Patients need doctors with consciences

Victoria Sweet

Perspectives in Biology and Medicine
Perspectives in Biology and Medicine

“Conscience clauses” define conscience as “religious beliefs” or “moral convictions,” and they come up, therefore, usually in relation to women’s reproductive rights. This article argues that conscience is better understood as a feeling of integrity, rightness, and self, and that we need it especially now, as huge corporations take over health care. After an illustrative story, the author reviews the history of patients’ rights and also the health-care consumer movement, which introduced the idea that health care is a commodity, and the doctor, therefore, simply a tradesman, whose duty is to provide what his patient wants. The author examines where this new commercial model of medicine leads: Patients demanding treatments that are bad for them and expensive for the health-care system; doctors who are forced to do what they think is wrong; a world where patients cannot trust their physicians to do their best for them. Patients need their doctors to have consciences. But in this time of expanding corporate power in health care, can the right to have a conscience also be a Trojan horse? Protecting corporate entities who legally are also entitled to have a conscience? The author proposes that the most powerful rule of conscience is the oldest, the Hippocratic oath’s formulation that doctors should enter the exam room solely for the benefit of their patients. When the definition of “benefit” comes into question, then we should use the strategies developed over the past 45 years—shared decision making, ethics committees, media oversight—all of which will become ever more important as technology creates ever new dilemmas for conscience.

Sweet V. Patients need doctors with consciences. Perspect Biol Med. 2019;62(3):401-413.

Conscientious objection in reproductive health – an ancient prerogative or harmful practice

JM Thorp Jr

BJOG: An International Journal of Obstetrics and Gynaecology
BJOG: An International Journal of Obstetrics and Gynaecology

We must return to our Pythagorean roots and not substitute a secular group conscience to replace individual conscience, and thereby protect the rights of all parties. My hope is that our specialty will uphold the right of individual clinicians to practise according to their consciences and we will continue to welcome Hippocratic clinicians into our ranks.

BJOG: An International Journal of Obstetrics and GynaecologyJr JT. Conscientious objection in reproductive health – an ancient prerogative or harmful practice. BJOG: An International Journal of Obstetrics and Gynaecology. 2018 Oct;125(11):1357-1358.

Hippocrates’ Oath and Asclepius’ Snake:The Birth of the Medical Profession

Thomas A Cavanaugh

Hippocrates' Oath and Asclepius' Snake: The Birth of the Medical Profession

Thomas A. Cavanagh. Hippocrates’ Oath and Asclepius’ Snake:The Birth of the Medical Profession. New York: Oxford University Press, 2018. 177 pp.

Publisher’s Description
T. A. Cavanaugh’s Hippocrates’ Oath and Asclepius’ Snake: The Birth of the Medical Profession articulates the Oath as establishing the medical profession’s unique internal medical ethic – in its most basic and least controvertible form, this ethic mandates that physicians help and not harm the sick. Relying on Greek myth, drama, and medical experience (e.g., homeopathy), the book shows how this medical ethic arose from reflection on the most vexing medical-ethical problem – injury caused by a physician – and argues that deliberate iatrogenic harm, especially the harm of a doctor choosing to kill (physician assisted suicide, euthanasia, abortion, and involvement in capital punishment), amounts to an abandonment of medicine as an exclusively therapeutic profession. The book argues that medicine as a profession necessarily involves stating before others what one stands for: the good one seeks and the bad one seeks to avoid on behalf of the sick, and rejects the view that medicine is purely a technique lacking its own unique internal ethic. It concludes noting that medical promising (as found in the White Coat Ceremony through which U. S. medical students matriculate) implicates medical autonomy which in turn merits respect, including honoring professional conscientious objections.

The Hippocratic “oath” (Some further reasonable hypotheses)

Sergio Musitelli, Ilaria Bossi


Although 65 treatises – either preserved or lost, but quoted by ancient authors like Bacchius (3rd century B.C.), Erotian (1st century A.D.) and Galen (c. 129-199 A.D.) – are ascribed to Hippocrates (c. 469-c. 399 B.C.) and consist of nearly 83 books, nonetheless there is no doubt that none of them was written by Hippocrates himself. This being the fact, we cannot help agreeing with Ulrich von Wilamowitz Möllendorf (1848-1931), who maintained that Hippocrates is a name without writings!

Indeed the most of the treatises of the “Corpus hippocraticum” are not the collection of Hippocrates’ works, but were likely the “library” of the Medical School of Kos. The fact that it contains some treatises that represent the theories of the Medical school of Cnidos (most probably founded by a certain Euryphon, almost contemporary with Hippocrates), with which it seems that Hippocrates entered into a relentless debate, is an absolute evidence.

