The End of the Hippocratic Oath and Why It Should Still Matter
- Post by: Cynthia Jones-Nosacek
- June 24, 2018
1. I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea and all the gods and goddesses as my witnesses, that, according to my ability and judgment, I will keep this Oath and this contract:
2. To hold him who taught me this art equally dear to me as my parents, to be a partner in life with him, and to fulfill his needs when required; to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract; and that by the set rules, lectures, and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to students bound by this contract and having sworn this Oath to the law of medicine, but to no others.
3. I will use those dietary regimens which will benefit my patients according to my greatest ability and judgment, and I will do no harm or injustice to them.
4. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.
5. In purity and according to divine law will I carry out my life and my art.
6. I will not use the knife, even upon those suffering from stones, but I will leave this to those who are trained in this craft.
7. Into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or corruption, including the seduction of women or men, whether they are free men or slaves.
8. Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.
9. So long as I maintain this Oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of all men for all time. However, should I transgress this Oath and violate it, may the opposite be my fate.
It comes as a surprise to many that the traditional Hippocratic oath is no longer sworn by a majority of medical students upon graduation. In 2009, it was found that only 11% of schools use the classic version. While about half of medical schools do still officially take some version of the Hippocratic Oath, only one of these versions had a prohibition against abortion, six against euthanasia, and four against sexual contact with patients. Forty-five percent had more than one option of oath for students to choose from.
So why is taking an oath in this day and age, particularly the Hippocratic Oath, so important? What difference does it make in patient care? Why is this oath so radical? And what does its demise spell out for supporters of the family?
Some Historical Background
The Hippocratic Oath was written in the fourth or fifth century B.C., though probably not by Hippocrates himself (there may have been several authors). Strongly influenced by Pythagorean philosophy, the teachers at the medical school on the island of Cos began a body of writings on the idea that medical treatment can be based on observed knowledge instead of divine intervention. Thus the main virtue was practical knowledge. It called upon the healing gods Apollo, Asclepius, Hygieia, and Panaceia and bound student to teacher. While the original oath does not contain the phrase “first, do no harm,” it does set forth certain obligations, such as beneficence (acting in the patient’s best interest), non-maleficence (avoiding hurting or harming the patient), and confidentiality. Along with the prohibitions against abortion, euthanasia, and sex with patients, it was also a promise to live a pure and holy life.
The Oath is part of the Hippocratic Corpus, a series of 60 writings on various medical topics written by several authors over the centuries covering the areas of diagnosis, epidemics, obstetrics, pediatrics, and surgery. These writings often give contradictory advice. From Greece, these ideas spread throughout the Mediterranean and even as far east as India. With the fall of the Roman Empire, much of this knowledge was lost in the West, but Byzantine Christians continued the oath. As evidence of this, one fourth-century Byzantine physician has the oath written on his tombstone, with a Christian preamble and in the shape of a cross.
In Western Europe, these texts were rediscovered, first by the Crusaders through their contact with the Muslims and later when Byzantine scholars fled to Italy with the fall of Constantinople to the Muslims in 1453. While European physicians eventually began to question the texts themselves, especially with their idea of various “humors” or bodily fluids being out of balance, the ethical standards remained.
In the United States, the American Medical Association (AMA) took the Oath as its inspiration when it developed its code of ethics in 1847 (though the AMA itself actually attributes their version to the work of the English philosopher-physician Thomas Percival). The latest publication on the history of the AMA code refers to Hippocrates as founder of the “goal of medicine as a profession . . . to relieve suffering and promote well-being in a relationship of fidelity with the patient.”
Modern Medical Bioethics
The modern study of medical bioethics began after the horrors of World War II. While Nazi physicians did not take the Hippocratic Oath, they used it as their defense during the Nuremberg trials. Dr. Fritz Klein, who was hanged for his experiments at Bergen-Belsen, stated that he wanted “to preserve human life. And out of respect for human life, I would remove a gangrenous appendix from a diseased body. The Jew is the gangrenous appendix in the body of mankind.” In their minds, knowledge for the benefit of humanity overrode the needs of the individual.
The response to these atrocities was the creation of the Nuremberg code and the Declaration of Geneva. However, abuses continued to occur. One example is the Tuskegee Syphilis Experiment, wherein African-American men in prison who were infected with syphilis were left untreated and observed by physicians in the U.S. Public Health Service without their consent between 1932 and 1972. In another example, tissue was removed from patients and experimented upon, sometimes making the researchers wealthy. Finally, there was the Willowbrook hepatitis experiment, wherein mentally disabled children were purposely infected with hepatitis either by being fed fecal extracts (thus discovering how Hepatitis A, also known as infectious hepatitis, was spread) or by being injected (Hepatitis B or serum hepatitis), all between 1956 and 1970.
Coinciding with some of these atrocities, there was in society a general loss of faith in authorities, including those in the medical profession. In 1966, 73% of Americans had “great confidence” in the leaders of the medical profession; by 2012, that number had dropped to 34% overall, and even lower among low-income patients.
