All posts by Ian Kirby

The Hippocratic Oath and Professional Ethics

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Pellegrino (1990) argues that the idea of medicine as a moral community can be linked back to Hippocrates.  What intrigues me about this is that, given that the Hippocratic Oath was written c.a. 500 BCE, this document is clearly one of the most momentous and long-lasting codes of ethics.  In this blog post, I will give some background information on the Hippocratic Oath and argue that the oath should presents a model code of professional ethics.

 File:Hippocrates rubens.jpg

Hippocrates engraving by Peter Paul Rubens, 1638. (Wikimedia)

            Hippocrates’ time (c.a. 460-370 BCE) was one when many untrained charlatans tried to present themselves off as physicians (Boylan “Hippocrates”).  These charlatans swindled their patients, convincing them that health problems were the product of supernatural forces not understandable by the patient (Couch 1934).  The term ‘fleecing’ shows up in descriptions of these quacks—etymologically, ‘fleecing’ is a metaphor for stripping a person “of money, property, etc., as a sheep is stripped of its fleece” (Oxford English Dictionary).  They were self-serving individualists trying to make a quick buck.  In this way, honest professional physicians were confronted with a dilemma, similar to what Pellegrino (1990) sees in contemporary professional medical ethics debates.

While it is uncertain if the oath itself was written by Hippocrates (Boylan “Hippocrates”), genuine physicians sought to protect patients from the dangers of these charlatans by setting up a code of ethics.  The Oath was a way of “establishing medicine as a profession that ordinary people could trust” and a way to distinguish trained physicians from medical con men.

The contents of The Oath may strike the contemporary reader as outdated, or perhaps misguided.  It contains specific bans of practices, such as “I will never induce an abortion” and “I will not engage in surgery”, which seem to run against contemporary medical ethics.  But if we put these proscriptions in historical context, they make sense.  In Hippocrates’ time, abortion and (most) surgeries[1] would surely endanger the lives of the patient.  The aim in forbidding these practices was to set up The Oath as a guide against physicians putting their patients through undue harm.

The Hippocratic Oath is a model code of professional ethics.  Unlike many modern professional codes, its intent was to describe the “moral vision” for members of the medical community rather than to protect members of the community from incurring on the law (Boylan “Hippocrates”).  In this way, it is a positive code of ethics—it describes what physicians ought to do, not only what they ought not do.  On may object that the two bans mentioned above (i.e. ban on abortion, and ban on surgery) seem to work against this aim.  But the reason for these bans is that physicians are supposed to help their patients, not harm them.  As Pellegrino (1990) argues, it is not enough to provide “mere commitment to common beliefs” to provide the ethics of a professional moral community.  Otherwise, morally repugnant groups like White supremacists and Nazi physicians would have claim to being members of a moral community (Pellegrino 1990).

Another important aspect of the Hippocratic Oath, which strengthens its position as a model code of professional ethics, is the inclusion of guidance for entering the profession.  Medical practitioners have an obligation to “teach his/her family the art of medicine, if they want to learn it, without tuition or any other conditions of service” (Boylan “Hippocrates”).  In this way, it shapes the medical community of inclusive.  Those whom the guiding moral theory appeals to (heal, don’t harm) appeal to have a right to join the profession.  At the same time, The Oath sets up medical knowledge not as a knowledge which is good in itself, but a knowledge that “generates obligations in those who possess it” (Pellegrino 1990).

 

 

 

Works Cited

Balance, Sir Charles. 1921. “The History of Brain Surgery”, The British Medical Journal 2.3181   (1041-1042).

Boylan. Michael. “Hippocrates”, The Stanford Encyclopedia of Philosophy (Winter 2012   Edition), Edward N. Zalta (ed.).

Courch, Herbert N. 1934. “The Hippocratic Patient and His Physician”, Transactions and             Proceedings of the American Philological Association 65 (138-162).

Pellegrino, Edmund D. 1990. “The Medical Profession as a Moral Community”, Bulletin of the     New York Academy of Medicine 66:2 (221-232).

Wikimedia.

[1] As an interesting aside, trepination, a surgical procedure of drilling a hole in the skull to relieve conditions such as brain swelling, has been practiced since pre-history (Balance 1921).

Can we preserve informed consent in public health? No.

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O’Neill (2004) provides a strong argument that the ethics of informed consent cannot be extended to public health provisions.  The rationale for this argument is that informed consent is a right that can inherently only benefits individual agents, not the health of an agent overall.  Cases like the spread of infectious diseases factor importantly in this discussion, because an individual’s decision to forgo certain public health provisions (i.e. vaccination, treatment of the disease) affect the population overall.  On O’Neill’s view, informed consent is a moral principle that should guide individual interactions between a doctor and their patients.  In this post, I will entertain an alternative hypothesis—that informed consent cannot be abandoned in public health policy.  From this, it can be decided if a tenable approach to public health can surface.  Ultimately, I conclude that it cannot.

Under a model of public health that does not abandon informed consent, no public health policy would result in a compulsory action.  Informed consent, in itself, would be considered a public good, on the same level as the prevention of disease transmission.  Public health policies would not be laws in the true sense, but guidelines.   A salient example is vaccination.  Suppose the legislature of country X passed a vaccination law with the goal of stopping the spread of some disease.  For the goal of preserving individual autonomy, the law has a clause which permits individuals to forego vaccination.

