In 1803 a Manchester physician named Thomas Percival published a small book whose title gave the language a phrase it still uses: Medical Ethics. Most of it concerns the conduct of physicians toward one another and toward the hospitals they served, but in the chapter on private practice there is a sentence that most of his readers would have found self-evidently good. A physician, Percival wrote, should not be forward to make gloomy prognostications, and should leave the breaking of bad news to someone else wherever he could, “for the Physician should be the minister of hope and comfort to the sick.”
At the back of the book, among the notes, the sentence has a shadow. Percival had circulated an earlier version of his work privately, and one of the readers who wrote to him about it, the clergyman and moralist Thomas Gisborne, suggested an amendment. Minister of hope and comfort, yes: but he proposed adding, “as far as truth and sincerity will admit.” Percival did not add it. He printed Gisborne’s suggestion in the note instead, argued with it at length, and left his own sentence standing in the text.
Over the following two centuries the footnote moved into the text. Hardly anyone in medicine now would defend the sentence as Percival meant it, and almost everyone would defend Gisborne’s qualification, so thoroughly that it no longer feels like a qualification. It feels like the bedrock of the profession, older than anyone in it. That migration is the subject of this essay, because an essay with this title has to begin by admitting how much of what now looks permanent arrived recently, against resistance, from the margins.
The tools of medicine should keep changing. A better way of finding a result, keeping a medication list accurate or helping someone understand a plan deserves a fair hearing, and I would not want anyone to inherit an avoidable difficulty merely because it belonged to the medicine in which I trained. Elsewhere on this site I have proposed three tests for any new technology, drawn from what Khadur Sahib remembers: fidelity, equality and embodiment. Those are tests for tools. This essay is about something prior to them: what the person in one chair should be able to expect from the person in the other, whatever happens to be on the desk between them. And it has to ask that question in a way that does not flatter the person asking it.
A Sentence and Its Footnote #
Percival’s book began in a quarrel. The Manchester Infirmary had been riven by disputes among its physicians, surgeons and apothecaries, three groups trained in three different ways and jealous of their places, and Percival was asked to draw up a scheme of conduct that might keep the peace. He circulated a version privately in 1794 and published the expanded work in 1803. It traveled further than anyone could have expected. When the newly founded American Medical Association adopted its first code of ethics in 1847, it drew heavily on Percival, and some of his sentences passed into American medicine almost word for word.
The passage on hope deserves to be read whole, because it is more careful than its reputation. Percival tells the physician not to be forward with gloomy predictions, partly because they savor, as he puts it, of empiricism, which in his day meant quackery, magnifying the importance of the doctor’s services. But the physician “should not fail on proper occasions to give to the friends of the patient timely notice of danger when it really occurs, and even to the patient himself, if absolutely necessary.” Even so, the office is so alarming when the physician performs it that it ought to be handed to “any other person of sufficient judgement and delicacy” whenever possible. The physician’s role is to be the minister of hope, administering what Percival calls cordials to the drooping spirit.
Gisborne’s objection, as Percival printed it, is a model of tact. He knew, he wrote, that Percival already meant the sentence in that sense. But there are few professional temptations to which medical men are more liable, “and frequently from the very best principles,” than that of using language more encouraging than sincerity would vindicate on cool reflection, and it might be right to guard the avenues against the error. In his own Enquiry into the Duties of Men, published in 1794, Gisborne put the principle in a sentence I would happily see carved over the door of every consulting room. The physician need not always say everything he thinks at every moment, but he must never represent the danger as less than he believes it to be. “He is at liberty to say little; but let that little be true.”
Percival’s reply fills several pages. He surveys the moralists, from the Church Fathers through Grotius, Pufendorf and Hutcheson, many of whom allowed falsehood for a good end. He quotes, to his credit, the strongest voice against himself: Samuel Johnson, as Boswell recorded him on 13 June 1784, in the last year of his life, when he was often ill. “You have no business with consequences,” Johnson said; “you are to tell the truth.” And then, with the authority of a patient: “Of all lying I have the greatest abhorrence of this, because I believe it has been frequently practised on myself.”