All of this led to changes in the field of bioethics. While the ideals of beneficence and non-maleficence were retained, patient autonomy as a specific principle was added as an ideal as well. Patient autonomy is defined as “what makes a life one’s own . . . that is shaped by personal preferences and choices.” The patient thus has the right to decide whether or not to do what the physician recommends. In other words, the physician cannot force compliance.
In addition to these obligations to the patient, new obligations to society are now understood to flow from the principle of justice, which used to refer to the patient alone. From this principle comes not only fair, equitable, and appropriate treatment of patients, but also fair, equitable, and appropriate distribution of resources.
While all of these are goods within themselves, the problems occur when these goods conflict; this is where the rubber meets the road for advocates of the natural family. Such conflicts happen more and more in our modern world, which upholds vastly different moral guidelines regarding sexuality and the beginning and end of life. Medicine is an applied science, meaning information is interpreted and applied to the particular patient. And where there are conflicts between patient, physician, and even society, which value prevails? When a boy tells his parents he wants to be a girl, and his parents object, does his physician intervene? Where there are no common core societal values, who decides such matters? If Drs. Stahl and Emmanuel, among others, had their way, it would be the patient and medical associations. According to this view, if a physician objected to, say, performing an abortion, then he/she should either perform the procedure anyway, move to another specialty, or leave the profession altogether. While acknowledging that even medical societies (and patients) can make mistakes, nevertheless, in this view, their values take precedence over those of the individual physician (or groups of physicians). Christian Fiala and Joyce Arthur call conscientious objection “dishonorable disobedience.”
Considering, though, that medical societies in the past have supported eugenics, should they always be one of the two arbiters? And if the other is patient autonomy, the parents of the children at Willowbrook signed consent papers. What about the “dishonorable disobedience” of those who fought against genocide or blew the whistle on Willowbrook? Should they have abandoned the field to those who held the “right” opinion?
And what happened to the Hippocratic Oath during this period? Obviously, as women entered the field, there were complaints about the phrase about treating the sons of physicians as “equal to my brothers in male lineage.” Others did not want to make a vow to pagan gods. While Pellegrino admits the need for taking an oath as a public promise and sign of formal entry into a profession, he also criticizes the oath as something which protected the medical guild—loyalty to the group above patient welfare. And though there is an emphasis on the duties owed by a physician to a patient, there was no mention of the collective responsibility to the health of society. Others commented on the lack of input in the writing of the oath by those who were at the receiving end of a physician’s services.
Alternative oaths have consequently been proposed. Some adopted the Declaration of Geneva (World Medical Association, see Addendum #2). In 1964, Dr. Louis Lasagna wrote an oath known as the Modern Physicians’ Oath, which is used by many medical schools (see Addendum #1). Neither carries a prohibition against abortion or euthanasia, with the Declaration of Geneva dropping any mention of respecting life from conception. In 1995, a group of 35 pro-life Jewish, Protestant, and Roman Catholic bioethicists and physicians, including C. Everett Koop, revised the Hippocratic Oath for modern times to include such concepts as “valid informed consent,” as well as the “legal protector” of those undergoing research (see Addendum #3). A further revision in 2009 conformed the oath more to the original (see Addendum #4).
So why take an oath? An oath, according to Merriam Webster, is “a solemn usually formal calling upon God or a god to witness to the truth of what one says or to witness that one sincerely intends to do what one says.” It is a public promise marking formal entry into a profession.Nowadays, unfortunately, most students take it lightly. Among those students who take any kind of oath, only 26% feel that doing so has a strong influence on their behavior, with 92% relying instead on their own sense of right and wrong. Next in importance comes “great moral teachers” (35%). Most see the oath as a ritual, its only value in its tradition. In this throwaway culture, this is perhaps not surprising. Also not surprising is that those for whom religion was “most important” or “very important” were more likely to say that the oath influenced them “a lot.”
So why take an oath? When properly sworn, it becomes a basis of common ethical values for the participants, a mutual and collective response. The Hippocratic Oath states that physicians have responsibilities that set them apart from everyone else. The oath makes medicine a vocation where, in the Catholic tradition, one works out one’s personal salvation by serving others.
So why take an oath? And what is it about the Hippocratic Oath that caused St. Pope John Paul II to state that it was “the intrinsic and undeniable ethical dimension of the health-care profession . . . which requires every doctor to commit himself to absolute respect for human life and its sacredness”? Perhaps if we go back to the original Hippocratic Oath and compare it to its modern versions, we can see why it should still matter.
For the sake of convenience, the Modern Oath of Lasagna will be referred to henceforth as “the Lasagna Oath,” the Physicians’ Pledge as “the Declaration of Geneva,” and the revisions of 1995 and 2009 by those years they were published. The quotations below come from the version of the original Hippocratic Oath as stated in the beginning of this essay. Each line or paragraph of each oath has been numbered as well for ease of reference.
The Hippocratic Oath
1. “I swear by Apollo the Physician, and Asclepius, and Hygieia and Panaceia and all the gods and goddesses as my witnesses, that, according to my ability and judgment, I will keep this Oath and this contract. . . . So long as I maintain this Oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of all men for all time. However, should I transgress this Oath and violate it, may the opposite be my fate.”
