Challenging Hippocrates

by P J King, RN

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For over 2000 years the Oath of Hypocrites has governed the practice of medicine. We are now being told it is time to cast it aside. The overthrow of centuries of medical tradition must not be taken lightly. It is incumbent on those who would do so to prove the superiority of the new, post-Hippocratic medicine before they venture further, and on us to know just what it is we are being asked to discard.

Most likely the Hippocratic Oath originated with the Pythagoreans, a school of ancient Greek philosophy. But this is not my concern here. Rather, I wish to discern what was the power of its ethic that resulted in its near-universal establishment.

The Oath does not delineate what it is physicians are to practice. It embodies values. But it is not merely one among many codes of ethics. The question it forces us to answer is this: Is the practice of medicine simply a matter of technique, or does it entail a commitment to some moral order?

The Oath addresses three planes of relationship -- the physician and his god, the physician and his teacher, and the physician and his patient. To each is sworn an oath of duty.

The Graeco-Roman world was a highly pluriform society. In it abortion was common and suicide was generally approved. The administration of poison for medical reasons was part of medical practice. It was in this context that Hippocratism emerged. Its proponents were a minority that dared go against the flow. Their answer to pluralism was not to relativize their values to suit their patient's particular set of values, but to commit themselves to one, non-negotiable standard.

It is noteworthy that the physician's duty to his patient is marked out primarily by a series of negatives rather than positives: "I will never use [treatment] to injure or wrong. ... I will not give poison to anyone though asked. ... I will not give a pessary to a woman to cause abortion." Duties stated positively are open to interpretation and modification. The Oath sets up absolutes: the physician is barred from the twin practices of abortion and euthanasia.

The Hippocratic physician swears his commitment to confidentiality, demonstrating a unity of life and the practice of his art. He wholly devotes himself to the interests of his patient. Even the patient's secrets are to be regarded as God's secrets.

Notice that the Oath, as originally intended, was to be sworn by the pupil before beginning his training and education, rather than at the end. In the setting of a culture more religiously and philosophically diverse than our own, the practice of medicine and Hippocratic values were to be inseparable.

The duties of the physician to his patient and to his teacher -- the two horizontal relationships -- are sworn before his gods. They exist in the context of a vertical relationship. Jew, Christian, and Muslim have since found in the Hippocratic Oath a congruence with their own ethics: in every patient I find the image of God himself. The point remains that, regardless of religious belief, the physician holds himself ultimately accountable to someone or something above and outside the doctor-patient relationship. The heart of the Oath is a covenant with the gods/God, which transcends his obligation to mere man.

The moral commitments of the physician are integral to his or her claim to being a member of a profession rather than merely holding a particular occupation. Most physicians still regard the heart of medicine as moral commitment. Those who would break with this tradition must recast medicine as technique and the practitioners thereof as mere technicians. This is an inevitable consequence of the attack on Hippocratism as time-bound and religiously grounded. The professional claims both knowledgeable skill and extraordinary trustworthiness. To maintain this high position the profession depends on the protection and support of a dominant elite. If it is no longer able to persuade this elite of the worth of its values and task, it must shift its values to accommodate those values which are acceptable. Clearly, Hippocratism is today being challenged.

Hippocratic medicine is healing and not harming (primum non nocere, above all, do no harm). The two fundamental "harms" are abortion and euthanasia. The Oath makes no mention of a responsibility of the physician to relieve human suffering. This is plainly to establish the more fundamental commitment to the sanctity of human life in a society in which suicide-euthanasia and abortion were common. As in the ancient world, so today, the duty to heal is being subordinated to the duty to relieve suffering. Although the physician may regard the two principles as equal, once the law of the inviolability of human life is discarded, whenever the two conflict, relief of suffering triumphs.

To many, elaborating on this exchange of principles may seem pedantic and the trade-off desirable. But the distinction is profound. We have arrived at a crossroads. Medicine can maintain its commitment to single-minded, covenantal Hippocratism as the ground of medical practice. Or it can throw away centuries of medical tradition in exchange for a primitive, pre-Hippocratic relativistic "new" medicine.


After the above was originally posted, the author was sent the following email. We reprint it here exactly as received. Note: The writer is the newsletter editor for the Hemlock Society of Florida.

Apparently your comprehensive research failed to disclose that no physician is required to take the oath and it is never legally binding. The American Medical Association is probably glad of that, because if the Oath were actually observed it would put them out of business. Notice in line 3 of the paragraph "DUTIES TO TEACHERS the physicians swear to teach their trade FREE OF CHARGE!

