Reflections on the Hippocratic Oaths

Author(s): June Goodfield

Source: The Hastings Center Studies, Vol. 1, No. 2, Values, Expertise, and Responsibility in
the Life Sciences (1973), pp. 79-92
Published by: The Hastings Center
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 CODES, MORALITY, LAW, & PROFESSIONALIZATION

Reflections
on the
Hippocratic Oaths
JUNE GOODFIELD

that more and more people have begun

to appreciate the force of Santayana's
dictum: "Those who ignore the lessons
of history are doomed to repeat it."
It is quite clear that the issue of medi-
cal ethics, medical etiquette, and the re-
S OMETIME during
lationship of the profession to society at
the early Twenties, Chauncey Leake,
large presently raises questions of such
according to his own accounts, was col-
depth and importance that it would be a
lecting material for a study on the his-
torical development of medical ethics. foolish doctor who would try to sweep
them aside. Nevertheless, even if he
He asked Dr. Maurice Fishbein, Editor
agreed about the importance of medical
of the Journal of the American Medical
ethics, he might still agree with Fishbein's
Association, for an opinion of the merits
comments, feeling that a historical survey
of such a project. Dr. Fishbein's reply,
is of no value in the consideration of his
as reported in the Preface to Chauncey
own situation and dilemmas. I am not so
Leake's edition of Percival's Medical
certain. We tend to think of our own
Ethics, is classic: "Unnecessary and of
social situation as simple, unique, and
no significance for an understanding of
static. Such an attitude comes naturally
the matter . . ."1 If this anecdote is true,
because it provides such an easy way to
it tells us that the medical profession
deal with difficulties. If the problem of
shared with the scientific profession a
contemporary medical ethics is both sim-
typical attitude toward historical studies,
ple and acultural then we can get away
namely, that in no way have they utility with a facile and universal solution. Since
or relevance to the practice of the craft,
most of us are lazy-minded and just want
and are best left to members of the pro-
to go on doing that which we enjoy doing
fession, when retired. It is only recently
most, i.e., practicing medicine and earn-
ing money, it is tempting to ignore the
1Thomas Percival, Medical Ethics, ed. and
problem.
introd. by Chauncey Leake (Baltimore: Wil-
liams and Williams, 1927 [originally published But history teaches us important things,
Manchester: 1803]). such as how rarely situations are simple;

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 80 HASTINGS CENTER STUDIES
how most problems of professional activi-
ties, with their concomitant questions of
ethics and accountability, arise not in a
vacuum, but in response to the demands
of a social situation. This, in its turn,
tells us that our response to contemporary
ethical problems must be made in the
light of our existing situation, and this
we must understand, analyze, and ap-
preciate, before we can hope to deal with
such problems effectively. In addition, if
there is a degree of relativism in our his-
torical situation, there is also a similar
degree of relativism across our cultures.
Recognition of relativism in history and
through culture does not, of course, imply
that there can be no answers to contem-
porary problems. Rather it implies that
there can be no universal answers which
would be equally applicable throughout-
time and across the space of different
societies. This again is no comfort for
the lazy-minded, for it means that if we
wish to consider the problems of say,
birth control, euthanasia, and artificial
transplants, we shall have to consider
them anew for such disparate societies as
those of North America, India and South
Vietnam.
My intention here, in this rather light-
hearted essay, is to look at some of the
variant forms of the Doctor's Oath, and
see what questions they raise about med-
ical ethics. These are not new issues, but
in reexamination we might note the par-
ticular force or validity they have in our
twentieth-century situation, and perhaps
incidentally demonstrate the teaching
value of history. For it is quite clear that
problems of medical ethics and medical
etiquette are closely bound up with prob-
lems of the professionalization of medi-
cine. As Chauncey Leake pointed out in
1927, when we study the evolution of the
present situation with regard to medical
ethics, then it may become clearer why
it is that the profession resists efforts to
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change its present relation to society.2
But where did all this start? I want to
look initially at the variations in the Oath
that was taken by doctors during the
years when the profession was emerging
and see where this variety originated and
what effects it might have had. The
classic work was done by W. H. S.
Jones. He wrote the definitive studies on
the various forms of the Oath and was,
in the 1920's, the recognized authority
on Hippocrates.3 As Jones points out,
there was no verbal fidelity in the preser-
vation of the Hippocratic text. Provided
the general sense came across, no one
worried about literal faithfulness. By con-
trast with the reverent attitude which kept
the texts of many classical authors com-
paratively pure, the Hippocratic material
was treated in a cavalier manner, prob-
ably because these works were textbooks,
with no pretention to be literary master-
pieces. Words get transposed, interpola-
tions are very common, and there are
losses of phrase and meaning. The rea-
son for this may lie in the changing cul-
tural context of medical problems. Un-
21 shall be arguing in a later series of papers,
that there are, indeed, common elements in all
professions whose tendencies increase the mem-
bers' reluctance to alter the "social contract"
with society. This has a great deal to do with
the process by which the social contract
evolved; until very recently, I believe, society
has been the weaker partner and many profes-
sions dislike and mistrust what they see as a
new interference in tradition hallowed by time.
