S1.

Biomedical Ethics
The Hippocratic Oath and Medical Ethics

1. The Hippocratic Oath overview

General information
 Historically taken by physicians.
 Most widely known Greek medical text.
 Original form: Requires new physical to swear, by a number of healing gods, to uphold specific
ethical standards. Considered a rite of passage for practitioners of medicine in many countries.
Nowadays, various modernized versions are used.
 Not legally binding.
 Alternatives: Osteopathic oath (US)

Development and changes

 Modified numerous times. One of the most significant revisions first drafted in 1948 by the
World Medical Association, The Declaration of Geneva. During WWII, WOMA showed
concern over state of medical ethics. Noted that the custom of medical schools to administer an
oath to doctors upon graduation had fallen into mere formality.
 1960s: Changed to require “utmost respect for human life from its beginning”, making it a more
secular obligation, not to be taken in the presence of God or any gods.

Abortion
 Traditionally prohibited. Various strands and some parties were willing to prescribe abortions for
the sake of the mother’s health. Remains controversial.
 In modern day, prohibition often omitted from many oaths taken in US medical schools.
 Multicultural and pluralistic society  ranging views. Some physicians see abortion as moral
wrong, while others conceive the abortion of a foetus resulting from rape an act of courage.

Lethal injection
 Controversial.
 Case study: 1991. Criminal Jose High set to be executed in Georgia, US. Execution team could
not find Jose’s vein and called in a professional doctor with the sole purpose of finding his vein
and injecting him with lethal poison. Up to this point, doctors had not been a part of the
execution team, but were only present to pronounce the death of the inmate. A group od
doctors sued the Georgia State medical board for not disciplining the doctors, stating that he
violated federal law and broke the Hippocratic Oath. In response, the Georgia legislature passed
laws protecting doctors who take part in lethal injections from civil and criminal prosecution.

Breaking the Hippocratic Oath

  In antiquity: range from a penalty to losing the right to practice medicine.
 Modern day: no direct punishments.
 Equivalent to malpractice – carries a wide range of punishments from legal action to civil
penalties.
 In US, several major judicial decisions made referencing the oath.

2. Seminar Reading

Fabrice Joterand, The Hippocratic Oath and Contemporary medicine reading I

On Steven Miles
 Oath rehearses a set of obligations that mix together both moral concerns and religious interest
in purity. Physicians play a key role in society and assume a “special ethical contract”. Patients
and society expect high standards of care for which the aim is the recovery and well being of the
patients. However, controversial. Multicultural and pluralistic society  difficult to produce a
coherent account of what beneficence or justice mean.
 Mills interprets the vow “to keep the ill from injustice” as a commitment to a view of the good.
 Criticizes the US health care delivery system by arguing that the Oath implies an obligation to
establish a universal health care. “More than 40 million American do not have public or private
health insurance for more than one year at a time”. To Miles, this is the result of an “unjust
health care financing”, part of a larger crisis of trust between the medical progression and
society.
o What does a universal health care system entail?
o Politicized? Create injustices of various sorts. Problem when countries disagree on one
universal medical code of conduct.
 The threat of malpractice lawsuits and the erosion of public trust in the medical profession due
to economic factors influencing health care delivery = important issues in contemporary
reflections on the medical professions that “damage” the image of medicine.

Steven Miles, The Hippocratic Oath and the Ethics of Medicine Reading II

The relevance of the oath for our time reading (page 171)
 Today the Oath is one medical ethic in a world of contending and diverse moral systems.
 Oaths do not compel ethical behaviour, but are human instruments crafted to sensitize the
reader to moral moments and choices.
 Irony of Oaths contemporary reception: how debate about examples has eclipsed the
examination of its core message.
 Content speaks to 3 critical issues in the ethics of medicine
o Who are you as a physician?
 Family of medicine. Invites us to reconceptualise medical ethics in a multidisciplinary
health-care system. Descendants of Greek characters sorted into different medical
branches.
o To what are you committed?
Centred on two main principles: beneficence and justice. Development of another
principle: respect for autonomy (vs. performing harmful research without consent, not
informing patients of the truth of their diseases, etc.)
o To what are you accountable?
The past is to be remembered and not idolized. Each physician obliged to make a
commitment to the ethics of medicine in light of the past, the problems our time, and
the judgement of those who follow us.
 The grandest challenge of our time: Financing of health-care: ethical dilemmas of capitated
reimbursement in managed care, the unbearable expense of health technologies in third world
countries, or universal access to health care.
o How can this be solved? Economically developed nations whose healers claim descent
from the Hippocratic tradition view universal access to affordable health care as a moral
obligation. US does not agree. Many US physicians argue that universal access to basic
health care is about societal or political values that are external to medical ethics.

3. Hippocratic Oath : Original

I swear by Apollo the physician, and Aesculapius the surgeon, likewise Hygeia and Panacea, and call all the gods
and goddesses to witness, that I will observe and keep this underwritten oath, to the utmost of my power and
judgment.

I will reverence my master who taught me the art. Equally with my parents, will I allow him things necessary for
his support, and will consider his sons as brothers. I will teach them my art without reward or agreement; and I
will impart all my acquirement, instructions, and whatever I know, to my master's children, as to my own; and
likewise to all my pupils, who shall bind and tie themselves by a professional oath, but to none else.

