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Careers

Is the Hippocratic oath still relevant to practising doctors today?

BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6629 (Published 14 December 2016) Cite this as: BMJ 2016;355:i6629
  1. Kathy Oxtoby
  1. kathyoxtoby{at}blueyonder.co.uk

Abstract

Doctors have so many different views about what professional oaths mean, says Kathy Oxtoby, that it could be time to consider what they should say or if they should take an oath at all

“I swear by Apollo the Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.”

This pledge from the Hippocratic oath—written nearly 2500 years ago—forms part of the most famous text in Western medicine. An oath historically taken by physicians, it requires readers to swear by the healing gods that they will uphold specific medical standards.

Meaningful, memorable, irrelevant?

Some clinicians see the oath as a rite of passage, others can’t remember taking it, and some think it is irrelevant. Whether doctors view it as meaningful or not, the oath still has the power to encourage debate, prompting them to consider what kind of vow would uphold the standards of their profession, or even if they should take a vow at all.

Medical students usually take an oath when they graduate but there is no standard approach across the UK. Some universities—like Aberdeen and Dundee—use a modified version of the original, while Bristol uses the “Bristol Promise,” which is said en masse out loud on the day of graduation (see box).

Different variations of the Hippocratic oath are taken by doctors around the world. A version created in the 1960s is used in the US, for example, while in Pakistan doctors adhere to the original oath.

Doctors’ experiences of taking an oath at their graduation ceremonies also vary. Some may not remember the exact words but can still remember how this rite of passage made them feel.

David James, chair of the Royal College of Paediatrics and Child Health trainees’ committee, qualified in 2006. While he doesn’t remember which version of the oath that he took, he does recall that it was “a serious and appropriate initiation into medicine.”

Deji Jaiyesimi, a paediatric specialty trainee year 3 based in Colchester, doesn’t recall taking the Hippocratic oath at his graduation ceremony five years ago. But he does remember talk during the ceremony of what was expected of doctors. “It was more than a ceremony—it made me feel I was entering into a special profession, and that I must do the best I could to support patients. The experience was inspirational,” he says.

Scarlett McNally, a consultant orthopaedic surgeon in East Sussex, didn’t take the Hippocratic oath when she graduated from Cambridge University in 1989, “because it wasn’t considered important at the time.” However, her work teaching at Brighton Medical School has highlighted why pledging an oath is a valuable experience for doctors.

“The graduation ceremony at the school is very moving. All the graduates who are about to become doctors say an oath together in front of their friends and family,” she says. “It’s lovely to have something that represents your move from one state to another, that shows that you need to step up to a different level, and that sets out your responsibilities and what’s expected of you.”

A moral compass

David Warriner, a clinical fellow at the Academy of Medical Royal Colleges, regards the oath as “a moral compass.”

“It helps you with circumstances you face where you’re not sure what to do,” he says. “It also gives you a sense of pride and purpose in terms of the wider scope of medical practice and the importance of putting patients at the heart of decisions you make, which we can forget sometimes.”

For Warriner, the original oath still resonates, particularly the phrase: “I will utterly reject harm and mischief,” which is commonly misquoted as “First do no harm.” He says, “For me that fits perfectly with not over diagnosing, not over treating, and sharing decision making.”

He finds the vow, “I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being,” which was included in the 1964 version of the oath, particularly meaningful. “When I teach juniors about how to help patients I remind them these are not blood tests—they are people,” he says.

In the age of social media, the revised Hippocratic oath also seems valid when it asks doctors to pledge: “I will respect secrets confided in me.” Warriner cites examples of clinicians posting pictures of patients on social media. “This space is a public forum so respect patients and think about whether you would want that done to your parents—so don’t do it,” he says.

One of the difficulties with the original oath is that medicine is constantly changing—along with people’s values and beliefs—and some of the central tenets no longer seem to fit (see box). For some, the oath may still chime as a guideline for best practice. For others the General Medical Council’s (GMC) Good Medical Practice guidelines are more applicable.

While appreciating the historical value of the Hippocratic oath, Judith Harrison, a clinical academic training fellow and a specialty trainee year 4 in psychiatry in Cardiff, says that GMC guidance has superseded it. “The oath is a useful record of how medical ethics have developed. But the GMC’s good practice guidelines go into more detail, have evolved through case law and disciplinary hearings, and are regularly reviewed,” she says.

Doctors have different views about what professional oaths mean and it could be time to consider what they want their oath to say—or if they wish to take an oath at all.

Sue Bailey, chair of the Academy of Medical Royal Colleges, is a supporter of the oath. “It reminds you why you’re doing medicine, what you should be doing every day, and when dealing with work pressures it acts as a safety valve and mitigates risk should you feel you are going against your oath,” she says. But she says that it could be time to have “an informed conversation” about what a doctor’s oath should look like.

