I will examine the Hippocratic oath by looking at the influences of other philosophies, such as the Aristocratic and Epicurean views, Platonism, and Stoicism. I will also assess which parts of the oath are and are not justified both in the past as well as now. Finally, I will then examine how moral principles interfere with the scientific search for knowledge, arguing that the classical Hippocratic oath does not do the justice of satisfying the appropriate ethical conduct of a physician, and moralities of both the physician and patient in the field of science and technology.
The Hippocratic Oath is an ancient pledge of medical code of conduct that binds physicians to their daily practices on treating patients. It establishes a certain set of ethical standards that defines their obligations to society and acceptable behaviour. Until today, it stills makes up the basic foundation of medical ethics.
The oath is in fact one of the many works in the Hippocrates Corpus; a collection of over 70 works and the oldest surviving complete medical book. Although it carries the name Hippocrates, there is reason to question if he ever even wrote it. History indicates they were written over many centuries in different Greek dialects by different anonymous writers, with each anonymous writer having different ideas of the body and healing (1). The facts suggest that he may not have been the author of the oath that bears his name. However, it is widely believed that different surviving treatises of the Corpus were pieced together overtime by believers of his philosophy, and together construct a story that personifies the ideal physician; some one that is caring, compassionate, wise and honest. And that exemplary physician is reflected in his legacy oath which sets high ethical standards for the practice of medicine.
The beginning of the original oath mentioned pagans and goddesses but we know that Hippocrates rejected spiritual explanations of illness. Instead he argued for a rational approach to treating patients by deriving rational conclusions from close observations of patients. Nonetheless, it’s ironic how the oath that bears his name starts by swearing by the gods “Apollo the physician, and Asclepius, and Hygieia and Panacea.” Hippocrates believed a patient is sick because of the imbalance of the “four humors” in the body (2). He became recognised as the father of modern medicine due to his holistic understanding of the human body as he does not rely on religious or magical beliefs commonly held in the ancient Greek days. (3)
There are various translations of the oath over the centuries, but the basic understanding of it is that the physicians (a) do no harm to their patients (b) prohibitions from dispensing deadly drugs, (c) inducing abortions, (d) against helping suicide, (c) performing surgery (d) having sex with patients and (d) keep and respect patient confidentiality.
The ancient oath is barely used today as none of the modern doctors swear by Apollo and Asclepius anymore, but the debate surrounding the morality of abortion and objection towards suicide remain concerns of modern medical ethics until today. Although more than 3000 years have passed, the dilemma posed by euthanasia still divides our society.
It is well known during the Greek classical times, that terminating one’s life was often considered to be honourable (4). However, this does not mean that the great philosophers of those times condoned it without qualification. Plato, Aristotle, Socrates, Seneca were all against it since their beliefs were that life is sacred and given by the gods, but they did not completely oppose it either and considered it acceptable under certain circumstances. Despite over half a century of arguments by supporters of Ludwig Edelstein that the oath was Pythagorean influenced, and that only they condemned suicide and abortion, it can be shown that Plato, Aristotle, the Epicureans, and other authors of antiquity opposed it too. Hence, it was not the Pythagoreans alone who outlawed suicide (5).
To the Platonics, any termination of life is against the wills of god and suicide is the result of ‘a spirit of slothful and abject cowardice.’ (6) but they are tolerant of those that are suffering from pain and recognise their need to commit suicide.
According to Plato, this was how Socrates felt about suicide, “I suppose it is not unreasonable to say that we must not put an end to ourselves until God sends some compulsion like the one which we are facing now (i.e. his death sentence). That seems likely, I admit, said Cebes (7).
Aristotle’s argument on suicide is that the act itself is wrong to the state and community. As long as man is part of a society, he argues that it is his duty to obey the laws of the society and if the law does not permit suicide, doing so would be an act against the rule of life since God has handed over to the the state the custodianship of human life. Aristotle expresses this view as follows, “one class of just acts are those acts in accordance with any virtue which are prescribed by the law: e.g. the law does not expressly permit suicide, and what it does not expressly permit, it forbids… and he who through anger voluntarily stabs himself does this contrary to the right rule of life. He acts unjustly towards the state for he suffers voluntarily…” (8). So in this position maintained by Aristotle, it is indicative that he was against suicide.
