Member Care and the Hippocratic Oath, Part 10—Summary

Hippocrates as Historical Precedent:

Roots and Responsibilities

The Hippocratic Oath in Greek and Latin.

La saeta lanza

fasta un cierto fito,

y la letra alcanza

desde Burgos a Egipto.

Sem Tob, 14th century, Spain

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Translation:

Darts hit their mark when carefully thrown

Writings go far when skilfully sown.

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This is our 10th and final discussion of the Hippocratic Oath. As the above moral proverb indicates (and many thanks to you Sem Tob for your universally-wise rhymes!), the truth in skilfully written words, such as those in the Hippocratic Oath, span across continents, generations, centuries, and health disciplines. The ethical core for health practitioners in the Oath, arguably, is unprecedented as a historical foundation of good practice.

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Just one case in point among many is the current version of the American Psychology’s Ethical Principles for Psychologists and Code of Conduct (2002). This code like its “cousin codes” in related health sciences, is replete with what can only be called by this point in our discussions, "hippocratisms.” Smile. Meander through the Introduction and the Preamble, and then on to the General Principles and then Ethical Standards sections and you will quickly bump into such familiar concepts/commitments as doing no harm, responsibility, competence, confidentiality, and yes, even not having sex with clients etc. Check it out at: http://www.apa.org/ethics/code2002.html  The Hippocratic foundation is there (along with other items such as justice, integrity, and rights along with more specific, contemporary standards involving things like psychological testing, court testimony, etc.).

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Final Application

We want to summarize the 10 core principles that we have covered over the past three plus months. These principles are commitments that are explicitly embedded in the Hippocratic Oath (HO). We want to remember our roots and our responsibilties. These core priciples could be likened to being the 10 commandments for healthcare practitioners. But let’s just call it the “10 HO Commitments”. We also list the first draft of the newly condensed version (10 items now) of the “15 Commitments for Member Care Workers” (from the 2006 article “Five Stones for Member Care: Upgrading Ethical Practice).”

http://www.fuller.edu/academics/school-of-psychology/integration-symposium-2009.aspx.

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Well, if this does not have your head spinning yet, then this may well do the trick: The 10 Commitments in the Hippocratic Oath will then be referenced to the 10 MCW Commitments (in parentheses)--although note there is definitely not a one-to-one correspondence. Here we go!

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10 HO Commitments (for health care workers)

1. Foundational Principle: Accountability to a Higher Power

2. High Standards: Agapeoath for Trans-Practitioners

3. Professional Obligations to Respect, Relate, and Reproduce

4. Hippocratic Heart: Dong Good and Doing No Harm

5. Respecting Human Life: Conception through Completion

6. Growing in Character and Competence

7. Prudence: No Sex with Clients

8. Confidentiality as a Lifestyle

9. Consequences of Good vs Poor Practice

10. Historical Precedents: Roots and Responsibilities

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10 MCW Commitments (for member care workers)

1. Ongoing training, personal growth, and self-care. (HO6)

2. Ongoing accountability for my personal/work life, including consulting/supervision. (HO1)

3. Recognizing my strengths/limits and representing my skills/ background accurately. (HO6)

4. Understanding/respecting felt needs, culture, and diversity of those with whom I work. (H03)

5. Working with other colleagues, and making referrals when needed. (HO3)

6. Preventing problems and offering supportive/restorative and at times pro bono services.(HO5)

7. Having high standards in my services and embracing specific ethical guidelines. (HO2)

8. Not imposing my disciplinary/regulatory norms on other MCWs. (H03)

9. Abiding by any legal requirements for offering member care where I reside/practice. (HO9)

10. Growing in my relationship to Christ, the Good Practitioner. (HO1)

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Reflection and Discussion

We hope these 10 entries since June have stimulated your thinking about new, old, and creative ways to understand member care. Take some time to identify/review three meaningful concepts for you in particular.

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I especially enjoyed the challenge of trying to relate the moral proverbs of Sem Tob and the indigenous artwork of Diego Rivera with member care thinking and the Hippocratic Oath. Perhaps you would like to have a go at some integrative member care work that includes the arts, sciences, and history etc. too.

