Reflections on the Hippocratic Oaths

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Reflections on the Hippocratic Oaths

Author(s): June GoodfieldReviewed work(s):Source: The Hastings Center Studies, Vol. 1, No. 2, Values, Expertise, and Responsibility in theLife Sciences (1973), pp. 79-92Published by: The Hastings CenterStable URL: http://www.jstor.org/stable/3527515.

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2/15

CODES,

MORALITY,

LAW,

&

PROFESSIONALIZATION

Reflections

o

t h e

ippocratic

a t h s

JUNE

GOODFIELD

OMETIME

uring

the

early

Twenties,

Chauncey

Leake,

according

o his own

accounts,

was

col-

lecting

material

for a

study

on

the

his-

torical

development

of

medical ethics.

He asked

Dr. Maurice

Fishbein,

Editor

of

the

Journal

of

the American

Medical

Association,

or an

opinion

of the

merits

of such a

project.

Dr. Fishbein's

reply,

as

reported

n the Prefaceto

Chauncey

Leake's edition

of

Percival's Medical

Ethics,

is classic:

"Unnecessary

and

of

no

significance

or an

understanding

f

the

matter

.

."1

If

this anecdote s

true,

it

tells

us that

the

medical

profession

shared with

the

scientific

profession

a

typical

attitude

toward

historical

studies,

namely,

that

in

no

way

have

they utility

or relevance o the

practice

of the

craft,

and

are

best left to

members

of

the

pro-

fession,

when

retired.

It

is

only

recently

that more and

more

people

have

begun

to

appreciate

the force

of

Santayana's

dictum:

"Those

who

ignore

the

lessons

of

history

are doomed

to

repeat

t."

It is

quite

clearthat

the issueof

medi-

cal ethics,medicaletiquette,and the re-

lationship

of

the

profession

o

society

at

large

presently

raises

questions

of

such

depth

and

importance

hat it

would be

a

foolish

doctor

who

would

try

to

sweep

them

aside.

Nevertheless,

even if

he

agreed

about

the

importance

of

medical

ethics,he

might

still

agree

with

Fishbein's

comments,

eeling

that

a

historical

urvey

is of no value in the consideration f his

own

situation

and

dilemmas.

am

not so

certain.

We

tend

to

think

of

our

own

social

situation

as

simple,

unique,

and

static.

Such

an

attitude

comes

naturally

because

it

provides

such an

easy

way

to

deal

with

difficulties.

f

the

problem

of

contemporary

medical

ethics

is

both

sim-

ple

and

acultural

hen

we

can

get

away

witha facileanduniversal olution.Since

most

of us are

lazy-minded

nd

just

want

to

go

on

doing

that

which

we

enjoy

doing

most,

i.e.,

practicing

medicine

and

earn-

ing

money,

it

is

tempting

to

ignore

the

problem.

But

history

eachesus

important

hings,

such

as how

rarely

situations

are

simple;

1Thomas Percival,

Medical

Ethics,

ed. and

introd.

by

Chauncey

Leake

(Baltimore:

Wil-

liams and

Williams,

1927

[originally

published

Manchester:

1803]).


3/15

80

HASTINGS

ENTER

STUDIES

how most

problems

of

professional

ctivi-

ties,

with their

concomitant

questions

of

ethics and

accountability,

rise not

in

a

vacuum,

but in

response

to

the

demands

of

a

social

situation.

This,

in

its

turn,

tells

us that

our

response

o

contemporary

ethical

problems

must be

made in

the

light of

our

existing

situation,

and

this

we must

understand,

analyze,

and

ap-

preciate,

before

we can

hope

to

deal with

such

problems

effectively.

In

addition,

f

there

s

a

degree

of

relativism

n

our his-

torical

situation,

there

is

also

a similar

degree

of

relativism

across

our

cultures.

Recognition

of

relativism n

history

and

through

ulture

does

not,

of

course,

mply

that

there can

be

no

answers o

contem-

porary

problems.

Rather

it

implies

that

there

can

be no

universal

answers

which

would

be

equally

applicable

throughout-

time

and

across

the

space

of

different

societies.

This

again

is

no

comfort

for

the lazy-minded,or it meansthat if we

wish

to

consider

the

problems

of

say,

birth

control,

euthanasia,

and

artificial

transplants,

we

shall

have to

consider

them

anew

for

such

disparate

ocieties as

those of

North

America,

India

and South

Vietnam.

My

intention

here,

in

this

rather

ight-

hearted

essay,

is

to

look

at

some of

the

variant

forms of

the Doctor's

Oath,

and

see what

questions

hey

raise

about

med-

ical ethics.

These are not

new

issues,

but

in

reexamination

we

might

note the

par-

ticular

orce or

validitythey

have in our

twentieth-century

ituation,

and

perhaps

incidentally

demonstrate

the

teaching

value of

history.

For

it is

quite

clear

that

problems

of

medical ethics

and medical

etiquette

are

closely

bound

up

with

prob-

lems of the

professionalization

f medi-

cine.

As

Chauncey

Leake

pointed

out in

1927,

when we

study

the

evolutionof

the

present

situation with

regard

to

medical

ethics,

then

it

may

become

clearer

why

it is

that

the

profession

resists

efforts to

change

its

present

relation

to

society.2

But where

did

all this start?

I want to

look

initially

at the variations

n the

Oath

that

was taken

by

doctors

during

the

years

when the

profession

was

emerging

and see where

this

varietyoriginated

and

what effects

it

might

have had.

The

classic work

was done

by

W. H.

S.

Jones.

He

wrote

the definitive

tudies

on

the various

forms

of the Oath

and

was,

in

the

1920's,

the

recognized

authority

on

Hippocrates.3

As Jones

points

out,

there

was no verbal

idelity

n the

preser-

vation of the

Hippocratic

ext. Provided

the

general

sense came

across,

no

one

worried

about

iteral aithfulness.

By

con-

trastwith

the

reverent

attitude

which

kept

the texts

of

many

classical

authors

com-

paratively

pure,

the

Hippocratic

material

was

treated

in

a

cavalier

manner,

prob-

ably

because

theseworks

were

textbooks,

with no

pretention

o be

literary

master-

pieces. Wordsget

transposed,

nterpola-

tions are

very

common,

and

there

are

losses of

phrase

and

meaning.

The

rea-

son for this

may

lie in

the

changing

cul-

tural

context of

medical

problems.

Un-

21

shall

be

arguing

in

a

later

series of

papers,

that

there

are,

indeed,

common

elements

in

all

professions

whose

tendencies

increase the

mem-

bers'

reluctance

to alter

the

"social

contract"

with

society.

This

has

a

great

deal

to do

with

the

process

by which

the

social

contract

evolved;

until

very

recently,

I

believe,

society

has

been the weaker

partner

and

many profes-

sions

dislike

and

mistrust

what

they

see

as

a

new

interference

in

tradition

hallowed

by

time.

