- Email: [email protected]
The Hippocratic Oath today
surveys should be
to doctors but there is little to attention from the most obvious draws support from other recent
unpalatable
important patient autonomy is, including the autonomy of
surveys’-5-namely, that many patients are not being adequately helped by conventional medicine, do not trust its side-effects, and report being considerably helped by nonconventional treatment. Whatever may be said (and rightly)
those who are poor and uneducated. Our students should be taught not to make moral judgments about patients in their professional activities. Not only are physicians untrained to make constructive moral judgments (if such training exists) but also they can interfere with proper medical care as we do our best to help the
about the need for more evidence in non-conventional health care, the medical community must face this issue squarely if it is not to alienate its clientele further.
patient. Perhaps the International Hippocratic Foundation could sponsor a meeting on a Hippocratic Oath for our times.
Baldwin of Bewdley
invited.
be
gained by diverting
conclusion,
which
Representatives
Parliamentary Group for Alternative and Complementary Medicine, House of Lords, London SW1, UK
of the poor and uneducated should be
D Robin, Robert F
*Eugene
McCauley
PO Box 1185, 528 Pacific, Trinidad, CA 95570-1185, USA
1 MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569-73. 2 Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med 1993; 328: 246-52. 3 Murray J, Shepherd S. Alternative or additional medicine? An exploratory study in general practice. Soc Sci Med 1993; 37: 983-88. 4 Sutherland LR, Verhoef MJ. Why do patients seek a second opinion or alternative medicine? J Clin Gastroenterol 1994; 19: 194-97. 5 Anon. Healthy choice. Which? 1995 (Nov): 8-13.
The
Hippocratic Oath today
SiR-Marketos and
colleagues (Jan 13, p 101)’ defend the original Hippocratic Oath and challenge our modern version.2 We wish to focus on two fundamental differences between the two. The original oath scarcely concerns itself with patient It is a code governing outcome or patient welfare. interactions among a group of males (only) united by a common profession. The revised oath is dedicated to the idea that the welfare and outcome of the patient should come first as a guide to the professional activities of
physicians. What do patients generally want from doctors? Usually, it is improved quality of life, improved quantity of their life, or both. The revised oath supports a partnership in which the physician supplies skills and support while the patient, consulting the physician, risks his or her welfare. As comforting and helpful as the demigod portrayed in the original oath might be for some patients, in reality physicians are not demigods but mere humans. The second basic difference reflects the fact that medical care is now often delivered by a team, including nurses, lay therapists, and others. Patient outcome in some contexts is better when directed by advanced-care nurses rather than by physicians. The revised oath has been amended to include health-care workers generally.3 There are two ideas in Marketos and colleagues’ essay that physicians should find unacceptable, indeed repugnant. Both flow from a quasireligious belief that physicians are demigods. Their essay states that doctors cannot do their duty without "sitting in moral judgment (or its modern equivalent, social judgment) on the rest of humanity [italics added]". We must not give into such elitism. Marketos et al indirectly raise the issue of eliminating medical care to the underdeveloped countries because there are areas already overpopulated. Perhaps they would advocate not treating diabetes in such areas because the treatment could aggravate
overpopulation. The statement that "patient autonomy is meaningless for the impoverished majority of the world’s population" is one that we interpret as an expression of extreme elitism. The history of the elimination of smallpox in India4 shows how
1
Marketos SG, Diamondopoulos AA, Bertsocas CS, Poulakou-Rebelalow E, Koutras DA. The Hippocratic Oath. Lancet
2
Robin ED, McCauley RF. Cultural lag and the Hippocratic Oath. Lancet 1995; 345: 1422-24. Robin ED, McCauley RF. Updated Hippocratic Oath revised for health care workers. Adv Nurse Practit 1995; 3: 14. Henderson DA. Lessons from the smallpox eradication. In: Medicine, science and society. New York: Wiley, 1984: 714-26.
1996; 347: 101-02.
3
4
Disclosing HIV
status to
partners
SiR-Seidel and Ntuli (Feb 14, p 469)’ investigated patterns of disclosure of information on some infectious diseases in 15 women and men. They claim to have found a difference between the sexes in their patterns of disclosure. However, the letter mentions only that men were less prepared to disclose sensitive personal information about tuberculosis, sexually transmitted disease (STD), and HIV than their female partners would have liked. No information is printed about how often, and to whom, women would be prepared to disclose information about these diseases and how much information their male partners would like. We do not find it surprising that individuals are more reluctant to disclose information about embarrassing or stigmatised infections than their partners would like. This is human nature and not necessarily sex-specific. The only fact in the letter that surprises us is that "most men" would tell their mothers that they had an STD or HIV. The finding that men are reluctant to discuss their illness appears to contradict the conclusion that health status is being used to maintain women in their traditional role of carers. How the non-disclosure of health status could control women in this way is not explained. Mutual trust and good communication between sexual partners are clearly important facets of HIV and STD control. Seidel and Ntuli’s claim that there are differences between men and women in this respect may be valid but their data and analysis are one-sided. *James Whitworth, Helen Pickering, Dilys Morgan Medical Research Council Programme on AIDS in Uganda, Uganda Virus Research Institute, PO Box 49, Entebbe, Uganda
1
Seidel G, Ntuli N. HIV, confidentiality, South Africa. Lancet 1996; 347: 469.
