On the face of it, the idea that a code of professional conduct dating to the ancient Iron Age could possibly retain any relevance in the current era of “Big Data,” religious and cultural pluralism, trillion-dollar government budgets, and nanotechnology seems preposterous. Yet the well-publicized challenges of contemporary health care mean that the ideals of the Hippocratic Oath (see sidebar on page 104)1—first formulated in Greece almost 2,500 years ago—remain, in our opinion, as important today as they have always been. Human technology has changed dramatically in the past 25 centuries; human nature has not.
Ancient Pledge
The Oath is an ancient pledge of medical ethical conduct. It addresses two important tenets: benefitting the ill and protecting patients against personal and social harm and injustice.
There are many translations of the Oath, but the essential meaning remains the same. It prohibits giving a lethal drug or using “a pessary to cause an abortion,” encourages practicing “in purity and according to divine law” and admonishes physicians not to “use the knife,” but rather, to “leave this to those who are trained in this craft.” It prohibits acts “of impropriety or corruption, including the seduction of women or men.” It advocates for patient privacy and concludes with the oath-taker’s need to strive for respect. Many of these ancient pledges are highly relevant to our modern practice of medicine and oncology.
While attributed to the Greek physician Hippocrates of Kos, the most well-known doctor of his era, the real original author of this most famous text in Western medicine is unknown, and there may have been several authors.2 After Greek political power collapsed and the influence of the Hippocratic school faded, the Oath fell into obscurity for nearly 2,000 years, only to be rediscovered by Medieval Christian scholars and used in a ceremony at the University of Wittenberg in 1508 CE.
By 1750, the Oath had been translated into English and other contemporary European languages, and for the past several centuries, a version of the Oath has often been recited by physicians graduating from medical school—a ritual that at times seems to have little significance beyond a general upholding of the medical tradition, and a rite of passage relegated to the attic of sterile memory shortly after completion.
The use of the Oath in these graduation ceremonies has been challenged. Many contemporary medical ethicists dismiss the original Hippocratic Oath as antiquated because of enormous scientific, social, economic, and political changes in the intervening centuries.3-6 As a consequence of contemporary sensitivities, several modernized versions of the Oath have been proposed,3,6 including a few witty parodies highlighting modern medical conundrums—eg, “I swear by Humana and … health maintenance organizations….”7
Most of these modern versions have avoided certain hot-button, politically divisive topics. In a 1993 survey of how the Oath was being used at 150 U.S. and Canadian medical schools, only 14% mentioned prohibition of euthanasia, 11% called upon deities, 8% foreswore abortion, and 3% forbade sexual contact with patients.6 Yet some physicians have countered that the older Oath, despite its historical trappings and archaisms, is more authentic and relevant than many of the diluted or “bowdlerized” modern versions.4,5
Uncomfortable Statements
Hippocrates, who died around 370 BCE, became the most well-known physician of classical Greece, yet little is known about the historical details of his life. In addition to the Oath, Hippocrates’ chief contribution to posterity is often cited as the separation of medicine as a discipline from religion. Influenced by Pythagorean rationalism, Hippocrates is credited with being among the first to disentangle causes of disease from ancient superstitions, attributing illnesses to poor diet and unhealthy environment rather than divine punishment. Perhaps it is ironic, then, that the Oath that bears his name starts by swearing by the gods “Apollo the physician, and Asclepius, and Hygieia and Panacea.”
While swearing by Greek gods may have been appropriate for Hippocrates and his contemporaries, should one not swear an Oath today instead by the Christian Lord, or Allah, or the Jewish God, or by Brahma, Krishna-Vishnu, Buddha, or other Eastern deities—or by no god at all? Several solutions to this uncomfortable dilemma have been proposed, including keeping the Apollonian reference as a historical reference, or replacing it with whatever one holds most sacred or loved (hopefully not something as banal as money or a treasured new house).8
Bioethicist Steven Miles, MD, has urged focus on the messages behind the opening invocation, seeing in this statement an opportunity for reflection.5 By naming gods, Dr. Miles points out, the Oath asks physicians to remember, through specific names and attributions, several important messages of medicine: dedication to healing, acceptance of human mortality, and gentleness in healing (the etymology of the name Asclepius, which may literally mean “unceasingly gentle”).
