A long time ago, some time in the 4th Century BCE, an important document was written codifying certain ancient rules of ethics. Attributed to the Hippocrates, a doctor was expected to swear by Asklepius, to teach medicine without charging a fee, he won’t provide pessaries for an abortion and, the bit so favoured by the anti-euthanasia lobby, “I will give no deadly medicine to anyone if asked, nor suggest any such.”
It all sounds very noble, even though, whatever the author of the Oath promised, there was no licensing of physicians in Classical times – anyone could treat a patient in any way they wished if the patient agreed. Supplying poison to murder someone was strictly frowned on, yet suicide was not uncommon in the face of serious disease. Aristotle and Pliny specified diseases that were justifications for suicide because of the severe pain they caused. Poison was the favourite way of taking one’s life. The Hippocratic oath was something of a minority statement. Only in Thebes was suicide illegal. When suffering got too bad, it was generally better to get a poison to end one’s life from a physician than from a herbalist. Probably then, as now, a few doctors objected and wanted to distance themselves from such alleviation of suffering.
One cannot help but wonder how many professors of medicine refuse a salary for teaching? Or make a solemn promise to Asclepius? “Taking the Hippocratic Oath”. Few if any institutions still swear by the Hippocratic oath, or even find it easy agree on the ethical duty of a new doctor. The often-repeated phrase, “First, do no harm” doesn’t exist in the original Oath. But would it stand up to rational analysis?
Obviously one way of never doing any harm would not be to treat anyone in case something went wrong (and in modern America, in case of a lawsuit). In practice, doctors not only treat patients by balancing doing probably good against avoiding probable harm, use triage to see who to treat first, and give deadly medicine quite often – though carefully dispensed to kill cancer cells, bacteria, or simply kill pain. ‘Doing no harm’ is a starting point and actually the first rule of trauma care, proceeding in a methodical manner, gathering information and stabilising the patient.
Once the patient is stabilised and options for doing good arise, the next question that arises (and one of law) is, what does the patient want?
Contrary to what you are maybe expecting me to say at this point, I do not think that there is never a place for paternalism in medicine. A classic case that came up and reported in the medical press concerned an elderly woman who had a simple, easily curable cancer. She refused to go to hospital as she believed she would die there if she went. A new doctor seeing her ‘bullied’ her a bit and told her, “Get in that ambulance, right now!” She did, and was duly discharged after successful treatment. But that is an unusual case: while a doctor is an expert on what treatments can be offered, the patient is normally the expert on what outcome he or she would prefer.
To some, it appears ‘obvious’ (clearly not, as people on both sides of the debate think it is ‘obvious yet disagree!) Death, whether one’s own or someone else’s is not, in the general run of things, the most palatable of options. Yet sometimes it is the ‘least worst option.’
In Antigone, Sophokles states that nobody is so silly as to wish to die: ‘Who prays to die is mad.’ ‘No man is so foolish that he is enamoured of death.’ However, in another play, The Women of Trachis, he refers to the dilemma presented by assisted euthanasia: The protagonist Herakles, who is suffering from unbearable pain, asks his son, Hyllus, to help him end his life:
“Lay my body thereupon and kindle it with flaming pine-torch. And let no tear of mourning be seen there.”
Hyllus complains that in so doing, he will ‘become a murderer’ and will be showing disrespect to the gods. “What a deed dost thou require of me my father that I should become the murderer guilty of thy blood. … Father, father, how can you? You are asking me to be your murderer, polluted with your blood.” And Heracles replies:
“No, I am not. I ask you to be my healer, or healer of my sufferings, sole physician of my pain.”
It is perhaps easy to speak about ‘high principles’ in the abstract. Somehow seeing someone you love enduring a suffering that you, as a physician, could end, pulls at a sense of humanity in a different way.
Until physicians unite and have the courage to do the right thing, properly and within a good law, people will take matters into their own hands.
Euthanasia and suicide in antiquity: viewpoint of the dramatists and philosophers
On “Battlefield Euthanasia: Should Mercy-Killings Be Allowed?”
Early management of the multiply injured patient (A&E textbook)
Myth vs Fact: ‘First Do No Harm’
First Do No Harm (Harvard Medical School)
“First do no harm” revisited (BMJ)
Medical oaths and declarations (BMJ)
So long, Hippocrates. Medical students choose their own oaths
Suicide in ancient Greece
Poisons, Poisoning and the Drug Trade (in Ancient Rome)
Would Hippocrates Rewrite His Oath? A new declaration
The Oath (Greek and translation)
From the bookshelf:
The Hippocratic Oath and the Ethics of Medicine by Steven Miles
Hippocratic Oaths: Medicine and Its Discontents by Raymond Tallis