By Iain Brassington
Contain your excitement if you can…
The World Medical Association has issued its latest version of the Declaration of Geneva. (h/t to Mark Rapa for bringing this to my attention.) This is apparently something that it does every decade, tinkering with phrasing as it sees fit.
So, then: what does it say? Well, for my money, the answer to that is “Not a lot”. Indeed, it’s notable for just how vague it is – if it’s supposed to be a statement of the underlying ethical principles of medicine (and it is: the blurb that introduces it states that it “outlines in concise terms the professional duties of physicians and affirms the ethical principles of the global medical profession”), it doesn’t really do all that fantastic a job. It’s probably worth looking at point-by-point to see exactly what’s going on.
I’ll say at the outset that I was put on alert by the first clause of the Declaration, which says that as a member of the medical profession, physicians “SOLEMNLY PLEDGE to dedicate my life to the service of humanity”. But the problem is that that’s absurd. You can’t expect people to devote their lives to the service of humanity, and if you can’t expect people to devote their lives to something, either you have to ditch the idea of having that as a pledge, or you have to accept that the pledge is pretty piecrust. I’m not wholly sure what “humanity” means anyway. It’s presumably more than just “humans”, because there’s a lot of medical practice that doesn’t serve humanity in any particularly grand sense – unless, of course, one serves humanity in abstracto by serving particular humans. But that being the case, there’s any number of things that serve humanity. Indeed, by being entirely self-centred, one would be serving humanity insofar as that it’s manifested in one particular human. And as for pledging one’s life to the service of humanity… Well, wouldn’t that imply that retirement is wrong? That one ought not to clock off at the end of the day and go to a party, on the basis that the wine will impair your ability to serve humanity for a few hours? Or that it might be morally wrong to choose certain specialities? (One might think that something like public health ethics serves humanity more than does cosmetic surgery, for example; but in that case, would that imply that medics have an obligation to practise the former over the latter?)
Incidentally: what’s the difference between a pledge and a solemn pledge? Is it simply a matter of captialisation?
A pledge that begins with ridiculous hyperbole, and the first line of which is never going to gain adherence, isn’t a pledge that is begging to be taken seriously.
What else is there?
- THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
So it looks like it’s service to humanity as manifested in particular individuals. OK: that helps a bit. But there comes a point at which a halt has to be called. A doctor has a right to time off, after all. And what is meant by well-being? Granted, it’ll usually coincide with health, but it might not. If it were the same thing, “health and well-being” would be pleonasm; if it’s not pleonasm, there’s a possibility that the two can diverge. We need to know more if either is to be the first consideration, let alone – putting the rules of grammar and logic to one side for a moment – both.
- I WILL RESPECT the autonomy and dignity of my patient;
This is unobjectionable as far as it goes, but it doesn’t go very far; debates about what dignity means, for example, are legion; so are questions about what autonomy is and what it requires. And, of course, “respect” could mean anything. One only uses the phrase “with all due respect” in the run up to calling another person a pillock. When it comes to solving practical problems, deciding what it means to respect autonomy and dignity is a much more pressing matter. Are intubation and catheterisation compatible with maintaining dignity?
- I WILL MAINTAIN the utmost respect for human life;
Once again, this doesn’t go very far. I can see already that this is going to be jumped on by antiabortionists, who’ll point out (correctly) that an embryo is human, and alive, and therefore a human life; (correctly) that “respect for human life” appears not to admit of degrees; and (for my money much less plausibly) that therefore it demands parity of respect for both the embryo and the woman gestating it. On the other hand, “respect” is not defined, and though it appears not to admit of degrees in this formulation… well, that’s so much the worse for this formulation. The point is that there’s still a need for a great deal of philosophical donkey-work to be done before we can make much practical sense of the claim – let alone decide whether to take it particularly seriously; and that’s a problem in an oath that’s supposed to outline the professional duties of physicians and affirm the principles of the profession.
Oh, and that’s before we’ve even begun to think about what pains we should have to take to preserve life as it nears its end. Does it mean that withholding or withdrawing treatment is ruled out, on the basis that that will predictably bring about the end of life? I leave to one side the question of whether that’s the same as euthanasia: I don’t think it is, but if “utmost respect for human life” means preserving life at all costs, it may not be a debate that needs to be had. If it doesn’t mean that, what does it mean?
