Abstract
This article views the Hippocratic Oath from a new perspective and draws consequences for modern health care. The Oath consists of two parts, a family-like alliance where the teacher of the “art” is equal to a father and a set of maxims how the “art” is to be practiced. Self-commitments stated before the gods tie the parts together and give the alliance trustworthiness. One might call this a proto-profession. Modern physicians form a similar alliance. Specific knowledge and skills and specific action guiding rules are elements of a profession but its trustworthiness rests on a combination of professional autonomy and public control. In order to be granted autonomy the profession must show some effort in enforcing its specific rules and in order to do so its members need to be convinced of the intrinsic value of their profession (the “soul of professionalism” according to Freidson). Whereas in antiquity physicians acted as single individuals the modern alliance is shaped by division of labour. Physicians use each other and other professions by mutual consent and the health care system as means in the diagnostic-therapeutic process. As any actor is reponsible for the means he uses physicians are co-responsible accordingly. Thus, professional conduct now entails care for the organisation of the alliance as detailed in the “Charter on Medical Professionalism”. The effort the profession gives to this task will confirm its trustworthiness.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Notes
“Professionalisation has given the medical profession high status in society. Currently, however, tendencies towards deprofessionalisation have become visible. The uniformity and “uniqueness” of the physician’s occupational image have permanently changed as a result of various circumstances. The high degree of specificity along with the increasing complexity of the problems encountered in the medical field along with a concurrent division of labour with other occupational groups as well as a diverse interconnectedness with economical and ethical issues have brought it about that issues which originally were discussed between physicians are now discussed publicly, thereby costing or already having cost the medical profession much of its former special status. Topics discussed today in this context are, for example, the publicly held debate on assisted suicide, the easing of the physicians’ prohibition against advertising, and also the increasing distrust with respect to medical practice.” [emphases mine].
I would like to thank Dr. Sieghild v. Blumenthal for her valuable counsel during the preparation of the translation. I alone am responsible for possible errors and imperfections of the translation.
According to the wording of the Oath, entry into instruction is precisely regulated. Students who are neither consanguinous nor of an elective affinity must swear the Oath prior to the beginning of instruction (συγγεγραμμένος and ὡρκισμένος are perfect participles). On the other hand, nothing is said about a formal completion of instruction. That accords with the presumption that the student–teacher relationship was not formally concluded either, but rather, as in the case of the obligation to support the teacher, ended only with his death. This in turn accords with the fact that the teacher is called διδάξαντος, using an aorist participle, that is. We therefore, departing from other authors, translate διδάξαντα in the present tense.
The first as well as the second half of the sentence are clauses of purpose. According to the first half of the sentence, the intention of the taker of the oath is a delivery, namely of a certain advantage; according to the second half it is a warding off, namely of harm and wrong. Apparently the suggestions concerning the conduct of life are the means used in both cases. However, the thing to be achieved—the advantage—as well as the things to be warded off—harm and wrong—are not in the accusative but in the dative following ἔπι. Thus one should translate literally using “with respect to.” The finality in the second half of the sentence is expressed by means of the future infinitive, εἴρξειν. By means of suggestions concerning the conduct of life a physician can only influence the actions of the sick; consequently, harm and wrong, which could be committed against the sick by a third party, by, say, the physician as well, cannot be meant. We therefore, as do Littré and Edelstein, interpret “harms” and “wrongs” to be those which the sick commit upon themselves. This interpretation is supported by the fact that harm and wrong, which the physician as practitioner could commit, are expressly addressed in item (9).
Diller and Lichtenthaeler, by translating “not even, if I am requested to do so” or “not on demand, either,” expand the oath taker’s refusal beyond killing on demand to killing in general. This translation can be justified by the participle, αἰτηθείς. But this does not seem very plausible, for, what reason should a physician have for killing a patient besides being requested to do so? [Killing out of compassion?] Furthermore, murder was a punishable offence in ancient times, too.
With respect to suicide, the oath taker rules out not only the administration of a suitable remedy but the counselling as well; with respect to abortion, only the remedy. For this reason, just what the referent of “In like manner” (ὁμοίως) is remains an open question. The analogousness can reside in the non-participation in assisted killings; however, what may also be meant is that the oath taker rejects giving counsel in the case of abortion just as he does in the case of suicide.
Literally, a “destructive stone” (πεσσὸν φθόριον).
In the original there are no numbered sections. Several translators read the remarks concerning assisted suicide and assisted abortion together with the passage concerning the conduct of life of the oath taker himself. This passage appears in the exact center of the text. From a compositional perspective, this could well have been intentional; that is, in view of its sense, it could apply to the entire text, and it harmonizes both with the beginning and with the end of the text. We therefore regard the passage as a distinct section.
