An Ethic Surviving Historical, Social, and Religious Conflict
by… Julie Balch, MD/PhD Candidate
Julie Balch is an MD/PhD student who started the curriculum with the Class of 2005. She entered the laboratory in the summer of 2003 to begin her basic science research. She is a well respected musician, author, and served two consecutive terms as Class President. Her undergraduate degree is in Biology and Music Performance in 1999 from Carnegie Mellon University in Pittsburgh, PA.
Though the medical oath has at times been modified or abridged it has remained viable for each era, not as an anachronistic tradition but as the keystone for medical ethics. - Ralph Crawshaw1
Whether it is through a television show, a Hollywood movie, a Robin Cook novel, or a supermarket magazine, we have all heard of the celebrated Hippocratic oath. However, very few people seem to have a grasp of either its content or its history. This oath, assumed to have been written by Hippocrates himself, invokes the highest standard of ethical behavior in any profession. It has survived more than two millennia of historical conflict, social diversification, and medical reorganization. Most medical students graduating from U.S. institutions recite some form of this ancient oath upon completion of their studies. But the original oath has not been impervious to social change. On the contrary, the fluctuation in the use of the Hippocratic oath and the creation of revisions, alternate versions, and supplementary codes of ethics was a direct result of historical and social discord. Nonetheless, this paper will attempt to prove that the original oath, however manipulated, remained the cornerstone for medical ethics from the time it was created throughout each era of struggle. Finally, this essay will demonstrate that despite many critics of the oath and in spite of every challenge, the Hippocratic oath still remains a valuable guide in the medical profession today.
Hippocrates belonged to an established and honored Greek medical tradition. His family claimed descent from Asclepius, son of the great deity Apollo, who himself was not only the sun god but also the physician. Asclepius was taught healing by Chiron the Centaur and became so skilled in medicine that he allegedly could restore the dead to life.2 The staff of Asclepius (pictured with one serpent) is today the symbol of the American Medical Association. The daughters of Asclepius were Hygeia and Panacea, whose names have been forever incorporated into the English language.3 The followers of Asclepius had for generations been the only controllers of the knowledge of healing when Hippocrates was born the son of the healer Heraclides on the Greek island of Kos (Cos) about 460 B.C.4 Hippocrates grew up in an era of intellectual exploration when there was a “deep commitment to the search for enlightenment regarding life’s many mysteries.” 5 He was known to have practiced empirical medicine: events were not observed in isolation, and physicians were required to note regularities, patterns, and relations.6 There is an immense body of medical writing known as the Corpus Hippocraticum, which most historians agree could not have been written by one person. However, these documents formulate the backbone of the “school of Hippocrates.” 7
The most important document to come out of this corpus is the Hippocratic oath, which has become the physicians’ rite of passage into a sacred profession. It is significant to note that this composition was called an “oath” as opposed to a declaration, a promise, a pledge, or any other less significant title. According to Merriam Webster’s Collegiate Dictionary, an oath is a solemn, usually formal, calling upon God or a god to witness to the truth of what one says or to witness that one sincerely intends to do what one says.
The original Hippocratic oath opened with an invocation of four Greek divinities: “I swear by Apollo the physician, by Asclepius, Hygeia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment the following oath….” This introduction, grounded as it was in Greek religious tradition, did not survive religious change. With the increasing acceptance of Christianity came the so-called Christian Hippocratic Oath in the tenth or eleventh century. It omitted reference to the Greek gods and substituted an appeal to “God or a god.” But otherwise these two documents--the original oath and the Christian oath--are not radically different. Scholars believe that Pythagoreanism, which was based on the ideals of Hippocrates, bridged the gap between Greek polytheism and Christianity since Christianity agreed with the general principles of Pythagorean ethics.8 Therefore, even through religious and cultural change, the ethics of Hippocrates in this case remained a common thread.
