The idea that a code of professional conduct dating to the ancient Iron Age could possibly retain any relevance in our modern era seems preposterous. Yet, the challenges of contemporary health care mean that the ideals of the Hippocratic Oath,1 first formulated in Greece almost 2,500 years ago, remain as important today as then. Human technology has changed dramatically in the last 25 centuries; human nature has not.
Many contemporary medical ethicists dismiss the original oath as irrelevant because of the enormous scientific, social, economic and political changes since Hippocrates’ time. Critics hold several of its tenets to be incompatible with modern medicine — for example, swearing by the Greek gods, and the perceived prohibitions of surgery, euthanasia and abortion. But one could argue that it is more relevant today than at any time in the past.
“I will not give a drug that is deadly to anyone if asked” is often interpreted as a prohibition of euthanasia (a “good” death or peaceful death). In ancient Greece, doctors were often used as skilled assassins or poisoners of political enemies, hence the forbidding statement. There was no evidence in Greek medicine of active participation in accelerating death. The meaning of euthanasia as “assisted suicide” was coined much later, in 1869.2 The statement could, however, apply to the participation of physicians in acts of torture, executions and inhumane treatment. Here, the moral stance is unequivocal and condemns any physician or medical association that is complicit in, collaborates with, conceals or aids in torture.3
In forbidding surgeries, the oath states, “I will cede this [surgery] to men who are practitioners of this activity.” The oath does not disavow surgery itself. It asks us to practice our best as we know it, but to be humble and seek expert advice as needed.
“I will not give a woman a destructive pessary” is interpreted as a prohibition of abortion. The prohibition only mentions the pessary, a soaked piece of wool inserted in the vagina to induce abortion, and which could cause lethal infections. The objection was perhaps to the specific dangerous method rather than a moral objection to abortion, but this remains an area of debate.
The oath forbids sexual contact with patients and addresses maintaining patient confidentiality. These tenets remain as valid today as in ancient times.
The most inspiring and important statements of the oath address harm and injustice: “But from what is to their harm and injustice I will keep them.” Preventing personal and social injustice is a major theme of the oath, which contains two passages related to injustice.
Physicians generally shy away from issues of social injustice and have commonly organized against efforts that address the lack of affordable health care and opposed beneficial reforms that may have affected their incomes.4
Today, we face two major issues in health care: universality and cost. Stated simply, lack of health care for a portion of our patients causes differential health care (social injustice) and medical harm. High costs of health care and high drug prices prevent patient access to them, thus causing harm. The Hippocratic Oath requires physicians to address and advocate for a universal health care and for lower and affordable health care costs and drug prices.
Every physician in the United States knows of patients who were denied access to health care, received delayed treatment, or were harmed or humiliated by the process.
In this context, the Affordable Care Act offers many advantages: millions more people insured; coverage for children up to the age of 26 years; protection against insurance denial for pre-existing medical conditions or cancelling insurance because of sickness; no capping of care received annually or in a lifetime; no denial of coverage on clinical trials, etc.
As with many endeavors of this magnitude, such as Medicare and Social Security, there are many problems associated with the Affordable Care Act. The initial experience with HealthCare.gov was problematic; administrative issues persist and frustrate. It is yet unclear whether the Affordable Care Act, implemented as planned, will actually raise or lower the costs and inefficiencies of the U.S. health care system. However, the older system left too many citizens out of the health care safety net and rendered them highly vulnerable in case of sickness. Physicians should support the preservation of the Affordable Care Act, but also ask that future health care coverage be universally available to all citizens. Today, all developed nations consider universal access to affordable health care as a moral obligation, part of social justice — everyone except the United States.
Health care coverage and cost of health care are enormous problems facing our society. In addressing them, physicians should put patients, our most sacred duty, first. Perhaps the Hippocratic Oath should begin with: “I swear by what is most sacred, my patients.”
Endnotes
1. Heinrich von Staden, “‘In a pure and holy way’: Personal and Professional Conduct in the Hippocratic Oath,” Journal of the History of Medicine and Allied Sciences, 51 (1996): 406-8.
2. William Lecky, “History of European Morals,” in The Compact Oxford English Dictionary, 2nd ed., (Oxford: Clarenden Press, 1991).
3. Anne-Marie Audet, “The Role of the Physician and the Medical Profession in the Prevention of International Torture and in the Treatment of its Survivors,” Annals of Internal Medicine, 122 (1995): 607-13.
4. Paul Starr, “What happened to Health Care Reform?” The American Prospect, 20 (1995): 20-31.
Hagop M. Kantarjian, M.D., is the Baker Institute Scholar in Health Policy. He serves as a professor and chair of the Department of Leukemia at The University of Texas MD Anderson Cancer Center, where he is also the Kelcie Margaret Kana Research Chair and associate vice president for global academic programs.