Every spring, at medical schools around the country, thousands of novice physicians are asked to stand and recite an oath. Most often the pledge takes its name if not its wording from a Greek physician who practiced and taught more than 24 centuries ago.
Is an ancient g.p. named Hippocrates relevant in the age of AIDS and in vitro surgery, Medicaid and managed care?
Absolutely, said Arnold M. Weissler, a cardiologist and professor of medicine at the Mayo Clinic.
"I really believe the Hippocratic Oath is as contemporary as any of them," said Weissler, who recently returned to clinical practice at age 63 after a 35-year career in academic medicine.
In an era of high-tech medicine, he said, physicians have tended to become technicians, sometimes overlooking the philosophical foundations of what they do. But to Weissler, the most compelling aspect of the Hippocratic ethic is its uncanny timelessness. "Like physicians of today, Hippocrates experienced the intense frustration of an incomplete understanding of the nature of disease, its unpredictable course and the inadequacy of treatment," Weissler wrote in an editorial in last month's Mayo Clinic Proceedings.
Uncertainty in the face of incomplete knowledge has always been the overwhelming fact of life in medicine, he said. "Hippocrates stated it as clearly as it's ever been stated by the hundreds of ethics committees throughout the country." Invoking the Oath
Abortion. AIDS testing. Malpractice. Lethal injection for capital punishment. Closing of emergency rooms. Euthanasia. Care of the uninsured. Good Samaritan laws. Clinical alerts. Rationing. Right-to-die. Sooner or later, in virtually every one of the fierce ethical debates wracking modern medicine, one side or the other -- or both -- invokes the Hippocratic Oath.
They may or may not have read it. They may or may not know where it came from. They may misinterpret or even misquote it. But the Hippocratic Oath is one of those sources whose mere mention seems to give an argument weight.
Since at least 1181, when it was first administered at the University of Montpellier in France, the Oath of Hippocrates has been an ethical model for physicians. By people who have little else in common -- liberals and conservatives, doctors and patients, organized medicine and its critics -- the oath is seen as medicine's bedrock.
But the real Hippocratic Oath is layered in myth. It almost certainly was not written by Hippocrates. No physician is required to take the oath, and it was never legally binding. Contrary to popular belief, medicine's fundamental precept, "First, do no harm," does not come from the Hippocratic Oath but from another Hippocratic work, "On Epidemics."
And it's hardly free of controversy.
Taken literally, the classic wording of the oath is archaic, sexist, paternalistic to patients and filled with anachronisms. Young doctors swear by Apollo and his son Aesculapius and "all the gods and goddesses" to consider their teachers' sons as brothers. They pledge to work only for the benefit of patients and to refrain from mischief and corruption. But the original oath also touches on the perennially volatile topics of suicide, abortion, surgery, seduction of patients and doctor-patient confidentiality.
The classic version forbids a doctor to provide any patient "a deadly poison," give any woman a pessary -- a vaginal suppository -- or "use the knife" even on "sufferers from stone."
"It's very nicely written, but it makes no sense for the 20th century," said Louis Weinstein, an obstetrician-gynecologist at the University of Arizona Health Sciences Center in Tucson.
Weinstein pitched his own version of the "Oath of the Healer" in a letter to the Journal of the American Medical Association last May. Weinstein's oath emphasizes preventive medicine, the right to die and a sense of limits: "I am not a God and I cannot perform miracles."
Weinstein's version also vows to "remember that it is wrong to terminate life in certain circumstances, permissible in some, and an act of supreme love in others" -- a statement that drew an angry letter from a fellow physician who accused Weinstein of composing a "hypocritical oath."
Mayo's Weissler and other latter-day fans of the ancient Greek emphasize the Hippocratic ethic more than the oath itself -- the broad ethical principles rather than the strict phrasing, whose authenticity is disputed by scholars anyway.
"It speaks well to how a physician should behave toward patients and colleagues and to his responsibilities to society," said Charles H. Epps Jr., dean of Howard University College of Medicine, who keeps an embossed copy of the Hippocratic Oath on the wall of his office at home. "I don't quibble much about the language. It's the thought behind it."
"The art consists in three things -- the disease, the patient, and the physician," one of the Hippocratic treatises says. "The physician is the servant of the art, and the patient must combat the disease along with the physician."
What, Weissler asks, could be more up-to-date? Updating Hippocrates
In 1989, every accredited American medical school administered an oath to graduating students, according to the current issue of Academic Medicine, a publication of the Association of American Medical Colleges. More often than not, it was a version of the Hippocratic Oath, though many schools substituted more contemporary pledges. All three medical schools in the District -- George Washington, Georgetown and Howard -- and the Uniformed Services University in Bethesda use a modified version of the Hippocratic Oath.
In the 1970s, even modified versions of the classic Hippocratic Oath came under attack for being obsolete and offensive. Some schools dropped the oath-taking ceremony altogether or made it optional. Some substituted other pledges, such as the Declaration of Geneva, which was adopted by the World Medical Association in 1948, or the Prayer of Maimonides, a 12th-century rabbi and physician. Others further revised the classic oath, deleting objectionable language and references to abortion, suicide and surgery -- and sometimes even adding such vows as the physician's duty to help prevent nuclear war.