Moreover, we must confess that, although Celsus (1st century B.C.-1st century A.D.) (De medicina, I, Prooemium) writes that “Hippocrates of Kos…separated this branch of learning (i.e. Medicine) from the study of philosophy”, we have nothing to learn from the hippocratic treatises under the scientific point of view.

However, whatever its origin, the “Oath” is a real landmark in the ethics of medicine and we can say – with Thuchydides (460/455-400 B.C.) (Histories, I, 22, 4) – that it is “an achievement for eternity”.

Suffice it to remember that every graduand in Medicine is generally still bound to take an oath that is a more or less modified and more or less updated text of the “Hippocratic oath” and that even the modern concept of bioethics has its very roots in the Hippocratic medical ethics.

“The art is long; life is short; opportunity fleeting; experiment treacherous; judgment difficult: The physician must be ready, not only to do his duty himself, but also to secure the co-operation of the patient, of the attendants and of externals, ” says the first “Aphorism” and the latest author of “Precepts” (chapter VI) writes: “where there is love of man, there is also love of the art”, and the “art” par excellence is medicine! These precepts go surely back to Hippocrates’s moral teaching.

Nonetheless, the preserved text of the marvellous “Oath” raises many problems. Namely:

1) which is the date of it”?

2) Is it mutilated or interpolated?

3) Who took the oath, i.e. all the practitioners or only those belonging to a guild?

4) What binding force had it beyond its moral sanction”?

5) Last but not least: was it a reality or merely a “counsel of perfection”?

In this article we have gathered and discussed all the available and most important sources, but do not presume to have solved all these problems and confine ourselves to proposing some reasonable hypotheses and letting the readers evaluate the positive and negative points of our proposals.

Musitelli S, Bossi I. The Hippocratic “oath” (Some further reasonable hypotheses). Research 2014; 1:733

Conscience and clinical practice: Medical ethics in the face of moral controversy

Farr A Curlin

Theoretical Medicine and Bioethics
Theoretical Medicine and Bioethics

Physicians sometimes refuse to provide legally permitted medical services on the grounds that they cannot do so in good conscience. Such conscientious refusals are at least as old as the Hippocratic movement. Yet new events, such as the refusal by health care professionals to prescribe or dispense post-coital (‘‘emergency’’) contraception, have kindled new debates about what physicians are obligated to do when patients request legal medical interventions to which their physicians have moral objections. In a recent national survey, we found that a large majority of physicians believe they are obligated in such circumstances to present all possible options to the patient, including information about obtaining the requested intervention, and to refer the patient to a clinician who does not object to the requested intervention. Yet a substantial minority of physicians—particularly those who are more religious and/or who themselves object to common controversial practices—disagree with these majority opinions.

Curlin FA. Conscience and clinical practice: Medical ethics in the face of moral controversy. Theor Med Bioeth. 2008;29(3):129-133.

(Thesis) Hospital Ethics Committees in the USA and in Germany Bioethics qua Practice, Nurses’ Participation and the Issues of Care

Helen Kohlen


In this work the institutionalisation of Hospital Ethics Committees in the USA and in Germany will be analysed by focussing on nurses’ participation and the representation of caring issues. Therefore, questions about the design of Hospital Ethics Committees and how their practices really look like, will be raised. The central question is, how the traditional care ethos of the helping professions in medicine and nursing can find its place in discussions of these committees while hospitals have increasingly been organised along economic criteria.

. . . .My observations and interviews in the field work show that care practices in the tradition of Hippocratic Medicine are no longer self-evident for the helping professions. Physicians and nurses do rather struggle for a care ethos especially with regard to end-of- life questions and regulations of tube-feeding. The “cases” for ethics consultation brought into the committees by physicians and nurses did not rarely emerge as social problems and as a lack of professional competence. The problems appeared to be solvable by translating them into a language of principles and making the process manageable. These principle-based discussions in the practical arena of the hospital resemble discourse practices embedded within the larger bioethical debates in the political arena. Technical procedures given by management and administration do fit into the use of abstract principles and contribute to a language that limits the possibilities to think – what is at stake for patients – in terms of caring relations rather than thinking in terms of rules, regulations and control.

Kohlen H. (Thesis) Hospital Ethics Committees in the USA and in Germany Bioethics qua Practice, Nurses’ Participation and the Issues of Care. Gotfried Wilhelm Leibniz University, Hanover, Germany. 2008 Apr 02.

