Principles of Formal and Material Cooperation

Principles of Formal and Material Cooperation
We cooperate with others in the world in order to achieve or preserve important goods, or in order to diminish or avoid worse evils or harms. According to Catholic moral teaching, it is for these basic reasons that we may legitimately cooperate in a limited way with others who do what we would consider to be wrong, depending on the type of cooperation. If this were not the case, great good that should be done would be neglected, and greater harms that should be avoided would continue. In this context, cooperation in moral wrong can be defined as “any physical or moral assistance knowingly given by an organization to the commission of a morally objectionable act principally performed by another (the principal agent).” The cooperator may or may not be morally culpable or blameworthy, depending on the type of cooperation.

To intend the wrongdoing of others is called formal cooperation. As applied to Catholic health care organizations, formal cooperation in evil occurs when the organization freely and directly participates in the objectionable action of another agent and/or shares in the object of that agent’s intention, either for its own sake or as a means to some other goal. Implicit formal cooperation occurs when the organization denies intending the wrongdoing of the principal agent, but participates in the action directly and in such a way that it could not be done without this participation. Catholic organizations are not permitted to engage in either implicit formal or formal cooperation in evil.

Formal cooperation is to be distinguished from material cooperation, principally in the matter of intention. As applied to Catholic health care, material cooperation occurs when the Catholic organization does not intend the immoral object of the principal agent’s act, yet is involved in circumstances that materially contribute to the immoral action in some causal way. Whether material cooperation would be permissible depends on further distinctions, following below.

Immediate material cooperation occurs when the organization provides for, contributes to or participates in specific circumstances that are essential to, or are an essential condition for, the principal agent to carry out a specific objectionable action. Directive n. 70 of the Ethical and Religious Directives specifically forbids Catholic health care organizations from engaging in immediate material cooperation in acts judged by the Church to be intrinsically immoral, “such as abortion, euthanasia, assisted suicide and direct sterilization.” These actions are considered “intrinsically immoral” inasmuch as they are evaluated to be essentially not good for the human person, regardless of circumstances or personal intentions. But under Church teaching, their gravity is not considered equal—e.g., direct killing of innocent human life is worse or more grave than direct sterilization, even though Church teaching evaluates both as intrinsically immoral. This matter of gravity is important for determining whether there is a proportionate enough reason to justify mediate material cooperation under the circumstances.

Mediate material cooperation occurs when the Catholic organization provides for, contributes to or participates in circumstances that are not essential to a principal agent’s specific wrongful action. Proximate mediate material cooperation makes a causal contribution to the principal agent’s act, which is directly ordered to the act. An example would be leasing space to an independent, self-insured family practice group, which in the course of practice writes some contraceptive prescriptions, but where the Catholic lessor neither condones such activity nor contributes anything essential to a contraceptive act itself. Remote mediate material cooperation makes a causal contribution to the principal agent’s act, which is indirectly ordered to the act. An example would be a Catholic hospital informally affiliating with a family practice group for some medical education and for preferred partner status. Some physicians in the group engage in some contraceptive practices in their own facility or at other facilities. The Catholic party does not contribute anything essential to that activity, but the physician practice indirectly benefits from the affiliation through increased patient volume, which in turn indirectly contributes to the writing of more contraceptive prescriptions.

Whether a particular form of mediate material cooperation can be properly characterized as “proximate” or “remote” is not always self-evident, and often depends on one’s understanding of the facts, or from which perspective one is examining the case. This is why ethical decisions on these matters ought not to be made in a vacuum or in isolation from multiple perspectives. Either form of mediate material cooperation may be permissible for the Catholic organization under certain conditions:

Either form of mediate material cooperation may be permissible for the Catholic organization under certain conditions: when there is a proportionately serious reason for the cooperation (increasing access to morally appropriate services for the poor and underserved, decreasing infant mortality, stewardship of limited resources, and securing Catholic health care presence in the community, are just a few examples of serious reasons why an organization might want to consider cooperating with another provider, and which may very well justify the cooperation);

