Kevin T. Keith: Hippocratic Oath

Many people ask about the Hippocratic Oath when discussing some practical issue in medical ethics: "What does the Hippocratic Oath say about this?", or "Does this violate the Hippocratic Oath?" The Oath is often invoked as a kind of moral argument against a certain medical practice: "that would violate the Hippocratic Oath!" It surprises many to find out just what is in the Hippocratic Oath, and what (little) power or authority it has within the medical profession. It often shocks them to discover that most medical ethicists don't regard it as having much significance for working out problems in medical ethics.

A brief overview of the Oath and its place in medical training and medical ethics may be helpful. There is much more that could be said on this issue, but the discussion below should provide a useful introduction for those interested.

Oaths and Problems With Oaths

Most or all US medical schools these days hold a graduation ceremony involving recitation of some sort of oath. It is a powerful bit of medical tradition, and expresses something of the moral aspirations of the profession. Traditionally - and as many members of the public still assume - the oath taken by medical graduates was "The Hippocratic Oath". Today, however, the original Hippocratic Oath is not usually the one recited. There are reasons for this, and they get to the heart of what an oath is, what it is intended to accomplish, and how it works to those ends.

Content and Functions of Oaths

An oath – a professional oath, an oath of office, an oath of truth-telling, or whatever the case may be – is a promise of fealty. It is a statement that the oath-taker endorses whatever beliefs or obligations the oath expresses, and, by the act of swearing the oath, binds themselves to uphold its terms. Often an oath is reinforced by an invocation of some value the oath-taker holds dear, such as a promise to their god, or a pledge of honor, which reassures the hearer that they will hold to the oath because they would not be willing to put that value in jeopardy.

Thus, both the explicit contents of the oath and the bond of obligation it expresses are of great significance. For an oath to serve its purpose, and for it to have binding power, both these aspects of the oath must be carefully crafted.

Arguments Against Oaths in General

There are good reasons for not adopting any oath, except perhaps as a symbolic act of commitment to ethical practice in general. The reasons are obvious: ethics is extremely complicated, and practical cases - especially in medicine - admit of many twists and unexpected details; it is impossible to craft a short statement that accounts for all possible cases. Also, there is general agreement that people with differing moral perspectives should have the right to practice the professions, so demanding that they accept a specific set of moral principles (at least one much more restrictive than the general moral constraints that bind our society as a whole) would be unfair. (I personally find that argument unpersuasive, but it is a consideration.)

More to the point, no one can agree on what should be in such an oath, so to impose one by fiat on students and then declare that they had to follow it whether they agreed or not would be impossible - yet it would also be impossible to create an oath that all could agree on. Given these complications, it may be best to have no oath, or only a very general one. (Note that the AMA has no formal ethics oath. They have a statement of "Principles of Ethics" that runs to 9 broad points, and a "Code of Ethics" that is more like an annotated legal code and contains hundreds of specific rules with extensive commentary, but no oral oath.)

The Hippocratic Oath Considered as an Oath

There is another aspect of oaths that is of significance in the case of the Hippocratic Oath specifically: an oath is not an expression of moral principle in and of itself, it is merely a promise. In taking an oath to tell "faithfully execute the office of President," you are not acknowledging a moral obligation (it is not immoral not to be President); you are creating a moral obligation – the obligation of faithfully executing promises – which then binds you to acts you would not have been bound to do otherwise. (You may say that anyone who is elected President has an obligation to serve faithfully. That may be true. But the point to taking an oath is that the oath adds to your obligation - it creates a new moral obligation, with enhanced binding force, that did not previously exist – otherwise there would be no point to taking the oath.) So the moral content of the oath is in the taking of the oath itself, not whatever it is you actually promise thereby. But most people see the actual content of the Hippocratic Oath (discussed in detail below) as having particular moral significance for medical practice – it expresses obligations for doctors that may seem to correspond to some notion of the good in medicine in and of itself – but, again, an oath as an oath is only a promise, not a guarantee that what is promised is itself morally right.

