March 09, 2006,
In 2000, The New England Journal of Medicine reported that patients being euthanized in the Netherlands sometimes experienced significant side effects (apart from death, that is), such as nausea, convulsions, or coma. This belied the assertion oft made by euthanasia proponents that being killed by a doctor necessarily provides the euphemistic “gentle landing” of euthanasia lore.
Responding to the Netherlands report, the NEJM published an editorial authored by Dr. Sherwin Nuland, author of the bestselling book How We Die and an internationally prominent physician and bioethicist from Yale University. Nuland, a supporter of euthanasia in limited cases, proposed a remedy: that doctors be provided “thorough training in [euthanasia] techniques.” Yes, you read right: One of the country’s most celebrated doctors urged that continuing medical education classes teach doctors how to kill.
Such “how to kill your patients” classes would clearly violate the famous Hippocratic Oath under which doctors have for some 2,500 years pledged, “I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect.”
Nuland knew that, of course. But he dismissed the relevance of the Oath, writing:
[T]hose who turn to the oath in an effort to shape or legitimize their ethical viewpoints [against euthanasia], must realize that the statement has been embraced over approximately the past 200 years far more as a symbol of professional cohesion than for its content. Its pithy sentences cannot be used as all-encompassing maxims to avoid the personal responsibility inherent in the practice of medicine. Ultimately, a physician’s conduct at the bedside is a matter of individual conscience.For most people, this is a very radical idea. When I read this quote in my lectures, audiences invariably gasp in surprise and shocked concern. You see, real people that is, patients don’t blithely dismiss the Hippocratic Oath as if it were merely akin to a secret handshake. In their commonsense understanding, the Oath protects their welfare by making doctors honor-bound to always “do no harm” (a catchphrase that succinctly summarizes the moral thrust of the Oath, although it does not appear in the document itself).
Unfortunately, we live in an age when pledges of duty and fidelity of the kind found in the Oath are fast becoming passé. Indeed, there is little doubt that the medical profession generally sides with Nuland: Very few doctors take the actual Oath anymore. But there remains the pull of tradition. So, many medical schools and professional associations have instituted various watery pledges or declarations that are mere shadows of the great document itself.
Most recently, for example, Cornell Medical School published a rewritten oath for its graduating doctors to take. Gone, of course, is the proscription against performing abortions. No surprise there: Doctors ceased foreswearing that particular procedure decades ago (although it is interesting to note that recent newspaper stories complain that very few doctors are willing to perform abortions).
But now, Cornell has cast aside two other crucial affirmations of the Oath: First, the prohibition against euthanasia has been erased ("I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect), and second, Cornell’s oath does not require its graduates to avoid sexual relations with their patients.
This is most unfortunate. The author of the Oath (whether or not it was actually Hippocrates) understood that killing is not a medical act. Moreover, the requirement that doctors pledge (on all they hold most sacred) to refrain from either killing or having sex with patients reflects the wisdom that doctors should refrain from taking too much (potentially corrupting) power over their patients into their own hands.
Illustrating the dramatic difference between the rich patient-protecting impetus of the original and the mostly non-specific generalities of the Cornell version, compare these similar provisions in the two oaths:
Hippocrates: "Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves." The clear call here is active, requiring doctors never to take advantage of patients in any way, with the specific example of engaging in sexual relations included to emphasize the point.
Cornell: "That into whatever house I shall enter, it shall be for the good of the sick. That I will maintain this sacred trust, holding myself far aloof from wrong, from corrupting, from the tempting of others to vice." This is a far more passive and vague approach. If Nuland is right, and a doctor’s own conscience is his only guide, what is deemed to constitute the “good of the patient” will vary from doctor to doctor. Indeed, if a physician believes that a patient’s ill health or serious disability makes his or her life not worth living, it would permit killing as the prescribed remedy even if the patient never asked to be killed (a common practice, not by mere coincidence, in the Netherlands nowadays). Besides: What does "tempting others to vice" mean in the context of today's anything goes morality?
Another poor substitute for the traditional Oath is the “Christian” physician’s pledge taken by graduates of Loma Linda University. Unfortunately, LLU has also emasculated the robustness of the original. Thus, LLU’s pledge states: "I will maintain the utmost respect for human life. I will not use my medical knowledge contrary to the laws of humanity. I will respect the rights and decision of my patients." Why edit out the explicit promise not to kill, if respecting human life is a priority? And if respecting patient decisions is paramount, that would permit voluntary euthanasia among other potentially harmful “treatments,” such as amputating the healthy limbs of mentally disturbed patients known as “amputee wannabes.”
Of perhaps even greater concern, LLU’s oath adds a clause that could interpose a conflict of interest between doctors and certain of their individual patients. "Acting as a good steward of the resources of society and of the talents granted me, I will endeavor to reflect God's mercy and compassion by caring for the lonely, the poor, the suffering, and those who are dying."
Under the Hippocratic medical principles, the doctor’s sole loyalty was owed to each and every patient as individuals. That is, the doctor is not free to give optimal care to one patient but provide a lower standard to another. In contrast, LLU’s version now requires physicians to treat individual patients in the context of a potentially superseding duty to broader society to steward resources which, in some hands, could be exercised at the direct expense of patients who are the most expensive to care for. Indeed, a fair reading of the LLU’s oath would justify bedside health-care rationing.
This is not to say, of course, that physicians shouldn’t make proper use of resources. But, to prevent discrimination and abuse, a doctor’s first duty must be to the individual patient, not to society as a whole. Placing a dual mandate on the doctor, as LLU’s oath appears to do, is dangerous precisely because resource management could trump the health, welfare, and even the lives of the sickest patients.
As the Christian bioethicist Gilbert Meilaender has written, the Hippocratic Oath commits doctors to “to the bodily life of their patients.” In an era when the economics of managed care and the growing utilitarian sway of contemporary bioethics increasingly endanger the weakest and most vulnerable among us, substituting the Oath’s venerable maxims with tepid generalities and the vagaries of individual consciences is precisely the wrong approach. Rather than being an archaic relic, the Oath’s “do no harm” approach to medical practice is more important than ever.