Reflections on the Hippocratic Oaths

Author(s): June Goodfield

Reviewed work(s):
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
Oaths
Hippocratic

JUNE GOODFIELD
that more and more people have begun
to appreciate the force of Santayana's
dictum: "Those who ignore the lessons
of historyare doomedto repeatit."
It is quite clear that the issue of medical ethics, medical etiquette,and the relationshipof the professionto society at
large presently raises questions of such
depth and importancethat it would be a
foolish doctor who would try to sweep
them aside. Nevertheless, even if he
agreed about the importanceof medical
ethics, he mightstill agreewith Fishbein's
comments,feelingthat a historicalsurvey
is of no value in the considerationof his
own situationand dilemmas.I am not so
certain. We tend to think of our own
social situation as simple, unique, and
static. Such an attitude comes naturally
because it providessuch an easy way to
deal with difficulties.If the problem of
contemporarymedicalethics is both simple and aculturalthen we can get away
with a facile and universalsolution.Since
most of us are lazy-mindedand just want
to go on doingthat whichwe enjoy doing
most, i.e., practicingmedicine and earning money, it is temptingto ignore the
problem.
But historyteachesus importantthings,
such as how rarelysituationsare simple;

S OMETIME
during

the early Twenties, Chauncey Leake,

accordingto his own accounts,was collecting materialfor a study on the historical development of medical ethics.
He asked Dr. Maurice Fishbein, Editor
of the Journalof the AmericanMedical
Association,for an opinionof the merits
of such a project. Dr. Fishbein'sreply,
as reportedin the Preface to Chauncey
Leake's edition of Percival's Medical
Ethics, is classic: "Unnecessaryand of
no significancefor an understandingof
the matter. . ."1 If this anecdoteis true,
it tells us that the medical profession
shared with the scientific profession a
typical attitudetowardhistoricalstudies,
namely, that in no way have they utility
or relevanceto the practiceof the craft,
and are best left to membersof the profession, when retired.It is only recently
1Thomas Percival, Medical Ethics, ed. and
introd. by Chauncey Leake (Baltimore: Williams and Williams, 1927 [originally published
Manchester: 1803]).

80
how most problemsof professionalactivities, with their concomitantquestionsof
ethics and accountability,arise not in a
vacuum,but in responseto the demands
of a social situation. This, in its turn,
tells us thatour responseto contemporary
ethical problems must be made in the
light of our existing situation, and this
we must understand,analyze, and appreciate,beforewe can hope to deal with
such problemseffectively.In addition,if
thereis a degreeof relativismin our historical situation, there is also a similar
degree of relativismacross our cultures.
Recognitionof relativismin history and
throughculturedoes not, of course,imply
that there can be no answersto contemporary problems.Rather it implies that
there can be no universalanswerswhich
would be equally applicablethroughouttime 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 disparatesocieties as
those of North America,India and South
Vietnam.

My intentionhere, in this ratherlightheartedessay, is to look at some of the

variantforms of the Doctor's Oath, and
see what questionsthey raise about medical ethics. These are not new issues, but
in reexaminationwe might note the particularforce or validitythey have in our
twentieth-centurysituation, and perhaps
incidentally demonstrate the teaching
value of history.For it is quite clear that
problemsof medical ethics and medical
etiquetteare closely boundup with problems of the professionalizationof medicine. As ChaunceyLeake pointed out in
1927, when we study the evolutionof the
present situationwith regard to medical
ethics, then it may become clearer why
it is that the professionresists effortsto

HASTINGSCENTERSTUDIES

change its presentrelationto society.2

But where did all this start?I want to
look initiallyat the variationsin the Oath
that was taken by doctors during the
years when the professionwas emerging
and see where this varietyoriginatedand
what effects it might have had. The
classic work was done by W. H. S.
Jones. He wrote the definitivestudies on
the various forms of the Oath and was,
in the 1920's, the recognizedauthority
on Hippocrates.3As Jones points out,
therewas no verbalfidelityin the preservation of the Hippocratictext. Provided
the general sense came across, no one
worriedaboutliteralfaithfulness.By contrastwith the reverentattitudewhichkept
the texts of many classical authorscomparativelypure, the Hippocraticmaterial
was treated in a cavalier manner,probably becausethese workswere textbooks,
with no pretentionto be literarymasterpieces. Words get transposed,interpolations are very common, and there are
losses of phrase and meaning.The reason for this may lie in the changingcultural context of medical problems. Un21 shall be arguing in a later series of papers,
that there are, indeed, common elements in all
professions whose tendencies increase the members' 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 professions 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 problems. Without it, we would be tempted to
regard doctors and scientists as merely reactionary.
3W. H. S. Jones, The Doctor's Oath: An
Essay in the History of Medicine (Cambridge,
Eng.: Cambridge University Press, 1924). Unless 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 participantsin the humanities project
of the Institute of Society, Ethics and the Life
Sciences.

