bull. ind. inst. hist. med. vol. xxv pp ethical aspects of the...

Bull. Ind. Inst. Hist. Med. Vol. XXV pp 150 to 169

ETHICAL ASPECTS OF THE HIPPOCRATIC OATH AND ITS REL-EVANCE TO CONTEMPORARY MEDICINE

SISIR. K. MAJUMDAR·

ABSTRACT

For centuries the Hippocratic Oath was the example of medical etiquette and,

as such, determined the professional attitude of physicians in modern medicine.

This essay includes a short biographical account of Hippocrates, throws some light

on the origin of the oath, cites the text of the oath (in English) and gives an ethical

interpretation of the oath. Analysis of the past very often offers creative guidance

to the present and also to the future, and the Hippocratic oath is no exception.

Introduction

The Hippocratic Oath ( 600 B.C. -100 A.D.) happened to be the examplar

of medical etiquette and as such deter-

mined the professional attitude of gen-erations of physicians in modern medi-

cine for the last 2500 years. This epicOath was probably administered in thefamily guilds of physicians; it might haveformed the statutes of societies of arti-

sans which perhaps were organized insecret. However, for reasons unknown,

the Oath is always related to the name ofHippocrates ( 460 - 356 B.C. ), " the

Father of Modern Medicine", though itseems to be more Pythagorean in its

moral and ethical flavour. It might have

been enriched by other authors in antiq-

uity.

In this century, the moral rules ofthe

Hippocratic Oath have undergone con-siderabledevelopment and modification,

and much of modern medical practice isat least officially ethically inspired by its

modern successors, the World MedicalAssociation's (WMA) declarations ofGeneva (1948, revised 1968 and 1983),London (1949: the Intemational Code of

Medical Ethics), Helsinki (1964, revised

1975 and 1983), Lisbon (1981), Sydney

(1968, revised 1983), Oslo (1970, re-vised 1983), Tokyo (1975, revised 1983),

Hawaii (1977, revised 1983) and Venice

(1983). All these modifications and de-

* Hasiniketan, 200 summerhouse drive, Wilmington,Dartford, Kent, DA 27 PB,England, U.K

Ethica/ aspects of the Hippocratic Oath - Majumdar

velopments confirm that medical ethicsare relative and not absolute (Black,

1984).

Recently, it is suggested that the

"four principles plus scope" approachconsisting of "respect for autonomy, be-

neficence, non-maleficence and justice"postulated by Beauchamp and Childress

(1989) plus, concern for their scope ofapplication in the real world, provides asimple, accessible, culturally neutral

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approach, a basic analytical framework.and a common basic language to think-

ing about ethical issues in health care(Gillon, 1994).

In view of the above observations,

this essay will make an attempt to explorethe evolutionary and traditional link, if

any, between the elements of the

Hippocratic Oath and the FourPrinciples

of modem medical ethics - autonomy,beneficence, non-maleficence and jus-

tice.

HIPPOCRATES - FATHER OF MODERN MEDICINE

Biography:

Born: 460 B.C. (1 st year, 80th Died: 356 B.C. (Age - 104 years)

Olympiad)

Place of Birth: Island of Kos - 12 miles off Turkish coast.

His Pupils: Two sons and his son-in-law.

Place of Death: Larissa, Thessaly.

Father: Heraclides - an Asklepiad

Mother: Phaenarete - Descendant of Hercules

Education/Profession:

* At home, by his Father

* At Samos (Birth place of Mathematician Pythagoras 530 B.C.)

* At Ionia - Ephesus, Miletus

* Egypt - Memphis

* Delos - During Peloponnesian War

* Athens: Temple of Apollo: "Citizen of Athens" - Capital of Greece

* Professional Teacher taking fees from Students

. ~ .

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Great Contemporaries:

* Plato (460 - 370 B.C.)

BUll. Ind. Inst. Hist. Med. Vol. XXV

Personally known to them

* Aristotle (384 - 322 B.C. )

* Mentioned by HOMER IN "THE ILIAD"

Corpus Hippocraticum:

(The Hippocratic Collection: 70 books)

Most Famous: 1. "Of the Epidemics"

2. " The Book of Prognostics"

3. "On the Sar;red Disease (Epilepsy)"

4. "On airs, waters and places"

5. "The Aphorism" - Collection of Brief Generalizations

summarizing Hippocrates' Teaching - "Vita Breva(Ars Ucro Longa" (Life is short, and the art long - First Aphorism)

* His Biography first written bySORANUS OF EPHESUS ( 130A.D.) in the Second Century,A.D.

