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Bull. Ind. Inst. Hist. Med. Vol. XXV pp 150 to 169 ETHICAL ASPECTS OF THE HIPPOCRATIC OATH AND ITS REL- EVANCE TO CONTEMPORARY 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 , 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 been enriched by other authors in antiq- uity. The Hippocratic Oath ( 600 B.C. - 100 A.D.) happened to be the examplar In this century, the moral rules ofthe of medical etiquette and as such deter- Hippocratic Oath have undergone con- mined the professional attitude of gen- siderabledevelopment and modification, erations of physicians in modern medi- and much of modern medical practice is cine for the last 2500 years. This epic at least officially ethically inspired by its Oath was probably administered in the modern successors, the World Medical family guilds of physicians; it might have Association's (WMA) declarations of formed the statutes of societies of arti- Geneva (1948, revised 1968 and 1983), sans which perhaps were organized in London (1949: the Intemational Code of secret. However, for reasons unknown, Medical ), Helsinki (1964, revised the Oath is always related to the name of 1975 and 1983), Lisbon (1981), Sydney Hippocrates ( 460 - 356 B.C. ), " the (1968, revised 1983), Oslo (1970, re- Father of Modern Medicine", though it vised 1983), Tokyo (1975, revised 1983), seems to be more Pythagorean in its Hawaii (1977, revised 1983) and Venice moral and ethical flavour. It might have (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 151 velopments confirm that approach, a basic analytical framework. are relative and not absolute (Black, and a common basic language to think- 1984). ing about ethical issues in health care (Gillon, 1994). Recently, it is suggested that the In view of the above observations, "four principles plus scope" approach this essay will make an attempt to explore consisting of "respect for autonomy, be- the evolutionary and traditional link, if neficence, non-maleficence and justice" any, between the elements of the postulated by Beauchamp and Childress Hippocratic Oath and the FourPrinciples (1989) plus, concern for their scope of of modem medical ethics - autonomy, application in the real world, provides a beneficence, non-maleficence and jus- simple, accessible, culturally neutral 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 : "Citizen of Athens" - Capital of Greece * Professional Teacher taking fees from Students

. ~ . 152 BUll. Ind. Inst. Hist. Med. Vol. XXV

Great Contemporaries: * Plato (460 - 370 B.C.) 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 by other instruction to my own sons, the SORANUS OF EPHESUS ( 130 sons of my teacher, and to pupils who A.D.) in the Second Century,A.D. have taken the physicians' Oath, but to nobody else. I will use treatment to help The Hippocratic Oath the sick according to my ability and judgment, butnever with a viewtoinjury '~Iswearby Apollo the physician, by and wrongdoing. Neither willI adminis- Aesculapius, by , by Panacea, ter a poison to anybody when asked to and by all the Gods and Goddesses, do so, nor willI suggest such a course. making them my witnesses, that I will Similarly I will not give to woman a carry out according to my ability and pessary to cause . But I will judgment, this oath and this indenture. keep pure and holy both my life and my To hold my teacher in this art equal to art. I will not use the knife, not even, my own parents,· to make him partner in verily, on sufferers from stone, but I will my livelihood,· when he is in need of give place to such as are craftsmen money to share mine with him; to con- therein. Into whatsoeverhouses I enter, sider his family as my own brothers, and I will enter to help the sick, and I will to teach them this art, if they want to abstain from all intentional wrongdoing learn it, without fee or indenture; to and harm, especially from abusing the impart precept, oral instruction, and all bodies of man or woman, bond or free. Ethical aspects of the Hippocratic Oath - Majumdar 153

And whatsoever I shall see or hear in the wait,1981). course of my profession, as well as As stipulated in the Oath, compas- outside my profession in my intercourse sion is a long accepted facet of medical with men, if it be what should not be practice in all systems of medicine in all published abroad, I will never divulge, countries - modern and ancient. In 1792 holding such things to be holy secrets. ThomasPercival (1740-1804), a physi- Now if I carry out this oath, and break it cian to the Manchester Infirmary, drew not, may Igain forever reputation among up a comprehensive scheme of medical all men for my life and for my art; but if conduct, part of which was designed I transgress it and forswear myself, especially for the medical staff of the may the opposite befall me. " Infirmary (Singer and Underwood, 1962). It was distributed to his medical col- Universalizability Of The Oath leagues and discussed forten years. In 1803 the revised work was published Immanuel Kant (1724 - 1804), the with the title - "Medical Ethics", and later German philosopher, thought that. foran there were two further editions. It re- action to be moral, the underlying maxim mains a standard work