The Hypocrisy of Hippocrates: Ethics from Medical Oaths

BY SHAAN BHANDARKAR

Long before the horrors of Tuskegee and Mengele, medical ethics claimed a center stage in the world of healing dating back to the times of Ancient Greece. Throughout the Classical era, patients reserved a comparable trust in both faith healers and the more traditional practitioners, who received training from other established practitioners at famous ancient medical schools. One such renowned practitioner and mentor, Hippocrates, developed an oath for his students to recite after the completion of their training. Today, the Hippocratic oath has visibly shaped numerous aspects of the expected conduct and behavior of physicians. The Hippocratic oath is widely recognized by historians as the first-ever delineations of medical ethics.1 In fact, 56% of medical schools still use some version of the Hippocratic oath to this day.2This oath immortalized the idea of non-maleficence or (more famously) “do no harm.” 

The Hippocratic Oath, from its original Greek translation to its modern interpretations, has remained as a powerful symbol of medical ethics.
Source: Wikimedia Commons

Doing no harm to a patient certainly seems like an easy rule for the whole healthcare gig. But what about inadvertent harm caused by an experimental therapy, the side effects of which were unknown to the overseeing physicians? Further questioning its representativeness of modern medical values, the oath presents some troublesome clauses around controversial issues like euthanasia and abortion. Can some 2,500-year-old document written in a time of limited medical knowledge really apply to the world we live in today?

Understanding why the Hippocratic oath was written in the first place can clarify why we do or do not need it today. As mentioned before, the ancient healthcare “marketplace” offered a variety of options from exorcists to faith healers to the practitioners educated at renowned medical schools.3 Hippocrates and his fellow scholars belonged to one such school in Greece: Cos. With his oath, Hippocrates intended to uphold the school’s prestige and reputation by creating a sort of  closely-knit “clan” of physicians. While the endeavor may seem nepotistic today, Hippocrates developed a vocational system of education where a trained physician would swear to teach the sons of his medical mentor at Cos and so on. Even before the times of Hippocrates, Greece valued their healers as worthy of claiming a lineage under the healing god Asclepius. Greek society worshipped these healers as the “Asclepians” and Hippocrates sought to revitalize this social perception with his own clan of physicians. This would especially prove crucial as ancient physicians would be vehemently competing with magical or spiritual healers for clients. Hippocrates aimed to endow medicine with legitimacy and some feel that his attempt at medical ethics served as a means to garner public confidence. Why else have a medical oath for a supposedly seclusive “clan” of healers be known so publicly?

Regardless of whether or not Hippocrates’s aims were altruistic, his connotation of medical ethics serve to reflect the ideas held by the physicians of his time. Furthermore, the corpus of works the Hippocratic oath is published under (known as the Hippocratic corpus) has been known to have different authors. Even though Hippocrates serves as the face of the works, evidence points to multiple contributors collaborating to create the corpus. Among the troublesome aspects of the oath, the oath has religious allusions to the Greek gods associated with healing including Apollo, Asclepius, Hygeia among others. Hippocrates is supposedly known for divorcing medicine from non-empirical faith healing, but it’s understandable how Hippocrates included these allusions to conform to expectations about Greek religion, which was so infused in common Greek culture.

The recital of the Hippocratic Oath is a long-cherished tradition for medical students to this day.
Source: Flickr

The passages in the Hippocratic Oath most cited as controversial refer to “not giving a lethal drug to any patient” and “not giving a women a pessary to cause abortion.”4The first clause about lethal drugs is superficially justifiable as being a natural conclusion from the idea of non-maleficence. If a doctor’s responsibility is to do “no harm,” why would giving a lethal drug even be up for debate? One representative facet of medicine focuses on the idea of pain and the obligation for a physician to reasonably attempt to ease the pain of the patient. Especially for patients deemed terminally ill, the term palliative care is used to refer to the health plans associated with ensuring the best end-of-life care for the patient in question. The debate around end-of-life care, especially euthanasia, have incited heated debates in modern medicine. Dr. Jack Kevorkian (notoriously nicknamed “Doctor Death”) championed the cause of physician-assisted suicide, promoting the idea of patients having a right to die.5 The 2005 case of Teri Schiavo, a patient in a persistent vegetative state, and the dispute between her husband and her parents about the removal of her feeding tube furthered awareness about the right to die.6 Since Schiavo herself could not give consent due to her condition, her case complicated the question of what a doctor’s prerogative should be in such a situation. A physician’s decision to assist in voluntary euthansia heavily depended on the patient’s consciousness and mental competency. In one of the works of the corpus outlining the expected conduct and behavior of a physician known as Decorum, the Hippocratics actually encourage a physician to ignore the opinion of the patient as their ailment could cloud their judgement.4The debate around euthanasia is still far from over with some suggesting policy reforms about ensuring second opinions on terminal diagnoses and for more specialized medical training programs that focus on delivering end-of-life medical considerations and potential euthanasia. Euthanasia strikes at the very ethical core of a physician’s devotion to doing no harm and perseverance in undertaking a medical career, so an oath including an oversimplification of the issue does not seem to be applicable.

