Ethics Toolbox: Healthy Advice from the 4th Century BC
November / December 2005
Ethics Toolbox
Healthy Advice from the 4th Century BC
Most of us think we know who Hippocrates was. Certainly no one disagrees with “not doing harm.” We want to do what we think is best for the patient, based on good science and consistent with the art. We seek well-established, evidence-based outcomes. Indeed, we want to know what is effective and what does not work. We want to help and not injure. So did Hippocrates. In fact, Hippocrates actually described what to actively exclude. He wanted us to rely on much more than vague opinion. The Greeks spoke to the variety of opinions. A low level of opinion was doxa, which represents unexamined opinion. Then there was phronesis, opinion based on fact. Finally, there was episteme or scientific knowledge and the ineffable “Sophia” or wisdom.
Healthcare vanguards seek quality, efficiency, and affordability. We work hard to continuously improve our care and interaction skills, to reduce duplication and waste, improve our outcomes, and ensure a high degree of safety. We all want to do the right thing for the right reasons at the right time. That’s what a guiding ethic is all about. But, where does a guiding ethic come from? It doesn’t come from “out of the blue,” nor is everyone entitled to his or her own relativistic unexamined opinion! One assumes it must surely be something more — something more reliable, something field-tested over time. What better foundation of medical ethics than the famed, field-tested Hippocratic Oath? The oath mandates that the physician (easily extrapolated to other caregivers) practice in a manner that embodies concern for propriety, safety, quality, and efficiency. It also mandates that we employ best practices after assessing an array of options to address and solve a given problem.
But wait. Is Hippocrates being misinterpreted? Careful inspection will reveal that Hippocrates’ meaning has been obscured over the centuries by misinterpretation, mistranslation, and misinformation. The oath is a not a “do no” sort of thing. Instead, it is a positive charge.
With the help of a seasoned scholar of ancient Greek,1 I have done an intensive and careful analysis of the original ancient Greek text. Our investigation yielded some interesting but perhaps not so surprising results. Most English translations of the Hippocratic Oath blend an affirmative beginning followed by a negative refrain. In actuality, Hippocrates told us what to actively exclude — not what not to do.2There indeed is no “do no harm” but something much stronger, something affirmative. What he did say, in closer approximation to the original Greek, was “I will use regimens [used mostly to refer to food or diet but its secondary meaning comes from the root found in the noun “diatia,” which means way of living or mode of life of the 4th century with implications of a healthy lifestyle] or treatments [literally translated as “rules of life,” that is the way in which one lives one’s life] into a regimen [or treatment or course of action] towards the assistance [help] of those being ill in accordance with my ability and judgment.” He goes on to say “I intend to exclude, [exclude is more accurate than abstain for Hippocrates does not use the middle voice in Greek, which he would have used if he meant to refer to himself. Instead Hippocrates uses the active voice to refer to this process of exclusion and advises that we] intend to actively exclude those treatments [or courses] towards a view [both to self-involvement and prospect] towards destruction [injury] and injustice or wrongdoing.”
The most salient element of the oath, to which people most often refer, is just not there. Instead, we find something richer and wiser. The two most frequently quoted sources of the oath miss the boat. One translation is close to the mark in saying, “I will use treatment to help the sick according to my ability and judgment but never with the view of injury or wrongdoing.” Similarly, another translation says, “I will follow that system or regimen which according to my ability and judgment, I consider for the benefit of my patients and abstain from anything which is deleterious or mischievous.” But the bottom line is that they are both inaccurate.
In our evidence-based era we demand more. We want to raise the knowledge bar and keep it high. We want to move from the anecdotal to the replicable. Our clinical decision-making can be dramatically enhanced by information from recent journal articles or from a comprehensive review from Medline. But beyond that lies the foundation of what we do and why we do it. Important clues to guide us through the complexity we face today may be found in Hippocrates’ vision of medicine. Who better to guide us in this era of evidence-based medicine, to help us to rethink our goals, outcomes, and directions? By infusing evidence-based medicine into our decision-making framework, we develop more reliable and safer outcomes constructed on the firm foundation of well-designed, replicable studies. Krisis may not be so far off from advanced decision theory, where we perform a differential assessment, look at a range of variables, and blend subjective and objective probabilities to come up with a more refined decision. By discerning the most appropriate course from an array of alternatives, uncertainty is transformed into a judgment. Maybe Hippocrates was an early decision theory and outcomes specialist, sort of the Donald Berwick of the 4th century B.C. He believed we should do something because it is the right thing to do, not merely because it’s in the black bag.
We are now being forced to scrutinize our foundations and fundamental principles. The shift from denial-based to consumer-engaged care will require careful navigation. Perhaps a clue lies hidden not in that recent journal article or even that leap of faith 10 years ago when you decided to listen to the Medical Staff lecture on quality improvement. This leap is over 2,000 years old.
The Hippocratic corpus is a robust and rich repository for ethical guidance. Even in the Hippocratic precepts, we see allusion to fees: “For the good physician, it is better to reproach a patient you have saved than to extort money from those at death’s door.” In general terms, medicine should do away with the suffering of the sick, lessen the violence of their diseases, and refuse to treat those who are overmastered by their diseases, realizing that in such instances medicine is powerless. Hippocrates even speaks to the physician’s duty to cooperate with externals, dealing with continuity of care and referrals.
The broader Hippocratic corpus speaks to a great many matters in medicine, but none more important than those that bear on the interaction between doctor and patient. Hippocrates speaks to confidentiality as a 4th century precursor to HIPPA when he writes, “Whatever in connection with my professional practice or not in connection with it, 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. Shall I see or hear in the course of my profession whilst in my intercourse with men if it be what shall not be published aboard I will never divulge, holding such things to be holy secrets.”
I think Hippocrates is someone we want to keep at the forefront of our ethics and, accordingly, someone we need to better understand! Certainly we have many better tools and more advanced technologies than the ancient Greeks, but the suggestion that all of our progress is but a series of footnotes to the ancient Greeks may not be so far off the mark.
Dennis A. Robbins (DennisRobbins@cox.net) is a healthcare innovator, author, and thought leader. He is president of Integrated Decisions, Ethics, Alternatives, and Solutions (IDEAS). Robbins has worked extensively on the interface of ethics with quality, liability, payment systems, health law, and health policy. He has served as an advisor on ethics and related issues for major national organizations, associations, law firms, hospital systems, and government. Robbins holds a PhD in philosophy from Boston College and a postdoctoral master’s degree in public health from Harvard. He is a member of the Editorial Advisory Board for Patient Safety and Quality Healthcare.
Notes
Reference
- Thanks to Antoinette Brazovski, Department of Foreign Languages and Literature, Northern Illinois University.
- Translation taken from the Loeb Classical Library. (1923). Hippocrates, Vol. 1, Ancient medicine. Airs, waters, places. Epidemics 1 & 3. The oath. Precepts. Nutriment. W. H. S. Jones (Trans.), Cambridge, MA: Harvard University Press.