With regard to healing the sick, I will devise and order for them the best diet, according to my judgment and
means; and I will take care that they suffer no hurt or damage.
Nor shall any man's entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do
so. Moreover, I will give no sort of medicine to any pregnant woman, with a view to destroy the child.

Further, I will comport myself and use my knowledge in a godly manner.I will not cut for the stone, but will
commit that affair entirely to the surgeons.Whatsoever house I may enter, my visit shall be for the convenience
and advantage of the patient; and I will willingly refrain from doing any injury or wrong from falsehood, and (in
an especial manner) from acts of an amorous nature, whatever may be the rank of those who it may be my duty to
cure, whether mistress or servant, bond or free.
Whatever, in the course of my practice, I may see or hear (even when not invited), whatever I may happen to
obtain knowledge of, if it be not proper to repeat it, I will keep sacred and secret within my own breast.

If I faithfully observe this oath, may I thrive and prosper in my fortune and profession, and live in the estimation
of posterity; or on breach thereof, may the reverse be my fate!
4. Hippocratic Oath : Modern modification

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such
knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment
and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding
may outweigh the surgeon's knife or the chemist's drug.
I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are
needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know.
Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it
may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and
awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may
affect the person's family and economic stability. My responsibility includes these related problems, if I am to care
adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those
sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection
thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy
of healing those who seek my help.
Seminar notes

Questions
 What does the oath tell us about medical teaching?
 What might be meant with “harm + injustice”?
 What are the inks between “deadly drugs” and abortive remedy prohibitions?
 What was the referred treatment?
 Why were sexual relations forbidden?
Was confidentiality absolute?

Characteristic of medicine of antiquity

 Greek and Roman, no government regulation of medicine
 No particular criteria to call himself a physician
 In this creation, how the medical teaching was organized was as “families of healers”
 Generational teaching like other crafts
 Development of teaching  individuals teach anyone for money (sophists). Undermine the
profession?
 Hippocrates took on students from outside his family

Terms: “Harm” and “Injustice”

 “Harm”  drugs; right dosage of medicine; limiting amount of sessions so as to not waste the
money of patients; healer to know what limits are; to refer to colleagues with appropriate skills
should the physician abandon a dying patient? Ethical obligation of hopeless cases to antiquity?
 “Injustice”  financial exploitation, charging too much; danger of neglecting the poor at
expense of focusing on the wealthy. Should the very poor be treated for free? Physician should
have enough money from treating wealthy to treat the poor for free.
 “Preferred treatment” for the Hippocratic healer  in order 1). Lifestyle: food, drink, living
conditions 2) Treatment by drugs; 3). Surgery

Application
 Hippocratic Oath influenced by Pythagorean thinking (emphasis on the sanctity of life). Link
between deadly drug and abortive remedy prohbitions.
 “I will neither give a deadly drug to anybody if asked for it, not will I make a suggestion to this
effect”  protection of public against poison and later on, euthanasia. Vaginal pessary for
abortion in Ancient Greek was legal – not compatible with Oath? Response: written at different
times by different writers. IN modern day, writers make clear that “deadly drugs” are associated
with euthanasia, and “abortive remedies” are linked to pessaries.
Sexual relations
 Why was sexual relations forbidden? Prevent temptation of sexual abuse against free people as
well as slaves (interesting conclusion? – to do with respect for human life in general?)! Physician
should not abuse access to household. At the time, healers mostly male.

The Oath in practice

 “Absolute confidentiality”  Oath founded upon ‘harm principle’. Will it harm third parties?
Where are the limits of confidentiality? Confidentiality not absolute.
 The Oath has a religious as well as practical (!) dimension. Healer adopts this morality to
preserve public reputation. ‘I am a reputable person. If you come to me for healing, I subscribe
to all these ethical restrictions.’

4 Principles of modern biomedical ethics

Beauchamps/Childress
 Beneficence
 No harm principle (non-maleficence)
 Justice
 AUTONOMY! (Main difference between past and modern biomedical ethics)
Autonomy a product of the 21st century. Movements of rights in society, theories of liberty and
the development of democratic societies. Human experimentation in Nazi Germany and in the
US in the 1940s and beyond. Highlighted that the autonomy of the patients needed to be
respected. Doctor’s interests must be secondary. What if the decision of the autonomous person
is against the person’s best interests? (Main feature of medical law) E.g. A mother deciding not
to inject her baby with drugs due to religious reason, but that could save a life. Should medical
authorities override the mother’s decision and save the baby? Decision of parents can be
overridden.

Hippocratic Oath in modern day

 Expresses the ethic of only one group of healers. Many groups in antiquity did not commit to
these ethical roots.
 Other ethical systems emphasise appearance and code of conduct important – includes
imperatives such as (i) no gossiping (ii) should not wear strong perfume (iii) should not use
extravagant headgear

Timeline of Oath
 When first established: only one ethical system amongst others
 Oldest documents dates to 300 CE, 700 years after written.
 At first, neither widely used, nor influential, until 500 years or so.
 Medieval church scholars rediscovered it and began altering it to conform to Christian doctrines
in the Middle Ages.
 18th century onwards, various versions of the Oath have ben widely used in medical school
graduation ceremonies in Europe and the US.
 16th century gained popularity - renaissance
 17th-18th century - less popular. People did not want to simply emulate Hippocrates, but would
want to think of new principles of medical ethics. One new principle : sympathy, or empathy.