The Distributed Hippocratic Oath

9 min readMay 11, 2019

5 Principles as a Framework for the Blockchain Evolution of Healthcare

A fragment of the Oath on the 3rd century Papyrus Oxyrhynchus 2547

Medicine is at the dawn of the largest disruption in history. Blockchain technology and smart contracts can provide the needed security to keep the lid on Pandora´s box.

In looking back in the history of healthcare and specifically the Hippocratic oath, I found interesting parallels which can serve as an inspiration and framework in moving forward in the coming integration of blockchain and healthcare.

3D printed organs, daily biohacking, customized stem cell injections, and revolutionary gene editing are just a few of the motors pushing the changes in medicine in the next years.

Still, to get to this level we have traveled from the cold stone age and through the dark middle ages (alas with amazing peaks of enlightenment and lows of primitive barbarity).

“There are 3 constants in life…change, choice and principles” — Stephen R. Covey

The oath was a framework for how physicians should conduct their practice in case of moral dilemmas. They chose certain principles because they knew with great knowledge and power comes great responsibility.

Basic Principles of a Physicians Oath

As a general simplification the different versions of the oaths can be summarized as follows:

1. Do No Harm

2. Non-discrimination

3. Service to Others — Charity

4. Respect the secrets of patients, even after death

5. Fraternity to colleagues and teachers

“In a survey of medical schools in the US in the year 2000, all of the then existing medical schools administered some type of profession oath. Among them, sixty-two of 122 used the Hippocratic Oath or a modified version of it. The other sixty schools used the original or modified Declaration of Geneva, Oath of Maimonides, or an oath authored by students and or faculty.” (7)

But shouldn´t this be a given, that Doctors want to help people get well again? I mean, whoever has the calling to heal sick people, surely follows the Golden-Rule and does not need to swear by it, right?

Nevertheless, at the very latest since the Milgram experiments, we know that even good people are capable of doing bad things if the circumstances are right (4). Only counter-conditioning and a conscious choice can make us immune to our “Oh-so-human-nature”.

There is an innate power in a group of humans aligning their thoughts and will in a solemn pledge.

Yet just as the Hippocratic Oath was a starting point in the ongoing journey of medical ethics, culminating in modifications and cross-disciplinary codes of conduct, we are still at the very beginning of the “Blockchain-Era-of-Things”. (8,9)

Basic definition of a Blockchain

In his brilliant talk in South Africa “Blockchain vs. Bullshit”, Andreas Antonopoulos makes the following requirements of any type of blockchain in general (10):

1. Decentralized

2. Open

3. Borderless and Transnational

4. Neutral

5. Efficient

6. Transparent

7. Immutable

The ironic thing is that as much as the blockchain thrives on distrust being the fabric of incentive, in healthcare the psychological need for a personal touch, dignity, and trust are of the essence.

Futurist Ray Kurzweils´prognosis that the average life expectancy will be 100 years by 2019 provides a diverse plethora of implications (13).

Children born today will not know a world without Blockchain Industries, just as Children born 20 years ago do not know a world without Google Search, Facebook Feeds and YouTube Videos.

Let me say that again: Little Max who is in the kindergarten today will never learn how to drive a car, will never know paper money, but it will be normal for him to carry his whole health history in his pocket or on or IN his wrist. He will ask Siri/Alexa in the future what pills or treatment he should take with every minuscule to major ailment he has.

Transhumanism will need a layer of decentralized security to be feasible. Blockchains can be that solution if done correctly. Let us now lay the groundwork so that Little Max future health data and body are neither “owned” by centralized governments or corporations, nor hackable by out-of-date database models.

The Hippocratic Protocol 2.0

Here are the 5 principles of the Physician's Creed with a Blockchain + Healthcare 2.0 twist to it. The fusion was an interesting journey and might act as a starting point for an ethical framework:

Do No Harm

In light of Google having “Don´t be evil” as a motto in their code of conduct, it seems sensible to think of legal or other regulatory measures to control this explosion of blockchain technologies. Since the Internet was “only” the method of primarily exchanging information until now (and value or consequences were triggered through the application of said information), the Blockchain Boom enables for the first time a global exchange of VALUES without intermediaries. Many experts say the ramifications are 10x bigger than those that the Internet had. At least.

So surely we need some control? Some might be shouting “A shit load of regulations please!!”. Well, probably not those reading this article, but one thing is for sure, is that jurisdictions worldwide will have to come to grips with this semi-new principle of “Trust through Transparency”. And it is also certain that they will arrive too late. Legal bodies will lag behind innovation on a scale not known before.

“Doctors need to be held accountable since power corrupts. There must be complaints procedures and litigation, commissions of enquiry, punishment and compensation. At the same time if you do not hide or deny any mistakes when things go wrong, and if your patients and their families know that you are distressed by whatever happened, you might, if you are lucky, receive the precious gift of forgiveness.” Henry Marsh, Surgeon, (15)

The good news is that many of today's common problems will just magically disappear through future transparency. All symptoms and treatments will be aggregated and “cause and effect” will be visible as never before. Malpractice before and after the diagnosis will be made accountable and unnecessary errors will be a thing of the past. Deliberate overtreatment because of pure profit will be almost impossible to disguise anymore.

So what can developers/we do in the case of Blockchain + Healthcare?

Push to make anonymized health results and KPIs publically or at least openly (inside a closed blockchain) accessible, even if the results are negative.

Outsource the medical quality assurance to neutral third-party actors, with no vested interests in outcomes of treatments or medication. Then outsource the controlling of these third-party analysts to another set of neutral observers. Checks and balances galore. Rinse, repeat and triple check.

