Transcript The Hippocratic Oath - University of Minnesota

The Hippocratic Oath
and the Ethics of Medicine
Steven Miles, MD
University of Minnesota
Believed to be the only
depiction of Hippocrates.
Hippocratic Medicine and Oath - 400 BC
• Rejected divine explanations for the
cause or treatment of disease in favor of
empirical, causal observational science.
• Moved from oral traditions to recorded
observations.
• Opened from hereditary occupational
families to a mission-professing guild.
BCE
Oath
“Hippocratic”
Medical
Works
1000
Fall of Athens
Time Line
CE
Oldest Oath
Papyrus
Deontological
works
Columbus
Voyage
Church
Editing
1st Medical
School use
Oath
CE
Oldest Oath
Papyrus
Surgery separates
from Medicine
Bladder stone
surgical innovation
240 BCE
1500
BCE
1000
Fall of Athens
The Cutting Insertion
I will not cut, and
certainly not
those suffering
from stone, but I
will cede this to
practitioners of
this activity.
Oaths Ethics‘Questions
•Who is the physician?
•What is the physician
committed to?
•Who is the physician
accountable to?
Who is the physician?
Opening of Oath: An invocation?...
“I swear by Apollo the Physician and
by Asclepius and by Hygieia and
Panacea and by all the gods as well as
goddesses, making them judges
[witnesses], to bring the following
oath … to fulfillment, in accordance
with my power and my judgment;”
… or a genealogy?
• “Is there a man who has not heard of
me—Amphitryon of Argos, son of
Alcaeus, grandson of Perseus, and
father of Heracles. I have lived here in
Thebes ever since the crop of Sown
Men sprang full grown out of the
Earth.”
• From Heracles by Euripides
If genealogy, what does it mean?
The Genesis Story of
Medicine I
Apollo
Physician, prophecy
Asclepius
Chiron (a Centaur)
Trainer of Achilles
Medical education
Coronis
Apollo: Prophecy & Prognosis
Apollo
• God of Reason
Physicians
• Reason- Natural
Cause and Effect:
– Points to cause,
diagnosis, and
treatment.
• God of
Prophecy
– Oracle at
Delphi
• Prognosis
Prometheus (Foresight)
• A titan who gave humans fire and
creativity to invent medicines and
imagine a prognosis.
• To prevent despair at foreseeing
death in a person who was dying.
Prom: I stopped mortals from
foreseeing doom.
Chorus: What cure did you discover for
that sickness?
Prom: I sowed in them blind hope.
– Aeschylus. Prometheus Bound
The Family of Medicine II
Epione
(Hercules
’
Daughter)
‘Soothing’
Asclepius
‘Unceasingly
Gentle’
Pindar’s Verdict on Asclepius
Still, even wisdom yields to hope of
profit. And gold induced no less
than he [Asclepius] to try to resurrect a man whom death already had
imprisoned….
We must seek from deity the things
that fit our mortal hearts, keeping
our condition and our destiny in
mind. My vital being, do not seek
immortal life; exhaust, instead, all
possibility.
•Pindar. Pythian Odes 3-63.
What does the Apollo Genesis
Story of Medicine Say?
• The passion to heal arises from
love and grief.
• Physicians must accept mortality
as a boundary for moral work.
• The names of Asclepius and
Epione say that healing is not a
war but a gentle rebalancing to
path to health.
The Family of Medicine III
Asclepius
Epione
Unceasingly Gentle
Iaso
Panacea
Healers Medicines
Soothing
Telesphorus
Convalescence
Hygieia
Aigle
Health Radiance
Podalirius
Machaon
The Family of Medicine IV
Asclepius
Epione
Podalirius
Machaon
Unceasingly Gentle
Hippocrates
Each Physician
Soothing
to regard my
teachers as
equal to my
parents
(Hippocrates dies in Larissa)
What is the physician
committed to?
What is the Physician Committed to?
MD in Society
Clinical Ethics
Principles
I will use regimens for the
benefit of the ill in
accordance with my ability
and my judgment, but from
[what is] to their harm or
injustice I will keep [them].
Into as many houses as I may enter, I
will go for the benefit of the ill,
while being far from all voluntary and
destructive injustice,
Examples
(2)
1. I will not give a drug
that is deadly to anyone if
asked, nor will I suggest
the way to such a counsel.
