Doctors' Diaries

The Hippocratic Oath Today:
Doctors' Responses

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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 [classical] 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, Massachusetts

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.

The longstanding guiding principle of health care 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 our 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 non 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 decision-making 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 that prolong and enhance life have obvious fundamental appeal. Instead of a timid, primum non nocere approach to our imperfect healthcare system, let us systematically improve its performance. Carpe diem.
Dr. Eric Rose
Columbia Presbyterian Medical Center
New York, New York

As a senior medical student about to move on to residency, the overwhelming emotion I have at this time is one of disillusionment. At the heart of the Hippocratic Oath, both classical and modern, is the vow to avoid doing harm and to help when appropriate and necessary. Yet medical education, both undergraduate and graduate, brutalizes its students.

Sleep deprivation is the norm—I have seen residents working up to 120 hours a week. With such inhuman work hours for so many years, alienation from one's family, health, and peace of mind is often the result. Falling asleep at the wheel is common, and deaths of both residents and medical students have been noted in the press. Medical mistakes are inevitable when people are so exhausted. The medical literature clearly and unequivocally states the risk to health and even life when people are sleep deprived, but medical educators seem to believe that somehow, magically, doctors can rise above their own physiology. Physical and psychological abuse from attending physicians are common complaints of both residents and students.

To quote from the Annals of Internal Medicine, "For many residents, fatigue cultivates anger, resentment, and bitterness rather than kindness, compassion, or empathy" (Annals of Internal Medicine 123(1995):512-517). How are we to provide compassionate care to others when our own educational system is the model of abuse? Primum non nocere indeed—the hypocrisy of this oath is that we can't even manage to muster nonmaleficence to practitioners of our own profession, let alone our patients.

I took the original Hippocratic Oath in 1982 upon my graduation from medical school and returned to this institution upon completion of my training. I have done my best working as an overworked, underpayed academic physician in high-risk obstetrics in a metropolitan city teaching university since then. I look back to the wisdom and guidance of Hippocrates everyday as I struggle to balance my duties, patient rights and allocation of hospital/societal resources for the sake of underprivileged and acutely ill mothers and their unborn children.

Several years ago, a junior medical class within our Catholic medical school demanded removal of any version of the Hippocratic Oath at graduation. Their argument was this oath was outdated, degrading, and inappropriate for the "modern reality" of medicine. The majority of our faculty were initially stunned and confused by these arguments at the time. Our academic community eventually compromised with a modern version of the Hippocratic Oath and the option for objecting students to step off the graduation stage during that portion of the ceremony. Some students remain belligerent to this day in this gesture, though most still choose to take a version of the Hippocratic Oath at graduation.

I now understand why this new generation of physicians might feel this way about the original Hippocratic Oath. It is particularly evident in this modern era when more students are choosing residencies in radiology, anesthesiology, and pathology for the sake of their lifestyle. Our outstanding residency program in OB/Gyne has difficulty in filling our slots because of significant workload and lifestyle issues. These Hippocratic Oath dissenters tend to openly complain about excessive clinical workload despite obvious patient needs. Many of these individuals rationalize a "shift-mentality" as their future practice of medicine that justifies going home when they are "off-duty" despite any other professional obligations. It appears that "job quality" is a priority when compared to "professional duty" in the medical practice of these particular future physicians.

Some of this new breed of colleagues also have a public display of disrespect for the indigent, confused, and simplistic patient. Instead of becoming an advocate and/or protector of society's weakest element, they would discard this needy population in preference for the medical procedure, economizing their clinical practice or optimizing their time at home with family and friends.

The most disconcerting attitude within this subset of these "New Age" practitioners is the blatant contempt and disrespect for their elder colleagues in our medical profession. Stated reasons are outdated practitioners and oblivious perspectives to the "modern face" of medicine. While I am still at an intermediate stage in my professional career, I continue to learn more about the practice and ethics of my specific profession from my soon-retiring colleagues than from any journal, Web site, or national meeting.

While I am liberal and approachable on most professional matters, I am utterly dismayed by these radical attitudes of my junior colleagues who lambaste the Hippocratic Oath. Perhaps this conflict between the generations in our medical profession is why I have given up the important academic positions of Clerkship and Residency Director of our Ob/Gyne program over the past decade.

While I truly love being a mentor, I see little opportunity to guide these young professionals into a lifelong career in service to humanity, when it is obvious their major interests lie in lifestyle and livelihood. This personal attitude may be further reinforced by the radical change in healthcare delivery that promotes the role of physician as clinical and economic manager rather than professional decision-maker and patient advocate in this era of managed medical care.

I therefore contend that any attempt to eliminate an appropriate version of the Hippocratic Oath upon graduation from medical school by our younger colleagues reflects a self-centered, misguided, and ill-advised attempt to test their reality of current medical practice. This personal attitude is in defiance of the time-tested, patient-oriented, and physician-managed practice of medicine. While this original philosophy dates back to the Greeks, it continues to provide a roadmap that maximizes patient/societal outcomes within our profession while limiting the individual benefit of payment, stature, and control of physicians upon healthcare delivery. The original Hippocratic Oath should become standard learning for patients and physicians alike.

Generation X has recently matriculated into the field of clinical medicine, and our national healthcare system will only suffer further when we tolerate physicians who do not care, apply inappropriate medical techniques, and have little professional respect for the patient-physician relationship as outlined in this product of early medical philosophy.

P.S. I continue to identify a small group of non-generation-X students and residents each year who defy this societal transformation and who strive to follow in the footsteps of myself and my elders. My solution for this "Gen X syndrome in medicine" is a realistic Third World medical experience for junior trainees (which I have done on several occasions) to give them a perspective that healthcare is a right for all human beings, not a scheduled or convenient privilege!!!

Read the Oaths The Hippocratic Oath: classical version
The Hippocratic Oath: modern version
Comments on the Oaths Non-doctors' responses

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