Percival’s conclusion is the conclusion of a decent man defending a practice he can feel the cost of. To a patient whose questions, if faithfully answered, might prove fatal to him, he wrote, “it would be a gross and unfeeling wrong to reveal the truth.” The patient’s right to it is “suspended, and even annihilated.” But the physician must do this only in cases of real emergency, “which happily seldom occur,” and must guard his mind sedulously against the injury it may sustain from “such violations of the native love of truth.”
I do not read that as the voice of a liar. I read it as the voice of a man who held a real good, hope, and believed that a particular method, concealment, was sometimes necessary to protect it. The value and the method came bundled together, and he could not imagine one without the other. Gisborne could. That is the whole difference between them, and it is the difference this essay is about.
Ninety and Ninety-Seven #
The bundle held for a long time. In 1961 Donald Oken published in JAMA the results of a questionnaire he had given to physicians at Michael Reese Hospital in Chicago, asking, among other things, whether they told patients that they had cancer. Ninety percent of those who responded said they preferred not to. In 1977 a group led by Dennis Novack gave the same questionnaire to 699 members of the medical staff of a university hospital. Of the 264 who answered, 97 percent said they preferred to tell. Reporting the result in JAMA in 1979, the authors called it a complete reversal of attitude. It had taken less than a generation.
The numbers need their limits stated. These were two surveys at two institutions, of the physicians who chose to answer, and they record stated preferences, not observed conduct. They are not a history of American medicine. But they mark, at two points in time, something that larger histories describe at greater length: within the working lives of physicians still alive, the sentence in Percival’s text and the qualification in his note changed places.
There is a detail in the 1979 report that is quoted far less often than the percentages, and I think it matters more. In both surveys, the physicians named clinical experience as the main reason for their policy. Experience had taught the doctors of 1961 to withhold the diagnosis and the doctors of 1977 to disclose it. The authors observed, with some dryness, that experience had been the determining factor in two opposite policies. They noted too that the 1977 respondents said they were less likely than their predecessors to change their policy or to be swayed by research. Their conclusion was that physicians were still basing their policies on “emotion-laden personal conviction rather than the outcome of properly designed scientific studies.”
That finding unsettles me in a useful way. The reversal changed the content of the conviction and kept its manner. The physicians who had arrived at the better view held it as their predecessors had held the worse one: on the strength of their own experience, and with less willingness to be moved. Anyone writing down what must not change in medicine should feel that observation pressing on his elbow. A commitment that feels permanent to me may be the ninety-seven percent speaking with the confidence of the ninety. What could keep it from being only that is whether it can say what it is for, and what would count as evidence against it.
And here the history offers something more hopeful than a warning. When the policy reversed, Percival’s value did not disappear. Hope and comfort are still among the things a sick person needs, and good physicians still try to provide them. What changed was the method. Hope came to be sought in the company of the truth, through how it is told, how fast, in whose presence, with what offered alongside it, instead of in the truth’s absence. Gisborne’s qualification turned out to be the condition on which Percival’s sentence could survive.
There is a mechanism behind that, and Johnson had already put his finger on it. I believe it has been frequently practised on myself. Benevolent deception does not stay inside the room where it is practiced. Once a profession is known to soften bad news by concealing it, every piece of good news it delivers becomes suspect. The patient told that a shadow on the film is nothing to worry about cannot know whether he is hearing a finding or a kindness, and so the reassurance, which was meant to be the cordial, loses its power to comfort. A physician who lies to one patient for that patient’s sake draws down a currency that every other physician must spend. Concealment, practiced to protect hope, ends by making hope unbelievable. That is why the method could not be kept even for the sake of the value it served: it was quietly destroying the value.
The Leopard’s Bargain #
Perhaps the most famous sentence ever written about preservation through change is spoken by a young aristocrat who intends to profit by it. In Giuseppe Tomasi di Lampedusa’s The Leopard, published in 1958, a year after its author’s death, the Prince of Salina watches the old order of Sicily give way in 1860, as Garibaldi’s forces land on the island. His nephew Tancredi, charming and ambitious, is leaving to join the rebels, and he explains himself to his uncle. In Archibald Colquhoun’s translation: “If we want things to stay as they are, things will have to change.”