Either form of mediate material cooperation may be permissible for the Catholic organization under certain conditions: the moral distance of the cooperator must be proportionate to the gravity of the wrongdoing (for example, mediate material cooperation in contraceptive counseling would not require as great a moral or causal distance as mediate material cooperation in direct sterilizations);

Either form of mediate material cooperation may be permissible for the Catholic organization under certain conditions: proximate mediate material cooperation requires a more serious reason for cooperation than remote mediate material cooperation (i.e., a causal contribution that is directly ordered to an objectionable act requires greater justification than a causal contribution that is indirectly ordered to an objectionable act); and

Either form of mediate material cooperation may be permissible for the Catholic organization under certain conditions: the danger of scandal must be sufficiently avoided. According to the Ethical and Religious Directives, n. 71: “The possibility of scandal must be considered when applying the principles governing cooperation. Cooperation, which in all other respects is morally licit, may need to be refused because of the scandal that might be caused. Scandal can sometimes be avoided by an appropriate explanation of what is in fact being done at the health care facility under Catholic auspices. The diocesan bishop has final responsibility for assessing and addressing issues of scandal, considering not only the circumstances in his local diocese but also the regional and national implications of his decision.”

Principles of Integrity and Totality
These principles dictate that the well-being of the whole person must be taken into account in deciding about any therapeutic intervention or use of technology (see Ethical and Religious Directives, nn. 29 and 33). Therapeutic procedures that are likely to cause harm or undesirable side effects can be justified only by a proportionate benefit to the patient. In this context, "integrity" refers to each individual’s duty to "preserve a view of the whole human person in which the values of the intellect, will, conscience, and fraternity are pre-eminent" (Gaudium et Spes, n. 61). refers to the duty to preserve intact the physical component of the integrated bodily and spiritual nature of human life, whereby every part of the human body "exists for the sake of the whole as the imperfect for the sake of the perfect" (St. Thomas Aquinas, Summa Theologica II, Question 65, Article 1). Accordingly, a part of the human body may be sacrificed if that sacrifice means continued survival for the person. While such sacrifices are normally justifiable under the principles of integrity and totality, they may sometimes be forgone under the principle of disproportionate means.

Principle of Proportionate and Disproportionate Means
Often used synonymously with the term "ordinary/extraordinary means" since the two sets of terms were equated in the 1980 Vatican Declaration on Euthanasia. This principle constitutes an important approach to the analysis of ethical questions arising from the general obligation to preserve human life and the limits of that obligation. Among other questions, the principle addresses whether the forgoing of life-sustaining treatment constitutes euthanasia or physician-assisted suicide in certain circumstances and it guides individuals and surrogate decision-makers in the weighing of benefits and burdens.

As conceived in the Catholic moral tradition, the principle holds that one is obligated to preserve his or her own life by making use of ordinary means, but is under no obligation to use extraordinary means (see Ethical and Religious Directives, nn. 32, 56 and 57). In other words, when a medical intervention or "means" is proportionate, one has a general obligation--all things considered--to accept the treatment. When the medical intervention constitutes a disproportionate means, then one is no longer obliged to undergo the treatment. Since judgments that a given means is either proportionate or disproportionate must be made in light of the personal (including religious beliefs), familial, economic, and social circumstances of each individual patient, an a priori list of treatments that can be classified as always and everywhere proportionate or disproportionate is not possible.

Proportionate means is any treatment that, in the given circumstances and in the judgment of the patient or the patient’s surrogate, offers a reasonable hope of benefit and is not too burdensome for the patient or others. What is a reasonable hope of benefit to the patient should be judged within the context of the whole person (i.e., considered holistically, not just physiologically). Generally, a treatment or means is not too burdensome when it offers benefits that outweigh the burdens to the patient and others. These determinations should be patient specific and include considerations of the expected medical outcomes and the patient’s personal, financial, familial, and social circumstances.

A disproportionate means is any treatment that, in the given circumstances and in the judgment of the patient or the patient’s surrogate, either offers no reasonable hope of benefit (taking into account the well-being of the whole person) or is too burdensome for the patient or others, i.e., the burdens or risks are disproportionate to or outweigh the expected benefits of the treatment. Again, these determinations should be patient specific and take into consideration the patient’s personal, financial, familial, and social circumstances.

