I am blessed to live in central Kentucky. Driving through the picturesque countryside, horse farms are seen throughout the region. Many are ornate and extensive. Others are more modest. Others still have a few horses for personal pleasure and a barn. No matter, they all share this one specific feature in common: fences. These fences require regular upkeep, including replacement of broken boards, staining, etc. Why do horses require fences? The obvious reason is that someone has decided they have a value that is worthy of protection. Although noble animals (at least by some estimations), they are wont to run wild and endanger themselves in a world of high-speed automobiles.

In like fashion, it is worthwhile to spend time reflecting upon the reasons for cultural “fences.” You may call them acceptable behaviors, norms or morals or another descriptor, but they are the “shalt nots.” In the case of country fences, this is to “say” to the horses: “this far and not beyond.” What are the fences that have been traditionally observed in the practice of medicine?

Perhaps the most obvious is the Hippocratic injunction essentially stating that we as healthcare professionals shall not kill. Why did Hippocrates construct this fence? Here it would be useful to reflect upon the practice of medicine prior to Hippocrates when the physician was also a killer. Margaret Mead, the anthropologist and not known as an orthodox Christian, famously commented about this in writing:

Prior to the time of Hippocrates and continuing after that time in some traditions (shamanic and otherwise), the physician with the power to heal also had the power to kill. Which was to be practiced upon the patient? Was there a conscious weighing of the interests of the patient along with other concerned parties (relatives, city, state, physician, et. al.)? What if the desire of the patient conflicted with the desires of the other parties? If these all figured into the heal/kill calculation, the patient presenting for treatment certainly had reason to regard that physician with caution. Trust, therefore, was impossible. Conversely, if the physician was bound by an oath that prohibited killing his patient, he could be trusted to act in said manner. Even though the patient may have asked for death, the doctor was bound not to comply. Thereby trust was established in the doctor/patient relationship.

More recently, we may look to the evolution of the practice of euthanasia by the Dutch. What was initially proposed as a practice to “help” those in the later stages of a terminal illness was extended to those who deemed their own lives not worth living. Eventually it “progressed” to include killing those who desired life but were deemed unworthy of life by that physician. Understand, this means they were killed against their wishes. The “slippery slope” argument is not given much weight in the practice of formal logic. But when a hurdle is cleared, it is reasonable to think the next hurdle will be more easily cleared.

There is a saying in the country: “Before you tear down a fence think about why there was a fence in the first place.” We face increasing pressure from cultural and governmental forces to do away with the injunction of “physicians do not kill.” Perhaps, it is time to more thoughtfully consider this Hippocratic fence that has been a pillar of modern medicine. When the fence is torn down, how far will the horses run?

Aaron Hensley, MD, is an anesthesiologist practicing in Lexington, Kentucky. He and his wife Marsha are the parents of three adult children. When not practicing medicine, he enjoys reading, cycling and beekeeping among other interests.