Formulating global posthippocratic health care virtues

Hans-Martin Sass, Ph.D.

International Scholar, Kennedy Institute of Ethics, Georgetown University, Washington DC 20057, USA.

Eubios Ethics Institute Newsletter 4 (January, 1994) 3.

After 2400 years it is time to say goodbye to paternalistic beneficence of physicians and to the principles of Hippocratic ethics. The principles expressed in the Hippocratic Oath are particularly unfit to support patient-physician interaction in determining health care goals and in recognizing patient's self-determination as an integral part of her of his individual human and civil right.1 Traditional elitist professional paternalism fails to address the quest for developing patient's ethics and individual health responsibility in the realm of predictive and preventive medicine and to recognise the plurality of values and wishes patients might have in regard to health care, quality and length of life.

There are at least three reasons for a major shift in future health care ethics: progress (a) in predictive and preventive medicine, (b) in intensive care and in methods of prolonging life as well as suffering, and (c) the emotional, ethical, and economic limits in providing all and every possible medical intervention, they all make the development and the support of an ethos of individualised health care a prime challenge in global bioethics.

Lay risk competence in health care matters and the development of virtues and principles for taking care of one's own health should be given priority over secondary issues in physician's ethics. Physician's ethics will have to change from paternalism to partnership. The global richness in individual, familial, and communal cultures calls for differentiated health care services according to the values and wishes of the individual client or patient, not those of the 'doctor' nor those of the 'system' which provides health care.

While contemporary European and Asian bioethics still concentrate on teaching and refining physician's ethics in a paternalistic way, Anglo-American bioethics put emphasis on the focuses primarily on the virtus and values of interactive lay-expert exchange in the determination of individual health care parameters, in the calling for self-determination and self-responsibility in predictive and preventive health care, and in identifying goals and limits for acute and intensive care intervention. Future bioethics research and teaching has to shift emphasis from physician's ethics to lay ethics and patient's ethics and the ethics of cooperation-in-trust (2).

Following is a set of interactive maxims, virtues and principles, in the care for health. Eight for the lay person and eight for the health care professional. Historians will recognise that they use as blueprint the 'Ten Rules for Physicians and Patients' formulated in the 15th century by the Confucian physician Gong Tingxian (3). The proposed TWO SETS OF HEALTH CARE RULES for presymptomatic healthy persons, patients, nurses, physicians and health administrators aim at the stimulation of a global cross-cultural debate on the ethos and the ethics of health care matters. Let us intensify the cross-cultural global discourse on virtues and principles in bioethics and let us win the future by saying goodbye to the specifics of our master's rules while adhering as obedient disciples to their ethos of caring for those in need, for the sick and the frail.

Eight health care rules for the lay person
1. Find truly educated and trustworthy health experts.
2. Develop competence and responsibility in health risk management.
3. Make extended use of predictive and preventive medicine.
4. Expect healing or relief from acute medicine, but be aware of the limits and risks of any medical intervention.
5. Expect information and advice from medical experts and be a fair partner with them.
6. Define and implement your sense of qualities of life, from childhood to old age, in sickness and in health.
7. Prepare advance directives and name proxy decision makers for circumstances of incompetence.
8. Act responsibly in the use of communal health care funds.

Eight health care rules for the health professional
1. Treat your patient as a person, not just his or her symptoms.
2. Assist your patient in developing health risk competence.
3. Integrate the 'clinical status' and the 'value status' of your patient into differential ethics, diagnosis and prognosis.
4. Be aware of the benefits, limits and risks of acute intervention and discuss those with your patient.
5. Be an expert partner with your patient and respect her or his wishes and values.
6. Continuously educate yourself and provide the best possible clinical and personal service.
7. Assist your patient in preparing advance directives and in working with proxies for the benefit of your patient.
8. Act responsibly in the use of communal health care funds.

1. W.T. Reich, ed., Encyclopedia of Bioethics, New York: MacMillan 1978, Vol. IV, p.1731.
2. H.M. Sass, "Professional organizations and professional ethics", , pp. 277-9 in Ethics, Trust, and the Professions, E.D. Pelligrino et al., eds., Washington D.C.: Georgetown University Press 1991; H.M. Sass, Inforierte Zustimmung als Vorstufe zur Autonomie des Patienten, Bochum: Zenturm fur Medizinische Ethik 1992.
3. H.M. Sass, ed., Medizin und Ethik, Stuttgart: Reclam 1989, pp. 352-5.

Continued to Part 2
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