on the subject. had to be a universalizable one. It had to Percival advised doctors "to unite ten- be a maxim which would hold for anyone derness with steadiness, and conde- else in similar circumstances in all places scension with authority", as to inspire and at all times. The Hippocratic Oath is the minds oftheir patients with gratitude, in total agreement with Kant's maxim. respect and confidence (Leake, 1927). The Hippocratic Oath and the World Maximally, effective health care depends Medical Association's International Code partly on health professionals taking a of Medical Ethics (Appendix I) are prob- human approach which actively involves ably the most widely known statements of patients, ratherthan making them recipi- medical commitment to the service of ents of what may be seen as a preoccu- humanity. The Oath is also intunewith the pationwith impersonal, high-tech proce- ethics of other ancient systems of medi- dures. But the human approach to treat- cine. The Charaka Samhita, the Indian ment is the central message of the Oath. Ayurvedic Medicine's code dating from It is still desirable, as dictated inthe Oath, about the first century A. D. instructs doc- inspite of high-tech advancement in mod- tors to "endeavour for the relief of pa- ern medicine. It is man that counts, and tients with all thy heart and soul; thou shalt not the machine or the method. not desert or injure thy patient for the sake of thy life or living'; (Sri Kant - Interpretation Of The Oath Murthy, 1973). Early Islamic physicians and the modern declaration, Declaration There are two distinct parts of the of Kuwait, instructs doctors to focus on Oath which seem to be only superficially the needy, be they near or far, virtuous connected or at least determined by or sinner, friend or ememy" (Ku- different moral standards. The first part 154 Bull. Ind. tnst. Hist. Med. Vol. XXV specifies the duties of the pupil towards give to a woman an abortive remedy. In his teacher and his teacher's family and purity and holiness Iwill guard my life and the pupil's obligations in transmitting my art" - such is the vow made in the medical knowledge. The second part Oath. gives a numberofrulesto be observed in the treatment of diseases, which could Poison is also a drug. All drugs have rather be called a short summary of got both beneficial effects (of course, medical ethics, as it were, at the time. with some tolerable and acceptable side- effects) when used rationally and also The Oath may be said to represent fatal or mortal effects when used in only the ancient ideal of the physician. excess and irrationally. The Oath forbids But, in contrast, charity motivated the the physician to assist his petient in a Christian doctors of the Dark Ages (400 suicide which he might contemplate. -1100 A.D.) and the Middle Ages (1100 Mortal accidents or suicides with over- - 1500 A.D) and duty to the community dose (drugs) are common in contempo- determines the working ethics of the rary medical practice, but doctorsdo not doctor of today. have any role in those misadventures. Doctors always refrain from any criminal Most ofthe statements contained in attempt on the patient's life. the document are worded in rather gen- eral terms. They are vague in their In over-dose cases, a drug may be commending of justice, of purity and considered as "Poison" in conformity holiness, concepts which do not imply with the concept in antiquity. any distinct meaning but may be under- stood in various ways. In contemporary medicine, Eutha- nasia has some fundamental relevance However, there are two stipulations to the administration of "poisons" to that have a more definite character and patients by physicians. re- seem to point the at basic beliefs un- fers to a medical act that deliberately derlying the whole ethical programme: shortens the life of a terminally and the rules concerning application of poi- seriously ill patient at his or her request son or abortive remedies. Their interpre- with the therapeutic help of a suitable tation should therefore provide a clue for drug; it is an act the primary intention of an ethical identification ofthe views em- which is to cause death. According to bodied in the Oath of Hippocrates. the Oath, it could be considered to be The Ethical Code asslstlnq in suicide orevan a criminal act Rules on Poison and Abortion on the part of the physician on the patient's life. But there is another side of "I will neither give a deadly drug to the story. The basic question is whether anybody if asked for it. Similarly Iwill not we accept their right ( autonomy in Ethical aspects of the Hippocratic Oath - Majumdar 155 modem vocabulary) to decide forthem- the Dutch Supreme Court gave the ver- selves ( the terminally and incurably ill dict that doctors can assist suicides of patients) how their lives will end, and depressed but otherwise physically health thereby ending the very painful agony patients (Time, 1994; BMJ, 1994). In which cannot be alleviated by any medi- accordance with this historic Dutch Ver- cal means available today. The back- dict, doctors in the Netherlands may bone of modern medical ethics is respect agree to requests for authanasia from for human life, and many doctors have patients who are neither terminally