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It has personally been a lot of work and I was not always sure where we would end up. Perhaps the same is true for you. Are you OK for example with the summary in the 10 HO Commitments?
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I am tempted to close with yet another gem from the Jewish rabbi Sem Tob in 14th century Spain. However  I want to finish now with something from an anonymous Christian monk in 8th century Ireland. This excerpt from the poem Pangur Ban (White Cat) aptly describes what this integrative journey into "Member Care and the Hippocratic Oath" has been like for me. Like the monk in this poem, I have been hunting at length for the right words to convey my thoughts and I have been keenly aware of how small my wisdom really is. Maybe you have a proverb or short poem that reflects your experience too.

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I and Pangur Ban my cat

‘Tis a like task we are at

Hunting mice is his delight

Hunting words I sit all night.

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Against the wall he sets his eye

Full and fierce and sharp and sly

Against the wall of knowledge I

All my little wisdom try.

Member Care and the Hippocratic Oath, Part 9

Should Member Care Practitioners Be Disciplined?

An impeached and disgraced President Nixon,

leaving the White House and US Presidency

some 35 years ago--August 9, 1974.

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Tórnase sin tardar

la mar mansa muy brava;

el mundo hoy despreciar

al que ayer honraba.

Por ende el grande estado

al hombre que ha saber,

face venir cuitado

y tristezas haber.

Sem Tob, 14th century, Spain

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Translation:

Just as placid seas quickly turn fierce in a storm

so honor today can become tomorrow’s scorn.

Therefore remember our exalted state

can suddenly turn to sadness by fate.

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If I keep this oath faithfully,

may I enjoy my life and practice my art,

respected by all men and in all times;

but if I swerve from it or violate it,

may the reverse be my lot.

Hippocratic Oath

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According to the final part of the Oath, practitioners freely invoke/embrace the consequences of good practice vs poor practice. One’s keeping of this Oath will result in three outcomes:

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1. Enjoying life vs not enjoying life

2. Practicing health care vs not being able or allowed to practice health care

3. Being respected by people always vs never being respected by people.

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It is not clear however in the Oath who or what is relegating the consequences for the quality of one’s practice. A god? Fate? Some type of Hellenistic karma? Or is it just the acknowledgement that one does not deserve good things from life if one deviates from properly caring for his/her clients/patients, with the word properly being defined by the general parameters of the Oath? Whatever the case, this is serious business and obviously one should never take such a life-impacting oath lightly.

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Applications

So should there be consequences for member care practitioners who fail to practice ethically and competently? Yes, of course. This is especially true if they consistently practice unethically and incompetently in ways that hurt others.

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But what should the consequences be, especially in a field like international member care that is largely unregulated? Should poor practitioners who make serious errors or who are consistently negligent be disciplined or otherwise removed from practice? Probably. But the modus for such action is hazy at best. Perhaps receiving informal or even formal correctives from one’s peers or organizational affiliations are the most we can hope for.
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In the Hippocratic Oath, there are no specific external referents to regulatory bodies such as a licensing board, a professional ethics committee, or civil law. For many member care practitioners, the same is true: there is no regulatory body to monitor member care practice and to receive any client complaints. This of course is not the case for professional caregivers in member care who are legally certified in a special field and part of a professional association.

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On the More Positive Side:

Good self-care and good social support are the core safeguards to help one continue to practice well and to avoid impairment in judgement, inferior services, and even burnout. In addition having different interests outside of one’s work, an ability to maintain perspective in difficult times, having fun, and being self-aware are also important qualities to promote well being and foster good practice. Know your limits, know your strengths, and know your relevant ethics codes!

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Bennett et al in Assessing and Managing Risk in Psychological Practice (2006) remind psychologists [and for our purposes member care practitioners] that good practice is “hard work.” We are encouraged to “Strive for excellence but not perfection” and to know that:

**"You will make mistakes.

**You cannot help everyone.

**You will not know everything.

**You cannot go it alone.

**It is helpful to have a proper mix of confidence and humility.” (p.5)

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Reflection and Discussion

We are entrusted to help foster the well-being of individuals, couples, children, families, teams, organizations etc. Again, it's serious business for sure! This serious and final part of the Hippocratic Oath reminds me of an admonition in Deuteronomy 28: 1-2, 15, attributed by many to Moses.

