I swear by Apollo, the healer

Michael Cook
2 August 2011
Reproduced with Permission

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…").

However, before 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.