The next challenge to the original form of the oath came during the era of Maimonides (1135-1204), the great Jewish sage, rabbi, philosopher and physician. Moses Maimonides was well versed in the classical writings of Hippocrates, Aristotle, and Galen as well as in the rabbinic teachings of the Bible and the Talmud.9 He codified Jewish law in his Mishne Torah, and wrote his classic “Guide for the Perplexed,” whose linking of religion, philosophy, and science was to influence medieval Christian scholarship. During his lifetime, a conflict arose which prompted a reworking of the oath: one of his female patient’s life was at risk due to her pregnancy. Maimonides felt that the life of the mother should take precedence over that of the fetus and that, if the need arose, an embryotomy should be performed. His advice contradicted the teaching of the Christian church and became accepted Jewish practice.10 This conflict of thought inspired the writings of the two prayers and codes of Maimonides, “gentle and quite similar to the Oath of Hippocrates.”11 It is believed by some historians that even though the oath is named for Maimonides, it was actually composed by a pupil of Immanuel Kant in 1793.12 Regardless of who actually composed the Oath of Maimonides it is apparent that the revision of the Hippocratic oath was initiated due to a conflict of religious beliefs, demonstrating that there was a historical impetus to change the age-old oath. Nonetheless, a closer look at the oath of Maimonides will reveal that the ethical foundation is based on that of Hippocrates.
We have evidence of the use of the Hippocratic oath from its creation through the eighteenth century, though there is not extensive documentation of variations on the oath. It is thought by some scholars that Galen, who lived at the end of the second century, brought Hippocrates’ work to completion.13 There is also testimony that throughout the early Middle Ages there was mention of medical oaths.14 Several ninth century manuscripts from Paris and Chartres remind physicians to abide by the Hippocratic oath. In the tenth and eleventh centuries, which saw the Christian oath take form, there are also manuscripts in Copenhagen pointing to the use of the Hippocratic oath.15 The twelfth century (perhaps extended to the eighteenth century depending on who actually authored this version) saw the creation of the Oath of Maimonides. “With the advent of the universities during the Middle Ages the oath became a part of the curriculum of medical students. Since incorporation into the rituals of universities… oaths have never fallen into disuse.”16 The first printing of the oath occurred in Verona in the late fifteenth century. Subsequently, it was frequently printed in Elizabethan England, together with interpretations. To supplement the personal oath, several codes outlining standards of conduct within medical institutions were developed in Europe in the eighteenth century, when there was a growth in the number of physicians and hospitals.17
If we move into the early nineteenth century, we will discover an increased interest in the ethics of the medical profession and, expanding on and supplementing the Hippocratic oath, a codification of physicians’ duties. In 1803, Thomas Percival, a British physician, published A Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons. This book, outlining an ethics for the medical community and prescribing a set of duties and responsibilities for the individual doctor, grew out of a major conflict at the Manchester Infirmary: surgeons stopped working (and therefore turned away patients at the hospital) at the onset of an epidemic.18 In the United States, the newly formed American Medical Association (AMA) responded to a different social crisis--a general distrust of the medical profession--with its 1847 Code of Ethics.
In the early 1800’s in the United States, quacks, midwives, homeopaths, hydropaths, botanic healers, Indian healers, and eclectics were found in abundance. They all offered their services, often of dubious benefit, to the sick. Even among physicians themselves there was a wide range of ability, as diploma mills abounded and there was no policy of licensing. Since there was a general lack of scientific knowledge, much of what doctors did was guesswork and no two doctors would make the same prescription, leading to doubt among many patients. It was at this time in history, when doctors felt threatened by other “practitioners,” when an overwhelming public distrust existed, and when conflict among even the allopathic physicians themselves occurred that American doctors organized into the AMA and adopted a professional code of ethics, expanding on the Hippocratic oath. Dale Smith conveys well what took place during this time: “The medical profession of the mid-nineteenth century was under assault by various social forces, and the AMA, its code of ethics, and perhaps the use of the Hippocratic Oath all served as tools for the defense of the profession.”
In the 1850’s and 1860’s, graduating pledges in the form of the Hippocratic oath grew more common.19 Perhaps this was due to an increasing awareness of the ethical responsibilities of the physician, but surely the reading of the oath was also for the benefit of future patients--to increase their confidence in the practitioners. In the 1870’s and 1880’s, licensing and proper professional regulation were introduced in the United States, which stiffened enforcement of requirements and forced state board examiners to accept diplomas only from reputable schools.20 The licensing laws, the development of new surgical techniques, the newly acquired scientific knowledge and other medical contributions slowly improved the public image of the medical profession.21 During this growth of confidence, Smith indicates that in the last decade of the 1800’s, “interest in the oath may have waned.” It is easy to make a connection between the increased public confidence in the scientific arena and subsequent thought that there was no longer a need for “ethics” to guide the medical profession. It has occurred in history before that the ethical conscience seems to develop during social conflict or unrest and subsides when “times are good.” With the positive public sentiment of the medical field before the beginning of the 1900’s, it seemed as though there was no need for Hippocrates.
