Oaths for Physicians -- Necessary Protection or Elaborate Hoax?

Erich H. Loewy, MD

In This Article

An Oath Made Freely

I think that the prospective physician having to take an oath that promises to place the biopsychosocial interests of the individual patient first while at the bedside and to work for a healthcare system that is accessible to all is not coercive to students as long as students are aware before they enter medical school that taking such an oath will be one of the requirements for graduation -- no more and no less than anatomy or a clerkship in medicine. After all, the medical profession owes to society a promise that the physicians who the profession ultimately licenses not only have sufficient technical knowledge but that, to the best of our knowledge, he or she is an honorable person. The problem with such an oath is that to pass anatomy or the medicine clerkship, the student has to have a minimum of knowledge as determined by the faculty. It is very difficult to ensure that students have character traits that allow them to prescribe poisons or cut patients. We, the faculty, have been delinquent in setting ethical standards that if violated will cause a student's dismissal. Over the years I have clearly seen students who were sociopath or psychopath graduated because they were "technically" good students. I have no proof, but I am quite sure that some students take the oath "tongue in cheek." I am quite sure that Dr. Swango (an MD who was a serial killer of patients and who, although suspect and even fired, easily found another job),[10] had no intention of keeping this oath, nor do the small number of students who are sociopaths or psychopaths.

Finding a way of detecting students who are ethically questionable and then dealing with them effectively is by no means an easy task. For example, cheating on examinations is certainly one of the more frequent occurrences rendering the individual ethically problematic. Is it, however, an obligation for other students to report their suspicions? On the one hand, one is certainly ill-advised to encourage students to report each other, and one may get into a greater mess than we bargained for. It can, for example, lead to falsely reporting a colleague of whom someone wishes to wreak vengeance for a variety of reasons. On the other hand, detecting such persons may be most difficult but not impossible.

When I was an undergraduate at NYU, I was certain that the person sitting next to me was copying the answers. It was a multiple choice examination, and he seemed to me to be checking the same boxes as I was. The professor -- one of the best I have ever had -- had distributed the test with exactly the same questions but in completely different order. Not only did my neighbor fail the test abysmally, but it was also quite evident from whom he had copied.

We should -- as a faculty and with the help of students -- set up a clear standard of ethical behavior that would, if breached, result in dismissal. Serious ethical breaches are not something that can be remedied by repeating a year or by learning more "facts." A cognitive deficiency, if possible, should be remedied early. If, despite every effort on the part of the faculty, the student still does not meet the expected criteria, dismissal will not be seriously challenged. It could, conceivably, be remedied by repeating a year. There is, however, no point in trying to remedy ethical failings cognitively. Taking a course in healthcare ethics is not liable to make an ethically sounder and more empathetic physician. On the contrary, because teaching ethics is properly teaching students to think clearly and to make good and sound arguments, intensively teaching ethics above and beyond what other students have learned could easily make such a student merely more dangerous.

After all, we teach students "medicine" not in order to make them healthier (albeit that we may hope that they will themselves adhere to a healthier lifestyle), but to handle their patients' biomedical problems more successfully. Likewise, we teach them healthcare ethics not to "make them more ethical," but to make them more sensitive to ethical problems in their practice and to give them the tools that are necessary to deal with them. It is a most difficult problem that has never, to my knowledge, been adequately handled. However, it is a problem that we must at least start to recognize as an imperative and consequently to work on setting up fair but strict criteria, which are known to the student.

For example, it seems obvious that convicted felons should -- even after they are released from prison -- not be allowed to enroll in medical schools or practice. This sounds harsh: After all, the felon "has paid his price to society" (whatever that means) and should now be able to engage honorably in an honorable profession. Against this, we on the faculty have 2 duties, both of which in the final analysis are social: (1) We must make sure that students have learned enough cognitive material to practice under supervision as interns and (2) -- perhaps even more importantly -- that students are persons who can be reasonably counted on to act ethically and not take advantage of their power over patients. We can derive this from common sense or from the oath's provision to keep patients from harm. As usual, there is an ethical quandary: (1) We can protect society by not giving a prior felon the chance to harm patients, or (2) in fairness to the previous felon, who has "paid his debt to society" (whatever that is supposed to mean), we may consider his slate wiped clean and protect the aspiring student.

I would argue that our duty to society and to future patients is greater than the obligation we have toward the freed felon and that, therefore, erring (and erring it certainly and unavoidably is) protecting patients and society is the lesser of 2 evils. However, that is an unusual situation, and not one of those we are likely to encounter. We will and do meet situations that, although not as egregious, may be far more dangerous in the long run. I think here of students who cheat, lie, falsify clinical records, and treat patients or fellow students of a different ethnic background or sex differently from they would others or are caught in other fraudulent situations. In my experience -- and that of many of my colleagues -- we have graduated the undoubted sociopath or psychopath, and have graduated students who falsified records, stolen books, and repeatedly made obviously demeaning remarks about patients or colleagues.

I remember serving on a "promotions committee" (a wonderful euphemism for committees constituted to deal with inadequate students) when we graduated a lady who had, on several occasions, lied to the dean, been involved in a murky credit card deal, had assaulted her husband so that he landed in the emergency department, etc. Although the chair of the committee remarked that she was "probably more dangerous than Swango," everyone except myself voted to allow her to graduate because she had good grades and they feared a suit. I insisted that my "nay" vote be recorded: I can foresee the day when a medical school is justifiably sued for graduating a known ethically unacceptable physician. Over the years, I could mention a number of other such problems, but almost anyone who has been actively involved in teaching in medical colleges or in residencies knows whereof I speak.

The medical oath taken upon graduation is not legally binding but has a powerful psychological influence both on the person who took it and on those who trustingly place their lives in these persons' hands. However, because of the way medicine is practiced today, we who administer the oath as well as those who take it know fully well that some portions of the oath cannot be adhered to. Most of the oaths imply (but do not state) that patients will be cared for regardless of their financial standing. This is, I believe, implied when the oath clearly states that I will not permit considerations of gender, race, religion, sexual orientation, nationality, or social standing to influence my duty to care for those in need of my service. Although this is the language taken from the Yale Oath, it nevertheless in almost the same form appears in all oaths examined. It is somewhat disturbing that the explicit injunctions not to be influenced by gender, race, etc, skirt the economic issue by tacitly sweeping it under the rug of "social standing."

Because economic standing is virtually implicit in social standing, we who administer the oath and our colleagues who take the oath are fully aware that because a majority of physicians will practice in a health maintenance organization/managed care organization (HMO/MCO) setting, they will not even be able to make a judgment about a patient's illness (the receptionist at the outer desk will have sent away the uninsured -- that is those whose social standing was not of an adequate level to be seen until refuge in an emergency department had to be sought, and often too late). Further in our reality today, physicians are not free to treat their patients in the way that their judgment suggests: Before many tests, referrals, interventions, and medications can be prescribed for patients, HMOs, MCOs, and various insurance companies have to approve. Often these approvals or disapprovals are done by laypeople who follow a given set of rules, and physicians are forced to literally fight their way up the ladder until they can speak to a physician who then makes the final judgment over the telephone without ever having seen the patient.

A law never intended for this purpose (Employee Retirement Income Security Act [ERISA]) makes it possible for these arbiters to claim that they were not engaged in the practice of medicine when they make the use of a given procedure, medication, or intervention impossible or limit a patient's access to a consultation deemed necessary by their physician. On the issue of universal access, the AMA code is quite explicit. Whatever system we finally decide on -- and the current state of affairs is not a system, but chaos -- we are, in the interim, ethically compelled to work for a system in which every patient who feels the need for medical care has complete access to it.


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