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Advancing Quality of Care at the End of Life A Hippocratic Oath for Our Time Current & Choice: "Physician, Heal Thy Sisters" Reporter Staff: Rachel Muir, Managing Editor |
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A Hippocratic Oath for Our TimeIt invokes Greek gods. It promotes nutritional therapy as the first defense against illness. It forbids euthanasia, abortion, and surgical procedures. It invokes dishonor and shame if it is sworn to falsely. Today’s medical students are probably surprised upon reading the original wording of what has come to be known as the solemn vow each new physician takes when entering the medical community — the Hippocratic Oath. Doubtful that the oath was written by Hippocrates at all, most historians attribute it to the Pythagoreans, a small cult of healers active in the fourth century B.C.
Furthermore, evidence suggests that the tradition of using the oath as a qualification for the practice of medicine did not become widespread until the middle of the last century. In a study published in a 1997 issue of the Journal of Clinical Ethics, Robert Orr, M.D., and colleagues surveyed 157 U.S. and Canadian allopathic and osteopathic medical schools to determine usage of the Hippocratic Oath. While literature published by the AAMC in 1928 indicates that only 24 percent of U.S. and Canadian medical schools administered some form of the Hippocratic Oath at that time, Dr. Orr, et. al., found that figure rose to 98 percent in 1993, with 100 percent of American schools administering oaths to their graduates. Of these, only one medical school — the State University of New York Upstate Medical University — used the exact original wording of the oath traditionally attributed to Hippocrates. The realization that the Hippocratic Oath is dynamic rather than static and that its administration to graduating medical students is a modern phenomenon may disillusion some newly minted physicians who believe they are uttering the same words passed down by their medical brethren since ancient Greece. “I was thrilled at my commencement in 1947 when I took the Hippocratic Oath,” says Louis Lasagna, M.D., dean of the Sackler School of Graduate Biomedical Sciences at Tufts University School of Medicine. “It had nothing to do with the content of it; it had to do with the fact that I was proud to be a member of a profession that had its own set of rules to ensure that ethical and competent medicine was practiced.” But over the years Dr. Lasagna did think about the content of the oath he took as a young man. In 1964, the New York Times asked him to write a column contemplating the meaning of the Hippocratic Oath for the modern medical student. Dr. Lasagna responded by proposing a “worldwide competition” to “select a covenant that best captures the spirit of a noble profession with great traditions, lest the new physician forget both his heritage and his responsibilities.” He ended by offering an “entry” of his own. Dr. Lasagna says his prime motivating factor while drawing up his oath was to combat what he perceived as the growing tendency of physicians to treat diseases rather than patients. Thus, he calls on new physicians to not only remember that “warmth, sympathy, and understanding may outweigh the surgeon’s knife or chemist’s drug,” but also to never forget that physicians “do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability.” Dr. Lasagna’s call for doctors to be compassionate patient advocates resonated with his readers in ways he never anticipated. The first indication he received that his proposed oath was being used by medical school graduates occurred 10 years after its publication, when a colleague from the University of California, San Francisco, informed him that the “Oath of Lasagna” was chosen for recitation by that year’s graduating class. It took a moment for the confused physician to realize his Times piece was being referred to. Today, the “Oath of Lasagna” is one of several oaths that have been offered to replace the original Hippocratic Oath while preserving its spirit. Other alternatives include the Oath of Maimonides, written by the 12th-century Jewish physician Moses Maimonides, and the Declaration of Geneva, composed by the World Medical Association in 1948. The trend among many medical schools, though, is to have each graduating class hammer out an oath of its own that reflects the professional ideals of its members. “Each class is asked to think about what the Hippocratic Oath means, what its purpose is, and how they want to articulate that,” says Nancy Angoff, M.D., assistant dean for student affairs at the Yale University School of Medicine. “There is much discussion about the nature of the oath as something that connects students to the practice of medicine and the physicians who have come before them. In that regard, they want to keep it reminiscent of the original oath as the first ethical grounding of their profession,” she says. “But at the same time they are not willing to accept all of the original words because they don’t believe all of them and they feel their integrity is at stake.” Dr. Angoff says the democratic process of deciding on the oath’s specific wording forces students to reflect on their definition of an ethical physician. Some years the oath is simply an altered version of the original; other years, it is the unique declaration of a specific class. Other schools stick to a tried-and-true version of the oath. Jack Gladstein, M.D., associate dean for student affairs at the University of Maryland School of Medicine, says “no flak or controversy” arises over the school’s version of the Hippocratic Oath, which has been in use for the past 20 years. It borrows selectively from the original wording, preserving its concern for loyalty to the profession of medicine and the ethical use of one’s talents. With so many differently worded oaths claiming the name of Hippocrates, Dr. Lasagna sticks to his suggestion that a competition be held to choose a common oath for all new physicians. “To the extent that we have everybody going their own way, we lose that thread of commonality preserved in the original Hippocratic Oath,” he remarks. “And I think that’s a pity.”
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