Hippocratic-Oath
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Do no harm” is the phrase people most associate with the Hippocratic Oath, but nowhere does the document say these exact words (“never do harm” is what it actually says [1]).

The Hippocratic Oath is the vow medical students take during their white coat ceremony at the beginning of medical training and again at graduation, proclaiming their commitment to medical ethics. The original oath has been modified multiple times in medicine’s history, but three versions are most commonly recited today. They are:

  • The original 5th-century-B.C. Oath of Hippocrates provided the first ethical guideline for physicians in ancient Greece.
  • The Declaration of Geneva was written in 1948 (amended numerous times, most recently in 2017) in response to the grotesquely inhumane treatment of individuals in Nazi Germany
  • The Modern Physician’s Oath is a 1964 revision by Dr. Louis Lasagna.

New versions of the Hippocratic Oath are increasingly vague

With each new version, however, the oath has grown increasingly vague to accommodate changing values within societies.

The 5th-century-B.C. oath proclaims, for example, “To please no one will I prescribe a deadly drug.” And later, “Nor will I give a woman a pessary to procure abortion.” These two issues are highly relevant in modern times. Physician-assisted suicide, over-prescription of opioids, and abortion are among other topics of debate and controversy today.

The first Declaration of Geneva kept the pledge to “maintain the utmost respect for human life from the time of conception.” However, there is no mention of physician-assisted suicide, euthanasia, or any deadly drug. 

The closest the younger Lasagna oath comes to addressing these controversial topics is when it vaguely notes, “I tread with care in matters of life and death. If it is given to me to save a life, all thanks. But it may also be within my power to take a life.”

The 2017 version of the Declaration of Geneva simply says, “I will maintain the utmost respect for human life,” on the matters of life and death.

Is it ethical to change the oath?

Though revisions to the original oath have diluted specific vows, many updates to the Hippocratic Oath have been useful and productive. Among them are these:

  • Simplifying the language
  • Taking out prayers of fidelity to the Greek gods and goddesses of health care
  • Adding a pledge to care for a physician’s own health are indisputably positive changes

But as the oath becomes more ambiguous, it’s natural to question the ethics of altering moral standards of medicine. Is it ethical to change the Hippocratic Oath to accommodate an ever-changing society?

Yes, according to Joseph Carrese [2] MD, MPH, FACP, chair of the Johns Hopkins Ethics Committee and professor of medicine at the Berman Institute of Bioethics. “Not only do I think it’s ethical to change the oath, I think there’s a strong argument for doing so.” Carrese explains that he doesn’t believe a document written thousands of years ago in a different historical and cultural context should strictly apply to every person, for all time, in all situations.

The original oath also fails to address modern concerns, he adds, such as the importance of working with patients as equals and the right for patients to make their own health care decisions. It even warns against using a knife in certain circumstances—particularly to remove kidney stones [3]—which limits the practice of surgery. Carrese notes that as time passes and physicians learn more about medicine, it is reasonable to revise the ethical guideline.

Some newcomers to the profession agree. Ian Coblentz [4], MD, an intern at UC San Diego Medical Center, explains that the original oath protects against procedures that, in the 5th-century-B.C., were extremely painful and risky due to a lack of technology. But now, doctors perform those procedures frequently with very little danger. “I don’t think [the authors of the oath] had an idea of how modern surgery could be,” Coblentz says. “So I think we do have to adapt the oath and the ethical principles we write into it for the technologies and the techniques we have in the modern-day.”

Personalized Vows

There has even been a recent trend in medical schools for students to work together to write their own[5] oath as a class. Medical schools like Harvard, Yale, and the University of Texas have allowed students to ditch the oaths of the past and write a pledge that holds true to their values, such as incorporating God into their vows and respecting patients of any sexual orientation.

UC San Diego’s med students recite a modern version of the Oath of Hippocrates, but if given the chance to write his own, Coblentz says he wouldn’t have changed much about the version he took. As long as certain basic principles of the oath remain, such as doing good for the patient and treating everyone equally, Coblentz believes there’s room for a diversity of oaths.