This

point,

incidentally,

also

demonstrates the

value

of

a

historical

perspective

on

these

prob-

lems.

Without

it,

we

would

be

tempted

to

regard

doctors

and

scientists

as

merely

reac-

tionary.

3W.

H. S.

Jones,

The Doctor's

Oath:

An

Essay

in

the

History

of

Medicine

(Cambridge,

Eng.:

Cambridge

University

Press,

1924).

Un-

less

stated

otherwise,

this book is the

source

for

my

various

versions of

the

Oath.

I

make

no claim

for

any

originality

in the bulk

of

this

paper;

it rests

heavily

on

the historical

work

of

others

and

the

stringent

and valuable

criticism

offered

by

participants

n the humanities

project

of the Institute

of

Society,

Ethics

and

the

Life

Sciences.


4/15

THE

HIPPOCRATIC

OATHS

81

like,

for

example,

a

commentary

on

Aristotle,

the

Hippocratic

Oath

had

a

very

clear-cut function for

doctors-

though

not for

society-in defining

heir

relationship

o

society.

The

interpolations

and

modifications

n the

text

can,

without

too

much

distortion,

be seen as

responses

to the different

social matrices

n

which

the Doctor's

Oath

played

a

part, showing

us

a

process whereby

an

institution

is

modified

to meet a

changing

social

or

ideological

demand. In

this

sense,

the

Oath was

a

tool,

not a

scholarly

work,

and

as such had

and has no more

claims

for

immutability

han

a

legal judgment

presently

has

in

English

or

American

society.

The

earliestrecorded

copy

of

the

Oath

is in

the

Vatican

Library,

and comes

from

the

tenth

or

eleventh

century.

t

is not

the

earliest

form

for it

is the

Oath

modified

so that "a Christian

may

take

it."

The

earliest

form,

the

Pagan

Oath,

comes

from

a

fourteenth-centurymanuscript

and

reads

as

follows:

I

swear

by

Apollo

Physician,

by

Asclepius,by

Health,

by

Heal-all,

and

by

all

the

gods

and

goddesses,

making

them

witnesses,

that

I will

carry

out,

according

o

my ability

and

judgment,

this

oathand this

indenture:

To

regardmy

teacher

n

this

art

as

equal

to

my parents;

o make him

part-

ner in

my

livelihood,

and when he

is

in

need of

money

to

share

mine with

him;

to

consider

his

offspring

o

equal

my

brothers;

o

teach

them

this

art,

if

they

require

o

learn

it,

without

fee

or

indenture;

and

to

impart

precept,

oral

instruction,

and all

the

other

learning,

to my sons, to the sons of my teacher,

and

to

pupils

who

have

signed

the in-

denture

and

sworn

obedience

to

the

physician's

Law,

but to

none

other.

I

will

not

give

poison

to

anyone

though

asked to

do

so,

nor

will I

sug-

gest

such

a

plan.

Similarly

I

will not

give

a

pessary

to

a

woman

to

cause

abortion.

But in

purity

and

in

holiness

I

will

guard

my

life

and

my

art.

I

will

not use

the

knife

either on

sufferers

from

stone,

but

I will

give

place

to such

as are craftsmen

herein.

Into whatsoever

houses

I

enter,

I

will do so to help the sick, keeping

myself

free

from

all

intentional

wrong-

doing

and

harm,

especially

rom

forni-

cation

with woman

or

man,

bond

or

free.

Whatsoever

n the course

of

practice

I see or hear

(or

even outside

my

practice

in social

intercourse)

that

ought

never

to be

published

abroad,

I

will not divulge, but consider such

things

to be

holy

secrets.

Now

if

I

keep

this

oath and

break

it

not,

may

I

enjoy

honor

in

my

life

and

art,

among

all men

for

all

time;

but if

I

transgress

nd forswear

myself,

may

the

opposite

befall

me.

Notice

how

already

there

is a

distinc-

tion between

the doctor

and the

surgeon.

Probably he sentence"I will not use the

knife

either

on

sufferers

from

stone,"

should,

Jones

suggests,

read,

"I

will

not

use

the knife even

on

sufferers

from

stone."

The

injunction s,

"leave

this to

the

operative

craftsman."

Now

let us look

at the

Oath,

modified

"insofaras a

Christian

could

swear it."

Blessed

by

God the

Father

of

our

Lord Jesus

Christ,

who

is

blessed

for

ever

and

ever;

I lie

not.

I

will

bring

no stain

upon

the

learn-

ing

of the

medical

art.

Neither

will I

give

poison

to

anybody

though

asked

to

do

so,

nor

will

I

suggest

uch

a

plan.

Similarly

I

will

not

give

treatment

o

women

to cause

abortion,

treatment

neither

from

above

nor

from

below.

But

I

will

teach

this

art,

to

those who

require

to

learn

it,

without

grudging

and

without

ndenture.

will

use

treat-

ment

to

help

the

sick

according

o

my

ability

and

judgment.

And in

purity

and in

holiness

I

will

guard

my

art.

Into

whatsoever

houses

I

enter,

I

will

do so

to

help

the

sick,

keeping

myself

free

from

all

wrongdoing,

ntentional

or

unintentional,

ending

to

death or

to

injury,

and

from

fornicationwith


5/15

82 HASTINGS

ENTER

STUDIES

bond

or

free,

man or

woman. What-

soever

in

the

course

of

practice

I

see

or

hear

(or

outside

my practice

in

social

intercourse)

that

ought

not to

be published abroad, I will not divulge,

but

consider

such

things

to be

holy

secrets.

Now if

I

keep

this

oath

and

break it

not,

may

God

be

my

helper

in

my

life

and

art,

and

may

I

be

honored

among

all

men for

all

time. If I

keep

faith,

well,

but if

I

forswear

myself

may

the

opposite

befall

me.

The

three

main

modifications,

besides.

of

course,

the

disappearance

of the

pagan

deities,

are

interesting

and

instructive.

The

first

one

relates

to

the

question

of

abortion.

Where

doctors

undertake

not

to

give

treatment

to

women

to

cause

abortion,

the

clause

"Treatment

neither

from

above nor

from

below,"

is

added to

the

sentence.

This

clause

was,

perhaps,

inserted

as

an

effective

counter-measure

against those who

thought

they

could still

hold

to

the

Oath if

they

used

means

other

than

a

pessary

to

cause

abortion.-'

Written

injunctions

are

fine

but

there

are

always

loopholes

Secondly,

notice

that

unintentional

harm

is

just

as

forbidden as

intentional

harm.

The

notion

of

criminal

negligence

has

entered in for

the

first

time.

Thirdly,

there is

no

lengthy

de-

scription of those to whom medical

knowledge

should

be

imparted-to

this

point

I

will

return.