For these reasons, most "bioethicists" - most of whom are not MDs - do not regard the Hippocratic Oath or any other such oath as carrying any moral weight; most, that is, would not say that a thing was or was not moral because it did or did not correspond to a statement in some oath.

Though there is a lot of tradition behind the Hippocratic Oath, much more critical attention has been paid to its content in more recent times. There have been various revisions or alternate oaths written over the years, intending to make the oath more relevant or to remove objectionable passages. Some medical schools have written their own; in some cases, the students themselves have debated the ethics of the profession and then written the oaths they would take. (None of these is legally binding on doctors in the US or most other countries, but, if you're going to take an oath anyway, it ought to be one you are willing to live up to, so it's important to get the terms right.)

The Hippocratic Oath: Content and Interpretation

Here is the standard translation of the Hippocratic Oath.

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfil according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

[Note that the phrase "an abortive remedy" is more accurately translated as "a destructive pessary" - the latter probably refers to abortion, but specifically names a particular method of abortion, rather than prohibiting abortion generally. Also, "stone" is understood to mean kidney stones in the bladder.]

Problems With the Hippocratic Oath

Even if you are going to adopt an oath, there are strong reasons for rejecting the Hippocratic Oath in its original form. For one thing, much of it is simply inapplicable, or applicable only by analogy, to modern times. For another, as previously discussed, the specific contents of the oath are open to moral analysis independently of the oath itself; the fact that they are in the Hippocratic Oath does not make them correct moral precepts for the practice of medicine, and asking doctors to bind themselves to practices that are not morally correct is not a good basis for that practice. So the important question for moral medical practice is not "what is in the Hippocratic Oath?," but rather "what is right practice in general, on fundamental moral grounds?"

Binding Obligation Under the Hippocratic Oath

The Oath contains, among other things, an explicit invocation of the Greek gods of health and medicine. It is reaffirmed at end of the Oath, with specific earthly rewards and punishments from those gods also specified. The religious content may be rather unsettling for moderns of whatever religious persuasion. Also, the idea that it is the promise of reward or punishment that motivates allegiance to the oath underscores the fact that it is the oath itself, and not the moral implications of medical practice, that the Hippocratic Oath takes to be binding. But, again as noted above, it is precisely these promises and expectations that make an oath binding (or, more binding than merely reciting the contents of the oath itself, which is again the point of an oath). Obviously, the Oath could be revised to invoke the speaker's personal religious loyalties rather than ancient Greek ones, but admitting that parts of the Oath should be revised immediately raises the question whether other parts might also be changed. The power of the Oath is the (somewhat exaggerated) traditional force it is seen to hold; if it needs to be revised, that tradition must be wrong.

Content of the Hippocratic Oath

There are other aspects of the Oath that raise questions for modern readers: a proscription of misbehavior with slaves (well-intended, clearly, but not quite to the point today); an explicit prohibition on surgery (or at least surgery for bladder stones), which at that time was so barbaric that it was not considered part of the profession of medicine; an explicit vow to "live my life in partnership with" the medical teacher and "if he is in need of money to give him a share of mine" (not exactly the way medicine - no longer an apprenticeship discipline - is taught today), and so forth.

Almost nothing of these precepts makes literal sense in the context of modern medicine – yet they make up more than a third of the specific practical instruction of the Oath. Again, it is easy to say the Oath should just be updated to reflect modern times, but that invites speculation as to why any of the practical content of the Oath is given, and why it should be accepted today.

The Hippocratic Oath on Abortion and Termination of Treatment

Probably the most contentious issues regarding the Oath are its implications for abortion and euthanasia. The Oath is often invoked – often ignorantly – in debates over these topics; it is worth spending some time considering them individually.

Regarding abortion, the question of the Oath's content is obviously salient: abortion is one of the few procedures specifically addressed, directly or indirectly, in text of the Oath itself. And, given the conservative reading of the Oath that was promulgated by Edelweiss, the translator who argued for a blanket prohibition on abortion, the Oath was seen by many, and is still invoked today, as declaring abortion illicit entirely.