The Hippocratic Oath

'~Iswearby Apollo the physician, byAesculapius, by Hygieia, by Panacea,and by all the Gods and Goddesses,making them my witnesses, that I willcarry out according to my ability andjudgment, this oath and this indenture.To hold my teacher in this art equal tomy own parents,· to make him partner inmy livelihood,· when he is in need ofmoney to share mine with him; to con-sider his family as my own brothers, andto teach them this art, if they want tolearn it, without fee or indenture; toimpart precept, oral instruction, and all

other instruction to my own sons, thesons of my teacher, and to pupils whohave taken the physicians' Oath, but tonobody else. I will use treatment to helpthe sick according to my ability andjudgment, butnever with a viewtoinjuryand wrongdoing. Neither willI adminis-ter a poison to anybody when asked todo so, nor willI suggest such a course.Similarly I will not give to woman apessary to cause abortion. But I willkeep pure and holy both my life and myart. I will not use the knife, not even,verily, on sufferers from stone, but I willgive place to such as are craftsmentherein. Into whatsoeverhouses I enter,I will enter to help the sick, and I willabstain from all intentional wrongdoingand harm, especially from abusing thebodies of man or woman, bond or free.

Ethical aspects of the Hippocratic Oath - Majumdar

And whatsoever I shall see or hear in thecourse of my profession, as well asoutside my profession in my intercoursewith men, if it be what should not bepublished abroad, I will never divulge,holding such things to be holy secrets.Now if I carry out this oath, and break itnot, may Igain forever reputation amongall men for my life and for my art; but ifI transgress it and forswear myself,may the opposite befall me. "

Universalizability Of The Oath

Immanuel Kant (1724 - 1804), theGerman philosopher, thought that. foranaction to be moral, the underlying maximhad to be a universalizable one. It had tobe a maxim which would hold for anyoneelse in similar circumstances in all placesand at all times. The Hippocratic Oath isin total agreement with Kant's maxim.The Hippocratic Oath and the WorldMedical Association's International Codeof Medical Ethics (Appendix I) are prob-ably the most widely known statements ofmedical commitment to the service ofhumanity. The Oath is also intunewith theethics of other ancient systems of medi-cine. The Charaka Samhita, the IndianAyurvedic Medicine's code dating fromabout the first century A. D. instructs doc-tors to "endeavour for the relief of pa-tients with all thy heart and soul; thou shaltnot desert or injure thy patient for thesake of thy life or living'; (Sri Kant -Murthy, 1973). Early Islamic physiciansand the modern declaration, Declarationof Kuwait, instructs doctors to focus onthe needy, be they near or far, virtuousor sinner, friend or ememy" (Ku-

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wait,1981).As stipulated in the Oath, compas-

sion is a long accepted facet of medicalpractice in all systems of medicine in allcountries - modern and ancient. In 1792ThomasPercival (1740-1804), a physi-cian to the Manchester Infirmary, drewup a comprehensive scheme of medicalconduct, part of which was designedespecially for the medical staff of theInfirmary (Singer and Underwood, 1962).It was distributed to his medical col-leagues and discussed forten years. In1803 the revised work was publishedwith the title - "Medical Ethics", and laterthere were two further editions. It re-mains a standard work on the subject.Percival advised doctors "to unite ten-derness with steadiness, and conde-scension with authority", as to inspirethe minds oftheir patients with gratitude,respect and confidence (Leake, 1927).Maximally, effective health care dependspartly on health professionals taking ahuman approach which actively involvespatients, ratherthan making them recipi-ents of what may be seen as a preoccu-pationwith impersonal, high-tech proce-dures. But the human approach to treat-ment is the central message of the Oath.It is still desirable, as dictated inthe Oath,inspite of high-tech advancement in mod-ern medicine. It is man that counts, andnot the machine or the method.

Interpretation Of The Oath

There are two distinct parts of theOath which seem to be only superficiallyconnected or at least determined bydifferent moral standards. The first part

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specifies the duties of the pupil towardshis teacher and his teacher's family andthe pupil's obligations in transmittingmedical knowledge. The second partgives a numberofrulesto be observed inthe treatment of diseases, which couldrather be called a short summary ofmedical ethics, as it were, at the time.

The Oath may be said to representonly the ancient ideal of the physician.But, in contrast, charity motivated theChristian doctors of the Dark Ages (400-1100 A.D.) and the Middle Ages (1100- 1500 A.D) and duty to the communitydetermines the working ethics of thedoctor of today.

Most ofthe statements contained inthe document are worded in rather gen-eral terms. They are vague in theircommending of justice, of purity andholiness, concepts which do not implyany distinct meaning but may be under-stood in various ways.

However, there are two stipulationsthat have a more definite character andseem to point the at basic beliefs un-derlying the whole ethical programme:the rules concerning application of poi-son or abortive remedies. Their interpre-tation should therefore provide a clue foran ethical identification ofthe views em-bodied in the Oath of Hippocrates.The Ethical CodeRules on Poison and Abortion

"I will neither give a deadly drug toanybody if asked for it. Similarly Iwill not

Bull. Ind. tnst. Hist. Med. Vol. XXV

give to a woman an abortive remedy. Inpurity and holiness Iwill guard my life andmy art" - such is the vow made in theOath.

Poison is also a drug. All drugs havegot both beneficial effects (of course,with some tolerable and acceptable side-effects) when used rationally and alsofatal or mortal effects when used inexcess and irrationally. The Oath forbidsthe physician to assist his petient in asuicide which he might contemplate.Mortal accidents or suicides with over-dose (drugs) are common in contempo-rary medical practice, but doctorsdo nothave any role in those misadventures.Doctors always refrain from any criminalattempt on the patient's life.