In the twentieth century, however, the medical profession returned to the Hippocratic tradition. From the 1920’s through today, there has been a steady increase in the use of some form of the Hippocratic oath. In 1928, about 19% of graduating medical students took the Hippocratic oath in North America.22 In 1959, 74% of American medical schools reported using an oath and in 1969, that number jumped to 92% of graduating students.23 In 1977, 94% took the oath, and finally, in 1993, 100% of medical schools in the U.S. administered an oath at graduation.24 The numbers illustrate an increase in the swearing of some form of Hippocratic oath, but do not explain the reason. If my previous hypothesis is correct, renewed interest in the oath should correlate to some historical or social change. It is necessary now to examine why there was such an increase in the use of the oath in the twentieth century.
One major revision occurred in the wake of a terrible human tragedy: the genocide which occurred in Nazi Germany. The Doctor’s Trial of 1946 stimulated much debate about ethics in the field of medicine. The Nuremberg Code, which outlined directives for human experimentation, was formulated in August 1947 by American judges debating the conduct of 23 physicians and scientists accused of murder and torture in the conduct of medical experiments in the concentration camps. “The key contribution of Nuremberg was to merge both Hippocratic ethics and the protection of human rights into a single code.” 25 The Nuremberg Code was not the only document to be written in response to the medical atrocities committed during the Nazi regime. In 1948, the General Assembly of the World Medical Association adopted the Declaration of Geneva, which is another revision of the Hippocratic oath. This declaration was a pledge, among other things, to have the utmost respect for human life and not to use medical knowledge contrary to the laws of humanity.
In the post-World War II era, several changes occurred in the medical community, all of which tested the endurance of the Hippocratic school of thought. In 1957, a Supreme Court ruling introduced the term “informed consent,” which included patients in the decision-making process (Salgo v. Stanford). Subsequent revisions of the oath had to occur due to this new concept as it was not inherent in the school of Hippocrates and many universities established their own oaths to suit the times. Beginning in the 1960’s, there was a general challenge to all established authority, and the medical field was a target during this period of questioning. David Rothman, in his Strangers at the Bedside, describes well what occurred in the mid-sixties: “…the practice of medicine in the United States underwent a most remarkable--and thoroughly controversial--transformation…the changes have altered almost every aspect of the relationship between doctor and patient- indeed, between medicine and society…”26 The 1960’s and 1970’s were times of cultural upheaval and instability. The civil rights movement, the patient’s rights movement, and the women’s rights movement all threatened established society. The only seemingly reliable ethic seemed to be that of Hippocrates as “…at the inception of the era of contemporary bioethics, the Hippocratic oath and the moral precepts it embodies were the immutable bedrock of medical ethics. They bound physicians in a moral community that reached across temporal, cultural, and national barriers. They seemed impervious even to the powerful scientific and societal forces then emerging.”27 The development of bioethics in 1971 as an entire field illustrates an intense acknowledgement of the ideals of Hippocrates. In the introduction to the Encyclopedia of Bioethics, it states that bioethics is an ethics based on rationality; it is primarily an avoidance of causing evil or a prevention of evil rather than a promoting of good; and its basic rules are applicable to all people, at all times and places, equally. From this elementary definition, it could have stemmed from any writings of the Hippocratic corpus. However, as the times were changing in the medical profession, a change in the Hippocratic ideal was needed.
The seventies not only witnessed the advent of the Bioethics movement, but they observed the American Hospital Association adopt the “Patient’s Bill of Rights” in 1972, and the creation of the reasonable patient standard. This era also witnessed the National Research Act passed by Congress, the birth of the first test tube baby, the development of the Belmont Report and the opening of the Kennedy Institute of Ethics (originally named the Joseph and Rose Kennedy Center for the Study of Human Reproduction and Bioethics). During this time Congress, under the leadership of Walter Mondale and Edward Kennedy, established a national commission to explore medical ethics.
