Deciphering the Hippocratic Oath in the 21st Century

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The Hippocratic Oath,¹ written almost 2,500 years ago, is attributed to the ancient Greek physician Hippocrates, but its real origin is unknown.² It is recited once by graduating physicians, then relegated to the attic of our memory. Many contemporary medical ethicists dismiss the original oath as irrelevant because of the enormous scientific, social, economic, and political changes since Hippocrates’ time.

The oath starts by swearing to the gods “Apollo the physician and [by] Asclepius and Hygieia and Panacea.” Apollo, the god of healing, loved Coronis, a human who fell in love with another man. She was killed in revenge by Apollo’s sister, Artemis. As she lay dying, Coronis told Apollo she was pregnant with his child. Apollo could not save her but pulled the unborn child from her womb—a son, named Asclepius, who became a physician and had two daughters, Hygieia, the goddess of health, and Panacea, the goddess of cures. According to the legend, Hippocrates was a descendant of Asclepius’ son, Podalirius. One cannot have a better pedigree as a medical doctor.

Critics of the Hippocratic Oath hold several of its tenets to be incompatible with modern medicine—for example, swearing by the Greek gods, and the perceived prohibitions of surgery, euthanasia, and abortion. But one could argue that it is more relevant today than at any time in the past.

Swearing by the Greek gods is objected to for religious reasons. Should one not swear by the Christian Lord, Allah, G-d, or other deities? In taking the oath, we vow to uphold it or suffer the judgment of the one sworn by. One should reflect on the messages behind this opening invocation. By naming the gods, the oath asks physicians to remember, through names and attributions, the important purposes and limits of medicine: dedication to healing; acceptance of human mortality; gentleness in healing (Asclepius means “unceasingly gentle”).

“I will not give a drug that is deadly to anyone if asked” is often interpreted as a prohibition of euthanasia (a “good” death or peaceful death). In ancient Greece, doctors were often used as skilled assassins of political enemies. There was thus a significant fear of the physician poisoner, hence the forbidding statement. The word “euthanasia” originated in 280 B.C., a century after the oath was written. But there was no evidence in Greek medicine of active participation in accelerating death. The meaning of euthanasia as “assisted suicide” was coined by the historian William Lecky in 1869³ and, presumably, was not on the mind of Hippocrates. The statement could, however, apply to the participation of physicians in acts of torture, executions, and inhumane treatment. The moral stance is unequivocal and condemns any physician or medical association that is complicit in, collaborates with, conceals, or aids in torture.⁴

In forbidding surgeries, the oath states, “I will cede this [surgery] to men who are practitioners of this activity.” The oath does not disavow surgery. Greek physicians were aggressive surgeons. The oath might have foreseen the future of specialized medicine two millennia later with team specialization and multidisciplinary medicine. In other words, it asks the physician to cede expertise to appropriate professionals when needed: surgeries to surgeons, radiotherapy to radiotherapists, cancer therapy to oncologists, etc. It asks us to practice our best as we know it, but to be humble and seek advice as needed.

Distrusting healers was common in ancient times because of the abundance of quacks. Entering the patient’s house where a physician “will go for the benefit of the ill, while being far from all voluntary and destructive injustice, especially from sexual acts” remains as sacred a principle today as then—an oath to protect patients from the undue influence of a perceived powerful physician, and to forbid physicians from injustice against or taking advantage of vulnerable patients (sexual or otherwise).⁵

The oath was also prescient in addressing the very contemporary concept of confidentiality: “Whatever I may see or hear in treatment or even without treatment … I will remain silent, holding such things to be unutterable.” Confidential information shared by patients must not be disclosed. Without trust, patients may withhold facts that help physicians with an accurate diagnosis and treatment. Sharing confidential information could be detrimental to the patient.

“I will not give a woman a destructive pessary” is interpreted as a prohibition of abortion. The prohibition only mentions the pessary, a soaked piece of wool inserted in the vagina to induce abortion, and which could cause lethal infections. The objection might have been due to the complications related to the method rather than a moral objection to abortion, which was legal in ancient Greece and accepted in the form of oral methods of abortion.

The most inspiring and important statements of the oath address harm and injustice: “But from what is to their harm and injustice I will keep them.” The oath contains two passages related to injustice— one upon entering the patient house (injustice against the patient) and the other against social injustice.

Preventing personal and social injustice is a major theme of the oath. Physicians generally shy away from issues of social injustice, and when they do address them, they may sometimes favor personal interests over patient or social justice. The American Medical Association urges physicians to provide some free care to the indigent and to help our society have adequate health care for all.⁶ However, historically, this organization opposed universal health care, and criticized other medical organizations that disagreed with its position. Physicians have also generally organized against efforts that address the lack of affordable health care, opposed reforms proposed by Presidents Franklin D. Roosevelt, Harry S. Truman, and Dwight D. Eisenhower, fought the passage of Medicare in 1965, and failed to support health care reforms proposed by the administration of President Bill Clinton.⁷