According to Diogenes, Epicurus, did not approve of suicide either. Epicurus states that each of us is free to put an end to our life if we are suffering from unbearable pain, provided this misfortune is neither brief nor intermittent. Cicero writes that Epicurus used to say, ‘I quit life's theatre when the play has ceased to please us.’ (9)
The Pythagoreans were just one of many schools, like the Academic, Peripatetic, that all opposed suicide. Only the Cynics and Stoics supported it entirely (10).
The Stoics, descendants of Socrates, believed that suicide is permissible, and where the timing and reason is right, a man can commit suicide. To them it is the right of human choice and this philosophy is very much reflected in the belief of Stoic philosopher Seneca who wrote: “Just as I choose a ship to sail in or a house to live in, so I choose a death for my passage through life.” (11)
In those days, there were laws against the committing suicide (12) and in Athens, suicides were buried with their right hands amputated (13,14). Therefore, the assumption that the oath’s origin is one of Pythagorean influence is unwarranted.
In antiquity, there are those who did not object to abortion while others justified only in certain circumstances, and others who were against it in all cases. Aristotle himself distinguished if it is allowed by whether the fetus is sentient or not, 40 days after conception for a male, and around 80 days for a female. He also stated that he would allow it for the purpose of population control, “As for the exposure and nurture of infants… let there be a law against nourishing those that are deformed… be distinguished from what is not by means of sensation and life.” (15). But the most powerful evidence against general acceptance of abortion in those days was from Soranus, one of the greatest gynaecologist who himself condemns it if performed for trivial reasons. (16). And in the entire Hippocrates Corpus, the prescriptions of abortion relates to the expulsion and termination of highly compromised pregnancies. (17). So it appears in the classical times, there were those that objected, felt justified only in certain circumstances, and others that were against it entirely. And till today, there is still a wide body of opinion that condemned abortion and the oath reflected that view.
The modern interpretation of the pledge “to do no harm” might be understood as “don’t cause more harm” because procedures and treatments that are harmful but have a good chance of saving a life is worthwhile and permitted. It cannot be taken in a literal sense because many treatments can have adverse effects. Procedures like biopsies and chemotherapy though hurtful, are recommended because it is for the greater good of the patient and sometimes it is the only option to save them. So rather it is taken to mean that medical benefits should outweigh the adverse effects.
Revolutionary advancements in medical care has now made it further possible to save and keep people alive longer. However sometimes saving a life can cause further harm and it comes at the cost of prolonged suffering. If a patient indicates they do not want to be brought back to life with a do not resuscitate (DNR) instruction on their hospital record (18), but doctors bring them back to life by jumpstarting their heart multiple times with electric shock, they are causing more harm to the patient. Getting back to life with so much trauma is equivalent of dying over many times instead of once and those that survive are often left with serious neurological disorders (19). And if prolonging a life entails the risk of infection and organ failure and recovery is out of the question, wont it be a fate worse than death? Since a vegetating human body no longer houses a moral rights holder, one with the capacity to lead a life of moral integrity that made her life sacred, what use is prolonging that life as keeping such bodies alive only desecrates human life rather than celebrating its sacred character. This conflict between the principles of beneficence (to save the patient’s life) and respect for patient’s choice and terminate the life sustaining treatment is distressing to modern doctors and will always remain a challenge for health care.
The interpretation of “I will not use the knife, even upon those suffering from stones, but I will leave this to those who are trained in this craft.” refers to that fact that general physicians should just yield to specialised professionals such that surgeries should be done by practiced surgeons and not general physicians. The Hippocratic Corpus and other historical records reveal in fact that Greek doctors in those days did not disapprove surgery but rather were very aggressive in their use (20). Hence this statement is justified today because in the modern context, surgeries should be done by specialised surgeons, radiotherapy by radiotherapists, cancer therapy by oncologists and so forth. Physicians must practice to the extent of their ability, not beyond, and it is important that they know their limits and seek the help of experts, as needed.
