Perhaps the most enduring - certainly the most quoted - tradition in the history of medicine is the Hippocratic Oath. Named after the famous Greek physician Hippocrates, this oath was written as a guideline for the medical ethics of doctors. Although the exact words have changed over time, the general content is the same - an oath to respect those who have imparted their knowledge upon the science of medicine, and respect to the patients as well as the promise to treat them to the best of the physicians' ability.

Who was Hippocrates, and Did he Write the Oath?

For a man considered by many to be the 'Father of Medicine', little is known about Hippocrates of Cos. He lived circa 460-380 BC, and was the contemporary of Socrates as well as a practising physician. Historians have suggested that Hippocrates might have been an Asclepiad, a member of a guild of physicians whose origins trace back to Asclepius, the god of healing. He was certainly held to be the most famous physician and teacher of medicine in his time. Over 60 treatises of medicine, called the Hippocratic Corpus have been attributed to him; however, these treatises had conflicting content and were written some time between 510 and 300 BC, and therefore could not all have been written by him.

The Oath was named after Hippocrates, certainly; however, its penmanship is still in question, although according to authorities in medical history, the contents of the oath suggest that it was penned during the 4th Century BC according to the doctrines of the Pythagorean philosophy, which makes it possible that Hippocrates had himself written it.

Perhaps the reasoning of Galen will shed some light on the matter. Galen was the last of the great Greek physicians, and the chief authority of anatomy, physiology and pathology, and whose views on Hippocrates were highly influential. He was fully aware of the disputes over the authorship of the Hippocrates treatises, and that one of these works, The Nature of Man, had been attributed to Polybus. However, Galen's view was that even if The Nature of Man had been written by Polybus, it would still be good evidence for the doctrines of Hippocrates himself¹. This is because Polybus was the son-in-law as well as the pupil of Hippocrates, and had taken over from Hippocrates the task of educating the young. What is most important is that he did not seem to have modified any of Hippocrates' doctrines in his own writings. Because of this, Galen believed that although some of the treatises may not have been written by Hippocrates' own hand, they most probably still recorded his views and opinions faithfully. Thus we can safely believe that, regardless of whether or not Hippocrates himself had written the Hippocratic Oath, the contents of the oath reflect Hippocrates' views on medical ethics.

The Original Version

I swear by Apollo the healer, by Aesculapius, by Health and all the powers of healing, and call to witness all the gods and goddesses that I may keep this Oath and Promise to the best of my ability and judgement.

I will pay the same respect to my master in the Science as to my parents and share my life with him and pay all my debts to him. I will regard his sons as my brothers and teach them the Science, if they desire to learn it, without fee or contract. I will hand on precepts, lectures and all other learning to my sons, to those of my master and to those pupils duly apprenticed and sworn, and to none other.

I will use my power to help the sick to the best of my ability and judgement; I will abstain from harming or wronging any man by it.

I will not give a fatal draught to anyone if I am asked, nor will I suggest any such thing. Neither will I give a woman means to procure an abortion.

I will be chaste and religious in my life and in my practice.

I will not cut, even for the stone, but I will leave such procedures to the practitioners of that craft.

Whenever I go into a house, I will go to help the sick and never with the intention of doing harm or injury. I will not abuse my position to indulge in sexual contacts with the bodies of women or of men, whether they be freemen or slaves.

Whatever I see or hear, professionally or privately, which ought not to be divulged, I will keep secret and tell no one.

If, therefore, I observe this Oath and do not violate it, may I prosper both in my life and in my profession, earning good repute among all men for my time. If I transgress and forswear this oath, may my lot be otherwise.

Translated by J Chadwick and WN Mann, 1950.

From Medical Ideal to Standard Ethics Guidelines

The Hippocratic Oath was not very well received when it was first penned, being a representation of only a minor segment of Greek opinion at the time. However, by the end of ancient times, physicians began conforming to the conditions of the oath. It is possible that when scientific medicine suffered a gross decline after the fall of the Roman Empire, this oath, along with the dictates of Hippocratic medicine, was all but forgotten in the West. It was through the perseverance of the spirit of inquiry in the East that the tenets of Hippocratic medicine - and the Hippocratic Oath - survived this period of deterioration, notably through the writings of Arabian authorities in medicine such as Al Kindi, Ali Abbas and Ibnu Sina². The knowledge of Greek medicine was later revived in the Christian West through the Latin translations of both these Arabic works and the original Greek texts.