In over-dose cases, a drug may beconsidered as "Poison" in conformitywith the concept in antiquity.

In contemporary medicine, Eutha-nasia has some fundamental relevanceto the administration of "poisons" topatients by physicians. Euthanasia re-fers to a medical act that deliberatelyshortens the life of a terminally andseriously ill patient at his or her requestwith the therapeutic help of a suitabledrug; it is an act the primary intention ofwhich is to cause death. According tothe Oath, it could be considered to beasslstlnq in suicide orevan a criminal acton the part of the physician on thepatient's life. But there is another side ofthe story. The basic question is whetherwe accept their right ( autonomy in

Ethical aspects of the Hippocratic Oath - Majumdar 155

modem vocabulary) to decide forthem-selves ( the terminally and incurably illpatients) how their lives will end, andthereby ending the very painful agonywhich cannot be alleviated by any medi-cal means available today. The back-bone of modern medical ethics is respectfor human life, and many doctors haveinterpreted this as being the need to keepa patient alive at all costs and for as longas possible, even against the will of thepatient concerned. Patients are some-times treated. even when the chances ofsuccess are very, very slight. This ap-proach might be an act of non-malefi-cence in tune with the clause ofthe Oath.But it does not agree with two othercardinal principles of "the GeorgetownMantra" - the autonomy of the patientand beneficence (Beauchamp andChildress, 1989). Autonomy is bestknown in the history of medical ethics asthe second form of Kant's "CategoricalImperative": the moral obligation to treatevery person as an end and nevermerely as a means. In a current form itis the requirement to respect the deci-sions of rational agents and therebyprovides a rationale for informed con-sent, truth-telling and promise keeping.Beneficence is the obligation to providebenefits and to balance benefits againstrisks, incurable physical and psychicpain in a terminally ill patient. Of course,in the backdrop ofthe Oath, the doctor isin a real dilemma. What is the way out?Relevant amendment ofthe Oath to sat-isfy the demand of the day! In the debateover euthanasia, this particular clause ofthe Oath seems to be obsolete. Recently,

the Dutch Supreme Court gave the ver-dict that doctors can assist suicides ofdepressed but otherwise physically healthpatients (Time, 1994; BMJ, 1994). Inaccordance with this historic Dutch Ver-dict, doctors in the Netherlands mayagree to requests for authanasia frompatients who are neither terminally ill norsuffering physically. In this particularcase, incurable psychic pain was givendue consideration. The time has come togive this care of an extraordinary nature- euthanasia - a solid legal and ethicalbasis, forthe benefit of both patients anddoctors alike; regulations are also re-quired to safeguard against its abuse ormisuse (Heintz, 1994). Euthanasia canbe part of good terminal care. The Oath,in order to be relevant today, must alsomarch with the dynamic need of thechanging medical world.

The Oath forbids the physician togive "pessary" to awoman, which was anabortive remedy in antiquity. Most oftheGreek philosophers commended abor-tion. ForPlato (427 - 347 B.C.) foeticideis one of regular institution of the idealstate; whenever the parents are beyondthat age which they think best for thebegetting of children, the embryo shouldbe destroyed (Republic, V, 461 c; Laws,V,740d).

Aristotle (384 - 322 B.C.), a pupil ofPlato at the Academy in Athens, reck-oned abortion the best procedure to keepthe population within the limits which heconsidered essential for a well-orderedcommunity (Politics, VII, 1335 b 20 ff).

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This prescription for population controlor family planning is not acceptable in amodem civilized society. Itwas differentwith the followers of Pythagoras (530 -498 B.C.). Pythagoreans (followers ofPythagoras) held that the embryo wasan animate being from the moment ofconception and hence abortion, when-ever practiced during pregnancy, meantdestruction of a living being.Pythagoreans thus rejected abortionunconditionally. The Hippocratic Oath,in its abortion clause echoes Pythago-rean doctrines. It is fair to say that bydedication to the Hippocratic Oath, par-ticularly to the clause on abortion andpoison, physicians of antiquity (or oftoday) guarded "the purity and holinessof the Pythagorean way of life" (Plato,Republic, X, 600b).

We have come a long way during thelast 2,500 years. Society today is muchmore complex than it was in antiquity.The need and ideas on abortion alsochanged to take meaningful notice ofthose ever-increasing complexities incontemporary society. The institution ofabortion law, along with its periodicamendments, changed abortion frombeing a crime to being something entirelylegal, under appropriate safeguards. Itis a positive departure from the abortionclause in the Oath. Medical, social,psychological and psychiatric reasonsdemandsthatdeparture. ltismoral. Itisethical. It is intunewith the times in whichwe live.

The clause on doctor-patient rela-tionship expects the doctor "to remain

Bull. Ind. tnst. His!. Med. Vol. XXV

free of all intentional injustice, of allmischief and in particular of sexual rela-tions with both female and male persons,be they free or slaves".

