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 Table of Contents  
REFLECTION
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 4-6

Hippocrates and Ethics


Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India

Date of Submission24-Jul-2020
Date of Acceptance24-Jul-2020
Date of Web Publication24-Dec-2021

Correspondence Address:
P S Ramani
Lilavati Hospital and Research Centre, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joss.joss_3_20

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How to cite this article:
Ramani P S. Hippocrates and Ethics. J Spinal Surg 2021;8:4-6

How to cite this URL:
Ramani P S. Hippocrates and Ethics. J Spinal Surg [serial online] 2021 [cited 2022 Jan 21];8:4-6. Available from: http://www.jossworld.org/text.asp?2021/8/4/4/333621





I am a recognized neuro spinal surgeon still actively working, seeing patients, writing, and publishing at the age of 82 years.

I have published several peer-reviewed articles in journals. I get at least two messages every week from ResearchGate App informing me as to which article has cited my reference, etc.

Digital marketing people are always watching such messages, and immediately, I receive an e-mail requesting me to write articles for them and that they would publish it in a peer-reviewed journal pretty quickly. They also request me to make the appropriate payment. That means they are looking for commerce. They also assure me that by doing so, my rating will improve, and soon, I could be among 10 topmost surgeons in the specialty.

I know this is a pseudo-jump, and immediately, my mind starts browsing through my memories in the folder of 54 years of specialty experience.


  Ethics in Medicine Top


When I became MBBS doctor, we were given Hippocrates Oath[1] saying that I will practice medicine to the best of my ability and that I will “do no harm” to the patients. Life was indeed very simple then.

With rapid progress in medicine and technology, working has become very complex. To follow ethics becomes a big challenge.[2] At the time of Hippocrates, the surgeries were basic. Now, we have the capability to engage ourselves to perform more complex procedures on the brain and the spinal cord. Surgeon's expertise, available technology, guiding staff and machines go a long way to make the procedure safe. Such approaches rely on research, newer ideas, and newer methods of interventions. The idea now is to provide optimal patient care after choosing the options. We are fully aware that such options are meant to give good long-term outcome and accept at the same time the reality that the procedure may produce some side effects. I will not use the word complication here as the side effect is knowingly accepted. For example, a patient with intramedullary tumor can be pronounced cured at the expense of some bladder dysfunction or some sensory loss if not motor. Does that mean that the Hippocratic Oath needs to be modified? In 2011, WFNS[3] has released a statement on ethics. They recommend guidelines for surgeon's professionalism in handling the patient, understand patient's rights, be aware of legal responsibilities, practice evidence-based medicines, etc. Clearly, the issues mentioned here were not present when Hippocrates was living.

In today's medical practice, guidelines are important, but they do not cover ethical issues as desired by Hippocrates. The dictum today should be for the surgeon to take a final decision, honestly and transparently to choose an approach which in his capable understanding is right for the patient.

Written consent of the patient is a good black and white document. Most of the times, the consent is quite exhaustive. A study has shown that not even 20% of the instructions are carefully read by the patient before signing it.[4],[5]

We have to admit the fact that in India while some doctors are assaulted and others taken to the court with the pretext of negligence, by and large, our society still believes and practices the fact that doctor/surgeon is a GOD and whatever he will be doing to give treatment to the patient will definitely be in the interest of the patient as decided by knowledge, prudence, and experience of the doctor.

Emergence of “shared decision making”[6],[7] between doctor, patient, his relatives, and friends is a new concept introduced in medicine. It is a good concept in the presence of the complex life of the surgeon with varied technology and monitoring devices. Today medical procedures are expensive, and most patients feel dissatisfied due to finances while they are leaving the hospital after a very successful surgery. Shared decision-making is a good policy here. It is always better to discuss financial issues with the patient and relatives well before he or she is admitted to the hospital. It gives a lot of satisfaction to the patient and the doctor during discharge.

Many of the surgeries done today are complex. No doubt the knowledge, expertise, and experience of the surgeon are challenged, and yet, the surgeon takes the decision to do the surgery in the best interest of the patient. I will cite an example. One lady was admitted for surgery. She came walking and her autonomic functions were intact. She had a massive extradural lesion covering seven vertebrae. The lesion was stuck to the dura and had to be virtually scrapped from the dura. Postoperatively, she was paraplegic with bladder and bowel involved. The expected few days' stay in the hospital was delayed by several weeks, putting constraint on relatives including disappointment. She was discharged on a stretcher with appropriate advice which she followed religiously. It took 1 year before she could walk independently albeit with some weakness and improved bladder and bowel function. The surgeon was confident of this outcome and he had anticipated and explained to the relatives the temporary discomfort through which the patient had to undergo. Such incidences do happen once in a while in each surgeon's life. The pathology proved to be benign giving the patient the verdict of “cured” from the surgeon.


