Hippocratic Oath & Autonomy

John is a healthy 45-year-old executive who has an appointment with his family doctor for a routine check-up. He read in the newspaper about a new expensive X-Ray test to detect heart disease called CT angiography. John was not concerned that the test was extremely expensive because he thought his insurance would cover it. He told his doctor he wanted to have the test done. The doctor refused his request. He explained that there is no clinical evidence that the test is of value to patients, like John, who have no symptoms or risk factors of heart disease. In addition, a CT angiogram would expose him to unnecessary radiation. John accepted his doctor’s argument, but he still wanted the test to put his mind at ease. Don’t physicians have a moral obligation to respect patient preferences? Isn’t that what the Hippocratic Oath is all about?

The 2500-year-old Hippocratic Oath has stood the test of time. It is still the most popular pledge made by medical students at the time of their graduation. In part, it states, “I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them”. The oath obliges the physician, based on his ability and judgment, to benefit the patient. This is the principle of beneficence. The Oath also places on the physician the obligation not to harm the patient (“primum no nocere”). This is the principle of non-maleficence. In this case, the physician exercises the principle of beneficence by refusing to order a test, which, in his judgment, is not needed. In addition, he exercises the principle of non-malfeasance because, in his judgment, the test may be harmful to the patient. It would expose him to unnecessary radiation.

Notice that the Hippocratic Oath is subjective. It is based strictly on the physician’s judgment even if his colleagues do not agree. Also, notice that it is based on the physician’s judgment, not the patient’s. The Oath implies that the physician has the experience and expertise to make decisions on behalf of the patient even if his judgment is in conflict with the patient’s wishes, as it is in this case. Thus, the Hippocratic Oath does not support John’s argument that the physician has a moral obligation to order a CT angiogram.

Serious challenges to the Hippocratic Oath began in the 1970s. First, one may challenge the way benefits to the patient are assessed. If CT angiograms were considered the standard of care for all patients regardless of symptoms or risk factors, the physician would be hard pressed to refuse the patient’s request for the test. The objective judgment of the profession would trump the subjective judgment of one physician. However, that is not the case here. At this time (July 2008) there is no objective evidence to support the benefit of this test in John’s case.

Another challenge to the Hippocratic Oath came for the American Medical Association. Although its previous codes were essentially Hippocratic, the AMA changed its code in a dramatic and significant way in 1980. The new version is the first to speak of patient rights. “The physician shall respect the rights of patients, of colleagues and of other health professionals, and shall safeguard patients’ confidences within the constraints of the law”. The 1980 AMA code breaks with the Hippocratic tradition, which does not mention anyone’s rights. From this time onward, the principle of respect for patient autonomy has been on the ascendency.

“Whether respect for the autonomy of patients should have priority over professional beneficence directed at those patients is a central problem in biomedical ethics” (Beauchamp & Childress, Principles of Biomedical Ethics, 2009). In this case John expresses his autonomy right by requesting that his doctor order the expensive test if only to put his mind at ease. The doctor, in turn, applies the principle of beneficence by denying the request because in his professional judgment the test is not indicated in John’s case. Moreover, he applies the principle of non-maleficence by refusing to subject his patient to the danger of unnecessary radiation. How can this conflict be resolved?

The answer to this conflict lies in the principle of distributive justice. Health care spending in the United States is spiraling out of control. New technologies are a major driving force for this increase. The principle of distributive justice refers to an appropriate, equitable, and fair distribution of health care resources. It is not appropriate for a doctor to order unnecessary tests that subject patients to danger. It is not equitable for one person to receive expensive diagnostic testing, merely for peace of mind, while 50 million uninsured Americans cannot afford the costs of basic health care. In addition, it is not fair to burden society with unnecessary costs.

Daniel Callahan, an expert on bioethics, argues that solving the current crisis in our health care system – rapidly rising costs and dwindling access – requires replacing the current “ethic of individual rights” with an “ethic of the common good”. In a similar vein Newsweek columnist, Robert J. Samuelson wrote: “We face a choice between a society where people accept modest sacrifices for a common good or a more contentious society where groups selfishly protect their own benefits.”