This article appears in the February 2001edition of the Catholic Medical Quarterly

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HIPPOCRATES: Where are you
when we need you?

Patrick Guinan

"Life is short and art long" Aphorisms
"Medicine is of all the arts the most noble." The Law

Abstract

Bioethical issues, particularly with the Human Genome Project nearing completion and the expanding AIDS epidemic in Africa, are demanding the attention of our national conscience. Physicians have traditionally provided the lion's share of the expertise in medical ethics. This is in part because medical practitioners over the past 2500 years, through trial and error, have perfected their art and gained unique insights into the human conditions of disease and suffering. Unfortunately, the bioethics establishment, which is currently addressing and resolving these problems, is composed predomi nantly of non-physicians. The voice of the Hippocratic tradition, and its predominant refrain "primum non nocere," is becoming less and less influential in the national debate on bioethics.

 

Introduction

The ethical issues involved in healthcare are be coming more relevant with each new medical development. The now nearly complete mapping of the human genome and the problems with the AIDS epidemic in Africa are but two examples.

Traditionally, medical ethics questions have been addressed by physicians. There were several reasons for this. First, there was no defined academic discipline of ethics to rely upon and because of this, there were no professional bioethicists. Second, physicians were of the educated class. Third, and most practically, physicians, confronted with these problems on a daily basis, developed what became the Hippocratic ethic.

The Hippocratic tradition includes, and is most known for, the Hippocratic Oath. But it includes much more. By involving "all the gods and goddesses" it assumes that a higher power is at work in human affairs. This higher power is also reflected in nature and in nature's inclination toward completeness. Should man comply with nature's tendency toward wholeness, by living a moderate life relative to work, play and food, he would live a virtuous life and be healthy and happy. These ideas are implicit in the Hippocratic Oath which more specific ally applies them to medical matters.

The Hippocratic legacy combined the practical art of medical healing with the Aristotelian concept of virtue ethics. Medicine, given the underlying absence of modem empirical science, was a trial and error art which, all in all, provided for its patients quite well. Medicine was nature served rather than nature mastered. The integration of its holistic mind-body approach, not unlike traditional Chinese medicine, provided a satisfying human element to therapy often lacking in our impersonal technological approach.

While the Hippocratic tradition has been criticized as no more than rules of etiquette to protect practitioners it, at core, is a virtue based ethical system. Its principles of beneficence, non-maleficence, and justice are reflected in the Hippocratic Oath. The art of treating sick patients demands patience and humility. The Hippocratic dictum "primum non nocere" precluded much of the mischief that human hubris might otherwise have caused. The Hippocratic legacy, which encompasses more than the brief Oath, has served physicians, and more importantly their patients, well for 2500 years. However, in the past 30-35 years there has been a break with this ethical legacy. For a variety of reasons, changes: medical, technological, and most importantly societal, occurred in the 1960s. The respect for medical leadership once eroded, non-MDs began to speak with, and were given, authority in the field of bioethics. The purpose of this report is to review the current academic backgrounds of the leadership in the bioethical community as documented in the membership of bioethical organizations.

 

Methods and Materials

The International Directory of Biomedical Organizations (2) reflects the make-up of the bioethical community of the United States. This compendium is not a compilation of ethical institutes throughout the world. For the purposes of this review only organizations in the United States will be included. In addition we will review the membership of the National Bioethical Advisory Commission and the National Human Embryo Research Panel.

There were 161 bioethical organizations in 40 states and the District of Columbia. A review of the directors revealed that 38(24%) were medical doctors: 34 with an MD alone and four MD with additional degrees (three with a PhD and 1 JD) (TABLE 1). The remaining 123 (76%) directors had a variety of degrees including 51 with PhDs, 14 with JDs, 5 with ministry degrees, 5 with masters degrees, 7 registered nurses (RN) and 41 with no degrees listed.

Table 1a
Professional Degrees

I. Bioethical Institutes

a.  Directors
  MD alone 34
MD + PhD 3
MD + JD 1
Subtotal with MD = 24%
38
  PhD 51
JD 14
Ministry 5
Masters 5
RN 7
No degree listed 41
Total
161

b. Professional Staff
  MD alone 64
MD + PhD 4
Subtotal with MD = 23%
68
  PhD 136
JD 25
Ministry 13
Masters 16
RN 12
Other 5
No degree listed 27
Total
302

 

Table 1b

II. National Bioethics Advisory Committee
  MD alone 3
  MD + PhD 2
Subtotal with MD = 27%
5
  PhD 6
  LLB 2
  JD 1
  Not listed 4
Total
18

III. Human Embryo Research Panel
  MD alone 5
  MD + PhD 1
  PhD 8
  JD 2
  Dr. Ed 1
  Not listed 2
Total
19

The professional staffs consisted of 302 individuals. There were 68 (23%) with an MD, and 234 individuals with additional designations: 136 with PhDs, 25 with JDs, 13 individuals with ministry degrees, 16 with masters degrees, 12 RNs, 5 with other degrees, and 27 with no degrees listed.

