Orthopedics Research and Traumatology

Open journal

ISSN 2473-0963

Changing Ethics and the Hippocrates Oath

Rakesh Bhargava*

Rakesh Bhargava, MBBS, MS

Professor and Head Department of Orthopedics, National Institute of Medical Sciences, Jaipur, RJ 303121, India; E-mail: drrakeshbhargava@hotmail.com

When I graduated in 1973 and registered with the Rajasthan state branch of the Medical Council of India, I was given a copy of the Hippocratic Oath.

That it is no longer the practice speaks volumes for what it is worth. Taking the Hippocratic Oath is probably no longer in practice, even though it can be of great worth and value for medical practitioners today.

How many freshly graduating doctors would even recognize it, let alone read it or swear by it?

Quite recently, this was the subject of a debate in the doc2doc blog of the BMJ, and in related publications.1,2

With an ongoing debate concerning the legalization of abortion and euthanasia, a tenet of the Oath stating ‘Not use my knowledge in contrary to the laws of humanity’ has already bitten the dust.

In 1964, Louis Lasagna, the Academic Dean of the School of Medicine at Tufts University, wrote a modern version of the Hippocratic Oath which was, and is still being used in many medical schools in the present day.3

Hippocratic Oath (Modern version)

  • I swear to fulfill, to the best of my ability and judgment, this covenant:
  • I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
  • I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
  • I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.
  • I will not be ashamed to say “I know not,” nor will I fail to call my colleagues when the skills of another are needed for a patient’s recovery.
  • I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given to me to save a life, all thanks. But it may also be within my power to take a life; this responsibility must be faced with great humbleness and awareness of my own frailty.
    Above all, I must not play at God.
  • I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect his family and economic stability. My responsibility includes in attending to these problems, if I am to care adequately for the sick.
  • I will prevent disease whenever I can, for prevention is preferable to cure.
  • I will remember that I remain a member of the society, obligated to all my fellow human beings, the sounds of mind and body as well as the infirmity.
  • If I do not violate this oath, may I enjoy life and art, be respected while I live and be remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.3

It can be easily pointed out that we are not ‘swearing by the Gods’ anymore.

The medical profession over the years has been given the adulation and the respect of the society, reserved for Gods, at least in India. Doctors were, and still are, remembered and revered, and the entire society in general, and the media, never fails to highlight the nobility of this profession. The Oath promises and assures all medical practitioners an everlasting reputation among their people throughout their lives, by the virtue of their skills and profession. This same medical fraternity; however, is presently experiencing anguish on account of their antipathy to the deviation in the focus of doctors towards their demands of power and fame.

The following three issues have been raised on account of the violation of the Oath, considered as the “Corpus Delicti”, namely “avoiding the twin traps of overtreatment and therapeutic nihilism”:

  1. Lack of ethical considerations while performing diagnostic investigations;
  2. Unethical prescribing of drugs and medicines;
  3. Performing surgeries unnecessarily by unethical means.

Some of these ethical issues may not be relevant to many or all developed nations; however, they are unfortunately omnipresent in all developing countries, especially in India.

Lack of Ethical Considerations while Performing Diagnostic Investigations

The commonly implemented medical malpractice is to prescribe diagnostic tests where they may not be clinically relevant, on account of the commission that doctors receive in exchange from the concerning laboratory.

I personally talked to some of the Laboratory Operators and what was disclosed in the conversation, was an eye opener for me at that time. I was told that there was a pre-existing practice of offering ‘cuts’ to the doctors because it was believed that the uniformity of the system of providing ‘cuts’ removed the ignominy associated with having to direct a patient to a laboratory for performing various tests. What was more appalling was the observation that the percentage of occurrence of

this practice varied between the laboratories and the physicians involved ranging across 25% to 50%. The saving grace was the absolute honesty about it all. When I asked why such a malpractice was so predominant in the system, the point of justification was that ‘Everybody is doing it’.

The point here that requires greater attention is that whether the laboratory charges will differ if you carry a doctor’s prescription, or go to the laboratory directly without prior intimation of the doctor.

Well, these charges will not be any different. The laboratories pay the doctors the compensation on the basis of their profits, and not by fleecing their patients. Some consolation there!