By the late 17th Century, standards of professional behaviour had been set in the Western World. The first code of medical ethics to be adopted by a professional organisation was written by English physician Thomas Percival (1740-1804) in 1794, which was adapted and adopted by the American Medical Association (AMA) in 1846. This code of ethics, which provided a gold standard for professional physicians, dictated the moral authority and independence of physicians in service to others and their responsibility towards the sick, as well as the physician's individual honour.

The seeds had been sown by Hippocrates - or one of his ghost writers.

After World War II, 23 doctors from Nazi Germany concentration camps were found guilty of breaching the code of medical ethics by performing horrifying medical experiments on prisoners. This incident led to the composition of the Nuremberg Code (1947), which represented the starting point in discussions regarding ethical treatment of human subjects, and outlined the ethics of medical research with regard to the rights of these subjects. This in turn led to the adoption of the Declaration of Geneva oath by the World Medical Association in 1948.

Today, most graduating medical students swear to some form of the oath before they go out into the world to practice medicine. However, this is usually a modern version, which is modified from the original.

The question is - why has such an old bit of writing, descended from ancient times, so profoundly influenced the practice of medicine throughout the history of medical science? Anthropologist Margaret Mead wrote:

For the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with the power to kill had power to cure, including specially the undoing of his own killing activities. He who had the power to cure would necessarily also be able to kill...With the Greeks the distinction was made clear. One profession, the followers of Asclepius, were to be dedicated completely to life under all circumstances, regardless of rank, age or intellect - the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child...

G E R Lloyd said of Hippocratic medicine: 'In the Western world, the name Hippocrates has always stood for an ideal.' And this is what the oath is all about - an ideal gold ethics standard representing a clear dividing line separating healers and killers, a commitment that physicians make to protect life, and never to take life away deliberately. In a world where society is always attempting to put the blame on physicians when things go wrong, this oath, when upheld, would protect not only physicians and their patients, but also their families and the society as a whole.

Modern versions of the Hippocratic Oath

Many people argue that the original Hippocratic Oath is invalid in a society that has seen drastic socio-economic, political and moral changes in society since the time of Hippocrates. This has led to the modification of the oath to something better suited for our times. Four of the most widely used versions are the Declaration of Geneva, the Prayer of Maimonides, the Oath of Lasagna³, and the Reinstatement of Hippocratic Oath. Although they differ in wording and content, the main tenets are the same - treat patients to the best of one's abilities, never cause intentional harm, and maintain patient confidentiality - although none of them call upon various deities to punish the physician if he transgresses from the oath, save for the Reinstatement!

The Prayer of Maimonides

The Prayer of Maimonides was once thought to have been written by the 12th-Century physician-philosopher Moses Maimonides. However, new evidence has come to light that the prayer, which had first been printed in 1793, had in fact been written by German physician Marcus Herz, who was a pupil of the German philosopher Immanuel Kant as well as the physician of the English philanthropist Moses Mendelssohn.

Although the prayer addresses God as the witness and source of guidance, and not old Greek deities, the gist of the prayer is very much the same as the original Hippocratic Oath - to dedicate oneself to treating patients to the best of one's abilities, as humanely as one could.

The Declaration of Geneva

The Declaration of Geneva was adopted by the General Assembly of the World Medical Association at Geneva in 1948, and was amended 20 years later at the 22nd World Medical Assembly at Sydney. Written with the medical crimes committed in Nazi Germany in view, it is a 'declaration of physicians' dedication to the humanitarian goals of medicine.' It is also perhaps the only one to mention treating people equally, without regard as to race, religion, social standing and political affiliations.

The Oath of Lasagna

The Oath of Lasagna was written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, it is perhaps the one most commonly used in today's medical schools. Like the other versions, it stresses on the importance of treating patients as human beings and not medical cases.

Reinstatement of Hippocratic Oath

The Reinstatement of Hippocratic Oath was introduced in June 1995 by The Value of Life Committee, Inc. Dr Joseph R Stanton, a member of the committee said of the oath:

It is the hope of the signers and endorsers of this 1995 Restatement that upcoming generations of young physicians in increasing numbers will embrace the Oath's principles in their personal and professional lives. In taking this pledge, they will stand shoulder to shoulder with the giants who have pledged it in the past and contributed so profoundly to advances in the art and science of medicine while leading exemplary and principled lives.