But medical student Benjamin Frush, at the University of North Carolina School of Medicine, is not so convinced that customized oaths are a good idea. In “The Hippocratic Oath and the Contemporary Medical Student[6], published in Academic Medicine and co-authored by fellow med students at the University of North Carolina, Frush and his colleagues write, “Such a practice contradicts the purpose of an oath, which draws its adherence into a community and acknowledges the presence of an authority greater than the oath-takers themselves.”

Frush goes on to say that although the original words of the 5th-century-B.C. Oath of Hippocrates may make it difficult for physicians today to endorse in good faith, “modern versions [that] still contain the ethos of the Oath—namely, the calling towards an objective view of good medicine—exist and should be recited rather than individual oaths.”

RELATED: The Ethical Stain on U.S. Medical Care

The oath is a public proclamation about a commitment to medicine

What’s important to Carrese, though, is not the specifics of what students recite, but that they take an oath at all, making a public proclamation about their commitment to the medical profession. Declaring the duties and values of the profession in front of the public, as well as friends and family, is highly valuable, Carrese says, because the medical profession is a public trust. “We exist in a contract or covenant with society—society allows us to exist as a profession and gives us certain privileges, and we need to fulfill certain commitments to retain those privileges and continue to exist as a profession.” The oath is a way for doctors to do that.

The dedication and sense of moral obligation that the oath represents are what Carrese, Frush, and Coblentz all seem to believe make it worth reciting. What’s also important to Coblentz is the promise his teachers made to him, his classmates, and future generations of doctors when his teachers took the oath many years ago. “As a student,” explains Coblentz, “it [was] affirming for me to hold my teachers accountable: ‘This is how you should teach me, as part of this family, as part of this profession.’”

Which moral standard is best?

“Creating one’s own standards of success suggests that good medicine is [equivalent] to personal preference, which the Oath . . . strongly argues against,” Frush notes. If medical vows differ nearly from doctor to doctor then, how can physicians and patients determine which moral standard is best?

“I’m not somebody who believes strongly that one size fits all,” Carrese explains. “And when I say that, I’m thinking about the tremendous cultural and religious diversity we have, not only in this country but of course the world.” The values and traditions of one cultural group, Carrese continues, may not apply to another group in the same way, and his view is that doctors should be flexible about how to manage patients. That is, at least, as long as physicians are avoiding human rights violations.

RELATED: Medical Ethics and the Impact of Technology

With differing worldviews come conflicting viewpoints, such as how to approach controversial topics like those mentioned earlier. For this reason, Carrese believes the oath should only address basic morals that virtually everyone agrees on. And they should avoid polarizing statements regarding physician-assisted suicide, abortion, or any other controversial subject. “Most people would agree, however,” Carrese concludes, “that a good starting point for any moral system or any moral code is the notion of respect, and the right to be self-determined, however the patient defines that.”

The original intent of the Hippocratic Oath

Luis Vera [7], PhD, who teaches ethics at Mount St. Mary’s University in Maryland, suggests something else. He says that an oath proclaiming a definitive stance, even in the face of controversy, is what the original authors intended. “We could easily assume that [the original oath] is enshrining values of its own culture,” Vera explains. “But that’s actually not true at all.”

The Oath of Hippocrates was written by a group of Pythagoreans [8]. They were a minority of Greek thinkers who followed the Pythagoras philosophy which encompassed a broad range of metaphysical and mathematical ideas. This was at a time when there was disagreement among society about abortion, suicide, even patient-doctor confidentiality.

“[The authors] understood themselves to be reformers[9]—they thought they were reforming the practice of medicine in a society that did not agree on these things,” Vera explains, referencing Allen Verhey’s writing in On Moral Medicine.[10] “The oath for them was setting out a particular view of what medicine was about.”

For Vera, the question of whether to change the oath, then, first comes down to the ethics surrounding these highly contested issues. “The right thing to do, I think, is to put that question off to the side for a little bit and for us to sort out some of these ethical issues. Conversations about abortion, physician-assisted death. They matter in themselves and it is good for us, as a society, to keep having those conversations in the most honest, civil, well-intentioned, and charitable way possible . . . which is already hard to do, right?” Vera says with a lighthearted laugh, before adding that there is likely no single solution that will completely resolve these debates.

