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Ethics
Oaths
and
Declarations
Who Makes Them?
Why?
I SWEAR by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that,
according to my ability and judgment, I will keep this Oath and this stipulation- to reckon him who taught me this Art
equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his
offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or
stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my
own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but
to none others.
I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my
patients, and abstain from whatever is deleterious and mischievous.
I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a
woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art.
I will not cut persons labouring under the stone, but will leave this to be done by men who are practitioners of this work.
Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of
mischief and corruption; and, further from the seduction of females or males, of freemen and slaves.
Whatever, in connection with my professional practice or not, I see or hear, in the life of men, which ought not to be
spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.
While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected
by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!
Hippocrates I SWEAR by Apollo the physician, and Aesculapius, and
Health, and All-heal, and all the gods and goddesses,
that, according to my ability and judgment, I will keep
this Oath and this stipulation- to reckon him who taught
me this Art equally dear to me as my parents, to share
my substance with him, and relieve his necessities if
required; to look upon his offspring in the same footing
as my own brothers, and to teach them this art, if they
shall wish to learn it, without fee or stipulation; and that
by precept, lecture, and every other mode of instruction,
I will impart a knowledge of the Art to my own sons, and
those of my teachers, and to disciples bound by a
stipulation and oath according to the law of medicine,
but to none others.
I will follow that system of regimen which, according to my
ability and judgment, I consider for the benefit of my patients,
and abstain from whatever is deleterious and mischievous.
I will give no deadly medicine to any one if asked, nor
suggest any such counsel; and in like manner I will not give
to a woman a pessary to produce abortion.
*******
I will not cut persons labouring under the stone, but will leave
this to be done by men who are practitioners of this work.
***
With purity and with holiness I will pass my life and
practice my Art.
***
Into whatever houses I enter, I will go into them for the
benefit of the sick, and will abstain from every voluntary
act of mischief and corruption; and, further from the
seduction of females or males, of freemen and slaves.
Whatever, in connection with my professional practice or
not, I see or hear, in the life of men, which ought not to be
spoken of abroad, I will not divulge, as reckoning that all
such should be kept secret.
Whatever, in connection with my professional practice or not,
I see or hear, in the life of men, which ought not to be spoken
of abroad, I will not divulge, as reckoning that all such should
be kept secret.
While I continue to keep this Oath unviolated, may it be
granted to me to enjoy life and the practice of the art,
respected by all men, in all times! But should I trespass and
violate this Oath, may the reverse be my lot!
1. Medicine is of all the arts the most noble; but, owing to the
ignorance of those who practice it, and of those who,
inconsiderately, form a judgment of them, it is at present far
behind all the other arts. Their mistake appears to me to arise
principally from this, that in the cities there is no punishment
connected with the practice of medicine (and with it alone)
except disgrace, and that does not hurt those who are familiar
with it. Such persons are the figures which are introduced in
tragedies, for as they have the shape, and dress, and personal
appearance of an actor, but are not actors, so also physicians
are many in title but very few in reality.
The Law of Hippocrates
2. Whoever is to acquire a competent knowledge of medicine,
ought to be possessed of the following advantages: a natural
disposition; instruction; a favorable position for the study;
early tuition; love of labour; leisure. First of all, a natural
talent is required; for, when Nature leads the way to what is
most excellent, instruction in the art takes place, which the
student must try to appropriate to himself by reflection,
becoming an early pupil in a place well adapted for
instruction. He must also bring to the task a love of labour
and perseverance, so that the instruction taking root may
bring forth proper and abundant fruits.
3. Instruction in medicine is like the culture of the
productions of the earth. For our natural disposition, is, as it
were, the soil; the tenets of our teacher are, as it were, the
seed; instruction in youth is like the planting of the seed in the
ground at the proper season; the place where the instruction is
communicated is like the food imparted to vegetables by the
atmosphere; diligent study is like the cultivation of the fields;
and it is time which imparts strength to all things and brings
them to maturity.
4. Having brought all these requisites to the study of
medicine, and having acquired a true knowledge of it, we
shall thus, in travelling through the cities, be esteemed
physicians not only in name but in reality. But inexperience is
a bad treasure, and a bad fund to those who possess it,
whether in opinion or reality, being devoid of self-reliance
and contentedness, and the nurse both of timidity and
audacity. For timidity betrays a want of powers, and audacity
a lack of skill. They are, indeed, two things, knowledge and
opinion, of which the one makes its possessor really to know,
the other to be ignorant.