The

Arabic

Oath

The

Oath

passed

into

the Arabic

through

Syriac,

and is

found in this

form

in the

Lives

of

Physicians,

written

by

Ibn

abi

Usaybia.

This dates from

the

middle

part

of the thirteenth

century,

and

it

was

Ibn abi

Usaybia

who was

possibly

the

first

to

suggest

that

the Oath

originated

not

so much to

protect

society

or

even

the

reputation

of the individual

physician,

but to

protect

the

reputation

of

the

school.

The Schools of

Greek

Medicine

were

hereditary

schools

and it could

well

be that when it

was found

necessary

to

admit

outsiders,

then

Hippocrates

ad-

ministered

an oath-before

admission

rather than after

qualifying-in

order

to

secure candidates of a suitable

character.

The

Arabic version of the

Oath is as

follows:

Hippocrates

said:

I swear in

the

name of

God,

the Master

of life

and

death,

the

Giver

of health and

Creator

of

healing

and of

every

treatment,

and

I

swear

in the name

of

Aesculapius,

and of all the holy ones of God, male

and

female,

and

I call them to

witness,

that I

will fulfill this

oath and

these

conditions.

I

will

regard

my

teacher

in this art as

my

father,

I will

share

with

him

my

means

of

livelihood

and

I will make

him

my partner

in

my

wealth,

and

I will

give

him

my

wealth

whenever

he

may

be in need of

it.

As for

his

descendents,

I

regard

them as

my

brothers, and I will teach

them this

art without

any

remuneration

or

condition,

should

they

desire

to

learn

it. And

I

associate

together

(i.e.

regard

as

equal),

in

the

injunctions

and

in the sciences and

in all else

contained

in

the

art,

my

own

children,

the children

of

my

teacher,

and

the

disciples

on whom the

oath

(or

cove-

nant)

has been

imposed,

and

who

have sworn to observe the medical

code

of honor.

And I will not do

so for

any

other than

these.

In all

my

treatment

I will strive

so

far

as lies in

my power

for the

benefit

of the

patients.

And

I will restrain

my-

self from

things

which

are

injurious

to

them,

or

are

likely

in

my

opinion

to do them harm. And

I will

not

give

them

any poisonous

drug

if

they

ask

4Has something-an extra clause or phrase,

perhaps-been

transposed

or

dropped

in

this

translation?

For

the

phrase,

"But

I

will

teach

the art.. ."

placed

now

next

to

the

abortion

clause

reads

as

though

it

referred to

the

teach-

ing

of

abortion.

In

all

other

versions

it is

placed

in a

less

ambiguous

position.

This trans-

position

was

surely

not

intentional.

The

hy-

pothesis

that it

is due

to

careless

copying

on

the

part

of

a

sleepy

monk

is,

for

my money,

the

most

likely

explanation.


6/15

THE

HIPPOCRATIC

OATHS

83

for

it,

nor will I

advise

them

thus.

Nor will I

contemplate

administering

any pessary

which

may

cause

abortion.

And

in

my

treatment

and

in the

prac-

tice of my art I will keep myself pure

and

holy.

And I will

not

operate

on

those who have stone

in

the

bladder;

rather I will leave

it for

those whose

profession

it is.

And

I will

enter

every

abode

into

which

I

may

go

only

for

the

benefit of

the

sick,

being

in

a

state

devoid

of

(all

deliberate

intention

of)

wrong-doing, injustice,

mischief-mak-

ing,

such as

might

be

intended

in

other

transactions, or in respect of sexual

relations with

woman or

man,

whether

free

or

slaves.

And as

for the

things

which I

may

see

or

hear

during

the time

of

treating

the

sick,

or

at times other than

those

in which I

am so

engaged,

about

such

behaviour

of men

as

should

not

be

talked of

outside,

I will

keep

silence,

considering

that such

things

should

not

be discussed.

He

who fulfills

this

oath

and does

not

violate

any part

of

it,

to

him

will

it

be

granted

to

carry

out

his treatment

and

his art under

the most

excellent

and favorable

conditions,

and to

be

praised

by

all

men in

future

for

ever;

while

the

contrary

will

be the

portion

of

him who

transgresses

it.

To

complete

this

potted

tour

around

doctors' oaths

we

can

take in a

couple

of

variations,

this

time

based

upon

an

Indian

theme.

The first

form

is

found

in

the

old

medical

books

of

India,

as

ad-

dresses to

students;

while

calling

for a

high

degree

of

moral

rectitude

on

the

part

of

the doctor with

regard

to his

own

behaviour,

the

injunctions

demand,

too,

a

high degree

of

moral

judgment

with

regard

to

the behaviour

of

others

To

insist

that

a

doctor

must refuse to

treat

a "hunter" or a "fowler"

surely

must

be

seen in

the

light

of the

Buddist belief

in

the

sanctity

of

all life-not

only

human.

Thou

shalt

renounce

lust,

anger,

greed,

ignorance,

vanity, egotistic

feel-

ings,

envy,

harshness,

niggardliness,

falsehood, idleness,

nay

all acts

that

soil the

good

name of man.

In

proper

season thou

shalt

pare

thy

nails

and

clip

thy

hair and

put

on the

sacred

cloth,

dyed

brownish

yellow,

live

the

life of a truthful self-controlled an-

chorite,

and be obedient

and

respectful

towards

thy

preceptor.

In

sleep,

in

rest,

or while

moving

about-while

at

meals

or in

study,

and in

all acts

thou

shalt

be

guided

by

my

directions...

Thou

shalt

help

with

thy professional

skill

and

knowledge,

the

Brahmanas,

thy

elders,

preceptors

and

friends,

the

in-

digent,

the

honest,

the

anchorites,

the

helpless and those who shall come to

thee

from a

distance,

or those

who

shall live close

by,

as well as

thy

rela-

tions

and

kinsmen,

to

the

best of

thy

knowledge

and

ability,

and

thou

shalt

give

them

medicine

without

charging

for it

any

remunerations

whatever,

and

God

will bless

thee for

that. Thou

shalt

not treat

medicinally

a

professional

hunter,

a

fowler,

a

habitual

sinner,

or

him who has been

degraded

in

life;

and

even

by

doing

so

thou

shalt

acquire

friends,

fame,

piety,

wealth

and

all

wished-for

objects

in

life,

and

thy

knowledge

shall

gain

publicity.

The

second,

the

Oath

of Charaka,

ac-

cording

to Mohan

Lal

Sharma,

has

re-

cently

received

much

prominence

in

the

Indian

Press,

and

is

administered

by

the

guru to a disciple.

Thou

shalt

speak

only

the

truth,

eat

no

meat,

eat

only

pure

articles

of

food,

be

free

from

envy

and

carry

no

arms.

There shall

be

nothing

that

thou shalt

not do

at

my

behest,

except

hating

the

king

or

causing

another's

death or

committing

an

act

of

unrighteousness.

