Darryl R. J. Macer, Ph.D. Eubios Ethics Institute 1990
We can define "morals" as judgements on individual activity, "values" as stated expressions of the cultural framework within which these judgements are made, and "ethics" as socially derived generalizations induced from individual morality. The healing situation requires special morals as it involves a sick, vulnerable person with a healer who is required to help, and not to exploit the vulnerability of the patient. One method of controlling behaviour was the following of ethical codes and the taking of Oaths. There are various ancient oaths that have been discovered (Konold 1978), from various cultures, but the most universally honoured is the Oath of Hippocrates.
The Hippocratic Oath was probably written around the 4th century BC by Pythagoreans, yet it has influenced world-wide medical ethics. It is still taken by over 90% of American medical students (Friedlander 1982). It is the focal piece of a long tradition, what we can call the Hippocratic tradition. There are many important questions regarding why it was accepted and is still so widely used and whether it still has a useful place as an oath, or as a source of principles for medical ethics today.
Medicine had been practised in the Near East and Egypt, Assyria, Babylonia, Persia before the rise of Greek culture. There was a flow of ideas between these trading states in the period three millenium ago. In the fifth century BC medicine in Babylonia and Egypt was practiced subject to strict state control (Aristotle I). There had been previous attempts to protect patients from incompetent doctors, the first recorded one being the Code of Hammurabi in 1727B.C. The Code stated the respective damages to a doctor for negligence when operating on Nobleman or Slave (Carrick 1985). There was also a regulation for the setting of medical fees based on the socioeconomic status of the patient (Nos. 215-217, Nos. 221-223). There are no surviving records of characteristics of the ideal physician from Assyro-Babylonian and Egyptian cultures, but there is a Persian description from the sixth century in the Sassanian Persians Dinkard (Amundsen 1978a). However, the physician refered to was a magician in this culture, involving supernatural elements. There does not appear to have been any prohibition on euthanasia (Carrick 1985). There were laws against abortion though, in the Persian Vendidad, and as early as the fifteenth century BC in Assyria (Amundsen 1978a), however there are prescriptions for abortive drugs in Egyptian medical papyri. It is not clear what the opinion of practising physicians in these cultures was before the rise of Greek medicine, and it is unlikely they had much influence on Hippocratic ethics.
The standard english translation of the Hippocratic Oath (Edelstein 1943) is:
I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfil according to my ability and judgment this oath and this covenant:
To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but to no one else.
I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.
I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.
I will not use the knife, not even on sufferers from stone, but will withdraw in favour of such men as are engaged in this work.
Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.
What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about.
If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honoured with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.
The author of the oath is unknown, but it is generally assigned to Pythagoreans after the detailed critique of Edelstein (1943). The Pythagoreans were one of the first groups of philosophers to take a serious interest in medicine. Some of the passages found in the Hippocratic Oath are incompatible with other works of the Hippocratic Corpus, and some of the ethical advice is clearly different to the practises of many Greek physicians. Different authors and groups wrote various sections of what was gathered by later physicians as the Hippocratic corpus.
The medical tradition is commonly called the Hippocratic Tradition, so prior to considering the Use of the Hippocratic Oath and the associated tradition, it is necessary to define the actual "duties" on the Oath-swearer. Some of the ideas today associated with the Hippocratic Oath are not to be found in the Oath itself. It is used as a basis for many traditions, from the quality of medical education, the idea of confidentiality, the importance of the person, the idea that medicine is more than a science but an Art of comforting (Guthrie 1957), the advancement of the profession rather than the individual doctor (MacG-Jackson & Short 1966), and the idea of medical consultation for the benefit of patients.
The first part of the oath is like a covenant where the physician undertakes obligations to his teacher and progeny out of gratitude for education. The vow or oath pledges the physician's loyalty to his teacher and a professional guild, and to secrecy. The pupil is adopted as a son by their teacher, as was common among the Pythagoreans of that time. Pythagoras, like Hippocrates, was an Ionian Greek, who gave rise to a cult with religious, political and philosophical interests.
The date of the Oath could be between the sixth to third century B.C. as the Pythagorean movement was capable of preparing such an Oath during this time. The Oath is most compatible with Pythagorean thought, but could have also been influenced from other traditions and cults. The original purpose may have been part of a reform movement to move away from the more dominant medical practices and ethical values of Classical times. The followers of Hippocrates were on the Island of Cos, so it would presumably have been first used at that medical school. Galen said that "in ancient times medicine was in the hands of families of physicians and one had to learn it during childhood, in the case of daily life. But in later times strangers came into the medical profession, and then the good old family teaching, begun in childhood, disappeared, and one needed books for learning as well as for retaining medical knowledge". A transition was occuring around the fourth century B.C. (Kudlien 1968).
There are at least four more major works in the Hippocratic Corpus which are also of unknown origin but specify the good manners that the ideal Hippocratic physician should display. These, together with the Oath, are sometimes called the deontological works. The Greek word for etiquette, euschemosyne, literally means being graceful, elegant, manifesting good form or bearing; the Greek word for ethics, ethika, means of, or for, morals. There is a subtle difference between them (Carrick 1985), though they usually overlap. For the Greek physician the rules of etiquette were not followed out of fear of civil punishment but out of the love for the Art and the benefit of his reputation in the highly competitive market for physicians. The rules of etiquette were only rules of thumb, never the unequivocal law. In the absence of medical licensure, the financial success of one's practice depended upon the patients' perceptions of the physician only. These works are probably aimed at young physicians.
The Law is a short work of 300 words, from around the fourth to fifth century B.C., Jones (1924) suggests it might have been a short address by a head of a medical school to graduating physicians. It complains about the lack of state control upon medicine that allows many quacks to practice, and the absence of no penalties to keep erring physicians in order. It sketches the type of education needed by a good physician, and urges physicians to acquire a real knowledge of medicine, not just an outward show. It shares the ethic of advancing the profession's interests as well as meeting the genuine needs of the patients. It states that medicine is the most illustrious of all the skills, and the last words imply an actual ritual of initiation into a craft or guild (Philips 1987). It also shares the allegiance to the secrecy of medical knowledge within a sect. The last two sentences imply that these physicians were initiated into a secret guild.