For the physicians, justice is theobligation to be fair. The allocation ofscarce medical resources is an areawhere this principle takes force. In thecurrent economic climate in health carethe physician is not always able to dowhat the Oath tells him to do. Here, thescope of the Oath seems to be limited.Sexual relationship with patients some-times causes concern. There are casesof clear violation ofthis clause from timeto time. Butthe General Medical Council,the statutory body regulating the conductof doctors in the U.K., acts as the watch-dog in this matter and takes disciplinaryaction against doctors who are legallyfound guilty of inappropriate relation-ships with their patients.

Medical confidentiality is the respect-ing of patients' secrets by the treatingdoctor regarding medical treatment andover-all management (including physi-cal, social, psychological and occupa-tional origin of the disease). The prin-ciple of medical confidentiality is one ofthe most venerable medico-moral obliga-tions of medical ethics. The HippocraticOath enjoins: "What I may see or hearin the course of the treatment or evenoutside of the treatment in regard to thelife of men, which on no account onemust spread abroad. Iwill keep to myselfholding such things shameful to be spo-ken about". Even today, accordingtothe


World Medical Association's Interna-tional Code of Medical Ethics, it is anabsolute requirement, even after thepatient's death (SMA, 1984).

In France, the obligation of medicalconfidentiality is stricter and is enshrinedin law as an absolute medical privilegewhich no one, including the patient, isallowed to override, even when to do sowould be in the patient's interest(Havard, 1985). In the real world ofmedical practice. doctors do face occa-sions where confidentiality needs to bebroken for very valid reasons. Accord-ingly, the SMA Handbook of MedicalEthics lists five types of exceptions tothe need to maintain medical confidenti-ality (SMA, 1984) and the General Medi-cal Council (GMC) lists eight (GMC.1985).

Medical confidentiality is an impor-tant medico-moral principle. It respectspatients' autonomy and privacy. Thereare occasions when forthe greater inter-est of the patient, confidentiality mayneed to be broken. It should not be madean absolute obligation. Exceptions ba-sed on the principles of non-maleficenceand justice may well be justified in rel-evant and suitable cases. Exceptionsshould also be considered in cases ofbenefits of medical research for thegreater interest of society; of course withthe prior consent of the patient, other-wise it will violate the patient's autonomy.

In the complex society of today, theobligation of confidentiality enjoined in

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the Oath has also been questioned bynon medical experts. Only the doctor iscalled upon to keep secret what he/shelearns about the lives of patients. Thisobligation is specific to medicine; it doesnot apply to the policemen. the journalist,the biographer, or not with the sameweight (Passmore, 1984). Itmight implythat a doctor's position in society isunique in relation to health and disease.

General Rules Of The EthicalCode

The clause on treatment of diseasesmentions dietetics first, drugs (pharma-cology) next and cutting (surgery) last.The Oath enjoins: "I will apply dieteticmeasures for the benefit of the sickaccording-to my ability and judgement; Iwill keep them from harm and injustice ............. I will not use the knife, not evenon sufferers from stone .... ."

Diet is still an important part of anymedical management; there were har-dly any drugs available for specific orrational therapy in those days. Com-paratively, today's therapeuticarmamentarium is rich. The clause on"cutting" (surgery) needs to be ana lysedfrom the socio-historical context of thetime in question. From the Renaissance(1500 - 1700 A.D;) down to the nine-teenth century, it was thought that theclause on "cutting" intends to draw a linebetween the practice of internal medi-cine and that of surgery. In those dayssurgery was held to be beneath thedignity of the physician (Th. Zwinger-

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Hippocratis Opera, 1579, p. 59). Howev-er, this clause is obsolete today andhence not included in the InternationalCode of Ethics. Even in the Middle Ages(1100-1500A.D.) "Surgeons" tended todo the job part-time and treated onlyminor wounds. Their main job wouldhave been as a barber or a butcher, andthe most popular cure was blood-letting.Frequent wars during the Middle Agesmeant that some surgeons were able topractise. Surgery was not taught in mostmedical schools of the day. Salerno's(near Naples in Italy) medical school wasthe only place in the Dark Ages ( 400 -1100 A.D.) where anatomy and surgerywere taught was an integral part of thecurriculum. Salerno was the first placeto use the term "Doctor of Medicine". Inthose days, associations (company) ofbarber-surgeons were also formed inLondon (14th century) and in Edinburgh(1505). Thetradition of barber-surgeonsis now an interesting piece of relic in theevolution of modern medicine.

In ancient Greece, medicine like allother arts and crafts was passed on fromfatherto son in closed family guilds. TheOath enjoins: " to give share ofprecepts and oral instruction and all theother leaming to my sons and to the sonsof him ". This amounts to perpetua-tion of a dynastic trend, which is nolonger acceptable in a modern civilizedsociety. Accordingly, this clause wasrightly excluded from the InternationalCode of Ethics. The dedication of theOath has also been amended. TheHippocratic Oath is dedicated to Apollo,

Bull. Ind. Inst. Hist. Med. Vol. XXV

the Gr~ek God of diseases, poetic andmusical inspirations, Asclepius, the godof healing, the son of Apollo and also theGod of "Temple Medicine, and Hygeia,Goddess of health, Panaceia, Goddessof nourishment - both daughters ofAsclepius. This dynastic ritual is out-of-date and not acceptable today. Greekmythology has no role to play in modernlife.

