What is the Hippocratic oath?

Medical Codes of Ethics

Western civilization has long held the writings of the fifth century BCE. Greek physician Hippocrates, and in particular the Hippocratic oath, as a model of ethical values to be followed in the medical profession. As the nature of Western civilization itself has changed over the centuries, interpretations of the ethical values behind the Hippocratic oath have also changed. The circumstances of modern medical practice and ethical values, however, have ironically made certain elements of the classical Hippocratic tradition even more relevant than they may have appeared in previous eras.

In fact, the Hippocratic oath is only the introductory section of the Corpus Hippocraticum (Hippocratic Collection) traditionally attributed to Hippocrates. (There is debate about whether he is the author of all the books or only some.) The actual medical observations of Hippocrates were studied and applied for many centuries, until scientific research rendered many of them recognizably obsolete. A number of sections of the corpus, however, reflect the Greek physician’s recurring concern for rules to guide the medical profession. Hippocrates’s chapters on “The Art,” “Decorum,” and “The Law” complement the more famous ethical precepts contained in the oath.

The first part of the oath itself covers the physician’s lifelong commitment to his or her teachers. This commitment extends not only to the symbolic bonds of respect but also to obligation to share one’s medical practice and even to provide financial assistance to one’s teachers, if requested. Additionally, the physician is committed to train, free of charge, the families of his or her teachers in the art of medicine.

The second part of the Hippocratic oath contains the more general pledges that would contribute to its value as an ethical guide for the medical profession. The physician is bound, in a very general way, to help the sick according to his or her ability and judgment in a manner that can never be interpreted as involving injury or wrongdoing. The physician is bound both to confidentiality concerning direct experiences in the patient-doctor relationship and to extreme discretion to avoid the circulation of professional knowledge that is not appropriate for publication abroad.

In addition to these general precepts, all of which have an ethical timelessness that would survive the centuries, there were two points in the oath that refer to specific issues that cannot be separated from the modern debate over medical ethics. Addressing the questions of euthanasia (“mercy killing”) and abortion, Hippocrates stated: “I will give no deadly drug to any, though it be asked of me, nor will I counsel such, and especially I will not aid a woman to procure abortion.”

Anyone searching for wider guidelines can glean many items of timeless wisdom from other sections of Hippocrates’s writings. In the pieces titled “The Physician” and “Decorum,” for example, the personal behavior of doctors is discussed. In all cases, Hippocrates exhorted physicians to maintain even levels of dignity and patience, to practice exemplary personal hygiene, and to avoid excesses in living habits that could introduce an element of distance between themselves and the patients who depend on them. Many centuries later, as in the eighteenth century English essay by Samuel Bard titled “A Discourse upon the Duties of a Physician,” one can see similar concerns for behavioral propriety toward the defenseless: for example, “Never affect to despise a man for the want of a regular education, and treat even harmless ignorance with delicacy and compassion” and protect against the effects of “foolhardiness and presumption.” These admonitions are indicative of the defining boundaries of the views of Hippocrates and those of the later, Christian era on the practice of medicine. The main attention of commentators on the Hippocratic corpus in recent generations has been directed to two broad divisions in the main ethical issues that he formulated: the physician’s role in abortion and in the decision to end life by either withholding or administering certain treatments. It took many centuries, however, for degrees of emphasis in analyzing the Hippocratic oath to take form. In the interim, and after a delay that separated the classical world from the late medieval world, different interpretations of the Hippocratic oath would appear, each reflecting the cultural environment to which it was meant to apply.

Several factors may explain why centuries passed before systematic attention was given to the rules of medicine first broached in the classical Greek and Roman worlds. The first of these was the general decline of political and economic conditions after the fall of Rome (fifth century CE), which had repercussions in a variety of cultural areas. Medical practices tended to revert to quite crude levels until the rediscovery of early medical texts, including those of Hippocrates, sparked interest in improving conditions of medical treatment in the late Middle Ages.

One can say that, in addition to editing elements of Hippocratic teachings to Christianize the pagan references that they contained, a second important redirection occurred in setting down medieval rules for the practice of medicine. It was Holy Roman Emperor Frederick II, around 1241, who specified for the first time that the higher authority of the state alone should define institutional procedures for certifying physicians. This was to be done through formal training and examinations in the universities of Naples or Salerno, and later in universities throughout the Western world.

In addition to rules leading to physicians’ certification, Frederick II stipulated that doctors must take an oath binding them to obligations that, in comparison to the Hippocratic oath or modern codes of medical ethics, covered very specific issues. One of these was an obligation to report any irregularities in an apothecary’s preparation of drugs that were to be dispensed to patients. Another enjoined doctors to provide free medical services to the poor.