Another uncomfortable prohibition in the original Oath, especially for medical students intending to spend much of their careers in the operating room, is the statement, “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.” Yet the Oath does not disavow surgery itself, and the Hippocratic Corpus and other historical records suggest that Greek doctors were in fact aggressive surgeons—at times far more aggressive than indicated.
This statement has been interpreted to mean that the physician should yield to “better professionals” whenever needed, whenever such professionals are available. In the modern context of medical specialization, surgeries should be done by practiced surgeons, radiotherapy by radiotherapists, cancer therapy by oncologists, and so on. Physicians must practice to the extent of their ability but not beyond; it is important for each of us to know our limits and seek the help of experts, as needed.
Other Troubling Passages
“I will not give a lethal drug to anyone if I am asked,” another controversial phrase in the Oath, has had many interpretations, one of which is the prohibition of euthanasia (literally “good death”). Historical context is again important here: in ancient Greece, doctors were sometimes used as skilled political assassins. There was thus a legitimate fear of the physician as a poisoner.
The word euthanasia was coined in about 280 BCE, a century after the oath was written. It referred to easeful or peaceful death, but there is no evidence in Greek medicine of active participation in accelerating such a death. The meaning of euthanasia in the sense of “assisted suicide” was instead coined by the historian William Lecky in 1869,9 and was not likely to have been a consideration of Hippocrates. This is relevant to our oncology practice today, where many cancer patients suffer from terminal disease, and at times severe pains and poor quality of life.
This statement has also been interpreted to condemn complicity of physicians in acts of torture, executions, and inhuman treatment procedures, particularly after the disclosure of atrocities in the Second World War that led to the World Medical Association’s 1948 Declaration of Geneva, a new “Charter of Medicine” that echoes many of the concerns of the Hippocratic Oath. The moral stance is unequivocal and condemns any physician or medical association that is complicit in, collaborates with, conceals, or aids in torture, even if such a person claims fear of retribution or is “just following orders.”10
A prohibition of abortion, which was a legal practice in ancient Greece, is inferred by the Oath’s statement, “I will not give a woman a pessary.” Some translations here refer to “a destructive pessary” without mention of abortion. Nevertheless, many have interpreted this as a prohibition on any abortion; others point out that this statement only mentions the pessary, a soaked piece of wool inserted in the vagina to induce abortion, which could cause lethal infections. The objection was perhaps to the specific dangerous method rather than a moral objection to abortion, but this remains an area of debate.
Less Difficult Statements
In ancient times, distrust of healers was common because of the abundance of quacks. The Hippocratic Oath included a statement regarding entering the patient’s house, where a physician would go only “for the benefit of the sick, avoiding any voluntary act of impropriety or corruption, including the seduction of women or men.” Quacks and charlatans are still with us, only a desperate Google search away, and patients continue to be exploited in a variety of ways. Patients are often highly vulnerable and continue to require protection from the undue influence of a selfish physician.11,12
Confidentiality is also less controversial: “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.” Just as was the case in healing relationships formed 2,500 years ago, confidential and personal information shared by patients with doctors must not be disclosed, in order to preserve trust and facilitate treatment. Without trust, patients may withhold facts that help physicians formulate an accurate diagnosis and therapeutic plan. Disclosing confidential information could be detrimental to the patient, unless not sharing such information could harm part of the physician’s larger circle of trust (for example, reporting cases of tuberculosis, syphilis, or other transmissible illnesses).
Finally, the Oath includes a statement about respect for teachers and about sharing information learned in the practice of medicine with students and other practitioners. While interpreted at times as exclusionary because of the mention of a written contract—limiting the spread of medical knowledge to only those who have paid for it can lead to disasters (as when the Chamberlen family’s preservation of their “trade secret” of obstetrical forceps for over a century contributed to countless needless deaths in childbirth)—this statement is primarily a reminder that the individual physician has an obligation to collaborate with and edify others. Life is short, the art of medicine is long, and the individual’s contribution to it tiny.
The Oath and Injustice
The most inspiring and perhaps most important statements of the Oath address harm and injustice: “I will do no harm or injustice to them.” The Oath contains two passages related to injustice, one upon entering the patient’s house as mentioned above (ie, injustice against a specific patient) and the other against social injustice.