5. Those things which are sacred, are to be imparted only to
sacred persons; and it is not lawful to impart them to the
profane until they have been initiated into the mysteries of the
science.
“Next in ingenuity to the old marriage custom is their
[Babylonians’] treatment of disease. They have no doctors,
but bring their invalids out into the street, where anyone who
comes along offers the sufferer advice on his complaint,
either from personal experiences or observation of a similar
complaint in others. Anyone will stop by the sick man’s side
and suggest remedies which he himself proved successful in
whatever the trouble may be, or which he has known to
succeed with other people. Nobody is allowed to pass a sick
person in silence; but everyone must ask him what is the
matter.” Herodotus Bk 1, 197.
Ancient Ways
“The practice of medicine they [Egyptians] split up into
separate parts, each doctor being responsible for the treatment
of only one disease. There are, in consequence, innumerable
doctors, some specializing in diseases of the eyes, others of
the head, others of the teeth, others of the stomach, and so on;
while others again deal with the sort of troubles which cannot
be exactly localized.”
Herodotus Bk 2, 84.
Trials: 1945-1949
International Tribunal: Major War Crimes.
24 accused= 12 death penalty, 7 imprisonment, 3 acquitted,
1 unfit, 1 suicide.
US Military tribunal: Doctors’ Trial
23 accused= 7 death penalty, 9 imprisonment, 7 acquitted.
Nuremberg
Doctors’ Trial: the accused faced four charges:
• Conspiracy to commit war crimes and crimes against
humanity as described in counts 2 and 3; (charge dropped)
• War crimes: performing medical experiments without the
subjects' consent on prisoners of war and civilians of
occupied countries, as well as participation in the massmurder
of concentration camp inmates.
• Crimes against humanity: committing crimes described
under count 2 also on German nationals.
• Membership in a criminal organization, the SS.
Nuremberg
Doctors’ Trial:
“Generally, the difference between a prison term and the
death sentence was membership in "an organization
declared criminal by the judgement of the International
Military Tribunal" — namely the SS.”
1933: Law for the protection of Hereditary Health. Prescribed
sterilization for :feeblemindedness, schizophrenia, manic-depression,
epilepsy, hereditary blindness, deafness, Huntingdon’s, alcoholics.
Drawn up by the Nazi party, which was very Nationalistic, and anti-
Bolschevik, under guidance of Dr. Rudin, University of Munich.
Nuremberg
Studied in Munich 1930, Philosophy and Medicine.
Nationalism stirring.
Eugenics, and anthropology: PhD on racial morphology of lower jaw.
1937: appointed, Institute for Hereditary, Biology and Racial
Purity, Frankfurt, as research assistant to von Vershuer,
who became father figure.
Became Nazi Party member, and later allowed to join the SS
Joined Army, awarded Iron Cross twice, wounded;
1943: Assigned to Auschwitz (Birkenau). Aborted a typhus
epidemic by killing a thousand (non-German) gypsies.
Carried out research, especially on twins (“Mengele’s
Children”), dwarfs and cripples
Josef Mengele
6 Million European Jews (4.5 m from Poland or Russia,
125,000 from Germany)
3.5 – 6 million ‘Slavs’
3.5 million non-Jewish Poles
Approx 4 million Russian PoW
Approx 1.5 million political dissidents
500,000 Gypsies
15,000 Homosexuals
2,000 Jehovah’s Witnesses
‘Holocaust’
Hypothermia
Genetics: defects and eugenics
Infectious diseases
High altitude experiments
Traumatic wounds and infection
Sterilization
Twin anthropology.
Experiments
• Full, voluntary, informed, consent
• Well planned and necessary and justifiable
• Based on knowledge and previous work (or animal
experiments)
• Avoid unnecessary physical and mental suffering
• Not if death or disabling injury likely, save on the
experimenters themselves
• Risk justified by the importance of the anticipated results
• All adequate precautions against injury or death
• Experimenters must be qualified skilful, careful scientists
• Experiment terminated at request of subject
• Or if likely to terminate in injury, disability or death.