In addition, the oath’s attitude on abortion also seems, at least superficially, very resolute. It is admittedly hard to interpret the true stance of the Hippocratics on abortion due to the development of safer procedures in the modern era. Surgical procedures for abortion did exist in 5th century BCE, but the Hippocratic oath nevertheless expresses a hesitation for surgery. As a part of the “do no harm” idea, the Hippocratic oath includes a vow to “not cut, even for [gall] stones.”4 However, the Hippocratic oath does include a clause saying to leave the cutting to the practitioners with a specialty in carrying out such procedures. Another work in the Hippocratic corpus, On the Nature of Child,  explains how to conduct one such procedure as well as other concoctions for supposedly terminating a pregnancy. Modern and past critics argue about the exact interpretation: the oath could be advocating for a general ban on abortion or a specific ban on the use of a pessaries in abortion. Still, the oath does again seem to simplify a major debate as a corollary of non-maleficence. That’s not to say that excluding any verse about abortion or euthanasia would be the most beneficial option. Their inclusion in the Hippocratic oath merits discussion and acknowledgement of how these issues apply to modern medicine. However, the Hippocratic oath in its historic version is certainly not the most ideal option for recital.

The Nuremberg Doctors’ Trial lasted from December 1946 to August 1947. The revelations of the Nazi doctors’ atrocities incited a greater international awareness to the ability of medicine to be perverted.
Source: United States Holocaust Memorial Museum

Interestingly enough, the Hippocratic oath did indeed disappear from medical school ceremonies globally for centuries.7 Aside from its use in medical history, the Hippocratic corpus offered explanations such as the humoral theory (the body being composed of four humoral fluids including blood and phlegm) that would be declared as pseudoscience in modern times. A greater public consciousness of medical ethics did however resurge after World War II. As the Nuremberg trials witnessed some of the first-ever institutions of international law in dealing with the former Axis powers, one of the most notorious trials included the trial of Nazi doctors stationed at concentration camps. These doctors, including the notorious Josef Mengele, obviously dismissed any idea of patient consent and ruthlessly carried out medical experiments on prisoners and even sickly civilians in the name of eugenics. Nazi eugenics perverted any semblance of “medicine” involved and even called the initiative the “Euthanasia Program” to mask its true purpose.8The Japanese were also found to have experimented on Chinese captives. The Japanese Imperial Research program sought to develop weapons of biological warfare with agents like cholera and plague with over 200,000 Chinese killed in the process.1 The Japanese even conducted “practice surgeries” on live Chinese prisoners without anesthesia. These atrocities prompted the formation of a World Medical Association (WMA) in Geneva and declarations for the creation of an international physician’s oath. The major addition in the 1948 Geneva WMA Physician’s Oath included a non-discriminatory clause so that a doctor could not permit considerations of race, sexual orientation, or social standing (among many other factors) to affect the quality of care and their duty to treat.9This was especially monumental considering the Hippocratic oath’s inclusion in the social context of slavery in ancient Greece. An unwritten tradition in ancient Greece for oath violations would demand no punishment if a dying patient was the slave as opposed to heavy punishments if the patient was “of noble birth.”

All these advances are not to say that the world magically inherited a universally-abided code of medical ethics. Even with the guise of increased ethical deliberation in medicine, the U.S. actually granted immunity from prosecution to the Japanese experimenters for their data on biological warfare. Aside from that, the Nuremberg trials really only focused on the vices of the Axis side with minimal accountability for war crimes committed by the Allied forces. The atomic bombs most certainly had a devastating effect on the communal health of Hiroshima and Nagasaki for generations afterwards due to the radiation exposure. It’s also noteworthy to consider the medical advances made due to the increased resources allocated to research beneficial for warfare. The discovery and mass production of penicillin was vital to World War II efforts. It may seem antithetical to some that medicine is most advanced in war where “doing harm” abounds. We cannot oversimplify the matter and conclude that wartime medical research is unethical. However, an increased focus on using medical research to gain advantages in combat can facilitate immoral acts, as has been witnessed in the past.