  Innovative Industry, Newer Technology, and Surgeon Top


Innovative surgical methodology and availability of newer advances in technology give better opportunity to treat with more safety, the patient at hand. At times and unfortunately, the surgeon gets lured by the newer developments and during collaborative decision-making he can project rather wrongly the extended advantages. It introduces an element of bias on behalf of the surgeon.

Several times the surgeon depends on the manufacturer for collaboration with devices for patient seeking surgical treatment. Eventually, the friendship expands and financial interests come into the picture. It is all the more important as there is fierce competition in the market. In the long run, such a behavior by the surgeon leads to loosing patient's trust which is unfortunate and ethically not sound. It is common knowledge that surgeons overvalue the device of his choice while speaking to the patient and his relations.[8],[9] To add to the story, there is always a lure for imported goods in Indian patients. Needless to mention here that financial interest on the part of the surgeon can interfere with his rational decision-making. Rationality in decision-making should prevail at all times.

The ticklish question is should the surgeon disclose to the patient that he has an interest in the company as far as the implant under discussion is concerned.[9] On one hand, it may help to increase the doubts in the mind of relatives regarding the eligibility of surgeon and GOD forbid if the things go array, then definitely the relations will be upset. Thus, disclosure, done even with honest intentions, may fireback at times if things are not proceeding in the right direction.


  Patient's Awareness Top


It is mandatory that in this sort of scene, the patient and his relatives must be intelligent enough to understand the treatment policy for him before signing on the consent form. Several times the expectations of patients after surgery are such that once operated, he will be turned into a young-looking healthy person forever. He expects a much higher than expected outcome, as explained by the surgeon.


  Message For The Surgeon Top


Before treating any patient, the surgeon must be aware as to what is the “gold standard” treatment for the medical problem that he is handling. He has to then compare his options with the standard and rational treatment that is usually in vogue before venturing into any conceived decision to treat the patient.


  Summary Top


In summary, technology is advancing in a fierce way, and it will expand more with the availability of 5G and 6G by 2030. However, the surgeon of integrity must follow rational ethical principles while treating a patient, irrespective of his status.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Askitopoulou H, Vgontzas AN. The relevance of the Hippocratic Oath to the ethical and moral values of contemporary medicine. Part II: Interpretation of the Hippocratic Oath-today's perspective. Eur Spine J 2018;27:1491-500.  Back to cited text no. 1
    
2.
Gillon R. Medical ethics: Four principles plus attention to scope. BMJ 1994;309:184-8.  Back to cited text no. 2
    
3.
Umansky F, Black PL, DiRocco C, Ferrer E, Goel A, Malik GM, et al. Statement of ethics in neurosurgery of the world federation of neurosurgical societies. World Neurosurg 2011;76:239-47.  Back to cited text no. 3
    
4.
Krupp W, Spanehl O, Laubach W, Seifert V. Informed consent in neurosurgery: Patients' recall of preoperative discussion. Acta Neurochir (Wien) 2000;142:233-8.  Back to cited text no. 4
    
5.
Park J, Park H. Surgical informed consent process in neurosurgery. J Korean Neurosurg Soc 2017;60:385-90.  Back to cited text no. 5
    
6.
Kessler TM, Nachbur BH, Kessler W. Patients' perception of preoperative information by interactive computer program-exemplified by cholecystectomy. Patient Educ Couns 2005;59:135-40.  Back to cited text no. 6
    
7.
Delp C, Jones J. Communicating information to patients: The use of cartoon illustrations to improve comprehension of instructions. Acad Emerg Med 1996;3:264-70.  Back to cited text no. 7
    
8.
Tanweer O, Wilson TA, Kalhorn SP, Golfinos JG, Huang PP, Kondziolka D. Neurosurgical decision making: Personal and professional preferences. J Neurosurg 2015;122:678-91.  Back to cited text no. 8
    
9.
McMeekin P, Flynn D, Ford GA, Rodgers H, Gray J, Thomson RG. Development of a decision analytic model to support decision making and risk communication about thrombolytic treatment. BMC Med Inform Decis Mak 2015;15:90. [doi: 10.1186/s12911-015-0213-z].  Back to cited text no. 9
    




 

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