WMA
Nuremberg Code
Declaration of Geneva (1948, 1968, 1983, 1994, 2005)
International Code of Medical Ethics (1949, 1968, 1983)
Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects
(1964, 1975, 1883, 1989, 1996, 2000, 2002, 2004)
Declaration of Oslo on Therapeutic Abortion (1970, 1983)
Declaration of Tokyo: Guidelines for Medical Doctors Concerning Torture and Other Cruel,
Inhuman or Degrading Treatment or Punishment in Relation to Detention and
Imprisonment (1975, 2005)
Declaration of Lisbon on the Rights of the Patient (1981, 1995, 2005)
Declaration of Venice on Terminal Illness (1983)
Declaration of Madrid on Professional Autonomy and Self- Regulation (1987)
Declaration of Hong Kong on the Abuse of the Elderly (1989, 1990)
Declaration of Hamburg Concerning Support for Medical Doctors Refusing to Participate in,
or to Condone, the Use of Torture or Other Forms of Cruel, Inhuman or Degrading
Treatment (1997)
Declaration of Ottawa on the Right of the Child to Health Care (1998)
Declaration on Ethical Considerations Regarding Health Databases (2000)
Declaration of Washington on Biological Weapons (2002)
WMA Declaration of Geneva
DUTIES OF PHYSICIANS IN GENERAL
A PHYSICIAN SHALL always maintain the highest standards of
professional conduct.
A PHYSICIAN SHALL not permit motives of profit to influence the
free and independent exercise of professional judgement on behalf of
patients.
A PHYSICIAN SHALL in all types of medical practice, be dedicated to
providing competent medical service in full technical and moral
independence, with compassion and respect for human dignity.
A PHYSICIAN SHALL deal honestly with patients and colleagues, and
strive to expose those physicians deficient in character or
competence, or who engage in fraud or deception.
WMA Declaration of Geneva
The following practices are deemed to be unethical conduct:
1. Self advertising by physicians, unless permitted by the
laws of the country and the Code of Ethics of the National
Medical Association.
2. Paying or receiving any fee or any other consideration
solely to procure the referral of a patient or for prescribing
or referring a patient to any source.
WMA Declaration of Geneva
A PHYSICIAN SHALL respect the rights of patients, of
colleagues, and of other health professionals and shall
safeguard patient confidences.
A PHYSICIAN SHALL act only in the patient's interest
when providing medical care which might have the effect
of weakening the physical and mental condition of the
patient.
A PHYSICIAN SHALL use great caution in divulging
discoveries or new techniques or treatment through nonprofessional
channels.
A PHYSICIAN SHALL certify only that which he has
personally verified.
WMA Declaration of Geneva
DUTIES OF PHYSICIANS TO THE SICK
A PHYSICIAN SHALL always bear in mind the obligation
of preserving human life.
A PHYSICIAN SHALL owe his patients complete loyalty
and all the resources of his science. Whenever an
examination or treatment is beyond the physician's
capacity he should summon another physician who has
the necessary ability.
A PHYSICIAN SHALL preserve absolute confidentiality on
all he knows about his patient even after the patient has
died.
A PHYSICIAN SHALL give emergency care as a
humanitarian duty unless he is assured that others are
willing and able to give such care.
WMA Declaration of Geneva
DUTIES OF PHYSICIANS TO EACH OTHER
A PHYSICIAN SHALL behave towards his colleagues as he
would have them behave towards him.
A PHYSICIAN SHALL NOT entice patients from his
colleagues.
A PHYSICIAN SHALL observe the principles of the
"Declaration of Geneva" approved by the World Medical
Association.
WMA Declaration of Geneva
AT THE TIME OF BEING ADMITTED AS A MEMBER
OF THE MEDICAL PROFESSION:
I SOLEMNLY PLEDGE to consecrate my life to the service
of humanity;
I WILL GIVE to my teachers the respect and gratitude that is
their due;
I WILL PRACTISE my profession with conscience and
dignity;
THE HEALTH OF MY PATIENT will be my first
consideration;
I WILL RESPECT the secrets that are confided in me, even
after the patient has died;
I WILL MAINTAIN by all the means in my power, the
honour and the noble traditions of the medical profession;
MY COLLEAGUES will be my sisters and brothers;
I WILL NOT PERMIT considerations of age, disease or
disability, creed, ethnic origin, gender, nationality,
political affiliation, race, sexual orientation, social
standing or any other factor to intervene between my duty
and my patient;
I WILL MAINTAIN the utmost respect for human life;
I WILL NOT USE my medical knowledge contrary to the
laws of humanity, even under threat;
I MAKE THESE PROMISES solemnly, freely and upon my
honour.
