The Fall of the Hippocratic Oath: Why the Hippocratic Oath should be Discarded in Favor of a Modified Version of Pellegrino’s Precepts

GUJHS. 2012 July; Vol. 6, No. 2: 9-17.

Emily Woodbury

Science, Technology, and International Affairs Program
School of Foreign Service, Georgetown University, Washington, D.C.

Introduction

Medicine as a profession demands of physicians extraordinary moral sensitivity as they respond to patient vulnerability (Pellegrino, 2008c; Pellegrino, 2006). The importance of a unique medical morality cannot be understated. Customs, social mores, and politics all too readily become moral norms without principled justification. For that reason, medicine requires guidance from a central medical ethic that is formalized in a professional oath that can at least offer some resistance to fluctuating social opinion (Pellegrino, Uncited, p. 2-8). For this paper, an Oath is taken to mean the solemn pronouncement by which members of a profession establish collective ethical standards and delineate acceptable professional behavior reflective of their unique roles and obligations in society. In the face of such modern challenges as the quality-of-care crisis, the third-payer system, and the burgeoning financial costs of healthcare, considerations of that professional Oath and discourse on medical morality are more critical than ever (Pellegrino, Uncited, p. 16; Pellegrino, 2008c, p. 421; Pellegrino, 2008b, p. 424).

Statement of Thesis

Two questions have become central to my consideration of the modern discourse on the Hippocratic Oath: firstly, should the Hippocratic Oath be removed from the culture of medical education and practice? Secondly, if so, can Pellegrino’s Precepts, as an alternative approach to medical morality, be held as a suitable replacement? In this paper, I will assert that the Hippocratic Oath should be discarded, heralding a “post-Hippocratic” era, and that a modified version of Pellegrino’s Precepts is the most appropriate substitute, with precepts five and eleven withdrawn, given that precepts, unlike oaths, are designed to guide behavior, not dictate it (See the Appendix for Pellegrino’s Precepts) (Pellegrino & Thomasma, 1988).

Context: The Hippocratic Oath and Pellegrino’s Precepts

The Hippocratic ethic, which includes the Hippocratic Oath and the deontological texts of the Law, Decorum, Precepts, and Physician, constitutes “one of the oldest binding documents in history” (Tyson, 2001). The original oath included an introduction by which physicians swore “by Apollo and Asclepius and Hygeia and Panacea and all the gods and goddesses” to respect such principles as beneficence, non-maleficence, and prohibitions against abortion, euthanasia, and sex with patients (Tyson, 2001).  The principles of patient autonomy and social justice are – to the modern eye – noticeably absent. Thomas Percival amended the Code in the 1700s, creating a vision of the physician as a ‘gentleman’ (Pellegrino & Thomasma, Uncited, Ch. 11). In 1847, the American Medical Association published its own Code of Ethics which stressed the responsibilities of physicians to other physicians and called, for instance, for absolute obedience from patients (Axelrod & Goold, 2000). The AMA issued its most recent version of that code – the AMA Professional Code – in 1978 as a brief, legalistic modern interpretation of the Hippocratic Oath (here-on referred to as the ‘modern Hippocratic oath’) (Pellegrino & Thomasma, Uncited, 2008).

Today, 100% of medical school graduates in the United States swear to some variation of the Hippocratic Oath (as opposed to just 24% in 1928) (Tyson, 2001). Most of these Oaths are vague in language and contain the principles of non-maleficence, beneficence, patient autonomy, and social justice (Tyson, 2001). Only 14% of these oaths prohibit euthanasia, 11% reference a deity, 8% forbid abortion, and 3% prohibit sexual relationships with patients; 50% of them do not reference accountability at all (Tyson, 2001).