THE HIPPOCRATIC OATHS

like, for example, a commentary on

Aristotle, the Hippocratic Oath had a
very clear-cut function for doctorsthough not for society-in definingtheir
relationshipto society.The interpolations
and modificationsin the text can, without
too much distortion,be seen as responses
to the differentsocial matricesin which
the Doctor'sOath 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 scholarlywork,
and as such had and has no more claims
for immutabilitythan a legal judgment
presently has in English or American
society.
The earliestrecordedcopy of the Oath
is in the VaticanLibrary,and comes from
the tenthor eleventhcentury.It is not the
earliestform for it is the Oath modified
so that "a Christianmay take it." The
earliest form, the Pagan Oath, comes
from a fourteenth-centurymanuscript
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,
accordingto my ability and judgment,
this oath and this indenture:
To regardmy teacherin this art as
equalto my parents;to makehim partner in my livelihood, and when he is
in need of money to share mine with
him; to considerhis offspringto equal
my brothers;to teach them this art, if
they requireto learn it, withoutfee or
indenture;and to impartprecept, oral
instruction,and all the other learning,
to my sons, to the sons of my teacher,
and to pupils who have signed the indenture and sworn obedience to the
physician'sLaw, but to none other.
I will not give poison to anyone
thoughasked to do so, nor will I suggest such a plan. SimilarlyI will not
give a pessary to a woman to cause
abortion.But in purityand in holiness
I will guardmy life and my art.

81
I will not use the knife either on
sufferersfrom stone, but I will give
place to such as are craftsmentherein.
Into whatsoever houses I enter, I
will do so to help the sick, keeping
myself free from all intentionalwrongdoing and harm,especiallyfrom fornication with woman or man, bond or
free.
Whatsoeverin the courseof practice
I see or hear (or even outside my
practice in social intercourse) that
ought never to be publishedabroad,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 transgressand forswearmyself,
may the oppositebefall me.
Notice how alreadythere is a distinction betweenthe doctor and the surgeon.
Probablythe 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 injunctionis, "leave this to
the operative craftsman."
Now let us look at the Oath, modified
"insofaras a Christiancould swear it."
Blessed by God the Father of our
Lord Jesus Christ, who is blessed for
ever and ever;I lie not.
I will bringno stain upon the learning of the medical art. Neither will I
give poison to anybody though asked
to do so, nor will I suggestsuch a plan.
SimilarlyI will not give treatmentto
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 withoutindenture.I will use treatment to help the sick accordingto my
ability and judgment. And in purity
and in holiness I will guard my art.
Into whatsoeverhouses I enter, I will
do so to help the sick, keepingmyself
free from all wrongdoing,intentional
or unintentional,tending to death or
to injury, and from fornication with

82

HASTINGSCENTERSTUDIES

bond or free, man or woman. Whatsoever 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 description 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 teaching of abortion. In all other versions it is
placed in a less ambiguous position. This transposition was surely not intentional. The hypothesis that it is due to careless copying on
the part of a sleepy monk is, for my money,
the most likely explanation.

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 administered 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 covenant) 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 myself 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

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 practice 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-making, 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 addresses 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 feelings, envy, harshness, niggardliness,
falsehood, idleness, nay all acts that

83
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 anchorite, 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 indigent, 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 relations 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, according to Mohan Lal Sharma, has recently 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 mayest 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
crime. Thou shouldst speak words that
are gentle, pure and righteous, pleasing, worthy, true, wholesome and modcrate. Thy behavior must be in keeping
with the time and place and heedful
of past experience. Thou shalt act always with a view to acquiring knowledge 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, selfpossessed and conduct thyself thoughtfully. 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 knowledge, 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 presence 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 medicine. I will give my services without
fee to the needy, and I will never
exact a higher fee than my work deserves. 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.

