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Hippocratic Oath

For other uses, see Hippocratic Oath (disambiguation).
Not to be confused with Hypocrisy.

The Hippocratic Oath is an oath of ethics historically taken by physicians. It is one of the most widely known of Greek medical texts. In its original form, it requires a new physician to swear, by a number of healing gods, to uphold specific ethical standards. The oath is the earliest expression of medical ethics in the Western world, establishing several principles of medical ethics which remain of paramount significance today. These include the principles of medical confidentiality and non-maleficence. As the foundational articulation of certain principles that continue to guide and inform medical practice, the ancient text is of more than historic and symbolic value. It is enshrined in the legal statutes of various jurisdictions, such that violations of the oath may carry criminal or other liability beyond the oath's symbolic nature.

The Greek physician Hippocrates (460–370 BC), to whom the oath is traditionally attributed

The original oath was written in Ionic Greek, between the fifth and third centuries BC.[1] Although it is traditionally attributed to the Greek doctor Hippocrates and it is usually included in the Hippocratic Corpus, some modern scholars do not regard it as having been written by Hippocrates himself.

Text of the oath

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Earliest surviving copy

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A fragment of the oath on the 3rd-century Papyrus Oxyrhynchus 2547.

The oldest partial fragments of the oath date to circa AD 275. The oldest extant version dates to roughly the 10th–11th century, held in the Vatican Library.[2] A commonly cited version, dated to 1595, appears in Koine Greek with a Latin translation.[3][4] In this translation, the author translates πεσσὸν to the Latin fœtum.

Below is the Hippocratic Oath, in Greek, from the 1923 Loeb edition, followed by the English translation:

"First do no harm"

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Main article: Primum non nocere

It is often said that "First do no harm" (Latin: Primum non nocere) is a part of the original Hippocratic oath. A related phrase is found in Epidemics, Book I, of the Hippocratic school: "Practice two things in your dealings with disease: either help or do not harm the patient".[7] Although no such phrase from which "First" or "Primum" can be translated appears in any well recognized version of the oath, a similar intention is vowed by, "I will abstain from all intentional wrong-doing and harm". "Primum non nocere" was claimed by the 19th-century English surgeon Thomas Inman to date from the 17th-century English physician Thomas Sydenham,[8] but Sydenham's available writings contain no such phrase or equivalent,[9] and it more likely took shape from longstanding popular nonmedical expression.[10]

Context and interpretation

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A 12th-century Greek manuscript of the oath

The oath is arguably the best known text of the Hippocratic Corpus, although most modern scholars do not attribute it to Hippocrates himself, estimating it to have been written in the fourth or fifth century BC.[11] Alternatively, classical scholar Ludwig Edelstein proposed that the oath was written by the Pythagoreans, an idea that others questioned for lack of evidence for a school of Pythagorean medicine.[12] While Pythagorean philosophy displays a correlation to the Oath's values, the proposal of a direct relationship has been mostly discredited in more recent studies.[13]

Its general ethical principles are also found in other works of the Corpus: the Physician mentions the obligation to keep the "holy things" of medicine within the medical community (i.e. not to divulge secrets); it also mentions the special position of the doctor with regard to his patients, especially women and girls.[14] However, several aspects of the oath contradict patterns of practice established elsewhere in the Corpus. Most notable is its ban on the use of the knife, even for small procedures such as lithotomy, even though other works in the Corpus provide guidance on performing surgical procedures.[15]

Providing poisonous drugs would certainly have been viewed as immoral by contemporary physicians if it resulted in murder. However, the absolute ban described in the oath also forbids euthanasia. Several accounts of ancient physicians willingly assisting suicides have survived.[16] Multiple explanations for the prohibition of euthanasia in the oath have been proposed: it is possible that not all physicians swore the oath, or that the oath was seeking to prevent widely held concerns that physicians could be employed as political assassins.[17]

