A Brief History of Medicine’s Hippocratic Oath
Or
How Times Have Changed
By Larry N. Smith
Abstract
Medicine has experienced many changes over the last three thousand years and surprising the good and the bad of these changes can be found in the evolution of the wording of the Hippocratic Oath. This commentary reveals why the original Oath became a part of modern medicine’s right of passage and how society is now changing the very reason that the Hippocratic Oath was brought into the world of medical ethics. By examining the modern language of the Oath, it is possible to understand how these words have diluted its meaning and intent. The long-term consequences of these changes cannot be foreseen, but history has shown what can happen without a strong oath to guide the practitioner.
Introduction
As medicine further sub-specializes, it becomes easy to understand how the practicing physician may lose sight of the individual uniqueness of each patient and of medicine’s foundations and unique obligations. It is important that we as a profession do not fall victim to the dehumanization of the individual, that has happened so many times before us. It is important to appreciate the origins of our Hippocratic Oath. In understanding this history, physicians can understand why we evoke his name so willingly, as a testament to our collective compassion.
Medicine has a long, distinguished history that unfortunately has had some undistinguished periods. From Mesopotamia and then Greece, medicine advanced as the understanding of the human body and its reaction to disease became understood. After stumbling through the Inquisition, medicine continued its slow advancement into Enlightenment. As the scientific period dawned, the practice of medicine progressed from Anton Van Leuwenhoek describing the animalcules that he saw through his newly invented microscope to the wider public discussing the pathophysiology of diseases like SARS or Extreme Drug Resistant-Mycobacterium Tuberculosis on television news programs. Medicine is not only discussed on health programs but is sensationalized in shows like Ben Casey, Marcus Welby and House. The overdramatized practice of TV medicine never depicts the reality of the emergency room or the real world from where the patient in need came from, but it suits society’s demands. Looking back, it is interesting to imagine Hippocrates in his times struggling to understand the illnesses that afflicted his patients.
Ancient Medicine
Hippocrates worked hard in his world of Greek medicine. With no real cures, his world was one of spiritual incantations practiced in Asclepion temples. Chronic infections like tuberculosis and leprosy as well as parasitic infections were a way of life then. These diseases, along with epilepsy and various deity inspired epidemics that would sweep through the city-states taking thousands, were documented in ancient medical writings. With no antibiotics and no real surgery, every treatment that Hippocrates prescribed must have also contained a healthy dose of frustration for both patient and doctor. While surgery had been recorded as far back as Sumerian times in the Mesopotamian Valley, its success rate was low and the penalties for failure high. One punishment for failure included cutting off the surgeon’s hands. It would be centuries before germ theory, anesthetics and antibiotics would be discovered or available.
The period was not without hope and limited successes, though. The famous Greek physician did make some headway in various sub-fields. Hippocrates contributed to orthopedics in his thesis on the management of fractures, as described in the Hippocratic Corpus of c.510-c.300 BC. He is also credited with having written the Hippocratic Oath, which surprisingly languished in the medical history books for thousands of years until it was put to use in the post-World War II period.
The Impact of the Twentieth Century
Interestingly, the post-war progression of the western social-scientific medical experiment can be found in the evolving language of the Hippocratic Oath. Ostensibly, the first recorded use of the oath outside of Greecewas at the University of Wittenberg, Germany, in 1508 – the same year Martin Luther became a professor there, and just nine years before he nailed his theses to the cathedral door. Over the next 400 years, the official use of any oath of medicine, or specifically the Hippocratic Oath, was sporadically instituted by medical universities. By 1928, only 19-24% of medical schools used the Hippocratic Oath in their matriculation ceremonies, but this was to change dramatically after World War II. Only after the world learned of the criminal abuses by Nazi doctors upon concentration-camp prisoners and how these abuses contributed directly to the Holocaust was the Hippocratic Oath pressed into widespread use in medical training programs. It was unfortunate that, by 1940, medicine’s historic code of ethics, conduct, compassion, charity and the art of healing with its Hippocratic rejection of the purposeful taking of human life had sunk to that level of scientific dehumanization and medically justified torture. This Nazi descent into self-justified vivisection and torture unfortunately had been promoted by the wrong-minded, scientifically driven eugenic beliefs that preceded the war (see figure 1 and 2). It was the Hippocratic Oath’s appreciation for the value of life and the physician’s role in preserving it that prompted its rise into the post-war medical consciousness and lexicon. By 1993, 98% of 150 medical schools that had responded to a survey conducted by Dr. Robert D. Orr of Loma Linda Medical Schoolused an oath. Out of these schools, only one used the original oath. All the others used a modern variation of the oath.1
Twenty First Century Changes to the Hippocratic Oath
By examining the evolving variations of the Hippocratic Oath, it is possible to appreciate its origins and the changes that have occurred over the last 3,000 years and particularly in the last 60 years. Arguably written by Hippocrates himself, the oath begins by invoking Apollo, and other gods and goddesses. Today, this opening sentence has been modified to the following words, “the presence of the Almighty.” The change reflects how modern societies have moved from polytheism to monotheism. Hippocrates also believed it was important to pass the knowledge of medicine to students free of charge. He states in the oath that he wants “to teach them this art, if they wish to learn it, without fee or stipulation.” Today, because of society’s pressures, legal compliance, economic forces, avarice, or all the above, the oath has been modified to read that a doctor should “impart a knowledge of the art of medicine to others.”
