published Thursday, June 16th, 2011

Cleaveland: Doctors need new ethics oath

Contrary to popular belief, physicians do not take a uniform, ethical pledge at the time of graduation from medical school. The Hippocratic Oath, which dates from the fourth century B.C., is the oldest of professional codes of medical conduct and for decades was administered at many graduation ceremonies.

After acknowledging reverence for the gods of healing, the early oath proclaimed respect for teachers, devotion to the service of patients and confidentiality in all dealings with the sick. The practitioner would avoid corrupt practices, refuse to terminate life at any stage and renounce surgical interventions. Because the classical pledge is outdated with little mention of the rights of patients, various modifications are used in its place by some medical schools.

In response to atrocities committed by Nazi physicians during World War II, the World Medical Association in 1948 promulgated a new code of ethics, the Declaration of Geneva. While affirming the primacy of the patient’s well-being, this oath specifies that no racial, ethnic, religious, economic, or social barriers can interfere with the care of patients. The oath concludes, “I will not use my medical knowledge contrary to the laws of humanity.”

The American Medical Association regularly updates its Code of Medical Ethics. Individual specialty groups have produced their own pledges as well as detailed manuals of ethical principles.

A panel of medical scholars presented the Tavistock Principles of Medical Ethics in the British Medical Journal in 2001. London’s Tavistock Square is home to the British Medical Association. The new code of conduct encompasses everyone involved in the care of patients.

This code emphasizes health care as a basic human right. Care involves treatment as well as prevention of illness and injury. Caregivers must strive to alleviate suffering and disability. While the care of the individual remains a central concern, caregivers must address the health of groups and populations. Cooperation by all caregivers is critical both to the care of patients and to the continuing need to improve the quality of care.

Some medical schools have a tradition in which each graduating class composes a unique ethical pledge which is administered at the time that degrees are granted. The oath, composed by the 2011 class at Vanderbilt School of Medicine, emphasizes “caring for the sick and promoting the well-being of others.” The pledge expresses a duty beyond the individual patient: “I will strive to improve the practice of medicine, advocating for the health of others and acting as a faithful steward, mentor, and leader.”

Whatever ethical oath is administered, the circumstances of modern medicine present a number of challenges. Resources are finite. Care is uneven across economic, racial, and ethnic boundaries. New technologies present unique challenges of access and affordability. Years ago, Duke University ethicist Harmon Smith posed the still unanswered question: “Who gets how much of what when there is not enough to go around?”

A pledge of ethical conduct at medical school graduation represents a lofty aspiration. But a one-time pledge is easily forgotten. A pledge taken on an annual basis would refresh the aspirations of the individual physician.

But what if all parties involved in health care — doctors of medicine, pharmacy, and dentistry; nurses, physical therapists, clinical psychologists, and medical technologists — renewed annually a common pledge such as the Tavistock Principles? What if health care administrators and health insurers joined in the same renewal of shared vows? Would this make a difference in the character and quality of health care in a community?

I believe it would. Chattanooga would be an excellent locale to test such an assumption.

Contact Clif Cleaveland at

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