If one uses the terms ordinary and extraordinary means (as opposed to proportionate and disproportionate), care must be taken not to confuse the terms "ordinary care" and "ordinary means." While patients may forego treatments that are disproportionate or extraordinary means, there is always an obligation to provide ordinary care due to the sick person, that is, to provide non-medical nursing interventions.

Principle of Human Dignity

The intrinsic worth that inheres in every human being. From the Catholic perspective (among other Christian perspectives), the source of human dignity is rooted in the concept of Imago Dei, in Christ’s redemption and in our ultimate destiny of union with God. Human dignity therefore transcends any social order as the basis for rights and is neither granted by society nor can it be legitimately violated by society. In this way, human dignity is the conceptual basis for human rights. While providing the foundation for many normative claims, one direct normative implication of human dignity is that every human being should be acknowledged as an inherently valuable member of the human community and as a unique expression of life, with an integrated bodily and spiritual nature. In Catholic moral thought, because there is a social or communal dimension to human dignity itself, persons must be conceived of, not in overly-individualistic terms, but as being inherently connected to the rest of society. Because the tradition emphasizes the integral nature of our body and spirit, the human body takes on greater significance and value than in the prevailing dualistic conception of the person (see the principle of respect for persons).

The normative implications of this conception of human dignity impacts much of Catholic moral thought as it pertains to a range of human life issues, including health care ethics. For example, the principle is foundational for the tradition’s understanding of distributive justice, the common good, the right to life and the right to health care. Other perspectives, both religious and secular, may conceive of human dignity in similar terms with a similar sense of its inherent worth or value and other implications, but may posit different sources for that dignity.

Principle of Respect for Autonomy
As commonly understood today, autonomy is the capacity for self-determination. Being autonomous, however, is not the same as being respected as an autonomous agent. To respect an autonomous agent is to acknowledge that person’s right to make choices and take action based on that person’s own values and belief system. On this account, respect involves not only refraining from interfering with others’ choices, but sometimes entails providing them with the necessary conditions and opportunities for exercising autonomy. The principle of respect for autonomy implies that one should be free from coercion in deciding to act, and that others are obligated to protect confidentiality, respect privacy, and tell the truth. In the practice of health care, a person’s autonomy is exercised through the process of obtaining informed consent. The principle of respect for autonomy, however, does not imply that one must cooperate with another’s actions in order to respect that individual’s autonomy.

Autonomy is given a central place or primary status in the prevailing modern liberalism of contemporary society, as reflected in Oregon’s Measure 16 that legalized physician-assisted suicide. However, the principle of respect for autonomy implies that autonomy has only a prima facie standing, that is, it can be overridden by competing moral considerations. For example, if an individual’s choices endanger public health, potentially harm others, or require a scarce resource, that individual’s autonomy may justifiably be restricted. Within the Catholic moral tradition, autonomy is similarly limited insofar as it must be measured by the principles of stewardship, respect for persons, justice and the common good.

Respect for autonomy, then, should not be construed as an absolute and foundational value, but a "middle principle" that requires every individual to respect every other individual’s self-determination to an appropriate extent within the context of community. A health care institution is a moral community that can be properly considered as an autonomous agent in its own right. Considered as such, Catholic health care institutions should never be required to assist with suicide, euthanasia, or any action that opposes its professional integrity, values, principles, or institutional conscience.

Principle of Respect for Persons
All individual human beings are presumed to be free and responsible persons and should be treated as such in proportion to their ability in the circumstances. Individuals with reduced autonomy are entitled to appropriate protection, according to the principles of subsidiarity, human dignity, justice, charity, and vicarious consent.