If one looks at more modern standards for the regulation of relations between physician and patient, it is possible to suggest that—until some very major changes took place in society’s views on delicate questions previously reserved for ecclesiastical law—similar operatives continued to govern the guidelines for medical ethics. In the “Code of Medical Ethics” (1846–47) by the American Medical Association
(AMA), for example, primary focus is still visibly on the physician’s obligation to place the patient’s interest before his or her own, particularly in terms of prospects for material or other forms of personal gain. Defense of the public’s interest against quackery or the distribution of drugs that are either dangerous or illegally prepared follows, as well as avoidance of “crude hypotheses” or “magnification of the importance of services” sought, merely for the purpose of “temporary effect and popularity.” Although there are enormous time spans between the classical Hippocratic model, the medieval variant offered by Frederick II, and the mid-nineteenth century AMA code, all are comparable in their focus on what, in the terminology of the 1847 code, would be called “Duties for Support of Professional Character” (part 1, article 1) or “Duties of the Profession to the Public” (part 2, article 1).

One hundred years later, however, different societal attitudes toward medical ethics would establish themselves in most Western nations, including the United States. Generally stated, the basic changes reflected in ethical debates emphasized (or questioned the rising emphasis on) the protection of individual rights and privacy in matters relating to human life and the intervention of physicians. On one hand, changing directions in the expression of ethical orientations stemmed from advances made in key areas of medical science in the twentieth century, such as technologies for combating terminal disease, saving the lives of severely preterm infants, and prolonging life in old age. On the other hand, and in an even broader context, extraordinary scientific discoveries concerning the genetic keys behind life itself introduced an entirely different dimension to medical ethics, that of responsibility for monitoring or “engineering” life that has not yet been conceived.

Modern Applications

Although neither the original nor edited versions of the Hippocratic oath are applied today as a condition for becoming a doctor, the medical profession in the United States has definitely formalized publication of what it considers to be a necessary code of medical ethics. Evolving versions of this “Code of Medical Ethics” date from the original (1847) text of the AMA as revised by specific decisions in 1903, 1912, and 1947.

When the AMA adopted a statement under the title “Guide to Responsible Professional Behavior” in 1980, it assigned to a formal body within its organization, the Council on Ethical and Judicial Affairs, the task of publishing, on a yearly basis, updated paragraphs that reflect ethical guidelines for the profession as a whole. These evolving guidelines are organized under such subheadings as “Social Policy Issues,” “Interprofessional Relations,” “Hospital Relations,” “Confidentiality,” and “Fees and Charges.”

At the turn of the twenty-first century, the public’s growing uncertainty about a doctor’s role in a market-oriented health care delivery system and increasing mistrust in the face of malpractice suits prompted physicians to question their professional responsibilities and roles within modern medicine. In 2002, a joint effort between the American Board of Internal Medicine (ABIM), the American College of Physicians-American Society of Internal Medicine (ACP-ASIM), and the European Federation of Internal Medicine (EFIM) introduced a new professional code of conduct designed to address these issues and help physicians meet the needs of patients in the twenty-first century. The charter incorporated traditional understanding of professional norms into the unique circumstances of modern medicine by addressing issues such as patient autonomy and choice, working in physician teams and respecting other professionals, managing conflicts of interest, social justice and equality in health care access, and market forces—issues not relevant during the time of Hippocrates. The American-British team noted that they hoped their efforts reaffirmed to a wary public the profession’s commitment to putting the needs of the patient first and offered guidelines to physicians for coping with the ethical problems in the modern world.

Along with such modern-day charters, physicians are bound to respect the ethical guidelines provided to them by their professional association. Failure to respect these guidelines is tantamount to breaking one’s binding ethical obligations and can lead to expulsion from the medical profession.

Several major changes, both in levels of medical technology and in social attitudes toward issues relating to medical practice, have played key roles in several spheres of an ongoing debate concerning medical ethics. In two cases, those of abortion and euthanasia, debate has focused on the ethics of deciding to end life; in the third, referred to generally as genetic engineering, the central question involves both the living and those yet to be born. In all these spheres, the legal and ethical debates have revolved around potential conflicts between physicians and patients but also in the context of wider social values.

Movement from the historical domain of idealized codes or oaths to the more practical and contemporary realm of changing societal reactions to what constitutes injury or breach of professional ethics in several areas of modern medicine is facilitated by reference to landmark legal decisions that have given a modern and quite different meaning to Hippocratic concepts.

