Most people know that medical professionals take an oath before they can join the profession called the Hippocratic Oath. The Hippocratic Oath is named after Hippocrates, A Greek physician.
The Hippocratic oath has been through a number of revisions and manifestations. In many ways, it little resembles the original Greek text.
One of the big changes in the oath is that it has been secularized. The religious aspects of the oath have been taken out. In the 1960s, the Hippocratic Oath was changed to require “utmost respect for human life from its beginning,” not to be taken in the presence of God or any gods, but before only other people. That’s important to note, because the medical profession is beholden not to a particular religion or philosophy, but to its obligation to society. Medical professionals don’t swear to a deity, but by their responsibility to their communities. When the oath was rewritten in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, the prayer was omitted, and that version has been widely accepted and is still in use today by many US medical schools.
The oath that is commonly used is:
I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.
I will not be ashamed to say, “I know not”, nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
Often, when people think of the Hippocratic Oath they think of the phrase, “First do no harm” (Latin: Primum non nocere). Although the phrase does not appear in the AD 245 version of the oath, similar intentions are vowed by, “I will abstain from all intentional wrong-doing and harm”. The phrase primum non nocere is believed to date from the 17th century.
Another equivalent phrase is found in Epidemics, Book I, of the Hippocratic school: “Practice two things in your dealings with disease: either help or do not harm the patient”. But the specific phrase supposedly comes from the 19th-century English surgeon Thomas Inman.
What we gather from the oath, and from its evolution, is that doctors and medical professionals are morally and ethically obligated to treat who they can, when and how they can, outside of the trappings of religion. It is not their job to play God, but it is their job to treat the ill, prevent sickness when possible, and do so with warmth and sympathy.
This is why the Medical Ethics and Diversity Act is one of the most shameful pieces of legislation of the last year, and it has been a year of truly reprehensible legislation.
The Medical Ethics and Diversity Act of Arkansas, signed by Governor Asa Hutchinson, allows health care professionals to deny any non-emergency services to patients according to their “conscience.” It also protects health care institutions from “discrimination, punishment, or retaliation as a result of any instance of conscientious medical objection.”
Hutchinson said, “I have signed into law SB289, The Medical Ethics and Diversity Act. I weighed this bill very carefully, and it should be noted that I opposed the bill in the 2017 legislative session. The bill was changed to ensure that the exercise of the right of conscience is limited to ‘conscience-based objections to a particular health care service.’ I support this right of conscience so long as emergency care is exempted, and conscience objection cannot be used to deny general health service to any class of people. Most importantly, the federal laws that prohibit discrimination on the basis of race, sex, gender, and national origin continue to apply to the delivery of health care services.”
In the past few months similar bill are cropping up in in places like South Carolina, even calling it the exact same thing, the “Medical Ethics and Diversity Act,” and attempting to legislate that
Despite its (conscience’s) preeminent importance, however, threats to the right of conscience of medical practitioners, health care institutions, and health care payers have become increasingly more common and severe in recent years. The swift pace of scientific advancement and the expansion of medical capabilities, along with the mistaken notion that medical practitioners, health care institutions, and health care payers are mere public utilities, promise only to make the current crisis worse, unless something is done to restore conscience to its rightful place.
(C) With this purpose in mind, the General Assembly declares that it is the public policy of the State of South Carolina to protect the right of conscience for medical practitioners, health care institutions, and health care payers.
(D) As the right of conscience is fundamental, no medical practitioner, health care institution, or health care payer should be compelled to participate in or pay for any medical procedure or prescribe or pay for any medication to which the practitioner or entity objects on the basis of conscience, whether such conscience is informed by religious, moral, ethical, or philosophical beliefs or principles.
(E) It is the purpose of this chapter to protect medical practitioners, health care institutions, and health care payers from discrimination, punishment, or retaliation as a result of any instance of conscientious medical objection.
