Hippocratic Oath: Discarded Relic or Living Soul of Medicine?

Author: 
Donald J. Palmisano, MD, JD
Article Type: 
Feature Article
Issue: 
March/April 1998
Volume Number: 
3
Issue Number: 
2

The Hippocratic Oath — Is it relevant today or does it belong in the scrap heap of history’s discarded relics?

I submit it is relevant today. I submit it is a touchstone that offers a moral compass — an ethical framework — for navigation through these times of crisis. In short, it is the soul of medicine.

I submit that the longevity of this Oath is compelling evidence that it is not a frivolous collection of words. Why is it so enduring? I believe it is deemed of value because it offers core values defined specifically, not generally; advice that leaves little room for equivocation or misunderstanding.

It does not say in general terms only that a physician should be good or ethical without further explanation of what those terms mean. It is a model of inductive reasoning; it goes from the specific to a conclusion of ethical behavior, moral behavior. For example:

Prescribe for the good of my patients according to my ability and my judgment and never do harm to anyone.

To please no one will I prescribe a deadly drug, nor give advice which may cause his death.

All that may come to my knowledge in the exercise of my profession or outside of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and never reveal.

Now I certainly can understand those who say they don’t want to swear to Apollo et al. A leading legend states that Apollo was the father of Aesculapius. The legend goes on to say Apollo killed his wife when she was pregnant with Aesculapius because of his wife’s unfaithfulness. Just before she died, Apollo ripped Aesculapius from his mother’s womb. Aesculapius was given to the centaur Chiron. He, of course, was one of the mythical creatures with the upper body of a man and the lower body of a horse. Chiron taught him wisdom and goodness. However, when he showed Aesculapius how to raise the dead, Zeus killed Aesculapius because it would upset the natural order to raise the dead. So why would you swear to Apollo, who allegedly is a murderer?

I submit it is the symbolic wording for the oath of that time. It signifies the words were meant to be serious; that they were meant to be kept. This oath was an external manifestation of intent. If the listing of Apollo, et al is criticism of the Oath, one could substitute one’s own belief in God or even, in the words of Henley in his immortal poem Invictus, “I thank whatever gods may be for my unconquerable soul.”

The Hippocratic Oath tells something about the physician taking this vow. Of course, some replacement oaths paint a different picture but also tell important information about the person taking these alternative oaths.

Consider the following excerpts from alternative oaths that either pledge allegiance to government or condone euthanasia. These other versions can be found in the appendix of Dr. Jane Orient’s book Your Doctor Is Not In.

“To be guided in all my action by the principles of Communist morality.” (Soviet Oath of Medical Ethics)

“If it is given to 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.” (Oath of Lasagna)

“And remember that it is wrong to terminate life in certain circumstances, permissible in some, and an act of supreme love in others.” (Oath of Weinstein)

Yes, the Hippocratic Oath has stood the test of time because it gives specific guidelines to the ethical and moral practice of medicine that have been embraced by the majority of physicians as well as the rest of society for over 2000 years.

Medicine is in crisis and it is appropriate to revisit the Hippocratic Oath. Review it, debate it, but do not ignore it.

The juggernaut of managed care has moved from sea to shining sea. Opportunistic managed care companies prove over and over again that their primary concern is not the patient — but the bottom line. They have replaced choice with gag-rules and hold-harmless clauses.

Let us not go quietly into this abyss, this new Dark Age, a Dark Age of medicine. Let us stand on principle. A revival of the Hippocratic Oath with reasoned discussion of what it means is a step away from the abyss.

We must understand what ethics mean. Never accept blindly a statement that something is ethical without reviewing the analysis that led to that conclusion.

For example, consider the following different ethical models:

Deontological: rightness is not defined in terms of their consequences; violate no rights.

Teleological: goal or consequence oriented.

Social utility: greatest good for the greatness number.

After selecting one of these reasoning models, was an analysis done that considered the following? Autonomy, Nonmaleficence, Beneficence, Justice.

Each of these analyses has additional choices to make in order to complete the analysis. For example, to do the justice analysis, one must decide which of the following theories one will use: Egalitarian, Communitarian, Libertarian, Utilitarian.

Thus it is obvious that it is possible to reach different conclusions as to what is ethical and what is not depending on the ethical model used.

The genius of the Hippocratic Oath is that it eliminates different views of what is ethical by clearly listing the conclusion as to what is to be done in specified circumstances. It is the essence of ethical medical practice. There may be individuals who disagree but the burden is on them to show why the proposed substitute and analysis is better. They don’t have 2000 years of acceptance on their side.