Day

and

night,

however

thou

may-

est be

engaged,

thou

shalt

endeavour

for

the

relief of

patients

with

all

thy

heart

and

soul.

Thou

shalt

not

desert

or

injure

thy

patient

ever for

the

sake

of

thy

life or

thy

living.

Thou

shalt not

commit

adultery

even in

thought.

Thou

shalt

not

covet

others'

possessions.

Thou shalt

be

modest in

thy

attire

and

appearance.

Thou

shouldst

not be

a

drunkard or

a sinful

man nor

shouldst

thou

associate with

the

abettors of


7/15

84 HASTINGS CENTER STUDIES

crime.

Thou

shouldst

speak

words

that

are

gentle,

pure

and

righteous,

pleas-

ing,

worthy,

true,

wholesome

and mod-

crate.

Thy

behavior must be in

keeping

with the time and

place

and heedful

of

past

experience.

Thou shalt

act al-

ways

with a

view to

acquiring

knowl-

edge

and

fullness of

equipment.

No

offering

of

presents

by

a woman

without the behest

of

her husband

or

guardian

shall be

accepted by

thee.

While

entering

the

patient's

house

thou

shall

be

accompanied

by

a

man who

is

known to the

patient

and

who has

his

permission

to enter and thou shalt

be well clad and

bent

of

head,

self-

possessed

and conduct

thyself thought-

fully.

Thou

shalt

make

thy

entry

in

the

proper

way.

Having

entered,

thy

speech,

mind,

intellect and senses

shall

be

entirely

devoted to

no

other

thought

than to that of

being

helpful

to

the

patient

and

of

things

concerning

him

only.

The

peculiar

customs of

the

patient's

household shall not be made

public.

Though

possessed

of knowl-

edge,

thou

shalt

not boast

very

much

of

thy knowledge.

Most

people

are

offended

by

the boastfulness of

even

those

who

are

otherwise

good

and

authoritative.-)

Finally,

let

us

compare

these

earlier

forms

with the

Oath as

presently

sworn

at

Montpellier

and

Glasgow

Universities,

both

of

which have

old

and

renowned

schools

of

medicine.

The

Montpellier

Oath.

In

the

pres-

ence

of

the

masters of

this

school,

of

my

dear

fellow-students

and

before

the

image

of

Hippocrates,

I

promise

and

I

swear,

in

the name of

the

Supreme

Being,

to be

faithful

to

the

laws of

man

and of honor

in

the

exercise

of medi-

cine.

I

will

give

my

services

without

fee to

the

needy,

and I

will

never

exact a

higher

fee than

my

work de-

serves. When I

am admitted inside

houses,

my eyes

shall not

see what

goes

on

there,

and

my

tongue

shall be

silent

about the

secrets

which shall be en-

trusted

to

me,

and

I will

not abuse

my

position

to

corrupt

morals or to en-

courage crime. Respectful and grateful

towards

my

masters,

I

will

give

back

to

their children

the

instruction that

I

have received

from their fathers.

May

men

grant

me

their

esteem

if I am

faithful

to

my

promises.

May

I be

covered

with shame and

despised

by

my

fellows

if I fall short.

The

Glasgow

Oath.

I do

solemnly

and sincerely declare that, as a Grad-

uate

in Medicine

of

the

University

of

Glasgow,

I

will exercise

the several

parts

of

my

profession,

to the best of

my

knowledge

and

abilities,

for the

good,

safety,

and

welfare of all

persons

committing

themselves,

or committed

to

my

care and

direction;

and that

I

will

not

knowingly

or

intentionally

do

anything

or

administer

anything

to

them to their hurt or prejudice, for any

consideration,

or

from

any

motive

whatever.

And I further declare that

I

will

keep

silence as to

anything

I

have seen

or

heard while

visiting

the

sick which it would

be

improper

to

divulge.

And

I

make this

solemn declaration

in virtue

of

the

Provisions of

the

Promissory

Oaths

Act,

1868,

substitut-

ing a Declaration for Oaths in certain

cases.

II

The

Oath in

all its

forms

represents

"those

noble

rules

of

conduct,

loyal

obedience

to which

has

raised

the

art

of

medicine

to

the

high position

it

now

holds." This

statement,

the

opinion

of W.

H.

S.

Jones,

carries

overtones of

nobility,

sublimity,

and

aspiration

worthy

of Prince

Albert.

I,

however,

take

a somewhat

cyn-

ical view of

the matter.

What

we

don't

know,

for

instance,

is

what,

if

any,

were

the

sanctions

to

be

imposed against

someone

who

broke the

Oath. Were there

any penalties

at all?

Did

all students swear

or

only

those

that

5Mohan Lal

Sharma,

"Oath

of

Charaka,"

New York State

Journal

of

Medicine,

71

(Oc-

tober

15,

1971),

p.

2457.


8/15

THE

HIPPOCRATIC

ATHS

85

belonged

to a

definite

guild

or school?

Was it

ever

actually

administered, r,

like

the Sermon

of

the

Mount,

merely

held

up

as a counsel of

perfection?

There

was

no General

Medical

Council,

and it

has

often

been

suggested

that a doctor

who

transgressed

he

Oath

was not

punished

unless,

in

fact,

he

actually

sinned

against

the civil or

criminal aws of

the

state.

One

enchantingpiece

in

the

Hippocratic

col-

lection,

called

Law,

actually

complains

about

this state of affairs."The

only

pen-

alty

to

which

an

erring

doctor

was sub-

ject

was

dishonor,

and as the author

of

Law

rightly

points

out,

this

was no

pun-

ishment

to

those who

were

"compacted

of it."

On

the otherhand

the

state seldom

brought

any

severe

sanctions

to

bear

either. W.

H.

S.

Jones

argues

that be-

cause

of

the

general

slackness

of

state

supervision

or

discipline,

t

was

therefore

necessary

to

make

every possible

appeal

to a doctor's

religious

cruples

and to his

moral

sense.7

The

first

traits which

enable us to

identify

he

properties

f

a

guild,

or

trade

union,

are also

apparent

from

the

first

form of

Oath;

they

are

jealouslyguarded

professional

privileges.

The new

doctor

must

give special

favors to

his

teacher

and

family.

He

can

reveal the

secrets

of

his craft

only

to his

sons,

and the

sons

of

his teacher

and

to

those

outsiderswho

have sworn

allegience

to

the

physician's

law. It

may

well

be

that

the

apprentice

took

the Oath before he

actually joined

the

guild,

rather

than

after he

became

a l e n

tells

us,

there

was

never

any

rule

whichsaid

that

as a matterof

medical

etiquette

new

knowledge

and

discoveries

must

be

made

public.

He

tells

how

surgeons

concealed

themselves

and

their

patients

during

the

course

of

operations,

not for

reasons

of

modesty

but

in

order

to

keep

some

of

their methods

secret.