Now, the immediate consequences for this are clear: anybody in the medical field would be able to deny medical help to LGBTQ people as they saw fit. Gay people, who often struggle with medical help, could be denied. For some gay people this could lead to even denial of important medicines, such as PrEP. But for trans people, and 70% of trans people already report experiencing discrimination at the hands of medical professionals, the implications are much more clear – there is the obvious issue of being denied hormone treatments which could be devastating to many trans folks. But there is the much more serious issue of being denied specialist, maintenance care. Trans men still need to see a gynecologist. Trans women still need to have their prostate checked. If doctors can simply refuse to see them because of their “conscience or philosophy” where are these men and women supposed to go? How are they supposed to have basic health screenings done? These are the kinds of things that could lead to serious health issues if not addressed. And doctors take an oath to prevent illness when they can.
But there are consequences to bills like this that are not so obvious that are just as pernicious. Pharmacists could deny women birth control. And we all know that birth control is an absolute necessity for many women.
EMTs could refuse care to someone if they didn’t deem it an “emergency.” This could have serious health consequences and long-last effects on people. And if those EMTs misjudge the situation it could be lethal. And according to the bill there may be no consequences for them.
Therapists and counselors could refuse to see same-sex couples. Or psychologists and psychiatrists could refuse to see gay people, trans people, or even single mothers or members of a particular religion.
Bills like this could prove disastrous for the health and well-being of entire communities who often struggle with health and access to health care to begin with. The bill is flatly discriminatory and flies in the face of everything a medical professional is supposed to stand for. That is why every group from the American Academy of Pediatrics, the American Psychiatric Association, the American Psychological Association, and the American Medical Association oppose it.
As professionals, we have certain obligations. I’m an educator. I have a job to share information, make things accessible, teach concepts, and create an environment in which students feel like they can share their ideas freely and with respect. A big part of my job is treating students fairly. Here’s the thing – there are plenty of students I don’t like. There are a lot of students I disagree with. I’ve had students who I thought were flat-out immoral. It is my job to assess those students and teach them just like any other student regardless of what I think about them or how despicable I find their positions. And I take that part of my job really seriously. If I am going to take points off of a paper, I disagree with I make damned sure I can justify that it is because the argument was bad and not because I just disagree with what the student was saying. It’s why one of my favorite things is giving really good grades to somebody I disagree with. It means we’ve both done our jobs well.
Medical professionals’ obligations are similar – but much more serious. A medical professional has an obligation to treat each patient fairly and justly, much like I do, but the ramifications are much more immediate. As much as I go on and on about how important my job is, physical, medical, and/or psychological care trumps it. So if I, as an educator, have to be held accountable when it comes to treating my students fairly, there is no excuse for medical professionals. Medical professionals care for people in the most basic and fundamental way. They have sworn to do so. We depend on them to help us maintain our bodily, mental, and emotional well-being. And, most importantly, nobody else can do it. There are very limited options when it comes to medical professionals. If one fails you, there might not be another, especially if you don’t live in a metropolitan area. For the state to tell medical professionals that they are no longer beholden to their professional obligations is unethical in a variety of ways. And, to be honest, if a person feels like they have to option to play God and decide who gets care based on their personal morals, religion, or philosophy, then they have no business being a medical professional anyway and should have been weeded out in medical school to begin with. Any medical professional who refuses care to an individual or group because of their personal biases should lose their license for failure to fulfill their professional obligations.
We wanted to get a professional opinion, so we reached out to Dr. Monica Bullock for her thoughts on this. Dr. Bullock is a Board-Certified family medicine physician currently pursuing additional training in Hospice and Palliative Medicine. She is cisgender and openly lesbian and was a first-generation college student.
Dr. Bullock says,
Legislation that allows health care professionals to refuse to provide medical care based on a loosely defined conscience objection is discriminatory in its intent and ramifications. The Arkansas law is a not so thinly veiled attempt to allow discrimination. The misplaced focus on protecting the morals of providers, institutions, and insurers will exacerbate the healthcare disparities that we have been working to close for decades. In my relatively short career, I have seen and heard more instances of discrimination against patients than I can count. Since anecdotal evidence isn’t a high standard, a search of the literature gives thousands of peer-reviewed evidenced based articles about healthcare discrimination and a paucity of articles on healthcare workers being forced to provide care against their own morals.