Tancredi means it shrewdly. The family will survive by attaching itself to the new order, and in the novel it does, partly through Tancredi’s marriage to the beautiful daughter of a newly rich local mayor whom the old families look down on. The line has entered Italian political vocabulary as a byword for reform designed to preserve the powerful, for changing the flag in order to keep the estates. It is the most serious objection this essay faces.
A physician who writes down what must not change in medicine is a member of a profession with privileges: authority, income, the deference of strangers, the right to decide on behalf of people who cannot check the decision. Professions have often spoken the language of permanent values at precisely the moments when those privileges were questioned. It is not hard to find, in the history of any learned trade, appeals to tradition that protected the practitioner more than the person served. Percival’s own code, admirable as much of it is, was born partly as an etiquette for rival practitioners, a way of settling who outranked whom in an infirmary. Phrases such as the doctor–patient relationship, clinical judgment and the art of medicine name real things. They can also be used to wave away scrutiny: to resist measurement, to resist patients reading what has been written about them, to resist other trained people taking on work that physicians once kept for themselves. An essay about enduring values, written from the physician’s chair, could be Tancredi’s bargain in a white coat: accept the new tools, adopt the new vocabulary of partnership and shared decisions, and keep everything that mattered to the doctor exactly where it was.
I do not think the objection can be refuted in general. It can only be answered commitment by commitment, with a test. For anything I propose to keep, the question is whose things would stay as they are. If a commitment, examined closely, mostly preserves the physician’s comfort, standing or convenience, it is the Leopard’s bargain, however nobly it is phrased. If it preserves something that the person in the other chair needs and could lose, it has a claim to permanence, and the physician’s habits are the things that may have to change to honor it.
Read that way, Tancredi’s sentence can be turned around and used in good faith. If we want the patient’s things to stay as they are, the right to know, the chance to be heard, the assurance that someone is answerable, then the profession’s things, its methods, formats, rituals and comforts, will have to change. That is exactly what happened between Percival’s sentence and Gisborne’s note. The physician’s comfortable method was given up so that the patient’s hope could be kept honestly. The Leopard’s bargain runs the other way.
Planks and Water #
The question of what persists through change is older than medicine’s version of it. Plutarch, in his life of Theseus, records that the Athenians preserved the thirty-oared ship in which Theseus had returned from Crete, down to the time of Demetrius of Phalerum. As the old timbers decayed they took them out and put new ones in, so that the ship became, in the old Dryden translation, “a standing example among the philosophers” for the question of growing things: some held that it remained the same ship, and others that it did not. Thomas Hobbes, in 1655, sharpened the puzzle. Suppose someone had kept the old planks as they were removed and reassembled them. Which then would be the ship of Theseus?
Medicine has a ship of its own. The Hippocratic Oath, the oldest text physicians still invoke, opens with an appeal to Apollo the Physician, to Asclepius, Hygieia and Panacea, and to all the gods and goddesses. It binds the new physician to regard his teacher as a parent and to teach the teacher’s sons without fee. It renounces cutting for the stone, leaving that work to those who practice it. It promises to keep silent about what is seen or heard in the course of treatment that ought not to be spread abroad. Most of those planks have been replaced. The gods have gone from most of the oaths recited at modern graduations; so has the guild’s arrangement about fees; surgery is no longer something a physician swears not to do. When the World Medical Association adopted the Declaration of Geneva in 1948 as a modern physician’s pledge, it promised, in the idiom of its day, “My colleagues will be my brothers,” and it promised to respect the secrets confided in the physician. When the Declaration was amended in 2017 it added a promise to respect “the autonomy and dignity of my patient,” and another, which no ancient oath would have thought to include, to attend to the physician’s own health.