This

highlights

one

im-

portant

distinction

be-

tweenthe practiceof

medicineand that

of

science.

qualified,

as is

now the case.

And

this

brings

up

another

question, namely

whether

he medical

society

was

a

totally

secret

one--secret

that

is

in

the

sense

that

all

outsiders

were

rigidly

excluded from

their

meetings

and

their

lectures.

Two

treatises in

the

Hippocratic

collection,

Precepts

and

Decorum,

carry quaint

and

obscure

overtoneswhich

are

very

familiar

to

those

who

have

troubled to

read the

libretto of

The

Magic

Flute

from

begin-

ning

to

end.

Freemasons

would

find

a

strange

familiarity

and,

as

Jones

points

U'Works

f

Hippocrates,

Trans.

by

Francis

Adams

(New

York:

Wm.

Wood,

1886).

7Ludwig Edelstein makes the same point.

"The

Oath

as a

whole

is

hardly

an

obligation

enforced

upon

the

physician

by

any

authority,

but

rather

one

which

he

accepts

of

his own

free

will. It

is not

a

legal

engagement;

as

the

wording

indicates,

it is a

solemn

promise

given

and

vouchsafed

only by

the

conscience

of him

who

swears."

(Emphasis

added.)

Ludwig

Edel-

stein,

"The

Hippocratic

Oath,"

Supplement

to

the

Bulletin

of

the

History

of Medicine,

No.

1

(Baltimore:

Johns

Hopkins'

Press,

1943).


9/15

86

HASTINGS

CENTER

STUDIES

out,

it is as

though

the

writer

purposely

did not wish to be

understood

by

those

who

were

unfamiliar

with

liturgy

or

ritual. Decorum

closes with

an

injunction

to

acquire

certain

knowledge

to

"keep

it

safe and to

pass

it

on."

Law,

an

address

to

young

students

given

at the

beginning

of

their

medical

course,

ends: "But

holy

things

are shewn to

holy

men. The

pro-

fane

may

not

be

shewn

them until

they

have

been

initiated

into the

rights

of

science."s

This

injunction

is

very

similar to

those

at the

end of

many

Arabic

alchemical

texts which

generally

finish

with,

"The

Godly

may

not

show this to

the un-

Godly:

outsiders

may

not have

it

ex-

plained."

This

does

suggest

that

secrecy

in

the

medical

profession may

have

its

origins

not in

an omniscient

attitude that

comes with

knowledge

nor

in

an

altruistic

concern

for

what

knowledge

the

laity

and

patient

can

"bear,"

but rather

by

virtue of

a

professional

injunction

meant

to

preserve

the

unity

and

status of

the

guild.9

As

Galen

tells

us,

there

was

never

any

rule

which

said

that

as a

matter of

med-

ical

etiquette

new

knowledge

and

dis-

coveries

must

be

made

public.

He

tells

how

surgeons

concealed

themselves

and

their

patients

during

the

course

of

op-

erations,

not

for

reasons of

modesty

but

in

order

to

keep

some of

their

methods

secret.

This

highlights

one

important

dis-

tinction

between

the

practice

of

medicine

and

that

of

science.

The

similar

ban

on

dissemination of

knowledge

in

alchemical

texts noted

above is without

doubt one

of the most

important

factors

that led

to

the intellectual fossilization

of

alchemy

as a

system

of

knowledge.

Scientific

un-

derstanding

grows by

a

dynamic

balance

between

imaginative

speculation

and

the

critical

judgment by

others.

It is

inter-

esting

to

speculate

whether

or not

med-

ical

knowledge

might

have

advanced

faster

had this

open

kind of attitude

been

encouraged,

for one has

only

to

recall

Harvey's

complaint.

He was

very

scorn-

ful of the

uncritical manner

in which doc-

tors assumed

that

what

they

were

told

about

the ancients'

knowledge

of the

cir-

culation

must

be true. And

they

were

so

passive

that

they

did not even

trouble

to observe

for

themselves.

Some

clauses

in the

Oath are

quite

incongruous,

for

example

those

which

refer

to

operations

in

general,

particularly

for

cutting

of the stone.

This clause

is

generally

sandwiched between clauses

containing

moral

injunctions.

Of

course,

the distinction was

constantly

emphasized

between

the doctor

and

the

"butcher,"

but

this

particular

clause

may

also

deal

with

yet

another

problem

of

medical

eth-

ics.

Some

people

have

suggested

that

it

contains

a hidden reference

to

castration,

which

was

abominated

by

the

Greeks.1o

But since this

operation

clause is not

present

in

the

Christian

form of

the

Oath,

it is

possible

that it

actually

does

illus-

trate a

response

to a

changing

social

situation,

a

response

to fashion

and

prej-

udices

of

certain

physicians

at

a

certain

period

of

time. It

is

very

likely

that it

was the

ban

on

operations

in

Rome,

no-

ticed and

recorded

by

Galen,

which

caused the insertion to be made at this

point

in

time,

some

centuries

after

the

-For

an

examination

of

the

Oath's

relation-

ship to secret cults see LudwigEdelstein's"The

Hippocratic

Oath,"

in

Ancient

Medicine,

ed.

by

Owsei

Temkin

and

C.

Lilian

Temkin,

trans.

by

C.

Lilian

Temkin

(Baltimore:

Johns

Hopkins Press,

1967),

pp.

3-64.

Also "The

Hippocratic Oath,"

Supplement

to

the

Bulletin

of

The

History

of

Medicine.

9TFhis

spect

of

secrecy

is

quite

distinct,

of

course,

from the

more familiar

one of

confi-

dentiality

with

regard

to

patient's

disclosures,

which

1

deal

with

later.

1"One

scholar,

Reinhold,

has even

gone

so

far

as to amend

the text

so as to read:

"I

will

not castrate

even

persons

who

are

not

grown-

up."

Jones' comment

is

right

on

target;

this

is

a

truly

unhappy

illustration

of the

art

of

correcting

corrupt

texts:

surely

the

phrase,

"I

will not

castrate,"

would have been

quite

adequate.


10/15

rHE

HIPPOCRATIC ATHS

87

initialChristianOath.

The distinction

be-

tween the

physician

and

the "butcher"

r

"barber"

surgeon,

though

present

in

pagan

times and

in

the

Pagan

Oath,

was

much

intensified

by

this

Roman

injunc-

tion

and reached ts

epitome

in

medieval

times. The

medical

profession

and the

public

have suffered

rom this

legacy

of

history.