ill nor interpreted this as being the need to keep suffering physically. In this particular a patient alive at all costs and for as long case, incurable psychic pain was given as possible, even against the will of the due consideration. The time has come to patient concerned. Patients are some- give this care of an extraordinary nature times treated. even when the chances of - euthanasia - a solid legal and ethical success are very, very slight. This ap- basis, forthe benefit of both patients and proach might be an act of non-malefi- doctors alike; regulations are also re- cence in tune with the clause ofthe Oath. quired to safeguard against its abuse or But it does not agree with two other misuse (Heintz, 1994). Euthanasia can cardinal principles of "the Georgetown be part of good terminal care. The Oath, Mantra" - the autonomy of the patient in order to be relevant today, must also and beneficence (Beauchamp and march with the dynamic need of the Childress, 1989). Autonomy is best changing medical world. known in the history of medical ethics as the second form of Kant's "Categorical The Oath forbids the physician to Imperative": the moral obligation to treat give "pessary" to a woman, which was an every person as an end and never abortive remedy in antiquity. Most ofthe merely as a means. In a current form it Greek philosophers commended abor- is the requirement to respect the deci- tion. ForPlato (427 - 347 B.C.) foeticide sions of rational agents and thereby is one of regular institution of the ideal provides a rationale for informed con- state; whenever the parents are beyond sent, truth-telling and promise keeping. that age which they think best for the Beneficence is the obligation to provide begetting of children, the embryo should benefits and to balance benefits against be destroyed (Republic, V, 461 c; Laws, risks, incurable physical and psychic V,740d). pain in a terminally ill patient. Of course, in the backdrop ofthe Oath, the doctor is Aristotle (384 - 322 B.C.), a pupil of in a real dilemma. What is the way out? Plato at the Academy in Athens, reck- Relevant amendment ofthe Oath to sat- oned abortion the best procedure to keep isfy the demand of the d ay! In the debate the population within the limits which he over euthanasia, this particular clause of considered essential for a well-ordered the Oath seems to be obsolete. Recently, community (Politics, VII, 1335 b 20 ff). 156 Bull. Ind. tnst. His!. Med. Vol. XXV

This prescription for population control free of all intentional injustice, of all or family planning is not acceptable in a mischief and in particular of sexual rela- modem civilized society. Itwas different tions with both female and male persons, with the followers of Pythagoras (530 - be they free or slaves". 498 B.C.). Pythagoreans (followers of Pythagoras) held that the embryo was For the physicians, justice is the an animate being from the moment of obligation to be fair. The allocation of conception and hence abortion, when- scarce medical resources is an area ever practiced during pregnancy, meant where this principle takes force. In the destruction of a living being. current economic climate in health care Pythagoreans thus rejected abortion the physician is not always able to do unconditionally. The Hippocratic Oath, what the Oath tells him to do. Here, the in its abortion clause echoes Pythago- scope of the Oath seems to be limited. rean doctrines. It is fair to say that by Sexual relationship with patients some- dedication to the Hippocratic Oath, par- times causes concern. There are cases ticularly to the clause on abortion and of clear violation ofthis clause from time poison, physicians of antiquity (or of to time. Butthe General Medical Council, today) guarded "the purity and holiness the statutory body regulating the conduct of the Pythagorean way of life" (Plato, of doctors in the U.K., acts as the watch- Republic, X, 600b). dog in this matter and takes disciplinary action against doctors who are legally We have come a long way during the found guilty of inappropriate relation- last 2,500 years. Society today is much ships with their patients. more complex than it was in antiquity. The need and ideas on abortion also Medical confidentiality is the respect- changed to take meaningful notice of ing of patients' secrets by the treating those ever-increasing complexities in doctor regarding medical treatment and contemporary society. The institution of over-all management (including physi- abortion law, along with its periodic cal, social, psychological and occupa- amendments, changed abortion from tional origin of the disease). The prin- being a crime to being something entirely ciple of medical confidentiality is one of legal, under appropriate safeguards. It the most venerable medico-moral obliga- is a positive departure from the abortion tions of medical ethics. The Hippocratic clause in the Oath. Medical, social, Oath enjoins: "What I may see or hear psychological and psychiatric reasons in the course of the treatment or even demandsthatdeparture. ltismoral. Itis outside of the treatment in regard to the ethical. It is intunewith the times in which life of men, which on no account one we live. must spread abroad. Iwill keep to myself The clause on doctor-patient rela- holding such things shameful to be spo- tionship expects the doctor "to remain ken about". Even today, accordingtothe Ethical aspects of the Hippocratic Oath - Majumdar 157

