Oaths for Physicians -- Necessary Protection or Elaborate Hoax?

Erich H. Loewy, MD

Disclosures
In This Article

Professional Sanctions

It is surprising -- and disheartening -- that medical boards are quite ready to either reeducate or otherwise sanction physicians who have a record of consistent malpractice or to give help to those who are substance abusers, but that medical societies are hesitant to deal with ethical violations. This is very similar to the problem at medical colleges I mentioned above. Trying to reeducate physicians who have a record of malpractice is, I think, as it should be -- especially if every effort to reeducate the physician or to "bring him up to speed" is successfully made and his performance monitored. It is certainly necessary to give as much help as we can to our colleagues who have become substance abusers. Unfortunately, there is little that can be done to educate physicians who grossly violate medical ethics -- we may possibly change outward performance but will probably do little to change inward intention.[1] It is well and good to change behavior, but if the change is purely one of outward performance without any inward change, then physicians will adhere to what they consider "silly rules" while they are watched and promptly violate them when they think that they are not being watched.

It is, likewise, disheartening that other gross failings to keep the oath rarely call forth an investigation. For example, a physician in California was found guilty of allowing a terminal patient to die in agony by refusing him the narcotics necessary to obtund pain. This is, unfortunately, not a rare occurrence. While dealing with the pain of cancer has substantially improved in the last few years, the pain of other and at least equally painful chronic diseases continues to be inadequately controlled. Pain control is badly done in most of the world, and while it is physicians who routinely deal with pain control, it has been shown that their callousness oftentimes increases through the years. And yet the chief complaint of most patients visiting a physician is pain. We have improved in treating the pain of malignancies, but we have improved little in the treatment of the pain of other chronic and very often equally painful diseases.[11,12,13,14,15,16,17] That, too, is not merely a medical error; it is likewise ethically unsound and violates the oath physicians take. Thus, it not only constitutes malpractice in the sense of deviating from what is accepted as proper practice, but malpractice in an ethical sense as well. To cure sometimes, to relieve often, to comfort always is a precept to which all physicians pay lip service but frequently fail to act upon.[18]

The medical board, while making note of it, failed to sanction this physician for what clearly was malpractice because there had not been repeated complaints. Had this physician knowingly failed to treat pneumonia or urosepsis with antimicrobials, there is little doubt that he would have been censured. There is little question that this was not only an instance of malpractice but -- and at least as egregiously -- a failure to live up to the oath and an act of sheer callousness, a state of affairs that should never be tolerated.

There are many reasons for hesitating to censure a colleague for what amounts to moral failure. It is easier and somehow less embarrassing to call someone on the carpet for making a technical error than it is to do so for a moral failure. All of us are far more ready to admit (if only to ourselves) to having made a medical error. Repeat technical errors can often be corrected by reeducation -- I have serious doubts that an ethical failure can. Most of us cannot claim to be "without sin" -- and our knowing this makes us hesitate to point out an ethical failing to a colleague and perhaps friend.

I was personally involved in a case in which the local medical society had finally succeeded in having the license of 3 physicians revoked. These physicians had had their staff privileges withdrawn from all hospitals in the area and were, we felt, practicing dangerous medicine. Since virtually all patients received injections of some sort, they were called "shot doctors." It happens that I became involved when a patient chanced to come into my office because she felt horribly ill. She arrested in my office, where I luckily had a defibrillator and other necessary items to resuscitate her. It turned out that this group of physicians tried to keep patients in digitalis toxicity as an aid for suppressing their appetite and that just about half an hour earlier, this woman had received intravenous cedilanid.

After admission to the hospital and after she had been stabilized, we very bluntly and repeatedly pointed out to her what had happened and warned her not to return to these physicians. She did well and was discharged -- only to return to the very physicians who could easily have cost her her life. In the meantime, the local medical society had amassed a large amount of data demonstrating failure to practice within acceptable limits and recommended to the State Board that their license be withdrawn. The Medical Society was promptly sued for "restraint of trade" and the physicians promptly regained their license. Such an experience makes physicians as well as their societies hesitant to act even in situations in which there is evident poor medical practice -- let alone to try to do this on some sort of ethical failing.

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