Social pressures and new medical realities have pushed further changes on the oath, as evidenced in the original version, which reads, “I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give a woman means (a pessary) to procure (produce) an abortion.” Clearly, the practice and insistence on the right to assisted suicide by Dr. Jack Kevorkian and others has challenged the first part of this passage. Meanwhile, the latter passage has become meaningless in today’s world of abortion on demand, which is pressured daily by society’s clamor for life-sustaining embryonic stem cells. Conveniently, this passage has been modified to read that the doctor should “reject abortion that deliberately takes a unique human life.” The key word “reject” replaces the definitive “will not.”
Today, efforts are in the works to modify the oath yet again, at Weill-Cornell Medical School. After careful study, a combined committee from Weil-Cornell and a corresponding body from Doha, Qatar – where Cornell has opened a medical school — has produced a more secular document. To help structure their recommendations for change, the committee used the Hippocratic Oath (Greek), The Oath of Maimonides (17th century Jewish), The Oath of Muslim Physicians, The Oath of Louis Lasagna (1964), The Declaration of Geneva (1983 version), and the AMA Ethical Guidelines. The committee chair Joseph J. Fins, MD, explains the rationale: “We wanted to be respectful of the diversity of perspectives on faith and belief and to be mindful that there are a number of ways to express personal commitment.”
The committee’s objectives were to preserve the sense of the oath’s intuitiveness yet make it pragmatically modern. There was a similar desire to remove the Victorian tone and wording. With this in mind, the committee added references to medicine’s responsibilities to public health and social justice, while stressing the ethical use of medical knowledge and powers, ensuring no gender bias in the oath.2 Accordingly, any religious nuances were removed from the oath, and a broader secular wording was inserted. Gone are any references or intonations to the sanctity of life, not charging for medical education, references to prescribing fatal doses of medicine, and most noticeably, any reference to abortion. Moreover, their oath no longer contains any reference to consequences if the oath is broken. Their goal of creating a socially benign oath that is inoffensive and with common ground for all appears to have been attained. To date, this new oath has been used only at Cornell Medical Schools and on review, it reads as a set of nonbinding guidelines. When Cornell matriculates its new members of the guild, it would make more sense not to refer to Hippocrates at all.3 For sure, the new wording is so enervated that it would not serve to restrain the conscience of a member of a concentration-camp medical staff. As pointed out by Dr. Robert Orr, “This trend of diluting the content of the Hippocratic ethic should be of major concern to the profession and its teachers.” 4
Other social pressures are making their influence felt. Pro-life groups have cited the earlier oaths that contain references to physicians not sanctioning abortion as justification for their pro-life position. Others point to civil rights and the law as reasons to modify the wording and therefore the intent of the oath. It is understood, then, that the givers and receivers of the oath are being pressured from every special-interest group that has a perceived stake in the wording of the pledge to have it changed to their benefit.