Principle of Respect for Persons
This principle may be given different content, depending on one’s conception of personhood. From the Catholic perspective, there are a number of anthropological considerations that have significant implications for this principle. For example, human persons are integrated body-spirit beings created in the image and likeness of God, with four integrated dimensions of human life: biological, psychological, social, and spiritual. The human person, then, can be understood in four interrelated ways: as a bodily subject, that is, we are not merely spirits that possess bodies, but we are body as much as we are spirit; as a knowing subject for which knowledge is a good both as an end in itself and as a means to fulfillment; as a social subject whose primary context is that of person situated in community; and as a self-transcendent subject insofar as we are related to God in our created nature, through God’s loving creation and in our ability to participate in that creation. As a subject, and not merely an object, a human person must be treated with respect in such a way that recognizes his or her human dignity.

Principle of Beneficence
Traditionally understood as the "first principle" of morality, the dictum "do good and avoid evil" lends some moral content to this principle. The principle of beneficence is a "middle principle" insofar as it is partially dependent for its content on how one defines the concepts of the good and goodness. As a middle principle, beneficence is not a specific moral rule and cannot by itself tell us what concrete actions constitute doing good and avoiding evil.

The Principle of Nonmaleficence, Primum non nocere, commonly translated as "first, do no harm," is often considered to be a corollary to the principle of beneficence. In this respect, it shares the same characteristics of beneficence and is considered as a middle principle. Considered in its own right, nonmaleficence is sometimes interpreted to imply that if one cannot do good without also causing harm, then one should not act at all (in that particular circumstance). The difficulty with this rigorist interpretation, however, is that it makes action almost impossible in a world where even the best actions may have some harmful results. The principle of double effect offers a more reasonable method of analysis for those conflict situations where avoiding harm would require no action, including actions that may be both morally good and necessary for achieving the good. It is important to note that, while nonmaleficence refers to doing no harm, nonmalevolence refers to not intending or willing harm. It may be helpful to think of nonmaleficence not simply as "doing no harm," but as "doing no evil," which is closer to its etymological roots.

As a middle principle, the principle of beneficence (and nonmaleficence) is the basis for certain specific moral norms (which vary depending on how one defines "goodness"). Some of the specific norms that arise from the principle of beneficence in the Catholic tradition are: 1) never deliberately kill innocent human life (which, in the medical context, must be distinguished from foregoing disproportionate means); 2) never deliberately (directly intend) harm; 3) seek the patient’s good; 4) act out of charity and justice; 5) respect the patient’s religious beliefs and value system in accord with the principle of religious freedom; 6) always seek the higher good; that is, never neglect one good except to pursue a proportionately greater or more important good; 7) never knowingly commit or approve an objectively evil action; 8) do not treat others paternalistically but help them to pursue their goals; 9) use wisdom and prudence in all things; that is, appreciate the complexity of life and make sound judgments for the good of oneself, others, and the common good.

Principle of the Common Good
In general, the common good consists of all the conditions of society and the goods secured by those conditions, which allow individuals to achieve human and spiritual flourishing. The social teaching of the Catholic Church insists that the human community, including its government, must be actively concerned in promoting the health and welfare of every one of its members so that each member can contribute to the common good of all. This teaching is encapsulated in the principle of the common good and its corollary principle of subsidiarity. According to this understanding, the principle of the common good has three essential elements: 1) respect for persons; 2) social welfare; and 3) peace and security. All three of these elements entail the provision of health care in some way as an essential element of the common good (see Ethical and Religious Directives, Part One, Introduction).

Principle of the Common Good
In so far as the common good presupposes respect for persons, it obligates public authorities to respect the fundamental human rights of each person. Society should allow each of its members to fulfill his or her vocation. Insofar as it presupposes social welfare, the common good requires that the infrastructure of society is conducive to the social well being and development of its individual members. In this respect, it is the proper function of public authorities to both arbitrate between competing interests and to ensure that individual members of society have access to the basic goods that are necessary for living a truly human life, e.g., food, clothing, health care, meaningful work, education, etc. Finally, this conception of the common good requires the peace and security that accompanies a just social order. Public authority, then, should be used to ensure, by morally acceptable means, the security of society and its individual members. [See: Documents of Vatican II, Gaudium et Spes, n. 26; USCC, NCC and Synagogue Council, "The Common Good: Old Idea, New Urgency," Origins 23 (June 24, 1993): 81-6.]