The interpreted AD 275 fragment of the oath contains a prohibition of abortion that is in contradiction to original Hippocratic text On the Nature of the Child, which contains a description of an abortion, without any implication that it was morally wrong,[18] and descriptions of abortifacient medications are numerous in the ancient medical literature.[19] The oath's stance on abortion was unclear even in the ancient world where physicians debated whether the specification of pessaries was a ban on simply pessaries, or a blanket ban on all abortion methods.[20] Scribonius Largus was adamant in AD 43 (the earliest surviving reference to the oath) that it precluded abortion.[21] In the 1st or 2nd century AD work Gynaecology, Soranus of Ephesus wrote that one party of medical practitioners followed the Oath and banished all abortifacients, while the other party—to which he belonged—was willing to prescribe abortions, but only for the sake of the mother's health.[21][22] William Henry Samuel Jones states that "abortion [...] though doctors are forbidden to cause it, was possibly not condemned in all cases". He believed that the oath prohibited abortions, though not under all circumstances.[20] John M. Riddle argues that because Hippocrates specified pessaries, he only meant pessaries and therefore it was acceptable for a Hippocratic doctor to perform abortions using oral drugs, violent means, a disruption of daily routine or eating habits, and more. Other scholars, most notably Ludwig Edelstein, believe that the author intended to prohibit any and all abortions.[20] Olivia De Brabandere writes that regardless of the author's original intention, the vague and polyvalent nature of the relevant line has allowed both professionals and non-professionals to interpret and use the oath in several ways.[20] While many Christian versions of the Hippocratic Oath, particularly from the Middle Ages, explicitly prohibited abortion, the prohibition is often omitted from many oaths taken in US medical schools today, though it remains controversial.[17]

The oath stands out among comparable ancient texts on medical ethics and professionalism through its heavily religious tone, a factor which makes attributing its authorship to Hippocrates particularly difficult. Phrases such as "but I will keep pure and holy both my life and my art" suggest a deep, almost monastic devotion to the art of medicine. He who keeps to the oath is promised "reputation among all men for my life and for my art". This contrasts heavily with Galenic writings on professional ethics, which employ a far more pragmatic approach, where good practice is defined as effective practice, without reference to deities.[23]

The oath's importance among the medical community is nonetheless attested by its appearance on the tombstones of physicians, and by the fourth century AD it had come to stand for the medical profession.[24]

The oath continued to be in use in the Byzantine Christian world with its references to pagan deities replaced by a Christian preamble, as in the 12th-century manuscript pictured in the shape of a cross.[25]

Modern versions and relevance

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An engraving of Hippocrates by Peter Paul Rubens, 1638

The Hippocratic Oath has been eclipsed as a document of professional ethics by more extensive, regularly updated ethical codes issued by national medical associations, such as the American Medical Association's Code of Medical Ethics (first adopted in 1847), and the British General Medical Council's Good Medical Practice. These documents provide a comprehensive overview of the obligations and professional behaviour of a doctor to their patients and wider society. Doctors who violate these codes may be subjected to disciplinary proceedings, including the loss of their license to practice medicine. Nonetheless, the length of these documents has made their distillations into shorter oaths an attractive proposition. In light of this fact, several updates to the oath have been offered in modern times,[26][27] some facetious.[28]

The oath has been modified numerous times.

One of the most significant revisions was first drafted in 1948 by the World Medical Association (WMA), called the Declaration of Geneva. "During the post World War II and immediately after its foundation, the WMA showed concern over the state of medical ethics in general and over the world. The WMA took up the responsibility for setting ethical guidelines for the world's physicians. It noted that in those years the custom of medical schools to administer an oath to its doctors upon graduation or receiving a license to practice medicine had fallen into disuse or become a mere formality".[29] In Nazi Germany, medical students did not take the Hippocratic Oath, although they knew the ethic of "nil nocere"—do no harm.[30][failed verification]

In the 1960s, the Hippocratic Oath was changed to require "utmost respect for human life from its beginning", making it a more secular obligation, not to be taken in the presence of any gods, but before only other people. When the oath was rewritten in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, the prayer was omitted, and that version has been widely accepted and is still in use today by many US medical schools:[31]

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not", nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

In a 1989 survey of 126 US medical schools, only three of them reported use of the original oath, while thirty-three used the Declaration of Geneva, sixty-seven used a modified Hippocratic Oath, four used the Oath of Maimonides, one used a covenant, eight used another oath, one used an unknown oath, and two did not use any kind of oath. Seven medical schools did not reply to the survey.[32]

As of 1993, only 14% of medical oaths prohibited euthanasia, and only 8% prohibited abortion.[33]