Today, we face many old and new deities; one is perhaps more powerful and capable of extremes of good and evil than any other: money. Other “deities” include drug companies, hospital and pharmacy organizations, health maintenance organizations (HMOs), and government and regulatory bodies, to name a few. We also face issues that did not exist before: human experimentation, interactions with pharmaceutical and insurance companies, evolving health care practices and health care reforms, cost of care and of drugs, and financial conflicts of interest. Most are directly or indirectly related to two mammoth issues: universality of health care and cost of health care. Stated simply, lack of health care for a portion of our patients causes differential health care (social injustice) and medical harm. High costs of health care and high drug prices prevent patient access to them, thus causing harm. The Hippocratic Oath requires physicians to address and advocate for a universal health care and for lower and affordable health care costs and drug prices.^8,9

The United States spends $2.7 trillion on health care, 18 percent of the GDP, and twice as much as other developed nations, without demonstrable additional benefits. The high cost of care is perceived to preclude universal insurance. But the excessive resources are not directed toward patient care, and are often wasted on bureaucracies, administrative costs, lobbying, advertising, and high profits to health care entities (hospitals, pharmacies, physicians, etc.) and to pharmaceutical and insurance companies. About 50 million individuals in the United States are uninsured; another 50 million have poor insurance policies that leave them vulnerable when they become sick. Three-quarters of patients who file for personal bankruptcies related to medical bills had insurance, suggesting that many insurance policies are inadequate.

Every physician in the United States knows of patients who were denied access to health care, received delayed treatment, or were harmed or humiliated by the process.^10,11 The Affordable Care Act, the law of the land, offers many advantages that did not exist with the previous health care order: millions more people insured; coverage for children up to the age of 26 years; protection against insurance denial for pre-existing medical conditions or cancelling insurance because of sickness; no capping of care received annually or in a lifetime; no denial of coverage on clinical trials, etc.¹²

As expected with many endeavors of this magnitude, such as Medicare and Social Security, there are inherent and unraveling problems associated with the Affordable Care Act. The initial experience with HealthCare.gov and with market exchanges has been problematic, to say the least, and administrative issues persist and frustrate. Physicians may be paid less and lose some autonomy. They may be subjected to more quality reporting that influences their pay (which is also dependent on the adoption of electronic medical records). Some physicians may lose the autonomy of small (solo) practices and join larger groups or hospital-based practices to avoid risks and secure reasonable salaries. It is also not clear whether the Affordable Care Act, implemented as planned, will actually raise or lower the costs and inefficiencies of the U.S. health care system. However, the older system left too many citizens out of the health care safety net and rendered them highly vulnerable in case of sickness. Physicians should not only support the preservation of the Affordable Care Act, but also ask that future health care coverage be universally available to all citizens.¹³ Today, all developed nations consider universal access to affordable health care as a moral obligation, part of social justice—every developed nation except the United States.

The high cost of drugs is another issue that causes harm and injustice. Many patients cannot afford drug prices and out-of-pocket expenses. Many declare bankruptcy. This disrupts their social and family networks, and destroys their American dreams. About 10 percent to 20 percent of patients do not take their medicines, or modify dosages significantly, because of financial considerations, which causes them harm.

The issues discussed above raise important concerns regarding physician conflicts of interest. In the fog of the war against disease, physicians must ensure that their own interests (personal gains, financial interests, relations with pharmaceutical companies and other health care entities) never supersede the patients’ interests, lest harm and injustice occur.

Health care coverage and the cost of health care and drugs have evolved into enormous problems facing patients and our society today. In addressing them, physicians should put patients, our most sacred duty, first. Perhaps the Hippocratic Oath should begin with: “I swear by what is most sacred, my patients.”

Endnotes

1. H. Von Staden, “‘In a pure and holy way’: Personal and professional conduct in the Hippocratic Oath,” Journal of the History of Medicine and Allied Sciences 51 (1996): 406-8.

2. S. Nittis, “The authorship and probable date of the Hippocratic Oath,” Bulletin of the History of Medicine 8 (1940): 1012-21.

3. W. Lecky, “History of European morals,” in Compact Oxford English Dictionary (2nd ed.) (Oxford: Clarenden Press, 1991).

4. Anonymous, “The role of the physician and the medical profession in the prevention of international torture and in the treatment of its survivors,” Annals of Internal Medicine 122 (1995): 607-13.

5. American Medical Association, Council on Ethical and Judicial Affairs; “Sexual misconduct in the practice of medicine,” Journal of the American Medical Association 266 (1991): 2741-45.

6. Council on Ethical and Judicial Affairs, American Medical Association, Opinions 9.065 and 2.095 (1999).

7. P. Starr, “What happened to health care reform?” The American Prospect 20 Winter (1995): 20-31.

8. H. Kantarjian, T. Fojo, M. Mathisen, and L. Zwelling, “Cancer drugs in the United States: justum pretium—the just price,” Journal of Clinical Oncology 31 (2013): 3600-3604.

9. H. Kantarjian, D. Steensma, and D. Light, “Should Oncologists Support the Affordable Care Act?” The Lancet Oncology 14 (2013): 1258-1259.

10. S. Miles, “What are we teaching about indigent patients,” JAMA 268 (1992): 2561-2562.

11. M. Stillman and M. Tailor, “Dead man walking,” New England Journal of Medicine 369 (2013): 1880-1881.

12. L. Zwelling and H. Kantarjian, “Obamacare: Why should we care?” Journal of Oncology Practice, published ahead of print at jop.ascopubs.org.

13. D. Berwick, “The toxic politics of health care,” JAMA 310 (2013): 1921-1922.

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