Fortunately

here

is much

more

cooperation

now,

but

powerful

relics of

this

division

exist

even

today,

in

the

dif-

ferent

attitudes

of

the

public,

and also

of

physicians

and

surgeons

towards the

introduction

of

new

therapeutic

tech-

niques

in

medicine

and

surgery;

e.g.,

the

differing

concerns

for

regulation

n the

case

of

drugs, ranging

from

thalidomide

to

The

Pill,

and in

the

case

of

surgical

procedures

ike heart

transplants,

y-pass

operations,

or

psycho-surgery.

Even

thoughearly

Christians

ad

great

reluctanceto

take oaths

of

any

kind-

a reluctancewhich

is

shared

by present-

day

Quakers'"-nevertheless,

t is

certain

that

many

Christian

doctors

subscribed

to it.

But in

relationto this

question

an-

other

striking

difference-almost

an

ideo-

logical

one-between

the

Christian orm

of

oath

and the

Pagan,

is

that in

the

Christian form

all

those

clauses

which

would tend to encourage the formation

of

a trade union

are

omitted.

Secret

so-

cieties

were

considered

contrary

to

the

teachings

of

the

Christian

religion,

and

even

today,

the

Roman

Catholic church

bans

secret

brotherhoods.A

clause which

encouraged

the

formation of

an inner

ring

of

physicians,

rom

which

outsiders

were

excluded,

demonstratedan aristo-

cratic exclusivenesswhich was in great

contrast to the universal

brotherhood

of

early Christianity.

And if

the

beginning,

and the

end,

of all medical

art

was

the

relief

of

pain

and

suffering,

then

it

should

be

tied and hindered

by

nothing-

whether

guild

rules,

or

secrecy,

or

pre-

occupation

with

status. "I

will teach

this

art

to those who

require

to learn

it,

without

grudging

and without

ndenture,"

says

the

ChristianOath

simply-without

reference

to

the

physician's

sons,

or

his

teacher's

sons,

or those who have

been

enrolled n the

guild.

If the Christian

opposition

to

secret

groups

finds its

rationale

n the

concept

of

universal

brotherhood,

hen we

are

brought

directly

to such

large

issues

as

the

relationship

etween

professional

and

universal

responsibilities.

t is

impossible

to know to what extent

such

issueswere

discussed

by

doctors in

ancient

times. I

suspect

not

at

all;

certainly

it is most

unlikely

rom

what

we

know of

this craft

guild.

Even

though

Socrates

and his

dis-

ciples

in the market

place might

examine

the nature

of

personal

and

universalre-

sponsibility,

I

would,

in

the absence of

direct

contrary

evidence,

be inclined to

think that the doctors

rarely

troubled

their

minds

with such

deep

issues,

seeing

such

debates as the

function of

philoso-

phers

not

physicians.

Moreover,

he

effec-

tive

philosophical

problem

posed

above

is a

sophisticated

one and we should

never

forget

that

problems

and

theories,

just

as

much

as

people

and

institutions,

have their

histories,

too.

If

now

we see

the

relationship

etween

professional

and

universal

responsibility

as an

issue

to

which

all

of

us,

doctors

and

lay

people,

too,

have

something

o

contribute,

hat is

no reason to

suppose

that the

early

Greeks

saw it this

way.

Such

a

new

awareness ould

reflectan

amalgam

of

several

things:

the

complex-

ity

of

the

present relationship

between

the

profession

and

society;

the

new

fuller

sociological

mplications

of

a

tough

pro-

fessionalization;

the

extent to which our

ideas about the

nature of

responsibility

have evolved

and

changed through

times

and cultures. We can

no

more take an

ahistorical view

of

this matter than we

can

of scientific theories.

They

were never

immutable then and

they

are not now.

11This belief

of

the

Quakers

is based

on the

phrase

"Swear

not

at

all"

in

Matthew

v.

34.


11/15

88

HASTINGS

CENTER

STUDIES

It

would,

therefore,

be as

unreasonable

of us

to

expect

strong

similarities

etween

the Greek

view

and our

contemporary

view on the

nature

of

responsibility,

as

it

would be

to

expect

similarities

etween

their

knowledge

on

atoms

and our

more

detailed,

sophisticated

heories.

The continuities

n the forms

of

the

Oath

are clear

enough,

but there

are

great

contrastsbetween

our

contemporary

situation

and

those

of

earlier times.

The

Oath as it evolved

had one

aim and

one

aim

only; namely

the

moral

regulation

of

the

physician

by

other

physicians.12

It

may

well

be,

as

Chauncey

Leake

sug-

gested,

that

during

the

height

of

Greek

civilization

the

generally accepted

view

he final

transition,

from

the broad

moral

precepts

of

Greek

medical

practice

to

the

un-

codified

but

accepted

system

of

medical

ethics of the

present day,

occurred

around

the

seventeenth

century

....

the

era

of

the search for

immutable

laws.....

of

morality

rendered

any

written

admoni-

tion

on

medical

ethics

unnecessary.

(It

must

be rememberedhat

the

Hippocratic

collection

emerged

only

in

the

Alexan-

drian

period,

several

centuries

after

this

height

of Greek

civilization.)

But

I

feel

that

Chauncey

Leake

may

have

suc-

cumbed

to

that well

known

seduction

of

history-seeing

Greek

life

through

rose-

colored

spectacles.

From

the

evidence,

I am not certain

that we are

entitledto

assume

that there

was

a

"generally

ac-

cepted

view

of

morality,"

r if there

were,

that

it was

necessarily

one conducive

to

good

medical

practice.

I would

prefer

to

emphasize

a

different

cultural

character-

istic

of the Greeks

as the crucial

factor,

and one which we do know survives

today.

For

in

ancient

Greece,

the

rivers

of

"philotimno"

un

deep.13

A

doctor

was

under

no

compulsion

to

act

"properly,"

but was

trained o consider

good

behavior

as the

right

thing.

Greeks

considered

themselves

artistsand men.

It was

per-

haps

love of the

art,

combined with

"philotimo"which purifiedthe doctors'

calling,

and

kept

it

pure,

just

as

much

as

any

general

standards

of

morality.

Nevertheless,

the

admonition

of

the

Hippocratic

collection

which

emerged

n

the

Alexandrian

epoch,

could

well

have

been

formulated

n

an

attempt

to

main-

tain

older,

unwritten

tandards,

however

these

originated.

I

emphasize

again:

the

compulsion

o ethical

practice

n

ancient

Greece

might

well

be

found

only

in

the

physician's

genuine

ove

both

of

his

craft

and

of

men,

and if

the

law

was

ineffec-

tive,

medical

etiquette

protected

the

pa-

tient

by

appealing

o

artistic

nstinct

with-

out

the

imposition

of

civil

penalties.

12See

the

essays

by

Ludwig

Edelstein

already

cited.

13I

refer

to

that

identifying

Greek

national

characteristic

"philotimo".

."personal

code of

honor."

If

any

one

is

tempted

to

regard

this

cultural

evidence as

anecdotal,

incongruous

or

slight,

they

should

refer to

many

of

the nu-

merous

discussions of

"philotimo."