Aside from the Hippocratic Oath, four prominent documents guide medical ethics: (1) the Declaration of Helsinki, which prohibits unethical experimentation on humans, (2) the Declaration of Geneva, also known as the World Medical Association Code of Ethics, which is a more explicit version of the modern Hippocratic Oath, (3) the 2002 Charter on Medical Professionalism which upholds the principles of patient welfare, patient autonomy, and social justice, and (4) Pellegrino’s Precepts (Silverman, 2011). Pellegrino’s Precepts were constructed by E. Pellegrino, PhD, an exemplary scholar of medical ethics who defends the position that the principle of beneficence is the most central aspect of medicine. These Precepts, listed below, are more appropriate than the Hippocratic Oath or any other guiding documents, because the Precepts are explicitly directed towards practicing medical professionals, not just a proposal of broad ethical tenants alone.

Dr. E. Pellegrino’s Precepts as a Suggested Replacement for the Hippocratic Oath (Pellegrino & Thomasma, 1988):

1) “To place the good of the patient at the center of my professional practice and, when the gravity of the situation demands, above my own self interest.

2)  To possess and maintain the competence in knowledge and skill I profess to have.

3)  To recognize the limitations of my competence and to call upon my colleagues in all the health professions whenever my patient’s needs require.

4)  To respect the values and beliefs of my colleagues in the other health professions and to recognize their moral accountability as individuals

5)  To care for all who need my help with equal concern and dedication independent of their ability to pay.

6)  To act primarily in behalf of my patient’s best interests, and not primarily to advance social, political, or fiscal policy, or my own interests.

7)  To respect my patient’s moral right to participate in the decisions that affect him or her, by explaining clearly, fairly, and in language understood by the patient the nature of his or her illness, together with the benefits and dangers of the treatments  propose to use.

8)  To assist my patients to make choices that coincide with their values or beliefs, without coercion, deception, or duplicity.

9) To hold in confidence what I hear, learn, and see as a necessary part of my care of the patient, except when there is clear, serious, and immediate danger of harms to others.

10)  As always, even if I cannot cure, and when death is inevitable, to assist my patient to die according to his or her life plan.

11)  Never to participate in direct, active, conscious killing of a patient, even for the reasons of mercy, of at the request of the state, or for any other reason.

12) To fulfill my obligation to society to participate in public policy decisions affecting the nation’s health by providing leadership, as well as expert and objective testimony.

13) To practice what I preach, teach, and believe and, thus, to embody the foregoing principles in my professional life”

 

The American Medical Association has no formal position on any of these documents but rather requires its members to adhere to the AMA Principles of Medical Ethics statement (2001, Frequently Asked Questions in Ethics).

Point: Reasons to Discard the Hippocratic Oath

There are several reasons that the Hippocratic Oath should be removed as a central medical ethic. Firstly, the classical version contains such a grave omission that is not salvageable, namely the omission of a medical value now taken as essential: patient autonomy. The modern Hippocratic Oath, in a failed attempt to address that omission, has language that is too vague and does not meet the challenge of the complex modern healthcare landscape. Finally, neither the classical nor the modern Hippocratic Oaths offer philosophical explanation for their dictates, and in never addressing philosophically why medical professionals are held to a special standard, they render themselves unjustified.

Unacceptable precepts within the classical Oath

Any argument for the removal of the Hippocratic Oath from modern medicine must begin with the unacceptable nature of many of its original precepts: “there are serious problems in reliance on a set of texts that is 2500 years old” (Pellegrino, 2008b, p. 432). Firstly, the paternalist nature of the Oath, with its portrayal of an exclusive fraternity of gentlemen-doctors as stewards of all medical knowledge and morality, is sexist and elitist in the modern democratic context (Pellegrino & Thomasma, Uncited, Ch. 11). The ancient religious foundation of the Oath has become irrelevant, and current divergence of opinion on specific issues such as abortion and euthanasia make the original Oath intolerable (Pellegrino, 2006). Perhaps most egregious within the original Oath is the subjugation of the patient as normatively subordinate: “If the physician is to help, his relationship to the patient must be that of the person in command to one who obeys” (Pellegrino & Thomasma, Uncited, Ch. 11). Modern acceptance of the autonomy of the patient makes that attitude unacceptable to physicians and the public alike.

