Do Doctors Need to Swear an Oath?

On August 6, 2004 I posted a topic “Hippocratic Oath: Is it Necessary? Are the Words Right?” In that post I presented a classic version of the Oath and a modern version, the latter, “written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.”

There are a number of modern versions of the Oath. Dr. Steven Miles, ethicist and physician, has published a version written in a modern vernacular and for which he has given me permission to post here. Steven H. Miles’ Vernacular version, University of Minnesota, 2007. (Based on Miles SH. The Hippocratic Oath and the Ethics of Medicine, Oxford University Press, 2006)

Hippocratic Oath: A 2007 Vernacular Version* Steven Miles

I swear by Human grief at the mortality of our loved ones, by the family of healers, by all manner of treatments and by health itself to fulfill this oath according to my power and judgment; and to respect those who have taught me this art and to support the institutions of health education, and to esteem those who aspire to become healers as my brothers and sisters and to share the facts, theories and methods of the healing sciences with them.

I will use treatments for the benefit of the ill in accordance with my ability and my judgment but from what is to their harm or injustice I will keep them. I will not assist with murder nor will I assist such endeavors. I will not endanger a woman in pregnancy.

In a pure and holy way I will guard my life and my art.

To each clinical encounter, I will go for the benefit of the ill and I will refrain from unjustly treating them, especially from sexual acts with my patients or their relatives. I will remain silent about the private things that I see or hear regardless or whether I learn of them during treatment or in broader conversations,

If I honor this oath and do not evade its spirit or violate it, may I enjoy the benefits of life and of this profession and be respected by all. If I transgress, the opposite be my lot.


*This version is derived from the translation of von Staden H. J Hist Med Allied Sci 1996;51:406 and the analysis of its cultural meaning in Miles SH. The Hippocratic Oath and the Ethics of Medicine, Oxford University Press, 2004. I deleted the passage, "I will not cut, and certainly not those suffering from stone, but I will cede [this] to men [who are] practitioners of this activity," because it was probably inserted centuries after the 500 BC writing of Oath. Steven Miles.

My question, as it was the 2004 posting is the same: is it really important to have an Oath for the profession of medicine to which students swear to uphold before they enter the profession? Should physicians in practice swear to the Oath too and maybe even each time they renew their licenses? Is an Oath and swearing to uphold it anachronistic in this time of modern medicine with all the current regulations and laws with penalties, malpractice lawsuits and often widespread bad publicity for those who disregard the rules? I really would like to hear from patients and physicians regarding the need for a professional oath in medicine. ..Maurice.

ADDENDUM 5-18-2007:
Ethicist Ken Kipnis today wrote the following view regarding the significance to the profession of medicine and professional behavior of students or physicians taking or living under an oath like the Hippocratic oath.

Apart from the practical question of whether novice doctors who publicly take the Hippocratic oath (or even some local updating of same) are more ethical than those that don't, I have two qualms about such rituals.

First, they convey the impression that a public vow is the foundation for the special obligations of physicians. This has to be false. If it were true, then doctors who somehow missed the Hippocratic Oath ceremony would be ethically free to disregard what would otherwise be their professional obligations. Obviously this is not so. At best, oaths are merely public solemnizations of already extant ethical provisions: neither their source nor their foundation. To the extent that these ceremonies suggest ethical foundationality (excuse the term), they are misleading and should not occur.

Second, the use of the Hippocratic Oath elevates the handiwork of a single person (or group) to canonical status: in effect beyond serious criticism. One cannot reject the Constitution without placing oneself outside the community of American jurisprudes. One cannot reject the Nicean Creed without placing oneself outside of a certain community of Christians. If only because ethical insight is dynamic, it is not wise for medicine to conceive itself as an interpretive community, bound together by a shared endorsement of a single text. Alasdair MacIntyre somewhere describes a vital tradition (medicine could be an example) as, in part, an ongoing argument about the nature and implications of its distinctive goods. The capacity to support vigorous debate about the ethics of medicine is, in my opinion, at the heart of medicine's professional responsibility. That job is impaired by the view, encouraged by the solemn and public intonation of venerable oaths, that what doctors need to know about ethics is to be discerned somehow within the four corners of a single ancient document. Does anyone believe that? If it were so, would there be so many attempts at revision. If medicine, as a profession, truly appreciated both the Oath's shortcomings and the importance of a common professional commitment, then the PROFESSION would develop both an adequate expression of that commitment and the organizational resources to interpret and revise the text as needed.