This point, incidentally, also demonstrates the
value of a historical perspective on these prob-
lems. Without it, we would be tempted to
regard doctors and scientists as merely reac-
tionary.
3W. H. S. Jones, The Doctor's Oath: An
Essay in the History of Medicine (Cambridge,
Eng.: Cambridge University Press, 1924). Un-
less stated otherwise, this book is the source
for my various versions of the Oath. I make
no claim for any originality in the bulk of this
paper; it rests heavily on the historical work of
others and the stringent and valuable criticism
offered by participants in the humanities project
of the Institute of Society, Ethics and the Life
Sciences.
 THE HIPPOCRATIC OATHS 81
like, for example, a commentary on
Aristotle, the Hippocratic Oath had a
very clear-cut function for doctors-
though not for society-in defining their
relationship to society. The interpolations
and modifications in the text can, without
too much distortion, be seen as responses
to the different social matrices in which
the Doctor's Oath played a part, showing
us a process whereby an institution is
modified to meet a changing social or
ideological demand. In this sense, the
Oath was a tool, not a scholarly work,
and as such had and has no more claims
for immutability than a legal judgment
presently has in English or American
society.
The earliest recorded copy of the Oath
is in the Vatican Library, and comes from
the tenth or eleventh century. It is not the
earliest form for it is the Oath modified
so that "a Christian may take it." The
earliest form, the Pagan Oath, comes
from a fourteenth-century manuscript
and reads as follows:
I swear by Apollo Physician, by
Asclepius, by Health, by Heal-all, and
by all the gods and goddesses, making
them witnesses, that I will carry out,
according to my ability and judgment,
this oath and this indenture:
To regard my teacher in this art as
equal to my parents; to make him part-
ner in my livelihood, and when he is
in need of money to share mine with
him; to consider his offspring to equal
my brothers; to teach them this art, if
they require to learn it, without fee or
indenture; and to impart precept, oral
instruction, and all the other learning,
to my sons, to the sons of my teacher,
and to pupils who have signed the in-
denture and sworn obedience to the
physician's Law, but to none other.
I will not give poison to anyone
though asked to do so, nor will I sug-
gest such a plan. Similarly I will not
give a pessary to a woman to cause
abortion. But in purity and in holiness
I will guard my life and my art.
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I will not use the knife either on
sufferers from stone, but I will give
place to such as are craftsmen therein.
Into whatsoever houses I enter, I
will do so to help the sick, keeping
myself free from all intentional wrong-
doing and harm, especially from forni-
cation with woman or man, bond or
free.
Whatsoever in the course of practice
I see or hear (or even outside my
practice in social intercourse) that
ought never to be published abroad, I
will not divulge, but consider such
things to be holy secrets.
Now if I keep this oath and break
it not, may I enjoy honor in my life
and art, among all men for all time;
but if I transgress and forswear myself,
may the opposite befall me.
Notice how already there is a distinc-
tion between the doctor and the surgeon.
Probably the sentence "I will not use the
knife either on sufferers from stone,"
should, Jones suggests, read, "I will not
use the knife even on sufferers from
stone." The injunction is, "leave this to
the operative craftsman."
Now let us look at the Oath, modified
"insofar as a Christian could swear it."
Blessed by God the Father of our
Lord Jesus Christ, who is blessed for
ever and ever; I lie not.
I will bring no stain upon the learn-
ing of the medical art. Neither will I
give poison to anybody though asked
to do so, nor will I suggest such a plan.
Similarly I will not give treatment to
women to cause abortion, treatment
neither from above nor from below.
But I will teach this art, to those who
require to learn it, without grudging
and without indenture. I will use treat-
ment to help the sick according to my
ability and judgment. And in purity
and in holiness I will guard my art.
Into whatsoever houses I enter, I will
do so to help the sick, keeping myself
free from all wrongdoing, intentional
or unintentional, tending to death or
to injury, and from fornication with
 82 HASTINGS CENTER STUDIES
bond or free, man or woman. What-
soever in the course of practice I see
or hear (or outside my practice in
social intercourse) that ought not to
be published abroad, I will not divulge,
but consider such things to be holy
secrets. Now if I keep this oath and
break it not, may God be my helper in
my life and art, and may I be honored
among all men for all time. If I keep
faith, well, but if I forswear myself
may the opposite befall me.
The three main modifications, besides.
of course, the disappearance of the pagan
deities, are interesting and instructive.
The first one relates to the question of
abortion. Where doctors undertake not
to give treatment to women to cause
abortion, the clause "Treatment neither
from above nor from below," is added to
the sentence. This clause was, perhaps,
inserted as an effective counter-measure
against those who thought they could still
hold to the Oath if they used means
other than a pessary to cause abortion.-'
Written injunctions are fine but there are
always loopholes! Secondly, notice that
unintentional harm is just as forbidden as
intentional harm. The notion of criminal
negligence has entered in for the first
time. Thirdly, there is no lengthy de-
scription of those to whom medical
knowledge should be imparted-to this
point I will return.