These laws are not new nor are the motivations behind them. While I most immediately worry about women’s healthcare and affirming medical and mental care for my fellow LGBTQ+ Americans, the ramifications are even further reaching. In a year that has brought attention to healthcare disparities, these laws put the most vulnerable at even higher risk. I practiced family medicine in a metro area of more than 700,000 people, even there, I was one of only a handful of providers that would provide affirming medical treatment to trans patients. A pharmacist refusing to fill birth control isn’t an issue when there is another pharmacist nearby. Unfortunately, for many people there are no other options for care.
This law will “do harm” to those people in lower income and more rural areas. It will do harm to already vulnerable religious, ethnic, sexual, and gender minorities. That inevitable harm should be enough for people to oppose it, as many major medical societies have done. Many people likely think it won’t impact them and I encourage you to think what else could be refused. Could it be your erectile dysfunction treatment, STI treatment for infections contracted outside of marriage, addiction treatment? Personally, I am morally repulsed by those who refuse to wear masks in the midst of this pandemic. If I am working in a rural urgent care or ER and someone who didn’t follow masking guidelines came in with non-emergent symptoms from COVID, this law could be used to support me in refusing to care for them. That decision is not one I would make as it would violate the oath I have taken on multiple occasions during my career.
Physicians swear an oath to care for ALL patients, even those with whom we disagree. For me that includes the patient who comes to the office with a red MAGA hat on, who exclaims to this straight-passing lesbian doctor that “those gays are ruining society with their pronouns”, and who repeatedly call me a nurse and then demand narcotics. People come to us for care and advice when they are vulnerable. The provider is always the one with the power in the interaction, whether we like it or not. It is our obligation to use our knowledge and skills to serve and heal those who trust us. We have to this based on the best scientific evidence available, not based on our own beliefs.
A special thanks to Dr. Bullock for her insights.
Professionals in other kinds of care have concerns, too.
As Claudia Shields, Director of Clinical Training for Antioch University in Los Angeles, says “I am not sure how a therapist can be competent if they are discriminatory,” “Our rights as therapists are important, but in a clinical context they are generally secondary to what is best for the client.”
“The practice of psychotherapy does not concern itself with the moral, religious, or personal positions of the clinician,” agreed Angela Kahn, an MFT in private practice in Los Angeles. “Those aspects of being are for the clinician’s own therapy. When a clinician allows personal beliefs to drive therapeutic decision-making, we question overall competence, no matter the content of the beliefs.”
The oath I cited earlier said, “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.” A person who takes that oath, or one similar to it, is vowing to be a vital member of society – of their communities and recognize that they have an obligation to all people. Society and “all my fellow human beings” means the rich tapestry of people that make up our entire community – those like us and those unlike us; those who we agree with and those who we disagree with – not just those who think or believe like we do.
These bills are dangerous. They will have serious health consequences for those who are already some of the most vulnerable in our communities. If you are in a state where these bills are cropping up, call your state legislator and ask them not to support it. If you’re in Arkansas, contact the ACLU and ask them what they’re going to do about it and how you can support their efforts.
Talk to your therapists or your doctors and make sure they don’t support measures like this one. Make sure the pharmacies you use are available to all people for all reasons.
And remember that allyship is an action, not an identity. You don’t get to call yourself an ally, you have to act like one. So do your part to support the folks who will be most affected by bills like these. What are you doing to support your gay and trans friends? What about women and different religious communities? How are you making their road a little smoother? How are you supporting vulnerable communities?
We have to hold our legislators accountable, and we have to remind our medical professionals that they took an oath, and we expect them to stick to it. It’s not enough for us to do no harm. We need to actively do good.
Music in this episode is “Fearless First” by Kevin MacLeod at https://incompetech.filmmusic.io/song/3742-fearless-first.