The International Code is secularand universal in character and excludedall religious references. The Code en-joins: "I solemnly pledge myself to con-secrate my life to the service of human-ity." The Code stipulates the duties ofphysicians in general, their duties to thesick and also to each other.

Additions And Modifications OverThe Years

The Hippocratic Oath is the basicfoundation. Overthe years various dec-larations of the World Medical Associa-tion (WMA) made necessary and rel-evant additions to the Hippocratic Oathin orderto make it useful to the practisingmodern physician. The main features ofthe additions are summarized below(Gillon,1992).

The Declaration of Geneva (1048,revised 1968 and 1983) is a sort ofupdated version of the HippocraticOath. It requiresthe doctorto consecratehis life to the service of humanity; to make"the health of my patient" his first con-sideration; to respect his patient's se-


crets (even after the patient's death); toprevent "considerations of religion, na-tionality, race, party politics, or socialstanding (intervening) between my dutyand my patient"; to "maintain utmostrespect for human life from its begin-ning" (until 1983 the wording of thisclause required" utmost respect for hu-man life from the time of conception")and not to use his medical knowledge"contrary to the laws of humanity"

The wor1d Medical Association's in-ternational code of medical ethics,adopted in London in 1949 and revisedin 1968and 1983, requires, among otherthings, adherence to the Declaration ofGeneva, the highest professional stan-dards, clinical decision uninfluenced bythe profit motive, honesty with patientsand colleagues and exposure of incom-petenland immoral colleagues. It statesthat" a physician shall owe his patientscomplete loyalty and all the resources ofhis science"; and it says that'" a physi-cian shall preserve absolute confidenti-ality on all he knows about his patienteven after the patient has died.

The Declaration of Helsinki (1964,revised 1975 and 1983) governs bio-medical research in human subjects,and among its many principles is thestipulation that " the interests of thesubject must always prevail over theinterests of science and society". It alsorequires that in any research the doctorshould" obtain the subject's freely giveninformed consent".

159".)

The Declaration of lisbon (1981)concerns the rights ofthe patient. Theseare declared to include the rights tochoose his or her physician freely; to becared for by a doctor whose clinical andethical judgements are free from outsideinterference; to accept or refuse treat-ment after receiving adequate informa-tion; to have his or her confidencesrespected; to die in dignity; and to re-ceive ordecline spiritual and moral com-fort including the help of a minister of anappropriate religion.

The Declaration of Sydney (1968,revised 1983), on death, states amongotherthings that" clinical interest lies notin the state of preservation of isolatedcells but in the fate of a person" and itstipulates the much more specific rulethat when transplantation of a deadperson's organs is envisaged determina-tion of death should be by two doctorsunconnected wit;l the transplantation.

The Declaration of Oslo (1970, re-vised 1983), on abortion, remains, evenafter its recent revision, which changed"human life from conception"to "humanlife from its beginning", the most equivo-cal of all these dceclarations for it re-quires doctors both to maintain the ut-most respect for human life from itsbeginning and to accept that attitudestowards the life of the unborn child arediverse and" a mater of individual con-viction and conscience which must berespected". Subject to a host of qualifi-cations the declaration has afwayssanc-tioned therapeutic abortion. .\,.

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The Declaration of Tokyo (1975,revised 1983), on torture, is unequivocalin forbidding doctors to "countenance,condone, or participate in the practiceof torture or other forms of cruel, inhu-man, or degrading procedures". It alsoforbids force feeding of mentally compe-tent hunger strikers.

The Declaration of Hawaii (1977,revised 1983), on psychiatric ethics,requires inter alia: that patients be of-fered the best treatment available t1ndbe given a choice when there is morethan one appropriate treatment; thatcompulsory treatment be given only ifthe patient lacks the capacity to expresshis wishes, or, owing to psychiatric ill-ness, cannot see what is in his bestinterests or is a severe threat to others;that there must be an independent andneutral appeal body for those treatedcompulsorily; that ''the psychiatric mustnot participate in compulsory psychia-trist treatment in the absence of psychi-atric illness"; that information aboutpatients must be confidential unless thepatient consents to its release" or elsevital common values orthe patient's bestinterest make disclosure imperative";that informed consent for the patient'sparticipation in teaching must be ob-tained ; and that" in clinical research asin therapy every subject must be offeredthe best available treatment. .. be subjectto informed consent, " and have the rightto withdraw at any time.

The Declaration of Venie>e (1983),the most recent declaration of the WorldMedical Association, reiterates the duty

BUll. Ind. Ins/. Hist. Med. Vol. XXV

ofthe doctor to heal and,. when possible,relieve suffering and sanctions the with-holding of treatment in terminal illnesswith the consent of the patient or, if thepatient is unable to express his will, thatof the patient's immediate family. Itallows the doctorto "refrain from employ-ing any extraordinary means whichwould prove of no benefit forthe patient"and permits the maintenance of organsfor transplantation after death has beencertified, given certain conditions.