Omissions within the classical Oath

The classical Hippocratic Oath is also indefensible as a basis for modern medical morality because of the principles it does not include. Firstly, nothing is said to posit the social responsibility held by medicine as a profession operating within complex political and financial institutions (Pellegrino, 2008c, p. 407). While social responsibility is surely required of physicians as citizens, it was not until Section 10 of the AMA’s 1946 Principles of Medical Ethics that social justice as a principle was formalized for the profession in the United States (Pellegrino, 2008c, p. 409). Further, the role of patient values and beliefs in medical decision-making is not recognized, in ignorance of the importance of the patient’s life-world (Pellegrino, 2008c, p. 407). Finally, the classical Oath, written for a world in which pharmaceuticals, insurance companies, and legislative regulation did not exist, does nothing to protect the “discretionary space” needed by modern physicians to protect their patients from undue influence (Pellegrino, 2008c, p. 437).

Language of the modern Oath

While many of those flaws were corrected in 1978 with the modern Hippocratic Oath, that new Oath is not a viable replacement. Firstly, the modern Oath is non-binding in nature and uses language that is less moral and rather legalistic in nature (Tyson, 2001). The Oath speaks in broad, normative precepts that are equivocal and idealistic without offering tangible guidance to practicing physicians.

Current challenges are too complex for the modern Oath

The modern Hippocratic Oath also cannot serve as a suitable replacement for the classical Hippocratic Oath because it does not meet the contextual challenges facing medicine in the 21st century. The recent increase in government regulation, the proliferation of the third-payer system, and the democratization of medical knowledge all place pressures on physicians that are new to the last 40 years; their ethical implications are not satisfactorily addressed by the modern Hippocratic Oath (Pellegrino, 2008b, p. 425, 412). The institutionalization of medicine and the popularization of team medicine also have immense implications for the modern practice of medicine for which the modern Oath does not provide adequate guidance.  Finally, the multitude of social roles that physicians now fill – businessman, bureaucrat, entrepreneur, therapist, employer, doctor – demands medical ethical guidelines with more precision than the modern Oath (Pellegrino, Uncited).

Lack of philosophical justification

By far the most significant reason why the Hippocratic Oath, in both its classical and modern forms, should be abandoned is that the Hippocratic Oath lacks philosophical underpinning (Pellegrino, 2008c, p. 406; Pellegrino, Uncited). Its statements are ex cathedra and do not address why medicine is unique and should therefore demand particularly moral behavior from physicians (Pellegrino, 2006). For any concept to be ethical, it must be questioned in its most distilled form, and the Hippocratic Oath, as merely a list of statements of expected behavior without defense, cannot stand that scrutiny. This reason alone justifies the reconstruction of a “post-Hippocratic” medical ethic.

Counter-Point: Reasons the Hippocratic Oath Should be Kept

The Hippocratic Oath, in reality, has yet to be removed for three central reasons that defend its inertness. Firstly, some of the content of the Hippocratic Oath is still relevant; therefore, physicians maintain the Oath in its central position out of respect for its longevity. Further, the legalistic nature of the Oath, irrespective of underlying ethical reasoning, offers some protection to physicians in an era when medical litigation and frivolous lawsuits render medicine a legally perilous endeavor. Finally, some physicians argue to maintain the Hippocratic Oath out of sheer practicality that the vast majority of medical professionals are not directly concerned about the Oath’s status and therefore it should not be changed.

(1) Some of its content is still relevant

One argument for why the Hippocratic Oath should be maintained as the central guide for medical ethics rests on the canon’s historical longevity and the fact that some of its content is still relevant. It was this document that formalized the central medical responsibilities of nonmaleficence and competence as well as asserted the appropriateness of yielding to specialists, guarding against financial corruption, and ensuring confidentiality (Pellegrino, 2008b, p. 430).  With such substantial contributions to medicine that have survived millennia, the argument can be made that the Hippocratic Oath needs only to be culturally modified to be kept.