The Physician dates from about 350-300 B.C., and includes advice at the end of the work that young doctors should learn surgery by treating war-related injuries. There are concerns shown for fairness in social relations and opposition to sexual exploitation of patients. There are also directives to do with the proper dress and behaviour of doctor, and also the physical shape and complexion of the doctor, which appear more to do with establishing a good reputation than any ethical recommendations (see Jones (1923) for translations of the Hippocratic works).
Precepts is written later, maybe in the first century B.C., and may have Stoic influence. There is a tension shown between furthering the self-interests of the practitioner and working for the benefit of patients. There are references to fee-setting suggesting that the wealth of the patients should be considered, to seek the fullest possible payment for services, while showing compassion to the needy, "the love of man". It also states you should not discuss fees during treatment. There is a need for a "brotherly" physician to behave well (Jones 1923).
Decorum is of similar origin, and shows Stoic influences, and like the others attacks the work of quacks. There is a utilitarian emphasis attempting to balance the needs of the patient with those of the physician. It also proclaims the grand ideals of the art of medicine, a form of wisdom, to provide for the patient's benefit and to secure for the physician the best reputation and greatest financial success possible. The physician who is the lover of wisdom is the equal to a god. Jones (1924) believes that Decorum and Precepts are from oral addresses to a secret society, such as a mystery guild.
There is also some advice for good conduct in the medical work, In The Surgery, in among the medical procedure. While these writings share the concern for the patient's best interests with the Oath, there is a difference in emphasis as the Oath does not consider the outward concerns for good business of a physician, something which is concentrated upon in the other writings. The Hippocratic work Prognostic says that prognosis is valued as it may win the confidence of a patient, as well as for medical advantages and for curiosity. It was necessary to persuade the patient to undergo treatment, when many quacks were present (Jones 1923). Prognosis is a useful device to eliminate the risk of failure from medicine, and protect physicians; but appeal to a code of ethics is better, as any patient can be treated, regardless of the likelihood of successful treatment. He promises to the public that he will do whatever is in his power to save and care the patient, with no guarantee of success.
Both parts of the Hippocratic Oath have been retained in the modern medical tradition. The first part laid out the duties of the pupil in a covenant form. The covenant could be viewed not only in a business but also is consistent with the Pythagorean ideals of brotherly behaviour. The pupil promises to regard his teacher as equal to his parents, to share his life with him, and to support him with money if needed. The pupil is made the adopted son of the teacher. There is a lack of evidence that medicine was normally passed on from father to son in closed family guilds as with other crafts, though it occured among the Pythagoreans (Edelstein 1943). There is still debate over whether the Asclepaids of the Island of Cos belonged to a familial or a more inclusive type of guild. However they appear to have only been local associations, which may of given some sort of status to physicians in the cult of Ascelpius when practising in foreign communities which offered no craft protection. The is not enough evidence to say whether the Hippocratic Oath was taken by the Asclepiads themselves, and there is no evidence to say that they adopted outsiders as members of their families with such a set of obligations (Edelstein 1943). Later, the prestige of physicians was to come from training in better-known Medical Schools (Bullough 1966), as it does today. More important in the modern contest is the instruction that the pupil must regard his teachers offspring and fellow pupils as his fathers, and teach them the art if they wish to learn it. The brotherhood of the family leads to the formation of a closed profession, which has been adopted enthusiastically by modern physicians.
One of the major motives expressed in Hippocratic writings for pursuing medicine is the love of mankind, or philanthropy. This quality has sometimes been called caring, compassion, humanitanism, altruism or beneficence. Recently the word philantropy has been associated with paternalism of physicians (May 1975, Veatch 1979). In Precepts a passage reads "For where there is love of man (philanthropia) there is also love of the art (philotechnia)". While this can appear to be a lofty ideal (Entralgo 1969), the original meaning of philantropia was the benevolence of the gods for man. By the fourth century B.C. the word was used with a more general meaning of friendliness in reference to personal and social relations, but is still retained the original meaning of a relationship between a social superior and inferior (Amundsen & Ferngren 1982). This philanthropy was very different to Christian charity (Hands 1968). The original passage in precepts occurs in the middle of a paragraph dealing with the question of medical fees, and the philanthropia refers to the physician but philotechnia actually refers to the poor patient (Amundsen & Ferngren 1982). Philanthropy in Hippocratic writings means no more than a certain friendliness of disposition. The verse has been commonly misinterpreted.
A similar passage occurs in the Physician which states the physician "must be a gentleman" ...who is "grave and philanthropos". However this does not mean the physician should be a lover of mankind as a reason for practising, but rather to be "kind to all". It tells the doctor to be dignified, not aggressive, harsh, arrogant or vulgar. Both passages suggest that philanthropia is used to designate the proper behaviour of the physician toward patients (Edelstein 1956). Public philanthropy was one of the most important means of obtaining honour in the Graeco-Roman worlds, the motive was not philantropia but philotimia, "love of honour". The impulse for giving was not pity (Hands 1968). Archeological work has found numerous public inscriptions honouring physicians for their work. Even in the Hippocratic work Maxims (I) the doctors motive is recorded, that "the quickness of the disease... spurs on the good doctor not to seek his profit, but rather to lay hold on reputation".
By the time of Galen (160 A.D.) there had been a major change in the idea of philantropy, so that it was more inward sympathy for the weak (Edelstein 1956). The ideal of philantropy or love of humanity was the highest professional virtue that a physician could possess. Galen did not invoke the Oath, but he called the best physician the philosopher who is motivated by love of humanity, and cited several historical examples, such as Diocles and Hippocrates, though accepted others are motivated by love of honour, or money, saying the most important thing is their proficiency in the healing arts (Galen I). Galen did understand the idea that surgeons would conceal their procedures to make themselves more competitive, but thought that they should share. A century earlier, Scribonius Largus (40 A.D.) had written that a true physician "is not allowed to harm anybody, not even an enemy of the state", the sympathy and humaneness of a physician are due to everybody, a philanthropy (Edelstein 1956). Scribonius (I) calls medicine not an art, or science, but a profession in the religious sense, like a vocation, with an associated ethos. The origins of this idea of philanthropy might go back to the second century B.C. in Stoic philosophy, such as Panaelus and Cicero. The most powerful boost was the growth of Christianity, with the idea of charity, as described in the next section.