Although it is similar to the Prayer of Maimodines in that God is witness to the oath, the contents are very much the same as the original Hippocratic Oath - including the vow that should the physician transgress from the oath, then he will readily be punished for it.

Hippocratic or Hypocritic?

.. or Why Alter the Original Oath?

Because of the similarity in sound, the ignorant may be forgiven for mistaking the word 'hypocritic' for Hippocratic. Ironically, the 'Hypocritic Oath' is what many disillusioned medical students have come to know the famous Hippocratic Oath as, since most of the modern versions have deviated so far away from the tenets of the original oath that they are barely recognisable. In a survey carried out in over 150 US and Canadian medical schools in 1993, it was found that only 14% of modern oaths forbid euthanasia, 8% prohibit abortion and 3% disallow sexual contact with patients. All of these were key points in the original oath. Interestingly - even in modern, enlightened times, up to 11% still swear by the names of ancient deities.

Perhaps the most drastic change to the Hippocratic Oath is this: it has degenerated over the ages from a solemn binding treaty where the physician takes full responsibility for his conduct to a meaningless formal adherence to tradition where doctors no longer have to worry about deities striking them down for malpractice (let alone being penalised for deviance from the oath).

There are some who would debate the practicality of maintaining the original oath in today's medical practice in a modern world that has undergone massive economic, political, technological and social changes since the time of the ancient Greeks. Certain parts of the original oath such as teaching the master's sons the secrets of medicine without fees and the promise not to bring a knife to another's body (even to remove a stone) but to leave it to 'practitioners of the craft' have been rendered obsolete as the modernisation of education has led to the teaching of medical science in institutions of higher learning, and specialisation in medicine has led to physicians who specialise in a variety of fields including surgery. Similarly, the legalisation of abortion and physician-assisted suicide in certain parts of the world has made it awkward for some medical practitioners there to carry on in the tradition of the original oath.

And then there are the ethical issues. Some doctors argue that the Hippocratic Oath was written long before it was known that microorganisms were the cause of infectious disease; therefore, are today' doctors, practising in a world of lethal pestilences, still morally obligated to treat patients afflicted with diseases such as Ebola and Lassa fever at the risk of their own lives? With the rise of health-care organisations demanding patient information for the purpose of documentation, and various other sectors of industry requiring health records for qualification, how can a patient' privacy still be maintained? And, seeing as the Hippocratic Oath reflected the moral ideals of the ancient Greeks, should modern versions not include experimentation ethics as well as the physician's responsibility to the public over-riding the need for patient secrecy?

(There are also those who have commented on the unsuitability of swearing to deities that are either no longer relevant in today's world or highly offensive to one's religion. It is highly doubtful that today's doctors would choose to put themselves in a position to be punished by divine forces for neglecting to adhere to some part of the oath.)

It is understandable that some radicals may demand the removal of the Hippocratic Oath at graduation with the argument that it is too antiquated to be of use. However, even in this modern age of technological and medical enlightenment, a gold standard in moral and medical ethics - no matter how utopian it sounds - is still needed not only to set an example to those who are inheriting the medical business, but also to protect those at the receiving end of the medical practice. Modification of the original oath is unavoidable - Hippocrates, being a man who was meticulous in his scientific methods and keen in his observations of the world with regard to man and disease, would surely have approved of the changes for the sake of keeping up with the developments of the world - but as long as our physicians and practitioners hold true to the basic tenets of the Hippocratic Oath, then it would continue to serve mankind for long after the name of its writer has been forgotten.

Bibliography

• Alexander, L, 1949. 'Medical Science under Dictatorship', New England Journal of Medicine, Vol. 39:39-44.

• Bodemer, CW, 1996. Grolier Electronic Encyclopaedia.

• Colarusso, C, 1995. 'The Presocratic Influence upon Hippocratic Medicine'. Written for the Greek Science course at Tufts University.

• Edelstein, L, 1943. From The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Johns Hopkins Press, Baltimore.

• Lloyd, GER, 1983. Hippocratic Writings. Penguin Books, England.

• Seidelman, WE, 1996. 'Nuremberg lamentation: for the forgotten victims of medical science'. British Medical Journal Vol. 313: 1463-1467.

• Weindling, P, 1996. 'Human guinea pigs and the ethics of experimentation: the BMJ's correspondent at the Nuremberg medical trial'. British Medical Journal Vol. 313: 1467-1470.

• BMJ 1996;313:1463-1467