2. I will not give a woman
a destructive pessary.
1. especially from sexual acts both
upon women's bodies and upon
men's, both of the free and of the
slaves.
2. About whatever I may see or hear
in or without treatment…-- things
that should not ever be blurted out
outside --I will remain silent, holding
such things to be [profane to speak
of].
What does the Physician
Promise to Society?
I will not give a drug that is
deadly to anyone if asked, nor
will I suggest the way to such a
counsel.
• Capital punishment?
• Euthanasia?
• Homicide?
Medically-Assisted Executions
•
•
•
Executions were common in ancient
Greece.
No record of Greek physicians striving
to make executions more effective or
“humane” as in United States’ use of
lethal injections.
Physician engagement in such a role is
best dated to 1789 when the French
physician-legislator, Joseph-Ignace
Guillotin, successfully promoted an antitorture law that required that all
executions be carried out by means of a
“machine that beheads painlessly.”
Hemlock Euthanasia
320 BCE, Theophrastus noted that Thrasyas of Mantineia had
discovered, “a plant which produces an easy and painless end; he
used the juices of hemlock poppy. … For the effect of this
compound there is absolutely no cure… death is made swift and
easy.”
Does not describe who used hemlock, nor for what purpose.
Greek medical treatises do not describe the use of hemlock to induce
death.
It was used for executions.
Euthanasia “good death” was not coined until 280 BCE, more than a
century after the Oath was written. “Of those things that a man
[human] prays for from the gods, nothing is better to meet with than
an easy (happy) death.” This coinage referred to a natural death
without agony--not to assisting death.
1869, William Lecky redefined euthanasia as intentionally ending life
in order to end suffering from disease.
I will not give a drug that is deadly to anyone if
asked, nor will I suggest the way to such a counsel.
Suicide in Greece of 400 BCE
Was in relation to moral honor, shame
Not in relation to suffering caused by
disease.
No medical discussion of physician
assisted suicide or euthanasia.
If medically assisted euthanasia been part
of ancient Greek medicine, it probably
would have been discussed in the
treatises, just as abortions by midwives
were discussed.
“I will not give a drug that is deadly”
addresses fear of physician poisoner.
•
Murder was commonly used when the Oath was
written to topple civic leaders, municipal figures
and settle family disputes. In addition to loyalty
or fear, physicians were under economic
pressure from the collapse of the Athenian
economy and cutbacks in the position of cityphysicians. Tensions between civic medicine and
medical ethics were widely discussed.
•
345 BCE, Plato wrote that a physician who
administers a poison with the intention of
causing death should be executed as such deeds
are acts of terror Plato. Laws 933.
What does the Physician
Promise to Society?
I will not give a woman a
destructive pessary.
• Antiabortion? Pro-life?
• Anti-trespass in a woman
chattel society?
• Pessaries are dangerous.
BCE
Oath
Lethal
Pessaries
CE
1000
Oldest Oath
Papyrus
Hardening Church
Position Against Abortion
Fetus as alive.
Church
Editing of Oath
1st Medical
School use
What Does the Physician
Promise to the Patient? 1
. . . especially from sexual acts
both upon women's bodies and
upon men's, both of the free and
of the slaves
A clinical ethics of being a guest.
What Does the Physician
Promise to the Patient? 2
About whatever I may see or
hear in or without treatment…
-- things that should not ever
be blurted out outside –
I will remain silent, holding
such things to be [profane to
speak of].
Who is the physician
accountable to?
If I render this oath fulfilled, and if
I do not blur and confound it may it
be to me to enjoy the benefits both
of life and of techne (art and
science), being held in good repute
among all human beings for time
eternal.
If, however, I transgress and perjure
myself, the opposite of these.
Oath’s Vision of Medical Ethics
Genesis: respect for love and grief,
bounded by mortality.
Empirical
Physician in Society
Personal Integrity
A
community
to transmit
knowledge
and values
In a pure and holy way,
I will guard my life
and my art and science.
Clinical Ethics
Judgment
of history.
Moral
Benefi
-cent,
Just
Summary
• Oath conforms to the medical practice
and rhetoric of Classic Greece.
• Roles: education, compiling knowledge,
and treatment.
• Ethics: beneficence and acting justly (dike)
in public and clinical spheres.
• Progressive and historically accountable
rather than deontologically, deistically
accountable.
Steven Miles MD
[email protected]