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“Now it shall be, if you diligently obey the LORD your God, being careful to do all His commandments which I command you today, the LORD your God will set you high above all the nations of the earth. And all these blessings will come upon you and overtake you if you obey the LORD your God…But it shall come about, if you do not obey the LORD your God, to observe to do all His commandments and His statutes with which I charge you today, that all these curses will come upon you and overtake you…”

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Comment on this final declaration of the Hippocratic Oath in light of this portion of Jewish-Christian Scripture (which may have preceded Hippocrates by up to 10 centuries!) and in light of these assertions:

1. There are pros and cons for member care practitioners who say that they are accountable to a Higher Being--God.

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2. Regardless of one’s profession in life, acting ethically will have certain consequences and acting unethically with have certain consequences.

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3. Learning and growth do not occur without making mistakes regardless of one’s level of experience.

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4. “Keep this oath faithfully” (Hippocrates) and “Diligently obey the Lord” (Moses). Both can be easily harmonized and can be done simultaneously.

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5. Discipline can be misapplied and good practitioners can be seriously hurt by people who are misinformed, overly spiritual, who have political agendas, and in some cases by those who have serious problems themselves. On the other end of the "discipline continuum" are poor practitioners who can essentially do whatever they want with impunity. Both extremes involve serious errors in discipline/accountability with the end result being that people get hurt. The Hippocratic heart (as described in Part 4 of this series) of "doing good and doing no harm" can thus sadly be broken.

Member Care and the Hippocratic Oath, Part 2

Should Member Care Practitioners Take an Oath Too?

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Face rico los hombres

con su prometimiento;

después fállanse pobres

odres llenos de viento.

Sem Tob, 14th century, Spain

Translation:

You might get rich by false promises tried

But you'll end up poor and empty inside.

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Many medical practitioners, health care professionals, politicians, and others have historically taken “oaths”. These oaths have been solemn commitments by people with important responsibilities, who are recognized for having mastered a certain body of knowledge and skill sets, and thus able to competently and ethically practice a profession. How might taking such an oath be relevant for the very diverse and largely unregulated member care field?

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Commitments and Agapeoath

The Hippocratic Oath begins with: “I swear…to keep according to my ability and my judgment, the following Oath and agreement.” See the previous entry to view the full Hippocratic Oath. I personally can imagine member care practitioners taking some type of an oath as part of their commitment to practice member care competently and ethically. Such an oath would lbe volunatary, likely brief, and include wording that would give it universal appeal and relevance for faith-based pratitioners from a variety of backgrounds.

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I would like to propose something called an agapeoath (agapeo + oath = agapeoath; pronounced uh-gah-PAY-oath). This term embodies the essence of sacrificial love (agapeo) and a serious promise (oath). It would be a solemn commitment to practice true love in a member care context as we endeavor to do good/do no harm to those who receive our services and as we pursue ongoing healthy relationships (aka "relational resiliency") with fellow workers.

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This commitment is sustained in spite of work/life's difficulties "come hell or high water." It is tough love that perseveres and does not "sell" one's integrity, principles, or colleagues for thirty pieces of anything when the going gets tough. It is practical and observable not simply idealistic or ethereal. It is love which "swears to one's own hurt"-- that is, keeping your word even when it may cost you things like your reputation and finances (Psalm 15: 4).
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Commitments and Trans-Practitioners