The Arabic Oath
The Oath passed into the Arabic
through Syriac, and is found in this form
4Has something-an extra clause or phrase,
perhaps-been transposed or dropped in this
translation? For the phrase, "But I will teach
the art.. ." placed now next to the abortion
clause reads as though it referred to the teach-
ing of abortion. In all other versions it is
placed in a less ambiguous position. This trans-
position was surely not intentional. The hy-
pothesis that it is due to careless copying on
the part of a sleepy monk is, for my money,
the most likely explanation.
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in the Lives of Physicians, written by Ibn
abi Usaybia. This dates from the middle
part of the thirteenth century, and it was
Ibn abi Usaybia who was possibly the
first to suggest that the Oath originated
not so much to protect society or even
the reputation of the individual physician,
but to protect the reputation of the
school. The Schools of Greek Medicine
were hereditary schools and it could well
be that when it was found necessary to
admit outsiders, then Hippocrates ad-
ministered an oath-before admission
rather than after qualifying-in order to
secure candidates of a suitable character.
The Arabic version of the Oath is as
follows:
Hippocrates said: I swear in the
name of God, the Master of life and
death, the Giver of health and Creator
of healing and of every treatment, and
I swear in the name of Aesculapius,
and of all the holy ones of God, male
and female, and I call them to witness,
that I will fulfill this oath and these
conditions. I will regard my teacher
in this art as my father, I will share
with him my means of livelihood and
I will make him my partner in my
wealth, and I will give him my wealth
whenever he may be in need of it.
As for his descendents, I regard
them as my brothers, and I will teach
them this art without any remuneration
or condition, should they desire to
learn it. And I associate together (i.e.
regard as equal), in the injunctions
and in the sciences and in all else
contained in the art, my own children,
the children of my teacher, and the
disciples on whom the oath (or cove-
nant) has been imposed, and who
have sworn to observe the medical
code of honor. And I will not do so for
any other than these.
In all my treatment I will strive so
far as lies in my power for the benefit
of the patients. And I will restrain my-
self from things which are injurious
to them, or are likely in my opinion
to do them harm. And I will not give
them any poisonous drug if they ask
 THE HIPPOCRATIC OATHS 83
for it, nor will I advise them thus.
Nor will I contemplate administering
any pessary which may cause abortion.
And in my treatment and in the prac-
tice of my art I will keep myself pure
and holy. And I will not operate on
those who have stone in the bladder;
rather I will leave it for those whose
profession it is. And I will enter every
abode into which I may go only for
the benefit of the sick, being in a state
devoid of (all deliberate intention of)
wrong-doing, injustice, mischief-mak-
ing, such as might be intended in other
transactions, or in respect of sexual
relations with woman or man, whether
free or slaves.
And as for the things which I may
see or hear during the time of treating
the sick, or at times other than those
in which I am so engaged, about such
behaviour of men as should not be
talked of outside, I will keep silence,
considering that such things should not
be discussed.
He who fulfills this oath and does
not violate any part of it, to him will
it be granted to carry out his treatment
and his art under the most excellent
and favorable conditions, and to be
praised by all men in future for ever;
while the contrary will be the portion
of him who transgresses it.
To complete this potted tour around
doctors' oaths we can take in a couple
of variations, this time based upon an
Indian theme. The first form is found in
the old medical books of India, as ad-
dresses to students; while calling for a
high degree of moral rectitude on the
part of the doctor with regard to his
own behaviour, the injunctions demand,
too, a high degree of moral judgment with
regard to the behaviour of others! To
insist that a doctor must refuse to treat
a "hunter" or a "fowler" surely must be
seen in the light of the Buddist belief in
the sanctity of all life-not only human.
Thou shalt renounce lust, anger,
greed, ignorance, vanity, egotistic feel-
ings, envy, harshness, niggardliness,
falsehood, idleness, nay all acts that
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soil the good name of man. In proper
season thou shalt pare thy nails and
clip thy hair and put on the sacred
cloth, dyed brownish yellow, live the
life of a truthful self-controlled an-
chorite, and be obedient and respectful
towards thy preceptor. In sleep, in rest,
or while moving about-while at meals
or in study, and in all acts thou shalt
be guided by my directions... Thou
shalt help with thy professional skill
and knowledge, the Brahmanas, thy
elders, preceptors and friends, the in-
digent, the honest, the anchorites, the
helpless and those who shall come to
thee from a distance, or those who
shall live close by, as well as thy rela-
tions and kinsmen, to the best of thy
knowledge and ability, and thou shalt
give them medicine without charging
for it any remunerations whatever, and
God will bless thee for that. Thou shalt
not treat medicinally a professional
hunter, a fowler, a habitual sinner, or
him who has been degraded in life; and
even by doing so thou shalt acquire
friends, fame, piety, wealth and all
wished-for objects in life, and thy
knowledge shall gain publicity.
The second, the Oath of Charaka, ac-
cording to Mohan Lal Sharma, has re-
cently received much prominence in the
Indian Press, and is administered by the
guru to a disciple.
Thou shalt speak only the truth, eat
no meat, eat only pure articles of food,
be free from envy and carry no arms.
There shall be nothing that thou shalt
not do at my behest, except hating
the king or causing another's death or
committing an act of unrighteousness.