The National Bioethics Advisory Commission included eighteen members, six with an MD degree, twelve without. The National Human Embryo Research Panel(4) included nineteen members, six with MD degree, thirteen without. Less than one third of the members of the National Bioethics Advisory Commission and the National Human Embryo Research Panel have MD degrees.

 

Discussion

Assuming that physicians had dominated medical ethical decision making from the time of Hippocrates, the shift of authority to non-physicians in the past thirty years is remarkable. Fewer than one quarter of directors and staff of bioethical organizations have MD degrees. It is assumed that the influence of the Hippocratic tradition is proportionately diminished. We now offer some thoughts upon why this has happened and what are the implications.

There are several possible causes:-

Reasons for Changes in Bioethical Leadership

  1. Distrust of authority, including that of the physician.
  2. Media s exposure of negative aspects of medicine.
  3. Increase in importance of science and relative value of PhD s knowledge in pharmacology and physiology.
  4. Increase in government intervention and legislation. Mandating of universal hospital ethics committees and institutional review boards requiring "experts".
  5. Medical Litigation.
  6. Most importantly, the emphasis on "autonomy".

 First, beginning in the 1960s there has been a societal rebellion against authority. The "Doctor knows best" is no longer a cogent dictum. Second, the media's need for headlines led to a more ready exposure of medicine's, as well as other's, weak nesses. The publicity the Belmont Report of research irregularities received in 1979 reflected negativity on the perceived sanctity of medicine. Third, science has become relatively more important in the cure of disease than art. While not dealing with the emotional aspect of disease, science can identify and correct the physical parameters of illness. PhDs predominate in the physical sciences. Fourth, the government began to intervene more aggressively in medicine, Laws mandating hospital ethics committees and institutional review boards were passed. These panels required experts, trained in philosophy and theology departments rather than medical schools. Fifth, our litiginous society encouraged malpractice law suits and a resultant defensive medicine mentality. Lawyers began specializing in biomedical ethical issues. Finally, and perhaps most importantly, there has been an inexorable drive toward human autonomy. "If I can do it, I should be allowed." The patient replaced the physician as the decision maker.

For a varying combination of these reasons physicians no longer predominate in the medical ethical arena. This is unfortunate because, despite the de personalizing influence technology has had on medicine, the Hippocratic respect for the patient and nature's tendency toward wholeness and health still dominates the medical profession. Patient care confers insights into the human condition denied to non-physicians. Medicine remains an art first and a science second.

There is evidence that medical doctors exhibit traits desirable in bioethical decision making. Numerous reports suggest that physicians outscore other professional groups in studies measuring psychological parameters such as empathy, compassion and benevolence.(6-8) Hard scientific data are essential in bioethical discussions, but so also are insights into the human condition, with its suffering and uncertainty, that are gained only slowly and humbly at the bedside.

The implication for bioethics of this gradual loss of the physician's experience and the Hippocratic ethic could be significant. One current example is the field of genetics. The Hippocratic "primum non nocere" suggests that germ line genetic manipulations could adversely affect others beside those requesting the manipulations, yet autonomy states that if I can technologically do it, I will. This Faustian cognitive imperative would not be permit ted to the disciple of Hippocrates. Unrestrained science and technology do not necessarily improve the human condition or make people happy.

The question "Hippocrates, where are you when we need you?" is all the more relevant today. If the Hippocratic tradition lives on at all in today's physicians, their representation on bioethics committees should be increased.

 

References & Bibliography

  1. Kass L: Toward a More Natural Science. The Free Press, NY, 1985.
  2. Nolan A, Coutts M: International Directory of Biomedical Organizations, National Reference Center of Bioethics Literature. Kennedy Institutes for Ethics, Georgetown University, Washington, DC 20057-1069, 1993.
  3. National Bioethics Advisory Committee. http:/bioethics.gov/about/nbacroster.htm
  4. Human Embryo Research Panel. NIH, First Report, 1994.
  5. Belmont Report, National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. 1979.
  6. Hogan R: Development of an empathy scale. J Consulting and Clinical Psychology. 33:307-316, 1969.
  7. Linn L, DiMatteo R, Cope D, Robbins A: Measuring physicians humanistic attitudes, values and behavior. Med Care 25:504-513, 1987.
  8. Magee M, Hojat M: Personality profiles of male and female positive role models in medicine. Psychol Rep 82: 547-559, 1998.
  9. Hojat M, NascaT, Magee M, Feeney K, Pascual R, Urbono F, and Gonnella J: A Comparison of the personality profiles of internal medical residents, physician Role Models, and the general population. Acad Med, 74:1327-1333, 1999.

Dr. Patrick Guinan is Associate Professor in the Dept. of Urology of the University of Illinois at Chicago.

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