Do no harm
The duty of the physician to do what they think benefits the patient or to keep them from harm is stated twice in the Hippocratic Oath, and this duty could be called the Hippocratic Principle (Smith 1979). Actually the maxim often claimed to be from the Hippocratic Oath, "primum non nocere," or "at least, do no harm" is not to be found in the Hippocratic Corpus, its origin is unknown (MacKinnon 1988). The principle can be formulated in several ways. The Hippocratic Oath states "but I will never use it to injure or wrong them [patients]", the idea that medicine is a moral enterprise and the knowledge should only be used for healing. Medical knowledge is privileged and should only be used to help, not for malevolent purposes. This idea is certainly found in the Hippocratic Oath, and has been part of the Hippocratic tradition. The Hippocratic work Epidemics states "to do no harm," which is a directive to take due care when treating disease. Galen rephrases this maxim "the physician must aim above all at helping the sick if he cannot, he should not harm them," (Galen II). This puts the "above all" on the helping motive, the reverse of the latin maxim, and is applicable to the idea of thinking of the risk-benefit ratio, at least try to do good. The fourth version is the latin maxim "Primum non nocere," which is on the cautious side, maybe more appropriate to ancient medicine which often resulted in worse symptoms than the injury, but also useful today. If harm is going to come to the patient, there must be some compensating benefit.
The oath describes the proper conduct of the physician, such as to refrain from injustice and mischief, which would be a common ideal, though it does include both women and men, free and slave (Edelstein 1943). Justice is required of the physician, beyond that in the laws of the state. The promise of silence or confidentiality is made a duty, beyond the level of a precaution.
The imperative not to have sexual intercourse with the patient, is in common with other groups also, such as the Stoics, Plato (II), and in the Hippocratic treatise, The Physician (Jones 1923). This sort of regulation is also found in the Oaths of other cultures. The Oath also protects the privacy of the patient, secrecy was a feature of Pythagoreans, but it may of been shared with some other groups (Kudlien 1970). Edelstein claims that the prohibition on abortion and euthanasia is exclusively Pythagorean, but this idea is also hinted at in other writings, including Plato (II), that the physician is more responsible for causing death than the layman by virtue of his knowledge (Carrick 1985). The prohibitions followed by "in purity and holiness I will guard my life and my art", which is a demand to religious holiness, certainly not to civil law, or to most philosophies. It is true that among the Ancient Greek philosophers the Pythagoreans are the major group consistently against abortion or euthanasia, believing that they are sins against god.
There were very strict traditions on the visiting of male physician's to women. Gynecology and Obstetrics were largely the area of women, in Western medicine, until the seventeenth century when male midwifery was introduced. Even when physicians were allowed to attend women for medical consultations there were strict precautions. The Visigothic law prohibited surgeons from bleeding free women in the absence of an approved witness (MacKinnery 1952). The Salernitan treatises of Archimatheus ordered the doctor "not to diminish his professional status by ogling the patient's wife, daughter or maid servants" based on the direction of the Hippocratic Oath. Apothecaries of sixteenth century France had to swear an oath including "never to examine women privately". Medieval Christianity and Islam had very strict views, the exception is the Jewish tradition which does not forbid solitary visits (Jakobovits 1975).
The Oath states "I will not use the knife", which appears to be against surgery, yet there are other writings assigned to Hippocrates that have much useful surgery, so Nittis (1940) suggested that this prohibition relates to castration, by changing the normal usage of one of the verbs. However, this interpretation is not generally accepted. Some scholars suggest that the clause against surgery is a later addition, as it is not mentioned in the oldest manuscript, that of the Christian version of the Oath (Jones 1924). However, Edelstein (1943) rejects the reference to castration altogether, and believes it was intended to be against lithotomy, but applicable to all surgical operations in accord with Pythagorean teaching. The patients which required, or desired, surgery might have been referred to others "who are engaged in that work".
Earlier we had mentioned that the forbiddance of surgery has been interpreted by some as refering to castration (Nittis 1940). Castration was very common in Antiquity, a considerable number of eunuchs were made by physicians. With the advent of Christianity voluntary castration became common, to avoid sensual passions. It was practised by Origon and many patriachs of Constantinople. The early Christian physician Paul of Aegina wrote "Although the aim of medicine is to correct and not to corrupt nature, the physician nevertheless at times finds himself compelled by those in authority to perform castration" (Nittis 1942). The Christian version of the Hippocratic Oath of the tenth century omits reference to this surgery verse, perhaps for this reason. Though the practise was forbidden by various ordinances, Italian parents were known to castrate their sons so that they would remain sopranos, which was only abolished by Pope Leo IX (Cawadis 1946). The 1215 Lateran Council decreed that clerical physicians were forbidden to practise surgery (Talbot 1968). After this, presumably the older form of the Hippocratic Oath would be more appropriate (surgeons and physicians received the same training).
Of much more importance is the promise not to give deadly drugs or abortive remedies to patients. This concerns the physician more in their capacity as pharmacists who possess very powerful drugs. There was certainly widespread abortion in the Ancient World, and infanticide was very common (Eyben 1980). There are many medical writings that refer to abortion methods, and many philosophical arguments were used to support it (Carrick 1985). Actually the earliest references to the Oath are in the first century A.D. by Scribonius Largus (I) in 40 A.D. Though Soranus (I), a Greek physician in Rome in 60 A.D., the most famous of the ancient gynaecologists, disagreed with the Hippocratic Oaths views on abortion, he did cite it, but he thought that it was necessary to think of the mother's life first. Reasons such as the wish to preserve her beauty or to hide the consequences of adultery he thought were not sufficient to warrant an abortion. The Hippocratic work On the Development of the Child does suggest that abortion could be obtained for any reason from many doctors, including that author. Pythagoreans, however, are known to have believed that life started at conception. The Christian version of the Oath extended the ban on supplying abortive pessaries, seen in the Urbinas manuscript of the Hippocratic Oath, to any method of abortion in the Ambrosian manuscript. Apothecaries, like the physicians, had to swear never to administer an abortive potion (Cumston 1926). The Hippocratic Oath was used by supporters of respect for human life in the question of euthanasia also by the second century writer Apuleius (I). It was consistent with the concept of the absolute sanctity of life of Judaism and Christianity (Frankena 1975).
