The Oath Revisited
by Robert E. Cranston, MD, MA (Ethics) and William P. Cheshire, MD, MA (Ethics)
A first step of academic research is to review what has already been discovered, evaluated or recorded on a given topic. In this regard, Dr. Bob Orr took a giant leap in 2009 by surveying and analyzing extant information on the Hippocratic Oath and other medical oaths used by physicians over the last several thousand years. If you stop reading this blog right now, and instead read Dr. Orr’s article, we will be satisfied and you will be edified.
Much has transpired since 2009. In 2017, the World Medical Association published its newest version of an updated oath, which they call a pledge. The difference in this choice of wording presages the difference in meaning and content between the original Hippocratic Oath, and the World Medical Association Pledge.
Although it is uncertain who authored the Hippocratic Oath, it is widely assumed it originated with a group of physicians who trained under the ancient Greek physician Hippocrates as his direct or second-generation disciples. In its day, the Hippocratic Oath was countercultural in several respects, namely, in forbidding physician-assistance in dying or participation in euthanasia, as well as in affording slaves respect by forbidding seduction of either male or female free men or slaves. Inductees took the oath in the names of “Apollo the physician, and Asclepius, and Hygieia and Panacea and all the gods and goddesses.” This would not correspond with Christian, Jewish or Muslim traditions today, but it does give evidence that the Hippocratic community believed in a transcendent reality, greater and beyond that seen, on which to base their professional assurance and hold themselves accountable.
Some aspects of the original Hippocratic Oath have inevitably changed over time. While we respect our medical mentors and many of us feel an obligation to teach the next generation of doctors, few of us hold “those who taught me this art equally dear to me as parents, to be a partner in life with him, and to fulfills his needs when requires; to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract.” The institutionalization of medical education has afforded many benefits but removes this obligation from physicians personally.
The wording of the original is entirely in the masculine gender, and although the use of the masculine gender is customarily intended as inclusive of both, females were not trained as physicians in ancient times. There is a slight majority of female medical students today across America, so explicitly inclusive gender is appropriate.
The Hippocratic Oath relegates “the knife” to non-physicians, “those who are trained in this craft.” Today we allow only trained physicians to become wielders of the scalpel. The spirit of that exclusion is retained, however, as physicians are expected to practice only within their area of specialty or training. Patient confidentiality was also an important part of the Hippocratic Oath that, codified today in HIPAA, has changed in context while keeping to the original principle.
Various changes were made to the oath over the next two millennia, and Muslim and Jewish traditions developed their own similar but separate oaths. In 1948, immediately after the Nuremberg trials in Germany that exposed the atrocities Nazi physicians performed in the name of research, the World Medical Association (WMA) outlined the then-current understanding of physician responsibilities. The WMA subsequently revised that document in 1968, 1983, 1994, 2005, 2006 and, most recently, in 2017. Alongside the World Medical Association Pledge, a plethora of other lesser-known oaths were and are in use. In 2014, Antiel, Hook, et al. documented numerous oaths pledged throughout the world, and they note that taking any oath is not mandatory and only one-fourth of practicing physicians in their study “acknowledged a strong influence of oaths in their practice.”
In comparing the WMA’s 2017 Chicago version with the original Hippocratic Oath, the following differences are seen:
- In all probability, the original Hippocratic Oath was administered prior to entering into training. In most medical schools today an oath, if taken, is usually placed at the beginning of year three (in a typical four-year curriculum) or at graduation. Some schools administer the oath in various forms multiple times.
- The World Medical Association Pledge is a pledge, not an oath. Thus, the original sense of transcendence is no longer seen as relevant. The once solemn oath is now a secular pledge, and one that no longer stands the test of time but might be modified again next year, readjusted as convenient or according to shifting cultural mores.
- The World Medical Association Pledge, specifically line four, lists patient autonomy as a focus of respect. The Hippocratic Oath doctor was, by modern standards, paternalistic, but now we often struggle with problems at the opposite extreme—autonomy run amok.
