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Should the Hippocratic Oath be rewritten?
When resources for health care are finite, the demand for health care is seemingly infinite, and the medical potential for satisfying that demand is always expanding, perhaps the time-honored allegiance of the physician to the individual patient no longer works.
That's what Christine Cassel, M.D., suggested in remarks at last month's conference sponsored by the Council of Medical Specialty Societies titled "Contemporary Health Care and the Ethic of Medicine: What Is a Physician to Do?"
Cassel is chair of the department of geriatrics and adult development at Mount Sinai Medical Center, New York.
"I propose that perhaps we should change our ethic," Cassel said. "Perhaps we should rewrite the Hippocratic Oath and change the value of medicine. It might be possible to do it for the better of the profession and of our patients."
Cassel's remarks were in opposition to comments by other speakers including APA Assembly Speaker-elect Jeremy Lazarus, M.D., who emphasized the moral nature of the doctor-patient relationship, and ethicist Edmund Pellegrino, M.D.
Though reflective, perhaps, of a minority viewpoint both at the conference and within medicine generally, Cassel's challenge marks a fault line that may deepen as pressures on the health care system increase: Where do the ethical physician's loyalties lie--with the individual patient or with the larger community? And how does that choice affect the relationship between a doctor and his or her patients?
Cassel suggested that concern about the health of populations is not necessarily antithetical to medicine, but seems so only to American physicians schooled in a tradition that long ago diverged from the discipline of public health.
"Most physicians don't know how to measure, evaluate, or even think about population health," Cassel said. "Public health as a field diverged from medicine more than a hundred years ago, and since that time what we know as medicine has been about individuals, not populations. We don't educate physicians to think about populations."
Cassel acknowledged that though "population health" has become a hot topic within medical-ethical circles, the development of an ethic--and an equitable health care system--that incorporates that concern is not a trivial matter; indeed, it is radical.
"We know it fundamentally changes the physician's fiduciary responsibility to the individual patient," Cassel said. "Is it good or is it bad?. . . .The one thing we know is that it is not consistent with the traditional Hippocratic Oath."
Yet Cassel also said that the health of the larger community cannot be ignored by physicians who approach each patient as an individual.
Rationing of care--or allocation of resources--is happening now and will continue, and the problem of how to do it equitably is not going to go away, she said.
"In the 1970's, when the field of medical ethics was just beginning to blossom, everyone said that the physician is responsible to do everything possible for the individual patient, and that society must decide about the ethical allocation of resources," she said.
"That has now changed."
(Psychiatric News, May 16, 1997)