Professional Oaths: History, Usage, Content and Changes
by Robert D. Orr, MD, CM
Today's Christian Doctor - Spring 2009
History of Medical Oaths
When a new ethical dilemma is discussed today, either in a professional forum or in the public square, someone often asks, “What does the Hippocratic Oath have to say about this issue?” This ancient document is truly regarded as a standard with contemporary relevance and application.
The Oath of Hippocrates, likely dating from a few centuries before Christ’s birth,1 defines a watershed in the history of western medicine. Most ancient Greek physicians were tradesmen who were looking out for themselves; e.g., treating the rich, ignoring the poor. Those who took this Oath, on the other hand, swore to instead seek first the patient’s best interests. This defining feature – seeking the patient’s best interest – was the beginning of medicine as a profession rather than merely a trade. It is interesting to note that at that time the Oath was administered to the novice at the beginning of training to be a physician, not at its completion as is the common practice today. Even more important, what began as a badge of non-conformity to the medical practices of the day has become the standard to which society often refers in analyzing issues in current practice.
The text of the revolutionary Oath includes pledges about teaching, dedication to patient’s welfare, and decorum. Of equal importance, it is not a code of ethics, i.e., sworn to peers, but an oath, sworn to divinity. The exact wording of the Hippocratic Oath has been the subject of much scholarly debate. The most frequently used translation was done by Ludwig Edelstein in 1943 (see sidebar, page 20). Perhaps more important than the exact words, however, is an understanding of its intent. Of the many analyses and commentaries on the Oath, that done by Leon Kass2 is, in my estimate, the most insightful and applicable to today’s medicine (see sidebar, page 22).
Hippocratic Oath – Classical Version
I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill 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 fulfill 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.
Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943.
Usage of Medical Oaths
The Hippocratic Oath is the oldest and best known of the several medical professional oaths used in the past and present. However, in the past 100 years, many individuals have declared the Oath to be archaic, and some have proposed revisions or even have developed entirely new oaths (or codes). Thus, while society looks to the classical Hippocratic Oath as the standard, most graduating medical students do not actually swear this particular oath.
In 1993, colleagues and I reviewed the literature and undertook a survey of all 157 allopathic and osteopathic schools of medicine in North America to learn what oaths were being used at that time.3 We learned from the literature that oath-taking increased dramatically in the 20th century: in 1928, 24 percent of schools administered an oath; in 1958, 72 percent; in 1977, 90 percent; and by 1989, 100 percent of US schools administered an oath to their graduating physicians.
We were able to obtain the name and text of most of the oaths used. Interestingly, seventy-four schools labeled the oath they used “The Hippocratic Oath,” but in fact, when we looked at the text, we found that only one so labeled used the ancient words (State University of New York at Syracuse). Thus, the term “Hippocratic Oath” is often used as a generic term meaning a medical professional oath. Seven schools volunteered that they allowed their students to either choose from a selection of oaths, or even write their own oath.
|Oaths Used in 1993||Number||%*|
|Oath of Hippocrates
- classical version
- modern version
- modified version**
- unknown version
|Declaration of Geneva
- 1948 version
- 1983 version
|The Osteopathic Oath||15||10|
|The Oath of Louis Lasagna||5||3|
|The Prayer of Maimonides||4||3|
|No oath administered||3||2|
*does not add up to 100% due to rounding
**some portions of the original oath with substantial changes, each one unique
Content of Oaths Used in 1993
We were able to analyze the content of 146 oaths using a modification of Kass’ analysis (see sidebar, page 22). The classical Hippocratic Oath contains fourteen identifiable content items. The Modern Hippocratic Oath includes ten of them; the Osteopathic Oath has nine; the 1948 Declaration of Geneva has seven; the 1983 Declaration of Geneva has six; the Oath of Louis Lasagna has six; and the Prayer of Maimonides has five. Except for the Prayer of Maimonides (which is really a prayer, not an oath), the fall-off in content items is directly related to the age of the oath – the newer the oath, the fewer of the original content items. To be fair, many of the newer oaths have added new items such as prevention of disease, commitments to science and learning, avoidance of greed, humility, care of the whole person, autonomy of patients, assistance with decision-making, gender-inclusive language, and wording suggesting that taking a patient’s life may be acceptable.
