Hippocratic Tradition- Medical Principalism

ethical theories with reason as the source

• natural law

• kantian ethics

ethical theories with relationship as source

• virtue ethics

• utilitarianism

• situational ethics

ethical theories with tradition as source

• divine command theory

• hippocratic oath

telos of medicine according to hippocratic tradition

physician as healer

how does hippocratic oath use covenantal language?

◼ A vertical oath

◼ A solemn and binding commitment

◼ Invokes a spiritual dimension

◼ More than a contract

how does the hippocratic oath establish a fiduciary relationship

◼ Covenantal arrangement based on trust

◼ High level of responsibility

the hippocratic oath is highly __________

deontological

beneficence

the quality or state of doing or producing good, namely the best interests of others

moral rules related to beneficence

• altruism

• charity

• kindness

• love

implications of beneficence for healthcare

◼ Healthcare providers should always act in the best interests of the patient

◼ Implies professional judgment and expertise

non-maleficence

“Primum non nocere” → First, do no harm.

◼ Idea is implied in the oath and embodied in the Hippocratic corpus

◼ We must actively prevent and remove harms from patients

◼ Includes the idea of confidentiality

specific prohibitions from hippocrates

• suicide

• abortion

distributive justice

Fair and equitable treatment of patients and distribution of the

benefits of healthcare

◼ Equal treatment of all patients, regardless of irrelevant factors

◼ Protecting individuals in marginalized groups

◼ Involves limiting barriers to legally-available treatments

strengths of hippocratic tradition

• Has endured for 2,400 years due to the self-evident nature of the principles

• Protects the interests of the individual patient

• Protects the sanctity and dignity of life as intrinsically valuable

criticisms of hippocratic tradition

• Does not consider societal good

• Relies heavily on the provider’s assessment (paternalism)

• Not broad enough to cover research ethics

key aspects of hippocratic oath

◼ Covenant with deity(ies)

◼ Covenant with teachers (professionalism)

◼ Covenant with patients

◼ Focused on the good of the patient (not the physician)

◼ Limits on ends (no abortion or euthanasia)

◼ Limits on means (for surgery – defer to someone more qualified)

◼ Medical Principlism initially crafted (autonomy added later)

autonomy

The right of competent patients to make informed decisions

about their own medical care

• implies informed consent and decision making capacity

4 rules of modern medical principalism

1. beneficence

2. nonmaleficence

3. distributive justice

4. autonomy

competency

• Legal determination, made by a judge

• Requires a court order and designation of a guardian

decision-making capacity

• A clinical determination, made by a physician

• A patient may temporarily lose decision-making capacity due to illness, anxiety, anesthesia, or pain

informed consent

◼ Contractual agreement - Healthcare provider explains, patient agrees

◼ Ideally, informed consent should be a process, not an event

process of informed consent

1. provision of info (disclosure)

2. assessment of understanding (comprehension)

3. assessment of decisional capacity

4. assurance that consent is voluntary

patient consent

Informed consent by a patient with decision- making capacity

3 levels of consent

1. patient consent

2. substituted judgement

3. best interests standard

substituted judgement

• A surrogate makes decisions when patient lacks capacity

• Applies to adults with mental disabilities, minors, comatose patients, demented, or otherwise incapacitated patients

best interests standard

• Basis for implied consent

• Logical outworking of beneficence

why is a placebo ok in a research study?

patients know it is possible to receive placebo & they signed informed; there is no SOP in research study