World Medical Association's Interna- the Oath has also been questioned by tional Code of Medical Ethics, it is an non medical experts. Only the doctor is absolute requirement, even after the called upon to keep secret what he/she patient's death (SMA, 1984). learns about the lives of patients. This obligation is specific to medicine; it does In France, the obligation of medical not apply to the policemen. the journalist, confidentiality is stricter and is enshrined the biographer, or not with the same in law as an absolute medical privilege weight (Passmore, 1984). Itmight imply which no one, including the patient, is that a doctor's position in society is allowed to override, even when to do so unique in relation to health and disease. would be in the patient's interest (Havard, 1985). In the real world of General Rules Of The Ethical medical practice. doctors do face occa- Code sions where confidentiality needs to be broken for very valid reasons. Accord- The clause on treatment of diseases ingly, the SMA Handbook of Medical mentions dietetics first, drugs (pharma- Ethics lists five types of exceptions to cology) next and cutting (surgery) last. the need to maintain medical confidenti- The Oath enjoins: "I will apply dietetic ality (SMA, 1984) and the General Medi- measures for the benefit of the sick cal Council (GMC) lists eight (GMC. according-to my ability and judgement; I 1985). will keep them from harm and injustice ...... I will not use the knife, not even Medical confidentiality is an impor- on sufferers from stone .... ." tant medico-moral principle. It respects patients' autonomy and privacy. There Diet is still an important part of any are occasions when forthe greater inter- medical management; there were har- est of the patient, confidentiality may dly any drugs available for specific or need to be broken. It should not be made rational therapy in those days. Com- an absolute obligation. Exceptions ba- paratively, today's therapeutic sed on the principles of non-maleficence armamentarium is rich. The clause on and justice may well be justified in rel- "cutting" (surgery) needs to be ana lysed evant and suitable cases. Exceptions from the socio-historical context of the should also be considered in cases of time in question. From the Renaissance benefits of medical research for the (1500 - 1700 A.D;) down to the nine- greater interest of society; of course with teenth century, it was thought that the the prior consent of the patient, other- clause on "cutting" intends to draw a line wise it will violate the patient's autonomy. between the practice of internal medi- cine and that of surgery. In those days In the complex society of today, the surgery was held to be beneath the obligation of confidentiality enjoined in dignity of the physician (Th. Zwinger- 158 Bull. Ind. Inst. Hist. Med. Vol. XXV

Hippocratis Opera, 1579, p. 59). Howev- the Gr~ek God of diseases, poetic and er, this clause is obsolete today and musical inspirations, , the god hence not included in the International of healing, the son of Apollo and also the Code of Ethics. Even in the Middle Ages God of "Temple Medicine, and Hygeia, (1100-1500A.D.) "Surgeons" tended to Goddess of health, Panaceia, Goddess do the job part-time and treated only of nourishment - both daughters of minor wounds. Their main job would Asclepius. This dynastic ritual is out-of- have been as a barber or a butcher, and date and not acceptable today. Greek the most popular cure was blood-letting. mythology has no role to play in modern Frequent wars during the Middle Ages life. meant that some surgeons were able to practise. Surgery was not taught in most The International Code is secular medical schools of the day. Salerno's and universal in character and excluded (near Naples in Italy) medical school was all religious references. The Code en- the only place in the Dark Ages ( 400 - joins: "I solemnly pledge myself to con- 1100 A.D.) where anatomy and surgery secrate my life to the service of human- were taught was an integral part of the ity." The Code stipulates the duties of curriculum. Salerno was the first place physicians in general, their duties to the to use the term "Doctor of Medicine". In sick and also to each other. those days, associations (company) of barber-surgeons were also formed in Additions And Modifications Over London (14th century) and in Edinburgh The Years (1505). Thetradition of barber-surgeons is now an interesting piece of relic in the The Hippocratic Oath is the basic evolution of modern medicine. foundation. Overthe years various dec- larations of the World Medical Associa- In ancient Greece, medicine like all tion (WMA) made necessary and rel- other arts and crafts was passed on from evant additions to the Hippocratic Oath fatherto son in closed family guilds. The in orderto make it useful to the practising Oath enjoins: " to give share of modern physician. The main features of precepts and oral instruction and all the the additions are summarized below other leaming to my sons and to the sons (Gillon,1992). of