Day and night, however thou may-
est be engaged, thou shalt endeavour
for the relief of patients with all thy
heart and soul. Thou shalt not desert
or injure thy patient ever for the sake
of thy life or thy living. Thou shalt not
commit adultery even in thought. Thou
shalt not covet others' possessions.
Thou shalt be modest in thy attire and
appearance. Thou shouldst not be a
drunkard or a sinful man nor shouldst
thou associate with the abettors of
 84 HASTINGS CENTER STUDIES
crime. Thou shouldst speak words that
are gentle, pure and righteous, pleas-
ing, worthy, true, wholesome and mod-
crate. Thy behavior must be in keeping
with the time and place and heedful
of past experience. Thou shalt act al-
ways with a view to acquiring knowl-
edge and fullness of equipment.
No offering of presents by a woman
without the behest of her husband or
guardian shall be accepted by thee.
While entering the patient's house thou
shall be accompanied by a man who
is known to the patient and who has
his permission to enter and thou shalt
be well clad and bent of head, self-
possessed and conduct thyself thought-
fully. Thou shalt make thy entry in
the proper way. Having entered, thy
speech, mind, intellect and senses shall
be entirely devoted to no other thought
than to that of being helpful to the
patient and of things concerning him
only. The peculiar customs of the
patient's household shall not be made
public. Though possessed of knowl-
edge, thou shalt not boast very much
of thy knowledge. Most people are
offended by the boastfulness of even
those who are otherwise good and
authoritative.-)
Finally, let us compare these earlier
forms with the Oath as presently sworn
at Montpellier and Glasgow Universities,
both of which have old and renowned
schools of medicine.
The Montpellier Oath. In the pres-
ence of the masters of this school, of
my dear fellow-students and before the
image of Hippocrates, I promise and
I swear, in the name of the Supreme
Being, to be faithful to the laws of man
and of honor in the exercise of medi-
cine. I will give my services without
fee to the needy, and I will never
exact a higher fee than my work de-
serves. When I am admitted inside
houses, my eyes shall not see what goes
5Mohan Lal Sharma, "Oath of Charaka,"
New York State Journal of Medicine, 71 (Oc-
tober 15, 1971), p. 2457.
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on there, and my tongue shall be silent
about the secrets which shall be en-
trusted to me, and I will not abuse my
position to corrupt morals or to en-
courage crime. Respectful and grateful
towards my masters, I will give back
to their children the instruction that I
have received from their fathers. May
men grant me their esteem if I am
faithful to my promises. May I be
covered with shame and despised by
my fellows if I fall short.
The Glasgow Oath. I do solemnly
and sincerely declare that, as a Grad-
uate in Medicine of the University of
Glasgow, I will exercise the several
parts of my profession, to the best of
my knowledge and abilities, for the
good, safety, and welfare of all persons
committing themselves, or committed
to my care and direction; and that I
will not knowingly or intentionally do
anything or administer anything to
them to their hurt or prejudice, for any
consideration, or from any motive
whatever. And I further declare that
I will keep silence as to anything I
have seen or heard while visiting the
sick which it would be improper to
divulge.
And I make this solemn declaration
in virtue of the Provisions of the
Promissory Oaths Act, 1868, substitut-
ing a Declaration for Oaths in certain
cases.
II
The Oath in all its forms represents
"those noble rules of conduct, loyal
obedience to which has raised the art of
medicine to the high position it now
holds." This statement, the opinion of W.
H. S. Jones, carries overtones of nobility,
sublimity, and aspiration worthy of Prince
Albert. I, however, take a somewhat cyn-
ical view of the matter.
What we don't know, for instance, is
what, if any, were the sanctions to be
imposed against someone who broke the
Oath. Were there any penalties at all?
Did all students swear or only those that
 THE HIPPOCRATIC OATHS 85

belonged to a definite guild or school?

Was it ever actually administered, or, like
the Sermon of the Mount, merely held
up as a counsel of perfection? There was
no General Medical Council, and it has
often been suggested that a doctor who
transgressed the Oath was not punished
unless, in fact, he actually sinned against s Galen
the civil or criminal laws of the state. One
enchanting piece in the Hippocratic col- tells us, there was never
lection, called Law, actually complains any rule which said that
about this state of affairs." The only pen-
alty to which an erring doctor was sub- as a matter of medical
ject was dishonor, and as the author of
etiquette new knowledge
Law rightly points out, this was no pun-
ishment to those who were "compacted and discoveries must be
of it." On the other hand the state seldom
made public. He tells
brought any severe sanctions to bear
either. W. H. S. Jones argues that be- how surgeons concealed
cause of the general slackness of state themselves and their
supervision or discipline, it was therefore
necessary to make every possible appeal patients during the course
to a doctor's religious scruples and to his of operations, not for
moral sense.7
The first traits which enable us to reasons of modesty but in
identify the properties of a guild, or trade order to keep some of
union, are also apparent from the first
their methods secret.
form of Oath; they are jealously guarded
professional privileges. The new doctor This highlights one im-
must give special favors to his teacher
portant distinction be-
and family. He can reveal the secrets of
his craft only to his sons, and the sons tween the practice of
of his teacher and to those outsiders who
medicine and that of
have sworn allegience to the physician's
law. It may well be that the apprentice science.