Laid out like that, the history is instructive. One plank, confidentiality, has run all the way from the Hippocratic text through 1948 to 2017. Autonomy entered the Declaration only in 2017, though the idea had been reshaping medical ethics since about the time of Novack’s survey. And truthfulness, the commitment that feels to me most like bedrock, appears in neither the ancient Oath nor the 1948 Declaration as a promise of its own. Is this the same ship? Hobbes’s version of the puzzle answers in an unexpected way. If someone reassembled the original planks and recited the Oath exactly as written, invocation and all, the result would be a museum piece. Nobody would mistake it for medicine.
Heraclitus gives a better image, if one reads the fragment that scholars generally take to be closer to his own words. The slogan everyone knows, that you cannot step twice into the same river, comes from Plato’s report of him in the Cratylus. The fragment itself says something stranger. In my rendering: upon those who step into the same rivers, different and again different waters flow. The rivers are the same. The waters are different. The sentence does not say that identity is an illusion. It says that a river is the same river because its water keeps changing, and that a river which stopped flowing would not become a purer river. It would become a pond.
A living practice is more like the river than the ship. Its identity lies in its course, the bed it runs in and the direction it runs, not in the particular water passing at a given moment. The commitments are the bed; the methods are the water. I do not want to lean on the image too hard, because it has an obvious weakness: rivers change their beds too, slowly, and a profession can flow steadily in a direction that serves itself. The image cannot settle anything alone. What it does is move the question. It is no longer which of these planks is original? It becomes which way is this running, and for whom?
Erosion by Default #
The Leopard is one danger, and it is the one a physician writing about values is most likely to be accused of. There is an opposite danger, and in a period of rapid change in medical tools it may be the larger. Tancredi pretends to change in order to keep everything. The opposite failure changes the bed along with the water and never notices that a decision was made.
Commitments in medicine are rarely abolished. Nobody convenes a meeting to vote against confidentiality, or against the patient’s chance to be heard, or against the referral that carries a question. They are eroded instead, by defaults: by the form that offers a box to tick in place of a sentence to write, by the setting that copies a document to everyone who might conceivably need it, by the schedule that allots a fixed number of minutes regardless of what the person in the chair has brought. Each default is reasonable on its own terms. Each saves someone time or protects someone from an error. Their cumulative effect can be to change what a visit is without anyone having chosen the change.
Confidentiality is the clearest example because it has lasted longest. It survived, in one form or another, from the Hippocratic text to the Declaration of 2017, through every change in the gods invoked and the fees arranged. The threat to it now is not that physicians will swear against it. It is that information about a person now moves through many more hands, and many more systems, than any oath-taker could have pictured, and that each new route is opened for a sensible reason. The commitment can be honored in every individual decision and still be lost in the sum of them.
That is why the test I proposed for the Leopard has to run in both directions. Of anything a physician wants to keep, ask whose things it keeps as they are. Of anything new that is offered, ask what commitment it quietly rewrites, and whether anyone has decided that the rewriting is acceptable. Neither question is hostile to change. The second is the condition on which change can be trusted.
Four Promises and What Happens Next #
With those warnings in place, I will say what I would keep. There are four expectations, and something behind them that is less an expectation than a posture. Each is tested by what happens after the visit, not by how it sounds on a page.
Consider a hypothetical patient: a man in his late fifties whom the clinic has asked to come in because his blood-pressure readings have been high. That is the agenda on the screen. His own agenda, which he will reach only if he is allowed to, is that he has been waking at four every morning since a business he spent twenty years building failed in the spring.
The first expectation is the chance to say what is wrong before being steered. Studies of recorded visits, some discussed in other essays on this site, suggest that this is less common than it ought to be. But the test of the commitment is not the length of the man’s opening. It is whether what he says changes what is asked next. A physician can let a patient talk for two full minutes and then ask the questions she had prepared before he came in. If the man mentions the four o’clock waking and the next question is about salt, he was given time and not attention.
The second is an honest account of uncertainty that does not become an excuse for being unhelpful. There is a lazy kind of candor in medicine that consists of listing everything a finding might mean and leaving the listener to sort the list. In the hypothetical case the physician does not yet know whether the readings reflect a lasting condition or a hard season of sleeplessness and strain, and she should say so. But the useful version commits to something: My best guess is this, here is how we will find out, and here is what would make me think differently. Uncertainty told that way gives the person somewhere to stand. Told the other way, it hands him the physician’s burden and calls it honesty.
