Enduring power

After 2,400 years, the Hippocratic Oath still inspires doctors. Why is a leading bioethicist mocking it?
J. Donald Boudreau | Jan 8 2014 | comment  



A ceremony in which medical students pledge to observe an updated version of the ancient Hippocratic Oath is a feature of many graduations. It is a commitment that has endured and inspired for hundreds of years.

Many medical schools have a ceremony called a ‘White Coat Ceremony’. It is an event in which students pledge to observe an updated version of the ancient Hippocratic Oath. It represents a commitment that has endured for hundreds of years. It is instrumental in forging the persona of the physician as a healer.

As long ago as 400BC, the father of Western medicine declared: “I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.” Even today, this still inspires doctors. It is one reason why the vast majority steadfastly refuses to participate in capital punishment. We will not administer the lethal injections that kill convicted criminals. 

So I was disturbed to read recently that the co-editor of the one of the world’s leading bioethics journals, Bioethics, had described the Oath as a collection of “wild and quite frankly oftentimes silly public promises” in a Canadian newspaper.

Udo Schuklenk stated that: “arguments from tradition have zero substance as arguments”. I consider that a careless and dangerous statement that tosses thousands of years of prudently lived human experiences out the window. It diminishes the value of time-honored practices in transmitting meaning and in guiding human actions towards worthwhile ends. It betrays a sad misunderstanding of the nature of “tradition” by equating it to dry and dusty relics rather than to rich, adaptable and vibrant guideposts for a meaningful life.

I cannot help but feel that Professor Schuklenk has been bamboozled by his own rhetorical flourish. It is impossible that he has utterly banished tradition from his life, intellectual or otherwise. Even though it may be seen as an arcane tradition, I hope that when he finished his studies he did not deprive his parents the pleasure of assisting at convocation, and that he wore the requisite academic apparel with pride. That is a tradition. It is a tradition that is collegial and welcoming. It is possible that he chose to receive the diploma in the mail instead, but I doubt it was his approach. Most readers would consider that response, given the circumstances, to be emotionally anaemic. Graduation is an important rite of passage that most of us in the developed world have the privilege of experiencing. 

I wonder if Prof Schuklenk threw his graduation cap in the air as many of his peers probably did. Perhaps he resisted doing so because, given his background in ethics, he was aware of the underlying symbolism of the hat toss. If he did resist that particular convention, his action (or inaction) would nonetheless indicate an engagement with the message transmitted by that tradition. In addition to making one feel good, traditions are able to activate critical thinking.

Our lives are chock-full of traditions; we cannot escape them. If one is married, the likelihood is high that one has a wedding band or other symbol to represent union, intimacy and fidelity. Wearing that ring is a tradition; it does not guarantee a faithful union but it can remind one of aspirational goals. If we have children, chances are that we appreciate the contribution that fables can make to their moral education. These traditional tales are myths and, as such, belong to a non-evidenced based world. But, they cultivate curiosity and creativity and perhaps even promote humanism. They should not be discarded so nonchalantly or sacrificed on the altar of reason.  

Prof Schuklenk refers to the Hippocratic Oath and tears it apart. He quibbles with details. He upbraids it for prohibiting abortions ─ which it does. He claims that it is opposed to surgery ─ which it is not. He mocks it as a product of a “smallish cult in Greece a very long time ago.”  Well, a very long time ago physicians needed to be reminded and guided as to what might constitute good and wise medical practices. And, I would argue that physicians of today are no less exempt from needing such counsels.

Notions of “first do no harm”, of respecting boundaries in the patient-doctor relationship, of keeping confidence and of the obligation to teach and mentor a younger generation are all there in the Hippocratic Oath and all have continued relevance. The Oath refers to Apollo, Asclepius and Hygieia; to slaves and free persons; and endorses gender discrimination, in that only the male lineage is to be initiated into the profession. There is no denying that these latter attributes are anachronistic.

But, the Oath is more than a list of “must-do’s” and “must never do’s”. It attempts to capture what is noble and immutable in medicine. Of course, it must be understood in historical and cultural contexts; not to do so is inappropriate and misleading. It has a fundamental purpose that is incontestably modern in outlook. Many of its messages continue to resonate with practicing physicians.

The earliest descriptions of medical practice, dated to between 44 and 48 AD, identified three characteristic features: humanitatis (love of mankind), misericordiae (mercy), and professionis voluntatem (the purpose of the profession). The Hippocratic Oath, which involves the physician swearing to fulfill the tenets of the covenant, according to ability and judgment, is focused on that third fundamental characteristic. It is critical that modern-day physicians continue to profess to fulfill certain obligations and not to transgress certain limits.

I have previously been an Associate Dean responsible for undergraduate medical education, where I spearheaded the introduction of a White Coat Ceremony, called ‘Donning the Healer’s Habit’. That title was chosen very carefully. I am currently involved in doing research in medical education. In both of these roles, I have come to appreciate the importance of not only equipping medical students with new knowledge and skills but also in guiding and supporting them as they are transformed into medical doctors.

A medical school is tasked with teaching students to know, to do and to become. The “becoming” part is not straightforward; far easier to teach someone how to wield the surgical knife than to yield the knife (ie, to know when not to use it or to use it at the right time, in the right amount, for the right patient and for the right reasons). This requirement to teach wisdom and prudence has much to do with the concept of professional identity formation. It is one of the most important issues in current medical education and is focused on maturation in non-cognitive domains. Rituals, symbols and rites of passage are important ingredients. Role models (past and current) are indispensable. A cherished mentor from the past was Hippocrates.

When Udo Schuklenk claims that “arguments from tradition have zero substance as arguments” he is blind to a reverberating imperative of medical schools. We as teachers and guardians of future lineages must be aware of our role in nurturing the development of the medical personae. I would suggest the following modification to his premise: “examples from tradition have boundless capacity to transmit beliefs, meanings and values.”  Should Prof Schuklenk have the honor to teach ethics to medical students, I hope that he keeps that uppermost in his mind (and heart).

J. Donald Boudreau is an Associate Professor of Medicine at McGill University and an Arnold P. Gold Foundation Professor of Medicine.



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