The original oath demanded witnesses, and sacred witnesses at that—someone with enough power to hold one to one’s promise and carry out punishment if it were not done. Most modern oaths, while they “solemnly pledge” (Declaration of Geneva, line 1) or “swear to fulfill” (Lasagna Oath, line 1), name no specific witnesses and have no penalty for violation of their terms (though the Lasagna Oath does state that “if I do not violate this oath, may I enjoy life and art, respected while I live, and remembered with affection thereafter,” line 10). While both the 1995 (line 1) and 2009 (line 1) oaths swear before God, only the 1995 oath demands witness of both God and family with the curse that the “reverse be my lot” if this vow is broken (line 6).
2. “To hold him who taught me this art equally dear to me as my parents, to be a partner in life with him, and to fulfill his needs when required, to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract; and that by the set rules, lectures, and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to students bound by this contract and having sworn this Oath to the law of medicine, but to no others.”
These lines obviously were written at a time when the physician was, by definition, male. Also, in a time where there were no 401k accounts or retirement pensions, supporting one’s teachers in their old age as one would support one’s parents acted as a form of “social security” for the teacher. And in a time when there were no medical schools, and professions were traditionally passed literally from father to son, this made sense. But even in the 21st century, modern oaths recognize the need for respect (Lasagna Oath, line 2; Declaration of Geneva, line 9) and even gratitude (Declaration of Geneva, line 9).
While there are complaints about the Oath commanding the hoarding of secrets (while all the other oaths go into detail about the obligation to share knowledge), perhaps another interpretation is that medicine is not for just anyone. When asked to list the qualities of the ideal physician, patients list attributes such as confidence, empathy, forthrightness, humaneness, personableness, respectfulness, and thoroughness. Thus, the ideal physician is not only knowledgeable, but compassionate and moral as well—in a sense, following the Oath.
3. “I will use those dietary regimens which will benefit my patients according to my greatest ability and judgment, and I will do no harm or injustice to them.”
Here is where beneficence and non-maleficence come in. The physician vows to do whatever is best for the patient. At the time of Hippocrates, therapeutic options were limited, but the ultimate end is still the same. Care is to be given “to my greatest ability” (emphasis added). Because each patient is different, judgment is called for. But on the other hand, I cannot intentionally do anything that would harm patients or treat them unfairly—nothing less than the best for my patients.
All the other oaths agree. The Lasgna Oath vows that the physician will work for the “benefit of the sick all measures” (line 3), that there “is art to medicine as well as science” and the physician treats “a sick human being”(line 7). It also mentions that preventing disease is preferable to treating it (line 8) and counsels physicians to avoid the “twin traps of overtreatment and therapeutic nihilism” (line 3). The Oath of Geneva counsels that the physician first consider “the health and well-being” of the patient (line 2) and commands that “no consideration . . . [will] intervene between my duty and my patient” (line 5). The 1995 oath states that the physician will treat “according to my ability and judgment,” and will choose a treatment which is for the benefit of the patient (line 3). The 2009 oath states that “I will always seek the healing and comfort of those who are sick” and adds the word “medical” before judgment (line 3).
As stated previously, there is nothing in the Hippocratic Oath or 2009 revision about a physician’s responsibility to society. The Lasagna Oath references a physician as a member of society with special obligations to “those of sound mind and body as well as the infirm” (line 9). The Declaration of Geneva has as its first pledge “to dedicate my life to the service of humanity” (line 1), then later mentions that practicing with “conscience and dignity” must also be in accordance with “good medical practice” (line 7), which could include the definitions of Ezekiel Emmanuel. The 1995 oath only states that care for one person must not compromise the treatment of another (line 2).
I would argue that the original Hippocratic Oath and the 2009 revision have it right when it comes to the responsibilities of the physician to society. Certainly, things such as poverty, racism, sexism, etc. can affect the treatment of the patient, but they are important only when they directly do so. When a physician takes his or her eyes off of the patient and looks to the greater good of society, that is when abuses such as Dr. Klein as well as the Tuskeegee and Willowbrook experiments occur. And society can only be improved when each patient is helped—mind, body, and soul.
That being said, Catholic moral teaching has always differentiated between ordinary/proportionate versus extraordinary/disproportionate treatment. As directive 57 of the Ethical and Religious Directives (ERDs) states: “A person may forgo extraordinary or disproportionate means of preserving life. Disproportionate means are those that in the patient’s judgment do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the family or the community.” Excessive burdens include great effort (moving a great distance for a particular treatment), severe pain (where the burden of the pain of the treatment is greater than what the patient can bear), exquisite means and great expense (patients are not expected to bankrupt themselves or their families for care nor obligated to try unproven treatments), and repugnance (dread of a treatment, especially where mutilation will occur). However, proportionate is not proportionalism where all actions are defined as neutral (including abortion and euthanasia) and thus the only criteria is the weighing of risk versus benefit. Thus, not only must a patient and physician have a good intention to desire a good result, but the means used to obtain that result must be good or neutral as well. For example, it is a good thing to want a home and shelter for one’s family. You cannot murder the previous owner to get it.