(2) The Oath protects against physician vulnerability

The modern era is rife with incredible challenges for healthcare, many of which are financial and legal in nature. The litigation culture that pervades the United States has invaded the practice of medicine and in response, many physicians practice defensive medicine to guard against frivolous lawsuits and subsequent malpractice insurance cost increases. By addressing what behavior is specifically appropriate for such contentious social issues as abortion and euthanasia in its classical form, the Hippocratic Oath offers guidance on issues that are the source of social conflict and therefore offers legal protection independent of philosophical underpinnings (Pellegrino, 2006).

(3) Simple practicality

Perhaps the most ubiquitous reason among physicians why the Hippocratic Oath should be kept is that its removal is simply unnecessary (Kenny, 2006). The argument is presented that the medical profession will only be changed by the philosophy of medicine if the majority of physicians feel that those changes need to be made, and the majority of physicians accepts the Hippocratic Oath as unattainable idealism or merely as guidance. In either case, many physicians either take what pieces they personally value in the classical version or pledge to the modern one, which, with its vague language, is hard to find fault with. In summary, as virtually all physicians have taken the Hippocratic Oath and very few have ever studied the philosophy of medicine, an argument for the significance of the removal of their Oath may be unpopular.

Response to Counterpoint

When placed under more exacting consideration, however, those counterpoints do not effectively defend the maintaining of the Hippocratic Oath. While certain portions of the Hippocratic Oath may still be relevant in the modern context, the majority is not appropriate and it is the majority of the document that should be considered. Continuing, legality should not be considered when determining which ethical guidelines are most appropriate: an oath should withstand and be distinct from any contemporary legal environment. Finally, nostalgia is not an appropriate defense for the Hippocratic Oath in the face of the rapidly changing ethical challenges facing medical professionals today.

(1) The majority of the Oath’s content is not relevant

Even if there are principles and precepts within the classical and modern Hippocratic Oaths that are relevant, even central, to the ethical practice of medicine, its sections that are not appropriate, such as the sections referencing ancient deities or prohibiting abortion, necessarily make the entirety insupportable because the document is meant to be normative. Some of those inappropriate sections have become absurd, even dangerous, such as the supplication for patience subordinance. Such statements are unacceptable in a democratic society and violate the physician-patient relationship that is at the heart of the philosophy of medicine.

(2) Legal vulnerability should be accounted for in laws, not an ethical Oath

While it is certainly true that the threat of punitive litigation has negatively affected the practice of medicine in the past twenty years, protections against frivolous malpractice suits should be included in the language and content of litigation laws issued by the state and not in the language nor content of an oath. While having legally-relevant content is surely not reason enough to condemn an oath – many of Pellegrino’s Precepts have legal significance, though with less explicitness that the Hippocratic Oath –, the content of the Hippocratic Oath cannot be defended simply because of its legal implications. An oath is a place for public declaration of the philosophical foundation and ethical guidelines of a profession – the act of profession itself. Protecting physicians by using vague language in the modern Oath as a means to defend a broader set of physician choices as “ethical” is inappropriate.

(3)Practicality and nostalgia should not be considered

While it is true that the Hippocratic Oath has been acculturated in medicine for millennia and that its replacement by another oath will meet resistance, an Oath is intended to be a normative statement based on sound philosophy and up-to-date ethical discourse. It cannot merely be a collection of piecemeal changes made to a 2500 documents in attempts to mask its lack of philosophical grounding. Physicians and scientists have been on the forefront of technological and social progress for centuries; their nostalgia for an outdated Oath surely should not inhibit their ability to adopt a new one even if they have not participated in rigorous discourse on the philosophy of medicine themselves.

What Should be Done

Dr. Pellegrino’s two part medical ethic is a defensible and appropriate replacement for the Hippocratic Oath. That ethic contains both a “universal set of precepts about the nature of medicine” to which all physicians must subscribe as well as “allowance for the personal philosophical and theological beliefs” of the physician (Pellegrino, 2008b, p. 436). It is suitable for two reasons. Firstly, it maintains the act the profession as a public declaration is needed to establish physician-patient contracts. Secondly, it rests upon the philosophical foundation that asserts that medicine requires particular moral vigilance of the physician due to the vulnerability of the patient in the physician-patient relationship. Thus, the Precepts provide a pragmatic, philosophically sound alternative to the Hippocratic Oath.

