“Primum non nocere” – Do no harm
Every year just before the weather chills and the trees begin to brace themselves against the long nights ahead loads of medical students gather in auditoriums across the country to recite the immortal phrases set down by Hippocrates thousands of years ago. So famous are these words and so oft repeated that many outside the medical community could recognize the sentences if not even in their original Latin forms.
We are sworn into the medical profession by promising to uphold these virtues. It is this promise that binds us in commonality, as Father Time slowly transforms us from the homogenous mass of wide-eyed, eager medical students into the commanding surgeons, inquisitive internists, or tech-savvy radiologists that we were born to become. More than that, it connects us to a rich history of service, dedication, and self-sacrifice that millions before us have undertaken.
How is it then that the fabric of our undertaking can so easily be undone? It has been over a week since the CIA released its “torture report” and in it the shaming admission that medical physicians themselves were at the forefront of such grotesque crimes against humanity.
Atul Gawande, renowned surgeon and author of books like “The Checklist Manifesto” in which he provides guidance on how to reduce mental errors has much less patience for the physicians making ethical errors.
“Voluntas aegroti suprema lex” – the patient has the right to refuse or choose their treatment.
Unfortunately, the history of medicine is as ripe with examples of human valor as it is with examples in human failure.
Since the great civilizations of Greece and Rome when torture devices such as the Sicillian Bull were implemented medical doctors have lent their expertise on how to maximize the pain inflicted on the victim. The first official reference to our participation in the practice is in the Constitutio Criminalis Carolina of 1532 [1. http://virtualmentor.ama-assn.org/2004/09/jdsc1-0409.html] which established the European legal roots of the physician’s presence during torture. It required a physician to certify that a person was not incapable of giving testimony by virtue of being blind, mute, or insane, and that he or she could survive a planned regimen of torture. Midwives also gave certificates to those that were pregnant to exempt them from such acts. As long as torture wasn’t illegal, doctors weren’t scrutinized for their participation.
This all changed during the Rennaisance when paper and metal movable types helped facilitate the spread of ideas throughout the world. One of those ideas was the thought that torture was an archaic practice, one in which the noble profession of physicians should have no part it. Even still, the first banning of the practice occurred in Austria 1775 (towards the end of the Renaissance) and only because the reliability of the perpetuator’s confession was questioned. It was like the famed English Juror William Blackstone had said centuries ago “It seems astonishing [to be] . . . rating a man’s virtue by the hardiness of his constitution, and his guilt by the sensibility of his nerves”.
Nevertheless medical involvement in torture continued for the next 200 hundred years until the world would collectively stop and gasp at the horrors revealed during the Doctor’s Trials in the 1940s, convicting 20 Nazi physicians for crimes against humanity and forcing an entire generation to ponder the basis of groupthink and medical ethics.
The World Medical Association would pass the Declaration of Geneva, the “Regulations in Time and Armed Conflict” and finally The Declaration of Tokyo [2. http://www.thehastingscenter.org/Publications/BriefingBook/Detail.aspx?id=2208] in which medical involvement in such acts was completely forbidden (as well as other specific guidelines directing physicians motive and behavior).
The Iraq war would bring about new allegations of physician participation on both Iraqi and American sides; the turn of the 21st century would be met with the hypocrisy of Guatenemo Bay and now we have more proof that some evil exists in the medical profession that must be addressed.
“Salus aegroti suprema lex” – a practitioner should act in the best interest of the patient.
Is there something unique to physicians that makes him or her the perfect perpetrator for such crimes? Michael Grodin, Professor at Boston University for Health Law and Medicine and also co-founder of Refugee Health and Human Rights, tackled this issue in a article entitled “Physicians and torture: lessons from the Nazi doctors” written for the International Red Cross.
In it he lists certain qualities that allow physicians to be especially vulnerable to engaging in torture [3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1378160/pdf/jmedeth00280-0006.pdf].
“The motivation for choosing a career as a physician is often a fantasy of power, either sadistic or voyeuristic, as medicine gives licence to look, touch and control. Doctors treat patients as impersonal medical cases so that they can more easily process what they have to do – taking a scientific approach to remain detached in their work, they heal by attacking and killing disease with surgery or therapy or whatever tools they have available. Medical students also go through an initiation ordeal. In the anatomy class they handle a dehumanized cadaver or watch operations without knowing the patients, and are made to feel shame for any lapses in which they show too much ‘‘weakness’’ or inability to dehumanize patients. Medicine as a profession contains the rudiments of evil, and some of the most humane of medical acts are only small steps away from real evil. For example, although surgery to amputate a gangrenous limb is a healing act, it involves the cutting and maiming of the human body, which in non-medical circumstances would be a harmful, criminal act”. – Micheal Grodin
Justice- concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality).
As a soon to be medical graduate I am saddened that some of our great minds, people that I would look up to if I saw them rounding on the floors, could participate in acts that bring such shame to the profession. I also think of my own journey and the ethical challenges I will undoubtedly face throughout my career. The most frightening aspect of all of this is that I am probably no different than these physicians when they themselves were at this stage in their lives; weeks before graduation confronted with a vast sky of discovery both with the potential to do good or evil.
I’ve had liters of blood pour out onto me after childbirth and even drained abscesses while patients writhed in pain under the thin pale blue cloth that separates our two worlds. Has my transformation already started underneath the guise of perfection and focus that medical students so often try and attain?
I am not sure, but I do know that I will keep the mistakes of my colleagues close to heart as a warning of what wrong may manifest itself in me. And the triumphs I will keep even closer, a warm light to help me navigate through the dark sea of clinical medicine. After all, this is how its always been.