 Defining the field of medicine

Additionally, Vera believes that, not unlike the Pythagoreans, it’s necessary for 21st-century doctors to clearly define what the field of medicine is meant to accomplish. Is medicine a robust, fruitful practice with internal goods—satisfying and excellent for its own sake with morality intrinsic to it? Or is it a consumer service—technical skills provided for a patient to fix their body and alleviate or prevent suffering?

Though he doesn’t put much stock in the latter view, Vera says there’s something to be said for it. “If we can make the patient’s autonomy the sole ethical criteria for good medicine,” he explains, “then we don’t have to sort out a lot of other [controversial topics], so it seems really convenient.”

Still, many bioethicists, Vera says, worry that viewing medicine solely as a consumer service could lead to unwanted consequences:

“If we really make patient autonomy the only deciding factor for the ethics of medicine, we are slouching toward the point where we can’t say that elective amputations of otherwise healthy limbs. . . . are any different than amputating a gangrenous leg.”

Therefore, Vera believes that medicine today must be a mix of both: a passionate commitment to the good of health, and a consumer service.

Protecting Basic Morals

So with differing versions of medical oaths, values, and ideas about the purpose of medicine, how can doctors and patients protect basic morals so that necessary ethical lines won’t disappear in the future? According to Vera, one important task for protecting moral boundaries is to keep asking ethical questions about the practice of medicine.

“It’s good for each generation of doctors to think deeply about the meaning of what they’re doing,” he says. “That’s a sign of a healthy, developing tradition—when each new generation not only receives the inheritance behind it but adds to it.”

When examining how the Hippocratic Oath has changed, it’s understandable, Vera adds, to question where the practice of medicine might lead—where ethical clarity ends and murky human error begins. We should respond to change, Vera urges, as an opportunity to openly and honestly discuss the purpose of the medical practice and what we hope for the future of our society.

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References


[1]Physician Oaths. Association of American Physicians and Surgeons. Retrieved from: http://www.aapsonline.org/ethics/oaths.htm

 [2] Joseph Carrese, MD, MPH, FACP. Chair of JHBMC Ethics Committee; Professor of Medicine, Johns Hopkins University. Phone interview, 10/18/2018 & 11/09/2018.

[3] Askitopoulou, H., & Vgontzas, A. N. (2018). The relevance of the Hippocratic Oath to the ethical and moral values of contemporary medicine. Parts I & II: interpretation of the Hippocratic Oath—today’s perspective. European Spine Journal. 27 (7). 1481–1490. Retrieved from: https://link.springer.com/article/10.1007/s00586-018-5615-z

[4] Ian Coblentz, MD. University of California San Diego Medical Center. Phone interview, 11/11/2018

[5] Weiner, S. (2018). The solemn truth about medical oaths. Association of American Medical Colleges. Retrieved from: https://news.aamc.org/medical-education/article/solemn-truth-about-medical-oaths/

[6] Frush, B. W., Eberly Jr., J. B., & Gross, C. R. (2018). The Hippocratic Oath and the contemporary medical student. Academic Medicine. 93 (5). 671. Retrieved from: https://journals.lww.com/academicmedicine/Fulltext/2018/05000/The_Hippocratic_Oath_and_the_Contemporary_Medical.2.aspx

[7] Luis Vera, PhD. Assistant Professor of Theology/Ethics, Mount St. Mary’s University, Maryland. In-person interview, 11/12/2018. Email exchange, 04/25/2019.

[8] Pythagoreanism. The Basics of Philosophy. Retrieved from: https://www.philosophybasics.com/movements_pythagoreanism.html

[9] Edelstein, L. (1967). The Hippocratic Oath: Text, translation, and interpretation. Ancient Medicine. 3–63. Retrieved from: https://books.google.com/books?hl=en&lr=&id=tkVpf1ofmfEC&oi=fnd&pg=PA3&dq=The+Hippocratic+Oath,+Text,+Translation+and+Interpretation&ots=Wj-nZsnpE4&sig=FXF0wNWYJVjCUyEob56Iof9N-nY#v=onepage&q=The%20Hippocratic%20Oath%2C%20Text%2C%20Translation%20and%20Interpretation&f=false

[10] Verhey, A. (1998). The doctor’s oath—and a Christian swearing it. On Moral Medicine: Theological Perspectives in Medical Ethics. 108–119.

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