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    Bring Back Hippocrates

    The Hippocratic Oath has largely disappeared from modern medicine. What have we lost?

    By Lydia S. Dugdale

    August 30, 2022
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    • Annette Foster

      Really enjoyed this story as I do most of the stories on Plough. I was surprised to learn that a percentage of Doctors do not take the Hippocratic Oath. I myself feel that Doctors today are in it only for the money, they don’t seem to have the compassion or caring that should hold true for all physicians. Love being a part of Plough, the daily prayers and stories. Thank you.

    “Do you think medicine is actually a moral profession?”

    I hadn’t expected this question. She was a senior medical student of mine, and I knew that morality was important to her. She had grown up in a religious family and still practiced her faith. I was sure she understood her interactions with patients to be far more than mere transactions. How could she imagine for a moment that medicine wasn’t a moral practice?

    But she had good reason to ask. Medical school curricula change with the times, and no undergirding ethic prevails to explain medicine’s telos. Apart from a few brief lectures on physician beneficence, patient autonomy, the doctrine of informed consent, and conflict of interest, medical education has very little to say on the topic of morality. The practice of medicine appears to be not much more than the exchange, for a fee, of “de-moralized” professional services – invigorated by the occasional technological breakthrough and accompanied by a few tips on good customer service.

    red and blue portrait of a surgeon wearing a cap, glasses and mask

    Artwork copyright © Anna and Elena Balbusso. Used by permission.

    Of course, moving from the classroom to the hospital bed changes perspective. Patients presume their doctors seek their good and intend no harm. In fact, nothing carries more symbolic weight of this expectation than the Hippocratic Oath.

    A case in point: while I was writing the previous paragraph, a young member of my family wandered into the office and inquired what I was writing. I told her and then asked, “Do you know what the Hippocratic Oath is?” She was quick to reply, “Of course. It’s the oath that doctors take to become a doctor.” Detecting some triumph in my expression, she began to doubt herself. “Well, isn’t it?” she asked. “No,” I replied. “It’s the oath people think doctors take to become a doctor. In fact, most doctors don’t.”

    Medical school curricula change with the times, and no undergirding ethic prevails to explain medicine’s telos.

    In recent years, the Hippocratic Oath has been invoked to justify mandatory health-care worker vaccination against Covid-19, and to insist on caring well for patients who treat doctors poorly. Conversely, when procedures go awry, it is not uncommon to hear frustrated patients reference the Hippocratic Oath and its famous injunction “first, do no harm.” The truth is that the Hippocratic Oath does not say that the doctor should “first, do no harm.” (That phrase appears in a different Hippocratic text, Epidemics I.) The myth of Hippocrates is more prolific than his oath.

    The Hippocratic Oath belongs to a collection of about seventy texts that compose the Hippocratic corpus. Some (but not all) are thought to have been penned by the ancient Greek paragon of doctoring, Hippocrates of Cos (ca. 460–370 BC). The writings are unified primarily by their Ionic Greek language, and they cover a range of topics, from questions of a physician’s decorum and ethics to medical duties, descriptions of diseases, and accounts of patient experiences.

    Hippocrates was contemporary to Socrates (ca. 470–399 BC). In the Protagoras the philosopher extols the good doctor – along with Phidias the sculptor and Homer the poet – as being what the scholar T. A. Cavanaugh calls “illustrative of the best of their kind.”1 If Phidias was a sculptor like no other, and Homer an unparalleled poet, the world had never seen the like of a physician such as Hippocrates. Even Aristotle, whose own father Nicomachus was physician to royalty, acknowledges in his Politics that Hippocrates is healer par excellence.

    In a world with so little moral consensus, what guidelines can best serve a culture that can agree neither on the ends of medicine nor on what is permissible?