took the Oath before he actually joined
the guild, rather than after he became qualified, as is now the case. And this
brings up another question, namely
U'Works of Hippocrates, Trans. by Francis whether the medical society was a totally
Adams (New York: Wm. Wood, 1886). secret one--secret that is in the sense that
7Ludwig Edelstein makes the same point.
all outsiders were rigidly excluded from
"The Oath as a whole is hardly an obligation
enforced upon the physician by any authority, their meetings and their lectures. Two
but rather one which he accepts of his own treatises in the Hippocratic collection,
free will. It is not a legal engagement; as the Precepts and Decorum, carry quaint and
wording indicates, it is a solemn promise given obscure overtones which are very familiar
and vouchsafed only by the conscience of him
to those who have troubled to read the
who swears." (Emphasis added.) Ludwig Edel-
stein, "The Hippocratic Oath," Supplement to libretto of The Magic Flute from begin-
the Bulletin of the History of Medicine, No. 1 ning to end. Freemasons would find a
(Baltimore: Johns Hopkins' Press, 1943). strange familiarity and, as Jones points

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 86 HASTINGS CENTER STUDIES
out, it is as though the writer purposely
did not wish to be understood by those
who were unfamiliar with liturgy or
ritual. Decorum closes with an injunction
to acquire certain knowledge to "keep it
safe and to pass it on." Law, an address
to young students given at the beginning
of their medical course, ends: "But holy
things are shewn to holy men. The pro-
fane may not be shewn them until they
have been initiated into the rights of
science."s
This injunction is very similar to those
at the end of many Arabic alchemical
texts which generally finish with, "The
Godly may not show this to the un-
Godly: outsiders may not have it ex-
plained." This does suggest that secrecy
in the medical profession may have its
origins not in an omniscient attitude that
comes with knowledge nor in an altruistic
concern for what knowledge the laity
and patient can "bear," but rather by
virtue of a professional injunction meant
to preserve the unity and status of the
guild.9
As Galen tells us, there was never any
rule which said that as a matter of med-
ical etiquette new knowledge and dis-
coveries must be made public. He tells
how surgeons concealed themselves and
their patients during the course of op-
erations, not for reasons of modesty but
in order to keep some of their methods
secret. This highlights one important dis-
tinction between the practice of medicine
and that of science. The similar ban on
dissemination of knowledge in alchemical
-For an examination of the Oath's relation-
ship to secret cults see Ludwig Edelstein's "The
Hippocratic Oath," in Ancient Medicine, ed.
by Owsei Temkin and C. Lilian Temkin,
trans. by C. Lilian Temkin (Baltimore: Johns
Hopkins Press, 1967), pp. 3-64. Also "The
Hippocratic Oath," Supplement to the Bulletin
of The History of Medicine.
9TFhis aspect of secrecy is quite distinct, of
course, from the more familiar one of confi-
dentiality with regard to patient's disclosures,
which 1 deal with later.
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texts noted above is without doubt one
of the most important factors that led to
the intellectual fossilization of alchemy
as a system of knowledge. Scientific un-
derstanding grows by a dynamic balance
between imaginative speculation and the
critical judgment by others. It is inter-
esting to speculate whether or not med-
ical knowledge might have advanced
faster had this open kind of attitude been
encouraged, for one has only to recall
Harvey's complaint. He was very scorn-
ful of the uncritical manner in which doc-
tors assumed that what they were told
about the ancients' knowledge of the cir-
culation must be true. And they were
so passive that they did not even trouble
to observe for themselves.
Some clauses in the Oath are quite
incongruous, for example those which
refer to operations in general, particularly
for cutting of the stone. This clause is
generally sandwiched between clauses
containing moral injunctions. Of course,
the distinction was constantly emphasized
between the doctor and the "butcher,"
but this particular clause may also deal
with yet another problem of medical eth-
ics. Some people have suggested that it
contains a hidden reference to castration,
which was abominated by the Greeks.1o
But since this operation clause is not
present in the Christian form of the Oath,
it is possible that it actually does illus-
trate a response to a changing social
situation, a response to fashion and prej-
udices of certain physicians at a certain
period of time. It is very likely that it
was the ban on operations in Rome, no-
ticed and recorded by Galen, which
caused the insertion to be made at this
point in time, some centuries after the
1"One scholar, Reinhold, has even gone so
far as to amend the text so as to read: "I will
not castrate even persons who are not grown-
up." Jones' comment is right on target; this
is a truly unhappy illustration of the art of
correcting corrupt texts: surely the phrase,
"I will not castrate," would have been quite
adequate.
 rHE HIPPOCRATIC OATHS 87
initial Christian Oath. The distinction be-
tween the physician and the "butcher" or
"barber" surgeon, though present in
pagan times and in the Pagan Oath, was
much intensified by this Roman injunc-
tion and reached its epitome in medieval
times. The medical profession and the
public have suffered from this legacy of
history. Fortunately there is much more
cooperation now, but powerful relics of
this division exist even today, in the dif-
ferent attitudes of the public, and also
of physicians and surgeons towards the
introduction of new therapeutic tech-
niques in medicine and surgery; e.g., the
differing concerns for regulation in the
case of drugs, ranging from thalidomide
to The Pill, and in the case of surgical
procedures like heart transplants, by-pass
operations, or psycho-surgery.
