Psychiatric Bulletin (2006) 30: 327-329. doi: 10.1192/pb.30.9.327
© 2006 The Royal College of Psychiatrists
Psychiatric Bulletin (2006) 30: 327-329
© 2006 The Royal College of Psychiatrists
Attitudes of mental health practitioners to the Hippocratic Oath: tradition and modernity in psychiatry
Marek Marzanski, Consultant Psychiatrist
Coventry Teaching Primary Care Trust, The Caludon Centre, Clifford Bridge
Road, Coventry CV2 2TE, email:
marek.marzanski{at}coventrypct.nhs.uk
Tim Coupe, Clinical Audit/Effectiveness Officer
Padmapriya Musunuri, Senior House Officer
Coventry Teaching Primary Care Trust, The Caludon Centre, Coventry
Declaration of interest
None.
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Abstract
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AIMS AND METHOD
To establish whether psychiatrists believe that medicine should be
practised according to the principles of the Hippocratic Oath, an anonymised
postal questionnaire survey was conducted of all medical staff at the Caludon
Centre, an 80-bed in-patient mental health unit in Coventry.
RESULTS
Thirty-three respondents (82.5%) believed that medicine should be practised
according to the Oath. Support for the 15 separate statements derived from the
Oath varied considerably.
CLINICAL IMPLICATIONS
The principles of the Oath remain an important guide to the ethical basis
of medical practice for most medical staff surveyed.
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Introduction
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Written in the 5th century BC, the Hippocratic Oath has been described as
the first serious attempt to bring together philosophy, ethics and therapy in
an integrated system of medical practice
(Zilboorg & Henry, 1941).
Hippocratic ethics influence many contemporary medical oaths and ethicists
(Roddy & Jones, 2002), but
although it is seen as an inspirational statement of the ethos of medicine by
some, the relevance of the Hippocratic Oath to modern clinical practice
continues to be questioned (Loefler,
2002). Very little is known, however, about psychiatrists’
attitudes to the Hippocratic Oath and whether they consider it still possible
to practise medicine according to the Oath. The aim of this study was to ask
how far psychiatrists believed that their practice reflected the principles of
the Hippocratic Oath.
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Method
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A survey was conducted in February 2004 of psychiatrists working at the
Caludon Centre, an 80-bed mental health in-patient unit in Coventry. An
anonymised questionnaire was constructed consisting of 15 statements or closed
questions restating the original Oath
(British Medical Association,
2004) using a simple Likert scale to measure agreement with each
statement (available from the authors on request). We added one
‘summary’ question which asked whether it was still possible to
practise medicine according to the Oath. Every doctor in the unit was
personally approached by the authors and asked to participate. Results were
collated and analysed with the Statistical Package for the Social Sciences
version 12 for Windows.
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Results
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Of the 44 psychiatrists at the Caludon Centre, 40 (91%) completed the
questionnaire; 17 were consultants and 23 were junior doctors. Their age
ranged from 27 to 74 years (mean 34 years); 32 (80%) were male and 8 (20%)
female.
The main results of the survey are summarised in Tables
1 and
2. There was no statistically
significant difference between the response of consultants and junior doctors
for any of the statements. A substantial majority of respondents believed that
medicine should be practised according to the Hippocratic Oath; unconditional
agreement with individual statements varied from 22 to 100%.
The first four statements specify the duties of a medical trainee towards
his teachers and other doctors. An overwhelming majority (97%) of medical
staff at the Caludon Centre said they respected their teachers. Most were
still willing to provide help in both professional (86%) and other matters
(64%). The tradition of solidarity among doctors also appears to remain
strong, with 81% of respondents claiming always or frequently to treat other
doctors as brothers. There was greater ambiguity about the transmission of
medical knowledge: 58% of doctors supported the dissemination of medical
knowledge to those who do not follow medical ethics and obey medical law.