Will it be easy to win the battle to preserve ethical medicine? No. It will not be easy but few things of value are easy to obtain. The cherished freedoms that we enjoy as Americans have been won at great cost.

However, we have the great advantage of living in America; the land of the free and the home of the brave. But we must be brave or soon we will not be free to practice in the patient’s best interest. The sine qua non of quality medicine is to do what is in the patient’s best interest and it takes courage to preserve that freedom. My Dad always told me: Do your homework, have courage, and don’t give up. Do this and very little is impossible.

There is always the skeptic who will say it can’t be done. But the skeptic is wrong and can again be proven wrong. Don’t forget these words of yesteryear placed on a Newsweek’s cover ad of March 3, 1997:

“Man will never reach the moon regardless of all future scientific advances.” (Dr. Lee De Forest, inventor of the Audion tube and a father of radio, February 25, 1967)

“Everything that can be invented has been invented.”(Charles H. Duell, U.S. commissioner of patents, 1899)

“Who the hell wants to hear actors talk?” (Harry M. Warner, Warner Brothers, 1927)

Finally, think back into our history for tales of courage preserving our right to live free and enjoy the rights enumerated in the Declaration of Independence and the U.S. Constitution. Remember, we have a land of the free because other Americans have died protecting those freedoms.

Let me give you just two examples where courage prevailed and the skeptic was proven wrong.

D-Day June 6, 1944. Normandy. The sighting of the awesome cliff of Point du Hoc makes an indelible impression. It is at Omaha Beach, one of the American landing sites. Here 2,400 of the 4,900 casualties on D-Day occurred.

The first wave of men to hit the beach there was Company A of the 116th Regiment of the Virginia National Guard. As University of New Orleans author and Professor Steven Ambrose points out in his book D-Day June 6, 1944, The Climactic Battle of World War II, they were hit by a tremendous barrage of machine gun and rifle bullets,

88 mm and 75 mm cannon, exploding mines, mortars, and hand grenades. Ninety percent of these Americans died there. The sheer cliffs, 117 feet up, had to be scaled and the guns silenced. Included in the enemy’s armament were two 155 mm cannons that could knock out the ships at sea.

Now this is worthy of a comment by a skeptic that it was an impossible task. Even General Bradley on the cruiser USS Augusta believed our forces had suffered an irreversible catastrophe.

Enter the rangers. But wait. The man chosen to lead the charge up the cliffs was drunk. Lt. Col. James A. Rudder decided he would have to lead the men himself. Lt. General Clarence Huebner heard of this and ordered him not to lead the men. Rudder replied: “I’m sorry to have to disobey orders, but if I don’t take it, it may not go.” The rest is history.

200 men of the 2nd Ranger Battalion led by Lt. Col. James A. Rudder under heavy fire scaled the sheer cliff of Pointe du Hoc 117 feet above the rocks to destroy the German guns that threatened everyone landing on Omaha Beach.

The rangers took heavy casualties, some were taken prisoner, and only 50 were still capable of fighting at the conclusion of the battle. Keep this story of courage in mind when people tell you it can’t be done. I visited Point de Hoc on the 45th anniversary with a group of physicians involved in the Normandy invasion. It was an unforgettable experience.

One last mention about not giving up. The usual chorus of skeptics no doubt gave this man no chance of returning home alive.

Listen in awe as my friend, Paul Galanti, retired Navy Pilot, and until recently the EVP of the Medical Society of Virginia and now a motivational speaker, relates how he spent almost seven years as a prisoner of war when his plane was shot down over North Vietnam. When I asked him for a quote to sustain people in adversity, he said: “Never give in, never give up.” Truly a man of courage who never gave up and continued to communicate with a modified Morse code to his fellow Americans to encourage them to keep the faith. This is an American who is an inspiration to us all.

Considering all of that, the battle to protect the ethical practice of medicine does not appear so formidable.

Carpe Diem and Godspeed on your quest to enhance choice and quality in medicine by promoting ethical medicine and the freedom of choice between patient and doctor without government coercion. The Hippocratic Oath is a strong shield toward those goals.

Dr. Palmisano is a member of the Board of Trustees of the American Medical Association. His address is 4417 Lorino Street, Suite 200, Metairie, LA 70006. (504) 455-5895. Fax (504) 455-5740. E-mail: djp@intrepidresources.com

Originally published in the Medical Sentinel and may be cited as: Palmisano, DJ. Hippocratic Oath: discarded Relic or Living soul of Medicine. Medical Sentinel, March/April 1998;3(2):47-48.
  

 

 

 

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