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PROFESSIONAL ISSUES

Employer health exams; relevance of Hippocratic oath

Ethics Forum. May 1, 2000.

Scenario: What ethical rules apply when employer requires a medical exam?

Reply:

Physicians who are employed by either businesses or insurance companies to perform medical examinations have dual responsibilities. On the one hand, there is the entity paying for the exam, which may be seeking to avoid incurring additional expenses for an injured employee; on the other hand is the employee, injured or sick, who may be seeking some form of compensation or to remain off the job. This apparent conflict of accountability to the employer and the employee may leave patients questioning the ethical obligations of these physicians.

Therefore, in instances when the physician has been hired by a company to perform physical examinations on employees, it would be most appropriate for that physician to inform the employee of the nature of the relationship the physician has with the company.

At the outset of the examination, the physician should make clear that the employer is paying for the services of the physician, and for example, that the examination serves to identify any potential employee health condition that could place the employee at risk, given the nature of the employment.

The physician should proceed to explain to the employee what the examination will consist of as well as obtain consent from the employee to perform the examination.

Preserving the confidentiality of the information that is gathered through such an examination is a problematic component of this relationship. The physician needs to inform the employee that information obtained during the evaluation may be shared with the employer or, if required by laws such as workers' compensation regulations, with other third parties. It is also important for the physician to explain that even though findings may be shared with the employer or other third parties, this does not influence the objectivity of the examination. Ultimately, it is ethically permissible for a physician to disclose information only to a third party, such as an employer, to which the patient consents.

Physicians should strive to conduct the examination in an atmosphere of trust and to avoid confrontation. In this respect, physicians have an obligation to meet the expectations of both the employee and the employer for performing a high-quality examination and maintaining legible, accurate and complete medical records. Physicians have a further obligation to the employees of informing them of abnormal findings that require immediate attention and to help, in such situations, to facilitate their needs.

Overall, the patient-physician relationship that is established in the context of employment-related examinations rests on the same fundamental ethical principles as any other relationship. This conclusion was presented by the Council on Ethical and Judicial Affairs in a recent report adopted by the AMA House of Delegates, entitled "Patient-Physician Relationship in the Context of Work-Related and Independent Medical Examinations."

The recommendations of the report specifically called for industry-employed physicians and independent medical examiners to (1) perform objective examinations that are not influenced by the preferences of the patient-employee, employer or insurance company when they are making a diagnosis during a work-related or independent examination, (2) maintain patient confidentiality and not divulge any information without the patient's written consent, (3) inform the patient about the terms of agreement with the employer and (4) inform the patient about important health information or abnormalities that the physician uncovers during the course of the examination. Employees should expect and receive the same ethical protections, as well as the same standard of care, as any other patient. --Leonard J. Morse, MD Member of the AMA Council on Ethical and Judicial Affairs

Scenario: Why do freshly minted doctors still recite the Hippocratic oath?

Reply:

Written around 400 B.C., the Hippocratic oath has endured as an expression of medical values throughout centuries of change in the Western medical profession. The oath was formulated at a time when disease was believed to be caused by an imbalance of the four humors -- blood, phlegm, black bile and yellow bile, which were believed to constitute the human body -- and techniques for the safe and efficient treatment of patients were limited.

Initially, the ideals stated in the oath were not subscribed to by a majority of ancient physicians; rather, they represented only a small segment of Greek physicians whose medical practices ran contrary to those of their contemporaries. Use of the oath did not gain wide acceptance until the early Middle Ages, when it was revised to reflect the ideals and beliefs of Christianity.

As the medical teachings of the Hippocratic corpus came to define the Western approach to disease and illness, use of the oath as the essential expression of medical values gained wide acceptance and defined medical professional conduct well into the early 19th century. At that point, as scientific medicine eclipsed the humoral understanding of disease and illness, the Hippocratic oath was abandoned as an outdated relic of a bygone era. It was believed that scientific expertise and the certainty it would bring to the clinical encounter would be the best assurance not only of technical competence but also of the highest ethical and professional conduct based on such expertise.

Despite initial optimism, however, it quickly became apparent that science could not act as an arbiter of ethical conduct. Toward the mid-19th century, therefore, a renewed interest in reviving use of the Hippocratic oath began to grow, an interest that gained momentum in the early 20th century and increased significantly throughout the decades. Recent studies have shown that a majority of medical schools in the United States report using some version of the Hippocratic oath during the White Coat or graduation ceremonies.

In the past several years, debates again have surfaced regarding the relevance of the Hippocratic oath for contemporary medical practice. Twentieth-century developments in technology and science have created medical possibilities that could not have been envisioned by the Hippocratic physicians. The patient-physician relationship has been substantially altered in the past 50 years, with a decline in physician paternalism and an increase in patient involvement in treatment decisions. Medical specialization has diversified the practices and interests of physicians, as have increasing societal and legal obligations. The emergence of the field of bioethics has broadened the dimensions for ethical consideration, seemingly beyond the content of the oath. All these changes raise doubts as to whether the ideals of a centuries-old text accurately reflect the ethical concerns and values of 21st-century medicine.

A closer examination of the actual texts of the oaths sworn in medical schools reveals that they have been significantly revised from the classical formulation. The original oath divided the responsibilities of physicians into three sections: obligations to the profession and to patients, specific rules to be observed in the treatment of disease, and expectations regarding the personal conduct of the physician.

Contemporary versions of the oath generally retain the statements emphasizing the physician's obligations to the medical profession and patients as well as some aspects of the personal conduct and character of the physician, such as maintaining confidentiality. Notably missing from these versions of the oath are the covenant with the gods, prohibitions on euthanasia and on performing abortions, individual conduct with regard to sexual relationships with patients, and personal accountability for one's judgment and actions.

Given such substantive revisions, what accounts for the continued use of the Hippocratic oath? Is it merely the ceremonial invocation of a historic tradition? Or does its use, in updated and altered forms, reflect something intrinsic to the profession of medicine?

The meaning of the Hippocratic oath for contemporary physicians may exist less in what it says than in what it stands for, although this by no means implies that the content of the oath is irrelevant. Rather, the shifting content of some aspects of the oath reveals its dynamic relationship with the changing context of medicine throughout the centuries. From the outset, the Hippocratic oath functioned to establish physicians as a moral community and delineated obligations and responsibilities specific to the medical profession.

Despite changes in the content throughout the centuries, the fundamental role of the Hippocratic oath is to demand that the medical profession, first and foremost, view itself as engaged in a moral enterprise. Rather than seeing the changing content of the oath as proof of its inadequacy for 21st-century physicians, these changes can be understood as reflecting the medical profession's struggle to define its moral position in the society of its day.

By swearing to the Hippocratic oath, therefore, medical graduates commit themselves not only to the content specific to their contemporary practice but also to the ideal that medicine is, at its most fundamental level, a moral enterprise. --Karen E. Geraghty Fellow, AMA Institute for Ethics

Ethics Forum answers questions on the ethics of medical practice. Readers are encouraged to submit questions and comments to the Institute for Ethics, AMA, 515 N. State St., Chicago, IL 60610; or by fax at (312) 464-4613. Actual names, addresses and affiliations of individuals whose queries are used will not be published.

Opinions expressed in Ethics Forum reflect the views of the authors and do not constitute official policy statements of the American Medical Association.

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