The next part of the Oath summarises the values and principles underpinning
medical practice: treatment according to the patient’s best interests
(beneficence), avoiding harm (non-malfeasance), prohibition of abortion and
assisted death and practising within one’s competence and with a high
degree of personal integrity. The results show strong support for the
principles of beneficence and non-malfeasance: 83% of respondents claimed to
always have their patients’ health as their first consideration, 17%
only frequently; 92% declared that they always avoid harming their patients,
with 8% acknowledging that it has not always been possible; 77% were against
the use of medical knowledge to end a patient’s life in any
circumstances; 18% were prepared to consider some exceptions and 6% were
rarely or never against euthanasia. The statement prohibiting the use of
abortion produced the most ambiguous response: 25% of doctors were always
against and 25% were never against termination of pregnancy by their patients.
The rest remained ambivalent -33% of psychiatrists reject abortion frequently,
a further 17% rarely. The question on termination of pregnancy also had the
highest non-completion rate, with some 10% of respondents choosing not to
answer the question.
The last part of the Oath deals with maintaining the integrity of the
therapeutic relationship. All of the respondents in our survey agreed with
this principle: 83% declared that they always practised their profession with
conscience and dignity; the other 17% did so frequently; 98% of psychiatrists
condemned corruption and 100% were against sexual relationships with patients;
77% stated that they undertake interventions only within their competence,
with 23% of respondents admitting that they had dealt with situations beyond
their clinical expertise. Maintaining confidentiality in psychiatry is
sometimes problematic. A quarter of psychiatrists acknowledged that it was not
always possible to hold information about their patients in complete
confidentiality.
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Discussion
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Only one respondent (2.5%) indicated that they supported all the statements
derived from the Oath and the level of support for the other statements
varied. Statements prohibiting the abuse of the therapeutic relationship and
those supporting the Hippocratic principles of beneficence and non-malfeasance
attracted almost unanimous support. However, errant behaviour may not have
been declared for fear of professional censure. Moreover, respondents were
presented with a restatement of the Oath rather than the original. One
principle, the prohibition of sharing medical knowledge with others, was
rejected by a small majority (58%) of respondents. The most equivocal
responses concerned statements about treating doctors as brothers (only 26%
always agreed), forbidding abortion (25% never agreed with this) and helping
teachers in non-professional matters (22% always agreed). Despite these
ambiguities, our survey suggests that the majority of psychiatrists believe
that medicine should be practised according to the principles of the
Hippocratic Oath. However, because of the small sample size the results may
not reflect the view of all UK psychiatrists.
In the past 25 years most of the major innovations in medical ethics have
come from outside the Hippocratic tradition, notably from law, politics and
economics. The role of traditional medical ethics in contemporary medicine is
unclear, although personal integrity, trust and acknowledging tradition have
been identified as key components of postmodern psychiatric ethics
(Dyer, 1999). Bioethics has
been criticised for failing to recognise how far medicine is a value-based as
well as an evidence-based discipline
(Fulford, 1993). We believe the
level of support shown in our survey for the principles of the Oath supports
the notion that moral values are still felt to be important to contemporary
psychiatric practice. According to Jaspers, tradition is the memory of the
profession (Jaspers, 1963) and
this needs to be safeguarded in the light of the multiple and changing demands
of society on medicine. These demands can be creative, helping to redefine the
role of the profession in a postmodern world. Such a redefinition, however,
should also be informed by traditional values and beliefs. These values can
make us aware of our history and identity and provide guidance in a time of
change. Articulated in a contemporary form, Hippocratic values such as
avoiding harm, acting in the best interest of the patient, compassion,
integrity, honesty and respect for human life maintain their relevance and
prove that goodness in medical practice does remain continuous across the
ages.
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References
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BRITISH MEDICAL ASSOCIATION (2004) Medical Ethics
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London: British Medical Association.DYER, A. R. (1999) Psychiatry as a profession. In
Psychiatric Ethics (eds S. Bloch, P. Chodoff & S.
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FULFORD, K. R. (1993) Bioethical blind spots: four
flaws in the field of view of traditional bioethics. Health Care
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JASPERS, K. (1963) General
Psychopathology (3rd edn), pp. 814-815.
Manchester: Manchester University Press.
LOEFLER, I. (2002) Why the Hippocratic ideals are
dead. BMJ, 324, 1463
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RODDY, E. & JONES, E. (2002) Hippocratic ideals
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ZILBOORG, G. & HENRY, G. (1941) A
History of Medical Psychology. London: Allen &
Unwin.
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Abstract
Introduction