Without Conscience

Elie Wiesel

New England Journal of Medicine, NEJM
New England Journal of Medicine

Inspired by Nazi ideology and implemented by its apostles, eugenics and euthanasia in the late 1930s and early 1940s served no social necessity and had no scientific justification. Like a poison, they ultimately contaminated all intellectual activity in Germany. But the doctors were the precursors. How can we explain their betrayal? What made them forget or eclipse the Hippocratic Oath? What gagged their conscience? What happened to their humanity?

Wiesel E. Without Conscience. N Engl J Med.. 2005 Apr 14;352(15):1511-1513.

(Correspondence) Military medicine and human rights

Andre N Sofair, Peter G Lurie

The Lancet
The Lancet

The Hippocratic Oath states: “I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrongdoing.” It is our responsibility to make these words a reality.

Sofair AN, Lurie PG. (Correspondence) Military medicine and human rights. The Lancet. 2004 Nov 20;364(1851.

Medicine and Conscience: The Debate on Medical Ethics and Research in Germany 50 Years after Nuremberg

Michael Wunder

Perspectives in Biology and Medicine
Perspectives in Biology and Medicine

Journal Extract
“The question is whether we will ever be able to learn from history,” Alexander Mitscherlich said in 1947. He was a member of the German Medical Commission, who by order of the German General Medical Council witnessed the Nuremberg Trial. “I believe,” Mitscherlich continued, “that we won’t master it by just keeping our distance morally. This is doubtless easy to achieve. However, it is useless for us as soon as we think of the dark future of this century, in which situations might occur leading to a similar coldness and ignorance towards the right to live of people more defenseless and disregarded” [1]. 1

Over the ensuing decades, neither physicians nor the public faced the tiring process of reviewing and questioning history. Even the reports of the German Medical Commission met with a growing disinterest and disapproval from the physicians in post-war Germany. 2 Almost 50 percent of the German physicians were members of the NSDAP (Nazi Party), and they resumed their work after 1945 after only a brief interruption.

Thus it is understandable that it was not the physicians’ organizations nor the medical historical departments of the universities that turned towards history at the beginning of the1980s. Rather, it was their children [End Page 373] and grandchildren, who were working in the hospitals, the psychiatric institutions, and homes for persons with disabilities. They began to ask what happened 40 or 50 years ago where they were working. They were not involved personally, nor did they blame their fathers and mothers. This is the generation to which I also belong. 3

After Auschwitz and Hadamar, particularly in Germany, discussion about medical ethics and about the future of medicine are nowadays impossible without reference to history. 4 This consideration was the basis of the program entitled “Medicine and Conscience” in the German Section of International Congress of Physicians for the Prevention of Nuclear War, held in Nuremberg in October 1996. 5 As a result of this congress, on the 50th anniversary of the pronouncement of judgment in the Nuremberg Trial, 20 August 1997, the Nuremberg Code 1997 was presented. Based on the historical experiences and the fundamental ideas of the 1947 Code, the 1997 Code is designed to answer current medical questions about the application of biosciences to human beings. It discusses 10 topics, including medical experiments, reproductive medicine, genetic diagnostics and therapy, transplantation, euthanasia, and distribution of resources. (Due to the time limit and the theme of this symposium, I will focus only on the topic of medical research.) The Nuremberg Code 1997 follows the widespread practice of considering informed consent to be a prerequisite in all fields of public health care service.

The critical-historical link to the Nuremberg Code 1947 that we attempted to make with Code 1997 had to confront two fundamental issues. First, we had to determine whether the Code’s significance was only historical or universally valid. To put it differently: was the 1947 Code only to be understood from the historical context? Did it only aim at the judgment of the practices of the Nazi physicians? Or did it imply a universal validity for medical research and medicine in a civilized world?

Historical evidence, as well as a look at the text of the Code, clearly speaks for a universal validity. Telford Taylor, the chief prosecutor of Nuremberg, stated in his introduction that the trial was no mere murder trial, since the defendants were physicians who had sworn the Hippocratic oath and thus had become murderers in the execution of their profession. Logically, the judges created with the Nuremberg Code a basis for the judgment of crimes which became possible within the bounds of medicine. 6[End Page 374]

Wunder M. Medicine and Conscience: The Debate on Medical Ethics and Research in Germany 50 Years after Nuremberg. Perspect Biol Med. 2000;43(3):373-381.

Remarks on medical ethics

Martin Bojar

Journal of Medical Ethics
Journal of Medical Ethics

Fulfilling the universal code of medical ethics is the ‘conditio sine qua non’ and we should prevent all attempts to change the basic document of European and world medicine, the Hippocratic Oath. Pross’s paper about the total failure of the German Medical Association to acknowledge and deal with war crimes perpetrated by doctors reinforces the need to adhere to the Hippocratic Oath.

Bojar M. Remarks on medical ethics. J Med Ethics. 1991;17(Supplement):39.