Swearing to care: the resurgence in medical oathsBMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7123.1671 (Published 20 December 1997) Cite this as: BMJ 1997;315:1671
- a Department of Primary Care, Imperial College School of Medicine, St Mary's Campus, London W2 1PG
- b Wellcome Research Fellow in the History of Medicine, Department of Anatomy, University College London, London WC1E 6BT
- Correspondence to: Dr Hurwitz
We are witnessing a resurgence of professional interest in medical oaths and codes of conduct. In the United Kingdom the General Medical Council has reissued its professional code and, together with the BMA, the royal colleges, and other organisations, has published a document on the “core values” of medical practice.1 2 There has been discussion of the role of oath taking at the end of medical training, and the BMA has drafted a new Hippocratic Oath on behalf of the World Medical Association (see third box).3 4 5 6 7 8 9 10 11 The American Medical Association has this year commemorated the 150th anniversary of its 1847 Code of Ethics with an extensive debate on the relevance of oaths and codes to modern practice.12 13 14
Declaration of Geneva
“At the time of being admitted as a Member of my Profession:
I solemnly pledge myself to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude which is their due;
I will practice my profession with conscience and dignity;
The health of those in my care will be my first consideration;
I will respect the secrets that are confided in me, even after the patient has died;
I will maintain by all the means in my power, the honour and the noble traditions of my profession;
My colleagues will be my sisters and brothers;
I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, or social standing to intervene between my duty and my patient;
I will maintain the utmost respect for human life from its beginning, even under threat, and I will not use my specialist knowledge contrary to the laws of humanity;
I make these promises solemnly, freely, and upon my honour.”20
In many Western countries the process of refashioning health care to contain costs is precipitating rapid flux in the social relationships of medical practice. Doctors are no longer in a simple clinical relationship with patients: the structure of health services now involves them in many other tasks, some of which may entail conflicting responsibilities. Funding organisations and managers increasingly influence the nature and extent of the care which can be provided. At the same time, health care has become multidisciplinary in nature and multiagency in delivery. Scientific advances and new technological capabilities throw up difficult and sometimes bizarre moral predicaments. All these changes make for greater moral complexity in everyday practice.
The medical profession is being forced to face hard choices in patient care and to re-examine its own role in health care, causing it to look again at the nature of its own values. The Hippocratic Oath is being re-examined afresh for moral guidance. Traditionally a solemn promise invoking supernatural authority as witness, the oath entails making a covenant with other members of the profession to share knowledge freely, to respect one's teachers, and to behave towards patients according to the Hippocratic Code (box). There follows the conditional curse invoked upon transgressors, which includes censure by and exclusion from the profession and from human happiness.
“I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practise my Art. I will not cut persons labouring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and further, from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.”15
The changing oath
Problems and controversies surround the textual authenticity and meaning of the original oath. It is not clear if or how much Hippocrates himself contributed to it, or how much it influenced health care in ancient Greece. It is probable that only a minority of doctors swore the oath. Some of its prohibitions seem to fly in the face of what is known about clinical practice in ancient Greece, which included surgery, abortion, and tolerance of infanticide.3 16 17
Those who have administered the oath during succeeding centuries have taken it on themselves to omit, add to, and change its clauses. For example, Elizabethan renditions required doctors to provide gratuitous care to the poor and not to flee from but to treat victims of plague.3 Present day versions tend to be agnostic on these matters.
Oath taking commits doctors to observe an ethical code
New obligations thrust on doctors may conflict with their first responsibility to care for patients
Complex and sometimes bizarre moral predicaments emerge from scientific advances and new technological capabilities
Modern health care is provided by multidisciplinary teams in multiagency environments
A pan-professional oath could allow all health carers to share a commitment to core values
A recent exegesis describes the oath as “a solemn promise: (a) of solidarity with teachers and other physicians; (b) of beneficence and non-maleficence towards patients; (c) not to assist suicide or abortion; (d) to leave surgery to surgeons; (e) not to harm, especially not to seduce patients; (f) to maintain confidentiality and never to gossip.”18 Tensions between the impetus of the original oath and the modern endeavour to ensure good practice according to bioethical principles are apparent in this text. Values a and d, which seek to foster an archaic professional exclusivity, sit uncomfortably with b, e, and f, which modern doctors would regard as fundamental principles: beneficence, non-maleficence, and confidentiality. Such incongruities point up the difficulties of applying the original oath to present day medical care. Many institutions bypass the problem altogether by administering oaths which are entirely modern in content, but which are titled Hippocratic.19
Who takes the oath?
Surveys show that about half of the medical schools in the United Kingdom and almost all of those in the United States administer an oath of some kind, mostly at graduation but occasionally earlier, a few at the outset of medical studies. Some use a modernised version of the Hippocratic Oath or of the Prayer of Maimonides, others use the Declaration of Geneva (box), and others still, their own institutional oath. The process of oath taking differs: some schools ask for graduands' affirmation by signature, in others the oath is read out or students recite it together during the graduation ceremony.6 9 19 The question of how voluntary such oath taking is has not been well documented. We have heard of no students who have opted out, or what would happen if they so chose.
Oaths and ethics
To the extent that oaths indicate a commitment to firm moral parameters, their affirmation may strengthen doctors' resolve to behave with integrity in extreme circumstances. This was the finding of a BMA working party investigating medical involvement in and resistance to human rights abuses. This group recommended that “medical schools incorporate medical ethics into the core curriculum, and that all medical graduates make a commitment, by means of affirmation, to observe an ethical code.”21
In the United Kingdom the GMC's code Duties of a Doctor has evolved over time in response to alleged breaches of its guidance, changes in the organisation of health care, new law, and changing mores in society.22 Since it has a statutory basis and carries great professional authority, what could swearing an oath add to it?