While in appearance these Precepts – as a list of acceptable behaviors – may seem similar to the Hippocratic Oath, they rest on a body of work that grounds them on sound philosophical theory. With that grounding, Pellegrino’s precepts tactfully guide medical ethics for the profession, maintain the accepted principles of beneficence, autonomy, and social justice, and respect the fact that physicians as a group are a collective of sui generis individuals. It is particularly noteworthy for its respect for the beneficence-in-trust of the patient. Pellegrino defined beneficence-in-trust as a principle that physicians must act with beneficence towards their patients, making the biomedically sound medical choices, while also appreciating that they should make those choices after first earning the trust of each patient by taking into account that individual patient’s distinct value system. While Pellegrino’s Precepts are a sound replacement for the Hippocratic Oath, two of its precepts should be removed on ethical grounds. These precepts are Precept 5, in which physicians would pledge to care for all who need their help with equal concern and dedication independent of their ability to pay, and Precept 11, in which they pledge never to participate in direct, active, conscious killing of a patient, even for the reason of mercy (Pellegrino & Thomasma, 1988).

Points

#1: Precept 5 of Pellegrino’s Precepts should be Removed

This precept, which holds that physicians must care for all that need their care with equal concern and dedication independent of their ability to pay, should be removed as it applies to physicians in private practice, not institutions such as hospitals. Physicians have a right to refuse any patient in a time of non-emergency, even if they do so because the patient cannot pay. While it is admirable when physicians aim to be impartial to patient financial status, the inclusion of this idealized precept ignores current trends in medicine, conflicts with the mutual model of medicine, and – above all – violates physician autonomy.

Firstly, healthcare is increasingly becoming a service-oriented industry, and while health should always be recognized as a common good as opposed to a commodity, the fact that physicians are filling a social need – the common good – as well as the needs of their patients as individuals does not mean that the needs of the physicians can be ignored (Pellegrino, 2008c, p. 414).  In the mutual model of medicine, both the patient’s and the physician’s needs are taken into account. Therefore, just as physicians have responsibilities, so do patients, responsibilities such as fidelity, justice (eg. not to abuse malpractice), and to pay their bills. When the physician knows that the patient will violate their covenant, the physician is not obligated to become responsible for them; instead, the physician is obligated to assist the patient in finding another provider. This act of refusing someone before he or she becomes a patient is an exercise of the physician’s autonomy. While stories of selfish and monetarily-motivated physicians are real and very concerning, that type of behavior is addressed by the other precepts that defend the good of the whole person and social justice. For that reason, this precept should be entirely removed – and not just changed to pertain only to accepted patients – because accepted patients are protected by Precept 1.  In summary, if the primary task of physicians is to heal and their ability to continue doing so in private practice is dependent on each individual patient paying for their services, then they have the right to deny pro-bono clients as an exercise of their own autonomy, except in instances when they are the only provider that could possible attend to the patient, like in the case of medical emergencies (2001, Principles of Medical Ethics).

Some might argue that Precept 5 of Pellegrino’s Precepts should be kept because finances should be irrelevant in medical decision-making. With the physician-patient relationship at the philosophical center of medicine, it is the physician’s moral duty to limit the effect of outside institutions and monetary consequences on the medical choices that affect their ‘vulnerable’ patients (Axelrod & Goold, 2000). If physicians include financial cost in their cost-benefit analysis for treatment or refuse to see a patient who needs their skills – the skills that physicians have a monopoly over and that society, including the poor, made allowances for them to gain – then they are perpetuating social injustice and violating the patient’s good. Further, if physicians in private practice are allowed to turn away patients due to the financial implications of those individuals not paying for services, then institutions such as hospitals may try to take the same refusal liberties, even if doing so has no ethical legitimacy, and that institutional refusal to treat the most financially vulnerable of the population could cause real harm to those individuals and to society.