HASTINGS CENTER STUDIES

on there, and my tongue shall be silent

about the secrets which shall be entrusted to me, and I will not abuse my
position to corrupt morals or to encourage 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 Graduate 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, substituting 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 cynical 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

85

THE HIPPOCRATIC
OATHS

belonged to a definite guild or school?

Was it ever actuallyadministered,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 suggestedthat a doctor who
transgressedthe Oath was not punished
unless, in fact, he actuallysinned against
the civil or criminallaws of the state. One
enchantingpiece in the Hippocraticcollection, called Law, actually complains
about this state of affairs."The only penalty to which an erring doctor was subject was dishonor,and as the author of
Law rightlypoints out, this was no punishment to those who were "compacted
of it." On the otherhandthe state seldom
brought any severe sanctions to bear
either. W. H. S. Jones argues that because of the general slackness of state
supervisionor discipline,it was therefore
necessaryto make every possible appeal
to a doctor'sreligiousscruplesand to his
moral sense.7
The first traits which enable us to
identifythe propertiesof a guild,or trade
union, are also apparentfrom the first
form of Oath;they are jealouslyguarded
professionalprivileges. The new doctor
must give special favors to his teacher
and family. He can reveal the secrets of
his craft only to his sons, and the sons
of his teacherand to those outsiderswho
have sworn allegienceto the physician's
law. It may well be that the apprentice
took the Oath before he actually joined
the guild, rather than after he became
U'Worksof Hippocrates, Trans. by Francis
Adams (New York: Wm. Wood, 1886).
7Ludwig Edelstein makes the same point.
"The Oath as a whole is hardly an obligation
enforced upon the physician by any authority,
but rather one which he accepts of his own
free will. It is not a legal engagement; as the
wording indicates, it is a solemn promise given
and vouchsafed only by the conscience of him
who swears." (Emphasis added.) Ludwig Edelstein, "The Hippocratic Oath," Supplement to
the Bulletin of the History of Medicine, No. 1
(Baltimore: Johns Hopkins' Press, 1943).

Galen

tells us, there was never

any rule which said that
as a matterof medical
etiquettenew knowledge
and discoveriesmust be
made public. He tells
how surgeonsconcealed
themselvesand their
patientsduringthe course
of operations,not for
reasonsof modestybut in
orderto keep some of
their methodssecret.
This highlightsone importantdistinctionbetween the practiceof
medicineand that of
science.
qualified, as is now the case. And this
brings up another question, namely
whetherthe medicalsociety was a totally
secretone--secret thatis in the sense that
all outsiderswere rigidly excluded from
their meetings and their lectures. Two
treatises in the Hippocratic collection,
Preceptsand Decorum,carry quaint and
obscureovertoneswhichare veryfamiliar
to those who have troubledto read the
libretto of The Magic Flute from beginning to end. Freemasonswould find a
strange familiarityand, as Jones points

86

HASTINGSCENTERSTUDIES

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 profane 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 unGodly: outsiders may not have it explained." 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 medical etiquette new knowledge and discoveries must be made public. He tells
how surgeons concealed themselves and
their patients during the course of operations, not for reasons of modesty but
in order to keep some of their methods
secret. This highlights one important distinction 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 relationship 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.

9TFhisaspect of secrecy is quite distinct, of

course, from the more familiar one of confidentiality with regard to patient's disclosures,
which 1 deal with later.

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 understanding grows by a dynamic balance
between imaginative speculation and the
critical judgment by others. It is interesting to speculate whether or not medical 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 scornful of the uncritical manner in which doctors assumed that what they were told
about the ancients' knowledge of the circulation 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 ethics. 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 illustrate a response to a changing social
situation, a response to fashion and prejudices of certain physicians at a certain
period of time. It is very likely that it
was the ban on operations in Rome, noticed 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 grownup." 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.