In this regard, however, the most important point is that the broad-brush translation used to support this reading is widely regarded as flawed. The actual text of the Oath does not mention abortion as such, but a particular method of abortion which carried particular dangers. Read literally, the Oath says nothing about other methods; as to the moral implications of that fact, it seems significant that the Oath addresses and is limited to a single procedure rather than a general type of treatment. Beyond that, Edelweiss bolsters his expansive translation with an argument regarding the philosophical beliefs of the philosophical sect of which Hippocrates was a member; however, this argument too has been challenged on grounds of historical accuracy (a subject of which I know nothing), and at any rate it forms no part of the actual text of the Oath, which, as noted, was specific and limited. So, it cannot be said that the Hippocratic Oath bans abortion as such; at most it cautions against a certain type of procedure, which is in keeping with its other limited prohibitions (such as a prohibition on surgery by those who are not experienced at it, but not a prohibition for "such men as are engaged in this work"). The reading of the Oath that supports a total ban is based on both a translation and an historical interpretation that are highly questionable, and arise from a particular individual with idiosyncratic views.

Questions about the Hippocratic Oath's implications for euthanasia also come up, particularly frequently during the legal and media maneuvering in the 2005 Terry Schiavo case (when this article was originally written). The discussion below will address this in (limited) detail.

Since the Oath is not binding under law or licensing regulations, it does not offer an avenue for practical action, at the very least.
Whether there is, in fact, a conflict between the Oath and the general practice of terminating life-supportive treatments (including food and water) is an open question. The Oath stipulates two things that bear on this issue: "I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice. [And] I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect." The former explicitly requires the physician to use food and water (and presumably other measures) for the benefit of the sick; the second explicitly prohibits what today we would call physician-assisted suicide (and presumably active euthanasia as well).The general intention, clearly, is that the physician will not act to cause the death of the patient. However, it is not clear that the rule requiring applying dietetic measures for the benefit of the sick means that you must force dietetic treatment on the patient if they themselves do not want it. If not, then this rule does not prohibit actions like that in the Schiavo case, wherein "dietetic measures" were discontinued in keeping with the patient's own previously-expressed wishes. And the prohibition on the use of "deadly drugs" does not literally apply in such cases either. So there are strong grounds for thinking that, even if the Oath prohibits direct action to "harm" or kill a patient, it does not authorize treating patients against their will, or prohibit patients from simply refusing treatments (indeed, the Oath does not apply to patients at all). To reach those conclusions you would have to read the Oath "between the lines" - and in fact go far beyond that to assert some positive right of physicians to "apply dietetic measures for the benefit of the sick over their objections," which is rather a lot to read into it.
Assuming the Oath does prohibit termination of food and water, however, there are many who would argue that that is one of the reasons the Oath needs to be replaced - that is, that we now realize that patient autonomy and the use of medical procedures to promote patients' values and choices is a higher ethical standard than those encapsulated in the Oath, and that for this reason the Oath should be revised or scrapped. Considerations of this kind - that the Oath is either out-moded or simply wrong in some of its precepts - are what prompted the many revisions of it linked above, including Christian, Jewish, and "modern" ones. These may not be so far off. Perhaps there are things about the Oath that need to be revised (anyone who's ever had a bladder stone would agree in a hurry!); if so, perhaps the prohibition on euthanasia is one of them. Some, at least, would think so (note Yale's clearly Hippocrates-inspired Oath, with its paternalistic sections removed and a strong emphasis on patient autonomy); they would deny the claim that there is a conflict between the Hippocratic Oath - rightly conceived - and termination of food and hydration, or perhaps even the giving of "deadly drugs", in some cases.

The Overall Moral Standing of the Hippocratic Oath

There is much good in the Hippocratic Oath - an explicit statement that the physician must hold the patient's good as the only purpose of treatment, several prohibitions on questionable acts, a vow that "in purity and holiness I will guard my life and art", a commandment to maintain confidentiality - but it comes in the context of precepts such as the above, which are no longer applicable or no longer acceptable. And some of its more famous passages are contentious: there is an ongoing debate whether the line about a "pessary" prohibits abortion, or merely one particular, unsafe method of, abortion; the same issue applies to the prohibition on surgery; the Oath also appears to prohibit women from practicing medicine. All these passages would be controversial at best, if not outrightly offensive, in modern practice.