4. “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.”
Simply stated, it is not a physician’s role to actively take a life. All life is precious and of infinite value from the moment of conception to natural death. To think otherwise is to give in to the now-common lie that some human beings are of more value than others. Unfortunately, societies have told this lie throughout the ages. From slavery to abortion, the world has ruled that some lives are worth more than others to the point that some human beings—the embryo, the fetus, the baby, the aged, the infirm, the disabled—have no rights at all.
To think otherwise—that all life is not precious and of infinite value—also blurs the line between healing and killing. The physician, on one hand, can heal the patient. The physician may also decide to take that patient’s life. This decision may be with the patient’s permission, such as in instances of doctor-prescribed death (more commonly known as physician-assisted suicide), or without it (abortion). But in either case, the physician has to agree that this human life does not deserve to continue.
Some bioethicists such as Ezekiel Emmanuel and organizations such as the American College of Obstetricians and Gynecologists (ACOG) state that not only should the physician refer for an abortion, but he/she has a duty to do so. However, even the act of referral implicates the physician. It is no different than a woman coming to me wanting to kill her husband; I refuse to help her, but give her the name of Jimmy the Snake. Even if someone else thinks that the taking of a human life is not immoral under certain circumstances, I should not be forced to cooperate.
Euthanasia is very different from prolonging the dying process (for example, removing a ventilator from a patient who has severe lung disease). However, this difference does not mean that the physician can abandon the patient and state “there is nothing I can do.” There is always something a physician can do, even if it means simply holding the hand of a dying patient.
Of course, the 1995 oath has the same restrictions, adding that the physician will not only not perform those procedures, but will not counsel doing such a thing “nor perform act or omission with the direct intent deliberately to end a human life” (line 3). The 2009 revision is simpler, more concise, and in line with available modern methods (for example, surgical abortions), stating “I will not help a patient commit suicide; neither will I help a woman obtain an abortion” (line 4). While the initial Declaration of Geneva included the promise to protect life “from conception” in 1948, the latest version from 2017 merely states that the physician “will maintain the utmost respect for human life” (line 4). The Lasagna Oath is silent on abortion and euthanasia, but it does state “it may also be within my power to take a life,” and commands that the decision be faced “with humbleness and awareness of my own frailty” while not “play[ing] at God” (line 6).
Pro-abortion advocates erroneously state that this restriction results in direct threats to women’s health and life, specifically in the case of ectopic pregnancy. Politicians have also erroneously stated that if abortion was illegal, ectopic pregnancy would not be treated. This is simply false. Treating an ectopic pregnancy falls under the Catholic understanding of “double effect,” wherein one can have a good effect (in this case, the treatment of a diseased fallopian tube) with the unintended evil consequence (the death of the embryo), as long as certain conditions are met. The intent must be good good (a desire to save the life of the mother), the result (more formally known as the end) is good (saving her life), and the treatment (of the diseased fallopian tube) is either good or neutral. Unfortunately, the (good) treatment results in the death of the embryo, an unintended, tragic, but foreseen consequence of that treatment.
5. “In purity and according to divine law will I carry out my life and my art.”
Purity complements the idea that a physician will treat a patient according to his or her “greatest ability or judgment” and avoid harm. More importantly, the physician will refrain from evil intent or means—even if a good end will result, and even if the patient will benefit. But what is purity? In the Greek, it meant clean (like washed clothing) or unadulterated (like milk or wine that is not watered down). It also included the purging of an army of “all discontented, cowardly, and inefficient soldiers.” It is a physician who acts with honesty and integrity. In place of purity, one could substitute “keeping my motives entirely unmixed.” For example, a physician will not recommend a certain procedure merely for financial gain, even though the patient will benefit, especially if there are other methods available that are not as lucrative but are as effective.
But as Pelligrino points out, virtue is expressed according to one’s values. Thus purity needs to be coupled with divine law, also known as natural law. Natural law was initially defended by such philosophers as Plato and Aristotle and further developed in the Christian tradition, especially by Thomas Aquinas. It is applicable to all rational humans, even atheists, and applicable throughout history. Natural law consists not of natural acts per se, though it includes natural actions such as eating and procreation. It is in opposition to the moral relativism that underlies modern society, though as Edward Furton states, “When a relativist suffers an injustice, all talk about the relativity of morality typically goes out the window.” Think of the arguments of Emmanuel and Fiala, et al. earlier. Ultimately, even a relativist believes there are some absolutes; otherwise, murder and rape would not be wrong in themselves, but depending on one’s point of view. This is why we put on trial those who have committed genocide. Some deny the universality of natural law because there is no universal compliance, but this confuses actions with fundamental values. Just because a person or even a society denies or refuses to follow a fundamental and universal law, does not mean that it therefore does not exist. Thus purity of purpose and natural law are needed in tandem.