OATHS
rHE HIPPOCRATIC

initialChristianOath. The distinctionbetweenthe physicianand the "butcher"or

"barber" surgeon, though present in
pagan times and in the Pagan Oath, was
much intensifiedby this Roman injunction and reachedits epitome in medieval
times. The medical profession and the
public have sufferedfrom this legacy of
history. Fortunatelythere is much more
cooperationnow, but powerfulrelics of
this divisionexist even today, in the different attitudes of the public, and also
of physicians and surgeons towards the
introduction of new therapeutic techniques in medicineand surgery;e.g., the
differingconcerns for regulationin the
case of drugs, rangingfrom thalidomide
to The Pill, and in the case of surgical
procedureslike heart transplants,by-pass
operations,or psycho-surgery.
Even thoughearlyChristianshad great
reluctanceto take oaths of any kinda reluctancewhich is sharedby presentday Quakers'"-nevertheless,it is certain
that many Christiandoctors subscribed
to it. But in relationto this question anotherstrikingdifference-almost an ideological one-between the Christianform
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 Christianreligion, and
even today, the Roman Catholic church
bans secretbrotherhoods.A clause which
encouraged the formation of an inner
ring of physicians,from which outsiders
were excluded, demonstratedan aristocratic exclusivenesswhich was in great
contrastto the universalbrotherhoodof
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 nothingwhether guild rules, or secrecy, or pre11This belief of the Quakers is based on the
phrase "Swear not at all" in Matthew v. 34.

87
occupationwith status. "I will teach this
art to those who require to learn it,
withoutgrudgingand withoutindenture,"
says the ChristianOath simply-without
referenceto the physician'ssons, or his
teacher'ssons, or those who have been
enrolledin the guild.
If the Christianopposition to secret
groups finds its rationalein the concept
of universal brotherhood,then we are
brought directly to such large issues as
the relationshipbetweenprofessionaland
universalresponsibilities.It is impossible
to know to what extent such issues were
discussedby doctors in ancient times. I
suspect not at all; certainly it is most
unlikelyfrom what we know of this craft
guild. Even though Socratesand his disciples in the marketplace mightexamine
the natureof personaland universalresponsibility,I would, in the absence of
direct contraryevidence, be inclined to
think that the doctors rarely troubled
their minds with such deep issues, seeing
such debates as the functionof philosophersnot physicians.Moreover,the effective philosophicalproblem posed above
is a sophisticated one and we should
never forget that problemsand theories,
just as much as people and institutions,
have their histories, too. If now we see
the relationshipbetweenprofessionaland
universal responsibilityas an issue to
which all of us, doctors and lay people,
too, have somethingto contribute,that is
no reason to suppose that the early
Greekssaw it this way.
Such a new awarenesscould reflectan
amalgamof several things: the complexity of the present relationshipbetween
the professionand society;the new fuller
sociologicalimplicationsof a tough professionalization; 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

HASTINGSCENTERSTUDIES

It would, therefore,be as unreasonable drian period, several centuriesafter this

of us to expectstrongsimilaritiesbetween height of Greek civilization.) But I feel
the Greek view and our contemporary that Chauncey Leake may have succumbedto that well known seductionof
view on the nature of responsibility,as
it wouldbe to expect similaritiesbetween history-seeing Greek life throughrosetheir knowledgeon atoms and our more
colored spectacles. From the evidence,
I am not certain that we are entitled to
detailed,sophisticatedtheories.
The continuitiesin the forms of the
assume that there was a "generallyacOath are clear enough, but there are
ceptedview of morality,"or if therewere,
between
contrasts
our
that
it was necessarilyone conduciveto
contemporary
great
situationand those of earliertimes. The
good medicalpractice.I would prefer to
Oath as it evolved had one aim and one
emphasizea differentculturalcharacteristic of the Greeks as the crucial factor,
aim only; namelythe moral regulationof
and one which we do know survives
the physician by other physicians.12 It
well
as
Leake
be,
today.
may
Chauncey
sugFor in ancient Greece, the rivers of
gested, that during the height of Greek
run deep.13 A doctor was
civilization the generally accepted view
"philotimno"
under no compulsionto act "properly,"
but was trainedto considergood behavior
as the right thing. Greeks considered
themselvesartists and men. It was perhaps love of the art, combined with
"philotimo"which purified the doctors'
calling,and kept it pure, just as much as
any general standardsof morality.
Nevertheless, the admonition of the
he final
Hippocraticcollection which emergedin
the Alexandrianepoch, could well have
transition, from the broad
been
formulatedin an attemptto mainmoral precepts of Greek
tain older, unwrittenstandards,however
medical practice to the unthese originated.I emphasizeagain: the
to ethical practicein ancient
compulsion
codified but accepted system
Greece might well be found only in the
of medical ethics of the
physician'sgenuinelove both of his craft
and of men, and if the law was ineffecpresent day, occurred
tive, medical etiquetteprotectedthe paaround the seventeenth
tientby appealingto artisticinstinctwithout
the impositionof civil penalties.
century .... the era of

the search for immutable

laws.....
of moralityrenderedany writtenadmonition on medical ethics unnecessary.(It
mustbe rememberedthat the Hippocratic
collection emerged only in the Alexan12Seethe essays by Ludwig Edelstein already

cited.