Non-Discrimination

The Blockchain as a technology is inherently non-discriminating. Anyone with an internet connection and a computer can participate. It is foreseeable that some current models of thinking will have a hard time swallowing this. A common argument against Bitcoin, for example, is its neutral, non-discriminating nature in regards to drug trafficking, money laundering and all things naughty in the dark web. Yet the main currency by a long run in which criminal and/or illegal dealings are done is still the US Dollar. Yet no one is calling for the abolishment of the USD.

It takes an unbiased and rational mind to acknowledge that the principle of not discriminating access to powerful tools more often than not provides much more benefits than risks, especially when the risks are spread out.

“Collective fear stimulates herd instinct, and tends to produce ferocity toward those who are not regarded as members of the herd.” Bertrand Russell (14)

The rise in terrorist attacks with larger vehicles has no one calling for the regulation of trucks and lorries. It is common sense that we must rather invest in the lowering of incentive and the raising of protection and awareness of pedestrians than in asking for a background check of the UPS or FedEx driver.

There are not significantly more trucks, pedestrians or terrorists in the world then there was 20 years ago. The difference, in my opinion, is that the macabre methods gain much more traction and a larger audience due to social media and the internet than before.

So what can developers/we do in the case of Blockchain + Healthcare?

Code for added redundancy, so that even the smallest participants in terms of financial, political or technical power, have access to data and scalable solutions. Lower any and all barriers to entry, and implement safeguards against centralist power players aiming for a monopoly on any data or intellectual property. Monopoly on implementation and providing solutions to problems are allowed since that is an external free market playing field.

Charity

Currently, there is no incentive for large corporations to undermine their own operations and market value by offering services in poorer countries.

Low-cost mass-analytics and the subsequent data exchange could provide the momentum and ROI for all sorts of non-profit organizations, not just Big Pharma.

“Look at the problem of drug-resistant TB in the world. Look at HIV in the world. What’s going to be required for everybody, in the long run, is the ability to do complex health interventions in poor settings.” — Jim Yong Kim (1)

In the Global Market Insights, Inc. Report: “The healthcare analytics market, having had a revenue of $5.5 billion in 2016, will collect a significant revenue of more than $16 billion with an annual growth rate exceeding 12 percent over the period of 2017 to 2024.”(5,6)

So what can developers/we do in the case of Blockchain + Healthcare?

Like the language learning App Duolingo, is free for the end-consumer, and has based its business model on media houses like the New York Times paying the manually corrected translations done by native speakers, while learning their new languages (Crowdsourcing through crowdcorrecting if you will), charity in health services could also be based upon an indirect model. Patients allowing access to anonymized health data may help pay for new treatments and medicines for example. This could be enabled by a utility token model.

Respect of Secrets

Here we are obviously navigating between the dignity and protection of the patient (3), and the unimaginable discoveries entailed in the marriage between Mr. Big Data and Ms. Quantified Self.

It is more important to know what sort of person has a disease than to know what sort of disease a person has. — Hippocrates (2)

Imagine high-quality health data, in a worldwide scope that makes current double-blind studies seem like a medicine man from the jungle saying he knows all diseases and cures in existence.

Here it seems important that we distinguish between metrics that might be public and open to health care providers and metrics that should be treated with respect. If everything is logged and immutable and our whole life (remember we will all be 100 years old at least if a truck or drone does not hit us;)) is transparent, then insurance agencies might throw us out at the slightest trespass. Our recent divorce and the subsequently logged cortisol levels and other bio-metrics might be the reason we are not hired. The transparent human with no margin for error or buffer for booze might make us all much more honest, but also somehow we would also lose our dignity.

So what can we do in the case of Blockchain + Healthcare?

We should strive to make as much as possible permission-based and access to sensitive information should be connected to an expiration date. Furthermore, the correct mix between a humanistic leniency and transition periods to rock hard accountability and efficiency should be a pillar in the framework in that we should invest the necessary time and energy in.

Fraternity

Transparency, openness, accountability and voluntary solidarity are a few of the characteristics that one might use to describe brotherly connectedness. The same goes for this merger of healthcare and blockchains. We should strive to make as much as possible open-source and easily accessible to all.

A lack of transparency results in distrust and a deep sense of insecurity. — Dalai Lama

At the moment cryptocurrencies are still the main driving force behind blockchain technologies. The advantages are comparably simple to understand and communicate. Yet still, we cannot say that Bitcoin or Ethereum is mainstream. The more people get involved now, the faster the technology will mature and we can democratize all value content types. Pay and get paid with Bitcoin.

So what can we do in the case of Blockchain + Healthcare?

Once smart contracts become readily available, become a user. Talk with your grandma about it. Demand decentralized ledger technology from your health care providers. Pay homage to Satoshi if you want to. Do not accept governments trying to centralize and control the blockchain tsunami. Just as they try to do it time and time again regarding the Internet, Users must fight back and bring Blockchain out of the Deep Web and into the depths of the hearts of our brothers and sisters around the world.

Little Max will thank you for it!

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Frank Xavier

Tech Enthusiast, Blockchain Blogger and Father

Writing to prepare the world for a better Post-Singularity Future.

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(1) Jim Yong Kim (n.d.). Retrieved November 29, 2017, from BrainyQuote.com Web site: https://www.brainyquote.com/quotes/jim_yong_kim_643898

(2) Hippocrates (n.d.). Retrieved November 29, 2017, from BrainyQuote.com Web site: https://www.brainyquote.com/quotes/hippocrates_132701

(3) Anonymising and sharing individual patient data https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707567/

(4) https://en.wikipedia.org/wiki/Milgram_experiment

(5) https://www.itnonline.com/article/analytics-next-big-health-it-undertaking

(6) https://www.itnonline.com/article/market-growth-healthcare-analytics