him ". This amounts to perpetua- tion of a dynastic trend, which is no The (1048, longer acceptable in a modern civilized revised 1968 and 1983) is a sort of society. Accordingly, this clause was updated version of the Hippocratic rightly excluded from the International Oath. It requiresthe doctorto consecrate Code of Ethics. The dedication of the his life to the service of humanity; to make Oath has also been amended. The "the health of my patient" his first con- Hippocratic Oath is dedicated to Apollo, sideration; to respect his patient's se- Ethical aspects of the Hippocratic Oath - Majumdar 159 ".) crets (even after the patient's death); to The Declaration of lisbon (1981) prevent "considerations of religion, na- concerns the rights ofthe patient. These tionality, race, party politics, or social are declared to include the rights to standing (intervening) between my duty choose his or her physician freely; to be and my patient"; to "maintain utmost cared for by a doctor whose clinical and respect for human life from its begin- ethical judgements are free from outside ning" (until 1983 the wording of this interference; to accept or refuse treat- clause required" utmost respect for hu- ment after receiving adequate informa- man life from the time of conception") tion; to have his or her confidences and not to use his medical knowledge" respected; to die in dignity; and to re- contrary to the laws of humanity" ceive ordecline spiritual and moral com- fort including the help of a minister of an The wor1d Medical Association's in- appropriate religion. ternational code of medical ethics, adopted in London in 1949 and revised The Declaration of Sydney (1968, in 1968and 1983, requires, among other revised 1983), on death, states among things, adherence to the Declaration of otherthings that" clinical interest lies not Geneva, the highest professional stan- in the state of preservation of isolated dards, clinical decision uninfluenced by cells but in the fate of a person" and it the profit motive, honesty with patients stipulates the much more specific rule and colleagues and exposure of incom- that when transplantation of a dead petenland immoral colleagues. It states person's organs is envisaged determina- that" a physician shall owe his patients tion of death should be by two doctors complete loyalty and all the resources of unconnected wit;l the transplantation. his science"; and it says that'" a physi- cian shall preserve absolute confidenti- The Declaration of Oslo (1970, re- ality on all he knows about his patient vised 1983), on abortion, remains, even even after the patient has died. after its recent revision, which changed "human life from conception"to "human The (1964, life from its beginning", the most equivo- revised 1975 and 1983) governs bio- cal of all these dceclarations for it re- medical research in human subjects, quires doctors both to maintain the ut- and among its many principles is the most respect for human life from its stipulation that " the interests of the beginning and to accept that attitudes subject must always prevail over the towards the life of the unborn child are interests of science and society". It also diverse and" a mater of individual con- requires that in any research the doctor viction and conscience which must be should" obtain the subject's freely given respected". Subject to a host of qualifi- ". cations the declaration has afwayssanc- tioned therapeutic abortion. .\,. 160 BUll. Ind. Ins/. Hist. Med. Vol. XXV

The Declaration of Tokyo (1975, ofthe doctor to heal and,. when possible, revised 1983), on torture, is unequivocal relieve suffering and sanctions the with- in forbidding doctors to "countenance, holding of treatment in terminal illness condone, or participate in the practice with the consent of the patient or, if the of torture or other forms of cruel, inhu- patient is unable to express his will, that man, or degrading procedures". It also of the patient's immediate family. It forbids force feeding of mentally compe- allows the doctorto "refrain from employ- tent hunger strikers. ing any extraordinary means which would prove of no benefit forthe patient" The Declaration of Hawaii (1977, and permits the maintenance of organs revised 1983), on psychiatric ethics, for transplantation after death has been requires inter alia: that patients be of- certified, given certain conditions. fered the best treatment available t1nd be given a choice when there is more In addition to these declarations, the than one appropriate treatment; that World Medical Association has issued compulsory treatment be given only if other statements about medical ethics: the patient lacks the capacity to express on discrimination in medicine, reiterat- his wishes, or, owing to psychiatric ill- ing its abhorrence of such discrimination ness, cannot see what is in his best on the basis, of religion, nationality, race, interests or is a severe threat to others; colour, politics, or social standing; on that there must be an independent and medical secrecy, affirming. the indivi- neutral appeal body for those treated dual's fundamental right" to privacy; and compulsorily; that ''the psychiatric must on the use of computers in medicine, not participate in compulsory