    The renowned doctor hailed from the revered clan of the Asklepiads, devotees of Asklepios, demigod of health. Their circle was exclusive; only sons of physician members were admitted to learn medicine. They were famous for shunning quackery and for admitting what they could not cure. They could be trusted to attempt to treat only what they thought could be healed. And healing, for the Asklepiads, was understood to preclude killing. Hippocrates broke with the Asklepiad tradition by taking on promising students (in addition to sons) for a fee. His oath, then, begins with a covenant of sorts between physician and apprentice – important to establish if the mentee is not a blood relative – followed by a list of licit and illicit acts.

    The young doctors swore before Apollo and a host of health-related gods and goddesses to “hold my teacher in this art equal to my own parents,” to commit to prescribing only those diets that offered benefit to patients, to keep “pure and holy” in both life and art, and to help the sick. They also pledged to refrain from a host of activities, including:

    – “all intentional wrong-doing and harm” to patients;
    – breaching patient confidentiality;
    – performing surgery for which they were not trained;
    – causing abortion;
    – poisoning or euthanizing patients or recommending such; and
    – “abusing the bodies of man or woman, bond or free” (understood as sexual relations with patients).

    The Greek word for “oath” – horkos – is related to the Greek word for “fence,” herkos. The terms of an oath define the limits of – or “fence in” – the area for a particular activity. “Just as the bounds of a soccer pitch (or any field of play) allow the game to take place, an oath establishes boundaries for important activities,” Cavanaugh notes in his book on the Hippocratic Oath.2 In taking the oath of Hippocrates, the Asklepiads professed what was in and out of bounds. Fundamental to these bounds was the commitment to helping and not harming or killing patients or their fetuses.

    Not every physician in antiquity swore the oath of Hippocrates. Legal and literary texts from the period suggest that some doctors had reputations as “unpunished killers,” and the Hippocratic corpus itself contains texts that refer to abortifacients and abortion technique. Even among Hippocrates’ own followers, some denied that medicine’s orientation toward healing precluded the taking of life. Nonetheless, in one of the rare references to the oath in classical medical literature, the physician Scribonius Largus (ca. AD 14–54) notes that Hippocrates forbade doctors from engaging in death-inducing activities. “How much more evil would he, who thought it wrong to destroy even the tenuous possibility of a man, judge the harming of a living human being?” After all, he adds, “medicine is the science of healing, not of harming.”3

    The question is not simply whether the medical profession is moral, but what kind of morality it professes.

    Although adherence to it was by no means universal, Hippocrates’ oath continued to assert its influence throughout the Middle Ages. Some Christians thought the business of swearing to Greek gods meant the oath wasn’t sufficiently Christian, so by the tenth century, a new version circulated replacing Greek divinities with the Christian God and strengthening its constraint on abortion. While it is difficult to know how many physicians ever took the oath, as of 1928 in the United States at least, only fourteen of seventy-nine medical schools required their students to swear the Hippocratic Oath in its original form.

    In contrast with its historic significance and use, today no American medical student is required to take the Hippocratic Oath. Almost all medical schools administer some sort of oath, yet they share no consensus on a single text, and many select and revise their oath each year. Medical ethicists Audiey Kao and Kayhan Parsi, in the journal Academic Medicine, suggest that “the emergence of ‘boutique’ oaths can lead to fragmentation and confusion about the ethical values of the medical profession and, thus, dilute the value of a professionally binding oath.” If 104 medical schools take 107 different oaths (some swear two!) what core ethical precepts remain? When medical students complete training and still have no clear sense of what medicine is really for, then the profession of medicine has failed to profess – literally, “to declare openly” – what it is for. Or, at least, its professing is neither consistent nor loud enough for trainees to hear.