Principle of Distributive Justice
Considered as one type of justice, distributive justice is a central concept in the Catholic tradition and is closely linked to the concepts of human dignity, the common good, and human rights. Considered as an ethical principle, distributive justice refers to what society or a larger group owes its individual members in proportion to: 1) the individual’s needs, contribution and responsibility; 2) the resources available to the society or organization (market considerations would be included under this, as well as other financial considerations); and 3) the society’s or organization’s responsibility to the common good. In the context of health care, distributive justice requires that everyone receive equitable access to the basic health care necessary for living a fully human life insofar as there is a basic human right to health care.

Principle of Distributive Justice
The principle of distributive justice implies that society has a duty to the individual in serious need and that all individuals have duties to others in serious need. In decisions regarding the allocation of resources, such as rationing decisions, the duty of society is not diminished because of the person’s status or nature of illness. Everyone is entitled to equal access to basic care necessary for living in a human way. Triage must presume an essential equality of persons. In other words, allocation decisions should not be based upon judgments of the quality of persons. Benefits and burdens should also be distributed in a just manner.

Principle of Double Effect
An action that is good in itself that has two effects--an intended and otherwise not reasonably attainable good effect, and an unintended yet foreseen evil effect--is licit, provided there is a due proportion between the intended good and the permitted evil.

When there is a clash between the two universal norms of "do good" and "avoid evil," the question arises as to whether the obligation to avoid evil requires one to abstain from a good action in order to prevent a foreseen but merely permitted concomitant evil effect. The answer is that one need not always abstain from a good action that has foreseen bad effects, depending on certain moral criteria identified in the principle of double effect. Though five are listed here, some authors emphasize only four basic moral criteria (the fifth listed here further specifies the third criterion):

The object of the act must not be intrinsically contradictory to one's fundamental commitment to God and neighbor (including oneself), that is, it must be a good action judged by its moral object (in other words, the action must not be intrinsically evil);

The direct intention of the agent must be to achieve the beneficial effects and to avoid the foreseen harmful effects as far as possible, that is, one must only indirectly intend the harm;

The foreseen beneficial effects must not be achieved by the means of the foreseen harmful effects, and no other means of achieving those effects are available;

The foreseen beneficial effects must be equal to or greater than the foreseen harmful effects (the proportionate judgment);

The beneficial effects must follow from the action at least as immediately as do the harmful effects.

The object of the act must not be intrinsically contradictory to one's fundamental commitment to God and neighbor (including oneself), that is, it must be a good action judged by its moral object (in other words, the action must not be intrinsically evil); The direct intention of the agent must be to achieve the beneficial effects and to avoid the foreseen harmful effects as far as possible, that is, one must only indirectly intend the harm; The foreseen beneficial effects must not be achieved by the means of the foreseen harmful effects, and no other means of achieving those effects are available; The foreseen beneficial effects must be equal to or greater than the foreseen harmful effects (the proportionate judgment); The beneficial effects must follow from the action at least as immediately as do the harmful effects.

Principle of Informed Consent
It is the right and responsibility of every competent individual to advance his or her own welfare. This right and responsibility is exercised by freely and voluntarily consenting or refusing consent to recommended medical procedures, based on a sufficient knowledge of the benefits, burdens, and risks involved. The ability to give informed consent depends on: 1) adequate disclosure of information; 2) patient freedom of choice; 3) patient comprehension of information; and 4) patient capacity for decision-making. By meeting these four requirements, three necessary conditions are satisfied: 1) that the individual’s decision is voluntary; 2) that this decision is made with an appropriate understanding of the circumstances; and 3) that the patient’s choice is deliberate insofar as the patient has carefully considered all of the expected benefits, burdens, risks and reasonable alternatives. Legally, adequate disclosure includes information concerning the following: 1) diagnosis; 2) nature and purpose of treatment; 3) risks of treatment; and 4) treatment alternatives.