The third is a plan the person understands well enough to argue with. Abbreviations give us away here. Follow up p.r.n. is a respectable entry in a chart, from the Latin pro re nata, as the occasion arises. To the man driving home it means very little, because he does not know which occasions the physician had in mind. A plan he can follow has to be made for his life, which means knowing what would make it hard: the cost of a prescription, the hours he can take off, the shame he may feel at needing help for something he thinks he should manage alone. A nod is not evidence of understanding, and a signature on a form is not evidence either. A man who is embarrassed may say yes to everything. The plan is finished when he could explain it to someone at home and say which part he doubts, and when the physician has heard the doubt and either answered it or changed the plan.
The fourth is that the question travels. When care passes to another clinician, the thing most easily lost is the reason for the handoff. Suppose the physician refers the man on. A referral that says insomnia, evaluate and treat passes along a person. A referral that says he has been waking early since a business loss in the spring; I am wondering whether this is depression, and whether treating it may matter more for his blood pressure than another tablet; can you help me answer that? passes along a question, and a question can be answered. A forwarded record, however complete, does not by itself make a handoff. Forty pages of history can arrive without a single sentence saying why the person is there. The test is simple to state and surprisingly often failed: does the clinician on the receiving end know what she is being asked?
Behind all four sits answerability. That includes being reachable through some sensible channel, and it includes something harder, which is being willing to come back and say, I have been thinking about what you told me, and I would like to change the plan. Reconsidering is part of the work. Saying so aloud is part of deserving the trust that made the first plan possible.
In the hypothetical case, answerability might look like nothing more than a telephone call. Some weeks later, looking at the readings the man has sent in, the physician sees that they have settled as his sleep has begun to recover, and she calls to say that she would like to change the plan they made and to see him before deciding anything further. It is an unremarkable call. It also requires her to say, in effect, that a plan she proposed with some confidence was premature, and to say it to a man who may have told his family that the doctor had sorted things out. Answerability includes a willingness to be seen revising. Physicians are trained, for good reasons, to project steadiness, and the harder lesson is that a revised plan, openly explained, is a form of steadiness and not a lapse from it.
Shared Conditions #
Written out like that, the commitments risk a particular distortion. They begin to sound like the private virtues of one diligent physician, who listens, explains, writes careful letters and is always reachable. That picture is flattering, and it is wrong, and it is dangerous.
It is wrong because almost none of these commitments can be kept by one person. The medical assistant who takes the man’s readings may be the one he tells about the business, perhaps because she seems less intimidating than the doctor. The person at the front desk may be the first to notice that he has not come back. A pharmacist may catch the medication he cannot afford before he gives up on it quietly. An interpreter, when one is needed, carries the explanation across a language, and family members often carry the plan home and decide what to make of it. The patient carries a share as well: bringing his questions, saying when the plan has stopped fitting. Each commitment is a property of an arrangement, and the physician is one part of the arrangement. A doctor who forgets that tends to make everyone else’s part harder.
It is dangerous because answerability modeled as one physician’s unlimited availability is a commitment designed to fail. A single exhausted person is a single point of failure. The physician who answers every message at midnight will eventually miss one, and the system that depended on her will have no way of noticing. Answerability that lasts has to be built into arrangements: who covers when the physician is away, how a result reaches the person who ordered it, what happens to a message nobody claims. Those are dull questions, and they decide whether the promise is real.
And the shared conditions have limits that should be said plainly. A patient can be invited to disagree, but he cannot be made responsible for the system’s handoffs. A family can carry a plan home, but it should not have to reconstruct a decision nobody explained. The person in the other chair is a partner in the arrangement, not its maintenance staff.