We must examine several possible consequences of individuals foregoing vaccination in country X.  It is possible that nobody would be vaccinated.  In this case, the spread of disease would be a necessary victim to preserve autonomy.  A second possibility is that everybody is vaccinated.  In this case, both the goal of preserving autonomy and of preventing the spread of disease are met.  A third possibility is that some people are vaccinated and some are not.  In this case, informed consent is preserved, but the spread of the disease is only partially curtailed.

Among these possibilities, the second and third seem to be desirable public health goals. (Note that, for the sake of this argument, I am not considering compromised herd immunity to be a variable.)  But only the second possibility effectively deals with the spread of the disease, and thus the only one that maximizes the public good.   If we examine the first and third cases, where some or all of the population chose not to obey the public health provision, we can clearly see that informed consent should not be afforded a privileged position in public health policy.

In the cases of informed consent that we have examined so far, the results of foregoing treatment were at worst detrimental to the individual’s health.  But public health is qualitatively different from individual health choices.  The goal is not treatment, but prevention.  Autonomy in treatment means that the person being treated can, ultimately, make his own decisions.  Does it even make sense to speak of autonomy in prevention on a group-level?  I doubt that it does.  After all, decisions (like foregoing vaccination) do not just have individual consequences, but group-level ones.  If we are to posit that public health policies should maintain individual autonomy, we are, in effect, not even making public health decisions.

 

Works Cited

O’Neill, Onora. 2004. “Informed Consent and Public Health”, Philosophical Transactions:           Biological Sciences 359 (1447): 1133-1136.

Transhumanism: What is it? and Why don’t people like it?

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In “Human Genetic Enhancements” (2012), Bostrom lays out some of the arguments in favor of genetic enhancements.  While he explicitly states that his arguments draw from the movement known as transhumanism, he does not respond to criticisms of transhumanism itself as much as he does to arguments against genetic enhancements.  In this post, I will outline some background information on transhumanism and an interesting debate between Francis Fukuyama and Bostrom.

According to Max More, a prominent supporter of transhumanism, it is a group of ideas that “refuses to accept traditional human limitations such as death, disease and other biological frailties” (from McNamee & Edwards 2006).  It does not restrict itself to genetic engineering, but also space colonization, artificial intelligence, etc.  (Bostrom gives some interesting information in a few YouTube interviews, such as this one). It can take one of two forms: strong transhumanism or weak transhumanism.  Both strong and weak transhumanists advocate using technology to enhance humanity (e.g. in appearance, intelligence, lifespan).  Strong transhumanists differ in arguing that we should use technology to become a new species (McNamee & Edwards 2006).

Because of the radical nature of its stronger supporters, transhumanism seems to have a rather dystopian connotation.  But the basic aim, to improve the human condition through technology, is not so far-fetched.  After all, improving technology is an important part of public health.  This is salient if one considers examples like sewage systems and clean water supplies (McNamee & Edwards 2006).  By and large, though, the term ‘transhumanism’ is more concerned with higher-level technology like genetic engineering (2006; Bostrom 2012).

Criticism of transhumanism has been vociferous.  In a 2004 Foreign Policy report, eight  public intellectuals wrote on what they considered “the world’s most dangerous ideas” that will have to be confronted in the future.  Francis Fukuyama, a political scientist, wrote his article on transhumanism.  He gives two main arguments against transhumanism.  The first is that our political right to equality presupposes that there is a fundamental human essence that transcends sex, class, or race.  That is to say, all members of the human species are afforded equality.  In a sense, the post-humans that transhumanists advocate for throw a wrench in our conception of equality by changing the fundamental human essence (cf. Bostrom 2012 112-113).

The second argument against transhumanism is that it seems to gloss over the two-sided nature of human characteristics.  “Our good characteristics” Fukuyama says, “are intimately connected to our bad ones” (2004).  What is seen as a negative trait in one context could be a positive one in another.  For instance, we may consider violence and aggression a negative characteristic in itself, but it is useful when we need to defend ourselves.  The biggest risk, he says, is that we do not really know how intricately these characteristics are intertwined. Transhumanists take it upon themselves to determine what is good or bad in a human.  We do not know the results of meddling with our biology in such a way (Fukuyama goes so far as to say that we cannot know).

In response to Fukuyama’s article, Bostrom (2004) argues that the Fukuyama’s argument is flawed.  He argues that evolutionary biology has revealed that there can be no distinctive “human essence”, because the human gene pool is not fixed.  Even if there were a human essence, he argues that this is not an argument for post-humans contradicting the basis to equal rights.  On his view, transhumanism does not advocate for creating beings that lack moral agency (or somehow transcend it), which he considers more fundamental to our rights than our essence.

Works Cited

Fukuyama, Francis. 2004. “The World’s Most Dangerous Ideas: Transhumanism” Foreign Policy 144: 42-43.

Bostrom, Nick. 2004. “Transhumanism: The World’s Most Dangerous Idea?” Foreign Policy.

Bostrom, Nick. 2012. “Human Genetic Enhancements: A Transhumanist Perspective” in   Arguing About Bioethics, ed. Stephen Holland. 105-115. New York: Routledge.

McNamee, S.D. and M.J. Edwards. 2006. “Transhumanism, Medical Technology and Slippery Slopes”, Journal of Medical Ethics 32.9: 513-518.