Since modern medicine increasingly allows us to extend life indefinitely, the question is no longer whether we can play God but when, how and who should do so. The modern version of the oath states: “Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all I must not play at God.” (21). The fact is a physician’s decision to take a human life is indeed playing God. In an increasing socialist environment, the state is playing God by manipulating financially dependent physicians as surrogates to promote death. The US Medicare system now pays physicians for holding end of life care discussions with elderly patients where discussions include the option of physician assisted suicide in states that are legal (22). While one may argue that relieving terminally ill patients from suffering and living a vegetative life, we are preventing further harm and pain, but what if crossing this threshold of acceptance leads to immoral ethics?
An increasing move toward physician-assisted suicide would only pose further threat and risk to those suffering from debilitating diseases and the elderly that may be depressed and lonely, and don’t have the will or energy to fight back to preserve their lives. A further danger is that those eligible for death by physician will expand to include the healthy and the very young. In 2014, the Netherlands legalized physician assisted euthanasia for “consenting minors” (23). And it also proposed a law, similar to the US proposed version of The Complete Lives System (24), where it allows physician administered euthanasia in healthy elderly people who believe they have “completed life” (25). The problem is that once society accepts killing as an answer to suffering, the age limits drops and even protective guidelines and legal boundaries soon becomes blur and don’t matter. A culture of death once set in motion will only expand.
What was once unthinkable, based on the ancient oath that physicians are obligated to honour the sanctity of life, physicians killing patients is now transformed into an “option” and a “choice”. When we move away from keeping life sacred, and telling oneself that it is a voluntary act of compassion and “death with dignity” the next step would be coercion, and vulnerable patients would be told that they should not be a burden to their families and to society. Ultimately we face a transition of voluntary to non voluntary death. The ancient oath stresses the best interest of individual patients, but physicians now are being coerced to act for the good of society, conserving limited resources. The needs of the society are placed above the needs of the individual patient. Physicians cannot adopt the premise that what is legal is moral. When the state of Vermont passed the physician assisted suicide law, inadvertently it requires them to violate the oath in order to practice medicine in the state. The law requires them to discuss the option of physician assisted suicide with terminal patients and either provide a lethal prescription to patients who request it, or refer the patient to another who will provide lethal prescription (26).
History has shown that the acceptance of the attitude that there is such a thing as “a life not worthy to be lived” is what led to the Nazi doctor’s acceptance of euthanasia and medical experiments on prisoners. When Dr Leon Alexander a psychiatrist at the Nuremberg War Crimes Trials interviewed the Nazi doctors involved, he wrote on the lessons to be learned, "This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted, and finally all non-Germans. But it is important to realize that the infinitely small wedged-in lever from which this entire trend of mind received its impetus was the attitude towards the non-rehabilitable sick."(27)
Revolutionary inventions and advancements in medicine that saved countless lives in the last quarter of the 20th century has also meant that traditional Hippocratic ethics were sacrificed in the name of progress. This biomedical revolution has led to countless and abominable crimes, committed in the name of medical science and research. The most notorious of these crimes was the genetic experimentation in human subjects by Dr Josef Mengele. As Albert Jonsen the bioethicist notes “never before, or since has medicine’s major moral mandate, ‘do no harm,’ been so flagrantly, and indefensibly violated than by the Nazi crime. (28). The accused were distinguished doctors who had vowed “to benefit “or do no harm and to adhere to the Hippocratic oath. The German doctors defended their moral grounds on the idea of utilitarian medical ethics, where these scientific experiments and the outcome of medical discoveries were for the greater good of the community and state, that they were for the benefit of the German people and the German state. And though various ethical documents like the Nuremberg Code was subsequently put in place for informed consent of medical experimentation, to safeguard the rights of people undergoing medical experimentation, it has not really ended unethical medical research. Between 1944 to 1974 the US Government conducted effects of nuclear weapons on the state prisoners in Oregon and Washington where they were irradiated to study the effects on sperm production. (29). In the search for human improvement, we cannot sacrifice the welfare of human subjects and justifying it to the interests of science and future patients.