The two adverbs, ἁγνῶς (“purely”) and ὁσίως (translated by us in German as “gottgefällig,” ‘pleasing to God’), together designate a kind of morally or, as the case may be, religiously complete life, yet they must have distinct meanings. Deichgräber (Die ärztliche Standesethik des hippokratischen Eides. Quellen und Studien zur Geschichte der Naturwissenschaften und der Medizin 3 (1933), pp. 79–99) quotes a saying which appeared above the entrance to the temple of Asklepios at Epidaurus, and which contained a specific definition of purity: ἁγνεία δ᾽ ἐστὶ φρονεῖν ὅσια, “purity is to think holy thoughts.” This interpretation suggests that to the intended completeness belongs not only the outward observance, namely purity in the sense of avoidance of defilement, but also the inner, private spontaneity of good conduct. This is difficult to translate. Instead of “gottgefällig” [“pleasing to God”], one could also say “conscientiously,” namely in the sense of “a wakeful conscience,” or even, though antiquated, “virtuously.” “Piously,” in any case, sounds too passive.
According to B.L. Gordon in Medicine Throughout Antiquity (1949, F.A. Davis Company, Philadelphia, pp. 529–539), it was common to perform what we call “minor procedures” today: treatment of fractures and dislocations, hernias, wounds (for example, injuries due to weapons), empyema, abscesses, even trepanation, ascites, fistulae, haemorrhoids, also kidney and bladder stones; knives and, for haemostasis, even cauterising instruments were used. But there was naturally no neurosurgery, no thoracic surgery, and no abdominal surgery; no organ transplantation, no anaesthesia, and only limited asepsis; the circulatory system had not yet been discovered. Thus, if in fact every sort of cutting is meant, then the oath taker would minimally be able, aside from counselling, to set fractures, dislocations, and hernias; also to stop a bleeding, and to apply a dressing.
Οἰκία is not just the house but the entire estate with a familial, socio-economic association comprised of husband, wife, children, and the servants, comprised again of free and unfree persons (or slaves).
The voluntary commitment to the obligation to secrecy is here provided with a double-justification: The oath taker wants to keep something secret because one must not make it public, but also because it is an ἄρρητον, something that is, within the context of mystery cults, literally “unspeakable.”
The root meaning of the verb συγχέω, translated here as “weaken” (as “entkräften” in German), is “pour together.” What seems to be meant is the confounding of the strictness of the Oath with less strict requirements. At the end of the Oath the oath taker addresses reward and punishment. It is noteworthy that he distinguishes—in both the positive and in the negative case—the outer observance from the inner attitude. Fulfilling and transgressing refer to the external actions, the doing of which and the refraining from which have been promised. Weakening and perjuring oneself refer—as does ὁσίως in the center of the text—each to an inner attitude. The promise is not taken seriously any longer or is fraudulent already at the moment of promising.
Whoever came under the suspicion of not agreeing with or, indeed, of doubting the official cult was—in modern terms—generally not only a heretic but also an enemy of the state. Suspicions of this sort could thus also be conceived with the intention of getting rid of somebody, as was presumably the case in the trial of Socrates. According to Xenophon, the indictment ran as follows: “That he does not believe in the gods in which the city believes, and instead he leads in other new daimons, and he corrupts the youth” (Xenophon 1955; I would like to thank Dr. Klaus Widdra for the translation). In Plato it reads, “Socrates commits injustice; for he corrupts the youth and does not believe in the gods which the city honours but in new daimons” (Plato 1991). The accusers thus didn’t attack a transgression of specific laws, but rather cultic-political nonconformity, and Socrates did not give legal arguments in his defence before the jury, as Plato relates it, but rather moral-philosophical or religious ones. That the death sentence against him was not carried out immediately had, in turn, more of a cultic reason than a legal one. The verdict was handed down at exactly the time when the Athenian delegation was on its way to Delos. This island was sacred to Apollo (Wissowa 1958). Due to reasons of cultic purity, the carrying out of the sentence had to be postponed until the return of the ship from Delos (Plato, Crito, 43c-d).
Quoted from the Chamber Law for Healthcare Professions (“Heilberufe-Kammergesetz—HkaG”) of the Free State of Bavaria in the version published 6 February 2002, GVBI 2002, p. 42:
Art. 2. (1) It is the responsibility of the professional trade association to attend, within the scope of the law, to the professional concerns of physicians; to monitor compliance with obligations of the medical profession; to promote advanced training for physicians; to provide social services for physicians and their dependants; and to be instrumental in public health awareness.