The

most

recent,

and

among

the

very

best,

can

be

found

in

David

Holden's

brilliant

and

astringent,

Greece

Without

Columns

(London:

Faber,

1972),

especially

pp.

30,

92-4, 97,

283.

He

demonstrates

the

negative

aspects

of

"philo-

timo"

too--hubris

and

blamelessness.


12/15

THE

HIPPOCRATIC

OATHS

89

Things began

to

change

in

the

Middle

Ages.14

Internal

sanctions

and

penalties

against

transgressors

f the

craft

tradi-

tion were backedby demands or action

on

the

part

of the

civil

authorities

as

well,

and

these

demands

came

from

the

doctors. But

the final

transition,

from

the

broad moral

precepts

of

Greek

med-

ical

practice

to

the

uncodified but

ac-

cepted system

of

medical

ethics

of

the

present

day,

occurred

around

the

seven-

teenth

century;

and the

truly

tough

pro-

fessionalismof modern medicine is an

even

later

development.

This

was

the

era of

the

search

or

immutable

aws,

not

only

in

science,

but

within

conduct,

and

law

and

morality

in

general.

Thomas

Percival

(1740-1804)

who

formulated

the

well-known,

and

much

used,

code

of

medical

ethics

could

not

have

envisaged,

thatby trying o covereverypossiblecon-

tingency,

two

unfortunate

consequences

followed.

There

was

conflict

which

came

from

sheer

multiplicity

f

the

rules

them-

selves

and

a

growing

emphasis

on

the

letter

of

the

law,

rather

han

on its

spirit.

For

external

sanctions,

with

pains

and

penalties,

can

enforce

only

those rules

which

are

specific,narrow,

and

concise.

On

the

other

hand,

as

we

learn

to

our

cost,

width

and

vagueness

ead

to

unfair-

ness

and

injustice,

both

to

the

doctor

and

to

the

patient.15

It

is

worth

glancing

briefly

at

the

ways

in

which

the

civil

authorities

have

either

intervened

or

been

called

in,

to

regulate

the

practical

physicians.

The

first

inter-

ventioncamewithregard o fees. Chaun-

cey

Leake

emphasizes

an old

point;

one

basic

ethical

question

arises

simply by

virtue

of the

fact

that,

if

physicians

have

a pecuniaryinterestin their work, can

they

in

all

honesty

really

desire

to

see

men

in

perfect

health?

(This

problem

can

be

avoided

f one

adopts

the

ancient

Chinese

practice;

namely,

of

only

paying

the

physicians

so

long

as one

is

in

health )

Though

in

an

ideal

world

the

answer

to the

question

would

be,

yes;

hedonistically

t

is,

of

course,

no.

Society

protects-or

has

protected-interests

of

the

patient

both

by

enacting

fee

codes

and

by

requiring

a certain standard

of

training

andskill

before

a mancan

prac-

tice medicine.

In

a

free market

economy

the

fee codes

certainly

do

no more

than

lay

down

the

minimum

which

shall

be

charged

and,

as

we know

only

too

well,

the doctorusuallychargeswhatthe mar-

ket will

stand.

But when

first

introduced,

the

fee code

provided

a

system

of

bal-

ance

and

checks-no

pun

intended.

The

code

of the laws

of

Hammurabi

f

Baby-

lon,

dating

from about

2200

B.C.,

lays

down

both

the

fees

to

be

given

for

a

physician's

ervices,

graded

according

o

the social

status

of the

patient,

and

also

the

punishments

to

be

inflicted

if

the

treatment

resulted

in

injury

or

death.

Neither

the Greeks

nor the Romans

pro-

vided

legal

regulations

controlling

the

practice

of medicine

until

forced

to

do

so

by

a

combination

of

quackery

and

drug-selling,

which

apparently

ed

to

a

situation

in which

it was

necessary

to

clean

up

both

the

profession

and

the

towns.

By

one

and the

same

stroke,

An-

tonius

Pius,

both

restricted

the

number

of

physicians

hat

could

practice

n

a

city

-thus

making

the doctors

happy-and

also

provided

hem

withan

annual

alary,

thus

making

them

happier.

This

was

all

done,

"in

order

that

they

may

honorably

serve the

poor

rather

than

basely grovel

before

the

rich."One

would

like

to

know

14A

brief

history

of

the

medical

profession

in

the

Middle

Ages

and

the

seventeenth

cen-

tury

is

impossible

here.

See,

however,

David

Riesman,

The

Story

of

Medicine

in the

Middle

Ages

(New

York:

1935).

15Percival,

Medical

Ethics.

Much of

Perci-

val's

medical

ethics has

been

adopted

and

adapted

by

the

British

and

American

medical

professions.


13/15

90

HASTINGS

ENTER

STUDIES

he

rela-

tionships

between

codi-

fied

ethics,

general

morality,

enforced

law,

and

professionalization

remain, indeed,

fascinat-

ing

and

perplexing.

Does the

appearance

of a

codified

ethic,

indicating

greater professionaliza-

tion,

also

indicate that

ethical

sensibility

is

on

the

rise?

Or

does

such

a

code

emerge precisely

because

moral

responsi-

bility

is on

the

decline?

When

ethical

considera-

tions have arisen...

does

professionalization

help

or hinder

an

appro-

priate

response?

just

how

successful this

was.'6

Perhaps

turning

doctors into civil

servants in this

way may have benefitted the poorer sec-

tions

of

society,

and

the

pill

was

surely

sweetened

by

the

exemption

that

these

doctors

enjoyed

from taxation

and

vari-

ous

public

duties.

Gradually

over

the

years,

the

profession

developed

not

only

prestige

but also

a

vested

interest

in

maintaining

its own

standards,

so

that

civil authorities

gradually

relinquished

their

control both over

the

moral

atti-

tudes

and

qualifications

of

the

physicians

and

also over their

finances.

Many

states in

the

U.S.A. still

reserve

the

right, technically

at

least,

to

require

good

moral character

from

all

those

who

would

practice

medicine

and

all

those

who are

practicing

medicine.

While it

may

be

possible

to

study

the

moral

char-

acter

of

a

student

while

at

school,

it

is

almost

impossible

to

do

so

when

he

gets

into

practice,

let

alone

continue to

moni-

tor him.

And,

therefore,

this

aspect

of

the

law

is

another

dead-letter

requirement.

The

only

recourse

that

a

patient

has

is to

bring

a civil

suit

against

the

doctor in

cases

of

immoral

practice,

and

the

likeli-

hood

of

success

will

vary

very

much.

However,

the

term

"medical

ethics,"

as introduced

by

Percival,

was,

as

Chaun-

cey

Leake reminds

us,

actually

a

mis-

nomer.