In addition to these declarations, theWorld Medical Association has issuedother statements about medical ethics:on discrimination in medicine, reiterat-ing its abhorrence of such discriminationon the basis, of religion, nationality, race,colour, politics, or social standing; onmedical secrecy, affirming. the indivi-dual's fundamental right" to privacy; andon the use of computers in medicine,again affirming the patient's right to pri-vacy but stating that the transfer of infor-mation rendered anonymous forthe pur-pose of research is not a breach ofconfidentiality. Other statements con-cern medical regulations in time of ar-med conflict, family planning,12 prin-ciples of provision of health care, pollu-tion, the principles of health care forsports medicine, recommendations con-cerning boxing, physician participationin capital punishment, medical manpower and medical care in rural areas.

The Suggested UpdateThe Hippocratic Oath enunciated about2500 years ago was almost certainly atemple Oath written by various Asclepi-

Ethical aspects of the Hippocratic Oath - ,:1ajumdar

ads (medical/temple priests) ratherthanHippocrates himself. Despite vastchanges in medical and social structureduring-the past 25 centuries, the originalhas been passed unmodified to a greatextent from generation to generation ofdoctors. Fordebate and discussion, thefollowing updated version of the Oathhas recently been suggested (Robin,1994);

"In the name of suffering humanity,with humility, compassion and dedica-tion to the welfare ofthe sick accordingto the best of my ability and judgment, Iwill keep this oath and stipulations.

Iwill be honest with my patients in allmedical maters. When this honesty re-veals bad news Iwill deliver it with under-standing and sympathy and tact.

Iwill provide my patients with accept-able alternatives for various forms ofdiagnosis, and medical and surgicaltreatment, explaining the risks and ben-efits of each alteranative as best I ;"nowit.I will allow my patients to make the

ultimate decision about their own care.In circumstances where my patients areincapable of making decisions I will ac-cept the decision of family members orloved ones, encouraging these surro-gates to decide as they believe thepatient would have decided.

Iwill not sit in moral judgment on anypatient, but will treat their illness to thebest of my ability regardless of the cir-cumstances.

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Iwill be empathetic to patients suffer-ing from illnesses caused by substancessuch as alcohol or drugs, or other formsof self abuse usually believed to be underthe voluntary control of humans.

Knowing my own inadequaces andthose of medicine generally, I will striveto cure when possible but to comfortalways.

I shall perform medical tests only if Ibelieve there is a reasonable chancethat the results will help produce animproved outcome for my patients.

Iwill not perform any tests or proce-dures or surgery solely to make money.I will freely refer my patient to otherphysicians if I am convinced that theyare better able than I to treat a givenpatient problem.

Iwill freely furnish copies of medicalrecordsto patients ortheirfamilies uponrequest.

Iwill do unto patients and theirfami-lies only what Iwould want done unto meor my family. I will not experiment onpatients unless the patients give trulyinformed consent. Iwill strive to instructpatients fully so theirtruly informed con-sent is possible.

I will remain a student all my profes-sional life, attempting to learn not onlyfrom formal medical sources but from mypatients as well.Iwill attemptto function as a teacher formy patients so that I can care for them

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more effectively and can apply the les-sons they provide to the care of otherpatients.

I will provide care to all patientsseeking it, regardless of sex, race,colour, creed, sexual preference,lifestyle, oreconomicstatus. In particu-lar, I will volunteer some of my time toproviding free care to the poor, the home-less, the disadvantaged, the dispos-sessed and the helpless.

Iwill turn away no patient, even thosewith dreaded contagious diseases likeAIDS.

I will encourage my patients to seekmedical opinions other than my ownbefore agreeing to accept my opinion.

I will treat my professional collea-gues with respect and honour; but I willnot hesitate to testify openly about phy-sicians and medical institutions thatare guilty of malpractice, malfeasance,cupidity or fraud.

I will defend with equal fervour col-leagues who are unjustly accused ofmalpractice, malfeasance, cupidity orfraud".

Conclusion

The Hippocratic Oath offers only atraditional framework. It needed to beamended according to the demands ofthe day from time to time.

The Hippocratic physicians("Iatroi,,) were in fadAsclepiads follow-

Bull. Ind. lnst. His!. Med. Vol. XXV

ers of Temple Medicine) - rather itinerantcraftsmen who carried their skill fromplace to place, establishing in each asurgery. People in general did not haveany choice and had to accept whateverwas available in the form of medicaladvice or treatment. The question ofpersonal choice or autonomy of patientsdid not arise. Autonomy is best known inthe history of ethics as the second formof Kant's Categorical Imperative: themoral obligation to treat every person asan end and never merely as a means. Ina current form it is the requirement torespect the decisions of rational agentsand thereby provides a rationale forinformed consent, truth telling and prom-ise keeping. There was no scope fortheconcept of autonomy in the Oath. It isentirely a modern concept for a modernsophisticated society.

Beneficence is the obligation to pro-vide benefits and to balance benefitsagainst risk. It echoes the philosophy ofthe Oath - " Iwill use treatment to helpthe sick according to my ability andjudgment, but never with a viewto injuryand wrongdoing. Neitherwill Iadministera poison to anybody when asked to doso, nor will I suggest such a course".Thus, non-maleficence in tllis way cap-tures the intuitions behind tlie Hippocra- .tic maxim to do no harm to patients.