Even though early Christians had great
reluctance to take oaths of any kind-
a reluctance which is shared by present-
day Quakers'"-nevertheless, it is certain
that many Christian doctors subscribed
to it. But in relation to this question an-
other striking difference-almost an ideo-
logical one-between the Christian form
of oath and the Pagan, is that in the
Christian form all those clauses which
would tend to encourage the formation
of a trade union are omitted. Secret so-
cieties were considered contrary to the
teachings of the Christian religion, and
even today, the Roman Catholic church
bans secret brotherhoods. A clause which
encouraged the formation of an inner
ring of physicians, from which outsiders
were excluded, demonstrated an aristo-
cratic exclusiveness which was in great
contrast to the universal brotherhood of
early Christianity. And if the beginning,
and the end, of all medical art was the
relief of pain and suffering, then it should
be tied and hindered by nothing-
whether guild rules, or secrecy, or pre-
11This belief of the Quakers is based on the
phrase "Swear not at all" in Matthew v. 34.
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occupation with status. "I will teach this
art to those who require to learn it,
without grudging and without indenture,"
says the Christian Oath simply-without
reference to the physician's sons, or his
teacher's sons, or those who have been
enrolled in the guild.
If the Christian opposition to secret
groups finds its rationale in the concept
of universal brotherhood, then we are
brought directly to such large issues as
the relationship between professional and
universal responsibilities. It is impossible
to know to what extent such issues were
discussed by doctors in ancient times. I
suspect not at all; certainly it is most
unlikely from what we know of this craft
guild. Even though Socrates and his dis-
ciples in the market place might examine
the nature of personal and universal re-
sponsibility, I would, in the absence of
direct contrary evidence, be inclined to
think that the doctors rarely troubled
their minds with such deep issues, seeing
such debates as the function of philoso-
phers not physicians. Moreover, the effec-
tive philosophical problem posed above
is a sophisticated one and we should
never forget that problems and theories,
just as much as people and institutions,
have their histories, too. If now we see
the relationship between professional and
universal responsibility as an issue to
which all of us, doctors and lay people,
too, have something to contribute, that is
no reason to suppose that the early
Greeks saw it this way.
Such a new awareness could reflect an
amalgam of several things: the complex-
ity of the present relationship between
the profession and society; the new fuller
sociological implications of a tough pro-
fessionalization; the extent to which our
ideas about the nature of responsibility
have evolved and changed through times
and cultures. We can no more take an
ahistorical view of this matter than we
can of scientific theories. They were never
immutable then and they are not now.
 88 HASTINGS CENTER STUDIES
It would, therefore, be as unreasonable
of us to expect strong similarities between
the Greek view and our contemporary
view on the nature of responsibility, as
it would be to expect similarities between
their knowledge on atoms and our more
detailed, sophisticated theories.
The continuities in the forms of the
Oath are clear enough, but there are
great contrasts between our contemporary
situation and those of earlier times. The
Oath as it evolved had one aim and one
aim only; namely the moral regulation of
the physician by other physicians.12 It
may well be, as Chauncey Leake sug-
gested, that during the height of Greek
civilization the generally accepted view
he final
transition, from the broad
moral precepts of Greek
medical practice to the un-
codified but accepted system
of medical ethics of the
present day, occurred
around the seventeenth
century .... the era of
the search for immutable
laws.....
of morality rendered any written admoni-
tion on medical ethics unnecessary. (It
must be remembered that the Hippocratic
collection emerged only in the Alexan-
12See the essays by Ludwig Edelstein already
cited.
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drian period, several centuries after this
height of Greek civilization.) But I feel
that Chauncey Leake may have suc-
cumbed to that well known seduction of
history-seeing Greek life through rose-
colored spectacles. From the evidence,
I am not certain that we are entitled to
assume that there was a "generally ac-
cepted view of morality," or if there were,
that it was necessarily one conducive to
good medical practice. I would prefer to
emphasize a different cultural character-
istic of the Greeks as the crucial factor,
and one which we do know survives
today.
For in ancient Greece, the rivers of
"philotimno" run deep.13 A doctor was
under no compulsion to act "properly,"
but was trained to consider good behavior
as the right thing. Greeks considered
themselves artists and men. It was per-
haps love of the art, combined with
"philotimo" which purified the doctors'
calling, and kept it pure, just as much as
any general standards of morality.
Nevertheless, the admonition of the
Hippocratic collection which emerged in
the Alexandrian epoch, could well have
been formulated in an attempt to main-
tain older, unwritten standards, however
these originated. I emphasize again: the
compulsion to ethical practice in ancient
Greece might well be found only in the
physician's genuine love both of his craft
and of men, and if the law was ineffec-
tive, medical etiquette protected the pa-
tient by appealing to artistic instinct with-
out the imposition of civil penalties.