“While the oath is still relevant, we need to respect how things might change,” she says. “So it would be interesting to think about what the Hippocratic oath will look like in a hundred years’ time, and whether its basic principles will stand the test of time.”

Regulated by law and the GMC

Some clinicians do not believe that doctors should take an oath at all. “I don’t think any doctor should swear any oath,” Clare Gerada, a GP partner in London, says. “We are not royalty or priests, but health professionals doing a job, regulated by law and the GMC. That should be enough.” She would like to see “a new charter to take account of the changing and transformational times we are in.”

“We have to have more honesty about the roles and responsibilities and extent of these for health professionals,” she adds. “Doctors should not be expected to sacrifice their lives for their patients, or to make their patients their first concern. I am not saying that doctors abandon patients when their shift is up, but we must ensure that policy makers do not expect doctors to make all the sacrifices and be worked literally to death.”

She suggests a charter that both patients and doctors could sign together, pledging to use healthcare resources wisely, and to take care of their own health. “It would be a charter for not just doctors, but for all of us.”

Warriner suggests that experienced doctors could consider retaking an oath. “It would be like reaffirming marriage vows: an opportunity to reaffirm you belief in making your patient the first consideration,” he says. “That belief is still spot on.”

History of the oath

Attributed to the Greek physician and teacher Hippocrates of Kos—who is often called the father of medicine—the true author of the oath is unknown, and there may have been several authors.

After Greek political power fell and the influence of the Hippocratic school faded, the oath fell into obscurity for nearly 2000 years. It was rediscovered by medieval Christian scholars and in 1508 was used in a ceremony at the University of Wittenberg.

By 1750 the Hippocratic oath had been translated into English and other European languages, and for several centuries a version of the oath was recited by graduating doctors.

As the practice of medicine has changed so have the oaths taken. One of the most significant revisions was first drafted in 1948 by the World Medical Association (WMA), called the Declaration of Geneva.

After the second world war the WMA took responsibility for setting ethical guidelines for the world’s doctors. Crucially, the WMA oath contains the pledge: “I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient.”

In the 1960s, the original Hippocratic oath was again modified by Louis Lasagna, academic dean of the school of medicine at Tufts University in the US. Lasagna’s oath was a secular version which was not to be taken in the presence of God or any gods.

The Bristol promise

Richard Huxtable, professor of medical ethics and law and director of the Centre for Ethics in Medicine from the school of social and community medicine at Bristol University, describes why Bristol medical students have their own oath:

“The ethics centre was created in 1996 in Bristol, and its first director professor, Alastair Campbell, was approached by medical students who wanted to create, in collaboration with his ethics colleagues, an oath that they could take together on graduation.

“It was very much a staff and student initiative. The “promise” was driven by the need to collectively recognise the values that would guide graduates’ careers.

“Twenty years on, the promise remains one of the most powerful moments in the medical school year. Students take the promise at the start of their studies and then again more formally on graduation day, along with staff.

“The values of the promise include: conscience, integrity, confidentiality, and to care for the public’s wellbeing.

“I would invite colleagues to look to what their students want as future professionals when they take an oath. Some may feel their current oath is sufficient, but you should be mindful of changing values and open to the fact that these might change as medical practices evolve.

“At the same time you should acknowledge values that are core to medical endeavour, such as maintaining confidences, avoiding harm, and respecting people’s rights.

“It’s about keeping the essence of the original oath, whilst keeping an eye on future horizons.

Every year we tell students the story of how the promise evolved, to convey how this was not something imposed from on high, but was a collaboration between students and staff.

“I feel privileged to take students through the oath each year.”

www.bristol.ac.uk/media-library/sites/medical-school/migrated/documents/promise.pdf

A calling

Cosmo Hallstrom, a fellow of the Royal College of Psychiatrists, graduated in medicine in 1971. He remembers the original Hippocratic oath being displayed in the common room at medical school. He didn’t attend his graduation where classmates swore the oath together, but he does believe in it.

“It reminds me of the longstanding tradition of medicine—that it evolved from ancient times, of its ancient mysteries, and the importance of continuing that noble tradition,” he says.

He says that the problem with the original Hippocratic oath is that “much of it is quite inappropriate these days.”

He gives examples such as “I will not cut”—a vow then aimed at physicians, which would be an impossible commitment in today’s medical profession. “I will not give to a woman a pessary to produce abortion,” is also no longer a pledge many doctors feel comfortable adhering to.

However, Hallstrom endorses the revised 1964 oath, particularly its last line where doctors vow to “always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.”

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