Hippocratic Oath Gets A 20th-century Facelift

Posted: July 30, 1991

For hundreds of years, it has been traditional for new physicians, upon graduating from medical school, to recite the Hippocratic oath - a statement of moral standards for the medical profession set forth by the ancient Greek healer Hippocrates in 400 B.C.

However, in recent years, that oath has undergone surgery.

What most Philadelphia-area grads (and most new physicians around the country) now swear is an oath that Dr. Richard J. Kozera, Temple University Medical School senior associate dean, calls "a modified version that uses modernized language and syntax."

Put another way: The modern oath - actually there are several modern versions - is stripped of phrases that critics feel are sexist, paternalistic, out-of-step with modern practice and just plain obscure.

Problem passages in the oath include such lines as:

* "I swear by Apollo the physician and Aesculapius (Greek God of Medicine, son of Apollo) . . . to reckon him who taught me this art equally dear to me as my parents, to share my substance with him . . . to look upon his offspring in the same footing as my own brothers . . . I will impart a knowledge of the art to my own sons . . .

* I will follow that system of regimen which, according to my . . . judgment, I consider for the benefit of my patients . . .

* I will give no deadly medicine . . . I will not give to a woman a pessary (device) to produce abortion.

* I will not cut persons laboring under the stone but will leave this to be done by men who are practitioners of this work.

In the oath taken today by graduates of the University of Pennsylvania, Thomas Jefferson, Temple and Hahnemann medical schools, Apollo and Aesculapius have disappeared, along with references to brothers and sons, and the notion of a personal obligation to one's mentor.

"I do solemnly swear by that which I hold most sacred: That I will be loyal to the profession of medicine and just and generous to its members," says an updated version.

Medical College of Pennsylvania students vote on the oath they will take. But when they choose the Hippocratic oath, it is always a modern version. Graduates of Osteopathic Medical School take the Osteopathic Oath.

The new versions of the Hippocratic contain a promise to practice "in uprightness and honor" rather than according to the doctor's "judgment" of what's best for the patient.

"When you get right down to it," comments Dr. Fred Burg, vice dean for education at University of Pennsylvania Medical School, "the ethical themes of the modern version are not all that different from those of the old. But they are easier to understand, and reflect contemporary views."

One such view is that physicians should not behave as if they are gods. ''Physician and patient are seen as colleagues and not parent and child," Burg says. It's not just the doctor's judgment, but the patient's wishes that count.

Specific references to "deadly medicine" and "abortion" have given way to statements such as: "I will exercise my art solely for the cure of my patients and will give no drug, perform no operation for a criminal purpose . . . "

Gone, too, is that line few now understand about not cutting anyone ''laboring under the stone." Some people think it has something to do with torture.

Not so, says Arthur Caplan, director of the Center for Biomedical Ethics at the University of Minnesota. Hippocrates said doctors should not operate on people passing kidney stones or gallstones even if they begged for help. Cutting was strictly the work of surgeons, who were also the barbers then.

"Physicians in Hippocrates' time looked down on surgeons because back then, all they did was cut - they had no healing powers," says Tom Horrocks, director of historical services at College of Physicians Library in Philadelphia. "That view of surgeons lasted a long while. In 18th century England, diagnosticians were called doctor, but surgeons were only called Mister."

And, even though surgeons are a respected part of the profession today, one doesn't cut out stones anymore anyway, notes Caplan. They are zapped by ultrasound.

In a speech to 1991 Penn Medical School graduates, former Surgeon General C. Everett Koop lamented what he called "the watering down" of the original oath. Koop, an abortion foe, argued that Hippocrates wanted doctors to adhere to a "higher ethical standard than that of society in general."

Both abortion and assisting suicides were legal and common in ancient Greece, but Hippocrates didn't approve. He and his disciples were in the minority in ancient Greek medical circles, Koop said, but their views eventually became dominant.

In Koop's view, abandoning the old oath is abandoning Hippocratic tradition.

Arthur Caplan does not agree. "Nobody really knows what Hippocrates' actual words were 2,500 years ago," he says.

"The idea of the oath is to impress upon new doctors that they are part of a profession with a long history and special moral duties. And that," Caplan thinks, "is still the case."

For the record, the most frequently quoted admonition by Hippocrates: ''First, do no harm" is not in any version of the oath. Hippocrates said many things about medical practice.

And he was not the only author of an oath. Students entering Temple Medical take the Geneva Oath, ethical guidelines drawn up by the World Medical Association in 1948. Among them: a promise to never "permit considerations of religion, nationality, race or social standing to intervene between my duty and my patient."

Medical College of Pennsylvania students sometimes vote to take the oath of 12th century physician Maimonides, which says, in part: "May neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind . . . and make me forgetful of my lofty aim of doing good . . ."

Osteopathic graduates pledge, among other things, to "preserve the health and life of my patients . . . to be vigilant in aiding the general welfare of the community . . . and to develop the principles of osteopathic medicine."

NEW OATH

I solemnly swear or affirm, by whatever I hold most sacred: That I will be loyal to the profession of medicine and just and generous to its members; That I will lead my life and practice my art in uprightness and honor; That into whatsoever house I shall enter, it shall be for the good of the sick to the utmost of my power, holding myself far aloof from wrong, from corruption, from the tempting of others to vice; That I will exercise my art solely for the benefit of my patients, and will give no drug, or perform no operation for a

criminal purpose, even if solicited, far less suggest it; That whatsoever I see or hear of the lives of patients which is not fitting to be spoken, I will keep inviolably secret. These things I do swear or affirm.

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