Hippocrates or Midas? Which Oath Rules?

It depends largely on where you are in the healthcare pantheon...

We are often reminded that we physicians are bound by the Hippocratic Oath. I remember taking it when I graduated from medical school in 1990. I have posted the classical version below.

Many other versions have come into existence in modernity. Frankly, I have no idea which one we took. I remember taking it when I graduated from medical school in 1990. I have posted the classical version below. We understood that it was a tradition much more than a true oath. We wanted to joint the great secret cult of medicine and that was one more step.

In fact, we were Christians, Hindus, Muslims, Buddhists and atheists. None of us were worshipers of Apollo, Asclepius, Hygieia, Panaceia or any of the other gods and goddesses which were called as witnesses as we crossed the finish line of medical education. By then we were worshipers of food, sleep and the hope of salaries.

Furthermore, the witnesses most concerned with our graduations were the parents, children, spouses, girlfriends, boyfriends and fiancees who were ready for life to move on…

The interesting part is that the oath persists in many forms. It persists because deep inside, even the most flippant among us recognized that we were embarking on a thing of moral gravity. That it could not be taken lightly. That because it was ancient oath, there was something of great importance behind it all.

Here’s the ancient oath:

Hippocratic Oath: Classical Version

https://www.pbs.org/wgbh/nova/article/hippocratic-oath-today/

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art—if they desire to learn it—without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

—Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943.

Our relationships with our patients, our dedication to science and proper clinical care, these things have essential ethical moorings. That’s why the oath, and statues of Hippocrates, are still found in medical centers or physician offices.

On the other hand, the oath is sometimes used against those in the medical profession. It can be weaponized in a terrible way when physicians are struggling in bad jobs, with toxic working conditions or poor compensation (especially when young and in crushing debt). This is true not only in the capitalist American system but in medical systems around the world. Physicians in training in the UK, India and other locales are often treated terribly.

Those in positions of influence (including physicians who profit from the system as it is) tell other physicians that they owe it to their patients to keep up the work. They can be reminded to press on no matter how bad things are because, well, the Hippocratic Oath and all. The thing is, the oath in some form does live in our hearts. (Not all of us…there are some bad doctors too.) But most physicians really do care and often wreck their own health, families and sanity to keep doing the right thing. This is evidenced by the fact that about 300 American physicians die by their own hands each year. (That’s about one full medical school class, by the way.)

Here’s a good example of this weaponization of physician morality. A staffing firm, NES, isn’t paying its physicians at one of its sites; nor is the hospital. But they continue to work, despite losing money and having their own bills to pay. They are fearful of being accused of abandonment. They are fearful of causing harm. The oath lives inside their heads, rent free.

https://www.medpagetoday.com/special-reports/exclusives/112710

But it occurred to me that those who employ us, those who manage us, those who tell us how to practice, what to do, what to say (or not say), those who punish us for delinquent charts or low patient satisfaction scores, those whose incomes come from our work, are increasingly non-medical people. Or more often now, they are decidedly non-medical corporations as private equity grabs up more and more of the healthcare economy.

We all see the profit reports from large healthcare corporations including the salaries of CEOs. Have a look: https://ceoworld.biz/2023/05/10/highest-paid-health-insurance-ceos-six-ceos-raked-in-a-record-123-million-last-year/

We know well the way pharmaceutical companies turn chemistry into gold, or platinum, in the clearest form of alchemy ever. This is evident in the profitability of pharmacy benefit managers. Here you go: https://phrma.org/Blog/New-analysis-shows-PBMs-use-fees-as-a-profit-center

Who would have imagined that a pandemic would be such a grand opportunity for financial gain? This link concerns COVID related sales…

https://finance.yahoo.com/news/pfizer-q3-earnings-revenue-profit-120058508.html

So I was wondering, what oath do those people take? What oath makes healthcare system executives pause before they make a decision? What oath, or sense of an oath, causes large hospital board members to lie in bed at night and stare at the ceiling, wandering about the sick who passed through the doors of their facilities that day? What oath runs through the minds of pharmaceutical executives as the contemplate the people who can barely affording their newest, heavily marketed drug?

Perhaps their oath is to King Midas. Remember Midas? Apollo offered him a gift and he asked to be able to turn anything he touched into gold.

https://mythologysource.com/the-story-of-king-midas/

I’m just playing around here, but maybe this is what an oath to Midas would look like.

“I swear by the memory of King Midas that I will endeavor to turn everything I touch into gold. I will at all times make it my concerted effort to wring gold from the sick, the injured, the young, the aged and especially from all those who work underneath my control. Whether in the sale of medications, the bedside care of young and old, the provision of procedures, the care of the chronically ill, the development of marketing strategies or even the very end of life I will do my best to turn even the simplest, most widely available and cheapest intervention or therapy into a thing of staggering cost. May I never fail to reward good workers with inexpensive pizza and chocolate. And if I should fail to turn everything I touch into gold, may Midas himself find me a new job somewhere else so that I can start again without any consequences.”

It doesn’t seem as if anything in healthcare will be less lucrative anytime soon. Our burden of chronic disease and expensive treatments seems to grow greater with every passing year.

Homo fragilis, an increasingly sick and fragile population as I wrote before, is a cash cow milked around the clock.

https://edwinleap.substack.com/p/treating-a-new-species-homo-fragili

So is long life, especially since it requires expensive medications and procedures, physical rehab facilities, assisted living and nursing homes. Midas himself would be embarrassed at the relative penury of what he accomplished in his gardens compared with what his modern followers accomplishes in hospitals, pharmacies, clinics and and skilled nursing facilities. And let us not forget, the pharmacological and surgical interventions applied to transition children have not only been done ‘for the kids,’ but have been highly profitable. (Hippocrates who wouldn’t ‘cut a stone,’ end a life or abort a baby would have been stunned by those activities.)

Of course, Ovid tells us that Midas returned his gift. He learned his lesson and changed his life.

I doubt if those who run healthcare will change their hearts anytime soon and run off to follow Pan as Midas did.

But until then, we who took the Oath of Hippocrates (if only in spirit) will have our work cut out for us, for as long as we can bear it.

And the devotees of Midas will keep on making bright, shiny piles of profit.

I suspect they will continue to sleep just fine.