What also makes much sense to me is embracing a series of commitments to practice member care responsibly. These commitments would be founded upon agapeo per the previously mentioned foundational oath of agapeo--agapeoath. Is this moving in a direction that the diversity of member care practitioners could embrace? I think so, but it is something to be discussed broadly.
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I would like to introduce another term: trans-practitioner. This term refers to member care workers who intentionally cross cultures, disciplines, sectors, organizations, genders, generations, and other "borders" for the sake of mutual learning and good practice. Trans-pracitioners seek and use core concepts which are relevant in many settings. One example is the set of “15 Commitments for Member Care Workers” that promotes high standards for character and competency and that aim to be applicable to the diversity of member care workers. These commitments are discussed earlier on this blog (see April 29, 2007) and in the article Ethics and Human Rights in Member Care (2009): http://www.fuller.edu/academics/school-of-psychology/integration-symposium-2009.aspx
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Taking the High RoadThe member care field is fairly loose. Not surprisingly, some unfortunate and clearly erroneous practices have occurred. We probably all know of cases where people receiving services have been negatively impacted; where there have been unresolved relationship struggles that have not been dealt with adequately and which have seriously injured people and disrupted mission/aid work; and where unchecked personal/systemic dysfunction have put wedges within different commiunities including the practitioner community.

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We can change these problem areas. But to do so we must not be afraid to admit them, discuss them, work through them, learn from them, and put appropriate safeguards in place. Such actions will require courage--a courage that seeks mutual transparency, accountability and the welfare of all. It will require integrity: an integrity which is not just based on living harmoniously with one’s own internal norms but based on the fuller integrity which arises from living congruently with externally-referenced norms/high standards such as the 15 commitments mentioned above.

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Maybe it is time to adjust our course as a field in a way that will help sustain us through the dark days and intense challenges in this world. Maybe it is time to take the higher road, a road demarcated by trans-practitioner commitments founded upon a solemn oath of agapeo.
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Final Thoughts

Hippocrates was not just on the right road. He helped forge the right road. He took his professional responsibility seriously as well as that of his colleagues and his students. He made a serious, public commitment to practice competently and ethically. Member care workers would do well to do the same.
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Reflection and Discussion
1. Should every member care practitioner have a clear set of commitments to which she/he is accountable? Consider this question in light of the above comments and in light of this quote: (context is exploring the relevance and lack of relevance of ethical codes for member care workers)

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“Many types of professional ethical codes exist that can relate to the practice of member care. For some practitioners, these codes are essential and are a good “fit.” But one size does not fit all! For example, as a psychologist and as an international affiliate of the American Psychological Association (APA), I abide by the APA’s Ethical Principles of Psychologists and Code of Conduct (2002). But a skilled Nigerian pastor providing trauma training/care in Sudan may not find this code so helpful. Such ethical codes are primarily relevant for the disciplines and countries for which they were intended. Yet many MCWs enter the member care field via a combination of their life experiences and informal training, and are not part of a professional association with a written ethics code. Common sense and one’s moral convictions only go so far. Further, appealing to another country or discipline’s ethical code can result in a rather cumbersome mismatch between the person and the code.” Ethics and Human Rights in Member Care (2009), Kelly O’Donnell
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2. How could a set of commitments help keep member care practitioners working together competently and with good relationships? Consider this question in light of the above comments and in light of this quote:

(context is a description of how the growing "darkness" has surrounded the woodland kingdom of the elves , and the consequences to relationships to peoples of good will in Middle Earth)
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"Indeed in nothing is the power of the Dark Lord more clearly shown than in the estrangement that divides all those who still oppose him...We live now upon an island amid many perils, and our hands are more often upon on the bowstring than the harp." The Fellowship of the Ring (1954), J.R.R. Tolkien
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3. Love is all you need, right? Consider this question in light of the above comments and in light of this quote:

(context is identifying some of the essential future directions for the member care field)
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"Above all, the core of E2MC [that is, Ethne to Ethne Member Care—providing/developing member care for/from all people groups] involves the trans-ethnê, New Testament practice of fervently loving one another—like encouraging one another each day; bearing one another’s burdens; and forgiving one another from the heart. By this all people will know that we are His disciples (John 13:35). The Great Commission and the Great Commandment are inseparable. Our love is the final apologetic. It is the ultimate measure of the effectiveness of our member care.” God in the Global Office, 2009, Kelly O’Donnell

Member Care and the Hippocratic Oath, Part 1

Hippocrates and Higher Powers

Non hay lanza que pase 
todas las armaduras,

nin que tanto traspase

como las escrituras.
Sem Tob, 14th century, Spain

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Translation:

No spear can pierce all armour in a fight

Nothing penetrates like words that we write.