In a 2000 survey of US medical schools, all of the then extant medical schools administered some type of professional oath. Among schools of modern medicine, sixty-two of 122 used the Hippocratic Oath, or a modified version of it. The other sixty schools used the original or modified Declaration of Geneva, Oath of Maimonides, or an oath authored by students or faculty or both. All nineteen osteopathic schools in the United States used the Osteopathic Oath,[34] which is taken in place of or in addition to the Hippocratic Oath. The Osteopathic Oath was first used in 1938, and the current version has been in use since 1954.[35]

In France, it is common for new medical graduates to sign a written oath.[36][37]

In 1995, Sir Joseph Rotblat, in his acceptance speech for the Nobel Peace Prize, suggested a Hippocratic Oath for Scientists.[38]

In November 2005, Saparmurat Niyazov, then leader of Turkmenistan, declared that doctors should swear an oath to him instead of the Hippocratic Oath.[39]

In 2007, US citizen Rafiq Abdus Sabir was convicted for making a pledge to al-Qaeda, thus agreeing to provide medical aid to wounded terrorists.[40]

As of 2018, all US medical school graduates made some form of public oath but none used the original Hippocratic Oath. A modified form or an oath unique to that school is often used. A review of 18 of these oaths was criticized for their wide variability: "Consistency would help society see that physicians are members of a profession that's committed to a shared set of essential ethical values."[41]

Violations

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There is no direct punishment for breaking the Hippocratic Oath, although an arguable equivalent in modern times is medical malpractice, which carries a wide range of punishments, from imprisonment to civil penalties.[42] Medical professionals may also be subject to other parts of the criminal and civil law for conduct contrary to both an oath taken and to a more general prohibition on, for example, doing physical or other harm to other persons. In the United States, several major judicial decisions have made reference to the classical Hippocratic Oath, either upholding or dismissing its bounds for medical ethics: Roe v. Wade, Washington v. Harper, Compassion in Dying v. State of Washington (1996), and Thorburn v. Department of Corrections (1998).[43] In antiquity, the punishment for breaking the Hippocratic oath could range from a penalty to losing the right to practice medicine.[44]

In 2022, at a college in the Indian state of Tamil Nadu, medical students took the Charaka shapath, a Sanskrit oath attributed to ancient sage and physician Maharishi Charak instead of the Hippocratic oath. The state government subsequently dismissed the Dean of the Madurai medical college for this act.[45][46][47] However, he was reinstated by the Tamil Nadu government and assumed office 4 days later.[48]

See also

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Ethical codes of conduct for physicians
Ethical principles for human experimentation
Ethical practices for engineers
Science

