This document discusses the ethical dilemmas physicians face in situations where harm may come to patients, such as executions, interrogations, or assisted suicides. Experts provide perspectives on reconciling these decisions with the Hippocratic Oath of "first, do no harm." They emphasize that physicians should not participate in or enable harm, and have a duty to speak out against unethical practices like torture. While assisted suicide may relieve patient suffering in some cases, the Hippocratic Oath prohibits actively ending a life. Physicians must follow professional ethics over legal or state demands that could violate their ethical responsibilities.

1. Friday Feedback: First, Do No
Harm?
by Molly Walker Medpage today
Following Hippocrates' famous dictum isn't always easy
MedPage Today recently surveyed our readers about whether the
psychologists named in the CIA torture report should face criminal charges.
But every day, health professionals are faced with a variety of moral
and ethical gray areas within the practice of medicine.
We contacted medical ethics experts and a variety of health
professionals and asked:
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Under what circumstances should physicians participate in
situations where harm can come to people (executions, prisoner

2. interrogations, assisted suicides), if the physicians can mitigate
the harm?
How should a physician reconcile any of those decisions with
what is acceptable within the scope of the Hippocratic Oath?
Ethics vs. Autonomy
Allen Keller, MD: "Professional ethics need to be
guiding principles for not only what we believe in
theory, but what we do in practice. Health
professionals must not become tools of the state to
inflict harm and, in fact, have a moral
responsibility to speak out against such things.
Society grants health professionals certain
privileges, not the least of which is a level of
respect and trust. With such respect and trust
comes responsibility. Society looks up to us and so
what we do or what we don't do matters -- when
we speak up or when we remain embarrassingly
silent. Physicians and other health professionals
have a responsibility to be moral leaders, not
enablers, participants, or developers of what we
know are unethical and immoral practices including
torture."
Neil Gokal, MD: "A physician has a role to direct
the care of a patient's health within the realm of
practicality, economics, ethics, and autonomy. This
is not unyielding to the direction of a physician's
guidance. When called upon in any instance, the
duty of a physician is to employ the most ethical,
reasonable, and practical principles to achieve the
most ethically and morally desired outcome as
congruently discerned by patient and provider.
This decision is one to be reconciled upon between
the giver and the requestor bastioned by a source

3. of greater understanding differing in any given
situation. Many times there is no right or wrong
answer; it's everything in between that carries the
force with which to reckon."
David Beyda, MD: "There are times when our
internal morals and the ethics of our profession
come in conflict. We can reconcile that conflict by
not participating, thereby not witnessing any
suffering, but that is hiding behind a curtain of 'if I
don't see it, it isn't happening.' The law may say
we must participate, but our ethics say 'nay.' The
law (water) and ethics (oil) do not mix so well.
Ethics (the oil) will always rise to the top."
S. Steve Samudrala, MD: "My personal belief is to
not participate in those situations. However, I do
believe physicians should be able to practice
medicine consistent within their own moral
compass and religious values that is legal.
Physicians need to look at their own moral
compass and their religious beliefs for guidance."
The Case of Assisted Suicide
Brian Flyer, MD: "Physician participation in
physician-assisted suicide is currently limited to
those states where it is legal. In those
circumstances, the physician and patient need to
address the 'harm,' as you put it. Clearly, there
are situations, where the harm of a being a burden
to oneself and others, caused by the ravages of
various diseases, including wasting, severe pain,
paralysis, and complete dependence, may
outweigh the harm of a slightly shorter end to
one's suffering. In my state, California, this option
is not legal."

4. Mark Melrose, DO: "The states of Oregon,
Washington, Vermont, and Montana legally permit
physician-assisted suicide. The ethical construct is
that following an exhaustive evaluation for other
methods of relieving pain and suffering, the
physician may provide a means for a terminally ill
patient to commit suicide when death is otherwise
inevitable. This is considerably different than
allowing a physician to administer a lethal injection
or assist in torture."
Beyda: "Consider this: the only one standing
between a suffering death and a peaceful death
may be a physician. The Hippocratic Oath negates
any legitimate involvement of a physician in
actively ending another person's life and that they
'do no harm.' But isn't it true that physicians do
harm by allowing terminally ill patients to endure
pain and suffering when they would like to end
their lives and have asked a physician to help in
doing so, and the physician refuses?"
Remember 'Do No Harm'
Melrose: "It is ethically not acceptable for
physicians to participate in procedures such as
executions or prisoner interrogations (torture) in
which the intent is to cause harm to a patient. The
primary responsibility of physicians is to first do no
harm! The Hippocratic Oath is neither legally
compelling, nor mandatory for graduation from
medical school but offers guidelines for ethical
physician behavior. It simply states in part: 'But it
may also be within my power to take a life; this
awesome responsibility must be faced with great
humbleness and awareness of my own frailty,'
meaning don't do it!"

5. Keller: ""Every health professional society
including the American Psychological Association
agrees that participation in torture is a violation of
ethics. This is consistent with every health
professional code of ethics, including do no harm.
I've been working on legislation in New York state
for several years which my colleagues and I think
can serve as a model that many other states
should follow. This legislation simply states that
participation in torture or abuse of prisoners or
other detainees can be grounds for loss of
professional licensure. In the wake of what we've
learned about medical participation in U.S. torture,
I wonder if health professionals who participated in
the mistreatment of detainees, either under order
or voluntarily, had said, 'I can't do this, I'll lose my
license,' then maybe this wouldn't have happened.
Self-interest is a very good motivator in addition to
core ethical principles. What health professionals
do in these situations really matters. If health
professionals say no, that can really matter as
well."
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