Actually it should be called Hypocritic Oath, with the AMA constantly calling on it to justify its opposition to death with dignity. I notice they are not calling on medical schools to abolish tuition.

The point is: MODERN MEDICAL TECHNOLOGY HAS RENDERED THE OATH HOPELESSLY OBSOLETE. Med school tuitions keep going up and hardly anybody believes in Apollo and Hygeia any more.

I dare you to post this.

Myrtle Brickman

The author replies:
Dear Ms. Brickman,

You are right in rebuking me for my failure to state that the Hippocratic Oath is no longer taken in medical schools. I have known this for a long time, and was negligent in not pointing this out to those who don't. Thank you for doing so.

As for physicians swearing to teach their art free of charge, it is you who have been careless. Physicians, like all of us, whether ancient or modern, must make a living. The physician-teacher who took the Oath, promised to teach his teacher's children "without fee or indenture." The Oath continues, "and to impart precept, oral instruction, and all the other learning, to my sons, to the sons of my teacher, and to the pupils who have signed the indenture. ..." (Emphasis mine.) It is highly unlikely that indentured pupils paid him nothing.

The Oath probably was originally used in a guild, in which ethical principles were passed from teacher to pupil along with clinical knowledge. The pupil was apparently taken into the teacher's household and regarded almost as though he were the teacher's son. Medical schools no longer operate this way. This does not vitiate the overriding ethical concerns of the Oath, especially in view of its immense role in shaping the development of western medical tradition, though, as you will read below, the crack in this dam occurred half a century ago. The burden is rather on you, and others eager to scrap as obsolete principles which have guided the medical profession for centuries (with or without the actual swearing of the Oath), to prove why we should now so blithely cast it aside.

BTW, you needn't ever "dare" me to post something. Asking is sufficient.

Sincerely,

PJ


As was pointed out in the first part, medical ethics does not exist in a vacuum, but is vulnerable to shifts in society's values. The most conspicuous example of such a shift occurred in Germany in the 1930s. The collapse of the Hippocratic legacy occurred rapidly and was largely unopposed by German psychiatrists. Although participation in the German euthanasia program was not mandatory, most psychiatrists chose of their own free will to cooperate in the murder of mental patients and handicapped children when empowered to do so. No written protest by a psychiatrist of that time and place is known. One, Dr. H. Jasperson, denounced the euthanasia program and tried, unsuccessfully, to persuade the heads of the university departments of psychiatry to make a collective protest. Neither he nor any other psychiatrist was suspended or dismissed for making such a protest. By and large, Nazi medicine was eager to participate.

In the face of such wholesale departure from Hippocratic tradition, it was deemed necessary after the Nuremburg medical trials to reinstate the values embodied in the Hippocratic Oath. The Nuremburg Code is a restatement of medical ethics embodied in the Oath. The restatement in reality, however, proved to be a restructuring. Two elements, basic to the Oath, are lacking, as they have been in nearly all subsequent re-statements.

The most important rewriting of the tradition occurred a year after the establishment of the World Medical Association in 1948 and was a self-conscious response to the German tragedy, the Declaration of Geneva.

The strength of the Hippocratic Oath was its context in theism. Man is answerable to "the gods" or to God, to a standard above and outside of himself. The Oath was a solemn covenant. The Declaration, in contrast, does not have transcendent character such as that from which the Oath drew its moral force. It is merely a set of ethical assertions. The ground has been laid for post-Hippocratic medicine in which man is his own god, arbitrarily deciding what is to be the ever-changing "good."

As has been observed, the Hippocratic Oath made human life inviolable by its use of negatives. The Declaration, in contrast, substitutes the positive, "respect for human life," thus opening the way for interpretation of just what constitutes such "respect" and virtually issuing an invitation for modification. This "invitation" was answered in the 1960s when that line of the Declaration was changed from "utmost respect for human life from the time of conception" to "utmost respect ... from its beginning."

"By abandoning the transcendent and covenantal character of the Oath, those who drafted this reformulation of Hippocratism have turned the principles of medical ethics into one long composite motion to be debated year on year at representative medical assemblies" [Nigel M. deS. Cameron, The New Medicine, p. 88].

Why did not the new World Medical Association simply re-swear the Hippocratic Oath? Ask Myrtle Brickman.


Posted 4 Sep 2000.

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Copyright 1996 by P J King. Used with permission.
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