How likely is that?

Ken Kipnis
Professor of Philosophy
University of Hawaii at Manoa
kkipnis@hawaii.edu

ADDITIONAL ADDENDUM 5-20-2007:

Physician ethicist Steven Miles who wrote the more modern vernacular version of the classic Hippocratic Oath posted above has kindly permitted me to post here his personal view of oaths as he wrote about the subject in "The Hippocratic Oath and the Ethics of Medicine" Oxford University Press, 2004, p 172).
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I have no doubt that the same criticism that have been raised about the Oath can be raised about ethics courses in medical or nursing school or indeed the entire field of bioethics. Nihilism can always claim the high ground although is seems that nihilists invariably use that weapon to blast opponents rather to inveigh against the significance of their own contributions.Here is what I wrote on this matter in “The Hippocratic Oath and the Ethics of Medicine” Oxford University Press, 2004, p 172). I stand by this assessment.

”Can Oath still speak to our time? Stuart Spicker, a medical ethicist, recently derided a new statement of medical ethics with these words:’As for oaths of virtually any sort - especially those generated for professionals - they’ve never directed professional conduct; neither, I suspect, will any contemporary version. Historians of medicine have years ago documented the irrelevancy of the Hippocratic Oath, especially in Hippocrates’ own time. More recent literature finds professionals ignoring the precepts altogether.[i]

’This harsh and unprovable assessment misapprehends the nature of oaths. Most of us respond to reminders that our lives are evaluated and in some mysterious way fulfilled by acknowledging some standard of moral coherence and purpose. The cautionary words of an oath, a sermon, a play, a friend, or even a stranger may cause us to reflect as we move along paths that are new to us or on those that are so oft-traveled that we have become unmindful of the importance of our steps. In these moments of renewed moral consciousness, we can choose in new ways with a refreshed sense of what is at stake. Oaths do not compel ethical behavior but they are human instruments that are crafted to sensitize the reader to moral moments and choices. Sometimes, as when Dr. Uzun resisted torture in Turkey, an honored moral voice can serve as an anchor that helps a person stand fast when the tide of history is running strongly in another direction.

Medical ethics instruments fall into two large groups: those that require a physician to perform them and those that exhort physicians to act in a certain way. Oaths and petitionary prayers are examples of those that are written to be read as first person proclamations of moral commitments.[ii] For example, Oath begins, “I swear by Apollo” and proceeds with to articulate its moral positions with “I will” or “I will not.” The Physicians’ Prayer of Moses Maimonides (12th CE) is a petitionary prayer: ”Inspire me with love for my Art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession.”[iii] The Oath of Asaph and Yohanan (6th CE) consists of two parts: rabbinic instructions on what is required of a physician (“Do not harden your heart from pitying the poor and healing the needy”) and a responsive proclamation (“We will do all that you exhorted and ordered, for it is a commandment of the Torah, and we must do it with all our hearts, with our soul and with all our might”).[iv] The 1998 Declaration of Geneva begins: “I solemnly pledge myself..” Reading in a proclamatory voice commits the physician to the avowed promises.

To an increasing degree, the first person voice of medical oaths is being supplanted by ethical instructions for a physician to study rather than proclaim. For example, the American Medical Association’s Council on Ethical and Judicial Affairs asserts that: “At a minimum, a physician’s ethical duties include terminating the physician-patient relationship before initiating a dating, romantic, or sexual relationship with a patient. [v] By contrast, a morally accountable person stands behind a statement like, “I will be far . from sexual acts both upon women’s bodies and upon men’s, both of the free and of the slaves.”[vi] Governments, international organizations, and professional associations promulgate many such hortatory codes, regulations, declarations, and laws. This voice offers several advantages to institutional sponsors. First, though they may be aimed at physicians, their moral authority rests with the sponsor. This obviates the need to assert a foundational value for the position in a world where the traditional foundations of moral claims are challenged. In response to the challenge, “Who says physicians should not have sex with patients?” the answer returns: “The AMA’s Council on Ethical and Judicial Affairs says so.” Second, sponsors may unilaterally define the boundaries of medical ethics. Some asserted boundaries are reasonably grounded in circumscribed expertise. For example, an association of neonatologists might offer an ethics opinion on the moral dilemmas posed by “extracorporeal membrane oxygenators” (a complex machine to oxygenate the blood of critically ill premature infants). However, sometimes a medical organization’s moral horizon may sunder a moral community. For example, the expansively named “Charter for Medical Professionalism” grounds its vision of medical ethics on the “frustration” of physicians in “industrialized countries.”[vii] By so doing, this Charter unjustifiably narrows the moral scope of medical professionalism to the parochial priorities of economically and politically privileged physicians and marginalizes the grave economic and human rights issues faced by physicians working in poor or totalitarian nations.