Despite the widespread use of abortion some recent statements on medical ethics cling to the Hippocratic Oath as a basis of medical ethics. The Canadian Medical Association Code of Medical Ethics states that the basic principles of the Hippocratic Oath are retained as basic guidelines. The reason given why physicians who practise abortion, or surgery, are said not to break the Oath is to refer to the preliminary part of the Oath which includes a phrase "I will fulfil this oath and this covenant according to my ability and judgement", which is interpreted in a twentieth century way as allowing the oathtaker to break the covenant if it is in their judgement justified (Kluge 1990). One has to wonder why there is a desire to maintain such an Oath as the expression of medical ethics. It reduces the importance of the oath, and it is better for guidelines to be based on following principles of medical ethics. The desire to make the medical profession appear like it follows long followed ethical traditions does not require the selective use of ancient writings.
The interpretation of giving a "deadly drug" can relate to murder or euthanasia. Poisoning was a common means of both at the time of writing. However, there were already many laws to prohibit murder, so it would be unnecessary to include this in the Oath, it is addressed to the exclusion of euthanasia, the more popular view in this period was the opposite. Plutarch (I) says that Pausanias, King of Sparta from 408-394 B.C. said that the best physician was the man who did not cause his patients to linger on, but buried them quickly. While the aim of medicine was to preserve or restore health, it was not to prolong it per se. This view is also seen in Aristotle; (II) and Plato; (IV). The Hippocratic treatise The Art defines medicine as having three roles: doing away with the sufferings of the sick, lessening the violence of their disease, and refusing to treat those who are overmastered by their disease, realising that in those cases medicine is powerless. The physician was completely free to treat or not (Art I). In Ancient Greek culture, Platonists, Cynics and Stoics, all considered suicide as an honourable alternative to hopeless illness (Daube 1972), and assisting in suicide was relatively common (Gourevitch 1969). Physicians actually gave their patients poisons for which they were asked, and the famous anatomist of the third century B.C., Erasistratus, took poison himself, to end the suffering from cancer. The Hippocratic Oath is as we have seen an esoteric document often inconsistent with the wider picture of Greco-Roman medical ethics. By the second to third century A.D. the Hippocratic idea that it was wrong to aid suicide had spread, though the real influence was probably the Christian belief that it violated the sixth commandment, so that patients should only be given drugs to relieve the pain. However, what is clearly not a Hippocratic idea is the duty to prolong the life of a patient who did not want to live. There was a rising idea of the respect for life (Temkin 1975), but this was not the same as is argued today, to prolong life. The actual idea to prolong life appears to come from the sixteenth century. Francis Bacon divided medicine into three areas, the preservation of health, the cure of diseases, and the prolongation of life, "the third part of medicine which I have set down is that which relates to the prolongation of life, which is new, and deficient; and the most noble of all," (Bacon I). He urges physicians to find cures for diseases that are incurable, though Bacon supported euthanasia (Amundsen 1978d).
It is important to consider the situation in Classical Greece and Rome regarding medical practice. The physician was classified socially as a businessman, occupying a low position in society (Edelstein 1931). Each physician had to prove themselves in a competitive and roving market. There was no system of medical licensure, no professional standards enforceable by sanctions against physicians who were "unethical", no physicians were required to swear any oath, a wide variety of views on ethics were held and that these changed over the long time periods and among different cults (Amundsen 1978a). No group of physicians or school of thought was so dominant as to separate orthodox medical practitioners from heterodox, no monopoly existed (Friedson 1971). Practitioners took patients on at their own discretion and had no special duties to treat people (Amundsen 1978d). If a group of physicians were to follow the strict practices of the Oath they would gain a good reputation which was essential in increasing their clientele among the competition. The lay population of that period faced substantial uncertainty about any physician, but if they were associated with a cult, they would have some sense of the physicians commitments.
The Oath is probably not a legal document, but was voluntarily taken by a few physicians. If the physician of the guild violated the Oath, he would still be able to practise medicine, the only control was a careful choice of members to join their guild, however, reputation was very important in securing business. The motivation to obey the laws of etiquette was for the love of the craft and financial reasons, not the fear of punishment. The word "etiquette" only implies "should", not "must" as the Oath implies, but there was no formal disciplinary body. Jones (1924) suggested that the Oath and other deontological works represent the views of secret societies of physicians. Some of the reasons for this are; the perculiar nature of the Greek of Decorum, which includes strange words and expresses characteristics of the liturgy of a secret society, the obscurity is greatest when the writer is speaking of the "gods", the Oaths regulations for student-teacher relationships and the passing on of knowledge, the Law implies a medical course, in Precepts (Chap. V) the genuine physician is called one "who has been made a brother". Though there is no conclusive trace of a special cult in Precepts or Decorum, they imply the existence of some sorts of cults, and they would of had distinct advantages. There would certainly be some advantages in following a reputable teacher or school. Xenophon (I) said that a man who wished to become a "public" physician had to name his teacher and account for his medical training.
There was no special ethic for physicians, the same civil law existed for all and each could be seen as joining in some elementary social contract to the individual patients. The freedom of medical practice in Greece had left no real control on the profession, in contrast to the state-imposed regulations found in neighbouring Babylonia, Assyria and Egypt. One of the primary elements in the emergence of the Oath and the associated code was the existence of the condition of free medical practice, and the willingness of some physicians to respond by accepting responsibility for their own professional conduct (Carrick 1985). The Oath may have been the start of a reform movement in the later part of the fourth century, to reshape the ethics of the physician (Edelstein 1956). The morality and outward performance characteristic of the Classical era, and reflected in the Hippocratic writings on medical etiquette, was to be supplemented by a morality of inner intention. The Hippocratic works show how a group of physicians was trying to form a profession, and on the other side of the coin, it is easy to see the advantages of forming and belonging to a guild with these aims. The public attitude was different to today also, medicine was not held in high esteem, as it is today, as we can see in some of the comments in the Hippocratic works such as the Art or Regimen in Acute Disease (Jones 1923), or Plato's comments. The reason for this was the wide divergencies of opinions between different physicians, the many cases when treatment did not cure, and the cases where the disease went away on its won accord; as well as the widespread quackery. The Hippocratic writings try to free medicine of quackery, superstition, and some rhetoric.