AMA
Principles of medical ethics
A physician shall be dedicated to providing competent medical care, with
compassion and respect for human dignity and rights.
A physician shall uphold the standards of professionalism, be honest in all
professional interactions, and strive to report physicians deficient in
character or competence, or engaging in fraud or deception, to
appropriate entities.
A physician shall respect the law and also recognize a responsibility to
seek changes in those requirements which are contrary to the best
interests of the patient.
A physician shall respect the rights of patients, colleagues, and other
health professionals, and shall safeguard patient confidences and
privacy within the constraints of the law.
A physician shall continue to study, apply, and advance scientific
knowledge, maintain a commitment to medical education, make
relevant information available to patients, colleagues, and the
public, obtain consultation, and use the talents of other health
professionals when indicated.
A physician shall, in the provision of appropriate patient care, except in
emergencies, be free to choose whom to serve, with whom to
associate, and the environment in which to provide medical care.
A physician shall recognize a responsibility to participate in activities
contributing to the improvement of the community and the
betterment of public health.
A physician shall, while caring for a patient, regard responsibility to the
patient as paramount.
A physician shall support access to medical care for all people.
Adopted by the AMA's House of Delegates June 17, 2001.
GMC
The duties of a doctor registered with the General Medical Council
Patients must be able to trust doctors with their lives and well-being. To
justify that trust, we as a profession have a duty to maintain a good
standard of practice and care and to show respect for human life. In
particular as a doctor you must:
• make the care of your patient your first concern;
• treat every patient politely and considerately;
• respect patients' dignity and privacy;
• listen to patients and respect their views;
• give patients information in a way they can understand;
• respect the rights of patients to be fully involved in decisions
about their care;
• keep your professional knowledge and skills up to date;
• recognize the limits of your professional competence;
• be honest and trustworthy;
• respect and protect confidential information;
• make sure that your personal beliefs do not prejudice your
patients' care;
• act quickly to protect patients from risk if you have good reason
to believe that you or a colleague may not be fit to practise;
• avoid abusing your position as a doctor; and
• work with colleagues in the ways that best serve patients'
interests.
In all these matters you must never discriminate unfairly
against your patients or colleagues. And you must
always be prepared to justify your actions to them.
Problems solved?
Tuskegee
Willowbrook
Jewish Chronic Disease Hospital
OC trial, Mexico (exp. pgcy)
Irradiation
Castration
• 1929, USPHS was interested in the
prevalence of syphilis among blacks
(originally to see if mass treatment
feasible)
• Macon County, Alabama had highest rates
• In 1932, Taliaferro Clark, Chief of USPHS
VD division devised a “study in nature”
• Because syphilis was so prevalent, they
wanted to study natural history of it
The Tuskegee Syphilis Study
copied from a lecture by Julie Fagan MD
10
Erroneous assumptions:
– Blacks were more prone to disease, vice, and crime
– Black males had excessive sexual desire, especially of
white women
– Treatment for VD in blacks was impossible, because
they would only accept treatment when symptomatic,
but not for latent infection
• USPHS believed that antisyphilis treatment might prove
unnecessary
– Based on Oslo study (1890-1910), which began when
only ineffective treatment (mercurials) available
– Because syphilis becomes latent (undetectable), 70% of
untreated pts unaffected
The Tuskegee Syphilis Study
However, every textbook at the outset of the Tuskegee
study (1932) recommended treating it, even at
advanced (latent) stages
• Rationale: though treatment difficult, it allayed
development of CV and CNS disease
– Also, treatment prevented transmission to partners and
offspring
• Study design: 400 Black males 25-60 with syphilis, who
were given an examination, X-rays, and a spinal tap
to document neurosyphilis (200 controls)
• Although they offered treatment to entice men to enroll,
the USPHS had no intention of treating
• Original study to last 6 months--it lasted 40 years
The Tuskegee Syphilis Study
• Deception: men given ineffective treatment (mercurial
ointment and arsenic compounds) to maintain
interest
• PHS decided to continue study until death of subjects in
1933
• $50 for burial given as an inducement for autopsy
consent
• Results published regularly beginning in 1936
• Documented the ravages of untreated syphilis--
– 84% of subjects had complications vs. 39% of control
subjects
• Life expectancy reduced by 20%
• Over 30% of deaths due directly to advanced syphilis in
“test” group
The Tuskegee Syphilis Study
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