Virtually, every patient visits us with an MRI, and no XRay report. The patients complain that the doctor did not bother to look at their X-ray films, and merely glanced at their reports. Inevitably, the patients failed to understand if undertaking the Xray for diagnosis was necessary.

Unethical Prescribing of Drugs and Medicines

There was a huge hue and cry over generic medicines. What is the semantics and politics behind this facade?

There are nearly 40,000 companies, big and small, that manufacture drugs in India, and these organizations continue to grow by the hour. These pharmaceutical companies are all licensed by the Drug Controller of India, and is associated with the production of good quality drugs following the appropriate ethical guidelines. The fact is that the actual manufacturers of generic drugs are generally very few in number, 1333 to be precise. The generic drug manufacturers thereafter sell their products to other smallscale manufacturers who capsule or bottle these pharmaceutical products, and sell it under their brand name. Thus, these sundry drug companies with minimum turnovers function as real packaging units. It is however, worth questioning as to how such companies are able to sell their products at cheaper rates than the generic manufacturers themselves. One of the possible reasons could be the overhead expenses the bulk manufacturers have to deal with, be it advertising, research and development costs that need to be addressed, while maintaining high profit margins. The smaller units generally prefer lower profit margins, but high turnovers.

These smaller units bear no hesitation to offer ‘cuts’ to the prescribers and when you envisage that for every doctor that refuses, there are more than an equal number of doctors who are willing to engage in this practice thus presenting, a panoramic picture to the situation. To stop the doctors from receiving their ‘legitimate cut’, there arose a hue and cry to force them to prescribe only generic drugs. Fair enough, but when a generic prescription goes out in the market, who dispenses the company brand? The chemist who is a trader and a businessman. The doctor may be discreet and discerning sometimes, but the chemist will always promote the brand maintaining maximum profit margins. Trusting him to do otherwise is like trusting Shylock, the character from Shakespeare’s play, Merchant of Venice, to dispense with his pound of flesh. So which will it be Scylla or Charybdis, the devil or the deep sea?

There are umpteen number of drug companies manufacturing drugs. Assuming that all the multinational companies manufacture high quality drugs, there is still a plethora of similar drugs being sold in the market. Give one reason why a doctor should prescribe a reputed company’s drug over another, all satisfying the same requisite criteria. Because they send regular multicolored brochures which are mostly a waste, or because the representatives associated with these companies leave my table loaded with free samples I do not need, and have a hard time giving it away because my patients do not need them either?

The Mr. Hyde in Dr. Jekyll has a very plausible and acceptable reason. Because that particular company rewards him, or may be takes him to conferences to enrich his knowledge and skills. You will find a large number of people who will cry foul at this justification, but look around, search and tell me one profession where this situation is not rampant in some form or the other.

The ethical issue is whether we are prescribing too much for too little or whether we are following evidence based medicines.

Performing Surgeries Unnecessarily by Unethical Means

“That warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug”, says the Oath

The Oath states ‘I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery’.

In October, 2013, at the International Society of Orthopaedic Surgery & Traumatology (SICOT) World Congress at Hyderabad, Dr. S. Rajashekaran, the President of Indian Olympic Association (IOA) in the past, gave a plenary lecture. He spoke of the needless fixations of the traumatic spine despite the absence of any definitive evidence of benefits. He also felt that there was an unnecessary use of implants, probably due to a growing push from the industry.

He also wondered if Dr. Jekylls were turning into Mr. Hydes.

Dr. Augusto Sarmiento, the Past President of American Academy of Orthopaedic Surgeons, practicing in Florida, U.S.A., published an article in the Journal of Bone and Joint Surgery American in 2008 entitled ‘Is Socrates dying’.4

He felt that medicine was ceasing as a profession and increasingly becoming a business. New and improved modality of treatment primarily benefits the manufacturer of the devices. The preference for surgery in the management of virtually all musculoskeletal conditions, is based on the economic considerations of the physician treating the patient or the corporate hospital in which the treatment is being undertaken. The education of the orthopedist is largely focused towards sustaining the marketing needs of the industry.

Huge kickbacks to the orthopedist for the usage and support of such industrial products, is a universal unspoken truth.5

Presently, we seem to be operating more towards the numbers and kickbacks, and non-operative treatment is now a passé.