Probably the most widely recognized issue reflecting such ethical conflicts, and one that received specific attention in the Hippocratic oath itself, involves abortion. In the United States, the climate of public opinion toward doctor-assisted pregnancy terminations was altered considerably by the landmark 1973 Supreme Court decision
Roe v. Wade
. In this decision, the Court judged that state laws defining abortion as a criminal offense were unconstitutional. The main thrust of the argument in Roe v. Wade was that, although the Constitution does not provide a specific guarantee of a civil right of privacy that could be applied to questions of life and death in medical care, parallels exist in Supreme Court decisions on other matters of individual rights with respect to procreation. These rights tend to fall under the Fourteenth Amendment’s concept of personal liberty and restrictions on state action. These rights, in the Court’s words, are “broad enough to encompass a woman’s decision whether or not to terminate her pregnancy.”

Reference to the fundamental right of “personal privacy” in Roe v. Wade granted individual women and their physicians recourse against specific state laws criminalizing abortion. It did not, however, consider the right to have an abortion to be unqualified; nor did it extend beyond the domain of pregnancy termination to cover a general assumption that constitutional protection of the right of privacy included the individual’s right to “do with one’s body as one pleases.” In fact, there was an explicit suggestion that the legal definition of protection of an individual’s right to privacy where critical medical decisions affecting vital life processes are concerned is “not unqualified and must be considered against important state interests in regulation.”

As time passed in the evolving debate over abortion, definitions of what this could mean became colored by the inevitable introduction of religious conceptions of defense of the unborn individual—the fetus—as a possessor of life separate from that of the pregnant woman. This was a precursor to the “right to life” versus “right to choice” debate that would place physicians between two poles of opinion as to where their final obligations should lie.

What seemed most important in the beginnings of the abortion debate (and then, a few years later, the euthanasia debate) was the Supreme Court’s inclusion of commentary on Hippocratic ethical precepts as part of its argument justifying recognition of individual rights to final responsibility for the disposition of someone else’s “future” life or the disposition of one’s own life. The Roe v. Wade brief actually argued that the strict Hippocratic injunction against abortion must be recognized as a reflection of only one segment of opinion and values (specifically Pythagorean) at a particular time in history. By underlining the fact that other views and practices were known to be current throughout antiquity, and that later Christian ethics chose to ignore diversity of interpretations of medical ethics in such matters, Roe v. Wade implied that diversity of ethical opinion within a social environment must be recognized in order to avoid too narrow a definition of what standards should be followed by physicians in dealing with their patients.

The implications of these two directions in interpreting the ethical bonds between patient and physician—the right to privacy in reaching individual decisions and recognition of a degree of social relativity in defining guidelines for medical ethics—are equally visible in the debate concerning the ultimate source of authority for deciding when to terminate life and the presumed authority of the Hippocratic oath in this process.

Two issues, one involving the ethics of sustaining life by means of advanced medical technology and the other involving the “engineering” of lives according to genetic predictions, fall under the provisions of the Hippocratic oath. As one approaches more contemporary statements of professional obligations of medical doctors, such as the “Principles of Medical Ethics” (1957) of the American Medical Association, one finds that, as certain areas of specificity in classical Hippocratic or Christian medical ethics (the illegality of abortions or the administration of deadly potions) tend to decline in visibility, another area begins to come to the forefront—namely, striving continually to improve medical knowledge and skills to be made available to patients and colleagues.

This more modern concern for the application of advancements in medical knowledge, especially in the technology of medical lifesaving therapy, has introduced a new focus for ethical debate: not “lifesaving” but “life-sustaining” techniques, particularly in cases judged to be otherwise terminal or hopeless. As with the issue of abortion, the question of a doctor’s responsibility to use every means within his or her reach to sustain life, even when there is no hope of a meaningful future for the patient, reflects a dilemma regarding Hippocratic injunctions. This debate is more important now than in any earlier era because advanced medical technology has made it possible either to extend the lives of aged patients who would die without life-sustaining machines or—in the case of younger persons afflicted by brain damage, for example—to sustain life although the patient remains in a comatose state.

A prototype in the latter case was a 1976 Supreme Court decision that allowed the parents of New Jersey car accident victim Karen Quinlan to instruct her physician to remove life support systems so that their comatose daughter would die. At issue in this complicated case, which also rested on legal discussions of the constitutional right of privacy, was the question of who should decide that inevitable natural death is preferable to prolongation of life by externally administered means. When the Court took this decision away from an appointed court guardian and gave it to those closest to the patient, the question became whose privacy was being protected. This dilemma is not unlike that inherent in the abortion debate, where the privacy of the pregnant woman is weighed against that of the as-yet-unconscious, unborn child. To whom does the physician’s oath to avoid doing injury actually apply?

