For many of us, using unproven techniques, unless as part of an approved research protocol, is not even a consideration. However, many good and caring physicians continue to be drawn in by the hype surrounding these techniques. These new techniques may, in fact, prove to be valuable and worthy of widespread implementation. However, we must insist—no, we must demand— that these nonstandard approaches are performed only under clinical research protocols until data on efficacy, safety, and cost-effectiveness can be provided to our patients. As a modern version of the Hippocratic Oath instructs, “I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.”
Often in the practice of Medicine, the lack of specific regulation require us to accept the responsibility to self-regulate. We must always respect the patient’s rights to be completely informed of the treatment they are to undergo. Specifically, they must be apprised of the reason for the treatment, the expected results, the duration of treatment, potential side effects, and the total cost of treatment. Our patients, our colleagues, and the regulatory authorities hold us, as physicians to a higher level. We need to define what is and what is not standard treatment . . . or it will be defined for us. Nonstandard treatment may, in fact, be better then standard treatment, but we need to validate efficacy in approved protocols that protect the patient and the patient’s rights. From this, we cannot waiver. It is our responsibility. It is our Oath.
As I listened to the recitation of the Hippocratic Oath and reveled in the euphoria I shared with these new graduates, I realized that by upholding its doctrine to “ . . . respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow” that we will continue to answer a higher calling, serve and protect the needs of others, and maintain the responsibility we have as healers.
I regard our independence to practice our craft as one of the principal rights we have as physicians and surgeons. We are given this right not by the university that granted us our degree, nor by local, state, or federal authorities, but by our patients. Our patients lay bare their bodies and souls to us, often times complete strangers, without a written or verbal contract but with unstated expectations. They enter this covenant with the hope, and yes, the expectations, that we are equipped both intellectually and ethically to cure or at least ameliorate their ills. Therein lies the sometimes overwhelming responsibility we have as healers. “I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.” Implicit in this classical translation of a portion of the Hippocratic Oath is the physician’s vow to maintain the good of the patient as the highest priority. Possibly the most difficult challenge to today’s physician with this portion of the Hippocratic Oath is economics. To practice our art, we have expenses, staff, rent, and supplies. We also have responsibilities to our family, especially our parents, spouse, and children. Our expenses continue to escalate without a parallel increase in our income stream. The conflict emerges when providing optimum care to patients is inversely related to making a living. Therein lies the basis of an ethical dilemma that all physicians must face. Do we use protocols or devices that might yield us great financial rewards, unencumbered by our participation in managed care, even though they have unproven efficacy and an unknown
safety profile? Or should we insist on providing our patients with the appropriate information with which they can make an informed decision?
to be continued…….Bruce R. Gilbert MD PhD
EUPHORIA! A single word encompassed my persona some 25 years ago during my medical school commencement. I had finally achieved my life’s goal of becoming a doctor and was ready to enter my residency with excitement . . . and a bit of trepidation.
As parents, attending graduation ceremonies instills great pride in our children’s accomplishments and provides us the luxury of cogitation and introspection. I recently attended my daughter’s college graduation from Columbia University, a neoclassical urban institution with 3 undergraduate schools, 13 graduate and professional schools, and a school of continuing education, as well as 5 affiliated colleges. Each of these schools has its own graduation followed by a larger combined university ceremony. This year’s attendance approached 40,000 guests including the graduates and their family and friends. My daughter’s impending entrance into medical school made the portion of the program during which the graduating medical school class recited the Hippocratic Oath even more engaging. A revered tradition thought to be written by Hippocrates or one of his students in the fourth century BCE, the Hippocratic Oath marked a physician’s “rite of passage.” At the completion of the recitation, one would transform from a medical student into a Doctor of Medicine, with all the “Rights, Privileges and Responsibilities hereto entrusted.” As these medical student graduates repeated with joined voices the oath passed down by a legacy of physicians, a silence spread throughout the massive audience witnessing the metamorphosis. My eyes welled up, my throat tightened, and my heart raced, just as it did 25 years ago. I also remember feeling at that time, although probably would never have admitted it then, some fear.
to be continued…….Bruce R. Gilbert MD PhD