Author’s
gender,
and support in rural
reply
letter-length summary of a complex project it is impossible to provide all the information as well as try to interpret it. This was a pilot study and the main interest was the innovative techniques, using storytelling and inviting dialogue and reflection, as in the most dynamic health education materials coming out of South Africa. SIR-In
a
973
to doctors but there is little to attention from the most obvious draws support from other recent
unpalatable
important patient autonomy is, including the autonomy of
surveys’-5-namely, that many patients are not being adequately helped by conventional medicine, do not trust its side-effects, and report being considerably helped by nonconventional treatment. Whatever may be said (and rightly)
those who are poor and uneducated. Our students should be taught not to make moral judgments about patients in their professional activities. Not only are physicians untrained to make constructive moral judgments (if such training exists) but also they can interfere with proper medical care as we do our best to help the
about the need for more evidence in non-conventional health care, the medical community must face this issue squarely if it is not to alienate its clientele further.
patient. Perhaps the International Hippocratic Foundation could sponsor a meeting on a Hippocratic Oath for our times.
Baldwin of Bewdley
invited.
be
gained by diverting
conclusion,
which
Representatives
Parliamentary Group for Alternative and Complementary Medicine, House of Lords, London SW1, UK
of the poor and uneducated should be
D Robin, Robert F
*Eugene
McCauley
PO Box 1185, 528 Pacific, Trinidad, CA 95570-1185, USA
1 MacLennan AH, Wilson DH, Taylor AW. Prevalence and cost of alternative medicine in Australia. Lancet 1996; 347: 569-73. 2 Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med 1993; 328: 246-52. 3 Murray J, Shepherd S. Alternative or additional medicine? An exploratory study in general practice. Soc Sci Med 1993; 37: 983-88. 4 Sutherland LR, Verhoef MJ. Why do patients seek a second opinion or alternative medicine? J Clin Gastroenterol 1994; 19: 194-97. 5 Anon. Healthy choice. Which? 1995 (Nov): 8-13.
The
Hippocratic Oath today
SiR-Marketos and
colleagues (Jan 13, p 101)’ defend the original Hippocratic Oath and challenge our modern version.2 We wish to focus on two fundamental differences between the two. The original oath scarcely concerns itself with patient It is a code governing outcome or patient welfare. interactions among a group of males (only) united by a common profession. The revised oath is dedicated to the idea that the welfare and outcome of the patient should come first as a guide to the professional activities of
physicians. What do patients generally want from doctors? Usually, it is improved quality of life, improved quantity of their life, or both. The revised oath supports a partnership in which the physician supplies skills and support while the patient, consulting the physician, risks his or her welfare. As comforting and helpful as the demigod portrayed in the original oath might be for some patients, in reality physicians are not demigods but mere humans. The second basic difference reflects the fact that medical care is now often delivered by a team, including nurses, lay therapists, and others. Patient outcome in some contexts is better when directed by advanced-care nurses rather than by physicians. The revised oath has been amended to include health-care workers generally.3 There are two ideas in Marketos and colleagues’ essay that physicians should find unacceptable, indeed repugnant. Both flow from a quasireligious belief that physicians are demigods. Their essay states that doctors cannot do their duty without "sitting in moral judgment (or its modern equivalent, social judgment) on the rest of humanity [italics added]". We must not give into such elitism. Marketos et al indirectly raise the issue of eliminating medical care to the underdeveloped countries because there are areas already overpopulated. Perhaps they would advocate not treating diabetes in such areas because the treatment could aggravate
overpopulation. The statement that "patient autonomy is meaningless for the impoverished majority of the world’s population" is one that we interpret as an expression of extreme elitism. The history of the elimination of smallpox in India4 shows how
1
Marketos SG, Diamondopoulos AA, Bertsocas CS, Poulakou-Rebelalow E, Koutras DA. The Hippocratic Oath. Lancet
2
Robin ED, McCauley RF. Cultural lag and the Hippocratic Oath. Lancet 1995; 345: 1422-24. Robin ED, McCauley RF. Updated Hippocratic Oath revised for health care workers. Adv Nurse Practit 1995; 3: 14. Henderson DA. Lessons from the smallpox eradication. In: Medicine, science and society. New York: Wiley, 1984: 714-26.
1996; 347: 101-02.
3
4
Disclosing HIV
status to
partners
SiR-Seidel and Ntuli (Feb 14, p 469)’ investigated patterns of disclosure of information on some infectious diseases in 15 women and men. They claim to have found a difference between the sexes in their patterns of disclosure. However, the letter mentions only that men were less prepared to disclose sensitive personal information about tuberculosis, sexually transmitted disease (STD), and HIV than their female partners would have liked. No information is printed about how often, and to whom, women would be prepared to disclose information about these diseases and how much information their male partners would like. We do not find it surprising that individuals are more reluctant to disclose information about embarrassing or stigmatised infections than their partners would like. This is human nature and not necessarily sex-specific. The only fact in the letter that surprises us is that "most men" would tell their mothers that they had an STD or HIV. The finding that men are reluctant to discuss their illness appears to contradict the conclusion that health status is being used to maintain women in their traditional role of carers. How the non-disclosure of health status could control women in this way is not explained. Mutual trust and good communication between sexual partners are clearly important facets of HIV and STD control. Seidel and Ntuli’s claim that there are differences between men and women in this respect may be valid but their data and analysis are one-sided. *James Whitworth, Helen Pickering, Dilys Morgan Medical Research Council Programme on AIDS in Uganda, Uganda Virus Research Institute, PO Box 49, Entebbe, Uganda
1
Seidel G, Ntuli N. HIV, confidentiality, South Africa. Lancet 1996; 347: 469.
Author’s
gender,
and support in rural
reply
letter-length summary of a complex project it is impossible to provide all the information as well as try to interpret it. This was a pilot study and the main interest was the innovative techniques, using storytelling and inviting dialogue and reflection, as in the most dynamic health education materials coming out of South Africa. SIR-In
a
973