Science has enormously improved the quality of life but it has also created great perils, threatening our very own existence. Stem cell therapy is trumpeted as a great scientific breakthrough and a biomedical revolution as it could lead to cures for leukaemia, Alzheimer’s, Parkinson’s, diabetes, AIDS and countless degenerative diseases, as it provides a vast amount of tissue for transplantation therapies (30). And though many years of basic research will be required before such therapies can be used to treat patients, the possibility of their potential have profound long term effect on human medicine and breakthrough in medical research.
Nonetheless, the development of embryonic stem cell research forces us to choose between two moralities of the oath: the obligation to prevent suffering and the duty to respect human life. In the rationale of embryonic stem cell research, it is impossible to respect both principles. Embryo stem cell research violates the concept of “first do no harm “and the preservation of life, the foundation of the Hippocratic oath because in order to acquire embryonic cells, the primitive embryo has to be irretrievably damaged. This means destroying a potential human being. The statement “I will give no deadly medicine to anyone if asked, nor suggest any such counsel” is very important to those involved in stem cell research as the idea is binding, never injure one person to benefit another. The question about when a person becomes human is not new. As discussed earlier, philosophers and scientist like Plato and Aristotle have debated it for over 2,000 years. Anti abortion groups argue that life is sacred and has value. The right to life is absolute and innocent unborn children have the same right as any other human being. If this position is not recognised, a similar domino effect may occur like when Hitler started his history of atrocities by legalizing abortion. (31).
When in vitro fertilization (IVF) was first introduced in 1978 to assist couples with reproduction, many found the whole idea distasteful or unnatural. But it offered infertile couples fresh hope (32). Now that many thousands of babies are born by IVF all over the world, it is hard to think back to that time where those who compared it to the analogy of Frankenstein and the monster created in the laboratory. IVF technology entails the destruction of human embryos because for it to be an established treatment, the success rate depends on experimentation of composition and temperature. Every element of the research meant destruction of the embryos and the procedure involves the administration of super-ovulating drugs so that large number of eggs could be produced, of which as many as possible were fertilized in vitro. The healthiest were chosen for insertion and the rest destroyed. So, in every IVF procedure there would be surplus embryos that would be discarded (though with patient informed consent), contrary to the doctrine of the sanctity of life. (33) . Forty years later, it’s widely held that the benefits over harm is too great and the fact that IVF can be used for fertile couples at risk of having children with genetically inherited disease, where the embryos could be screened for healthy ones and selected for implantation. In most developed countries, even those that are predominantly Roman Catholic, such as Ireland in vitro fertilization has been accepted, and this means that the creation and destruction of early embryos is regarded as an acceptable, inevitable, routine procedure.
The ancient classical oath is a covenant between the physician and patient not between physicians and modern society. It does not address the issues of the physician’s moral engagement with the needs of society. Though it does not compel moral behaviour nor satisfy physicians and patients in the modern world, it inspires physicians to reinvent valuable ethical principles in the face of revolutionary advancements in medicine, with the most important obligation, to benefit the ill. It must be modified to guide ethical standards in human research without jeopardising human rights, while allowing breakthrough in modern medicine to benefit mankind. The endurance of the oath’s ethical values through the centuries shows us that modern medicine has to continue to endorse the true meaning of the Oath and uphold its true integrity but where several aspects of it need might need evaluation and evolution.
The Declaration of Geneva, revision of the ancient Hippocratic Oath, formed by the World Medical Association in response to the medical crimes committed by the Nazi. It is a declaration of a physician’s dedication to humanitarian goals of medicine and their commitment to practice within a set of guidelines regarding both human rights and the rights of patients. It is an adapted version of the original oath’s moral truths that could be comprehended and acknowledged in a modern way. (34) Together with the Declaration of Helsinki, which provides guidance on the topics of human test subjects, and as a guiding statement of ethical principles for doctors involved in medical research (35), these two ethical documents form the cornerstone of modern bioethics.