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April 2004, Volume 54, Issue 4

Student's Corner

The Hippocratic oath: Has it ceased to be relevant?

W. Qidwai  ( Department of Family Medicine, The Aga Khan University, Karachi. )

The Greek physician Hippocrates (460-377 B.C) is traditionally regarded as the founder of medicine, scientific discipline and medical ethics.1 The Hippocratic Oath, taken by ancient and medieval doctors, requires high ethical standards from medical doctors. Its principles are considered important in professional and ethical education of medical doctors even today.2
The Hippocratic Oath has survived, with over-riding power, the test of time since it addresses the intrinsic nature of medicine. Even those who know little of it or reject parts of it acknowledge it to be a symbol of the values of medicine. It has been argued that it is its drive to the heart of medicine that makes the Hippocratic Oath inspiring even today.3
The moral and ethical message of the Hippocratic Oath has exhibited remarkable resiliency through the ages, in varied cultures. Although its language may appear odd, its precepts are as valid today as they were in Hippocrates' time. This can be best understood through an historical review of the oath's transmission and acceptance in different eras of western history. The longevity of the oath, however, is clearly attributable to its intrinsic merit, its high moral reverent tone, and a literary eloquence that placed Hippocrates among the best writers of antiquity.4
Historically, the ethics of a professional were the ethics of a gentleman. Since the industrial revolution in the 19th century, it has been argued that it has become imperative to apply the principle of autonomy to issues in the ethics of health care.5
The social changes in the 1960s, where citizens asked for a greater voice in all affairs that affected them gave rise to formal approaches to ethics in the health fields.6
The increasing incorporation of medical technology coupled with social demands (including those for health care) has brought about significant changes in medical practice. This situation has in turn sparked a growth in the philosophical debate over problems pertaining to ethical practice. It is argued that these issues no longer find answers in the Hippocratic ethical model. It is said that the crisis in Hippocratic ethics could be described as a period of paradigm shift in which a new set of values appears to be emerging.7
Recent studies suggest that there is a great distance between the thinking of Hippocrates and present scientific medicine. Hippocratic philosophy rejects the epistemological principles of modern science, which studies the nature of knowledge with reference to its limits and validity. The Hippocratic logic is probabilistic and temporal and rejects the principles of non-contradiction, of identity and therefore the abstract determinism of contemporary science. The present force of the oath is explained because its ethics and epistemology are matters of medicine that understands the real world of the ill, trying to avoid suffering and injustice.8 Despite all the criticism, the Hippocratic oath is sworn by graduating medical students at more than 60% of US medical schools, and is perhaps the most enduring medical oath of Western civilization.9
The underlying purpose of the Hippocratic oath and most medical ethics codes dictated during the twentieth century, is patient protection. Nowadays, however, clients of health services do not conform themselves with ethical declarations of the medical profession but demand that the rights that arise from those declarations, become legal instruments that force professionals, health authorities and governments to satisfy their health needs and respect their individual rights. Probably this is a consequence of the depersonalization of medical care, the weakening of ethical bases of physician-patient relationship and the emergence of new economical and social philosophies. Now, clients also have more expectations and a better knowledge about medicine than in yesteryears.10
The impact of Hippocratic Oath on medical practice is universally recognized. However, physicians continue to raise questions about its validity with the result that not all medical schools use it in graduation ceremonies. It is postulated that this oath does not harmonize with present bioethical concepts and that the principles of beneficence, lack of harm, autonomy and justice, elaborated by Anglo-Saxon philosophers, would do so. The Hippocratic Oath contains these principles and many others, such as gratitude, compassion, justice, honesty, humbleness, sanctity, integrity, confidentiality, fidelity to the bond, and respect for human life and dignity. These are ethical values that does apply to modern dilemmas in medicine.
As a whole, the Hippocratic Oath expresses an ideal of medical behavior and it must be interpreted in the context of ancient Greek culture and history. Some uncertainties about its relevance are due to a lack of understanding of its exceptional content of values. Modified versions of the oath or original texts presumptuously pretend to replace a document that has lasted 2500 years and that meant a revolution for medical practice.
Students should have the opportunity to analyze content of the Hippocratic Oath and the way its values are related to concrete situations of present medical practice. Medical schools should shelter it without objections, as the expression of a reflexive compromise acquired by physicians during their studies and to be applied in medical practice.11
The identified limitations of the Hippocratic Oath or other pertinent oaths and codes enable students to appreciate the value of the broader principles that support medical ethics.12 In student's view, the oath seems to be an emotionally important ritual, whose value probably transcends its actual content.13
Oaths are like promises but generally have greater moral weight and have a public character along with prescription of consequences for failure to uphold them.14 It signifies a willingness to submit to a way of life that demands some suppression of self-interest. If studying the oath more explicitly strengthens the physician's dedication to the welfare of the patient, the effort will be worthwhile.15
Ethical rules are similar for physicians in most countries that follow the Hippocratic oath. They have no formal legal force, but can be used as a reference to provide answers to solve individual cases.16
Those who question the relevance of Hippocratic oath in today's medical practice, should reconsider their position. One should be concerned that questioning the relevance of the Hippocratic oath, reflects the breakdown in the trust that should exist in the doctor patient relationship. In view of the increasing complexity of medical practice today, the relevance of Hippocratic oath has increased because it offers an avenue to uphold the principles of bioethics.

References

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3. Emanuel L. The question is: what is medicine supposed to be all about?
J Clin Ethics 1990;1:289-90.
4. Davey LM. The oath of Hippocrates: an historical review. Neurosurgery 2001;49:554-66.
5. Majumdar SK. Aristotle's ethical theory and modern health care.Bull Indian Inst Hist Med Hyderabad 1996;26:75-80.
6. Kenny NP. Codes and character: the pillars of professional ethics.
J Am Coll Dent 1998;65:5-8.
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Rev Med Chil 2000;128:371-3.
11. Goic A. The Hippocratic Oath. Rev Med Chil 1998;126:1151-2.
12. Pearlman RA. The value of an oath of professional conduct: process, content, or both? J Clin Ethics. 1990;1:292-3.
13. Yakir A, Glick SM. Medical students' attitudes to the physician's oath.Med Educ 1998;32:133-7.
14. Sulmasy DP. What is an oath and why should a physician swear one?
Theor Med Bioeth 1999;20:329-46.
15. Pellegrino ED. The Hippocratic Oath and clinical ethics. J Clin Ethics 1990;1:290-1.
16. France FH. Ethics and biomedical information. Int J Med Inf 1998;49:111-15.

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