The last principle - justice- is theobligation to be fair. This is an Aristote-lian concept and not a Hippocratic one.The principle of justice or equality attrib-uted to Aristotle is that equals should •


be treated equally and unequals unequ-ally in proportion to the relevant inequali-ties. In the contemporary medical mar-ket, a fair distribution of benefits mayseem to be duty more on managers andpolicy makers, than on individual doctorsor nurses. This is a new situation notenvisaged in antiquity and hence is noteven mentioned in the Oath.

In antiquity, the Oath was adminis-tered secretly to members of the Guild("Koinon" - Greek), who were selectedby descent from doctorfather to son, or.by marriage (son-in-law) or by sociallyapproved adoption. Hippocrates'sgrandfather and fatherwere Guild mem-bers before him, as were his two sonsand hisson-in-Iawafterhim. This heredi-tary and secretive practice is totally ob-solete today and unacceptable. Today,the Oath is administered publicly to newmedical graduates all over the world.Thus, the medical world of today hasmoved far away from that secretiveHippocratic tradition. It is a sign ofenrichment, advancement and magna-nimity of the epic Oath. The modemisedversion of the Hippocratic Oath - theInternational Code of Ethics, seems tobe a compatible combination of theHippocratic concept of " do good - noharm "to patients (beneficence and non-maleficence), Kantian concept of au-tonomy and the Aristotelian concept ofjustice.

The progress of biomedical sci-ences and medical technology and theirapplication of medical practice has

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brought new ethical dilemmas. Abor-tion, euthanasia, embryo research forvarious purposes, genetical engineeringare some of the pertinent question inmodem medical practice today. Discus-sions of "medical ethics" , "bioethics"and "health policy ethics" have prolifer-ated, nor only among those directly in-volved in scientific research or the pro-visions of health care but also in univer-sity departments of philosophy, theol-ogy, Jaw, economics and sociology.Experts in these fields have contributedgreatly to the debate and dispelled theimpression that medical ethics is some-thing which only interests those workingdirectly to provide health care. Manyissues will not be solved by doctorsalone. That is why the British MedicalAssociation welcomes wider informedpublic discussion of medical ethicalproblems as the most helpful way for-ward. This is a new situation. It demandsa different approach.

Summary

The Greek physician of antiquity -Hippocrates (460 - 357 B.C) is consid-ered to be the "Father of Modern Medi-cine". For centuries the Hippocratic Oathwas the example of medical etiquetteand, as such, determined the profes-sional attitude of physicians. TheHippocratic Oath clearly falls into twoparts. The first part specifies the dutiesof the pupil towards his teacher and histeacher's family and the pupil's obliga-tions in transmitting medical

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The second part gives a set of rulesto be observed in the treatment of dis-eases - rather a short summary of medi-cal ethics. This essay includes a shortbiographical account of Hippocrates,throws some light on the origin of theOath, cites the text of the Oath (In En-glish) and gives an ethical interpretationof the Oath. Overthe past 2500 years theworld of science, philosophy and medi-cine has undergone radical transforma-tions. Old impressions about humanhealth and disease silently slipped intooblivion and new realities have appearedon the horizon of medical science. Inview of these transformations, this essaymakes an attempt to assess the rele-vance of the ethics of the HippocraticOath to the ethical problems modernphysicians are facing today. Analysis ofthe past very often offers creative guid-ance to the present and also to the future,and the Hippocratic Oath is no exception.The World Medical Association (WMA),formed in 1947, produced a modern re-statement ofthe HippocraticOath, which

Bull. Ind. Inst. Hist. Med. Vol. XXV

is now known as the International Codeof Medical Ethics. Subsequently, theWMA has published awealth of materialon a numberof important ethical mattersmodern medicine is facing today.

The central strand in health careethics today is what is known as "theGeorgetown Mantra" containing thefour principles- autonomy, beneficence,non-maleficence and justice. Ofthe fourprinciples, beneficence and non-ma-leficence echo the philosophy of theHippocratic Oath, but autonomy and jus-tice are totally non-Hippocratic conceptsin medical ethics. Autonomy has ema-nated from Kant's Categorical Impera-tive and justice is purely an Aristotelianconcept. The society is dynamic and notstagnant; bio-medical profiterns are pro-liferating; periodic relevant amendmentsof the Oath and of its successor - theInternational Code of Ethics - have beenmade from time to time, This need foramendments will remain an on-goingprocess.