The Lasagna Oath does not address this need. The Declaration of Geneva merely states that the physician “will practice . . . with conscience and dignity and in accordance with good medicine” (line 7). It is, however, kept almost verbatim in the 1995 (line 4) and 2009 (line 5).
6. “I will not use the knife, even upon those suffering from stones, but I will leave this to those who are trained in this craft.”
Some would insist, tongue-in-cheek, that general surgeons and urologists should not say this oath because of this sentence. However, as stated before, the original Hippocratic corpus, of which the oath is a part, did have a section on surgery.
Knowing the limits of one’s knowledge is part of beneficence. After all, a physician cannot act in a patient’s best interest when going beyond the limits of his or her skills.
The Lasagna Oath states that there is no shame in not knowing or requesting a second opinion (line 5). The Declaration of Geneva does not directly address this topic, but the 1995 version of the Hippocratic Oath does (line 6). The 2009 version states “I will seek the counsel of those with appropriate special skills for the benefit of my patient” (line 6).
7. “Into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or corruption, including the seduction of women or men, whether they are free men or slaves.”
Considering what has already been stated, we would by now all probably nod our heads in agreement with this promise of the physician to enter a home (or exam or hospital room) solely for the benefit of the patient and avoid knowingly harming them. But with our modern ideas of the rights of women and abhorrence of slavery, we do not realize how radical this statement was for the times. In ancient Greece, women had no political rights. Even foreign men and slaves had more. They were under the authority of their husbands or fathers. They could not inherit property or be litigants in a lawsuit. Slaves were property and could be bought, sold, and even beaten by their master. In court, their testimony was only obtained under torture. Varro, a first-century Roman philosopher, called slaves instrumenti vocali, a machine with a voice. And yet, the Hippocratic Oath recognizes that all people, male and female, slave and free, have a certain dignity and humanity, even those who have little or no status in society at large. The best medical care is not just for the male, the rich, or the powerful.
The Oath also recognizes the vulnerability of the patient. Even in this age of patient autonomy, the patient is never an equal partner in the physician/patient relationship. A patient who comes to see a physician is at a disadvantage in three ways. First, the sick patient is in a weakened state, in a sense, forced to give up his or her independence and rely on another. When a patient is under general anesthesia, that dependence is complete. Second, the physician has knowledge that the patient does not have and needs. Finally, even if the patient is a fellow physician, the treating physician still has the power to treat or not to treat, to prescribe a medication or to refuse. The only right the patient has is to refuse what has been recommended. Thus, the patient needs to trust, to some degree is forced to trust, the judgment of the physician. I am only half joking in my standard reply to my staff when a patient is rude to them and sweet as pie to me: The patient knows that I can kill them.
Considering the inequality of the relationship and the power the physician has over the patient, it only makes sense that the most intimate of contact—i.e., sexual—should be avoided. Also, being emotionally involved with a patient can make it difficult for a physician to be objective. Even if the patient consents, the physician should draw back. This is recognized even by Code of Ethics 9.1.1 of the AMA, which has an entire course for physicians to help determine “boundaries.”
Neither the Lasagna Oath nor the Declaration of Geneva address this directly, other than their previous statements about the dignity of the patient (lines 3,7). They are silent about sexual contact as well. But the 1995 and 2009 versions retain it (lines 4,7).
8. “Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.”
Long before HIPAA (Health Insurance Portability and Accountability Act of 1996), there was the Hippocratic Oath. This phrase recognizes not only the absolute need for the patient to trust the physician, but again recognizes the vulnerability of the patient. Patients need to be able to tell physicians their deepest secrets, things they may have told no one else, and know that the information will not be passed on without their permission. When you think about it, the number of people with the potential to be “in the know” is amazing. From the person who takes the information for the appointment to the insurance clerk filing the claim to the insurance company itself, as many as a dozen people may be involved in each medical encounter.
The original oath recognizes that there are limits or, as the converse of the oath would state: “I will not keep secret that which ought to be spoken of outside.” For example, if the patient is suicidal or homicidal, if the information is needed by another health-care professional providing health care, such sharing is necessary. Sometimes, a physician is required by law to report. However, the minimum amount of information that is needed should be given. Whenever possible, the patient needs to be informed that this will be done unless there is an emergency or the patient is unresponsive.
The Declaration of Geneva respects that secrets are confidential even after death (line 6) while the Lasagna Oath respects the privacy of the patient (line 6) and the 2009 requires “strict confidence” (line 8). Only the 1995 version, like the original, has exceptions, vowing to keep secrets “which ought not be spoken abroad” (line 5).
The Hippocratic Oath and Autonomy
So what about patient autonomy? What about the right of a patient to approve—or refuse—the treatment that the physician determines is in the patient’s best interest? Neither the original Hippocratic Oath, the Lasagna, or the 2009 mention the concept of autonomy specifically. The 1995 version mentions not performing any treatment without valid informed consent (line 4). The Declaration of Geneva mentions autonomy specifically (line 3).
So how does patient autonomy come into play? Are the other oaths “benign authoritarianism,” as Pellegrino states? Since he served on the Value of Life Committee that wrote the 1995 version, I am not surprised that informed consent is mentioned. But does the lack of specific mention of the concept of patient autonomy in the other versions really imply that the physician, as long as he or she has the best of intentions, can force the patient to receive care?
