Most people, when asked to name the professional moral code that guides physicians, would first think of the Hippocratic oath. Who hasn't heard of that ancient set of principles that directs, "First do no harm"?
Indeed, many professional associations, scholars and medical students still bow to the Hippocratic tradition.
But Robert M. Veatch, a professor of medical ethics at Georgetown University's Kennedy Institute of Ethics, argues forcefully in this book that the Hippocratic oath is "unacceptable to any thinking person." Indeed, he writes, "It should offend the patient and challenge any health care professional to look elsewhere for moral authority."
Veatch's objections to the Hippocratic oath's moral authority are many and well-reasoned. He starts by relating the oath's history as the reflection of an ancient and eccentric Greek cult. It likely was written not by the historical figure, Hippocrates, but by one of his followers after Hippocrates' death, at some time in the fourth century B.C.
The classic version of the oath actually starts with the physician's swearing by "Apollo the physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses." To Veatch, this emphasizes the oath's origins as a document of a pagan Greek religion, which leads to problems throughout.
For example, Veatch invites us to consider the "conflict between respecting the rights of the patient and trying to do what the physician believes will benefit the patient." In cases of terminal illness, Hippocratic physicians ("following the mandate to always act to benefit the patient and protect the patient from harm") have sometimes felt morally obliged not to disclose information about diagnosis, prognosis or potential treatment because of the harm that might be caused the patient by the resulting psychological distress.
Withholding such information from the patient is called exercising "therapeutic privilege," yet it violates the basic right of a patient to be told about his/her condition and to give consent before treatment.
Such a perspective, Veatch argues, is paternalistic and it substitutes "the physician's own judgment rather than the views of some broader, more objective moral community or of the patients themselves that forms the basis for deciding what will benefit patients."
Another problematic area of the oath is its directive on confidentiality. Modern rights-based values prescribe confidentiality of personal medical information unless the patient has explicitly agreed to disclosure. But in the Hippocratic view, even if the patient has forbidden disclosure, the physician is actually required to breach confidentiality if he or she believes that this will benefit the patient. Once again, the physician's own judgment is supreme here, rather than that of a wider moral community.
Veatch, the recipient of a Lifetime Achievement Award from the American Society for Bioethics and the Humanities and a former member of the editorial board of the Journal of the American Medical Association, continues for several chapters in this vein.
While thoughtfully laying out the oath's difficulties, he provides a fascinating history of the ritual of medical school oath taking and the limits of professional associations' moral codes.
Ultimately, "Hippocratic, Religious and Secular Medical Ethics: The Points of Conflict" pokes some large holes in the sheath of moral authority in which professional groups have historically wrapped themselves by issuing elaborate codes of medical ethics.
As Veatch importantly notes, these codes were imposed on patients without their knowledge or consent. As an alternative, he argues persuasively for the universal importance of certain moral norms that we, as human beings, share. These norms, derived from both religious and secular experience, can be seen in the 2005 Universal Declaration on Bioethics and Human Rights (included in the appendix).
Among the key points in this historic and detailed document are full respect for human dignity, human rights, and fundamental freedoms; fully informed and consenting patients; and guarantees of privacy and confidentiality for patients.
"Hippocratic, Religious and Secular Medical Ethics: The Points of Conflict" is likely the pinnacle of the more than 40 books that Veatch has written or edited.
With extensive notes, bibliography, and index, this is a definitive scholarly treatment of the subject that will doubtless remain the standard reference for many years to come. At the same time, it will engage the thoughtful layperson with straightforward prose and compelling questions.
Anyone who ponders the thicket of medical ethics will find much of value here.