APPENDIX - I

Code Of Medical I will maintain the utmost respect forhuman life from its beginning even underthreat and I will not use my medicalknowledge contrary to the laws of hu-manity;I make these promises solemnly, freelyand upon my honour.The English text of the International

Code of Medical Ethics is as follows:

InternationalEthics

One of the first acts of the WorldMedical Association, when formed in1947, was to produce a modern restate-ment of the Hippocratic Oath, known asthe Declaration of Geneva, and to baseupon it an International Code of MedicalEthics which applies in time of bothpeach and war. The Declaration ofGeneva, as amended by the 22nd WorldMedical Assembly, Sydney" Australia,in August 1968 and the 35th WorldMedical Assembly, Venice, Italy, in Oc-tober 1983, reads:

At the time of being admitted as a mem-ber of the Medical Profession:I solemnly pledge myselfto consecratemy life to the service of humanity;Iwill give to my teachers the respect andgratitude which is their due;

I will practise my profession with con-science and dignity;The health of my patient will be my firstconsideration;

I will respect the secrets which areconfided in me, even after the patient hasdied;I will maintain by all the means in my

power, the honour and the noble tradi-tions of the medical profession;My colleagues will be my brothers;I will not permit considerations of reli-

gion, nationality, race, party politics orsocial standing to intervene between myduty and my patients;

Duties of physicians in generalA PHYSICIAN SHALL always maintainthe highest standards of professionalconduct.A PHYSICIAN SHALL not permit mo-

tives of profit to influence the free andindependent exercise of professionaljudgement on behalf of patients.A PHYSICIAN SHALL, in all types ofmedical practice, be dedicated to pro-viding competent medical service in fulltechnical and moral independence, withcompassion and respect for human dig-nity.

A PHYSICIAN SHALL deal honestlywith patients and colleagues, and strive toexpose those physicians deficient incharacter or competence, or who en-gage in fraud or deception.The following practices are deemed tobe unethical conduct:a) Self advertising by physicians, unlesspermitted by the laws of the country andthe Code of Ethics of the national medi-cal association.b) Paying or receiving any fee or any

other consideration solely to procure thereferral of a patient or for prescribing or

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referring a patient to any source.A PHYSICIAN SHALL respect the rightsof patients, of colleagues, and of otherhealth professionals, and shall safeguardpatient confidences.A PHYSICIAN SHALL act only in the

patient's interest when providing medicalcare which might have the effect ofweakening the physical and mental con-dition of the patient.A PHYSICIAN SHALL use great cautionin divulging discoveries or new tech-niques ortreatment through non-profes-sional channels.A PHYSICIAN SHALL certify only thatwhich he has personally verified.

Duties of physicians to the sick

A PHYSICIAN SHALL always bearin mind the obligation of preserving hu-man life. A PHYSICIAN SHALL owe hispatients complete loyalty and all the re-sources of his science. Whenever anexamination ortreatment is beyond the

Bull. Ind. Ins!. Hist. Med. Vol. XXV

physician's capacity he should summonanother physician who has the neces-sary ability.A PHYSICIAN SHALL preserve absoluteconfidentiality on all he knows about hispatient even after the patient has died.A PHYSICIAN SHALL give emergencycare as a humanitarian duty unless he isassured that others are willing and abletogive such care.

Duties of physicians to each other

A PHYSICIAN SHALL behave towardshis colleagues as he would have thembehave towards him.

A PHYSICIAN SHALL NOT entice pa-tients from his colleagues.

A PHYSICIAN SHALL observe the prin-ciples of "The Declaration of Geneva"approved by the World Medical Associa-tion.


REFERENCES1. Beauchamp, T.L.& Childress,J.F. 1989 Principles of Biomedical Ethics, 3rd

Edn.Oxford University Press,OxfordNew York: P.67-112,120-183,194-247,256-301.

2. Black,D.B. 1984 lconoclastic Ethics, J.Med. Ethics10:179-182

3. British Medical Journal 1994 Judges make historic ruling on Eutha-nasia, 309 : 7-8.

4. British Medical Association 1984 The Handbook of Medical Ethics,BMA House, London P.6 and 70-72.

5. General Medical Council 1985 Professional Conduct and disciplines:fitness to practise. GMC,London :P.19- 21.

6. Gillon, R. 1992 Philosophical Medical Ethics. John.Wiley & sons Chichester (UK), P. 9-12.

7. Gillon, R. 1994 Medical ethics: four principles plusattention to scope. Brit. Med. J. 309:184 - 188.

8. Havard ,J. 1985 Medical confidence J.Med.Ethics11:8 - 1,.. .

168 BUll. Ind. Ins!. Hist. Med. Vol. XXV

9. Heintz, AP.M.

10. Kuwait

1994 Euthanasia: can be part of good tenni-nal care. Brit. Med. J. 308:1656.

1981 International conference on IslamicMedicine, January 1981 (1401 in theIslamic calender).

1927 Percival's Medical Ethics, Williams &Wilkins, Baltimore.

1984 Academic Ethics? J. Applied phi-losophy, 1: 63-77.

1994 The Hippocratic Oathupdated. Brit. Med.J. 309:96.

1988 Man, Malady and Medicine (Historyof Indian Medicine) Dasgupta & Co.,Calcutta" India, P.S1.

1962 A short History of Medicine .ClarendonPress Oxford, P. 189.

1973 Professional ethics in ancient IndianMedicine Ind.J.Hist.Med.18:4B.

1994 Ethics: killing the psychic Pain. 144:71(July, 4 - Report by ATovfexis).

11. Leake, C.D. (Ed)

12. Passmore, J

13. Robin, E.D

14. Roy Chowdhury, AK.

15. Singer, C.& Underwood, E.A.

16. Srikanta MurthY,K.R.

17. The Time International


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