I would argue not. There are several reasons why those who speak the oath and follow its precepts must allow the patient to be the final arbiter. In the original oath, the physician vows to do no injustice (line 3), which is echoed in the 2009 version (line 3); refuses to say that any human life is not worth living (both line 4); and respects the vulnerability of the patient (both line 7), with the 2009 demanding specifically that the physician treat the patient with dignity. But most importantly is the reference to divine law in the original (line 5) and holiness in the 2009 version (line 5).
These references are telling. They remind the physician that the patient is made in the image and likeness of God (Genesis 1:27), a reality recognized by Judaism, Christianity, and Islam. The Hebrew word for “likeness of God” is tzel’mam, which means the essence or nature of the thing. Rashi says that it means we are like God in our ability to discern and understand, which Maimonides believes means we can use our intellect to perceive things beyond our senses. Being made in the “likeness of God” means that we are His representatives on earth, his vice-regents as it were. Thus we have the freedom to choose; we have free will. From all of this comes our dignity. So since the patient is another whose nature is in the likeness of God with the ability to discern and to understand, a fellow person who is responsible to God for the stewardship granted over his or her own body, then the physician must allow the patient to have the final say in terms of what treatment is or is not acceptable.
That does not mean, however, that the physician is a puppet to answer to the desires or whims of the patient or even of society. As a fellow human being with his or her own dignity, the physician must stay true to his or her values as well.
What if, after a thorough discussion, the patient insists on carrying through with an abortion, assisted suicide, or even taking antibiotics to treat a viral infection that the physician deems not in the patient’s best interests? Then the physician has a duty to transfer care, but not necessarily to a specific person or clinic who will complete the patient’s desired treatment. After all, “the patient is an independent moral agent who is free to decide where and from whom he or she will seek care.” However, a “general list of other providers or institutions based on geographic vicinity or even area of specialty might be provided; however, the list may not be developed based on the criterion of whether they are known or believed to offer the immoral procedure. In practice, this means that the list must include any providers or institutions that fit the chosen criterion (geography, specialty, both, or other) and also oppose the immoral practice.” By respecting the right of the patient, when fully informed, to make mistakes, the physician honors the dignity of the patient. Otherwise the patient is no more than an object, a slave even, under the control of the physician.
Even in this throwaway culture, the Hippocratic Oath has a place. In a time of relativism, where one period’s pop value is another’s horror (for example, eugenics), a vow based on the fundamentals of attempting to discern what is best for the patient and which looks to the well-being of the patient over the well-being of society remains the patient’s best protection. It also remains the best protection of the family, as it counsels against anti-family, anti-life policies. And for the physician of faith, who makes this vow before God, it remains the bedrock of medical practice.
Cynthia Jones-Nosacek, M.D., is a family practice physician with over 35 years olf experience who is currently practicing in Wisconsin.
Addendum #1—Modern Physicians’ Oath of Lasagna
1. I swear to fulfill, to the best of my ability and judgment, this covenant:
2. I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
3. I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
4. I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.
5. I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.
6. I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
7. I will remember that I 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. My responsibility includes these related problems, if I am to care adequately for the sick.
8. I will prevent disease whenever I can, for prevention is preferable to cure.
9. I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
10. If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I 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.
Addendum #2—The Physician’s Pledge (Declaration of Geneva)
AS A MEMBER OF THE MEDICAL PROFESSION:
1. I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
2. THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
3. I WILL RESPECT the autonomy and dignity of my patient;
4. I WILL MAINTAIN the utmost respect for human life;
5. 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;
6. I WILL RESPECT the secrets that are confided in me, even after the patient has died;
7. I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice;
8. I WILL FOSTER the honour and noble traditions of the medical profession;
9. I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;
10. I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;
11. I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;
12. I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
13. I MAKE THESE PROMISES solemnly, freely, and upon my honour.
Addendum #3—A.D. 1995 Restatement of the Oath of Hippocrates.
(circa 400 B.C.)
1. I SWEAR in the presence of the Almighty and before my family, my teachers and my peers that according to my ability and judgment I will keep this Oath and Stipulation:
2. TO RECKON all who have taught me this art equally dear to me as my parents and in the same spirit and dedication to impart a knowledge of the art of medicine to others. I will continue with diligence to keep abreast of advances in medicine. I will treat without exception all who seek my ministrations, so long as the treatment of others is not compromised thereby, and I will seek the counsel of particularly skilled physicians where indicated for the benefit of my patient.
3. I WILL FOLLOW that method of treatment which according to my ability and judgment, I consider for the benefit of my patient and abstain from whatever is harmful or mischievous. I will neither prescribe nor administer a lethal dose of medicine to any patient even if asked nor counsel any such thing nor perform act or omission with direct intent deliberately to end a human life. I will maintain the utmost respect for every human life from fertilization to natural death and reject abortion that deliberately takes a unique human life.
