Let us begin with two questions: “What are medical ethics?” and “Why should they interest the general public?” The answers are straightforward.
Medical ethics are a code of conduct that requires the medical profession to behave in a way that ensures their patients’ safety while in the care of the profession’s practitioners.
Originally the code referred to physicians, or surgeons, although the latter were included at a later date. But the profession today should include dentists, nurses, pharmacists, and technicians administering radiography, electrocardiography and the whole gamut of ancillary activities. These professionals can be categorized most simply as “medics” – a term that includes the whole group.
Everyone, without exception, will sooner or later require the services of medics, starting with physicians, for him/herself, or for someone close. Therefore, it is desirable that people know what their attendants think and also how they are expected to behave. This is a matter of self-interest.
It is better to speak about people, rather than patients. This is because the word patient is derived from the Latin deponent verb patior, meaning “I suffer.” While some medical interactions are to help people in discomfort or pain sufficiently intense to merit the title “suffering,” most interactions are for people who are simply uncomfortable or even symptom-free.
An ethical code cannot be enforced. It is a matter of regret that such people as Joseph Mengele, George Habash, Bashar Assad, Baruch Goldstein, and Harold Shipman – the GP from Yorkshire who murdered an estimated 250 elderly people while attending others successfully – could become members of the profession. Although such characters can be considered the exception, or statistical outliers, one must accept that further into the body of the national distribution of the profession there are likely to be people whose ideation may not be so pathological, but which is still worrisome.
This may indicate that the criteria for accepting students into medical school are flawed.
Pre-entry assessment tends to focus on intellectual ability. This is necessary because the medical discipline is complicated and involves an understanding of basic scientific principles. But emotional maturity and motivation are just as important, and there are no recognized assessments of these characteristics that are sufficiently rigorous or reliable in a scientific way to permit their use as assessment instruments.
One would expect intellectual ability to permit an individual to recognize the importance of an ethical code as a guide to appropriate behavior, and to absorb its recommendations and adhere to them. The exceptions mentioned indicate that this is an oversimplification.
Most people, at least in the developed world, are aware that medical practitioners swear the Hippocratic Oath, or a variant of it, when they enter the profession on completing their final academic examination.
Hippocrates (460-370 BCE) is generally regarded as the father of science-based medical practice. Although the science has changed over the centuries, the general principle that practice will be decided by objective facts is as valid now as when Hippocrates first recognized its importance.
However, the content of the oath is not so familiar to most people.
The oath is divided into three sections. The first is related solely to the new practitioner’s relationship with his, or today also her, fellow professionals. It includes a requirement to subsidize his/her teacher if the latter is in financial difficulty. This section could be interpreted as the obligation of a member of a trade union to his/her fellow trade unionists. It does not mention the patient.
The second section is concerned with methods of treatment with emphasis on the importance of avoiding potentially dangerous activity.
The third section deals with the doctor/patient relationship and the avoidance of harm to the latter. A particularly interesting inclusion is that the doctor must treat slaves and those who are free in the same way. In other words, when it comes to medicine all humans are equal.
Given Hippocrates’ dates, it is a remarkably forward-looking document.
Some scholars argue that the oath is attributed to Hippocrates rather than being written by him. But even if this is so, it is an ancient document that can be called the “Greek Model.”
About a millennium and a half later, or so it is believed, Maimonides composed the prayer for the physician. While there are various translations they are in agreement. The prayer appeals to the deity to recognize that the medic is a human being with all the human faults. It appeals for divine help to overcome these weaknesses, and to ensure that the medic sees only a fellow human in distress.
There is also an oath attributed to Maimonides, but this is in essence a shortened form of the prayer with multiple references to the deity.
Scholarly studies argue that while the prayer and oath are attributed to Maimonides, they were in fact written by a physician called Marcus Herz in 1793. Herz was physician to Moses Mendelssohn, so Maimonides’ prayer and oath can still reasonably be called the “Jewish Model.”
While substantial numbers of medical professionals do not believe in a deity, this does not invalidate the Jewish Model as a guide for them. Personal beliefs are irrelevant in this context. Non-believers should recognize that the prayer tells us that a medical interaction is a one-to-one situation, in which the patient seeks help from the medic who is not Superman or Wonder Woman, but a normal human being who is fallible in a variety of ways. Although the atheist would not seek help from a deity to avoid these failures, he/she should recognize why one might react in this way. Since this is a guide to conduct, it is clear what is required of the practitioner.
When expressed as an oath, the Jewish Model reads like a prayer with its invocation for Divine help.
These considerations are important when one compares the Jewish Model with the Greek Model. The latter is expressed as an oath in unequivocal terms stating confidence in the neophyte’s ability to comply with the required way to behave. Furthermore, the Greek Model indicates how the beginner should relate to his/her fellow professionals, and this suggests entry into membership of an elite club.
The Jewish Model encourages humility, a characteristic with which the medical profession is not usually associated. It may be going too far to say that the Greek Model generates arrogance, but it certainly gives one the impression that admission into the profession is something separating that group of people from their non-professional peers.
For these reasons, it is tempting to say that the Jewish Model is superior to the Greek Model. This temptation must be resisted, strongly, since it opens the door to an attitude of exclusiveness, the antithesis of the model’s aims. But it is reasonable to say that the Jewish Model is preferable to the Greek Model.
Since this is the case, should there be a move to make it the international standard? Any attempt to do so would be diplomatic folly.
Ethics of any description is not a commodity that can be bought and sold like an irrigation system, or computer program, or even military hardware. Ethics is a way of thinking, a philosophy, and if one attempts to generate the universal use of the Jewish Model, our enemies will soon use that situation to attack us. Those who call themselves “left-wing” will charge us with racism and possibly of attempting ideological imperialism.
Those who are “right-wing” will make noises about the “Protocols of the Elders of Zion” and secret codes.
It would be unwise to give these people more weapons to enlarge the variety of tools that they already use against us.
The situation within the State of Israel is an entirely different matter. In Israel, all medical students, independent of ethnicity or stage of study, undergraduate or postgraduate, should not only be instructed in the Jewish Model, but also so influenced that later when they work they will behave in a way that is consistent with its requirements.
Jewish medical students in the Diaspora should also be informed about the Jewish Model, and instructed in such a way as to ensure that their professional conduct will adhere to its guidelines.
One must not forget that this is their heritage too. ■
The writer is a retired physician from Scotland who lives in Beersheba.