psychia- again affirming the patient's right to pri- trist treatment in the absence of psychi- vacy but stating that the transfer of infor- atric illness"; that information about mation rendered anonymous forthe pur- patients must be confidential unless the pose of research is not a breach of patient consents to its release" or else confidentiality. Other statements con- vital common values orthe patient's best cern medical regulations in time of ar- interest make disclosure imperative"; med conflict, family planning,12 prin- that informed consent for the patient's ciples of provision of health care, pollu- participation in teaching must be ob- tion, the principles of health care for tained ; and that" in clinical research as sports medicine, recommendations con- in therapy every subject must be offered cerning boxing, physician participation the best available treatment. .. be subject in capital punishment, medical man to informed consent, " and have the right power and medical care in rural areas. to withdraw at any time. The Suggested Update The Declaration of Venie>e (1983), The Hippocratic Oath enunciated about the most recent declaration of the World 2500 years ago was almost certainly a Medical Association, reiterates the duty temple Oath written by various Asclepi- Ethical aspects of the Hippocratic Oath - ,:1ajumdar 161 ads (medical/temple priests) ratherthan Iwill be empathetic to patients suffer- Hippocrates himself. Despite vast ing from illnesses caused by substances changes in medical and social structure such as alcohol or drugs, or other forms during-the past 25 centuries, the original of self abuse usually believed to be under has been passed unmodified to a great the voluntary control of humans. extent from generation to generation of doctors. Fordebate and discussion, the Knowing my own inadequaces and following updated version of the Oath those of medicine generally, I will strive has recently been suggested (Robin, to cure when possible but to comfort 1994); always.

"In the name of suffering humanity, I shall perform medical tests only if I with humility, compassion and dedica- believe there is a reasonable chance tion to the welfare ofthe sick according that the results will help produce an to the best of my ability and judgment, I improved outcome for my patients. will keep this oath and stipulations. Iwill not perform any tests or proce- Iwill be honest with my patients in all dures or surgery solely to make money. medical maters. When this honesty re- I will freely refer my patient to other veals bad news Iwill deliver it with under- physicians if I am convinced that they standing and sympathy and tact. are better able than I to treat a given patient problem. Iwill provide my patients with accept- able alternatives for various forms of Iwill freely furnish copies of medical diagnosis, and medical and surgical recordsto patients ortheirfamilies upon treatment, explaining the risks and ben- request. efits of each alteranative as best I ;"now it. Iwill do unto patients and theirfami- I will allow my patients to make the lies only what Iwould want done unto me ultimate decision about their own care. or my family. I will not experiment on In circumstances where my patients are patients unless the patients give truly incapable of making decisions I will ac- informed consent. Iwill strive to instruct cept the decision of family members or patients fully so theirtruly informed con- loved ones, encouraging these surro- sent is possible. gates to decide as they believe the patient would have decided. I will remain a student all my profes- sional life, attempting to learn not only Iwill not sit in moral judgment on any from formal medical sources but from my patient, but will treat their illness to the patients as well. best of my ability regardless of the cir- Iwill attemptto function as a teacher for cumstances. my patients so that I can care for them 162 Bull. Ind. lnst. His!. Med. Vol. XXV more effectively and can apply the les- ers of Temple Medicine) - rather itinerant sons they provide to the care of other craftsmen who carried their skill from patients. place to place, establishing in each a surgery. People in general did not have I will provide care to all patients any choice and had to accept whatever seeking it, regardless of sex, race, was available in the form of medical colour, creed, sexual preference, advice or treatment. The question of lifestyle, oreconomicstatus. In particu- personal choice or autonomy of patients lar, I will volunteer some of my time to did not arise. Autonomy is best known in providing free care to the poor, the home- the history of ethics as the second form less, the disadvantaged, the dispos- of Kant's Categorical Imperative: the sessed and the helpless. moral obligation to treat every person as an end and never merely as a means. In Iwill turn away no patient, even those a current form it is the requirement to with dreaded contagious diseases like respect the decisions of rational agents AIDS. and thereby provides a rationale for informed consent, truth telling and prom- I will encourage my patients to seek ise keeping. There was no scope forthe medical opinions other than my own concept of autonomy in the Oath. It is before