4. WITH PURITY, HOLINESS AND BENEFICENCE I will pass my life and practice my art. Except for the prudent correction of an imminent danger, I will neither treat any patient nor carry out any research on any human being without the valid informed consent of the subject or the appropriate legal protector thereof, understanding that research must have as its purpose the furtherance of the health of that individual. Into whatever patient setting I enter, I will go for the benefit of the sick and will abstain from every voluntary act of mischief or corruption and further from the seduction of any patient.
5. WHATEVER IN CONNECTION with my professional practice or not in connection with it I may see or hear in the lives of my patients which ought not be spoken abroad I will not divulge, reckoning that all such should be kept secret.
6. WHILE I CONTINUE to keep this Oath unviolated may it be granted to me to enjoy life and the practice of the art and science of medicine with the blessing of the Almighty and respected by my peers and society, but should I trespass and violate this Oath, may the reverse be my lot.
Addendum#4—Hippocratic Oath | 2009
1. In the presence of the Almighty, I promise to keep this Oath to the best of my ability and judgment.
2. Those who have taught me the art of medicine I will respect, and will seek to faithfully impart my knowledge to those who also accept this covenant, and to whom I am a mentor.
3. I will always seek the healing and comfort of those who are sick according to my ability and medical judgment, protecting them from harm and injustice.
4. I will not help a patient commit suicide; neither will I help a woman obtain an abortion.
5. In purity and holiness, I will guard my professional moral integrity.
6. When indicated, I will seek the counsel of those with appropriate special skills for the benefit of my patient.
7. I will always act for the benefit of the sick, treating them with respect and dignity, and avoiding all sexual involvement with my patients.
8. Whatever I may see or hear about my patients, I will hold in strict confidence.
9. May I be found faithful to these promises and so enjoy life and the practice of the art of medicine at all times.
 Translated by Michael North, National Library of Medicine, 2002, available at, www.nlm.nih.gov/hmd/greek/greek_oath. html (numbering of paragraphs added).
 Melissa Bailey, “So Long, Hippocrates, Medical Students Choose Their Own Oaths,” Stat, September 21, 2016, available at www.statnews.com/2016/09/21/hippocratic-oath-medical-students-doctors.
 A.C. Kao & K.P. Parsi, “Content Analysis of Oaths Administered in U.S. Medical Schools in 2000,” Academic Medicine 79.9 (September 2004):882-87.
 Shernaz Dossabhoy, Jessica Feng, and Manisha S. Desai, “The Use and Relevance of the Hippocratic Oath 2015: Survey of US Medical Schools,” Journal of Anesthesia History 2.3 (July 2016): 107.
 “Greek Medicine,” History of Medicine Division, National Library of Medicine, National Institutes of Health, available at https://www.nlm.nih.gov/hmd/greek/greek_oath.html.
 Edmund D. Pelligrino and David C. Thomasma, The Virtues in Medical Practice (New York: Oxford University Press, 1993), 184-86.
 “Greek Medicine,” National Institutes of Health.
 “Hippocrates and the Rise of Rational Medicine,” Greek Medicine, The National Library of Medicine, The National Institutes of Health, last updated February 7, 2012, available at https://www.nlm.nih.gov/hmd/greek/greek_rationality.html.
 Pellegrino and Thomasma, The Virtues in Medical Practice.
 “History of the Code,” American Medical Association, 2017, available at https://www.ama-assn.org/sites/default/files/media-browser/public/ethics/ama-code-ethics-history.pdf.
 Robert J. Lifton, The Nazi Doctors: Medical Killing and the Psychology of Genocide (New York: Basic Books, 1986), 15-16.
 Evelyne Schuster, “Fifty Years Later: The Significance of the Nuremberg Code,” New England Journal of Medicine 337 (November 13, 1997): 1,436-40.
 World Medical Association, “The Declaration of Geneva,” adopted September 1948, available at https://www.wma.net/policies-post/wma-declaration-of-geneva/.
 “Tuskegee Study, 1932-1972,” Centers for Disease Control and Prevention, last reviewed December 14, 2015, available at https://www.cdc.gov/tuskegee/.
 Rebecca Skloot, The Immortal Life of Henrietta Lacks (New York: Crown Publishing Group, 2010).
 F.J. Ingelfinger, “Ethics of Experiments on Children,” New England Journal of Medicine 288.15 (1973): 791-92.
 Robert J. Blendon, John M. Benson, and Joachim O. Hera, “Public Trust in Physicians—US Medicine in International Perspective,” New England Journal of Medicine 371 (2014): 1,570-72.
 Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 4th ed. (New York: Oxford University Press, 1994), 58.
 Ibid., 327.
 Ronit J. Stahl and Ezekiel J. Emmanuel, “Physicians, Not Conscripts—Conscientious Objection in Health Care,” New England Journal of Medicine 376 (2017): 1,380-85.
 Christian Fiala and Joyce H. Arthur, “‘Dishonorable Disobedience’—Why Refusal to Treat in Reproductive Healthcare Is Not Conscientious Objection,” Women—Psychosomatic Gynaecology and Obstetrics 1 (2014): 12-23.