While preventing personal and social injustice is a major concern of the Oath, physicians in general shy away from issues of social injustice, and when they do engage with societal issues, may at times have favored their own financial or personal interests. The American Medical Association (AMA), for instance, states that physicians have an obligation to provide some free care to the “indigent,” and that, as a group, they should work with policymakers to help society provide adequate health care to all.13
Yet, as an institution, the AMA has historically worked against the adoption of universal health care and other policies that could expand access to care but decrease the incomes of practitioners, and criticized professional medical organizations that disagreed with their position. Many physicians likewise have organized against efforts to address the lack of affordable health care, opposing reforms proposed by Presidents Roosevelt, Truman, and Eisenhower, fighting the passage of Medicare in 1965, and later failing to support or influence reform efforts proposed by the Clinton administration.14
Today, we face (and may swear by) old and new deities, including one perhaps more powerful and capable of extremes of good and evil than any other: money. We face problems that are intensely relevant to modern cancer research and care, and which (of course) did not exist at the time of the Oath: new types of medical and cancer research that include human experimentation, interactions with pharmaceutical and insurance companies, different practices and care patterns, unique stress from the cost of care and of drugs, and financial conflicts of interest.15-19
Most of these problems are directly or indirectly connected with two large looming factors: universality of health-care accessibility and affordable cost. Stated simply, lack of health care for a substantial portion of patients can contribute to social injustice and medical harm. High costs of health care and high drug prices prevent patients from affording and benefitting from them, thus causing harm. Adherence to the Hippocratic Oath requires physicians to address and advocate for better access to health care and for more affordable cost structures.15-19
Coverage and Costs
Because of how health care is financed in the United States, every physician knows of patients who have been denied access to health care perceived as necessary or received delayed treatment, and who have been harmed or humiliated by the process.20,21 The Affordable Care Act offers many advantages to patients that did not exist with the previous health-care order.17-19 In the context of oncology, it broadens cancer care to millions more, expands Medicaid, and eliminates some ethical dilemmas associated with cancer care in previously uninsured patients.
Broader insurance is associated with better access to cancer screening, earlier diagnosis, earlier treatment, and better outcomes. Patients with cancer are better covered on clinical trials. Closing the hole in Medicare Part D should reduce out-of-pocket expenses. Essential elements in cancer care such as emergency care and physical rehabilitation are covered. Annual and lifetime coverage in cancer care, which can be very expensive, are not capped.17,18
That said, the Affordable Care Act has many limitations, which should be addressed. The initial rollout of HealthCare.gov and the insurance exchanges was a disappointment, and while this is now improving, other uncertainties and challenges remain. It is yet unclear whether the Affordable Care Act will increase or reduce the insurance premiums or alter the overall cost of care, whether bargain-basement policies sold as part of health-care exchanges will actually allow patients to receive appropriate care, and whether the Act will simplify or complicate the inefficiencies of the health-care system.
Physicians should argue not simply to preserve the Affordable Care Act, which is a step forward but flawed, but also to improve on it and strive to extend future health-care coverage to become universally available to all Americans.22 [Editor’s note: See “Does the United States Have the Best Health-Care System in the World?” in the August 15 issue of The ASCO Post for more commentary from Dr. Kantarjian on health-care costs and the Affordable Care Act, or visit http://bit.ly/1whwepf .]
The high and growing cost of drugs, particularly cancer drugs, is another issue that should be viewed through the social justice lens of the Oath. Many patients cannot afford high drug prices and out-of-pocket expenses. About 10% to 20% of patients decide not to take their medicines or modify their dosages significantly. This worsens outcome and causes harm.
These two issues—health-care coverage and cost of health care and drugs, which also raise issues of physicians’ conflicts of interests23-27—have slowly and subtly evolved into enormous problems facing our patients and our society, and causing personal and social injustice and harm. In addressing them, physicians should put patients first. Patients are our most sacred duty, and perhaps the Oath should begin with this invocation: “I swear by what is most sacred, my patients….”
Primum Non Nocere
Notably, what many people consider to be the paramount principle and most famous statement attributed to the Oath—“First do no harm”—is actually not in the Oath. Instead, this principle most likely evolved from works in the 19th century, such as Florence Nightingale’s writing on hospital architecture, which states, “the very first requirement … it should do the sick no harm.”5
Unfortunately, this mythic statement is incomplete, since all therapies entail risk. This risk must be weighed against potential benefits every time a treatment is considered. As medical ethicist Daniel Sokol has proposed, a better enunciation of the principle would be “First do no net harm,”28 always considering the two most important guiding principles of the Oath: beneficence and justice. ■
Disclosure: Drs. Kantarjian and Steensma reported no potential conflicts of interest.