- The Hippocratic Oath specifically forbids euthanasia and abortion. The World Medical Association Pledge states, “I will maintain the utmost respect for human life,” but it does not define what respect should mean, not does it identify which human lives qualify for protection, thus opening the door to permitting both euthanasia and abortion.
- The World Medical Association Pledge specifies at length all the subsections of diverse humanity the doctor should respect, whereas the Hippocratic Oath more broadly names men, women, slave and free. In 50 A.D. approximately half the people in Rome were slaves.
- The World Medical Association Pledge pledges that confidences will be maintained even after patient death. The Hippocratic Oath doesn’t clarify this.
- The Hippocratic Oath includes dietary regimens as useful. This probably included herbal medications under this rubric, and today we have many more pharmacologic options. Diet, per se, is not mentioned by the World Medical Association Pledge but, interestingly, is becoming more of a focus today. Anorexia and orthorexia were likely not problems in those days.
- The World Medical Association Pledge refers to practicing medicine with “conscience and dignity and in accordance with good medical practice,” whereas the Hippocratic Oath states, “In purity and according to divine law will I carry out my life and my art.” The Hippocratic Oath, thus, not only confirms a divine yardstick, but also calls for the highest possible standard of personal behavior among physicians. The World Medical Association Pledge appeals to the lesser standard of human rules and laws.
- The World Medical Association Pledge implies that, if “good medical practice” broadens to include actions which violate the physician’s conscience, they would be expected to provide these services nevertheless, suggesting that physician refusal to participate in actions contrary to their moral beliefs is not protected by the guidelines of “Purity…and divine law.” Thus, the World Medical Association Pledge significantly weakens acknowledgment of the healthcare right of conscience.
- The World Medical Association Pledge employs the phrase, “violate human rights and civil liberties, even under threat,” which is aimed at participation in prisoner torture or execution, a modern problem. The Hippocratic Oath promises the doctor “will benefit my patients according to my greatest ability and judgment, and I will do no harm or injustice to them.” The specific phrase, “First, do no harm,” is quoted from the Hippocratic writings, not the Hippocratic Oath, but the World Medical Association Pledge rendering is appropriate and consistent in spirit with the Hippocratic writings.
- The World Medical Association Pledge vows to “Attend to my own health, well-being, and abilities,” which is an appropriate thought given today’s high rate of physician burnout and suicide rates among physicians, but was not a stated concern in the Hippocratic Oath.
- The Hippocratic Oath essentially calls for a divine blessing on the physician who practices within its constraints, but a curse on those who do not. No such accountability is seen in the World Medical Association Pledge, perhaps because the document is meant to apply internationally, whereas legal mandates affecting medical practice vary across jurisdictions.
In summary, the World Medical Association Pledge is fundamentally secular and does not acknowledge a transcendent obligation or basis for physician accountability. It also downplays the importance of respect for medical educators, but it does improve on the Hippocratic Oath by adding specific clauses on diversity, autonomy, physician self-care and civil rights in general, while strengthening confidentiality constraints. Whereas the World Medical Association Pledge elaborates specifically who is to be respected, this is in keeping with the original meaning of the Hippocratic Oath, which affirms respect for all in language that was broad and inclusive in the day it was written.
Of crucial importance, the World Medical Association Pledge asks medicine to leave behind the Hippocratic Oath prohibition on taking human life. While giving a vague nod to “utmost respect for human life,” the World Medical Association Pledge does not forbid abortion or euthanasia. As the intended successor to the Hippocratic Oath, its omission of this essential prohibition seems, in fact, to allow it. Those who would require physicians to participate in such acts, which were forbidden under the Hippocratic Oath, will rejoice in the language of the World Medical Association Pledge, for the principle of healthcare right of conscience, indispensable to moral medicine, is tossed aside.
While some of the differences in language reflect changes in time and technology—forbidding the use of “the knife,” for instance—the World Medical Association Pledge moves the practice of medicine away from being a sacred fiduciary trust based on timeless divine principles toward a focus on patient autonomy and principles more restricted to this particular era in time. It has lost much in the transition.
Nota bene: Opinions expressed here are ours alone and do not necessarily reflect those of CMDA, its Ethics Committee or the institutions with which the authors are professionally affiliated.
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