 Stahl and Emmanuel, “Physicians, Not Conscripts.”
 See Ingelfinger, “Ethics of Experiments on Children.”
 Peter Tyson, “The Hippocratic Oath Today,” PBS, NOVA, available at http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html, March 27, 2001.
 Pellegrino and Thomasma, The Virtues of Medical Practice, 33-36.
 Beauchamp and Childress, Principles of Biomedical Ethics, 8.
 “‘Hippocrates Rises Anew’: Prominent Ethicians and Physicians Issue A.D. 1995 Restatement of the Oath of Hippocrates (Circa 400 B.C.),” National Federation of Catholic Physicians Guild Newsletter (Summer 1995): 4-5.
 Pellegrino and Thomasma, The Virtues in Medical Practice, 33-36.
 Ryan M. Antiel, Farr A. Curlin, and C. Christopher Hook, “The Impact of Medical School Oaths and Other Professional Codes of Ethics: Results of a National Physician Survey,” JAMA Internal Medicine 171.5 (2011): 469-71.
 Tyson, “The Hippocratic Oath Today.”
 Antiel, Curlin, and Hook, “The Impact of Medical School Oaths.”
 Pellegrino and Thomasma, The Virtues in Medical Practice, 33-36.
 John Paul II, Evangelium Vitae 89 (March 25, 1995).
 Pellegrino and Thomasma, The Virtues in Medical Practice, 33-36.
 N.M. Bendapudi et al., “Patients’ Perspectives on Ideal Physician Behaviors,” Mayo Clinic Proceedings 81 (2006): 338-49.
 U.S. Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, 4th ed. (Washington, D.C.: USCCB, 2001).
 G. Brown, “Selected Moral Principles: Ordinary and Extraordinary Means,” in Foundational Principles, Part I of Catholic Health Care Ethics: A Manual for Practitioners, 2nd ed. (Philadelphia, PA: National Catholic Bioethics Center, 2009), 17.
 See Stahl and Emmanuel, “Physicians, Not Conscripts.”
 American College of Obstetricians and Gynecologists, Practice Bulletin Number 143, “Medical Management of First-Trimester Abortion,” March 2014, reaffirmed 2016.
 “Below the Radar: Health Care Providers’ Religious Refusal Can Endanger Women’s Life and Health,” National Women’s Law Center, January 2011, available at https://www.nwlc.org/wp-content/uploads/2015/08/nwlcbelowtheradar2011.pdf.
 Wendy Davis, Forgetting to Be Afraid (New York: Penguin/Random House, 2014).
 E. Fulton and A. Moraczewski, “Selected Moral Principles: Double Effect,” in Foundational Principles, Catholic Health Care Ethics.
 William Barclay, William Barclay’s Daily Study Bible, available at studylight.org/commentaries/dsb/matthey-5.
 Pellegrino and Thomasma, The Virtues in Medical Practice, 14-15.
 E. Furton, “The Natural Moral Law,” in Foundational Principles, Catholic Health Care Ethics, 35-39.
 Philip A. Pecorino, “Deontological Theories: Natural Law,” 2002, available at http://www.qcc.cuny.edu/SocialSciences/ppecorino/ETHICS_TEXT/Chapter_7_Deontological_Theories_Natural_Law/Natural_Law_Theory.htm.
 E. Furton, “The Natural Moral Law,” 36.
 Ibid., 35-39.
 Background Information 19, “Women, Children, and Slaves,” the British Museum, available at http://www.ancientgreece.co.uk/staff/resources/background/bg18/home.html.
 Mary Beard and John Henderson, Classics: A Very Short Introduction (Oxford: OUP, 2000).
 “Romantic or Sexual Relationships With Patients,” American Medical Association, AMA Code of Medical Ethics, available at https://www.ama-assn.org/delivering-care/romantic-or-sexual-relationships-patients.
 “Confidentiality,” Code of Medical Ethics Opinion 3.2.1, American Medical Association, available at https://www.ama-assn.org/delivering-care/confidentiality.
 Pellegrino and Thomasma, The Virtues in Medical Practice, 186.
 “Human Nature,” Torah 101, Mechon Mamre, available at https://www.mechon-mamre.org/jewfaq/human.htm.
 J.R. Porter, “Creation,” The Oxford Companion to the Bible, B. Metzger and M. Coogan, eds. (New York: OUP, 1993).
 Catechism of the Catholic Church (New York: Doubleday Press, 1997), paragraph 357.
 “Transfer of Care vs. Referral: A Crucial Moral Decision,” The National Catholic Bioethics Center, May 19, 2015, available at https://www.ncbcenter.org/resources/news/transfer-care-vs-referral-crucial-moral-distinction/.
 This oath was added as another, updated version. However, the 1995 version included Catholic, Jewish, and Protestant members on the committee; while the 2009 mentions such organizations as the Christian Medical and Dental Society, the Islamic Medical Association, the American Academy of Prolife Obstetricians and Gynecologists, etc., no Catholic groups are specifically mentioned (though Catholics are members of these groups) so I chose the earlier version for this paper.