World War II highlighted a peak for medical immorality, which justifiably coincided with an overall global trust in medicine, especially for the American public. The trend of specialization in medicine in the 50s also created an increased belief that medicine became a commercial profession.7 Patients believed that they were being thrown from one doctor to the next, without personalized care. Medicine seemed to become synonymous with taking advantage of a patient instead of the selfless care alluded to all those centuries ago in the Hippocratic oath. In response to this public distrust, the recitation of the Hippocratic oath resurfaced in American medical communities in the 1960s. Dr. Louis Lasagna created a revision of the Hippocratic oath to emphasize the compassion of the patient. The “Lasagna oath” addresses the issues of abortion and euthanasia by promising to treat such issues with “humility.” The Lasagna oath creates an admirable social image of  a physician not treating a medical chart, but a breathing human being as their patient. Lasagna also deftly counters the commercial perspective of medicine. He depicts medicine not as some reductive feat that regards a patient as a medley of symptoms, but as a humanizing and empathetic experience.

Louis Lasagna created the modern Lasagna oath that pledges to treat patients as suffering individuals, as opposed to defining them with mere lists of symptoms.
Source: Wikipedia

The Lasagna oath and its revisions seem to be the most predominant in current recitations from medical school students aside from individual oaths written by the schools themselves. Yet, some healers throughout history have believed Hippocrates’s oath to be riddled with ethnocentrism and assumptions of conformity to Greek (or generally Western culture). Ayurvedic healers take the Charaka oath, named after the founder of ayurvedic medicine, Acharya Charak. Charaka actually created his charter for medical ethics supposedly two centuries before Hippocrates ever created his oath. As per modern standards, it is fair to say that Hippocrates’s major contribution of the humoral theory is as much pseudoscience as anything else. The Charaka oath actually refers to the ideas of humility and compassion that Lasagna features in his oath. With no overt statements on euthanasia or abortion, it can be argued that the Charaka oath should have been the paradigm for medical ethics in the first place despite its other religious allusions (which the original Hippocratic oath technically contained as well). 

But, in the context of medical ethics, which oath to swear upon is a matter of personal choice. Who to swear to — the patients —  is the constant that binds all approaches to healing across the world. It’s naive to think that any oath will ensure a persistent conformity to the values it espouses. Even after the encouraging discussion of the Lasagna oath in American medical schools in the 60s, the Tuskegee experiment (persisting through the 70s) featured an atrocious perversion of medical values by withholding treatment from the African-American syphilis patients for the purpose of the study. The WMA Geneva Oath already provides a firm international standard for physician conduct, so the recitation of a single medical oath upon the completion of medical school is not necessary. However, the practice of indulging in conversation about medical ethics at medical schools is a necessity. Both aspiring physicians and current physicians owe at least that much to the history of suffering and pain hidden in the leaves of our medical texts.

Shaan Bhandarkar is a first-year in Morse College, aspiring to study Psychology on the Neuroscience track. He can be reached at shaan.bhandarkar@yale.edu

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References

  1. Hajar R. (2017). The Physician’s Oath: Historical Perspectives. Heart views : the official journal of the Gulf Heart Association, 18(4), 154–159. doi:10.4103/HEARTVIEWS.HEARTVIEWS_131_17
  2.  Bailey, M., Bailey, M., Cleveland, J. W., & MrPeach. (2016, September 21). Medical students revise their Hippocratic oath to reflect modern values. Retrieved November 15, 2019, from https://www.statnews.com/2016/09/21/hippocratic-oath-medical-students-doctors/.
  3.  Nutton, V. (2014). Ancient medicine. London: Routledge.
  4.  Hippocrates, Lloyd, G., Withington, E. T., Lonie, I. M., Chadwick, J., & Mann, W. N. (2005). Hippocratic Writings. London: Penguin.
  5. Schneider, K. (2011, June 3). Dr. Jack Kevorkian Dies at 83; A Doctor Who Helped End Lives. The New York Times. Retrieved from https://www.nytimes.com/2011/06/04/us/04kevorkian.html
  6.  Sanburn, J. (2015, March 31). How Terri Schiavo Shaped the Right-to-Die Movement. TIME.
  7.  Smith, D. C. (1996). The Hippocratic Oath and Modern Medicine. Journal of the History of Medicine and Allied Sciences, 51(4), 484–500. doi: 10.1093/jhmas/51.4.484
  8. Annas, G. J., & Grodin, M. A. (2018). Reflections on the 70th Anniversary of the Nuremberg Doctors’ Trial. American journal of public health, 108(1), 10–12. doi:10.2105/AJPH.2017.304203
  9. WMA – The World Medical Association-Declaration of Geneva. (n.d.). Retrieved November 15, 2019, from https://www.wma.net/what-we-do/medical-ethics/declaration-of-geneva/.

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