Hellenistic physicians often violated its injunctions, yet it was much later to be widely accepted. The dominant view as to why the Hippocratic Oath has so widely been adopted is that these Pythagorean teachings were deemed compatible with Christianity (Konold 1978, MacKinney 1952). However, the small number of early Church Fathers who knew of the Oath, including Tertullian, Cyprian and Ambrose, were generally disapproving of it (Kibre 1945). For centuries following the appearance of the Oath, the medical profession of that time has left no sign that it accepted it. In the early Middle Ages the pattern of physicians was similar. As time moved on it become apparent that there should be some regulation of medicine. The first evidence that the Oath was being taken seriously is the rhetorical discourse of Libanius (370 A.D.) that implies that all doctors must assent to its clauses before practising (Amundsen 1978b). There is also a letter of advice written by St. Jerome (late fourth century) to a priest visiting the sick, in which the Oath is mentioned and some ethical advice given (MacKinnery 1952). Yet its form was not fixed, and its details could be easily changed so that it was adopted by Christians, Jews and Muslims. A major Christian influence was the responsibility toward the poor and the sick, the duty to care was a new concept (MacG-Jackson & Short 1966). Christian charity led to a revolution in the attitude of society toward the sick, as first seen on a large scale in the great plague of the third century (Eusebius I). The first "hospitals" were founded in the fourth century, later they became centred around monasteric orders. After this time there were various versions of the Hippocratic Oath circulating for several centuries (Larkey 1977). Visigothic law in Spain of the sixth and seventh century includes several provisions governing physicians behaviour, including the writing up of contracts with individual patients before treatment (Amundsen 1978c). And in the Ostrogothic Kingdom of Italy, Cassidorus wrote to a physician referring to "certain sacred oaths of a priestly nature" by which medical students were obligated, thought to refer to the Hippocratic Oath (MacKinnery 1952). The practice of medicine in Classical Greece and Europe had always been a right, not a privilege, until the beginning of these geographically limited licensure requirements. We can talk of the medical "profession" in Classical Greece and Rome only in the sense that the phrase designates the people who called themselves physicians (Amundsen 1978d).
It is under the Arabs that the Hippocratic Oath was first administered by a civil power as an entry requirement and guarantee of competence for the medical profession and where we first hear conflicts between state and doctors basing themselves on the words of the Oath. The first time that medical practice was limited by a major governing authority in the Middle Ages was in Baghdad in 931 (Burrow 1978). Further discussion of the use of the Hippocratic Oath in Islamic medical ethics is described later. The physicians al-Rahawi (d. 925) and al-Majusi (d. 994) both urged physicians to adhere to the Hippocratic Oath, which had earlier been translated into Arabic (Hamarneh 1968). A similar development occured in Western Europe where medical practice begun to be under external regulation by canon and secular law, medical licensure requirements were made, and professional organizations emerged with obligations to the state (Amundsen 1978a). MacKinnery (1952) has summarised some of the eighth to tenth century medical etiquette works. They include topics such as bedside manner, in addition to qualifications and training of the physician, and the spiritual aspects of medicine. There are several ninth century manuscripts from Paris and Chatres which say that the physician should "be mindful of the Hippocratic Oath," and "He who wishes to begin the art of medicine and the science of nature ought to take the Oath and not to shrink in any way whatsoever from the consequences. And then by this process of oath taking let him take up the teachings." There is also an eleventh century manuscript in Copenhagen of Salernitan influence which begins, "Before the physician takes the Hippocratic Oath". These all point to the requirement of physicians to take the Hippocratic Oath at least in some medical schools from the ninth century. There are also some traces of Hippocratic etiquette which are recorded, those these are not a code but a set of ideals.
The major link of the Hippocratic Oath to modern times is the existence of a tenth century manuscript of a Christian version of the Oath entitled "From the Oath according to Hippocrates insofar as a Christian may Swear it" (Jones 1924). There are three old manuscripts, the oldest being the Vatican library manuscript, Urbinas 64, the three versions show much variation in detail, so it is probable that there was no fixed form of the oath. There are many changes made, including:
* pagan deities are replaced by Christian references (2 Cor. 11:31), and God is called on as a helper rather than any swearing by God.
* the pledge of secrecy of teaching is replaced by a pledge to teach the Art "to those who require to learn it", this tends to discourage the formation of a secret organisation or profession, as a teacher should teach willingly without any indenture or apprenticeship agreement. The Christian reviser discourages the formation of guilds of physicians to restrict medical practice.
* the prohibition upon surgery is rejected.
* a stronger prohibition against abortion.
What is retained is the pledge to use treatments to help the sick according to the physician's ability and judgement (Veatch 1981).
In 1140 in Sicily, the King Roger II initiated a state examination for medicine, "out of concern for safety and welfare of the people" (Sigerist 1960). Emperor Frederick II in 1241 published regulations for physicians, giving a monopoly of medicine to those who passed the exams and were licensed (Frederick II), also adding the obligation to give medical advice to the poor without charge. A nine year course was to be studied including the first three years study of logic, and an oath of loyalty to the state, not to the profession, was taken. This type of legislation may of helped establish the preeminence of the medical schools such as at Salerno. At Salerno and Montpellier students were required to swear the Hippocratic Oath, at least by the year 1181 in Montpellier (Guthrie 1957). Similar legislation was reenacted in Spain in 1283, Germany in 1347 (Veatch 1981) and in Italy in 1365.
Elsewhere in Europe licensure was accomplished by private guilds. The first area of guild development in medicine was in surgery, in France in 1258 there was a guild established (Bullough 1966). There were many guilds in the following century. The growth of guilds partly depended on the increased application of an ancient body of medical ethics and partly upon legal sanctions. These guilds had the right to make and enforce standards of quality in their products, to limit competition between members and to limit entry into the profession. They attempted to hold a monopoly on service and training and licensing. The medical guilds stressed the dangers of quacks to the public, using the argument that quality control was essential for the common good (Cosman 1973). They were to monopolise the practice in larger towns, and any practitioners outside of the guild would be arrested. In certain places medical guilds promised free treatment of the poor, but the Christian obligation to care for the sick had been lost. The Physicians had again become businessmen, intent on making a living, and much of the writings of physicians in Middle Ages concerns fees (Amundsen & Ferngren 1982). The craft guilds developed their own ethical codes. The members of the guilds gained a monopoly, and the public gained safer medicine (Friedson 1970).