References

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  1. ^ Edelstein, Ludwig (1943). The Hippocratic Oath: Text, Translation and Interpretation. Johns Hopkins Press. p. 56. ISBN 978-0-8018-0184-6.
  2. ^ "Codices urbinates graeci Bibliothecae Vaticanae: Folio 64(Urb.gr.64)". Vatican Library: DigiVatLib. 900–1100. p. folio:116 microfilm: 121.
  3. ^ North, Michael (2002). "Greek Medicine: "I Swear by Apollo Physician...": Green Medicine from the Gods to Galen". National Institute of Health; National Library of Medicine; History of Medicine Division.
  4. ^ Wecheli, Andreae (1595). "Hippocrates. Τα ενρισκομενα Opera omnia". Frankfurt: National Institute of Health; National Library of Medicine; History of Medicine Division).
  5. ^ a b Hippocrates of Cos (1923). "The Oath". Loeb Classical Library. 147: 298–299. doi:10.4159/DLCL.hippocrates_cos-oath.1923. Retrieved 6 October 2015.
  6. ^ "Greek Medicine – The Hippocratic Oath". www.nlm.nih.gov. National Library of Medicine – NIH. Retrieved 29 July 2020.
  7. ^ Lloyd, Geoffrey, ed. (1983). Hippocratic Writings (2nd ed.). London: Penguin Books. pp. 94. ISBN 978-0-14-044451-3.
  8. ^ Sokol, Daniel K. (2013). "'First do no harm' revisited". BMJ. 347: f6426. doi:10.1136/bmj.f6426. PMID 24163087. S2CID 33952216. Retrieved 20 September 2014.
  9. ^ Smith, C. M. (2005). "Origin and Uses of Primum Non Nocere – Above All, Do No Harm!". The Journal of Clinical Pharmacology. 45 (4): 371–77. doi:10.1177/0091270004273680. PMID 15778417. S2CID 41058798.
  10. ^ Suss, Richard A. (November 21, 2024). "First Do No Harm Is Proverbial, Not Hippocratic". OSF Preprints. doi:10.31219/osf.io/c23jq.
  11. ^ Jouanna, Jacques (2001). Hippocrates. Baltimore, Md.: Johns Hopkins University Press. ISBN 978-0-8018-6818-4.
  12. ^ Temkin, Owsei (2002). "On second thought" and other essays in the history of medicine and science. Baltimore, MD: Johns Hopkins University Press. ISBN 978-0-8018-6774-3.
  13. ^ Askitopoulou, Helen; Vgontzas, Antoniοs N. (2018-07-01). "The relevance of the Hippocratic Oath to the ethical and moral values of contemporary medicine. Part I: The Hippocratic Oath from antiquity to modern times". European Spine Journal. 27 (7): 1481–1490. doi:10.1007/s00586-017-5348-4. ISSN 1432-0932. PMID 29080001. S2CID 10142596.
  14. ^ Potter, Paul, ed. (1995). Hippocrates (Reprint ed.). Cambridge, Massachusetts: Harvard Univ. Press u.a. pp. 295–315. ISBN 978-0-674-99531-4.
  15. ^ Nutton, Vivian (2012). Ancient medicine (2nd ed.). Milton Park, Abingdon, Oxon: Routledge. p. 68. ISBN 978-0-415-52095-9.
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  17. ^ a b Markel, Howard (2004). ""I Swear by Apollo" – On Taking the Hippocratic Oath" (PDF). The New England Journal of Medicine. 350 (20). Massachusetts Medical Society: 2026–2029. doi:10.1056/NEJMp048092. PMID 15141039. Retrieved 1 March 2017.
  18. ^ Lonie, Iain M. (1981). The Hippocratic treatises, "On generation," "On the nature of the child," "Diseases IV" a commentary. Berlin: De Gruyter. p. 7. ISBN 978-3-11-086396-3.
  19. ^ King, Helen (1998). Hippocrates' woman: reading the female body in ancient Greece. London: Routledge. pp. 132–156. ISBN 978-0-415-13895-6.
  20. ^ a b c d De Brabandere, Olivia (2018). The "Hippocratic" Stance on Abortion: The Translation, Interpretation, and Use of the Hippocratic Oath in the Abortion Debate from the Ancient World to Present-Day (Master of Arts thesis). Queen's University. pp. 3–4, 7, 58.
  21. ^ a b "Scribonius Largus"
  22. ^ Soranus, Owsei Temkin (1956). Soranus' Gynecology. I.19.60: JHU Press. ISBN 978-0-8018-4320-4. Retrieved 6 October 2015.{{cite book}}: CS1 maint: location (link)
  23. ^ Wear, Andrew; Geyer-Kordesch, Johanna; French, Roger Kenneth, eds. (1993). Doctors and Ethics: The Earlier Historical Setting of Professional Ethics. Amsterdam: Rodopi. pp. 10–37.
  24. ^ von Staden, H (1996). "In a pure and holy way. Personal and professional conduct in the Hippocratic Oath". Journal of the History of Medicine and Allied Sciences. 51 (4): 404–437. doi:10.1093/jhmas/51.4.404. PMID 9019063.