References
1. Hippocratic Oath. Translated by Michael North, National Library of Medicine, 2002. Available at http://www.nlm.nih.gov/hmd/greek/greek_oath.html. Accessed September 10, 2014.
2. Nittis S: The authorship and probable date of the Hippocratic Oath. Bull Hist Med 8:1012-1021, 1940.
3. Lasagna L: Hippocratic Oath: Modern Version. Tufts University, 1964. Available at http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html. Accessed September 10, 2014.
4. Hulkower R: The history of the Hippocratic Oath: Outdated, inauthentic, and yet still relevant. Einstein J Biol Med 25:41-44, 2010.
5. Miles SH: The Hippocratic Oath and the Ethics of Medicine, pp 22-23. New York, Oxford University Press, 2004.
6. Orr R, Pang N, Pellegrino E, et al: Use of the Hippocratic Oath: A review of twentieth century practice and a content analysis of oaths administered in medical schools in the U.S. and Canada in 1993. J Clin Ethics 8:377-388, 1997.
7. Schiedermayer DL: The Hippocratic Oath: Corporate version. N Engl J Med 314:62, 1986.
8. Verhey A: The doctors’ oath—and a Christian swearing in. Linacre Q 51:139-158, 1984.
9. Lecky W: History of European morals. Citation from Compact Oxford English Dictionary, 2nd ed. Oxford, Clarendon Press, 1991.
10. American College of Physicians: The role of the physician and the medical profession in the prevention of international torture and in the treatment of its survivors. Ann Intern Med 122:607-613, 1995.
11. American Medical Association, Council on Ethical and Judicial Affairs: Sexual misconduct in the practice of medicine. JAMA 266:2741-2745, 1991.
12. Gartrell N, Milliken N, Goodson W, et al: Physician-patient sexual contact: Prevalence and problems. West J Med 157:139-143, 1992.
13. Council on Ethical and Judicial Affairs, American Medical Association: Opinions 9.065 and 2.095. 1999.
14. Starr P: What happened to health care reform? Am Prospect 20(Winter):20-31, 1995.
15. Kantarjian H, Fojo T, Mathisen M, et al: Cancer drugs in the United States: Justum pretium—the just price. J Clin Oncol 31:3600-3604, 2013.
16. Kantarjian H, Steensma D, Rius Sanjuan J, et al: High cancer drug prices in the United States: Reasons and proposed solutions. J Oncol Pract 10(4):e208-e211, 2014.
17. Kantarjian HM, Steensma DP, Light DW: The Patient Protection and Affordable Care Act: Is it good or bad for oncology? Cancer 120(11):1600-1603, 2014.
18. Kantarjian H, Steensma D, Light D: Should oncologists support the Affordable Care Act? Lancet Oncol 14:1258-1259, 2013.
19. Zwelling L, Kantarjian H: Obamacare: Why should we care? J Oncol Pract 10(1):12-14, 2014.
20. Miles S: What are we teaching about indigent patients JAMA 268:2561-2562, 1992.
21. Stillman M, Tailor M: Dead man walking. N Engl J Med 369:1880-1881, 2013.
22. Berwick D: The toxic politics of health care. JAMA 310:1921-1922, 2013.
23. Rettig RA: The Industrialization of clinical research. Health Aff 19:129-146, 2000.
24. Boyd EA, Bero LA: Assessing faculty financial relationships with industry: A case study. JAMA 284:2209-2214, 2000.
25. Campbell EG, Seashore L, Blumenthal D: Looking a gift horse in the mouth: Corporate gifts supporting life sciences research. JAMA 279:995-999, 1998.
26. Bodenheimer T: Uneasy alliance: Clinical investigators and the pharmaceutical industry. N Engl J Med 342:1539-1544, 2000.
27. Nathan DG, Weatherall DJ: Academic Freedom in clinical research. N Engl J Med 347:1368-1370, 2002.
28. Sokol D: “First do no harm” revisited. BMJ 347:f6426, 2013.
Dr. Kantarjian is Chairman of the Leukemia Department at The University of Texas MD Anderson Cancer Center and a Baker Institute Scholar for Health Policies at Rice University, Houston. Dr. Steensma is a physician in the Dana-Farber Cancer Institute Adult Leukemia Program and Associate Professor of Medicine at Harvard Medical School, Boston.
Disclaimer: This commentary represents the views of the authors and may not necessarily reflect the views of ASCO.