    I routinely ask my students, “What’s the goal, the telos, of medicine? What is medicine for?” I am most often met with a blank stare. Medical training tends to elide this question entirely. Is medicine for healing? For the restoration of wholeness? Does it include physical and mental health, or only physical? What about interventions that patients may desire that are not fundamentally oriented toward their health – the Brazilian butt lift, for example? To be sure, these questions are hotly contested where they are considered at all, and if teaching physicians fail even to bring them to the table, many young doctors never have the occasion to think through why they do what they do. Without having a sense of medicine’s orientation it is difficult to discern its fences, to know what is in and out of bounds. But in a world with so little moral consensus, what guidelines can best serve a culture that can agree neither on the ends of medicine nor on what is permissible? If the Hippocratic Oath could not gain consensus in the fifth century BC, what are we to expect from our polarized world today?

    The Hippocratic Oath lays a foundation for medicine’s telos. Since the oath’s clear goal is toward benefiting the sick, it makes sense for medicine as a profession to aim at restoring health. Such a teleological orientation, of course, is open to broad interpretation, but it offers a helpful starting point.

    The oath also outlines doctors’ fundamental duties toward patients – to help and not to harm. (Curiously, only 85 percent of commencement oaths pledge this.) You might ask, “What about the other elements of the oath? No abortion or euthanasia or sex with patients or divulging secrets?” While I certainly hope for consensus on the last two, most people today know that there is no consensus on the first two. However, even if society is unable to prohibit killing altogether, senior physicians might at least be able to train young doctors to consider every patient-oriented decision against the backdrop of restoring health and mitigating disease in a manner that helps and does not harm patients. This framing immediately eliminates the possibility of sexual relations with patients and breaching of confidentiality. Indeed, it demands even more: it requires moral reasoning by physician and patient together to adjudicate what is ultimately best for a patient’s health – it underscores that medicine is fundamentally a moral practice.

    Beyond identifying the aims of medicine and the duties of doctors, medical practitioners must consider what sort of practice medicine itself ought to be. The philosopher Alasdair MacIntyre defines a practice as “any coherent and complex form of socially established cooperative human activity through which goods internal to that form of activity are realized in the course of trying to achieve those standards of excellence which are appropriate to, and partially definitive of, that form of activity, with the result that human powers to achieve excellence, and human conceptions of the ends and goods involved, are systematically extended.”4 If society wants the practice of medicine and the people it serves to flourish, then we must consider which activities will extend what is excellent, good, and purposeful about the practice, and choose not to pursue activities that corrode medicine.

    What, then, of oath-taking? Is it necessary?

    Here Cavanaugh offers several compelling reasons to take a medical oath.5 The profession, he notes, deals in grave matters – vulnerability, sickness, and death – fitting for a solemn oath. (By contrast, it would be a stretch for cosmeticians to take solemn vows, he says.) Furthermore, a public oath demonstrates reflection, commitment, and deliberateness – its public nature encourages oath-takers to keep their promises. And finally, oaths define the field of play and focus subsequent deliberation. Oaths make clear what kind of art doctors practice.

    My student was wise to ponder the moral nature of our work. And yet, the question is not simply whether the medical profession is moral, but what kind of morality it professes. In a divided world, physicians must seek unity on the fundamentals. When doctors commit to pursuing health and wholeness in ways that help and don’t harm patients, they begin to achieve a practice of medicine befitting a “good doctor” – a practice that realizes medicine’s internal goods, a practice that benefits all.

    Footnotes

    1. T. A. Cavanaugh. Hippocrates’ Oath and Asclepius’ Snake: The Birth of the Medical Profession (New York: Oxford University Press, 2018), 33.
    2. Cavanaugh, Hippocrates’ Oath, 43.
    3. Albert R. Jonsen, A Short History of Medical Ethics (New York: Oxford Univ. Press, 2000), 4–5.
    4. Alasdair MacIntyre, After Virtue (Notre Dame, IN: Notre Dame Univ. Press:2010), 187.
    5. Cavanaugh, Hippocrates’ Oath, 124–30.
    Contributed By LydiaSDugdale Lydia S. Dugdale

    Lydia S. Dugdale is a physician and ethicist at Columbia University in New York City, where she also directs the Center for Clinical Medical Ethics.

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