We have not located any studies which examine whether oath taking affects doctors' competence to deliberate effectively on ethical matters. The main intention of a medical oath seems to be to declare the core values of the profession and to engender and strengthen the necessary resolve in doctors to exemplify professional integrity, including traditional moral virtues such as compassion and honesty. Oaths also provide moral orientation through rule-like precepts and prohibitions, from which generalities the practitioner is left to infer or extrapolate to the specifics of everyday practice. Medical codes on the other hand seek to clarify the means by which such moral ends can be achieved, by offering guidance for everyday practice, outlining applicability in exemplary cases together with grounds for identifying exceptions. Affirmation of an ethical code by means of an oath therefore permits the oath to contain within its remit a supplementary field of guidance.
Others at the bedside
All the medical oaths and codes we have considered are traditionally viewed as relating only to doctors, although there is a suggestion that the Hippocratic Oath was originally designed to be taken by doctors' assistants and associates.23 But many of the moral difficulties in present day health care arise in the context of complex organisations in which other members of the healthcare team are bound by different codes of conduct (or by none at all), perhaps with conflicting responsibilities and obligations. Some of these people have the power to influence clinical decisions since they represent and are answerable to powerful third parties (government, insurance companies, NHS trusts, health maintenance organisations) which have determinative influence on the care doctors can provide.
More than one medical commentator has used parody to predict the impotence of any new Hippocratic oath in these circumstances:
“Whatsoever I shall see or hear of the lives of men that is not fitting to be spoken, I shall document fully in their charts so that complete, problem-oriented records may be available for any insurers, legal counsellors, or government agencies that may become involved … I will exercise my art not solely for the cure of my patients but will take into account the return-on-investment, the cost-benefit ratio … since, in the overall picture society will benefit, even though an individual patient may suffer some hardship or relapse.”24
A pan-professional oath?
Such problems are clearly not for doctors alone to resolve. The American Academy of Arts and Sciences has recently instigated a transatlantic initiative to create a shared ethical code for health carers (see editorial in this issue by Berwick et al). It outlines a number of serious dilemmas which require the concerted attention of all healthcare professions and which would benefit from open public debate. Is it ethical to exclude specific treatments from healthcare coverage or service packages? Is it ethical to keep information secret which might benefit all patients everywhere but which provides an organisation with a competitive advantage? Can it be ethical to care selectively for less sick patients instead of more sick ones because of political or financial imperatives?
If a pan-professional oath were to be established it could engender a positive degree of moral cohesion between all caring professions, across institutional boundaries, influencing perhaps even the organisation of health care. This is the lesson to be drawn from the American Medical Association's recent attack on the ethical impropriety of so called gag clauses, which seek to place contractual constraints on doctors' freedom of speech. After the association's intervention, several health plans in the United States immediately removed such clauses, and more than 100 submitted their contracts to the association for ethical review.25
The hope is that a single oath for all health care professions could heal split loyalties and ameliorate existing moral tensions in health care. The intention is honourable, and no one should underestimate the difficulty of the task. A comparison of existing codes for non-doctors and the recent BMA draft revision of the Hippocratic Oath (box) might serve as a good starting point for exploring common ground. It bodes well, we think, that, like the doctors' oath, the conduct codes of nurses and managers place patients' welfare paramount.26 27 The challenge, then, may not be one of agreeing ends, but means. Agreeing on such an oath would provide an inclusive opportunity for healthcare workers from different walks of life to speak with one voice for the benefit of patients.
Draft revision of the Hippocratic Oath
“The practice of medicine is a privilege which carries important responsibilities. All doctors should observe the core values of the profession which centre on the duty to help sick people and to avoid harm. I promise that my medical knowledge will be used to benefit people's health. They are my first concern. I will listen to them and provide the best care I can. I will be honest, respectful and compassionate towards patients. In emergencies, I will do my best to help anyone in medical need.
“I will make every effort to ensure that the rights of all patients are respected, including vulnerable groups who lack means of making their needs known, be it through immaturity, mental incapacity, imprisonment or detention or other circumstance.
“My professional judgment will be exercised as independently as possible and not be influenced by political pressures nor by factors such as the social standing of the patient. I will not put personal profit or advancement above my duty to patients.
“I recognise the special value of human life but I also know that the prolongation of human life is not the only aim of health care. Where abortion is permitted, I agree that it should take place only within an ethical and legal framework. I will not provide treatments which are pointless or harmful or which an informed and competent patient refuses.
“I will ensure patients receive the information and support they want to make decisions about disease prevention and improvement of their health. I will answer as truthfully as I can and respect patients' decisions unless that puts others at risk of harm. If I cannot agree with their requests, I will explain why.
“If my patients have limited mental awareness, I will still encourage them to participate in decisions as much as they feel able and willing to do so.
“I will do my best to maintain confidentiality about all patients. If there are overriding reasons which prevent my keeping a patient's confidentiality I will explain them.
“I will recognise the limits of my knowledge and seek advice from colleagues when necessary. I will acknowledge my mistakes. I will do my best to keep myself and colleagues informed of new developments and ensure that poor standards or bad practices are exposed to those who can improve them.
“I will show respect for all those with whom I work and be ready to share my knowledge by teaching others what I know.
“I will use my training and professional standing to improve the community in which I work. I will treat patients equitably and support a fair and humane distribution of health resources. I will try to influence positively authorities whose policies harm public health. I will oppose policies which breach internationally accepted standards of human rights. I will strive to change laws which are contrary to patients' interests or to my professional ethics.”11
We thank the BMA's ethics department for help in locating information for this paper.