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 numerous 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 "philotimo" too--hubris and blamelessness.

THE HIPPOCRATIC OATHS

Things began to change in the Middle

Ages.14 Internal sanctions and penalties
against transgressorsof the craft tradition were backed by demandsfor action
on the part of the civil authoritiesas
well, and these demandscame from the
doctors. But the final transition, from
the broad moral preceptsof Greek medical practice to the uncodifiedbut accepted system of medical ethics of the
present day, occurredaroundthe seventeenth century;and the truly tough professionalism of modern medicine is an
even later development. This was the
era of the searchfor immutablelaws, 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
medicalethics could not have envisaged,
thatby tryingto covereverypossiblecontingency, two unfortunateconsequences
followed. There was conflictwhich came
from sheer multiplicityof the rules themselves and a growing emphasis on the
letterof the law, ratherthan 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 vaguenesslead to unfairness and injustice,both to the doctor and
to the patient.15
It is worthglancingbrieflyat the ways
in which the civil authoritieshave either
intervenedor been called in, to regulate
the practical physicians.The first interventioncame with regardto fees. Chaun14A brief history of the medical profession
in the Middle Ages and the seventeenth century is impossible here. See, however, David
Riesman, The Story of Medicine in the Middle
Ages (New York: 1935).
15Percival, Medical Ethics. Much of Percival's medical ethics has been adopted and
adapted by the British and American medical
professions.

89
cey Leake emphasizesan old point; one
basic ethical question arises simply by
virtue of the fact that, if physicianshave
a pecuniary interest in their work, can
they in all honesty really desire to see
men in perfect health? (This problem
can be avoidedif one adopts the ancient
Chinesepractice;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;
hedonisticallyit is, of course, no. Society
protects-or has protected-interests of
the patient both by enacting fee codes
and by requiringa certain standardof
trainingand skill before a man can practice medicine.In a free marketeconomy
the fee codes certainlydo no more than
lay down the minimumwhich shall be
chargedand, as we know only too well,
the doctor usuallychargeswhat the market will stand. But when firstintroduced,
the fee code provided a system of balance and checks-no pun intended.The
code of the laws of Hammurabiof Babylon, dating from about 2200 B.C., lays
down both the fees to be given for a
physician'sservices, graded accordingto
the social status of the patient, and also
the punishmentsto be inflicted if the
treatment resulted in injury or death.
Neither the Greeksnor the Romansprovided legal regulations controlling the
practice of medicine until forced to do
so by a combinationof quackery and
drug-selling,which apparentlyled to a
situation in which it was necessary to
clean up both the profession and the
towns. By one and the same stroke, Antonius Pius, both restrictedthe number
of physiciansthat could practicein a city
-thus making the doctors happy-and
also providedthemwith an annualsalary,
thus makingthem happier.This was all
done, "in order that they may honorably
serve the poor ratherthan basely grovel
before the rich."One would like to know

90

he relationships between codified ethics, general

morality, enforced law,
and professionalization
remain, indeed, fascinating and perplexing.
Does the appearanceof a
codified ethic, indicating
greater professionalization, also indicate that
ethical sensibility is on
the rise? Or does such
a code emerge precisely
because moral responsibility is on the decline?
When ethical considerations have arisen...
does professionalization
help or hinder an appropriate response?
just how successful this was.'6 Perhaps
turning doctors into civil servants in this
way may have benefitted the poorer secI'(In theory this should work. Certainly it
has often been tried. But a recent and very
amusing paper by Tabin of Hungary examining
the spread of parasolventia in his country
shows the difficulties. Parasolventia is not a
new viral disease but the tendency of patients
to give and doctors to accept gifts (wine,
geese, etc.) in the expectation of better medical treatment.