All of these developments stimulated change within the medical field and, with this change, a reworking of Hippocrates. However, the two most threatening events to the original Hippocratic oath were the court cases of Roe v. Wade (1973) and the case of Karen Ann Quinlan (1976). The original oath states: “To please no one will I prescribe a deadly drug, nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion.” The Roe v. Wade decision made abortion legal in the United States and the case of Karen Ann Quinlan authorized doctors to remove her from a respirator, which could have prompted her death. Both of these decisions, made with considerable public debate, brought about several reworkings of the original oath (e.g. Oath of Dr. Lasagna and Oath of Louis Weinstein). In his twentieth-century Hippocratic oath content analysis, Robert Orr noticed that there was a dramatic decline in stating the segment of the oath that promises to abstain from abortion and euthanasia as “…the downward trend coincides temporally with the legalization of abortion in the Roe v. Wade decision in 1973 and with the increased belief both by society and by physicians that it may be acceptable for the physician to actively intervene to end a life.”28
Medical schools began to question the relevance of the ancient oath to society, and several universities began to either eliminate the oath completely, combine the Hippocratic wording with more “up to date” terminology and relevance, or formulate their own oaths (e.g. Yale’s oath). What is important to note is that although the oath was mended or rearranged to fit the time, it was still in practice. Smith asserts that the “use of the Hippocratic oath in medical schools during the twentieth century has increased at about the rate of specialization. It is possible that, as the medical profession became increasingly fragmented by specialization and then increasingly assaulted by social forces, the oath provides a sense of unity or is at least an attempt by faculties to provide a sense of unity and professional tradition for the young physicians they send forth into the profession.”29 The ethic of Hippocrates, though somewhat modified, would still prevail in the face of adversity.
As we move through the eighties, the nineties and into our current society, there are ongoing advancements in technology and changes within the scientific and medical community, all of which will continue to test the ideals of Hippocrates. The end of life questions brought about by the introduction of respirators, dialysis, and artificial feeding tubes permit the continuation of life beyond what would have been the natural point of death a century ago and force society to make difficult decisions. At the same time, they cause medical institutions to rework their graduating oaths.30 Dramatic advances in molecular genetics, including the discovery of locations of specific genes as well as the development of diagnostic screening tests for these genes, have revolutionized the study of human heredity within the past two decades. The cloning of Dolly in Scotland in 1997 and, more recently, the success of the human genome project have stimulated worldwide ethical debate. In this country, Congress mandated a large amount of the project budget to ethical, legal and historical implications. The continuously changing doctor-patient relationship with a decrease in physician paternalism and an increase in patient autonomy has altered the treatment patterns and has caused changes in graduating pledges of young doctors. Further changes in the delivery and financing of healthcare may severely affect the outlook on Hippocrates as the time that the doctor can spend with a patient is being swallowed by HMO’s. In the increased interest of preventive medicine, graduates of Tufts Medical School modified their Hippocratic oath to include the phrase “I will prevent disease whenever I can, for prevention is better than cure.”31 The preference of graduates of universities to write their own version of the Hippocratic oath that would include current philosophy and trends within the medical community is increasing.
These major historical and societal changes will continue to shape the Hippocratic ideal, which may include severe stretching, cutting, pasting, and mending. The fluctuation of the use of the oath, as well as the alterations and modifications can be explained by understanding the historical context. Whether it was a religious conflict, a social debacle, or a worldwide genocide that occurred, each period produced its own version of the oath. When there was a confidence in the medical profession, the sentiments of Hippocrates were not thought to be needed, but as social unrest reached a climax, so, too, did the use of the Hippocratic ideal.