Notwithstanding the increasing number of instruments and the shift to hortatory medical ethics codes, one could argue that Oath is doing better than ever. It was rarely mentioned in Europe until about 1500 when it emerged in the context of Renaissance interest in Greek and Roman civilizations.[viii] The percentage of US medical schools reciting an oath increased from 24% in 1928, to 72% in 1958, and to 98% by 1993.[ix] Half of these schools use a variant of the Hippocratic Oath; the rest use other performative texts. Even so, only a handful of schools expose students to the text of Oath during their medical ethics education.[x] One might speculate that the use of the oath format reflects an unmet hunger for sacred ceremonies. This may be partly true but I think that oaths endure because they require the physician to speak of their values. At some level, physicians recognize that a personal revelation of moral commitments is necessary to the practice of medicine.”
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[i] Message on Medical College of Wisconsin Bioethics Discussions, e-mail chat line. Feb 8 2002. (used with permission of author.)
[ii] Sulmasy DP. What is an oath and why should a physician swear one? Theoret Med & Bioethics 1999;20:329-46; Hasday LR. The Hippocratic Oath as literary text: A dialogue between law and medicine. Yale J Health Policy, Law, Ethics 2002;II(2):299-323.
[iii] Rosner F. The physician’s prayer attributed to Moses Maimonides. Bull Hist Med 1967;41:440-54.
[iv] Shlomo P. “The Oath of Asaph the Physician and Yohanan Ben Zabda. Its Relation to the Hippocratic Oath and the Doctrina Duarum Viarum of the Didache.” Proceedings of the Israel Acad Sci and Humanities 1975;9:223-64.
[v] E-8.14 Sexual Misconduct in the Practice of Medicine. in: 1992 Code of Ethics: Annotated Current Opinions. Chicago, IL: American Medical Association, 1992.
[vi] Examples of this difference are easy to see. For example, Oath says, ”In a pure and holy way, I will guard my life and my art and science” whereas a recent document in the instructional voice says, “The profession is responsible for the integrity of this knowledge, which is based on scientific evidence and physician experience.” American Board of Internal Medicine Foundation et al. op. cit. See also the World Medical Organization. Declaration of Helsinki. Brit Med J 1996;313(7070):1448-9.
[vii] American Board of Internal Medicine Foundation, American College of Physicians-American Society of Internal Medicine Foundation, and European Federations of Internal Medicine. Medical Professionalism in the New Millennium: A Physicians Charter. Ann Int Med 2002;136:243-6.
[viii] Nutton V. What’s in an oath? J Roy Coll Phys in London 1995;29:518-24.
[ix] Friedlander WJ. Oaths given by US and Canadian medical schools. Soc Sci & Med 1982;16:115-20; Carey EJ. The formal use of the Hippocratic Oath for medical students at commencement exercises. Bull Assn Amer Med Coll 1928;159-66; Irish DP, McMurray DW. Professional oaths and American Medical Colleges J Chronic Disease 19655;18:275-89; Orr RD, Pang N, Pellegrino ED, Siegler M. Use of the Hippocratic Oath: A review of twentieth century practice and a content analysis of oaths administered in medical schools in the US and Canada in 1993. J Clin Ethics 1997;8(winter):374-5.
[x] Dubois JM, Burkemper H. Ethics education in US medical schools: A study of syllabi. Acad Med 2002;77432-37