Art. 17. Physicians are duty bound to practice their professions scrupulously and to live up to the trust which is put in them in the context of their professions.
Art. 20. The code of professional conduct is enacted by the State Chamber of Physicians, and it requires the approval of the State Ministry for Health, Nutrition and Consumer Protection.
In the Olympic Games of ancient Greece, physical fitness was part of that perfection which brought the contest victor into the proximity of the gods.
Pledge
The following pledge applies to every physician:
“Upon my acceptance into the medical profession, I pledge to put my life in the service of humanity.
I will practice my profession with diligence and dignity.
Maintaining and restoring the good health of my patients shall be the highest imperative of my actions.
I will safeguard, even after the death of the patient, all secrets entrusted to me.
I will preserve the honour and noble tradition of the medical profession with all my powers, and I will make no distinctions in performing my medical duties with respect to religion, nationality, or race, nor with respect to party affiliation or social position.
I will show reverence for every human life beginning from conception, and I will not, even if threatened, employ my medical abilities contrary to the demands of humanity.
I will show my teachers and colleagues the respect due to them. All this I promise upon my honour.”
That is not to say that there were no effective treatments in antiquity. See fn. 10. In his dialogue, Protagoras, Plato—at the beginning of the 4th century BC— presupposes, as common and familiar, medical procedures “with burning and cutting, with medical remedies and starvation diets” (Rufener 179). But there was no medical equipment industry, no pharmaceutical industry, no standardised medications.
Walton and Kerridge have enumerated the attempts to promote patient safety and their rather poor success, p. 20.
Freidson wanted to “save professionalism from itself” (p.196).
References
Bleicken, J. 1995. Die athenische Demokratie. 4th ed. Schöningh, Paderborn. p. 284ff.
Diller, H. (Ed.). 1994. Hippokrates. Schriften. Philipp Reclam, Stuttgart. p. 8 ff.
Edelstein, L. 1969. Der hippokratische Eid. Trans. from the English by Klaus Bartels. Artemis Verlag, Zurich and Stuttgart. p.7 f.
Faller, H., and H. Lang. 2010. Medizinische Psychologie und Soziologie, 3rd ed. Berlin: Springer. 194.
Freidson, E. 2001. Professionalism, the Third Logic. The University of Chicago Press.
Kettner, M., and F. Heubel. 2012. Lob der Profession. Ethik in der Medizin 24(137–146): 145.
Kudlien, F. 1990. Der ärztliche Beruf in Staat und Gesellschaft der Antike. In Jahrbuch des Instituts für Geschichte der Medizin der Robert Bosch Stiftung, vol. 7, ed. W.F. Kümmel. Stuttgart: Hippokrates Verlag.
Leven, K.-H. 2005. Hippokratischer Eid. In Enzyklopädie Medizingeschichte, ed. W. Gerabek, B. Hage, G. Keil, and W. Wegner, 598f. Berlin: Walter de Gruyter.
Lichtenthaeler, C. 2005. Text des Hippokratischen Eides. In Enzyklopädie Medizingeschichte, ed. W. Gerabek, B. Hage, G. Keil, and W. Wegner, 599f. Berlin: Walter de Gruyter.
Medical Professionalism Project. 2002. Lancet 359: 520–522. Also: Medical professionalism in the new millennium. A physician charter. Annals internal medicine [Online]. http://annals.org/content/136/3/243.full. Accessed 9 Jan 2012. Trans F.H.
Plato. 1991. Die Großen Dialoge. Trans Rudolf Rufener. Munich: Artemis & Winkler p. 57.
Siegrist, J. 2005. Medizinische soziologie, 6th ed. Munich: Elsevier GmbH. 226.
Walton, M., and I. Kerridge. 2014. Do no harm: is it time to rethink the Hippocratic Oath? Medical Education 48: 17–27.
Wissowa, G. (Ed.). 1958. Paulys Realencyclopädie des klassischen Altertums. Achter Halbband, 2467–2470. Suttgart: Alfred Druckenmüller Verlag.
Xenophon. 1955. Apologia Socratous, ed. by E.C. Marchant, Vol. II, 2nd ed. Oxford.
Ziegler, K. (Ed.).1958. Paulys Realencyclopädie des klassischen Altertums. 36. Halbband, zweites Drittel, 457–493. Alfred Druckenmüller Verlag, Stuttgart.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Heubel, F. The “Soul of Professionalism” in the Hippocratic Oath and today. Med Health Care and Philos 18, 185–194 (2015). https://doi.org/10.1007/s11019-014-9589-2
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11019-014-9589-2