  25. ^ Nutton, Vivian (2012). Ancient medicine (2nd ed.). Milton Park, Abingdon, Oxon: Routledge. p. 415, note 87. ISBN 978-0-415-52095-9.
  26. ^ Buchholz B, et al. Prohibición de la litotomía y derivación a expertos en los juramentos médicos de la genealogía hipocrática. Actas Urologicas Espanolas. Volume 40, Issue 10, December 2016, Pages 640–645.
  27. ^ Oswald, H.; Phelan, P. D.; Lanigan, A.; Hibbert, M.; Bowes, G.; Olinsky, A. (1994). "Outcome of childhood asthma in mid-adult life". BMJ (Clinical Research Ed.). 309 (6947): 95–96. doi:10.1136/bmj.309.6947.95. PMC 2540578. PMID 8038676.
  28. ^ Schiedermayer, D. L. (1986). "The Hippocratic Oath — Corporate Version". New England Journal of Medicine. 314 (1): 62. doi:10.1056/NEJM198601023140122. PMID 3940324.
  29. ^ World Medical Association, Inc. "WMA History". www.wma.net. World Medical Association, Inc. Archived from the original on 6 February 2015. Retrieved 1 November 2014.
  30. ^ Baumslag, Naomi (2005). Murderous Medicine: Nazi Doctors, Human Experimentation, and Typhus. Praeger Publishers. pp. xxv. ISBN 978-0-275-98312-3.
  31. ^ "The Hippocratic Oath Today". PBS. 27 March 2001.
  32. ^ Crawshaw, R (8 October 1994). "The Hippocratic oath. Is alive and well in North America". BMJ (Clinical Research Ed.). 309 (6959): 952–953. doi:10.1136/bmj.309.6959.952. PMC 2541124. PMID 7950672.
  33. ^ Markel, Howard (2004). ""I Swear by Apollo" — On Taking the Hippocratic Oath" (PDF). The New England Journal of Medicine. 350 (20). Massachusetts Medical Society: 2026–9. doi:10.1056/NEJMp048092. PMID 15141039. Retrieved 1 March 2017.
  34. ^ Kao, AC; Parsi, KP (September 2004). "Content analyses of oaths administered at U.S. medical schools in 2000". Academic Medicine. 79 (9): 882–7. doi:10.1097/00001888-200409000-00015. PMID 15326016.
  35. ^ "Osteopathic Oath". American Osteopathic Association. Retrieved 28 November 2014.
  36. ^ Sritharan, Kaji; Georgina Russell; Zoe Fritz; Davina Wong; Matthew Rollin; Jake Dunning; Bruce Wayne; Philip Morgan; Catherine Sheehan (December 2000). "Medical oaths and declarations". BMJ. 323 (7327): 1440–1. doi:10.1136/bmj.323.7327.1440. PMC 1121898. PMID 11751345.
  37. ^ Crawshaw, R; Pennington, T H; Pennington, C I; Reiss, H; Loudon, I (October 1994). "Letters". BMJ. 309 (6959): 952–953. doi:10.1136/bmj.309.6959.952. PMC 2541124. PMID 7950672.
  38. ^ "Nobel Prize winner calls for ethics oath". Physics World. 19 December 1997. Retrieved 2008-07-19.
  39. ^ "Turkmen Doctors Pledge Allegiance To Niyazov". RadioFreeEurope/RadioLiberty. 15 November 2005. Retrieved 24 August 2024.
  40. ^ "Trial and Terror". Archived from the original on 2021-05-07. Retrieved 2021-05-07.
  41. ^ Weiner, Stacey (10 July 2018). "The solemn truth about medical oaths". aamc.org. American Association of Medical Colleges. Retrieved 17 June 2022.
  42. ^ Groner M.D., Johnathan (2008). "The Hippocratic Paradox: The Role of The Medical Profession In Capital Punishment In The United States". Fordham Urban Law.
  43. ^ Hasday, Lisa (23 February 2013). "The Hippocratic Oath as Literary Text: A Dialogue". Yale Journal of Health Policy, Law, and Ethics. 2 (2): Article 4. Retrieved 6 October 2015.
  44. ^ Nutton, Vivian (2004). Ancient Medicine. New York, NY: Routledge.
  45. ^ "Madurai college dean removed after MBBS students take 'Charak Shapath'". The News Minute. 2022-05-01. Retrieved 2022-05-02.
  46. ^ "Sanskrit replaces Hippocratic Oath; Tamil Nadu shunts out Madurai Medical College dean". Deccan Herald. 2022-05-01. Retrieved 2022-05-02.
  47. ^ "TN medical college dean removed after row over Charak Shapath". Google News. Retrieved 2022-05-02.
  48. ^ https://www.newindianexpress.com/states/tamil-nadu/2022/May/06/charak-shapath-row-a-rathinavel-returns-as-dean-of-madurai-medical-college-2450259.html

Further reading

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