However, despite the counterpoints, Precept 5 should still be removed. While physicians should absolutely remove financial considerations from the treatment of patients they have already accepted, they have the right to refuse that acceptance in the beginning. In Pellegrino’s precept 3, physicians are called upon to recognize their own limitations and refer elsewhere; one such limitation for private practices is financial. They may, subsequently, refer to larger institutions. Physicians seeing patients as part of an institution, such as a hospital, are obligated to see them because the financial default of one patient does not impact their own direct financial security. While the medical relationship is always one-on-one, the financial relationship is not. This is what distinguishes private practice physicians from institutional physicians as it applies to this precept. Isolated physicians, therefore, are not morally obligated until they say “how can I help you?”, forming a social contract and transforming a person into their patient. While this ability to refuse patients may shift from private practices to hospitals the environment where medical care for some individuals is received, with the current trends towards licensed practical nurses providing primary care and with physicians’ obligations to accept patients if there is no other care available, the removal of this precept will not dramatically restrict access to care for the poor.

Further, physicians will still be obligated to follow precept 12 which calls upon them to provide leadership for the patient good at the society level. All physicians must defend the principle of Justice in medicine for all people, not just their patients. To that end, physicians are morally obligated to support government efforts to provide universal health insurance so as to maximize the number of patients that can be attended to by private physicians. Until universal coverage is a reality, however, to require private physicians to treat without compensation violates physician autonomy and does not respect the multiple roles in society that physicians now hold, keeping in mind that physicians will still be called upon by Pellegrino’s Precepts to advance social justice in policy and in medical emergencies.

#2: Precept 11 of Pellegrino’s Precepts should be removed

This precept, which holds that physicians must never participated in direct, active, conscious killing of a patient for any reason, is inappropriate because under certain circumstances it is morally defensible to cause the death of a patient even if the amelioration of physical pain is not the primary intention, though it can never be obligated of a physician even if he or she believes assisted suicide is permissible for others. A patient’s assisted suicide can be ethical when it is of his own choice, though never at the state’s or an institution’s request. Specifically, euthanasia should not be prohibited because it may be permissible in protecting the dignity of the patient and because prohibitions against such a contentious issue violate the moral accountability of individual physicians.

It is the physician’s duty to protect or, if called for, to reinstate the dignity of his patients. Though it has been argued that dignity is the objective foundation of all of morality, dignity as a concept, when considered in reality as distinct from theoretical supposition, is a subjective one (Pellegrino, 2008a). If it is the patient’s competent decision, in cases of terminal illness that involve either incredible pain or great suffering – not always in unison –, that to maintain their dignity they must control the time and circumstance of their own death, then it should be permissible within the physician’s Oath for his physician to facilitate that passing.[1] Further, the inclusion of a prohibition against euthanasia in Pellegrino’s Precepts is incongruous with the omission of statements on such issues as abortion and sexual relations with patients. These are not included because they are issues of great complexity and legitimate controversy and are dependent on the personal moral values of the physician and the patient. By including this precept, the Oath violates the moral responsibility and values of other medical professionals as described in Precept 4 by trying to force an artificial unification across medicine of a particular moral belief that is not inherent in the physician-patient relationship since euthanasia can in fact be beneficent if one considers the greater good of the patient to supersede his medical good. It should, therefore, be omitted.

The defense of precept 11 rests on the assertion that human life is the greatest good. The taking of that good from another is unacceptable and should be prohibited in any declaration of medical ethics. Even if the patient’s terminal illness puts them in incredible emotional or spiritual suffering, the death of the patient at the hands of a physician may only occur in efforts to reduce physical pain. While physicians may cease treatment that is no longer indicated for the good of the patient, direct assisted-suicide is homicide of the patient and is unacceptable. Further, the dignity of human beings is such that they cannot allow their dignity to be infringed upon through assisted suicide, even if it is something they feel they want. Death as a side-effect of pain relief respects that dignity while intentional causing of death violates their dignity.