agreeing to accept my opinion. entirely a modern concept for a modern sophisticated society. I will treat my professional collea- gues with respect and honour; but I will Beneficence is the obligation to pro- not hesitate to testify openly about phy- vide benefits and to balance benefits sicians and medical institutions that against risk. It echoes the philosophy of are guilty of malpractice, malfeasance, the Oath - " Iwill use treatment to help cupidity or fraud. the sick according to my ability and judgment, but never with a viewto injury I will defend with equal fervour col- and wrongdoing. Neitherwill Iadminister leagues who are unjustly accused of a poison to anybody when asked to do malpractice, malfeasance, cupidity or so, nor will I suggest such a course". fraud". Thus, non-maleficence in tllis way cap- Conclusion tures the intuitions behind tlie Hippocra- . tic maxim to do no harm to patients. The Hippocratic Oath offers only a traditional framework. It needed to be The last principle - justice- is the amended according to the demands of obligation to be fair. This is an Aristote- the day from time to time. lian concept and not a Hippocratic one. The Hippocratic physicians The principle of justice or equality attrib- ("Iatroi,,) were in fadAsclepiads follow- uted to Aristotle is that equals should • Ethical aspects of the Hippocratic Oath - Majumdar 163 be treated equally and unequals unequ- brought new ethical dilemmas. Abor- ally in proportion to the relevant inequali- tion, euthanasia, embryo research for ties. In the contemporary medical mar- various purposes, genetical engineering ket, a fair distribution of benefits may are some of the pertinent question in seem to be duty more on managers and modem medical practice today. Discus- policy makers, than on individual doctors sions of "medical ethics" , "bioethics" or nurses. This is a new situation not and "health policy ethics" have prolifer- envisaged in antiquity and hence is not ated, nor only among those directly in- even mentioned in the Oath. volved in scientific research or the pro- visions of health care but also in univer- In antiquity, the Oath was adminis- sity departments of philosophy, theol- tered secretly to members of the Guild ogy, Jaw, economics and sociology. ("Koinon" - Greek), who were selected Experts in these fields have contributed by descent from doctorfather to son, or. greatly to the debate and dispelled the by marriage (son-in-law) or by socially impression that medical ethics is some- approved adoption. Hippocrates's thing which only interests those working grandfather and fatherwere Guild mem- directly to provide health care. Many bers before him, as were his two sons issues will not be solved by doctors and hisson-in-Iawafterhim. This heredi- alone. That is why the British Medical tary and secretive practice is totally ob- Association welcomes wider informed solete today and unacceptable. Today, public discussion of medical ethical the Oath is administered publicly to new problems as the most helpful way for- medical graduates all over the world. ward. This is a new situation. It demands Thus, the medical world of today has a different approach. moved far away from that secretive Hippocratic tradition. It is a sign of Summary enrichment, advancement and magna- nimity of the epic Oath. The modemised The Greek physician of antiquity - version of the Hippocratic Oath - the Hippocrates (460 - 357 B.C) is consid- International Code of Ethics, seems to ered to be the "Father of Modern Medi- be a compatible combination of the cine". For centuries the Hippocratic Oath Hippocratic concept of " do good - no was the example of medical etiquette harm "to patients (beneficence and non- and, as such, determined the profes- maleficence), Kantian concept of au- sional attitude of physicians. The tonomy and the Aristotelian concept of Hippocratic Oath clearly falls into two justice. parts. The first part specifies the duties of the pupil towards his teacher and his The progress of biomedical sci- teacher's family and the pupil's obliga- ences and medical technology and their tions in transmitting medical application of medical practice has 164 Bull. Ind. Inst. Hist. Med. Vol. XXV

The second part gives a set of rules is now known as the International Code to be observed in the treatment of dis- of Medical Ethics. Subsequently, the eases - rather a short summary of medi- WMA has published a wealth of material cal ethics. This essay includes a short on a numberof important ethical matters biographical account of Hippocrates, modern medicine is facing today. throws some light on the origin of the Oath, cites the text of the Oath (In En- The central strand in health care glish) and gives an ethical interpretation ethics today is what is known as "the of the Oath. Overthe past 2500 years the Georgetown Mantra" containing the world of science, philosophy and medi- four principles- autonomy, beneficence, cine has undergone radical transforma- non-maleficence and justice. Ofthe four tions. Old impressions about human principles, beneficence and non-ma- health and disease silently slipped into leficence echo the philosophy of the oblivion and new realities have appeared Hippocratic Oath, but autonomy and jus- on the horizon