Ideals and the Hippocratic Oath

Hippocrates was a Greek philosopher and physician who lived from 460 to 377BC. The Hippocratic oath laid down the moral code of conduct for the practice of medicine. It was probably not the first time this had ever been done as the Ancient Egyptians and the Chinese had older civilisations.

Many people think that doctors still swear the Hippocratic Oath but as it starts with the words: "I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses,"¹ few people, with or without religious convictions, would find this acceptable. It still has much that is relevant today and it has been updated in fairly recent times.² Brain Hurwitz and Ruth Richardson discussed the need for a modern version in the BMJ³ in 1997.

All of medical ethics can be distilled into the words, "treat the patient at all times as you would wish others to treat you."

The GMC is charged with supervision of the conduct of the profession. This includes educational standards, personal 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. They have a number of publications, many of which are available at their website. The booklet "Good Medical Practice"⁴ is sent to all doctors and available on-line. The start of the document is quoted:

Patients must be able to trust doctors with their lives and well-being. To justify that trust, we as a profession have a duty to maintain a good standard of practice and care and to show respect for human life. In particular as a doctor you must:

• Make the care of your patient your first concern.
• Treat every patient politely and considerately.
• Respect patients' dignity and privacy.
• Listen to patients and respect their views.
• Give patients information in a way they can understand.
• Respect the rights of patients to be fully involved in decisions about their care.
• Keep your professional knowledge and skills up to date.
• Recognise the limits of your professional competence.
• Be honest and trustworthy.
• Respect and protect confidential information.
• Make sure that your personal beliefs do not prejudice your patients' care.
• Act quickly to protect patients from risk if you have good reason to believe that you or a colleague may not be fit to practise.
• Avoid abusing your position as a doctor.
• Work with colleagues in the ways that best serve patients' interests.

In all these matters you must never discriminate unfairly against your patients or colleagues. And you must always be prepared to justify your actions to them.

These 14 items are worthy of some elaboration.

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.

Treat every patient politely and considerately

Complaints and even litigation are more often precipitated by attitudes than the belief that a mistake has been made. Being polite and considerate is part of concern for the patient as an individual. If due politeness and consideration is not reciprocated there is no reason why the patient should not be told but never cease to be polite and considerate. 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. In the words of Rudyard Kipling,⁵ "If you can keep your head when all about you are loosing theirs and blaming it on you."

Respect patients' dignity and privacy

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 are being used increasingly in Primary Care, as is standard practice in Secondary Care. They may be an unwelcome intrusion, especially if known to the patient. It is not an easy matter but nowadays the pendulum is swinging towards their presence. Be careful about glib remarks made during intimate examinations. They are especially liable to misunderstanding.

Listen to patients and respect their views

Communication is a two-way process. In a free society everyone is entitled to their beliefs and opinions no matter how absurd they may appear to others. 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. This is discussed much more fuly in ethnic matters.

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 and they may return to say, "I was right and you were wrong."

Give patients information in a way they can understand

Consent can only be "informed" if the patient understands what he has been told. Avoid jargon, technical terms and abbreviations. When advising about lifestyle make sure the patient knows what you mean by fibre or aerobic exercise. 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 can be omitted but it becomes more important if the adverse consequences are serious or fatal.

Respect the rights of patients to be fully involved in decisions about their care

It is sign of the times that patients wish to be involved. Not everyone does but as far as possible it is good practice to involve your patients in making decisions about them. When the GMC relaunched Good Medical Practice in 2006, "partnership with patients" was an important issue.

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 re-validation. We should try to practice evidence-based medicine where it exists.

Recognise the limits of your professional 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, not our egos.

Be honest and trustworthy

The GMC places great emphasis on this as patients need to be able to trust their doctors as honest people. In recent years they have been very strict about those who have falsified research. The reason for this is that if it misleads those who act on it, then the care of not one but many patients is at risk.

Respect and protect confidential information

This is also a reflection of the Hippocratic Oath. We have always respected this and the National Programme for IT (NPfIT), now called Connecting for Health will have to ascertain that confidentiality is assured. They anticipate a scheme whereby different groups will have different levels of access to records. As the care team becomes wider, the question of who should be entitled to share information becomes more vexed. 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.⁶ Thus if a doctor knows or suspects that a patient is a terrorist planning to kill many people his duty of care is to prevent this from happening. 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. 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.

Make sure that your personal beliefs do not prejudice your patients' care

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 is happy to comply. We cannot impose our views on others.

Act quickly to protect patients if you believe that you or a colleague may not be fit to practise

A doctor who is not fit to practise from mental or physical illness must not do so. It is a very 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.

Avoid abusing your position as a doctor

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.

Work with colleagues in the ways that best serve patients' interests

Nowadays even a single-handed GP is part of a team. The team may include other doctors, nurses, other health professionals, social workers and even those from outside of health care. We are part of a team and the aim of us all is to serve the interests of our patients.

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 MPS, MDU or whoever is your indemnity insurer will be happy to offer advice. Sometimes the answer has to be based on knowledge of the law. If you do not have such insurance because you are employed by a trust which holds vicarious liability, then ask those senior to you or management within the trust. You can even 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.