I was amused when I read in newspaper that not unlike previous
years, top-scorers in the HKDSE chose to study medicine, and their reason was
to be a good doctor and to help others. Sooner
or later, they will realize that it is not easy to become a good doctor. More than that, there is no equal sign between
a good doctor and helping others.
It is much easier to score high in an examination, or to be
proficient in a certain skill. There are
always tricks to learn and ways to practice. People seldom frown on a chef who is a
fooling-around-foul-mouth-jerk. They
just remember his signature dish. Magazines
will interview him for his pigeon pithivier with French mushroom duxelles and
foie gras. He will never be threatened
to have his name removed from the chef register by the “chef council” if it
really exists.
You need more to be a good doctor. Among other parameters, there are ethical
considerations. Our Red Book, the Code
of Professional Conduct published by the Medical Council, provides some
guidance on medical ethics. In section C
it reproduces the International Code of Medical Ethics adopted by the World
Medical Association. It spells out
“Duties of Physicians in General”, under which there are 12 items; “Duties of
Physicians to Patients”, under which there are 7 items; and “Duties of
Physicians to Colleagues”, under which there are 3 items. Section D refers us to the Declaration of
Geneva, in which the doctor makes 10 pledges.
For easy memory, especially during viva examination, there is an
ABCDE mnemonic for medical ethics: Autonomy; Beneficence; Confidentiality; Do
no harm; Justice. The most mentioned
principle by laymen and doctors alike is the fourth one: Do no harm. Many believe that it came from the Hippocratic
Oath. However, the exact Latin phase of “Primum non nocere” was likely to
originate from another series written by Hippocrates called Epidemics. (Epidemics means visits. There were 7 books describing physicians’
visits to patients in different areas.)
Actually, “Primum non nocere” means:
“First, do no harm”. Some regard it the
first principle in medical ethics. Others
see it as a practice guideline. When
facing an ethical dilemma, or when making a medical decision, check whether you
might harm the patient by your intervention first.
If you construe the word “harm” in the narrowest sense, “Primum non nocere” becomes meaningless.
Every surgical procedure is harming the
patient physically. Even telling the
patient what he is suffering from might harm his feeling. Therefore, “harm” must be relative. That is, taking everything together, there is
more benefit than harm. The question is:
Who is to decide whether it is doing more harm than good?
Evidence-based medicine is the cornerstone of modern medicine. It can provide an objective measurement for
medical interventions. However, life is
not that simple. Liposuction is unlikely
to improve life expectancy, but it is practiced every day. There is a strong component of value judgment
in which objective measurement alone does not help. In the good old days, it was the doctor who
made the call. The doctor was relied on
to choose for the patient with his knowledge and good intent. As time moved on, and maybe as people realized
that there existed bad doctors, patients wanted to have their says. The ultimate decision was from the patient. To help the patient to make the decision, the
doctor’s responsibility became to inform the patient of every aspect of the
medical interventions: different options, pros, cons and complications. Nowadays, it is not enough just to inform the
patient of each and every detail. The
doctor has to practically educate the patient from scratch, taking into
consideration the patient’s background, mentality, religion, value, his
obsession towards alternative medicine, and his position in the family and
society. Whether the doctor has
discharged his responsibility would be judged not only by his own consciousness
or the patient involved. He is
answerable to the Medical Council, the courts of law, the media, and the
society at large.
If the above is not complicated enough, I remind you that we have
been talking about one patient. In a
disaster scene, the doctor needs to decide on attending which patient first. Working under our
more-than-a-little-bit-far-from-satisfactory Hospital Authority, the doctor
needs to see 50 patients in a morning outpatient session. In real life where resources are limited,
there is always the problem of rationing.
Maybe that was the reason why the wise Hippocrates of Kos did not
include “Primum non nocere” in his Oath.
Rather, he opted for the middle way: "I will apply, for the benefit of the sick, all measures that are required, avoiding those twin traps of overtreatment and therapeutic nihilism."
(Source: HKMA News Aug 2018)
(Source: HKMA News Aug 2018)