The Unchanging, Reserved #
The vocabulary of my own tradition has a word for what does not change, and I find that it helps me most by refusing to let me use it carelessly. The word is ਸਤਿ, sat, which means true, and also real, what genuinely is. It stands near the very opening of the Guru Granth Sahib, and the short shalok at the beginning of Japji speaks of the True as true at the beginning, true through the ages, true now and true to come. That is my description of the passage, not a translation.
What strikes me, reading as a physician and not as a theologian, is where that permanence is placed. As I read it, the unchanging belongs to the Real. It is not ascribed to any human arrangement: not to a custom, not to a code, not to the habits of a profession, however venerable. Nothing Percival wrote, nothing in the Declaration of Geneva and nothing in this essay is entitled to borrow the word. There is also a line of Guru Nanak’s, in Sri Rag, that is often rendered in English as saying that truth is higher than everything, but higher still is truthful living. Truthful living is conduct, and conduct has to be performed again, in each encounter, in whatever form that encounter requires.
I do not want to press scripture into service as professional guidance; they are different kinds of thing, and I speak only for my own reading. But the reading does a specific piece of work for me in this essay. It denies me ownership of the permanent. The physician who believes he possesses unchanging values is halfway to the Leopard’s bargain, because whatever he already does can then be described as fidelity. The physician who believes that permanence lies beyond him, and that his part is truthful conduct renewed each time, has to keep asking whether what he did today was truthful. That question cannot be settled once. It has to be asked again tomorrow, by someone who has not been allowed to assume the answer.
Keeping a Promise by Changing It #
So the phrase must not change acquires a more demanding meaning than it seemed to have at the start. It cannot refer to the habits that feel familiar to the physician, because some familiar habits are exactly what prevent the stated value from being realized. A process can preserve the appearance of continuity while leaving nobody clearly responsible for the next step. A courteous conversation can end without the patient knowing what was decided. A commitment can stay constant while the method of honoring it changes completely, and often it must.
Here is one example of what I mean, offered as a method I would want to test against myself, not as a report of how I already work. One familiar habit in medicine is that no news is good news: a test is ordered, and if the result is normal, nobody calls. The habit is efficient, and it is also, from the patient’s side, an exercise in interpreting silence. Silence after a test can mean that the result was normal, that it has not come back, that it came back and was missed, or that it was seen and the message went astray. The person waiting cannot tell which. A commitment to answerability, taken seriously, would retire the habit: every result reported, including the normal ones, so that silence never has to be interpreted. The value is old. Percival would have recognized it as part of being a minister of comfort. The method is new, and it costs effort, and it has to be built into an arrangement because no single person can remember to do it every time.
Every one of the commitments above can be tested in the same way. Can the person explain the next step in terms that make sense in his own life? Does the receiving clinician know the purpose of a referral? Is there a usable way to raise a concern when the plan no longer fits? Is there any result whose absence would leave someone guessing? These are questions for examination, not claims that one measure can certify humane care. They keep the writer of a personal essay from the comfortable position such essays offer. Stating a value is easy on a page. Identifying the practice that could contradict it is harder and more useful.
I want to be clear about the register of all this. These are expectations I hold for how I want to work, not a record that I have always met them. What I hope to preserve should make me more willing to reconsider my methods, including the methods through which I have learned to feel competent. Competence is precisely where the Leopard hides, because a method that has made a physician feel capable for twenty years is the hardest one to see as a method.
Percival, I have come to think, left us a better model than his sentence. He did not delete Gisborne’s objection or Johnson’s dissent. He printed them in his own book, beside his own argument, where any reader could weigh them, and readers eventually decided against him. If someone later adds a note to what I have written here, saying that a commitment I thought permanent was only a habit of my time, I hope I would have the grace to print it in the margin and let it argue. The next tool is already on its way, and the question I would most want to put to it is the one I would most want put to me at the end of any ordinary visit. Does the person leaving know what was decided, and whom to call if it turns out to be wrong?