The items most often deleted from newer oaths are: proscription of sexual contact with patients (retained in only 3 percent), covenant with deity (11 percent), foreswearing abortion (8 percent), foreswearing euthanasia (14 percent), and agreement to be accountable for keeping the oath (43 percent).
Changes: What and Why?
Why have there been such dramatic changes in the practice of oath administration and the content of the oaths used? Clearly, the practice of medicine has changed immeasurably in the past 2,500 years. And of course, the Oath is not Holy Writ. The question then becomes whether the Oath is foundational, whether it set the stage for the practice of medicine – for all time.
Albert Jonsen, a medical historian, maintains that the thrust of the Hippocratic Oath focused on the competence of the physician and the best interests of the patient.4 He goes on to conclude that this revolutionary focus subsequently combined with the compassion taught and modeled by Jesus to develop the ethos of modern medicine. Nigel Cameron, theologian and ethicist, concurs and laments that this historic combination of skill and moral commitment has devolved in recent years to a lesser concept, that medicine is all about technique, ignoring the moral commitment. He concludes that the current practice of medical professional oath-taking focuses more on the process rather than the content.5
It is important in looking at the changes to understand the original intent of the writer of the Oath. For example, Kass points out that the proscription against operating on a patient with kidney stones was not because such surgery was immoral. The intent was to focus on the welfare of the patient, i.e., if surgery was not done, the stone might pass; but if surgery was attempted by the untrained physician, there was a high likelihood that the patient would die of infection.
Many of the changes can be attributed to the societal changes of the 1960s and ’70s. During that period of time in western culture, patient rights and autonomy came to the fore (along with consumer rights, minority rights, women’s rights, etc.). I would not for a moment suggest that we return to the pre-1960 age of medical paternalism where physicians decided what to do without patient input or consent. But, I believe the pendulum has swung too far, that physicians have ceded their moral authority and been unwilling to assert the traditional boundaries of medical practice. Nowhere is this more evident than in the acceptance of abortion and the clamor for physician-assisted suicide or even euthanasia.
One other finding from our 1993 survey may shed some light on these changes. Allowing graduating medical students to write their own oath seems antithetical. This postmodern approach is like saying to the students, “Okay, you are doctors now. What does that mean to you?” If there is an ethic in medicine, if there are foundational standards, it seems self-evident that the practitioners of the art should articulate those standards rather than asking new inductees to choose their own standards and boundaries.
The practice of medical oath-taking in North America has steadily increased in the past 100 years, but the content has been steadily diluted and secularized, seriously diminishing the core values of the profession. As Cameron has suggested, when we can no longer agree on the content, we have focused instead on the process. This departure from the Hippocratic tradition is very troubling. Very troubling, indeed.
1 The author of the Oath is unknown. Various scholars have dated its origin between 600 BC and 100 AD; the most commonly cited date is about 450 BC.
2 “Is There a Medical Ethic? The Hippocratic Oath and the Sources of Ethical Medicine.” Chapter 9 in Toward a More Natural Science, by LR Kass; New York: The Free Press, 1985.
3 Orr RD, Pang N, Pellegrino ED, Siegler M. “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.” Journal of Clinical Ethics 1997; 8 (4): 377-88.
4 Jonsen AR. The New Medicine & the Old Ethics. Cambridge, MA: Harvard University Press, 1990.
5 Cameron, NMdeS. The New Medicine: Life and Death after Hippocrates. Wheaton, IL: Crossway Books, 1991.
ABOUT THE AUTHOR
Robert D. Orr, MD, CM, received his MD, C M from McGill University in 1966, did residency training in family medicine, and practiced in Vermont for 18 years. Since completing a fellowship in clinical ethics at the University of Chicago, he has taught clinical ethics at Loma Linda University School of Medicine (CA), the University of Vermont College of Medicine, the Graduate College at Union University (NY) and Trinity International University (IL). He lectures widely and has co-authored or co-edited 6 books, 11 book chapters, and over 150 articles on ethics, ethics consultation and end-of-life care. His awards include the Vermont Family Doctor of the Year (1989), the Isaac Hayes and John Bell Award for Leadership in Medical Ethics and Professionalism (AMA, 1999), Scholar in Residence at the Kilns (CS Lewis Foundation , 2006) the Servant of Christ Award (Christian Medical & Dental Associations, 2009) and Distinguished Service Award (Loma Linda University). His most recent book is Medical Ethics and the Faith Factor (Wm. B. Eerdmans, 2009).