The Hippocratic Oath is supposed to be the gold standard for integrity. But how effective has it been in the medical profession?
Year after year doctors are ranked among
the most trusted professions. In the UK, they have been top-ranked for 25 years
running. One reason for this must surely be the prestige of the 2400-year-old Hippocratic
Oath. This is so revered that it is constantly being used as a gold standard
for other professions.
In 2007 the UK’s
chief scientific advisor, Sir David King, published an ethical code for
scientists modelled on the oath. AFter Climategate, some American researchers called for an oath for climatologists ("I vow to always advise against any intervention into the functioning of Earth systems that I believe might harm humanity, the biosphere...").
An oath for
software engineers has been mooted (first, do no malware…). And in the wake
of the media scandal in Britain, columnist
George Monbiot suggested a Hippocratic Oath for journalists (“ We will not curry favour with politicians,
businesses or other dominant groups…”).
other professions rush off to draft their own oaths, they ought to know
something about the chequered history of the Hippocratic Oath and how effective
it has been in keeping doctors on the straight and narrow.
Non-doctors commonly think that 25
centuries of the medical profession have been united in a solemn commitment to
work for the welfare of their patients. Surprisingly, though, the Hippocratic
Oath is a relatively recent phenomenon. It was first administered to students
at the University of Wittenberg in Germany in 1508. Not until 1804 in France did
it become a formal part of a graduation ceremony. And even in the 1920s in the
United States only one-fifth of medical schools required it.
What made the oath popular was the
disgraceful conduct of Nazi doctors. Doctors were key participants in the Nazi
ideology, which some of its theorists described as “applied biology”. Doctors
provided the rationale for sterilising 400,000 German citizens in the 1930s and
1940s and for the euthanasia of 200,000 mentally or physically handicapped.
Some Nazi doctors helped to organise the death camps and conducted barbaric
experiments upon prisoners.
After World War II there was a movement to
consciously reframe medicine as a humanitarian service rather than just as a
technical discipline. This gave rise to codes of medical ethics, the emergence
of bioethics and photos of medical students taking the Hippocratic Oath.
However, Hippocrates would not recognise
his oath if he were to attend a graduation ceremony today. Obviously some of
its anachronistic features had to go. Swearing by Apollo, Asclepius, Hygieia,
and Panacea is no longer binding. Hippocrates’ students were exhorted to share
their goods with their master and “To look upon his children as my own
brothers”. If only…
More controversially, the Greek oath
contained clauses forbidding abortion and euthanasia. It was said to be the
first time that killing and curing had been separated. Hippocrates was devoted
only to healing his patients regardless of rank, age or sex. But both of these
procedures are highly contested today. In a 1993 survey of medical oaths in the
US and Canada, only 14 percent banned euthanasia, and only 8 percent abortion.
Hippocrates also took a much tougher line
on sexual relations with patients. “In every house where I come I will enter
only for the good of my patients, keeping myself far from all intentional
ill-doing and all seduction and especially from the pleasures of love with
women or with men, be they free or slaves.” Only 3 percent of US and Canadian
oaths prohibited such contact.
But the contemporary oath is more than
window-dressing. Physicians need to feel that their professional lives have a
moral compass higher than self-interest. Furthermore, doctors know that
regulations, financial incentives and public reporting are not enough to
guarantee that patients receive the best possible care.
Updated oaths include clauses addressing
issues like financial conflicts-of-interest, use of technology, medical error,
whistle-blowing and racial discrimination. However, a survey in the Annals of
Internal Medicine a few years ago indicated that doctors often ignore these
guidelines. For instance, more than 90 percent agreed that doctors should
report significantly impaired or incompetent colleagues – but only half did so.
A survey this year in the journal BMJ
Quality and Safety found that only 80% of doctors strongly agreed that “Doctors
should put patients’ welfare above the doctor’s own financial interests”. About
8% did not agree that it was “never appropriate” to have a sexual relationship
with a patient.
Perhaps the point is that protocols and
codes are not enough to produce ethical doctors or ethical journalists. There
has to be something deeper. Hippocrates would have called it virtue. But how to
make people virtuous is a problem that we still are far from solving.
Cook is editor of MercatorNet.