Like the transitions of medical knowledge and the manner in which it is delivered, the transitions of the oath are a product of society’s collective pressures, medical advancements and seemingly an ethical decay of the Hippocratic spirit. Such changes are evident in many aspects of the discipline – from charity and compassion to scientific dehumanization and the destruction of the unborn through the flawed doctrine that ontogeny recapitulates phylogeny. These seismic shifts reflect the private- and public-policy history of the world, and specifically America, in the twentieth, and now the twenty-first centuries. Indeed, the last century saw American elitists argue that charity was a disservice to the poor and a waste of money. In the same period, some members of Darwinian-Eugenic-Malthusian associations began the devaluation of living adult organisms and the defenseless fetus. The Nazis and others enthusiastically believed this rhetoric too.5, 6, 7, 8 These social-scientific pressures will likely continue – forcing the basic tenets of medicine to transform based on scientifically directed or self-serving social policies.9, 10, 11, 12
This state of affairs forces the question: Should physicians hold themselves responsible to a higher position than the selfish needs of society, or are we just a reflection of society’s needs? Similarly, will we let the decay of the value of life that is recently conceived, diseased or old be driven by the perception of individual civil rights, or will we just accept that our position is to provide the services our patients demand? In 1991, Surgeon General C. Everett Koop speaking at Loma Linda University School of Medicine stressed that the Hippocratic Oath “calls physicians to a higher ethical standard than that of society in general.” Weill-Cornell, on the other hand, feels that the oath and the physician’s ethics should be more reflective of a society’s beliefs and expectations.13
Understandably, no oath is so powerful that its wording can ensure the ethical and humanitarian compliance of everyone who has taken it. Humankind and particularly physicians are capable of rationalizing any behavior, particularly if there is public and private support for that behavior. It will be interesting to see if medicine really can continue to honor Hippocrates by invoking him in the oath, or if it would be better to construct an oath without his name. While pressures from society, science, public policy and religious secularization have been driving changes to this once-respected and revered pledge, time will tell if such pressures ever end or if organized medicine actually cares to set an end to the changes.
Conclusion
Evoking the name of Hippocrates may not elicit the same level of compassion and appreciation today that it did as little as thirty years ago. As physicians, we can choose to continue the high ethical standards that the Oath once espoused. History has shown us what doctors are capable of if they accept their role as just instruments of government or science. Let us hope this history is not forgotten and not repeated.
Acknowledgements
The author wishes to thank Mr. James Royal for his editorial assistance.
References
1. Dr. Robert D. Orr; The Hippocratic Oath: Is It Still Relevant?; Center for Christian Bioethics, Loma Linda University; March 1998; Vol. 14; No. 1
2. Interview with Dr. Joseph J. Fins; August 3, 2007
3. Dean Gotto Unveils Revised Hippocratic Oath for New Generation of Weill Cornell Graduates; http://bigmedium.med.cornell.edu/cgi-bin/moxiebin/bm_tools.cgi?print=28;s=1_;site=8
4. Dr. Robert D. Orr; The Hippocratic Oath: Is It Still Relevant?; Center for Christian Bioethics, Loma Linda University; March 1998; Vol. 14; No. 1
5. Eugenics: America’s Darkest Days, Sterilization; http://iml.jou.ufl.edu/projects/Spring02/Holland/Sterlization.htm
6. Elof Axel Carlson; The Unfit: A History of a Bad Idea; Cold Spring Harbor Laboratory Press; Copyright 2001; Chapter 14; pp 247-261
7. Michael G. Kenny; Racial Science in Social Context, John R. Baker on Eugenics, Race, and the Public Role of the Scientist by; Isis, Vol. 95, number 3, Sept 2004, pp 394-419
8. Elof Axel Carlson; The Unfit: A History of a Bad Idea; copyright 2001; Cold Spring Harbor Laboratory Press, Cold Spring Harbor, New York
9. The Hippocratic Oath; http://www.news.cornell.edu/stories/June05/Hippocratic_Oath.mh.html
10. Weill Cornell Hippocratic Oath; Cornell University News Service; Melissa Hantman; June 22, 2006; http://www.news.cornell.edu/stiries/june05/hippocratc_Oath.mh.html
11. Central Illinois Right to Life; The Hippocratic Oath; http://www.cirtl.org/hippocratic.htm
12. Howard Markel; History of Medicine: On the Hippocratic Oath; Science Week; 2004; New England Journal of Medicine; 2004; 350:2026; http://www.scienceweek.com/2004/sa040917-6.htm
13. Dr. Robert D. Orr; The Hippocratic Oath: Is It Still Relevant?; Center for Christian Bioethics, Loma Linda University; March 1998; Vol. 14; No. 1
