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I Swear by Apollo, the Healer

By Michael Cook

Doctors’ attitudes to the Hippocratic Oath reveal that codes of conduct are not enough to produce ethical doctors – and scientists.

Back in 2007, the UK’s chief scientific advisor, Sir David King, published an ethical code for scientists. “Our social licence to operate as scientists needs to be founded on a continually renewed relationship of trust between scientists and society,” he explained.

Since then the code has not had a lot of publicity. Perhaps this is the fate of pronouncements with which no one can possibly disagree. Who, after all, could quarrel with “Act with skill and care in all scientific work” or “Seek to discuss the issues that science raises for society”? “Minimise and justify any adverse effect your work may have on people, animals and the natural environment” is a bit more challenging, but any failure to minimise can always be offset by energetic self-justification. No one lobs nuclear missiles without some justification.

The model for the code was clearly the Hippocratic Oath, which was composed about 400 BC. Non-doctors commonly think that 25 centuries of the medical profession have been united in a solemn commitment to work for the welfare of their patients. It gives the medical profession an aura of integrity.

Surprisingly, though, the Hippocratic Oath is a relatively recent phenomenon. It was first administered to students at the University of Wittenberg in Germany in 1508. Not until 1804 in France did it become a formal part of a graduation ceremony. And even in the 1920s in the United States only one-fifth of medical schools required it.

What made the oath popular was the disgraceful conduct of Nazi doctors who conducted barbaric experiments upon prisoners in jails and concentration camps. After World War II there was a movement to consciously reframe medicine as a humanitarian service rather than just as a technical discipline. This gave rise to codes of medical ethics, the emergence of bioethics and photos of medical students taking the Hippocratic Oath.

However, Hippocrates would not recognise his oath if he were to attend a graduation ceremony today. Obviously some of its anachronistic features had to go. Swearing by Apollo, Asclepius, Hygieia and Panacea is no longer binding. Hippocrates’ students were exhorted to share their goods with their master and “To look upon his children as my own brothers”. If only…

More controversially, the Greek oath contained clauses forbidding abortion and euthanasia. It was said to be the first time that killing and curing had been separated. Hippocrates was devoted only to healing his patients regardless of rank, age or sex. But both of these procedures are highly contested today. In a 1993 survey of medical oaths in the US and Canada, only 14% banned euthanasia, and only 8% abortion.

Hippocrates also took a much tougher line on sexual relations with patients. “In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.” Only 3% of US and Canadian oaths prohibited such contact.

But the contemporary oath is more than window-dressing. Physicians need to feel that their professional lives have a moral compass higher than self-interest. Furthermore, doctors know that regulations, financial incentives and public reporting are not enough to guarantee that patients receive the best possible care.

Updated oaths include clauses on issues like financial conflicts-of-interest, use of technology, medical error, whistle-blowing and racial discrimination. However, a survey in the Annals of Internal Medicine a few years ago indicated that doctors often ignore these guidelines. For instance, more than 90% agreed that doctors should report significantly impaired or incompetent colleagues – but only half did so.

A survey this year in the journal BMJ Quality and Safety found that only 80% of doctors strongly agreed that “Doctors should put patients’ welfare above the doctor’s own financial interests”. About 8% did not agree that it was “never appropriate” to have a sexual relationship with a patient.

Perhaps the point is that protocols and codes are not enough to produce ethical doctors – and scientists. There has to be something deeper. Hippocrates would have called it virtue. But how to make people virtuous is a problem that we still are far from solving.

Michael Cook is editor of the online bioethics newsletter BioEdge.