- I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient;
OK: That’s fair enough, although “my duty to my patient” is a bit wooly.
- I WILL RESPECT the secrets that are confided in me, even after the patient has died;
It’s the R-word again! But the wording here is deeply strange. In what sense is a secret worthy of respect? Indeed, what would it mean to respect a secret in the first place? One might respect the wishes of a confidant, and that might be a part of respecting the confidant. Is that what’s meant? OK, then: next question. Doesn’t death make a difference? It’s plausible to think that we owe certain duties to the living as a way of reflecting something like their autonomy or status as persons. It might be that this concern trumps the good that we could do by breaching confidentiality – hence classroom debates about whether to tell a patient’s partner that the patient is HIV+. But if the patient is dead… well, then autonomy is gone. Their personhood is past. Is it really the case that we should carry on before? It might be, but it’s not crazy to think otherwise. One might perfectly straightforwardly deny that it’s possible to wrong or to harm the dead; therefore there would be no fault in disclosing information.
“But the Declaration says this!” will not solve this kind of problem. That takes engagement of a quite different sort; and if you’re going to engage with the problem in the right kind of way, it’s not obvious what the Declaration adds.
For sure, there might be worries about people being less willing to disclose important information should they expect that it’ll be shared post-mortem; but in that case, the focus has shifted slightly.
- I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice;
I have no idea at all what this is supposed to mean, especially if this clause is supposed to be a part of defining what good medical practice is in the first place. The place of conscience is also deeply contested, and this clause simply ignores that. Most obviously, what would it mean for things like abortion or assistance in dying? What about people who appeal to religious conscience to refuse to participate in certain procedures on members of the opposite sex? (Robert Card considered this problem a couple of years ago, and I blogged about it here.) And, like it or not, someone’s conscience might direct them to behave in a way that is not compatible with being blind to sex, race, sexual orientation and so on. Do we try to change their conscience, or do we let them abide by it?
- I WILL FOSTER the honour and noble traditions of the medical profession;
Huh? It’s just a job, mate. Get over it.
- I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;
Of course, giving people their due is right; that’s part of it being their due. It’s not obvious why this is being elevated to a principle of physicians’ ethics. What’s also unclear is what their due is. I mean, teachers get paid; a principle of fair pay is that you do the work and are given a reward that both parties agree to be of a value equal to that work. Quite why one should merit gratitude on top of that is unclear. Still, it’s an improvement on the last version of the Declaration, which – as the WMA admits – talked only of students having obligations of gratitude to teachers, with no reciprocity. I don’t think I’m owed gratitude by my students. If they express it, then that’s lovely. But I’m not owed it. And I don’t think that medics are all that different from philosophers on that front.
- I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;
Presumably “medical knowledge” does not extend to “I am carrying an infectious and deadly disease”. On the other hand, it’d be good to see someone using this part of the pledge as a defence for leaking withheld results from medical trials, or passing on the formula for a life-saving drug to a manufacturer of cheap generics.
- I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;
OK. I suppose that that’s compatible with the stuff about putting patients first, inasmuch as that one has to ensure that one is capable in order to discharge that duty. There’s a kind of Kantian duty-to-self here.
- I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
I have a problem with the “even under threat” bit, which seems ridiculously onerous. A duty that one has prima facie may not be compelling when one is under threat; at the outside, this clause would seem to require the supererogatory. More, there may plausibly be times when a medic ought to participate in wicked practices if by doing so the least-bad outcome can be secured. This ought not to damage the integrity or reputation of the profession or the professional in any way. (I blogged in 2015 and 2013 about cases that touch on that idea.)
- I MAKE THESE PROMISES solemnly, freely, and upon my honour.
But the bit that perplexes me above all else is the codicil at the end: “©2017 World Medical Association Inc. All Rights Reserved. All intellectual property rights in the Declaration of Geneva are vested in the World Medical Association.”
An oath that has a copyright tag? I’m struggling to get my head around that…