HASTINGSCENTERSTUDIES

tions of society, and the pill was surely

sweetened by the exemption that these
doctors enjoyed from taxation and various public duties. Gradually over the
years, the profession developed not only
prestige but also a vested interest in
maintaining its own standards, so that
civil authorities gradually relinquished
their control both over the moral attitudes and qualifications of the physicians
and also over their finances.
Many states in the U.S.A. still reserve
the right, technically at least, to require
good moral character from all those who
would practice medicine and all those
who are practicing medicine. While it
may be possible to study the moral character of a student while at school, it is
almost impossible to do so when he gets
into practice, let alone continue to monitor him. And, therefore, this aspect of the
law is another dead-letter requirement.
The only recourse that a patient has is to
bring a civil suit against the doctor in
cases of immoral practice, and the likelihood of success will vary very much.
However, the term "medical ethics,"
as introduced by Percival, was, as Chauncey Leake reminds us, actually a misnomer. Professional courtesy is not the
same thing as professional morality, and
medical ethics is by no means the same
thing as medical etiquette, though these
are usually confused or taken to be the
same in the mind of the profession. If
we consider the "ethics" to be based on
Greek notions of good taste, rather than
absolute standards of morality, then what
we are now really referring to in the
twentieth century is the rules of etiquette
which regulate the conduct of members
of the profession with regard to each
other. But, using Chauncey Leake's definition of ethics as, "concerned with the
ultimate consequences of the conduct of
physicians towards their individual patients and towards society as a whole,
and which should include a consideration
of the motive and will behind the con-

THE HIPPOCRATIC OATHS

duct," I am led to a drastic conclusion.

It may well be that, on examination,we
have no medicalethics, and that throughout medical history we never have had
them, either.
Fifty years ago, ChaunceyLeakecould
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 rapidlypassing away in the growth
of specialism,group clinics, and general hospitalizationof the sick. The
close personal relations between the
physicianand his individualpatientare
disappearingin the routine of technical diagnoses, mass treatment,and
nation-wide prophylaxis.Medicine is
being recognizedmore and more as a
matter for national and international
public health efforts, ratherthan as a
profession catering to individual ambition. Its aim is its own end-the
preventionof disease. With the economicpressureof insurancecompanies,
with general public health education,
and with frequentperiodic health examinations,it will become financially
more interestingfor the general practitionerto keep his clients well than to
treat them when they become sick.
[Italics added.] This is bound to alter
the status of medical ethics.

91
would it take only financialincentives?
ChaunceyLeake was realisticenough, in
1927, in recognizingthe strong pull of
the financial carrot, but in the context
of contemporaryAmerican society it is
difficultto see how, short of revertingto
the ancient Chinese practice, even this
could be manipulated.The problemthat
I see is that this is a questionof 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 technique, or love of the affluence,or love
of the status, as the real motivationfor
entering medicine, we may not get a
satisfactoryethical relationshipbetween
doctors and society. But if this did happen it is clear to me that our ethical
aphorismswould then not even have to
be stated, let alone codified. And any
Oath would become redundant.

III
Looking back over what I have written, I hear a voice accusingme of issuing
a whole series of blank checks which
have not yet been cashed. How much
more basic researchin the history and
sociology of the medicalprofessionmust
be done before these promissorynotes
Since 1927, much of what Chauncey can be redeemed!In relative
terms the
Leake predicted in that quotation has
much youngerprofessionof science has
come to pass. But he missed out on one
received infinitely more attention, and
point and this proves to be fundamental. the earlieryearsof the
emergingscientific
He clearlybelievedthat the medicalproprofessioncarry much more documentafession would, could, metamorphoseinto
tion of problems both internal and exguardianand protector of national and
ternal.
internationalpublic health efforts, rather
The relationships between codified
than being solely a profession which ethics,
general morality, enforced law,
satisfiedindividualambitions,whetherinand professionalizationremain, indeed,
tellectual or financial. It may well be
fascinatingand perplexing.Does the aptrue that should it become financially pearance of a codified ethic,
indicating
more rewardingfor a doctor to keep his
greater professionalization,also indicate
patients well, rather than to treat them, that ethical sensibilityis on the rise? Or
then, indeed, the whole status of medical does such a code emerge
precisely beethics, such as it is, would alter. But
cause moral responsibilityis on the de-

92
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 Hippocratic Oath was related to the general
morality only marginally, and that initially 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

HASTINGS CENTER STUDIES

not a codified ethics, which is too often

full of loopholes or so vague and platitudinous as to be without meaning. Certainly 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 promote, 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.