The oath also has spawned countless parodies. A "Corporate" version appeared in a letter to the New England Journal of Medicine from a Milwaukee physician five years ago. "I swear by Humana and the American Hospital Supply Corporation . . ." it began. Among its provisions: "I will not use the knife unless I am a surgeon, but I will try to learn some form of endoscopy."
Still others have taken a serious crack at drafting a new physicians' oath, usually drawing from a diversity of sources including writings attributed to Hippocrates. The most recent example is Yale University School of Medicine, which had resumed using the Hippocratic Oath in 1983 after dropping it during the 1970s. Last year, the dean asked pediatrician and chaplain Alan C. Mermann to help draw up an ethical oath more suited to today's practice of medicine.
Borrowing from half a dozen documents, including the Hippocratic Oath, the Prayer of Maimonides and the Declaration of Geneva, Mermann drafted the Yale Physician's Oath on his word processor. It was given this year for the first time.
"This is not a Shakespearean sonnet," Mermann said. "I sat down and took pieces from all of them. I literally cut them up and took it sentence by sentence. We took out the explicit religion -- the God talk -- and the surgery and the references to abortion."
The new Yale version begins: "Now being admitted to the high calling of the physician, I solemnly pledge to consecrate my life to the care of the sick, the promotion of health and the service of humanity." It pledges that considerations of "race, religion, nationality or social standing" will not influence a doctor's duty to care for those in need. It also emphasizes confidentiality, preventive care and "the moral right of patients to participate fully in the medical decisions that affect them."
An earlier alternative to the Hippocratic Oath was suggested by Louis Lasagna, a prominent pharmacologist who is now dean of the Sackler School of Graduate Biomedical Sciences at Tufts University in Boston.
Doctors had lost both their sense of continuity with the past and their bond with contemporaries, Lasagna warned in proposing his own oath in an article in the New York Times in 1964. Lasagna's version emphasizes humility ("Above all, I must not play at God.") and the "twin traps of overtreatment and therapeutic nihilism."
But even the classic Hippocratic Oath carries ethical weight, Lasagna said in an interview, "not because of literal phraseology but because it may make graduating physicians realize they're part of an old and for the most part honorable tradition with some scruples. Everybody knows these folks are not really swearing by Apollo." 'The Great Physician'
Historians agree that a man named Hippocrates was born in the 5th century B.C. on the Greek island of Cos and became an influential physician. Little else is known about his life. Hippocrates is mentioned twice in the writings of Plato and was referred to by Aristotle as "the Great Physician."
Over the next two centuries, a body of writings attributed to Hippocrates was compiled and became known as the Hippocratic Collection. These writings suggest a natural basis for medicine, rooted in the belief that disease resulted from an imbalance of four vital fluids: blood, phlegm, black bile and yellow bile. The writings emphasize natural healing, cleanliness, proper diet, rest and moderation.
The Hippocratic Collection -- some 70 treatises dealing with anatomy, diseases, diagnosis, prognosis, diet, drugs, surgery and medical ethics -- may have made up the library of an ancient medical school such as the one at Cos. From the diversity of topic and style, scholars know that neither Hippocrates nor anyone else was the sole author.
"There's no doubt that the oath is ancient and that it was written in Greek by someone or some cult of people who practiced medicine," said John M. Riddle, a professor of history at North Carolina State University. But precisely who wrote down the oath or the other teachings that have come to be identified with Hippocrates and his followers is not known and probably never will be.
"Most of us have given up on the task," Riddle said. "We've decided to say: Somebody wrote those treatises. Let's just read them for what they're worth and not waste any more time trying to figure out who Santa Claus was." Weight of Tradition
A literal reading of the classic Hippocratic Oath has always been problematic for 20th century physicians because of its outdated references to medical apprenticeship, pessaries and cutting for stones.
"Whoever swears the Hippocratic Oath is sure to commit perjury," wrote physician-historian Henry E. Sigerist in 1941. "Why then do we still swear it? Because it is old; because the name of Hippocrates is attached to it, and because generations of physicians have sworn it before us. In short, we do it because it fits into the sentimental picture we have made of our past."
Even schools that have heavily rewritten the classic oath still call it the Hippocratic Oath, the Academic Medicine study found. "They cling to the name if not to the oath itself," said co-author and University of Pittsburgh historian Jonothan Erlen. "It has a nice ring to it. It has the weight of authority and history."
But that tradition cuts two ways. "It puts a physician in a very paternalistic relationship to the patient," said Walter J. Friedlander, professor emeritus of medicine at the University of Nebraska College of Medicine in Omaha. "It's the physician getting his way, as it were, whereas now there's more concern about the patient's right to self-determination."