Professional

courtesy

is

not

the

same

thing

as

professional morality,

and

medical

ethics

is

by

no means

the

same

thing

as

medical

etiquette,

though

these

are

usually

confused

or taken

to be

the

same in

the

mind

of

the

profession.

If

we

consider

the

"ethics"

to

be

based

on

Greek

notions

of

good

taste,

rather

than

absolute

standards

of

morality,

then

what

we

are now

really

referring

to in

the

twentieth

century

is the

rules of

etiquette

which

regulate

the

conduct of

members

of

the

profession

with

regard

to

each

other.

But,

using

Chauncey

Leake's

defi-

nition

of ethics

as,

"concerned with

the

ultimate

consequences

of the

conduct

of

physicians

towards

their

individual

pa-

tients

and

towards

society

as

a

whole,

and

which

should include

a

consideration

of

the

motive and will

behind the

con-

I'(In

theory

this

should

work.

Certainly

it

has often

been

tried. But

a recent

and

very

amusing paper by

Tabin of

Hungary

examining

the

spread

of

parasolventia

in

his

country

shows the

difficulties.

Parasolventia

is not a

new viral

disease

but

the

tendency

of

patients

to

give

and

doctors

to

accept gifts

(wine,

geese,

etc.)

in

the

expectation

of better medi-

cal treatment.


14/15

THE

HIPPOCRATIC

OATHS

91

duct,"

I

am led

to

a drastic

conclusion.

It

may

well

be

that,

on

examination,

we

have

no

medical

ethics,

and

that

through-

out

medical

history

we

never

have

had

them,

either.

Fifty years

ago,

Chauncey

Leake

could

write

with

this

kind

of

optimism:

New

conditions

are now

arising

in

medical

practice.

No

matter

how

greatly

we

may

lament

the

fact,

the

old

family

doctor,

beloved

of

us

all,

is

rapidly

passing away

in

the

growth

of

specialism,

group

clinics,

and

gen-

eral hospitalizationof the sick. The

close

personal

relations

between

the

physician

and

his

individual

patient

are

disappearing

n

the

routine

of

tech-

nical

diagnoses,

mass

treatment,

and

nation-wide

prophylaxis.

Medicine

is

being recognized

more

and

more

as

a

matter for

national

and

international

public

health

efforts,

rather

than

as

a

professioncatering

to

individual

am-

bition. Its aim is its own

end-the

prevention

of

disease.

With

the

eco-

nomic

pressure

f

insurance

ompanies,

with

general

public

health

education,

and

with

frequent

periodic

health

ex-

aminations,

t

will

become

financially

more

interesting

or

the

general

prac-

titioner o

keep

his

clients

well

than

to

treat

them

when

they

become

sick.

[Italicsadded.]

This

is

bound to

alter

the

status

of medical

ethics.

Since

1927,

much of

what

Chauncey

Leake

predicted

in

that

quotation

has

come to

pass.

But

he

missed

out on

one

point

and

this

proves

to

be

fundamental.

He

clearly

believed

that

the

medical

pro-

fession

would,

could,

metamorphose

nto

guardian

and

protector

of

national

and

international ublichealthefforts,rather

than

being

solely

a

profession

which

satisfied

ndividual

mbitions,

whether

n-

tellectual

or

financial.

It

may

well

be

true

that

should

it

become

financially

more

rewarding

or

a

doctor

to

keep

his

patients well,

rather

than

to

treat

them,

then,

indeed,

the

whole

statusof

medical

ethics,

such

as it

is,

would

alter.

But

would

it take

only

financial

incentives?

Chauncey

Leake

was realistic

enough,

in

1927,

in

recognizing

he

strong

pull

of

the

financial

carrot,

but

in

the

context

of

contemporary

American

society

it

is

difficult

o see

how,

short

of

reverting

o

the ancient

Chinese

practice,

even

this

could

be

manipulated.

The

problem

that

I see

is that

this

is

a

question

of

general

and

total

morality,

both

of

the

attitudes

of the

profession

and

of

individual

doctors.

It

may

well

be that until

we

manage

to recover love

of

the art

and love

of

people, as

opposed

to love

of the

tech-

nique,

or

love

of the

affluence,

or

love

of

the

status,

as

the real

motivation

or

entering

medicine, we

may

not

get

a

satisfactoryethical

relationship

between

doctors

and

society.

But

if this

did

hap-

pen

it

is clear

to

me

that

our

ethical

aphorisms

would

then

not

even

have

to

be stated, let alone codified. And

any

Oath

would

become

redundant.

III

Looking

back

over

what

I

have

writ-

ten,

I

hear

a

voice

accusing

me

of

issuing

a

whole

series

of blank

checks

which

have

not

yet

been

cashed.

How

much

more

basic

research n the history and

sociology

of

the medical

profession

must

be done

before

these

promissory

notes

can

be

redeemed

In

relative

terms

the

much

younger

profession

of

science

has

received

infinitely

more

attention,

and

theearlier

years

of

the

emerging

cientific

profession

carry

much

more

documenta-

tion

of

problems

both

internal

and

ex-

ternal.

The

relationships

between

codified

ethics,

general

morality,

enforced

law,

and

professionalization

emain,

indeed,

fascinating

and

perplexing.

Does

the

ap-

pearance

of

a

codified

ethic,

indicating

greater

professionalization,

lso

indicate

that ethical

sensibility

s

on

the

rise?

Or

does

such

a code

emerge

precisely

be-

cause

moral

responsibility

s

on

the

de-


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HASTINGS

CENTER

STUDIES

cline?

When ethical

considerations

have

arisen,

or

in the case

of

science

been

forcibly imprinted

on the

profession's

consciousness,

does

professionalization

help

or

hinder

an

appropriate

response?

Our

answers,

when

we have

any,

can

only

be

tentative.

I

believe that the

Hippo-

cratic

Oath

was

related to the

general

morality only

marginally,

and

that

ini-

tially

it

served

the needs

of an

emerging

profession

or

guild,

rather

than those of

society.

Ultimately,

nothing

can

serve us

-society

or

professions-better

than

a

wide

general

morality.

And where this

does not

exist,

nothing,

it

appears,

can

properly

function in

its

place. Certainly

not a codified

ethics,

which

is too

often

full of

loopholes

or so

vague

and

plati-

tudinous

as to

be

without

meaning.

Cer-

tainly

not

an enforced

law,

which is

too

often

unenforceable,

or so

precise

as

to

be

inhumanely

restrictive.

On

the

other

hand,

where

the

general

standards

of

professional

and social

morality

are

high,

then

both codified

ethics

and

enforced

law become

irrelevant,

redundant,

and

unnecessary.

The

problem

is,

what is

it

that

promotes,

or can be made

to

pro-

mote,

a

high

moral

purpose

in a

society

or a

profession?

About

the

answer

to

that

question,

all we

know is that

it

will

not

be

simple.

Reflections on the Hippocratic Oaths

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