I prefer to think in terms of "a" Hippocratic Oath as opposed to "the" Hippocratic Oath, and in these terms I believe it is as relevant today as when the concept was initially introduced in classical times. The taking of a Hippocratic Oath occurs at a critical time in the development of physicians, setting the moment separate from the previous process and laying the groundwork for their future careers and their future care of patients.

I do not see it as a legally binding oath, but as a sign of personal importance, commitment, and solemnity, just as when we mark the birth of our young, choose life's partners, and bury our dead. The exact wording we use to mark these events changes through time and through cultures, but the basic human emotions that these words wish to convey are universal: celebration, commitment, and mourning.

Similarly, a Hippocratic Oath intends to convey our inner emotions and thoughts as we pass from one stage of our journey (medical school) to the next stages of training and providing care. Whether we do this through the words of other times (the Hippocratic Oath) or through the words of our present times (modern iterations of a Hippocratic Oath), we are bonding with our fellow students in the moment, joining our mentors in the present, and recognizing our predecessors.

Yes, I believe "a" Hippocratic Oath is relevant—for me in June of 1990 (when I took it), in March of 2001, and every day of my life in this profession in which I am honored to be a member.

What is the essence of a Hippocratic Oath? Simple and echoed throughout time, whatever the words: "May I care for others as I would have them care for me."

Daniel G. Deschler, M.D., FACS

The classical Hippocratic oath is at once largely irrelevant to medical practice while also grossly inadequate to express the duties that we owe to our patients. Think of the key points from each of its eight paragraphs:

Three paragraphs (1, 2, and 8) occupy themselves with the oath or the medical guild, including swearing to gods who are either not relevant or perhaps offensive to one's religion, proposing fee-splitting with your teacher as well as financial support to him or her or their progeny while passing on knowledge only to others in the guild, and again asking for reward or punishment for upholding or disregarding this oath. Little here relates the new physician to his or her patients.

Another two paragraphs (5 and 6) are curios, promising to leave surgery to others (it used to be the barbers) and forswearing sex with your patients or their families. The first is wrong and outmoded, given that surgery has been a core skill in medicine for hundreds of years now, while the second hardly sets a sufficiently high moral standard for our profession.

Only three paragraphs (3, 4, and 7) apply in any serious fashion to what most physicians and laypeople would expect to be the content of a solemn oath at medical school graduation. The first of these suggests giving good advice on diet and keeping patients from harm. The second prohibits both euthanasia and abortion. The third promises patient confidentiality.

Now giving good dietary advice is certainly laudable, but it hardly expresses a comprehensive commitment to provide knowledgeable treatment of all sorts, without performing a sort of biblical exegesis. Keeping patients from harm, by contrast, is a critical concept to any relevant medical oath, as is the confidentiality of patient information. However, many physicians are fully supportive of abortions, and some physicians are sympathetic to aiding in euthanasia for terminally ill patients precisely to "keep them from harm."

To summarize the operational part of the Hippocratic oath, then, all physicians would swear to (1) give good dietary advice, (2) keep the patient from harm, and (3) maintain confidentiality; would probably swear (4) to abjure euthanasia; and might swear (5) to abjure abortion.

The revised oath by Dr. Louis Lasagna, which I am reasonably sure we used at my Harvard Medical School graduation in 1969, contrasts sharply with the uninspiring curios of the Hippocratic oath. Lasagna picked up on many of the major themes of our profession: Do positive good, not just keep from harm. Promote our knowledge and skills for the benefit of the patient. Provide sound advice and guidance to the person and family, not just manipulate the diseased organ systems. Focus on prevention. His oath also specifically includes the important Hippocratic concepts of avoiding harm and keeping confidentiality.

Lasagna's message comes dramatically closer to expressing the mission and complexity of our profession and offers the appropriate breadth and inspiration for the graduation of new physicians as well as for all of our personal renewal from time to time. His oath, or a version of it, is something I did and could swear to. As for the classical Hippocratic oath, I'll think of it every time I am tempted to split fees with my teachers or sleep with my patients.

Steven R. Kanner, M.D., MSM
Massachusetts General Hospital Weston
Weston, MA, USA

I do not have strong feelings about the oath. I think it is an outstanding, profound declaration, especially considering when it was written. There are a few items that are not pertinent anymore, but I still like to see it included in med school graduation ceremonies, at least in the printed program.

I graduated from med school (University of Minn.) in 1958. We had a small ceremony prior to the main graduation. There was a printed version somewhat similar to Louis Lasagna's PC version. I don't remember if we recited it or not. I really doubt it, but I can't recall for certain.

At any rate, it is nice as a tradition but probably more of a big deal to the lay public than to physicians.

Anonymous

The longstanding guiding principle of healthcare is primum non nocere, first do no harm. While this was a logical guidepost for medicine in the ancient Greece of Hippocrates, it is clearly dated in a world where people recognize and accept risk driving automobiles, smoking cigarettes, skiing, bungee jumping, having cosmetic facelifts, and donating kidneys and portions of their liver and lungs to friends and relatives in need of organ transplants.

Health-care providers are called upon to improve and maintain the health of our patients, a mission that has become increasingly complex as our knowledge of disease and therapeutic armamentarium have grown. Given that surgeons' ministrations routinely include wounds we intentionally create, taken literally, my colleagues and I violate the Hippocratic concept of primum no nocere daily.

Our society, founded on the Jeffersonian concept of "life, liberty, and the pursuit of happiness," has consonantly invested heavily in research and development of new knowledge and methods to prolong and enhance human life. Our modern first principle of health policy and medical decisionmaking should be that patients should decide autonomously how they will be treated, provided their decisions do not potentially injure others. For the 15 percent of GDP that our healthcare system costs, providers should be able to deliver: 1) frank and meaningful advice with regard to risks and benefits of all reasonable treatment strategies, including no treatment at all; 2) effective treatments free of all needless risks; and 3) a continuing stream of innovative solutions to healthcare problems for which our present standard therapies are inadequate.

I propose the creation within the U.S. Department of Health and Human Services of a Center for Healthcare System Performance. The goals of this center would be to ensure continuous improvement in the quality of healthcare delivery. Quality would be measured based on the expected deliverables of our healthcare system, assuring: 1) patient autonomy, access, dignity, and convenience; 2) measurable, maximally beneficial treatment outcomes with minimal risk; and 3) a rational and efficient process of introducing new treatments.

Intrinsic to the development of new therapies is the recognition that higher levels of risk and uncertainty are acceptable for treatments for problems for which present solutions are poor. Conversely, new treatments for which standard therapies are highly effective should require rigorous documentation of safety.

The Center would coordinate activities of the National Institutes of Health, the Food and Drug Administration, and Healthcare Finance Administration to ensure their synergistic approach to maximizing the quality of American healthcare delivery. We should set the expectation to continue to lead the world with measurable achievement of goals analogous to our efforts in spaceflight and environmental preservation.

Products and services which prolong and enhance life have obvious fundamental appeal. Instead of a timid, primum non nocere approach to our imperfect health-care system, let us systematically improve its performance. Carpe diem.

Dr. Eric Rose
Columbia Presbyterian Medical Center
New York, NY