ScienceWeek

HISTORY OF MEDICINE: ON THE HIPPOCRATIC OATH

The following points are made by Howard Markel (New Engl. J. Med. 2004 350:2026):

1) Although many scholars dispute the exact authorship of the writings ascribed to the ancient physician Hippocrates, who probably lived sometime between 460 and 380 B.C., the oath named for him is simultaneously one of the most revered, protean, and misunderstood documents in the history of medicine.(1) To begin with, it is often misquoted. For example, the mantra of "First, do no harm" (a phrase translated into Latin as "Primum non nocere") is often mistakenly ascribed to the oath, although it appears nowhere in that venerable pledge. Hippocrates came closest to issuing this directive in his treatise Epidemics, in an axiom that reads, "As to diseases, make a habit of two things -- to help, or at least, to do no harm."

2) Many physicians practicing today are surprised to learn that the first recorded administration of the Hippocratic Oath in a medical school setting was at the University of Wittenberg in Germany in 1508 and that it did not become a standard part of a formal medical school graduation ceremony until 1804, when it was incorporated into the commencement exercises at Montpellier, France.(2) The custom spread in fits and starts on both sides of the Atlantic during the 19th century, but even well into the 20th century relatively few American physicians formally took the oath. According to a survey conducted for the Association of American Medical Colleges in 1928, for example, only 19 percent of the medical schools in North America included the oath in their commencement exercises.(3) With the discovery of the atrocities that were committed in the name of medicine during World War II and the growing interest in bioethics in the succeeding decades, oath taking began playing an increasing part in graduation ceremonies.(4)

3) Today, nearly every US medical school administers some type of professional oath to its share of about 16,000 men and women who are eager to take possession of their medical degrees. Yet it is doubtful that Hippocrates would recognize most of the pledges that are anachronistically ascribed to him. Such revisionism is hardly unique to our era. Indeed, the tinkering with Hippocrates' oath began soon after its first utterance and generally reflected the changing values, customs, and beliefs associated with the ethical practice of medicine.

4) Consequently, there are stark differences between the promises made in the original version and the oaths sworn today. To take the most obvious example, few if any of us now believe in the ancient Greek gods Apollo, Asclepius, Hygieia, and Panaceia, and we therefore no longer pledge allegiance to them. Indeed, the evidence indicates that spirituality in general -- regardless of its form -- now has a distant relationship with medical science: a "content analysis" of the oaths administered at 147 US and Canadian medical schools in 1993 showed that only 11 percent of the versions invoked a deity.(5)

5) There are two highly controversial vows in the original Hippocratic Oath that physicians continue to ponder and struggle with as a profession: the pledges never to participate in euthanasia and abortion.(1) These prohibitions applied primarily to those identified as Hippocratic physicians, a medical sect that represented only a small minority of all self-proclaimed healers. The Hippocratics' reasons for refusing to participate in euthanasia may have been based on a philosophical or moral belief in preserving the sanctity of life or simply on their wish to avoid involvement in any act of assisted suicide, murder, or manslaughter. We have fairly reliable historical documentation, however, that many ancient Greeks and Romans who were confronted with terminal illness preferred a quick, painless death by means of poison to letting nature take its course. Moreover, there were no laws in the ancient world against suicide, and it was not uncommon for physicians to recommend this option to a patient with an incurable disease. Similarly, abortion, typically effected by means of a pessary that induced premature labor, was practiced in both ancient Greece and the Roman Empire. Many Christian revisions of the Hippocratic Oath, especially those written during the Middle Ages, prohibited all abortive procedures. Not surprisingly, the contentious debate over both of these issues continues today, although the relevant sections are simply omitted in most oaths administered by US medical schools. As of 1993, only 14 percent of such oaths prohibited euthanasia, and only 8 percent prohibited abortion.(5)

References (abridged):

1. Edelstein L. The Hippocratic Oath: text, translation and interpretation. In: Temkin O, Temkin CL, eds. Ancient medicine: selected papers of Ludwig Edelstein. Baltimore: Johns Hopkins University Press, 1967:3-64

2. Nutton V. What's in an oath? J R Coll Physicians Lond 1995;29:518-524

3. Carey EJ. The formal use of the Hippocratic Oath for medical students at commencement exercises. Bull Assoc Am Med Coll 1928;3:159-66

4. Smith DC. The Hippocratic Oath and modern medicine. J Hist Med Allied Sci 1996;51:484-500

5. 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. J Clin Ethics 1997;8:377-388

New Engl. J. Med. http://www.nejm.org

ScienceWeek http://scienceweek.com