The role specific duties for physicians were grounded in civil law, a type of social contract. By the fourteenth century there was a highly developed professional code, with its principles taken mostly from Hippocratic writings, further building on the centuries of writings which had been the Hippocratic ideal (Welbourn 1938). The Oath was printed in the Articella by the sixteenth century, translated into Latin as the Iusiurandum (Kibre 1945), as was the Law. Also among general medical writings there are comments on etiquette. The Hippocratic legacy continued. The Oath was very frequently printed in Elizabethian England, together with interpretations. By 1600 medical licensing was the norm, and physicians were publicly accountable, and medical schools began to assume a position of greater importance within the University than other faculties (O'Malley 1968). The Oath was one of the first parts of the Hippocratic Corpus to be translated into English, though there had been earlier Latin versions. There are at least four different translations of the Oath in the sixteenth century, which give different interpretations to parts of the Oath (Larkey 1936). The relation of the student to his teacher is given broader meaning. The ideal of treating the poor is added to the Oath, which had been seen in the much earlier Christian and Muslim versions. Newton (1586) included in the Oath, "that I shall not be squeamish to bestow my skill upon the poor and needy, freely and without fee". The Oath was considered in an almost legal sense, and held to improve the art of medicine as an ideal to aspire to.
One of the most important developments in medical practice was to be the emergence and organisation of the medical professions. These corporate bodies were the forerunners of the Royal College existing in Britain, and similar bodies in other countries. They provided regulatable professional associations, a forum for the discussion of various problems including the ethics of medicine, and they published agreed codes. The Paris medical faculty published a code in 1452. In 1552 the Royal College of Physicians (RCP) of London drew up the Dtauta Moralia, their local ethical code. Many more codes were formed in the eighteenth century, when there was a large growth in the number of physicians and hospitals. The physician of the eighteenth century was very individualistic, and competition arose between them for patients and the use of hospital beds. There was much abusive writing between them (Wilkinson 1988).
There was an interrelationship between the development of medical ethics in Britain and America. In the period 1765 to 1865 there were more values changes in the character of the physician/physician, physician/patient, physician/community relationships, and in medical education. Three British physicians who contributed to this change are John Gregory (1724-1773), Thomas Percival (1740-1804) and Michael Ryan (1800-1841) (Burns 1974). Percival was asked in 1792 to draft a code of rules to regulate and govern practitioners at Manchester hospital, after many conflicts between physicians, surgeons and apothecaries there. Gregory (1773) had believed in a thorough education in ethics for physicians, but Percival did not, rather he laid out many precepts about transactions between the members of different guilds, all with the aim of increasing patient care. Ryan was to produce a manual of medical law and ethics. He stressed how any society should incorporate its values about professional behaviour into civil statutes which impose legal obligations on professionals. Percival's code at the beginning of the nineteenth century retained the core of the Hippocratic tradition (Percival 1803, Waddington 1975), though recognising surgery as an honourable art. The principle concern is with professional etiquette, cautioning physicians to display respect for one another, avoid criticism of colleagues, and to conceal any professional differences with other physicians from the public as this would lead to a degrading of the medical profession. Doctors should work to enhance public respect for the entire medical profession.
These three works were widely read in America also. The main American work was by Benjamin Rush (1794) who included an appendix to a medical work which he called On the Duties of a Physician. He had attended John Gregory's lectures while in Edinburgh. He was described as the Hippocrates of Pennsylvania. The first American code was made in 1808 by the Boston Medical "Police", using the second chapter of Percival's book (Burns 1974). There were other state codes copying this, and some that also includes Gregory's ideas. This code was adopted in 1847 as the code of the American Medical Association (AMA). The situation in 1847 was one of crisis in the United States as there were many "quacks" who were competing for patients. Exponents of this code of ethics hoped that the public would cooperate with the doctors in establishing good standards. The code required orthodox training, and forbid advertising (Konold 1978). The next major work in medical ethics was the book of the American, Hooker (1849), interpreting the AMA code. The British Medical Association (BMA) tried to formulate a code, but it took them more than ten years. In 1858 the British Government passed a medical act, under the influence of the BMA. This set up the General Medical Council, which was entrusted with the legal regulation of medical practice and the oversight of professional conduct. In 1887 it issued the first statement on professional misconduct, but only after World War II did it deliver extensive guidelines on professional conduct.
The most significant revisions to the AMA code since then have been in 1957 when the detailed set of rules was replaced with a set of ten guiding principles, which was principally based on the World Medical Association (WMA) code, while retaining the warning against professional associations with "unscientific practitioners". They obligate the physician to expose the legal and ethical violations of other doctors. In 1980 a patient's rights perspective was introduced (Veatch 1981). Other non-Hippocratic factors have been introduced such as to take into account the interests of the rest of society, the physicians rights and duties, and the need to consider the judgement of the patient and other health care workers. The WMA (1948) has tried to retain an updated Hippocratic Oath with "the health of my patient being the first consideration", colleagues to be treated as brothers, and the physician is to maintain "by all means in my power, the honour and the noble traditions of the medical profession". It attempts to make the original Oath fully applicable to modern conditions in a pluralistic world. It does offer a basis for professional pride and solidarity. The international profession was formed.
There are various oaths still in use. In the United States 90% of medical students swear an Oath, while in Britain very few do, and some Schools, such as Cambridge or Durham, have never administered the Oath (Guthrie 1957). The Edinburgh medical school has an oath, but it omits the obligation to the teaching of future students and the respect for life. Similar abbreviated forms are sometimes used elsewhere (Wilkinson 1988). The modern Oaths usually share the Hippocratic ideas of doing no harm and to practice confidentiality, and often include respect for life and for teachers. There are also codes, which are statements of the principles of medical ethics, such as the WMA code or the AMA code. Different associations such as the World Psychiatric Association or International Council of Nurses and the International Dental Federation also have codes. Also the WMA has various declarations concerning the treatment of human beings, regarding experimentation (Helsinki 1964, 1983 update), determination of death (Sydney 1968, 1983 update), therapeutic abortion (Oslo 1970, 1983 update), torture (Tokyo 1975, 1983 update), patient rights (Lisbon 1981), and the right to refuse extraordinary treatment (Venice 1983).
