Analyzing the Hippocratic Oath

September 17, 2009

Hippocratic OathI’d like to wish all the medical students beginning their arduous four-year med school journey this month the best of luck.  Reminiscing on my first days of medical school, I recall the thrill of reciting the Hippocratic Oath for the first time as part of a ritualistic White Coat Ceremony.  It felt like the incantation somehow connected me to a long line of great men, from Hippocrates to Benjamin Rush to my childhood family doctor.  It marked a distinct line between the life I had already lived and the medical profession that was to become a considerable part of my identity.  But is the Hippocratic Oath an outdated, out of touch relic in the complex modern world?

The original oath swears to deities that no longer “exist”, makes unreasonable promises of servitude to teachers, mandates free tuition, possibly forbids abortion and seems to prohibit surgery.  Yet almost 100% of medical schools in the Unites States administer some contemporary adaptation of the Hippocratic Oath.  According to the AMA’s Code of Ethics, the Oath of Hippocrates “has remained in Western civilization as an expression of ideal conduct for the physician.”

Has it?  In all fairness, no one really recites verbatim the actual translation of Hippocrates’ Oath any more. Most medical schools use variations that preserve the best qualities of the oath, such as compassion and “first doing no harm,” and omit the tenets that seem bizarre in a modern context.

But let’s consider, line by line, the original Oath and how well it holds up, both literally and figuratively, for today’s medical physician, and then let’s see if we can distill it down to a 140 character tweet. 

The Hippocratic Oath

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:
* While Ancient Greek Polytheism is certainly available as a choice of religions, it is not required that all medical students have a personal connection and faith in Apollo, Asclepius, et al, for the terms of this Oath to be meaningful.  But the very act of swearing to a higher power, whether it be to a god or personal sense of honor, is a fundamental human tie that binds marriages and professions with a sense of duty and principle.

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*.
*If medical school teachers are “equals to your parents,” does this mean they will show up from time to time on Christmas morning or on random summer weekends bringing sausages for the grill, a six-pack, and some family photo albums to reminisce upon?  In modern times this seems socially awkward and sad.  I doubt most physicians would give money to their mentors if asked, although within one year of graduating medical school the alumni association was already calling me for a donation.  It was satisfying to say “no way, I won’t even consider it until I’ve paid off my own 6-figure educational debt.”  Call me selfish.  The legacy system of teaching medicine to any offspring of said teachers also lingers, as many private institutions give precedence in their admissions process to the family of former graduates.  While good for fund raising and fraternal tribalism, it undermines what I believe should be a strict meritocracy.  Translated into 2009, this section might best implore physicians to be lifelong learners themselves, and to be teachers as well as clinicians for their patients.

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.*
*Oddly enough, our reductionistic approach to individual nutrients, obsession with new diets, and dubiously effective food pyramids haven’t made our eating much healthier than the Mediterranean Diet, a cuisine and culture shaped and passed on through the millennia, going back to… ancient Greece.  Hippocrates seems timeless on this one, although his use of potions to induce vomiting to restore the body’s humors might be considered “not standard of care.”  There are so many “harms and injustices” in the world to protect patients from that this last bit is overly idealistic.  I can barely protect myself.  At least we should solemnly swear “to try really hard” not to add to the 50,000-98,000 deaths caused by medical errors in hospitals each year.   First do no harm.

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.
*The deadly drug part may be interpreted in several ways.  Opponents of euthanasia cite it as a moral foundation prohibiting physician-assisted suicide.  Other scholars point out that the physician of those times was often approached as a political assassin, and was asked for poisons.  Euthanasia can also be seen in a compassionate light, especially by those who have witnessed a loved one suffering from terminal illness.  “Deadly drugs” in recent terms also conjures thoughts of the physician who administers intravenous propofol as a sleep aid to celebrities.  The abortion thing is a royal mess, but some have argued this part is a mistranslation of the Greek text, and that Hippocrates forbid the use of certain abortion-causing pessaries because of the high rate of maternal infection they caused.  Perhaps he would look favorably upon the Roe v. Wade decision which has made the lethal back alley abortion rare.  I doubt the abortion issue can be satisfactorily codified in current times, but in ancient Greece abortion was legal.  In addition, words like “purity” and “holiness,” when used righteously, may be considered harbingers of amorality and hypocrisy (see Sanford, Swaggart, Haggard, Craig, etc.), and so their use here should be construed as a sentimental nod to our better natures instead of a holier-than-though proclamation.