Principle of Informed Consent
Depending on the circumstances, consent may take on two other forms. In cases where individuals are brought to the hospital in an unconscious state or with no decision-making capacity consent can be presumed, provided that the procedures performed are necessary and cannot be postponed until the person has regained consciousness or decision-making capacity. It also may happen that a surgeon sees the critical need of more extensive surgery in the course of an operation. In these circumstances, there may be no time to contact the spouse, parents or surrogate of the unconscious patient. For incompetent or incapacitated individuals, this right and duty of the patient to give consent is to be exercised on his or her behalf by a surrogate. This is known as vicarious consent, which is regulated by individual state and federal laws, following various standards of surrogate decision-making, including substituted judgment and best interests. (See also, Ethical and Religious Directives, nn. 26, 27 and 28)

Principle of Religious Freedom
All persons have a right to religious freedom, which has its foundation in human dignity. This principle implies that competent individuals should never be forced to act in a manner contrary to their religious beliefs and that they have the right to refuse participation in any treatment or procedure that is contrary to their conscience, nor should they be restrained from acting in accordance with their own beliefs, within due limits. This principle applies equally to patients, physicians, nurses and others who work in any health care facility. [See Documents of Vatican II, Declaration on Religious Freedom, n. 2.]

When a competent patient refuses a medical or surgical procedure on the basis of religious convictions, then those treatments which otherwise might be considered proportionate means by others may legitimately be considered disproportionate means for religious reasons. In such cases, it may be appropriate to remind the patient of the risks involved in foregoing treatment. If such efforts fail, however, it would be considered a violation of this principle to coercively administer the procedure. It also would be generally inappropriate to seek a court order so as to force the patient to submit to the procedure. However, probate courts have been known to override a patient’s decision to forgo life-sustaining treatments on the basis of religious convictions when that person’s death would result in undue harm to others (e.g., dependent children).

If the patient for whom the medically necessary treatment is being refused on the grounds of religious freedom is a child or infant and his or her life is at stake, guardianship might be sought on the grounds that the parents are failing in their moral and legal obligation to provide normal care for their child. Probate courts frequently override surrogate decisions made on behalf of minors to forgo life-sustaining treatment on the basis of religious convictions. Exceptions are made in the cases of "mature minors." In the case of a child or infant, it should also be noted that the physician and hospital run the risk of legal liability if they do not provide treatment and the child or infant dies as a consequence.

Principle of Stewardship
Stewardship requires us to appreciate the two great gifts that a wise and loving God has given: the earth, with all its natural resources, and our own human nature, with its biological, psychological, social and spiritual capacities. This principle is grounded in the presupposition that God has absolute Dominion over creation, and that, insofar as human beings are made in God’s image and likeness (Imago Dei), we have been given a limited dominion over creation and are responsible for its care. The principle requires that the gifts of human life and its natural environment be used with profound respect for their intrinsic ends. The gift of human creativity especially should be used to cultivate nature and the environment, recognizing the limitations of our actual knowledge and the risks of destroying these gifts. Accordingly, simply because something can be done does not necessarily mean that it should be done (the fallacy of the technological imperative). As applied to Catholic-sponsored health care, the principle of stewardship includes but is not reducible to concern for scarce resources (see Ethical and Religious Directives, n. 6); rather, it also implies a responsibility to see that the mission of Catholic health care is carried out as a ministry with its particular commitment to human dignity and the common good.

Principle of Subsidiarity
Often considered a corollary of the principle of the common good, subsidiarity requires those in positions of authority to recognize that individuals have a right to participate in decisions that directly affect them, in accord with their dignity and with their responsibility to the common good. Decisions should be made at the most appropriate level in a society or organization, that is, one should not withdraw those decisions or choices that rightly belong to individuals or smaller groups and assign them to a higher authority. However, a higher authority properly intervenes in decisions when necessary to secure or protect the needs and rights of all. The principle implies that, when a decision is to be made, we should identify the most appropriate forum and level of decision making, and how best and to what degree those individuals most affected should participate in the decision making process.

