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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