First Do No Self-harm – The New “Physician’s Pledge”

This article was first published by Dr Jane Barker, NRGPN Board member, on the website To Medicine with Love.

Last week I met up with a newly graduated medical student whom I had mentored during his training. He had missed the award ceremony for his medical degree for personal reasons. When we met, without prior discussion, we both produced from our pockets a copy of the “Physician’s Pledge”, the newest version of the Hippocratic Oath, having independently decided that the time was right to read it together.

We walked up to the Byron Bay lighthouse and together stood on the hang-gliding platform, looking out over the stunning view from Tallows Beach to Broken Head, and together read the pledge: “I solemnly pledge to dedicate my life to the service of humanity” … he, ready to launch into his career, me coming towards the end of mine; a handing over of the baton, as it were. I reflected on the words, what they had meant in my life and asked myself whether I had upheld them.

It was a special moment.

The Hippocratic Oath

The Hippocratic Oath was found in early Greek writing, 2500 years ago, and could still be relevant today, if adapted to take into consideration modern medical science and changes in societal values. There are several different early versions and different translations. Back then it was an oath made to the Ancient Greek Gods:

“I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea and all the gods and goddesses as my witnesses, that, according to my ability and judgement, I will keep this Oath and this contract:” (1)

The Hippocratic Oath is the first known record of an expression of medical ethics and covers many issues which are at the heart of medical practice today; and the recital of the Physician’s Oath has for many years been a part of the graduation ceremony of new physicians. Over the years it has been modernised and the newest version, the Physician’s Pledge, is based on the Declaration of Geneva, published in 1948.(2)

The European world of 1946 was recovering from the horrors of the 2nd World War. Of particular concern to the medical profession was the shocking involvement of doctors of several nationalities in torture and genocide. It was in this climate that the Geneva Declaration was published in 1948 containing the words:

I will maintain the utmost respect for human life, from the time of conception; even under threat, I will not use my medical knowledge contrary to the laws of humanity. (2)

The Declaration of Geneva has been revised six times since it was originally proposed. The world, and medicine itself, have changed so much over the past 70 years that newer versions are needed which retain the essence of the original oath of Hippocrates, but take into consideration the ethical and moral values of our times. The version I recited with my friend was not the same oath I made with my graduating class 44 years ago, but the newly minted “Physician’s Pledge” published in October 2017.(3) A working party representing the World Medical Association spent two years formulating the new pledge which is secular in nature and the WMA hopes that it will be adopted across the medical world.

Changes to the new pledge

Under the umbrella promise to “dedicate my life to the service of humanity”, the pledge follows the principles of patient centred medical care, making a change to the 1948 Declaration by vowing to “respect the autonomy and dignity of my patient”. This is a welcome move away from a past of paternalistic Medicine.

Unlike the 1948 version, in this modern pledge there is no specific reference to abortion or euthanasia, or indeed the inappropriate prolonging of life. These are among the most significant issues in modern medical ethics. Instead it pledges to “maintain the utmost respect for human life” and “not to use my medical knowledge to violate human rights and civil liberties, even under threat”.

While there is no longer reference to brotherhood the pledge vows to “give to my teachers, colleagues, and students the respect and gratitude that is their due”.

Respecting and valuing students is an important addition, as students often feel they are not treated with dignity. My own belief is that we cannot expect our students to practise with the compassion and caring our patients need and deserve, unless we serve as role models of this in our own interactions with patients and colleagues, and our treatment of ourselves. We should indeed treat our students with compassion and caring which involves valuing, respecting and honouring them. This new clause challenges our universities and teaching hospitals to do just this.

First do no self-harm

The pledge once again demands the altruism so often thought to be a vital part of our profession – “the health and wellbeing of my patient will be my first consideration” – but for the first time it includes a pledge to care about ourselves – “I will attend to my own health, well-being, and abilities in order to provide care of the highest standard”.

Primum non nocere – first do no harm – was in fact not included in the original Hippocratic oath as is often presumed, but as Medicine advances it becomes increasingly relevant. To first do no self-harm can be equated to the DRS ABCD(4) used in Adult Life Support training. The first D is a reminder to move the patient away from anything which is dangerous to them or the practitioner. In this context we could first consider danger to the practitioner.

Medicine has long been considered a demanding profession, in fact as this pledge implies, much is asked of us. We are aware that the stressors of medicine have taken a high toll in burnout, anxiety, depression, alcohol and substance use and suicidality. A doctor practising with these impairments puts the wellbeing of their patients at risk. While in this pledge the doctor is asked to care for themselves for the sake of the patient, doctors, no less than any other people, deserve to care for themselves for their own sakes.

Our profession should not ask so much of its doctors that they are put at risk of mental health issues and suicide. By including self-care in the new Physician’s Pledge, advocacy for self-care cannot be treated as a fluffy add-on, or yet another thing that doctors have to do, but as an integral part of medical training and the responsibility of our colleges and institutions as well as ourselves. The welfare of our clinicians is of vital importance and we need to become a profession that truly cares for its own. If as the “caring profession’ we do not do this, then we fail not only our patients and colleagues, but fail to set a standard for other professions, indeed for all workplaces.

It is worth taking a moment to ponder on this new pledge. Does it serve modern medicine? Does it ask us to change ingrained cultures in medicine? Has it the potential to better our profession? Is the pledge one that you yourself would ask our young doctors to commit to? Is it a pledge you could commit to yourself?

What can and must we do to create an environment in medical schools and hospitals which is supportive not only to our patients but to all staff equally, as well? This is the challenge and inspiration that the new oath offers to us.

World Medical Association Declaration of Geneva – The Physician’s Pledge

AS A MEMBER OF THE MEDICAL PROFESSION:

• I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
• THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
• I WILL RESPECT the autonomy and dignity of my patient;
• I WILL MAINTAIN the utmost respect for human life;
•  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;
• I WILL RESPECT the secrets that are confided in me, even after the patient has died;
• I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice;
• I WILL FOSTER the honour and noble traditions of the medical profession;
• I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;
• I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;
• I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;
• I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
• I MAKE THESE PROMISES solemnly, freely, and upon my honour.

©2017 World Medical Association Inc. All Rights Reserved. All intellectual property rights in the Declaration of Geneva are vested in the World Medical Association.

References:

1. Ancient Greek version of Hippocratic oath:
2. Declaration of Geneva 1948:
3. Physician’s Pledge October 2017:
4. DRS ABCD