We should examine some of the competing traditions, which are often at variance with the Hippocratic tradition. We may better understand why the Oath has been retained, and question whether it still has a place in the future. We should look for universal features which are appropriate for medicine today.
Judaism includes guiding regulations for appropriate behaviour for physicians within Jewish Law, both the rabbinic tradition or Talmud, and the Torah. There is a description of peoples proper attitude to wise doctors written about 180 B.C. in the Old Testament Biblical book, Ecclesiasticus 38: 1-15. It describes a physician who conscientiously practises his profession and is an agent of God. This attitude is found in Judaism, Christianity and Islam. Around the fifth to seventh century A.D. the book of Asaph the physician, the oldest known Jewish medical textbook was written. At the end is an Oath which he and his colleagues administered to their pupils at the end of training, called the "Oath of a Thousand Words", it reflects some of the articles of the Hippocratic Oath (Rosner 1977). The pagan gods and goddesses of ancient Greece are replaced by Yahweh, the physician must follow the commandments as in the Law of Moses. There is more emphasis placed on the character of the physician and his need to trust God, while working as God's agent. A principle ethical code is the codification formerly ascribed to Moses Maimonides (1135-1204), but now believed to be the work of an eighteenth century Jewish physician Marcus Heuz (Rosner 1967). Unlike the Hippocratic Oath, but in common with some codes, such as the ancient Chinese code, there is the idea of helping the poor and needy (Veatch 1981). A key feature of Jewish Law is the overriding value and sanctity of human life, rejecting any Hippocratic, Christian or Modern compromises (Jakobovits 1975). The duty to preserve life is the dominant obligation, and this is reflected in their medical ethics. It does share the commitment to healing and the relative unimportance of patient rights. There is no Jewish version of the Hippocratic Oath itself. The omission may be due to the strong aversion to swearing an Oath, much stronger than the Christian adversion. It seems that Jewish students were not exempted from swearing an Oath during medical training, which may of even prevented some Jewish students taking their degrees (Jakobovits 1975). The Hippocratic Oath made less of an impression on the Jews than it did on the Christians and Muslims, as Jewish law lays down special moral qualifications only for religious officials. Physicians must follow the regular rules, such as respect due to teachers, protection of human life, laws against euthanasia and abortion, sterilisation and chastity.
Catholicism has had historical points of contact with the Hippocratic tradition, though early Christianity showed little awareness of the Hippocratic cult, and the neo-Pythagorean mystery cults were often explicitly rejected by early Christians. In the fourth century Greek and Christian thought converged, and Jerome does refer to Hippocrates but not to the Oath (MacKinney 1977). The traditions remained separate during the Middle Ages (Amundsen 1978b). The physician's role model is Christ, not Hippocrates. There are five basic principles of Catholic medical ethics, those of stewardship of the body, inviolability of human life, the principle of totality, of sexuality and procreation, and the principle of double effect (Veatch 1981). There are many Catholic Hospitals and Medical Institutions which are instructed to follow the Catholic ethical codes, which differ principally from the standard Western codes with regard to reproductive questions and abortion. Modern Protestant medical ethics is based more on viewing the relations between the patient and the physician as a covenant (Ramsey 1970), than the sharply formulated principles of Catholic moral theology (May 1975). Christian codes regard beneficence, such as striving to do the best for the patient and avoiding harm in the Hippocratic ideal, as a command which does not just apply to the patient but an active duty to all people.
Islamic medical ethics was largely formulated during the ninth and tenth centuries, while Arab scholarship was at its zenith, with influence from the Hippocratic corpus (Ullman 1978). Islamic medical tradition has dual sources from scripture and the Hellenistic world. What was to emerge was not a dichotomy but the growing Muslim civilisation developed a mixed approach of drawing on other values, the way of "adab" (Nanji 1988). This balance was framed in the ninth century work "Practical Ethics of the Physician" (Levey 1977), which actually was written by a Christian, Ali al-Ruhawi. This was a 223 page book and describes the desirable characters and etiquette of a physician, such as he must be sensible, learned, pious and act without haste, and have faith in God. He later goes on to explain the "dignity of the art of medicine", which means that the physician must be honoured above royalty. Doctors are held in very high esteem by the public, and medicine is considered a noble profession. Complaints are generally not voiced (Asper & Haddad 1978). They do not require the Hippocratic Oath, as an oath is not needed as the profession was given by God only to those who are qualified. He writes that Hippocrates wrote the Oath so that people could study medicine more as it would not be limited to hereditary sons. Al-Ruhawi says that there are many quacks in his time so he advocated examinations. Following this, there was further writings, with much Hippocratic influence, and his countryman, al-Majusi, urged the taking of the Hippocratic Oath (Hamarneh 1968). In the thirteenth century an Arabic version of the Hippocratic Oath is found in the Lives of Physicians written by Ibn Abi Usaybia (Jones 1924).
Modern Islamic ethics uses a system based upon moral law as recorded in the Koran and the Hadith, and is basically "Allah's will be done", very different to the Hippocratic tradition, though there is still some influence. Islamic medical ethics is gaining importance because of the number of Muslims in the world and the greater desire to follow the Islamic lifestyle by them (Rispler-Chaim 1989). All contraceptives are permitted, in keeping with coitus interruptus, which had been practised already by Muhammed. Intentional AID is considered as adultery. If an explicit reference to the classical sources of Islamic law cannot be found, then it may be considered in the light of "public benefit" (Maslaha).
