct authorities and if in doubt seek advice.
• Never discriminate unfairly against patients or colleagues:
  • However much we may disapprove of a patient's lifestyle we must not deny them autonomy or care. If a doctor has a conscientious objection to anything such as contraception or termination of pregnancy, the doctor is not obliged to be party to it. However, he must not be obstructive and must refer on the patient to a colleague who has no objection. We cannot impose our views on others.
• Never abuse your patients' trust in you or the public's trust in the profession:
  • Doctors have a favoured position in society and we must not abuse that trust. Avoid financial arrangements with patients or sexual liaisons. Patients are regarded as vulnerable and the doctor will be seen as a predator.

Ethics can be a very difficult issue and it often helps to discuss dilemmas with others. Partners or trainers may be the first point of call but others are also available to offer advice. Difficult decisions are often best shared. The Medical Protection Society, the Medical Defence Union, or whoever is your indemnity insurer will be happy to offer advice. You can also call the GMC and ask them for advice.

When you make an ethical decision remember that you may be called upon to justify it. Complex matters of ethics often do not have a simple right or wrong but all aspects of the argument need to have been explored. Consider the implications of your actions.

There are ethical problems with the use of new methods and technologies in medicine and all of these are affected by economic and political influences.⁹