Principle of Toleration
Tolerance of moral and religious views other than one’s own is often considered a civic virtue in the United States. In the Catholic moral tradition, however, the principle has a long history that is rooted not purely in a democratic conception of government, but of government as it is properly related to the common good. For example, St. Thomas Aquinas refers to the Principle of Toleration where he addresses the questions of whether or not every evil or vice should be repressed in every circumstance under human law (Summa Theologica I-II, Q. 96, A. 2) and whether or not those who govern should try to prevent every evil under every circumstance (Summa Theologica I-II, Q. 90, A. 2). As with the Principles of Double Effect, Integrity and Totality, and the Principles of Cooperation, the Principle of Toleration was developed as a set of moral criteria for discerning how to pursue good in a world in which evil is inevitable.

Principle of Toleration
According to this principle, those who govern both society and the individual institutions that constitute important elements of the common good may at times—where prudence dictates—tolerate the evil actions of others (including some intrinsic evils), if two criteria are met: 1) if a greater good or set of goods would be lost if the evil action were not tolerated; or, 2) if greater evils would occur were the original evil not tolerated. The Principle of Toleration, however, should be not be considered a "loop hole" to the prohibition against formal and immediate material cooperation. In other words, the principle of toleration cannot justify an illicit participation in an intrinsically evil action, but only the toleration of others participating in evil actions where the eradication of this participation is not practically or morally feasible.

Hippocratic Oath 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: To hold him who taught me this art equally dear to me as my parents, to be a partner in life with him, and to fulfill his needs when required; to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract; and that by the set rules, lectures, and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to students bound by this contract and having sworn this Oath to the law of medicine, but to no others. I will use those dietary regimens which will benefit my patients according to my greatest ability and judgement, and I will do no harm or injustice to them. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion. In purity and according to divine law will I carry out my life and my art. I will not use the knife, even upon those suffering from stones, but I will leave this to those who are trained in this craft. Into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or corruption, including the seduction of women or men, whether they are free men or slaves. Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private. So long as I maintain this Oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of all men for all time. However, should I transgress this Oath and violate it, may the opposite be my fate.

Hippocratic Oath Regardless of the specific authorship of the famous Oath, that it comes down to us from that era is denied by none. Undeniable also is the fact that it profoundly influenced the practice of medicine across recorded history.

Hippocratic Oath Anthropologist Margaret Mead pointed out that prior to Hippocrates, the shaman and the doctor could be the same person. With Hippocrates, Mead wrote: "For the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with the power to kill had power to cure, including specially the undoing of his own killing activities. He who had the power to cure would necessarily also be able to kill...With the Greeks the distinction was made clear. One profession, the followers of Asclipius [Aesculapius], were to be dedicated completely to life under all circumstances, regardless of rank, age or intellect -- the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child..." Mead calls the Oath's interdiction of ever deliberately killing: "...a priceless possession of society which we cannot afford to tarnish, but society always is attempting to make the physician into a killer -- to kill the defective child at birth, to leave the sleeping pills beside the bed of the cancer patient...It is the duty of society to protect the physician from such requests." (5)

Hippocratic Oath So it can be seen that the appearance of the Oath (c. 400 B.C.) represented a clear dividing line after which medicine was unalterably committed to protecting life and never deliberately killing. This found expression in the Oath's simple grandeur with an admirable economy of words -- "I will give no one a deadly medicine even if asked, nor counsel any such thing; I will not give a woman a pesary to induce abortion..." affirmed at Helsinki...

Hippocratic Oath The Oath represented the gold standard of moral and ethical behavior to which all physicians who took it were bound. Where lived up to, it protected patient, family, physicians and society. Where violated, as it was massively this century in the Third Reich, the darkest chapters in medical history were written, culminating in physicians in the dock charged and found guilty of "crimes against humanity". (6)

Hippocratic Oath Medicine responded vigorously to those violations and betrayals. At Geneva in 1949, the unchanging principles of the Oath were restated in the unanimously adopted Medical Declaration of Geneva with its additional magnificent line, "I will maintain the utmost respect for human life from the time of its conception". Almost simultaneously, exposition of the doctrine of informed consent regarding medication and non-therapeutic experimentation was ringingly affirmed at Helsinki..

Principles of Formal and Material Cooperation

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