13I refer to that identifying Greek national
characteristic "philotimo". .."personal code of
honor." If any one is tempted to regard this
cultural evidence as anecdotal, incongruous or
slight, they should refer to many of the nu-
merous discussions of "philotimo." The most
recent, and among the very best, can be found
in David Holden's brilliant and astringent,
Greece Without Columns (London: Faber,
1972), especially pp. 30, 92-4, 97, 283. He
demonstrates the negative aspects of "philo-
timo" too--hubris and blamelessness.
 THE HIPPOCRATIC
Things began to change in the Middle
Ages.14 Internal sanctions and penalties
against transgressors of the craft tradi-
tion were backed by demands for action
on the part of the civil authorities as
well, and these demands came from the
doctors. But the final transition, from
the broad moral precepts of Greek med-
ical practice to the uncodified but ac-
cepted system of medical ethics of the
present day, occurred around the seven-
teenth century; and the truly tough pro-
fessionalism of modern medicine is an
even later development. This was the
era of the search for immutable laws, not
only in science, but within conduct, and
law and morality in general. Thomas
Percival (1740-1804) who formulated
the well-known, and much used, code of
medical ethics could not have envisaged,
that by trying to cover every possible con-
tingency, two unfortunate consequences
followed. There was conflict which came
from sheer multiplicity of the rules them-
selves and a growing emphasis on the
letter of the law, rather than on its spirit.
For external sanctions, with pains and
penalties, can enforce only those rules
which are specific, narrow, and concise.
On the other hand, as we learn to our
cost, width and vagueness lead to unfair-
ness and injustice, both to the doctor and
to the patient.15
It is worth glancing briefly at the ways
in which the civil authorities have either
intervened or been called in, to regulate
the practical physicians. The first inter-
vention came with regard to fees. Chaun-
14A brief history of the medical profession
in the Middle Ages and the seventeenth cen-
tury is impossible here. See, however, David
Riesman, The Story of Medicine in the Middle
Ages (New York: 1935).
15Percival, Medical Ethics. Much of Perci-
val's medical ethics has been adopted and
adapted by the British and American medical
professions.
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OATHS 89
cey Leake emphasizes an old point; one
basic ethical question arises simply by
virtue of the fact that, if physicians have
a pecuniary interest in their work, can
they in all honesty really desire to see
men in perfect health? (This problem
can be avoided if one adopts the ancient
Chinese practice; namely, of only paying
the physicians so long as one is in
health!) Though in an ideal world the
answer to the question would be, yes;
hedonistically it is, of course, no. Society
protects-or has protected-interests of
the patient both by enacting fee codes
and by requiring a certain standard of
training and skill before a man can prac-
tice medicine. In a free market economy
the fee codes certainly do no more than
lay down the minimum which shall be
charged and, as we know only too well,
the doctor usually charges what the mar-
ket will stand. But when first introduced,
the fee code provided a system of bal-
ance and checks-no pun intended. The
code of the laws of Hammurabi of Baby-
lon, dating from about 2200 B.C., lays
down both the fees to be given for a
physician's services, graded according to
the social status of the patient, and also
the punishments to be inflicted if the
treatment resulted in injury or death.
Neither the Greeks nor the Romans pro-
vided legal regulations controlling the
practice of medicine until forced to do
so by a combination of quackery and
drug-selling, which apparently led to a
situation in which it was necessary to
clean up both the profession and the
towns. By one and the same stroke, An-
tonius Pius, both restricted the number
of physicians that could practice in a city
-thus making the doctors happy-and
also provided them with an annual salary,
thus making them happier. This was all
done, "in order that they may honorably
serve the poor rather than basely grovel
before the rich." One would like to know
 90 HASTINGS CENTER STUDIES

tions of society, and the pill was surely

sweetened by the exemption that these
doctors enjoyed from taxation and vari-
ous public duties. Gradually over the
years, the profession developed not only
prestige but also a vested interest in
he rela- maintaining its own standards, so that
civil authorities gradually relinquished
tionships between codi- their control both over the moral atti-
fied ethics, general tudes and qualifications of the physicians
and also over their finances.
morality, enforced law,
Many states in the U.S.A. still reserve
and professionalization the right, technically at least, to require
good moral character from all those who
remain, indeed, fascinat-
would practice medicine and all those
ing and perplexing. who are practicing medicine. While it
Does the appearance of a may be possible to study the moral char-
acter of a student while at school, it is
codified ethic, indicating almost impossible to do so when he gets
greater professionaliza- into practice, let alone continue to moni-
tor him. And, therefore, this aspect of the
tion, also indicate that law is another dead-letter requirement.
ethical sensibility is on The only recourse that a patient has is to
bring a civil suit against the doctor in
the rise? Or does such
cases of immoral practice, and the likeli-
a code emerge precisely hood of success will vary very much.
However, the term "medical ethics,"
because moral responsi- as introduced by Percival, was, as Chaun-
bility is on the decline? cey Leake reminds us, actually a mis-
When ethical considera- nomer. Professional courtesy is not the
same thing as professional morality, and
tions have arisen... medical ethics is by no means the same
does professionalization thing as medical etiquette, though these
are usually confused or taken to be the
help or hinder an appro- same in the mind of the profession. If
we consider the "ethics" to be based on
priate response?