To return again to the clearly outmoded passages - Greek gods, no surgery, no sex with slaves - it is easy to ignore these as merely vestigial, but the problem is this means that, if the vaunted Hippocratic Oath is the end-all and be-all of medical ethics, then the end-all and be-all of medical ethics is riddled with vestigial passages that we are intended to ignore. It seems like a bad idea to have an ethical oath that you are expressly directed to ignore (in part) even while you take it. And which parts really are outmoded? Is the prohibition (if any) on abortion still in effect, or is it vestigial also? (Abortion, after all, is much more widely accepted today than, say, the Greek gods are - why should passages prohibiting abortion be accepted, and passages requiring worship of the Greek Pantheon be ignored, if it is only a question of which ones are "outmoded"?)

So, in the end, although the Hippocratic Oath holds a kind of (mythical) revered place in medical tradition, it cannot be employed as an actual, literal statement of medical ethics or values without engaging a far-reaching debate over what those values should be - after which we would undoubtedly wind up with something very different from the Hippocratic Oath.

As to that revered place in tradition, the Oath's historical popularity has varied widely over time. Originally it applied only to doctors trained in the circle of Hippocrates himself - a fringe group in the ancient Mediterranean. It grew in popularity during the Common Era, but was not formally recited by doctors until the Enlightenment, and was widely used only recently. Oaths of whatever kind did not become really common until the resurgence of formal medical ethics scholarship and ethics codes after the Nazi abuses. Those who argue in favor of the Oath usually do so on grounds of medical tradition - but that tradition is actually less than 300 years old, and became widespread only in the last 60. Seen across the entire span of the Oath's history, the actual traditional treatment of the Hippocratic Oath is benign neglect.

For all these reasons, the Hippocratic Oath currently holds only symbolic authority within the medical profession. There is a rearguard of traditionalist physicians who hold that the Oath is binding simply because it has been seen to be binding in the past, but on a substantive basis there is little disagreement that the actual content of the Oath is not compelling on moral grounds. Parts of it are pointless today, and parts of it are clearly immoral (women can and should be doctors, doctors can and should practice surgery, patients can and should have the right to request or refuse treatments according to their own values). Other parts of it are arguably wrong in the moral perspective of many decent, thoughtful people who prefer to think carefully about morals rather than adhere blindly to a random grab-bag of precepts by a several-thousand-years-dead Bronze Age primitive. There are careful, systematic ways to think about healthcare ethics - and ethicists today prefer to use them, and to leave symbolic statements of ancient values in their historical place.

Alternative Oaths

For the reasons given above, there have been, as I have said, several variations on the Hippocratic Oath, and many alternative oaths.

A widely-used one is a revision of the Hippocratic Oath written by Louis Lasagna, MD - the widely-respected and highly influential pioneer of modern medical ethics.

The lovely Oath of Maimonides, by the great rabbi, clearly influenced by the Hippocratic Oath but put in other terms, is here (this one seems to be popular at some medical schools).

A rather strained version, recast into Christian terms, is here.

A more general form of the Hippocratic Oath, adopted by the World Medical Association in the aftermath of the Nuremburg Trials, is here (the Code of Geneva).

A copy of Yale Medical School's Oath can be found here.

A British medical school's version of the Hippocratic Oath is here.

An excellent summary of the types of oaths commonly used in medical schools today is here.

Postscript

A phrase often associated with the Hippocratic Oath is "Primum Non Nocere" - usually translated as "Above all, do no harm." This is a medical slogan widely believed to be from the Hippocratic Oath but which does not actually appear there (or anywhere else in Hippocrates). In a work entitled Epidemics, Hippocrates did write "As to diseases, make a habit of two things-to help, or at least to do no harm" - which is not the same thing, but expresses a similar sentiment. But even if ol' Hipp did say the "above all . . . " bit, he wouldn't have said it in Latin.