Hindu medical ethics are different to the Christian or Islamic approaches. There are some oaths, including the Oath of the Caraka Samhita from the first century which is structurally similar to the Hippocratic Oath (Jaggi 1978). The Oath of commitment to the teacher is actually much stronger, and after this are some moral teachings. There is also an instruction to pray for all creatures, and a list of people not to be treated including enemies of the king or the unusual or those of immoral conduct or those on the point of death. The directive to leave dying patients without medical help is not found in the Hippocratic Oath (Etziony 1973), but is seen in some Hippocratic writings. There are also instructions on good etiquette as well as ethics. The code is linked to the idea that ill health is because of bad behaviour in this or past lives (Veatch 1981). Since the thirteenth century there has been influence from Buddhism and Greco-Arab influence which led to Yunani medicine, which has a code similar to the Hippocratic one. The Indian philosophy also includes the idea of do no harm as one guiding principle. Indian medical ethics today includes Hindu and Western influences, plus many folk traditions and other religious groups. The present code of physicians conduct in India dates from one made in 1956 to replace the Hippocratic principles introduced by the British (Jaggi 1978).
The urgent problem in the third world is the very low number of physicians and medical resources for such a large population (Desai 1988). This leaves new problems such as to decide on the relative priorities of preventive and curative medicine, something not solved by medical oaths. Medicine may only treat those who can be successfully treated as there are no enough resources to treat all.
Modern secular philosophy is quite different from that of either Hippocrates or religious ethics, and within the last decade has led to the emergence of the concept of patient rights (McCullough 1980). The pPatient rights movement, a kind of consumers movement, encompasses a broad coalition of those unhappy with the paternalism of medicine, including abortion rights activists, critics of the professional domination of medical research, and advocates of the freedom of choice for or against treatments for the terminally ill (Veatch 1981). The American Hospital Association (1972) formulated a "Patient's Bill of Rights" which included these concerns and within several years this was adopted into law by U.S. Government agencies. The Parliamentary Assembly of the Council of Europe (1976) adopted a recommendation "On the Rights of the Sick and Dying" which also states that the patient has the right to refuse medical treatment. These are significant departures from the paternalism of the Hippocratic doctor. The responsibility for the development of medical ethical guidelines is shifting from the physician to society as a whole.
Socialist medical ethics also involves using oaths, for instance the "Oath of Soviet Physicians " (1971), which replaced the Hippocratic Oath. The pledge of loyalty is changed to the service of people and for the interests of Soviet society. This is in contrast to the Hippocratic Oath where the physician must work for the sole interests of the patient. In socialist countries the right to personal health care is also stressed. There is still some residue of the Hippocratic tradition among Soviet physicians however.
Chinese medical ethics involves the convergence of Confucianism, Taoism and Buddhism (Unschuld 1979). There is a struggle between professionalization of medicine and the control of medical resources, and concerns regarding the relationship between the profession and lay people. In the seventh century Sun Simiao wrote "On the Absolute Sincerity of Great Physicians," sometimes called the Chinese Hippocratic Oath (Qiu 1988). Among the commitments are equality of treatment, attempts to save all creatures, and not to seek wealth. They should regard physicians as equal to patients, and not publicly criticise other physicians as this only leads to jeopardising the public image. He mentioned that some of the public thought that physicians were greedy, so they should not appear to care about money (Unschuld 1979). The Confucian scholar Lu Chih (754-805) urged similar virtues, of humaneness and compassion, stating that the medical resources must be distributed fairly among the population. Every family should have someone with medical knowledge to be able to care for their relatives. Medicine was not to be practiced as an occupation but as part of humaneness, without a fee. The Taoists and Buddhists, revised this with the concept of "Great Physicians" who possess special knowledge and responsibility, thus creating an elite, along with the Hippocratic ideas of keeping professional secrets, and the brotherhood of physicians. In China, as in the West, there were some physicians who wanted to call one specific system proper and to demand the outlawing of heterodox concepts. The codes of ethics appear to have been initiated by individual practitioners for the benefits of public respect as well as humaneness, but professional organisations were unknown in Eastern societies until this century, leaving it up to individuals (Unschuld 1978). There is a strong emphasis upon the virtues, including the concern for equal treatment of all classes, with writers such as Kung T'ing-hsien in 1615 attacking those physicians who had reduced medicine to a profession. It is historically interesting that before the communistic ideal of the last few decades there has been a long history of the idea of equality which is not found in the Hippocratic tradition which addresses behaviour to the individual patient only. They do share the concern for a prohibition on killing, and the two sides of ethical behaviour, to do good and not to do harm.
Japanese medical ethics is a mixture of Buddhist and Confucian influences combined with Shinto influence. From the fifth and sixth century the medical profession has been restricted to the privileged classes. With the centralisation of government in the seventh and eighth centuries there was a bureau of medicine established, with the Yoro penal and civil codes creating an official physician class. Because of shortages of doctors there was room for some others. After the Heian period (800-1200) the government-sponsored health service was replaced by professional physicians. In the sixteenth century a code of practice was drawn up that is very similar to the Hippocratic code, called the Seventeen Rules of Enjuin (Kitagawa 1978). The code requires that physicians should always be kind to people, and devoted to loving people. There is a very strong paternalistic attitude by doctors even today (Ninomiya 1978). Among the code of Enjuin is the directive to keep the Art secret, and to form a brotherhood. There was concern about quacks also (Takemi 1978). The most important issue in Japanese medicine today is the paternalism, that means for example, that 90% of the doctors will not tell their patients if they have serious cancer. In a situation where patients are not aware of their disease, the question of informed consent seems a distant issue.
As we have seen, there is a very wide variety of different practical ethics exhibited by different doctors. When problems in medical ethics arise, many Western doctors first turn to the Hippocratic Oath or its modern analogues articulated by organised groups of professional physicians reflecting the Hippocratic tradition. However the Hippocratic tradition is often in conflict with other traditions as illustrated. In some countries the Hippocratic Oath is so widely used that the possibility of changing it has not been considered, only minor changes made (Levy & Ohry 1987). However, there are many medical ethicists who suggest that we should change the idea that an ethic for medicine can be based on a professionally articulated code. There is a complex set of understandings between the professional and society so a contract theory has been suggested by many (Veatch 1981). There has been a growing body of writing suggesting that medical ethics fundamentally involves social relationships among lay people and health professionals built upon complex layers of mutual loyalty, fidelity, respect, and support (Pellegrino 1973, Magraw 1973, Brody 1976). With this at the backs of our minds, let us consider new genetic technology, and resume this discussion in the final chapter of this book.
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