Greek notions of good taste, rather than
absolute standards of morality, then what
just how successful this was.'6 Perhaps
we are now really referring to in the
turning doctors into civil servants in this
twentieth century is the rules of etiquette
way may have benefitted the poorer sec-
which regulate the conduct of members
of the profession with regard to each
I'(In theory this should work. Certainly it
has often been tried. But a recent and very other. But, using Chauncey Leake's defi-
amusing paper by Tabin of Hungary examining nition of ethics as, "concerned with the
the spread of parasolventia in his country ultimate consequences of the conduct of
shows the difficulties. Parasolventia is not a
physicians towards their individual pa-
new viral disease but the tendency of patients
to give and doctors to accept gifts (wine,
tients and towards society as a whole,
geese, etc.) in the expectation of better medi- and which should include a consideration
cal treatment. of the motive and will behind the con-

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 THE HIPPOCRATIC OATHS 91
duct," I am led to a drastic conclusion.
It may well be that, on examination, we
have no medical ethics, and that through-
out medical history we never have had
them, either.
Fifty years ago, Chauncey Leake could
write with this kind of optimism:
New conditions are now arising in
medical practice. No matter how
greatly we may lament the fact, the
old family doctor, beloved of us all,
is rapidly passing away in the growth
of specialism, group clinics, and gen-
eral hospitalization of the sick. The
close personal relations between the
physician and his individual patient are
disappearing in the routine of tech-
nical diagnoses, mass treatment, and
nation-wide prophylaxis. Medicine is
being recognized more and more as a
matter for national and international
public health efforts, rather than as a
profession catering to individual am-
bition. Its aim is its own end-the
prevention of disease. With the eco-
nomic pressure of insurance companies,
with general public health education,
and with frequent periodic health ex-
aminations, it will become financially
more interesting for the general prac-
titioner to keep his clients well than to
treat them when they become sick.
[Italics added.] This is bound to alter
the status of medical ethics.
Since 1927, much of what Chauncey
Leake predicted in that quotation has
come to pass. But he missed out on one
point and this proves to be fundamental.
He clearly believed that the medical pro-
fession would, could, metamorphose into
guardian and protector of national and
international public health efforts, rather
than being solely a profession which
satisfied individual ambitions, whether in-
tellectual or financial. It may well be
true that should it become financially
more rewarding for a doctor to keep his
patients well, rather than to treat them,
then, indeed, the whole status of medical
ethics, such as it is, would alter. But
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would it take only financial incentives?
Chauncey Leake was realistic enough, in
1927, in recognizing the strong pull of
the financial carrot, but in the context
of contemporary American society it is
difficult to see how, short of reverting to
the ancient Chinese practice, even this
could be manipulated. The problem that
I see is that this is a question of general
and total morality, both of the attitudes
of the profession and of individual
doctors.
It may well be that until we manage
to recover love of the art and love of
people, as opposed to love of the tech-
nique, or love of the affluence, or love
of the status, as the real motivation for
entering medicine, we may not get a
satisfactory ethical relationship between
doctors and society. But if this did hap-
pen it is clear to me that our ethical
aphorisms would then not even have to
be stated, let alone codified. And any
Oath would become redundant.
III
Looking back over what I have writ-
ten, I hear a voice accusing me of issuing
a whole series of blank checks which
have not yet been cashed. How much
more basic research in the history and
sociology of the medical profession must
be done before these promissory notes
can be redeemed! In relative terms the
much younger profession of science has
received infinitely more attention, and
the earlier years of the emerging scientific
profession carry much more documenta-
tion of problems both internal and ex-
ternal.
The relationships between codified
ethics, general morality, enforced law,
and professionalization remain, indeed,
fascinating and perplexing. Does the ap-
pearance of a codified ethic, indicating
greater professionalization, also indicate
that ethical sensibility is on the rise? Or
does such a code emerge precisely be-
cause moral responsibility is on the de-
 92 HASTINGS CENTER STUDIES
cline? When ethical considerations have
arisen, or in the case of science been
forcibly imprinted on the profession's
consciousness, does professionalization
help or hinder an appropriate response?
Our answers, when we have any, can only
be tentative. I believe that the Hippo-
cratic Oath was related to the general
morality only marginally, and that ini-
tially it served the needs of an emerging
profession or guild, rather than those of
society. Ultimately, nothing can serve us
-society or professions-better than a
wide general morality. And where this
does not exist, nothing, it appears, can
properly function in its place. Certainly
not a codified ethics, which is too often
full of loopholes or so vague and plati-
tudinous as to be without meaning. Cer-
tainly not an enforced law, which is too
often unenforceable, or so precise as to
be inhumanely restrictive. On the other
hand, where the general standards of
professional and social morality are high,
then both codified ethics and enforced
law become irrelevant, redundant, and
unnecessary. The problem is, what is it
that promotes, or can be made to pro-
mote, a high moral purpose in a society
or a profession? About the answer to
that question, all we know is that it will
not be simple.

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