Regardless which form of oath was utilized throughout history, it has remained succinct and incisive in its content and meaning. The Hippocratic oath has set a standard for the field of medicine that has survived through the ancient world, the Middle Ages, the Renaissance and the Enlightenment, through two world wars, and through the greatest period of scientific discovery. “The Oath is a declaration of virtue based on faith and self-respect. Its form is the product of an ancient civilisation [sic] and an extinct religion, both of which it has outlasted…Its true meaning, overall respect for the patient, can be accommodated in different cultures and historical periods.”32 Emmanouil Pikoulis remarked that Hippocrates was the first to define stringent ethical demands within any professional field.33 Other professions are now looking to the medical ethic and are posing an adoption of their own oath, whether they are scientists, engineers, or executives.34
The miracle of the oath is that it has been accepted, notwithstanding the minor changes, in culturally, religiously, and socially diverse communities worldwide. “What is important is not only the Oath itself, but also its wide acceptance, in so many countries, over so long a period, as the solemn accompaniment to full-fledged admission to the profession of medicine.”35 Dale Smith said that the “content varies, and the issues are diverse, but the oath is in various ways as reflective of the values of the contemporary profession as it was for the ancients. It remains a commitment to the idea that there are ideals and principles in the profession of medicine, a heritage worth claiming.”36 Every social, political, and religious struggle throughout history has looked to the ideal that Hippocrates set forth two thousand years ago. Each era of struggle formulated its own solution, but in every case, the ethics of Hippocrates was consulted. Ludwig Edelstein, whose 1943 text, translation and interpretation of the oath has become the standard English version, left us with a remarkable thought that provides an excellent explanation of the historical value of the oath:
As time went on, the Hippocratic Oath became the nucleus of all medical ethics. In all countries, in all epochs in which monotheism, in its purely religious or in its more secularized form, was the accepted creed, the Hippocratic oath was applauded as the embodiment of truth. Not only Jews and Christians, but the Arabs, the mediaeval [sic] doctors, men of the Renaissance, scientists of the Enlightenment, and scholars of the nineteenth century embraced the ideals of the Oath.37
The writings of Hippocrates have persevered for over two millennia as the standard of medical ethics by which to abide, and we will continue to see the influence of his ideals through this current period of scientific discovery and throughout many centuries to come.
- Crawshaw, R.S. (1970). The Contemporary Use of Medical Oaths. Journal of Chronic Disease, 23, pp. 145-150.
- King, Lester S. (1963). The Growth of Medical Thought. The University of Chicago Press.
- Dorman, John. (1995). The Hippocratic Oath. Journal of American College Health, 44, pp. 84-89.
- Furst, Lilian R. (2000). Medical Progress and Social Reality. State University of New York Press.
- Pikoulis, Emmanouil; Waasdorp, Christine; et al. (1998). Hippocrates: The true father of medicine. American Surgeon, 64, pp. 274-5.
- Furst, Medical Progress and Social Reality, p. 23.
- King, 18.
- Dorman, 86.
- Dunn, Peter M. (1998). Maimonides and his philosophy of medicine. Archives of Disease in Childhood Fetal & Neonatal Edition, 79, pp. 227-228.
- Dunn, 228.
- Berry, Frank B. (1968). Oaths and Ethics. Medical Times, 10, pp. 141a-142a.
- Orr, Robert D. et al. (1997). The Use of the Hippocratic Oath: A Review of Twentieth Century Practice and a Content Analysis of Oaths Administered in Medical Schools in the U.S. and Canada in 1993. The Journal of Clinical Ethics, 8, pp. 377-388.
- Dorman, 88.
- Crawshaw, 145.
- Macer, Darryl R.J. (1990). Shaping Genes: Ethics, Law and Science of Using New Genetic Technology in Medicine and Agriculture. Eubios Ethics Institute, pp. 1-17.
- Crawshaw, 145.
- Macer, 12.
- Furst, 24.
- Smith, Dale C. (1996). The Hippocratic Oath and Modern Medicine. Journal of the History of Medicine and Allied Sciences, 51, pp. 484-501.
- Furst, 24.
- Smith, 490.
- Smith, 494.
- Crawshaw, 146.
- Orr, 382.
- Schuster, Evelyne. (1998). The Nuremberg Code: Hippocratic ethics and human rights. Lancet, 351, pp. 974-978.
- Rothman, David J. (1991). Strangers at the Bedside Basic Books
- Pellegrino, Edmund D. (1996). Ethics. JAMA, 275, pp. 1807-1809.
- Orr, 285.
- Smith, 495.
- Furst, 27.
- Furst, 27.
- Marketos, Spyros G.; Diamandopoulos, Athanasios A. (1996). The Hippocratic Oath. Lancet, 347, pp. 101-103.
- Pikoulis, 274.
- Rotblat, Joseph. (1999). A Hippocratic Oath for Scientists. Science, 286, p. 1475.
- Duncan, Dwight G.; Lubin, Peter. (1996). The use and abuse of history in Compassion in dying. Harvard Journal of Law & Public Policy, 20, pp. 175-215.
- Smith, 500.
- Edelstein, Ludwig. (1943). The Hippocratic Oath Text, Translation and Interpretation. The Johns Hopkins Press, Baltimore.