In the modern context of medical specialization, surgeries should be done by practiced surgeons, radiotherapy by radiotherapists, cancer therapy by oncologists, and so on. Physicians must practice to the extent of their ability but not beyond; it is important for each of us to know our limits and seek the help of experts, as needed. Historical context is again important here: in ancient Greece, doctors were sometimes used as skilled political assassins.
There was thus a legitimate fear of the physician as a poisoner. The word euthanasia was coined in about BCE, a century after the oath was written. It referred to easeful or peaceful death, but there is no evidence in Greek medicine of active participation in accelerating such a death. This is relevant to our oncology practice today, where many cancer patients suffer from terminal disease, and at times severe pains and poor quality of life.
Nevertheless, many have interpreted this as a prohibition on any abortion; others point out that this statement only mentions the pessary, a soaked piece of wool inserted in the vagina to induce abortion, which could cause lethal infections.
The objection was perhaps to the specific dangerous method rather than a moral objection to abortion, but this remains an area of debate. In ancient times, distrust of healers was common because of the abundance of quacks.
Patients are often highly vulnerable and continue to require protection from the undue influence of a selfish physician. Without trust, patients may withhold facts that help physicians formulate an accurate diagnosis and therapeutic plan. Finally, the Oath includes a statement about respect for teachers and about sharing information learned in the practice of medicine with students and other practitioners.
While preventing personal and social injustice is a major concern of the Oath, physicians in general shy away from issues of social injustice, and when they do engage with societal issues, may at times have favored their own financial or personal interests. Yet, as an institution, the AMA has historically worked against the adoption of universal health care and other policies that could expand access to care but decrease the incomes of practitioners, and criticized professional medical organizations that disagreed with their position.
Many physicians likewise have organized against efforts to address the lack of affordable health care, opposing reforms proposed by Presidents Roosevelt, Truman, and Eisenhower, fighting the passage of Medicare in , and later failing to support or influence reform efforts proposed by the Clinton administration.
Today, we face and may swear by old and new deities, including one perhaps more powerful and capable of extremes of good and evil than any other: money. We face problems that are intensely relevant to modern cancer research and care, and which of course did not exist at the time of the Oath: new types of medical and cancer research that include human experimentation, interactions with pharmaceutical and insurance companies, different practices and care patterns, unique stress from the cost of care and of drugs, and financial conflicts of interest.
Most of these problems are directly or indirectly connected with two large looming factors: universality of health-care accessibility and affordable cost. Stated simply, lack of health care for a substantial portion of patients can contribute to social injustice and medical harm. High costs of health care and high drug prices prevent patients from affording and benefitting from them, thus causing harm.
Adherence to the Hippocratic Oath requires physicians to address and advocate for better access to health care and for more affordable cost structures. Because of how health care is financed in the United States, every physician knows of patients who have been denied access to health care perceived as necessary or received delayed treatment, and who have been harmed or humiliated by the process.
Broader insurance is associated with better access to cancer screening, earlier diagnosis, earlier treatment, and better outcomes. Patients with cancer are better covered on clinical trials.
Closing the hole in Medicare Part D should reduce out-of-pocket expenses. Essential elements in cancer care such as emergency care and physical rehabilitation are covered. Annual and lifetime coverage in cancer care, which can be very expensive, are not capped.
That said, the Affordable Care Act has many limitations, which should be addressed. The initial rollout of HealthCare. It is yet unclear whether the Affordable Care Act will increase or reduce the insurance premiums or alter the overall cost of care, whether bargain-basement policies sold as part of health-care exchanges will actually allow patients to receive appropriate care, and whether the Act will simplify or complicate the inefficiencies of the health-care system.
Physicians should argue not simply to preserve the Affordable Care Act, which is a step forward but flawed, but also to improve on it and strive to extend future health-care coverage to become universally available to all Americans. The high and growing cost of drugs, particularly cancer drugs, is another issue that should be viewed through the social justice lens of the Oath. Many patients cannot afford high drug prices and out-of-pocket expenses.
This worsens outcome and causes harm. In addressing them, physicians should put patients first. Unfortunately, this mythic statement is incomplete, since all therapies entail risk. This risk must be weighed against potential benefits every time a treatment is considered. Disclosure: Drs. Kantarjian and Steensma reported no potential conflicts of interest. Hippocratic Oath.
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