Ask any treating physician why and wherefore, and the most bizarre rhetoric will be “If I don’t do it someone else will”.

This has now become the most compelling indication for performing surgery.6

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.”

We have completely forgotten this tenet of the covenant.

In the latest issue of the Journal of Bone and Joint Surgery, Dr. Augusto Sarmiento writes in the Orthopedic Forum about “What’s Important: Putting the Patient first”.7

Many of the issues he holds responsible for the changing priorities of the Orthopaedic Surgeons in particular hold good for all the physicians, in general. Once again, they have rendered the Oath redundant.

Since medicine involves apprenticeship, postgraduates are learning similar concepts. Neither the teachers nor the students being taught are aware of evidence based guidelines or protocols.

In the race of outdoing others, everyone seems to be playing a game of numbers.

Sometimes these numbers are largely falsified, such that even the manufacturers are baffled, for they do not sell as many implants as the claims associated with the sale.

To Impart Precept, Oral Instruction, and all other Instructions in Medical Institutions

Medical colleges seem to be showing a mushrooming growth at the most frantic, yet hazardous pace. There may be an actual shortage of doctors and trained medical personnel, but the phenomenal spurt in medical seats is absolutely baffling. The Government is also in no position to employ all of them, even if it may want to. The selection procedure seems to be procuring admissions through the backdoor, all for a price, as there are hordes of parents willing to shell out mindboggling sums of money to make their wards doctors.

The Hippocrates oath said “, without fee or indenture”

In the form of a huge fee structure, the amounts that the new Institutions shell out to the Medical Council of India for inspections and recognition, over and possibly under the table, in white and black, is beyond conjecture. No one, not even someone who is not a businessman can perceive as to why the parents would be willing to invest in such magnitudes, rather than accept them as dead investments. Money will be recovered but how? That is where it all begins, where the Mr. Hyde in Dr. Jekyll takes birth.6

Is it corruption in medicine as in all the social milieu around us? Has changing ethics in decadent medical sciences rendered even the modern version of the Hippocrates Oath out of context? Do we need to draft a new and a more relevant Oath, or maybe dispense with this enigma altogether?

It is surprising that in a recent Medscape Readers poll, 55% doctors said that they recited the Oath in its original form. Surprisingly, 58% still felt that it was very meaningful while another 235 felt that it was somewhat meaningful. 63% were of the opinion that it should be preserved in its original form, and only 28% felt that it needed revision. Considering a matter of prioritizing the patient first, only 30% felt so always, whereas the larger majority of 54% felt that this should be the case most of the time, and that putting the patient before anything else did not contribute towards Physician burnout (45%).

It is again significant that 57% of the respondents were above 55 years of age, and 25% were below 45 years of age.8

If we go by the statistics, the Hippocrates Oath is still considered sacrosanct by many, of all ages, although our actions do not seem to imply the same. Are these answers the best thought out responses? Is this all a hoax and a façade? Maybe, this situation demands a little pondering.

 

1. Rosenhek J. Is the Oath outdated? Doctors Review, December 2009.

2. Iqba C. Is the Hippocratic Oath outdated? Association for Academic Surgery. 2014. Web site. http://www.aasurg.org/blog/hippocratic-oath-outdated/. Accessed May 2, 2017.

3. Lasagna, Louis. Hippocratic Oath—Modern Version. WGBH Educational Foundation for PBS and NOVA Online. 1964. Retrieved 7 November 2001.

4. Sarmiento A. Is Socrates dying? J Bone Joint Surg Am. 2008; 90(3): 675-676. doi: 10.2106/jbjs.g.01508

5. Sarmiento A. Medicine Challenged. MA, USA: Publish America; 2008.

6. Rakesh B. Whither Orthopedics today_An introspection. Indian J Orthop. 2017; 51(1): 14-17. Web site. http://www.ijoonline.com/text.asp?2017/51/1/14/197515. Accessed May 2, 2017.

7. Sarmiento A. What’s important: Putting patients First. Orthopaedic Forum Bone Joint Surg Am. 2016; 98(21): 1854-1855. doi: 10.2106/JBJS.16.01091

8. Medscape Orthopaedics. Is Hippocrates oath still relevant? Medscape Readers Polls, November 22, 2016. Web site. http://www.medscape.com/viewarticle/872234. Accessed May 2, 2017.

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