Professionalism, pragmatism, and the Hippocratic Oath.

In a recent post about a study of plagiarism in the personal statements of applicants for medical residency programs, the issue of professionalism reared its head. The authors of that study identified plagiarism in these application essays as a breach of professionalism, and one likely to be a harbinger of more such breaches as the applicant’s medical career progressed. Moreover, the authors noted that:

increasing public scrutiny of physicians’ ethical behavior is likely to put pressure on training programs to enforce strict rules of conduct, beginning with the application process.

I think it’s worth taking a closer look at what “professionalism” encompasses and at why it would be important to a professional community (like the professional community of physicians). To do this, let’s go way back to an era where physicians were working very hard to distinguish themselves from some of the other thinkers and purveyors of services in the public square – the time when the physicians known as the Hippocratics were flourishing in ancient Greece.

These physicians were working to make medicine a more scientific practice. They sought not just ways to heal, but an understanding of why these treatments were effective (and of how the bodies they were treating worked). But another big part of what the Hippocratics were trying to do involved establishing standards to professionalize their healing practices – and trying to establish a public reputation that would leave the public with a good opinion of learned medicine. After all, they weren’t necessarily pursuing medical knowledge for its own sake, but because they wanted to use it to help patients (and to make a living from providing these services). However, getting patients depended on being judged trustworthy by the people who might need treatment.

Professionalism, in other words, had to do not only with the relationship between members of the professional community but also with the relationship between that professional community and the larger society in which it was embedded.

The physicians in this group we’re calling the Hippocratics left a number of writings, including a statement of their responsibilities called “The Oath”. It’s worth noting that the Hippocratic corpus contains a diversity of works that reflect some significant differences of opinion among the physicians in this community – including some works (on abortion and surgery, for example) that seem to contradict some of the specific claims of “The Oath”. Still, “The Oath” gives us pretty good insight into the kind of concerns that would motivate a community of practitioners who were trying to professionalize.

We’re going to look at “The Oath” in its entirety, with my commentary interspersed. I’m using the translation of by J. Chadwick in Hippocratic Writings, edited by G.E.R. Lloyd.

I swear by Apollo the healer, by Aesculapius, by Health and all the powers of healing, and call to witness all the gods and goddesses that I may keep this Oath and Promise to the best of my ability and judgment.

In other words, it’s a serious oath.

I will pay the same respect to my master in the Science as to my parents and share my life with him and pay all my debts to him. I will regard his sons as my brothers and teach them the Science, if they desire to learn it, without fee or contract.

This is a recognition of the physician’s debt to professional community, those who taught him. It’s also a recognition of his duty to educate next generation of the profession.

I will hand on precepts, lectures and all other learning to my sons, to those of my master and to those pupils duly apprenticed and sworn, and to none other.

This part is all about keeping trade secrets secret. The assumption was that learned medicine involved knowledge that should not be shared with everyone, especially because a lot of people wouldn’t have the wisdom or intelligence or good character to use it appropriately. Also, given that these physicians wanted to be able to earn a living from their healing practices, they needed to keep something of a monopoly on this knowledge.

I will use my power to help the sick to the best of my ability and judgment; I will abstain from harming or wronging any man by it.

Here’s the recognition of the physician’s duty to his patients, the well-known commitment to do no harm. Obviously, this commitment is in the patients’ interests, but it’s also tied to the reputation of the professional community. Maintaining good stats, as it were, by not doing any harm should be expected to raise the community’s opinion of the profession of learned medicine.

I will not give a fatal draught to anyone if I am asked, nor will I suggest any such thing. Neither will I give a woman means to procure an abortion.

These two sentences forbid the physician’s participation in euthanasia or abortion. Note, however, that other writings in the Hippocratic corpus indicate that physicians in this tradition did participate in such procedures. Maybe this was a matter of local variations in what the physicians (and the public they served) found acceptable. Maybe there was a healthy debate among the Hippocratics about these practices.

I will be chaste and religious in my life and in my practice.

This part basically calls upon the physician to conduct himself as a good person. After all, the reputation of whole profession would be connected, at least in the public’s view, to the reputation of individual practitioners.

I will not cut, even for the stone, but I will leave such procedures to the practitioners of that craft.

Cutting was the turf of surgeons, not physicians. Here, too, there are other writings in the Hippocratic corpus that indicate that physicians in this tradition did some surgery. However, before the germ theory of disease or the discovery of antibiotics, you might imagine that performing surgery could lead to a lot of complications, running afoul of the precept to do no harm. Again, that was going to hurt the professional community’s stats, so it seemed reasonable just to leave it to the surgeons and let them worry about maintaining their own reputation.

Whenever I go into a house, I will go to help the sick and never with the intention of doing harm or injury.

This reads as an awareness of the physician’s power and of the responsibilities that come with it. If patients are trusting the physician and giving him this privileged access, for the good of the professional community he had better live up to that trust.

I will not abuse my position to indulge in sexual contacts with the bodies of women or men, whether they be freemen or slaves.

This is more of the same. Having privileged access means you have the opportunity to abuse it, but that kind of abuse could tarnish the reputation of the whole profession, even of physicians whose conduct met the highest standards of integrity.

Whatever I see or hear, professionally or privately, which ought not to be divulged, I will keep secret and tell no one.

To modern eyes, this part might suggest a commitment to maintain patient privacy. It’s more likely, however, that this was another admonition to protect the trade secrets of the professional community.

If, therefore, I observe this Oath and do not violate it, may I prosper both in my life and in my profession, earning good repute among all men for all time. If I transgress and forswear this Oath, may my lot be otherwise.

“Swear to God and hope to die, stick a needle in my eye!” Did we mention that it’s a serious oath?

The main thing I think is worth noticing here is the extent to which professionalism is driven by a need for the professional community to build good relations with the larger society – the source of their clients. Pick any modern code of conduct from a professional society and you will see the emphasis on duties to those clients, and to the larger public those clients inhabit, but this emphasis is at least as important for the professional community as for the people their profession is meant to serve. The code describes the conduct that members should exhibit to earn the trust of the public, without which they won’t get to practice their profession – or, at any rate, they might not be viewed as having special skills worth paying for, or as being the kind of people who could be trusted not to use those special skills against you.

Professionalism is not idealistic, then, but extremely pragmatic.