The Hippocratic Oath and the Golden Rule   12/95

by Del Meyer, MD

Ethics is the branch of philosophy that is concerned with what is morally good and bad, what conduct is right or wrong. Since the 16th century a fundamental rule of conduct that exceeded all other rules was termed the Golden Rule. It was recorded by Luke, the physician, as "Do to others as you would have them do to you." A negative form, "Do not do to others what you would not like done to yourselves," occurred in the 2nd century Apology of Aristides, and in the Analects of Confucius during the 6th century BC.

Medical ethics, the overall theme of the month, has been defined as the moral standards of practice. These standards of professional conduct are those that are traditionally accepted by members of the medical profession or are promulgated by our professional organizations. Unethical behavior is frequently called "unprofessional conduct" and may be the basis of adverse action from any organization that provides us the privilege of practice. Many of the concepts are basically noble ideals, with difficulty in determining criteria, so that exceptions have to be allowed.

In a large Hippocratic collection dating from the 9th century, we find some of the first great expositions of the ethical basis of medicine. An oath attributed to Hippocrates, who lived 14 centuries earlier in the 5th century BC, gives many of the principles used over millennia. Important ones read as follows:

The regimen I adopt shall be for the benefit of my patients according to my ability and judgment, and not for their hurt or for any wrong. I will give no deadly drug to any, though it be asked of me... Whatsoever house I enter, there will I go for the benefit of the sick, refraining from all wrongdoing or corruption, and especially from any act of seduction... Whatsoever things I see or hear concerning the life of men, in my attendance on the sick or even apart therefrom, which ought not to be noised abroad, I will keep silence thereon, counting such things to be as sacred secrets.

This points out that 25 centuries ago, not only were the traditional principles of "do no harm" and "patient confidentiality" emphasized, "sexual misconduct" was already considered important enough to at least be highlighted if not labeled an "occupational risk" of our profession. The latter has become increasingly important in recent years. Objectivity is frequently lost in these charges.

An example from our training days may be illustrative. Physical Diagnosis is in the Sophomore curriculum of most medical schools. At Kansas, the demonstration for this course took place in a large amphitheater. When the physical examination of the breasts was presented, an appropriately prepared and volunteered patient was rolled into the amphitheater on a gurney. As the professor lectured, he moved to the demonstration of the physical examination. He placed the pillow that was under the patient's head, under the right scapula, and pulled the drape down to the waist to demonstrate the right anterior oblique position. This placed the breast being examined into a vertical hemispheric position for the most optimal evaluation. After careful inspection for any contour abnormalities, he then proceeded to palpate in a circular motion as he continued to lecture. A classmate raised a question and the professor answered as he continued to demonstrate the palpatory exam. There were several additional questions as he continued his examination, before the lady finally raised her head and asked the professor, "Am I paying for this examination or are you?"

This, of course, brought matters into sharp focus in a relatively restrained humorous mode and the lecture continued as the right breast was redraped and the professor said, "So sorry." He did not continue the finer points of subareolar exam until he could give it his undivided and uninterrupted attention. He redraped before accepting questions.

When I lectured to the Respiratory Therapy students at American River College in the early 1970s, my presentation was videotaped and replayed each year for nearly a decade. Can you imagine a breast examination lecture being videotaped and shown out of context? What may have been mild indiscretions at one time, may be major ones in a different more hostile era. A video camera demonstrating a breast exam that was of the highest ethical standards may appear to a lay observer as fondling or caressing rather than palpating. That shouldn't be surprising. But as physicians we must protect our ability to provide this service or examination to our patients before we totally defer this exam to mammography, just to avoid risks. Imaging techniques are not 100% accurate. Unfortunately, the breast masses that are palpable are the very ones that imaging may overlook.

As we help fellow physicians improve their professional skills and ethical behavior, we should be able to bring a certain maturity to the review process and lend a certain credence and professional judgment to those being accused. I've had physicians confide in me that the criticism they made of a colleague in retrospect was in error -- but it was too late to correct the damage or salvage a career.

Physicians must constantly practice humility as we practice medicine. What we do is the most complicated, humanly variable, frequently misunderstood most demanding work on earth. Having seen over 20,000 patients referred by colleagues for several decades, I think that well over 99% of physicians have the highest ethical behavior of any other business or professional person anywhere, bar none.

Humility, not only in our practice, but also in our review of our colleagues practice, may produce the highest ethical behavior, simply because it allows the principles of the Hippocratic Oath and the Golden Rule to be a beacon for everyone to see. If we practice the OATH and the RULE we will be a credit to our profession and an effective advocate for our patients.