Yet, this point is not justification enough to keep the principle. While it is true that human life is inherently the greatest good, when that life becomes miserable because of great suffering linked to an imminently terminal illness – with or without immense physical pain – , then that good is lessened and can supplanted by other goods valued by the patient. There are already protocols for determining competence of a patient, such as the Patient Competency Rating Scale, and if a competent, imminently terminal patient determines that assisted suicide is in their greatest good, then the physician should not be prohibited by an Oath from considering that plea (Leathem, Murphy, Flett, 1998).  It is critical in medicine that the good of the patient not be reduced to their medical good, and while there is risk of abuse of this system – particularly when it comes to concerns that cost will provide impetus of end-of-life decision-making by physicians –, it is important to remember that the decision will always be the patient’s, never the physician’s. It does not diminish the patient’s moral dignity to decide to end their life if they are beyond medical assistance. Their physicians will still be held account to precept 1 to protect that patient’s good and autonomy.  If a miserable and protracted death will cause a greater disintegration of their life-world than the choice to end controllably a body that is irretrievable, then assisted suicide serves the function of the alleviation of acute emotional pain and is therefore permissible in imminently terminal patients. While, of course, no physician should be required to assist a suicide if doing so violates his own values, an Oath should not restrict physicians from doing so if they chose.

Conclusion

Medicine as a profession attracts a wide variety of individuals with divergent personal values and beliefs and, in many ways, as J.A. Marcum states in Humanizing Modern Medicine,  “medicine is what [those] physician[s] care to make it” (Marcum, 2008). A physician may view ‘medicine’ as a means to help the sick, an institution, a lifetime of personal relationships, a profitable business, an organic expression of human empathy, a rigorous application of scientific innovation, or a disciplined body of knowledge. This myriad of interpretations necessitates a unified philosophical grounding for medicine and an agreement within the medical professional community on ethical constraints. The Hippocratic Oath fails to meet those demands. Founded on the patient-physician relationship as the central unique bedrock of medicine, Pellegrino’s Precepts make an appropriate and defensible replacement so long as precept 5 and precept 11 are removed because they violate physician autonomy. Guided by an Oath with a strong philosophical basis and clearly defined precepts, physicians will be better equipped to approach the challenges of practicing medicine in the modern United States in an ethical and socially-just manner.

 

Appendix

Dr. E. Pellegrino’s Precepts as a Suggested Replacement for the Hippocratic Oath (Pellegrino & Thomasma,1988).

 

1) “To place the good of the patient at the center of my professional practice and, when the gravity of the situation demands, above my own self interest.

2)  To possess and maintain the competence in knowledge and skill I profess to have.

3)  To recognize the limitations of my competence and to call upon my colleagues in all the health professions whenever my patient’s needs require.

4)  To respect the values and beliefs of my colleagues in the other health professions and to recognize their moral accountability as individuals

5)  To care for all who need my help with equal concern and dedication independent of their ability to pay.

6)  To act primarily in behalf of my patient’s best interests, and not primarily to advance social, political, or fiscal policy, or my own interests.

7)  To respect my patient’s moral right to participate in the decisions that affect him or her, by explaining clearly, fairly, and in language understood by the patient the nature of his or her illness, together with the benefits and dangers of the treatments  propose to use.

8)  To assist my patients to make choices that coincide with their values or beliefs, without coercion, deception, or duplicity.

9) To hold in confidence what I hear, learn, and see as a necessary part of my care of the patient, except when there is clear, serious, and immediate danger of harms to others.

10)  As always, even if I cannot cure, and when death is inevitable, to assist my patient to die according to his or her life plan.

11)  Never to participate in direct, active, conscious killing of a patient, even for the reasons of mercy, of at the request of the state, or for any other reason.

12) To fulfill my obligation to society to participate in public policy decisions affecting the nation’s health by providing leadership, as well as expert and objective testimony.

13) To practice what I preach, teach, and believe and, thus, to embody the foregoing principles in my professional life”

 

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[1] Note: That Oath stands independent of the legal or institutional prohibitions that in many states exist; law should not be a stand-in for medical ethics, but it some states, it may make this argument moot.

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