of medical science. In tice are totally non-Hippocratic concepts view of these transformations, this essay in medical ethics. Autonomy has ema- makes an attempt to assess the rele- nated from Kant's Categorical Impera- vance of the ethics of the Hippocratic tive and justice is purely an Aristotelian Oath to the ethical problems modern concept. The society is dynamic and not physicians are facing today. Analysis of stagnant; bio-medical profiterns are pro- the past very often offers creative guid- liferating; periodic relevant amendments ance to the present and also to the future, of the Oath and of its successor - the and the Hippocratic Oath is no exception. International Code of Ethics - have been The World Medical Association (WMA), made from time to time, This need for formed in 1947, produced a modern re- amendments will remain an on-going statement ofthe HippocraticOath, which process. Ethical aspects of the Hippocratic Oath - Majumdar 165

APPENDIX - I International Code Of Medical I will maintain the utmost respect for Ethics human life from its beginning even under threat and I will not use my medical One of the first acts of the World knowledge contrary to the laws of hu- Medical Association, when formed in manity; 1947, was to produce a modern restate- I make these promises solemnly, freely ment of the Hippocratic Oath, known as and upon my honour. the Declaration of Geneva, and to base The English text of the International upon it an International Code of Medical Code of Medical Ethics is as follows: Ethics which applies in time of both peach and war. The Declaration of Duties of physicians in general Geneva, as amended by the 22nd World A PHYSICIAN SHALL always maintain Medical Assembly, Sydney" Australia, the highest standards of professional in August 1968 and the 35th World conduct. Medical Assembly, Venice, Italy, in Oc- A PHYSICIAN SHALL not permit mo- tober 1983, reads: tives of profit to influence the free and independent exercise of professional At the time of being admitted as a mem- judgement on behalf of patients. ber of the Medical Profession: A PHYSICIAN SHALL, in all types of I solemnly pledge myselfto consecrate medical practice, be dedicated to pro- my life to the service of humanity; viding competent medical service in full Iwill give to my teachers the respect and technical and moral independence, with gratitude which is their due; compassion and respect for human dig- nity. I will practise my profession with con- science and dignity; A PHYSICIAN SHALL deal honestly The health of my patient will be my first with patients and colleagues, and strive to consideration; expose those physicians deficient in I will respect the secrets which are character or competence, or who en- confided in me, even after the patient has gage in fraud or deception. died; The following practices are deemed to I will maintain by all the means in my be unethical conduct: power, the honour and the noble tradi- a) Self advertising by physicians, unless tions of the medical profession; permitted by the laws of the country and My colleagues will be my brothers; the Code of Ethics of the national medi- I will not permit considerations of reli- cal association. gion, nationality, race, party politics or b) Paying or receiving any fee or any social standing to intervene between my other consideration solely to procure the duty and my patients; referral of a patient or for prescribing or 166 Bull. Ind. Ins!. Hist. Med. Vol. XXV referring a patient to any source. physician's capacity he should summon A PHYSICIAN SHALL respect the rights another physician who has the neces- of patients, of colleagues, and of other sary ability. health professionals, and shall safeguard A PHYSICIAN SHALL preserve absolute patient confidences. confidentiality on all he knows about his A PHYSICIAN SHALL act only in the patient even after the patient has died. patient's interest when providing medical A PHYSICIAN SHALL give emergency care which might have the effect of care as a humanitarian duty unless he is weakening the physical and mental con- assured that others are willing and ableto dition of the patient. give such care. A PHYSICIAN SHALL use great caution in divulging discoveries or new tech- Duties of physicians to each other niques ortreatment through non-profes- sional channels. A PHYSICIAN SHALL behave towards A PHYSICIAN SHALL certify only that his colleagues as he would have them which he has personally verified. behave towards him.

Duties of physicians to the sick A PHYSICIAN SHALL NOT entice pa- tients from his colleagues. A PHYSICIAN SHALL always bear in mind the obligation of preserving hu- A PHYSICIAN SHALL observe the prin- man life. A PHYSICIAN SHALL owe his ciples of "The Declaration of Geneva" patients complete loyalty and all the re- approved by the World Medical Associa- sources of his science. Whenever an tion. examination ortreatment is beyond the Ethical aspects of the Hippocratic Oath - Majumdar 167 REFERENCES

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17. The Time International 1994 Ethics: killing the psychic Pain. 144:71 (July, 4 - Report by ATovfexis). Ethical aspects of the Hippocratic Oath - Majumdar 169 mmr

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