Legal solutions to subareas of the euthanasia debate were attained in stages, especially in cases of the very aged or patients afflicted with known terminal diseases. A living will
, for example, allows individuals to instruct their physicians not to sustain their lives by artificial means if, beyond a certain point, they are unable to express their own will to die. In some cases, this discretion is assigned to the next of kin. In both cases, the objective is to remove ultimate responsibility for inevitable natural death from the physician’s shoulders and to place it as closely as possible to within the private sphere of the patient.

Another area in which the oath's injunction against administering "deadly drugs" causes conflict is in the case of inmates who have been sentenced to death via lethal injection. While the AMA's Code of Medical Ethics also prohibits the involvement of doctors in executions, it is nevertheless not uncommon, and many states afford legal protections to physicians who assist in capital punishment. In 1991, a group of doctors sued the Georgia State Medical Board for not disciplining a doctor who had inserted an IV into an inmate so that lethal injection could take place, arguing that the doctor had violated his Hippocratic oath. However, as the oath is not legally binding, there are no legal grounds to actually discipline such doctors in most states.

A final area of contemporary debate over medical ethics illustrates how far conceptions of ultimate responsibility for the protection of life have gone beyond frames of reference that might have been familiar not only in Hippocrates’s time but also as recently as the generation of doctors trained before the 1980s. Impressive advances in the research field of human genetics by the mid-1980s began to make it possible to predict, through analysis of deoxyribonucleic acid (DNA) structures, the likelihood that certain genetic traits (specifically debilitating chronic diseases) might be transmitted to the offspring of couples under study. Inherent in the rising debate over the ethics of such studies, which range from the prediction of reproductive combinations (genetic counseling) through actual attempts to detach and splice DNA chains (genetic engineering), was the delicate question of who, if anyone, should hold the responsibility of determining if individuals have ultimate control over their genes. In the most extreme hypothetical argument, a notion of scientific exclusion of certain gene combinations, or planning of desirable gene pools in future generations, began to appear in the 1980s and 1990s. These notions represent potential problems for medical ethics that, because of exponential changes in technological possibilities, surpass the entire realm of Hippocratic principles.

Perspective and Prospects

Despite the introduction of certain legal precedents that tried to protect both physicians and their patients against dilemmas stemming from the assumed immutable ethical principles of the Hippocratic oath, society continues to witness practical shortcomings in modern understanding of who needs to be protected and how such protection should be institutionalized.

Malpractice insurance offers legal protection to physicians against personal damage claims levied by aggrieved patients or those surviving deceased patients; by the late twentieth century in the United States, these rates had soared. The larger debate regarding whether what physicians have done in individual cases was right or wrong rests on the assumption that his or her judgment can be put to the test by private parties defending their rights against professional incompetence. Therefore, the issue, as well as the institutional and/or legal devices pursued to resolve it, lies beyond the strict realm of a patient’s privacy vis-à-vis a physician’s responsibilities.

More characteristic examples of the contemporary social-ethical dilemma of whether doctors are fulfilling their appropriate professional responsibilities in recognizing patients’ rights to certain types of treatment continue to fall into legally unresolved categories. The most obvious appears to be the ongoing debate concerning the legality of physician-assisted abortions. The considerations that have been introduced clearly go beyond the black-or-white principles that simple comparison with the content of the Hippocratic oath might involve. Courts and legislators involved in the ethics of abortion have had to devote extensive attention to the considerations of how pregnancies were induced (with attention to the anomalies of incest or rape, for example) or to questions of whether tax-appropriated funds gathered from an ethically divided public body can be dispensed to pay for medically approved abortions.

Still other dimensions of contemporary physician-patient relationships reveal that new forms of legislation will be needed before debates over the applicability of Hippocratic principles to modern society will recede from front-page prominence. With living wills having more or less resolved the question of individuals’ right to instruct physicians or families to make decisions for them when personal capacities decline to incoherence, signs of new legal dilemmas began to emerge in the 1990s concerning fully coherent, terminally ill patients. Despairing of future suffering that can come well before any question of life support devices arises, some patients contracted their physicians—initially one physician in particular, Jack Kevorkian of Detroit, Michigan—to perform “mercy killing” by the administration of lethal poisons. Thus, one of the specific negative injunctions of the original Hippocratic oath returned the question of individual physicians’ ethical and legal obligations to the forefront of public attention and court proceedings more than two millennia after its initial statement.

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