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.
*While many have inaccurately claimed that this passage disallows surgery, it more accurately instructs the physician to practice within acceptable boundaries of training.  As a family doctor I should not be in the operating room attempting a transsphenoidal hypophysectomy, nor should a neurosurgeon try to juggle the patient with diabetes, coronary artery disease, dementia, Parkinson’s Disease, arthritis, idiopathic thrombocytopenia, history of three strokes, peripheral vascular disease, smoking, adrenal adenoma, insomnia, venous insufficiency, breast cancer, and gallstones (I don’t know how you do it, Mrs. X).  “Sufferers from stone” may have been suffering kidney or gallbladder stones, the pain of which could certainly drive some mad enough to demand their physician just start cutting.

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.
*A nice nod to human rights and the universal dignity of mankind, if only in the narrow context of a physician not having sex with his patients, even if they are slaves.  The practice of making house calls is coming back, and it makes sense in terms of patient comfort, quarantining infectious disease, and seeing the context of a person’s illness, but is certainly limited by economics.  Practicing medicine for the benefit of the sick precludes any personal, political, or moral judgment as to the worthiness of the patient to be healed, and is therefore timelessly relevant.

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.
*Besides the awkward wording, this section needs little analysis.  It speaks to the fundamental importance of patient confidentiality, most recently codified in the HIPAA regulations and patient bills of rights.  While the exchange of information, stories, vignettes, and medical knowledge is crucial to the betterment of medical practice, avoiding the disclosure of identifiable details has never changed.

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.
*This conclusion is quite grandiose and unforgiving.  We are all human and imperfect, and forgiveness and redemption are as important for physicians as for anyone else.  At least one half of us break our marriage vows.  As far as “may the opposite of all this be my lot,” let’s break that down.  Here is the opposite statement as I see it: “May it be granted to me to suffer death and Reality TV, being dishonored with obscurity among all men for a short time.” Ouch.

[Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943]

Even though the Hippocratic Oath contains multiple anachronistic pledges, ranging from extinct gods to outlawed slavery, many of its underlying ideals have persisted in importance today.  It is neither comprehensive nor sufficient as an oath for modern physicians, and some would question the very utility of taking vows at all.  But if you’ve ever taken an oath or made a formal promise to love, honor, and cherish another person for the rest of your life, you understand the special invocation to our better natures such a pledge represents.  At weddings and white coat ceremonies I am able to renew my marital and professional vows, and it offers a chance for refocusing, recommitting, and reflecting on what I want to make of my life and work.  It helps to treat the cynicism and inevitable disillusionment that life can slowly infect us with.

I realize that this post is getting way too long, especially in the era of Twitter and texting.  Perhaps the Hippocratic Oath and its offshoots are too lengthy to be relevant outside of ceremonial proceedings.  With Twitter representing the most recent evolution in our means of communication, it makes me wonder if an oath could be crafted in 140 characters or less for the modern era.  The Hippocratic Tweet might be a public affirmation of purpose and intent, suitable even for Generation Y (aka the millenials), with the forced cogency and terseness of haiku.  This would be my distilled version:

I pledge service to humanity, conscience, and dignity; I will endeavor to heal, protect, learn, resist cynicism, and inspire with this art.

Challenging.  Yes. Ridiculous? Probably.

What would be your oath to family, to life, to your career, or to your world if you only had 140 characters?

Maybe I should go join Twitter later today.

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