Evidence and Editorial Note #
Documented findings. Public biography: MBBS in Amritsar, postgraduate training in Little Rock and Fresno, practice in California since 2010; Sikh. Thomas Percival’s Medical Ethics (private version 1794; published 1803), its origin in disputes among the physicians, surgeons and apothecaries of the Manchester Infirmary, and its influence on the American Medical Association’s 1847 code: the Wikipedia article on Percival and standard histories of medical ethics. The text of Percival’s chapter II, section 3 (“minister of hope and comfort to the sick”), and his Note III, including Gisborne’s proposed addition “as far as truth and sincerity will admit,” Gisborne’s sentence “He is at liberty to say little; but let that little be true” from his Enquiry into the Duties of Men (1794), Johnson’s remarks as recorded by Boswell under 13 June 1784, and Percival’s conclusion: the 1849 Oxford edition of Percival’s Medical Ethics, read in full text at the Internet Archive. Oken D, “What to tell cancer patients: a study of medical attitudes,” JAMA 175 (1961): 1120–1128, and Novack DH et al., “Changes in physicians’ attitudes toward telling the cancer patient,” JAMA 241 (1979): 897–900 (questionnaire to 699 university-hospital staff in 1977; 264 respondents; 97 percent preferring to tell, against 90 percent preferring not to tell in 1961; clinical experience as the determinant of opposite policies; respondents less likely to change policy or be swayed by research; the quoted phrase on personal conviction): the PubMed records and abstract. Giuseppe Tomasi di Lampedusa, Il Gattopardo (1958), and Tancredi’s line in Archibald Colquhoun’s English translation (1960): standard literary reference. Plutarch’s Life of Theseus on the ship (Dryden translation as revised by Clough) and Hobbes’s De Corpore (1655): standard sources. Heraclitus, fragment B12 (Diels–Kranz), in the author’s rendering, and Plato, Cratylus 402a: standard sources. The content of the Hippocratic Oath: standard translations. The Declaration of Geneva as adopted in 1948 and as amended in 2017: the World Medical Association’s current policy page and its archived 1948 text. The studies of recorded visits referred to in a clause are treated, with sources, in other essays on this site. Pro re nata: standard medical Latin. ਸਤਿ near the opening of the Guru Granth Sahib and the opening shalok of Japji are described, not quoted; the line from Sri Rag is given as a common English paraphrase. The three tests of fidelity, equality and embodiment: as set out in the flagship essay on this site. Vendor representations. None; no product is named.
Recollection and tradition. The training chronology is the author’s published biography. The patient in the blood-pressure example is hypothetical, introduced as such, and is not drawn from any actual encounter; the referral wording and the phrases attributed to a clinician are examples of wording, not recollections. The reading of ਸਤਿ and of the line from Sri Rag is the author’s own reflection and is not offered as a statement of what Sikhs in general believe. The essay makes no claim that the author has always met the expectations it sets out, and states the opposite plainly; the practice of reporting every result is offered as a method to be tested, not as a description of his own practice.
Analysis and forecast. The readings of Percival, Gisborne, Johnson, the disclosure surveys, Lampedusa, the Ship of Theseus, Heraclitus and the Declaration of Geneva, the proposed test for the Leopard’s bargain, the account of erosion by default, and the four expectations are the author’s ethical preferences and interpretation as of November 6, 2026; they are not a statement of any legal or professional standard of care. Independence. This essay is not sponsored by any institution, company, health system or technology developer. It is personal reflection, not medical advice; readers seeking care should contact their own physician’s office.
About the Author #
Kanwar Partap Singh Gill, MD, traces his family roots to Khadur Sahib in Punjab’s Majha region and grew up in Amritsar. He attended Spring Dale School and completed pre-medical studies at Khalsa College in 1994–1996. He earned his MBBS from Sri Guru Ram Das Institute of Medical Sciences and Research in Amritsar in 2002.
He completed PGY-1 at the University of Arkansas for Medical Sciences in Little Rock in 2007–2008, and PGY-2 and PGY-3 with UCSF Fresno at Community Regional Medical Center from 2008 through 2010. He has practiced medicine in California since 2010.
His career has crossed four distinct information eras: predominantly paper-based medicine, early and fragmented electronic records, the integrated-EHR era, and the emerging age of generative and agentic artificial intelligence.