Ironically, many of the values expressed in the Hippocratic Oath were not typical of the practice of medicine in Hippocrates's time, said historian Riddle. While some have interpreted the Hippocratic prohibition against giving patients "deadly poison" as a ban on suicide, the ancient Greeks and Romans alike accepted suicide, he said.
Similarly, the Hippocratic pledge not to give a woman a "pessary" had a very specific Greek meaning and should not be seen as a sweeping condemnation of abortion, he said. A pessary, an oval pebble inserted into the vagina as a means of birth control, was considered by the ancients as the least effective, least preferable method, likely to cause ulcerations.
In the Middle Ages, some Christian versions of the Hippocratic Oath dropped the word "pessary" and substituted a prohibition against abortion. And one of the most influential modern translators of the Hippocratic Collection, the 19th century French scholar Emile Littre, did likewise. Littre, a devout Catholic, explained in a footnote that he didn't believe Hippocrates could have meant anything else but a ban on abortion.
"It just got into modern scholarship that Hippocrates had prohibited abortion," Riddle said, even though Hippocrates himself had been excoriated by the early Christian theologian Tertullian for performing abortions.
The oath's stricture against "cutting for the stone," Riddle said, refers to an abdominal incision to remove bladder stones -- perhaps the most dangerous surgical operation performed in ancient times. Essentially, it meant that physicians should leave surgery to surgical specialists -- "as if today a physician were to take an oath saying he wouldn't do open-heart surgery." Beyond Ceremony
The Academic Medicine study of medical school oaths found that in 1989 oaths were given at 127 schools -- with some schools offering students a choice among several pledges. A majority -- 74 schools -- used a version of the Hippocratic Oath. The wording usually resembled the ancient oath but in some cases was modernized. An additional 47 schools followed the wording of the Declaration of Geneva. The rest used more contemporary medical oaths, such as those based on the Prayer of Maimonides, the Oath of Lasagna or the Doctors' Meditation by Albert Axelrod.
The researchers -- a physician, a historian and a nurse-ethicist -- analyzed each medical school oath to see whether it included any or all of six commonly accepted ethical principles of the practice of medicine in the late 20th century: respect for patients' autonomy, truth-telling, "Do no harm," commitment to patients' well-being, confidentiality and fairness.
No oath used by an American medical school included all six, the study found. Most failed to highlight a respect for patients' autonomy, for example, which "seems to demonstrate an inconsistency with the present societal emphasis on patients' participation in decision-making."
The typical medical school oath does "a nice job" of expressing the need for confidentiality and for not harming the patient, said co-author Erlen, curator of history of medicine at the Falk Library at the University of Pittsburgh. "But the idea of truth-telling and informed consent -- and somehow addressing the changing doctor-patient relationship -- just isn't there."
Medical schools "may even want to ask why they continue to have their graduates take oaths, particularly in the case of those schools that cling to the wording of traditional pledges," they concluded. Erlen's co-authors included Emil Dickstein, a professor of medicine at Northeastern Ohio University College of Medicine, and Judith A. Erlen, a nurse-ethicist at the University of Pittsburgh.
"Why are we going through with this ceremony?" asked Judith Erlen. "Is it just a rote exercise, or is it supposed to be truly meaningful? If it's just tradition, fine -- say that. But if you're doing it because you think this is the way medicine should be practiced, then we're in trouble."
Washington's medical schools -- George Washington, Georgetown and Howard -- include a recitation of a simplified version of the oath as part of the graduation ceremony. So does the Johns Hopkins School of Medicine in Baltimore.
"We firmly believe the basic concepts are very relevant to today's medicine," said Sterling Lloyd, assistant dean for student affairs at Howard's College of Medicine. Students recite a shortened version of the Hippocratic Oath, rewritten by the class of 1972. The oath does not mention "deadly poison," surgery or abortion.
Georgetown University School of Medicine takes the oath "rather formally and very seriously," said William Ayers, associate dean. Not only is the Hippocratic Oath read at graduation -- led by a faculty member elected by the graduating class -- but this year it was read aloud to first-year medical students "as a sort of prelude of what they faced."
Former Surgeon General C. Everett Koop, in his commencement speech at George Washington last spring, called the Hippocratic Oath "the most enduring ethical legacy of the practice of medicine." By taking the oath, Koop told GW graduates, "we remind ourselves that we are part of an ethical tradition that transcends the legal vicissitudes of time and the fickleness of the law."
Now being admitted to the high calling of the physician, I solemnly pledge to consecrate my life to the care of the sick, the promotion of health and the service of humanity.
I will practice medicine with conscience and in truth. The health and dignity of my patients will be my first concern. I will hold in confidence all that my patients relate to me. I will not permit considerations of race, religion, nationality, or social standing to influence my duty to care for those in need of my service.
I will respect the moral right of patients to participate fully in the medical decisions that affect them. I will assist my patients to make choices that coincide with their own values and beliefs.
I will try to increase my competence constantly and respect those who teach and those who broaden our knowledge by research. I will try to prevent, as well cure, disease.
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 colleague 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, or a cancerous growth, but a sick human being, whose illness may affect his family and his 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 men and women, 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.