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This is the first of 10 brief discussions about the Hippocratic Oath and its relevance for member care. As the above 14th century proverb suggests, the written word--in this case the Hippocratic Oath--has adeptly penetrated practitioner hearts, human history, and the health sciences themselves.
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I really enjoyed studying Greek mythology and life in ancient Greece as a boy. It was thrilling to read over and over again about the heroic feats of Achilles at Troy; the decade-long wanderings of courageous Odysseus; the harrowing foot race along the sea between peerless Atlanta and love-struck Hippomenes; the atoning descent into treacherous Hades by Heracles; satyrs, naiads, centaurs, tritons, and many other mostly delightful mythical creatures. So intentionally meandering now into the ancient Greek world has both a familiar and fascinating feel to it!

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Hippocrates lived in the fourth century BC (circa 460-370 BC). He is considered to be the "father" of western medicine and is credited with helping to further develop and establish the practice of medicine in Greece at a time when Greek civilization was flourishing under Pericles.
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The Hippocratic Oath (reproduced below, translation by the National Institute of Health in the USA) is attributed to Hippocrates and pertains to the ethical practice of medicine. What were the core principles to embrace which would guide specific medical interventions? The Oath summarizes these key principles. Physicians in his day and beyond swore this oath or some variation of it. The principles of "doing good and doing no harm" for example, are still widely accepted and a usefulwayto summarize the Oath itself.

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The Oath is relevant in so many ways for member care practitioners and the member care field. The first application we propose is to look at the opening salvo and consider our work, as Hippocrates et al did, in light of Higher Powers and accountabilty.

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A Foundational Application

By Jove, by the gods above, by Apollo, or by Whoever or Whatever, we humans are not alone in our health care activities. Hippocrates appealed to a Higher Power (gods) to whom all humans and physicians were ultimately accountable and in some sense dependent upon. The specific gods listed by Hippocrates were apparently linked to healing in Greek religion/mythology (Apollo, Asclepius, Hygieia, and Panacea).

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Member care practice likewise starts with a Higher Power--God--who sees all, knows all, is the source of healing, and who holds us accountable for our personal and professsional actions. It is not ultimately good practice codes or professional standards to which we are accountable, but a Creator. We also note for reference that "Master Care"--care for and care by God the Master--is placed at the center (beginning) of the international/macro member care model (Doing Member Care Well, 2002, chapter one).

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Further, we as member care practitioners facilitate healing because being made in the image of God, we emulate the Creator who heals. In the Judeo-Christian tradition, this is YHWH-Rapha, a special name for God which means the Lord that Heals. So perhaps we might see Hippocrates et al as getting their theology wrong, but they were certainly on the right track as they began with and appealed to Higher Powers as being the "first principle" to consider for their healing arts.

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In short: Member care starts with God. Member caregivers are accountable to God. Simple.

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Hippocratic Oath (other translations/versions are slightly longer but essentially the same)

I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

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To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.
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I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.
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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.

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But I will preserve the purity of my life and my arts.
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I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.
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In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

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All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.
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If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.

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Reflection and Discussion

Member care should not be ahistorical.

Comment on this assertion

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Member care also has some roots outside of the Judeo-Christian tradition and which pre-date the New Testament.

Comment on this assertion.

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Member care, like any of the helping professions/healing arts, must philosophically and ethically start with a First Principle, a Higher Power.

Comment on this assertion.

Note: During these 10 discussions of the Hippocratic Oath we will introduce two additional items into the integrative mix: a special proverb and a special work of art. Our goal is to broaden our understanding of member care in some new and creative ways.These two items are:
a. a related proverb in Spanish from Sem Tob, a relatively unknown 12th century Rabbi in the court of Peter I in Castilla, Spain. The English translations are courtesy Kelly O'Donnell.
b. a related piece of art from Diego Rivera, the widely-known 20th century Mexican artist who created large murals depicting various social themes as well as paintings depicting indigenous life in Mexico.