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The Ever-changing Oath of Hippocrates

The Oath of Hippocrates...or the lack thereof

     Hippocrates was a real physician in Greece during the fifth century before Christ. Unlike most Greeks of the time, he lived to be elderly. Of all of his writings, the most famous is his "Oath," which is interesting on many levels. One point of interest is the fact that the oath itself was written as a code for physicians who were organized into a type of guild. It expressed a professional ideal for which most doctors still grasp. It was Hippocrates, in referring to the art of the physician, who said,
"Life is short, and the Art is long; the occasion fleeting; experience fallacious, and judgement difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals cooperate."
     I would love to see this as a clause in a managed care contract.
     Recently I had the pleasure to attend the Oath ceremony of the newest Dr. DiLeo, Liza Anne DiLeo, M.D., and watch Hippocrates once again be quoted with reverence. When I myself had graduated from medical school in 1977, we at LSU took the oath, too. Normally this would have been a swell of memories, re-reading the printed oath of 1998, but the memories seemed to fall short. Was it my imagination, or was the Hippocratic Oath a little shorter than how I had remembered it?
     It's interesting to read the original Oath of Hippocrates while contemplating the controversial medical issues of today:
Hippocrates swore:
"I swear by Apollo the physician and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgement I will keep this Oath and this stipulation--to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others."
     In these first paragraphs, Hippocrates makes this a real oath, a swearing to a holy deity. Later it was changed to God Almighty, and in 1998 it is simply an oath swearing "by whatever I hold most sacred..." "Whatever" is a word that allows a great deal of latitude--no need to even cross one's fingers behind the back. Hippocrates then goes on to pledge free teaching to those in the field or to those in the family of those in the field. Today we have tuition for those whose grade point averages qualify them for spaces at medical schools. The oath of 1998 pledges one "to be just and generous to its members," which of course doesn't mean anything free at all, since generosity is relative and in the eyes of the bestower. When he talks of imparting knowledge to his sons, those of his teachers, and to disciples, but none others, he alludes to the guild-like exclusiveness of those predestined by blood to be eligible for a medical career. Today we have HMO and PPO panels which allow only specific doctors to see their patients.
Hippocrates swore,
"I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel."
     Are you listening, Dr. Kevorkian?
     The oath of today, on the other hand, has changed the refusal to give deadly medicine to a refusal to give any drug or perform any operation "for criminal purpose, and will never recommend such a thing." This seems to indicate that should Dr. Kevorkian's court challenges be victorious and euthanasia no longer be illegal, then--hey!--no problem. Hippocrates strived for an ethical absolute, but in 1998 ethical absolutes can fly out of the window if they're decriminalized.
Hippocrates swore,
"...and in like manner I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art."
     This is another reflection of how decriminalizing a medical practice plucks it from the unethical. Roe vs. Wade changed the oath with the stroke of the interpretive pen wielded by a majority of Chief Justices 25 years ago. In the oath I witnessed at the graduation, this whole passage on abortion was simply deleted--along with the next paragraph which decried removing gall stones by surgery, probably because the survival rate was so dismal for surgery patients then.
     Today we have laparoscopes.
     Abortion and surgery deletions did much to shorten the ceremony I attended. The oath skipped right on to confidentiality, the last part of the original Hippocratic Oath.
Hippocrates swore,
"I will not divulge, as reckoning that all such should be kept secret."
     Today the oath says, "That whatever I shall see or hear that concerns the lives of my patients which is not fitting to be spoken, I will keep forever secret."
     Which is not fitting to be spoken?
     Again, we who are entrusted with a patient's confidential matters also enjoy a great deal of latitude.
Hippocrates summarized,
"While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times. But should I trespass and violate this Oath, may the reverse be my lot."
     Today's Oath pretty much gets this right, but refers not to a good life, but to a good reputation.
     Drs. Robert Orr and Norman Pang, in their "Review of 20th Century Practice and a Content analysis of Oaths Administered in Medical Schools in the U.S. and Canada in 1993," conclude that,
"There has been a steady increase in the percentage of medical graduates who swear an oath during this century. At the same time, there has been a steady decrease in the inclusion of content items found in the classical Hippocratic Oath."
     In comparing and contrasting current versions of the Oath with the original version, they report that,
"all still pledge a commitment to patients, only 43% vow to be accountable for their actions, only 14% include a prohibition against euthanasia, only 11% invoke a deity, only 8% foreswear abortion, and only 3% retain a proscription against sexual contact with patients."
     A comedian whose shtick was that of a Father Guido Sarducci once said that the Ten Commandments were actually the ten suggestions: "Thou really ought not covet thy neighbor's wife." It seems that each generation of doctors is Sarducci-izing the Hippocratic Oath more and more, until it will one day fall away as a hint of a suggestion of a half-hearted inclination--if it's convenient, that is. Now I admit that condemning removing a gall bladder that's gone bad was a bit shortsighted on his part, but we really shouldn't embrace Hippocrates with piety if we're misquoting him by exclusion.

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