|LESSONS FROM HISTORY
|Year : 2015 | Volume
| Issue : 1 | Page : 81-86
Hippocrates and the hippocratic oath
Saurabh K Gupta
Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||22-May-2015|
Dr. Saurabh K Gupta
Department of Cardiology, Room No. 23, 7th Floor, CT Centre, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
For a long-time men had a philosophic view of health and disease, and this lasted till almost 2500 years back. Hippocrates, the great Greek physician, is believed to have seperated the "art of healing" and philosophy. An astute observer, Hippocrates during his practice employed principles that laid the foundation of modern medicine. The medical fraternity worldwide unanimously bestowed the title of "father of medicine" to this great man. Apart from being a physician, he was instrumental in bringing about the concept of ethics in the realm of medicine. The famous document "Hippocratic Oath" while being respected by almost all has generated a great amount of debate among historians. Nonetheless, almost all medical schools across the world have the Oath ceremony where medical graduates agree to the commandments of the Hippocratic Oath, either in its original or modified form. Although a statement of promise this Oath does not have any legal implications as might be seen by a person outside the medical community. This article outlines the contributions made by Hippocrates to the medical world with an emphasis on the Hippocratic Oath.
Keywords: Hippocrates, Hippocratic Oath, Oath
|How to cite this article:|
Gupta SK. Hippocrates and the hippocratic oath. J Pract Cardiovasc Sci 2015;1:81-6
| Introduction|| |
Five and half years after I joined the medical college, during the convocation ceremony, I undertook the Hippocratic Oath in the presence of hundreds of medical professionals. Although I have indelible memories of this landmark day of my career, I have only a faint recollection of the great Hippocratic Oath. So fascinating has been the journey in the field of medicine that I never ventured in this important aspect of medicine. However, a recent discussion on medical ethics revived my interest. The discussion that was otherwise casual had lasting effect on my psyche and prompted me to learn more about Hippocrates, the father of medicine.
Historians have done a commendable job in recreating the extremely complicated sequence of the development of medicine.  No one statement can define the boundaries of ever increasing field of medicine. Instead, modern medicine is an amalgamation of knowledge acquired over thousands of years of human civilization and is a source of learning in itself. In this article, however, I shall restrict myself to Hippocrates and the Oath he is credited with.
| History of Medicine|| |
There are ample evidences to support the fact that primitive man practiced medicine. The earliest evidence of medical prescriptions dates back to 3000 BCE in the Kingdom of Sumeria. The codes of conduct were laid by Hammurabi, well-acclaimed ruler of Babylon, approximately 2000 years before the Christian era. These rules are testimony to the fact that the concept of medical ethics was well formulated early in the history of mankind.
Medicine in ancient Egypt
Egypt was an epicenter for the development of medicine in ancient times. Like the Greeks, various gods were believed to preside over the arts and sciences. Horus, the God of the health, lost his eye in a fight that was miraculously restored. This eye of Horus is believed to have an appearance similar to the sign "Rx," a common representation for prescription. This sign "Rx" is otherwise known to represent the Latin word "recipe" meaning "to take." Unfortunately, we have scant information regarding medicine in ancient Egypt. Nonetheless, two persons need special mention. Sekhet-eanach is considered as the first physician in the history of mankind by some scholars. Imhotep was the other well-known physician and was worshipped as the god of medicine, until well in the Christian era. Few researchers even suggest that Imhotep, rather than Hippocrates, should be regarded as the father of medicine.
Medicine in ancient India
Rig-Veda and later Ayurveda laid the foundation of Indian medicine which was successfully carried forward by Charaka, Sushruta, and other physicians. Like other historical aspects exact timing of Charaka Samhita and Sushruta Samhita, two landmark manuscripts of Indian medicine are speculative at best, although the majority of historians believe that they practiced before Hippocrates.
Medicine in ancient Greek
Till well into the early Greek era, the disease was believed to be an act of magic and society largely depended on magicians and "witch doctors." This pattern continued well into the Greek civilization and continues to have some effect even today. The presence of personalities in the likes of Socrates and Pythagoras, the great philosopher of Greek civilization provided apt environment for unparalleled growth in the field of medicine.
| Hippocrates and Hippocratic Medicine|| |
Hippocrates was born in 460 BC in the Island of Cos, close to the then Asia minor. He is said to be the direct descendant of Aesculapius, the Greek God of healing. Hippocrates traveled extensively during his lifetime and after an illustrious professional career, died in Larissa in 355 BC. He is believed to have taught his pupils and run an open-air clinic under a gigantic oriental plane tree (Platanus orientalis). This plane tree, the largest in Europe exists even today standing tall in the town of Cos. However, some scholars believe that this tree is only 500 years old, and, therefore, unlikely to be the one related to Hippocrates. The derivatives of the tree have been taken to various academic centers of excellence across the globe, including Yale University, University of Glasgow and National Library of Medicine in the United States [Figure 1].
|Figure 1: Plaque situated at National Library of Medicine stating the gift of tree of Hippocrates from Island of Cos.|
Click here to view
Very little is known about the man himself; most of his reputation as a physician comes from the study of Corpus Hippocraticum, a collection of more than 100 books. They varied in style, tone, and medical doctrine and therefore it is very likely a work of more than one author. Although much of it is obsolete, the principles of teaching described are surprisingly modern. This monumental work was first published in 1526 and was later translated in English. Irrespective of incomplete knowledge and lack of relevance of most of the writing, Hippocrates must be credited for separating medicine from philosophy. He was instrumental in bringing scientific methods of careful observation and logical reasoning. He declined that the disease is the result of punishment by the God. Instead, he believed that the human body possessed four fundamental qualities, the hot and the cold, the dry and the moist and that it was composed of four humors - blood, phlegm, yellow bile and black bile. Further, he envisaged that disturbance of the relative predominance of the humors caused disease, and it is the physician's duty to bring this balance back in a person who is sick. In one of his books, he mentioned about the effect of food, occupation and climate in causing disease. He advised physicians to observe the prevailing winds, the water supply, nature of the soil and habit of the people to be able to deduce what diseases are more prevalent or likely to become prevalent in their region of work. By indicating these aspects of disease causation, he was the first to introduce epidemiology.
He was an astute observer of clinical signs and believed in systematic assessment. He said that the examination should begin from the face of the patient. "Hippocratic facies" to describe a patient with "nose sharp, eye hollow, temples shrunken, ears cold and with their lobes turned outward, the skin of the parched face and tense, the color yellow or very dusky" to describe impending death is a testimony to his wisdom in providing a vivid description of what we know today as "low cardiac output state." Similarly, his portrayal of "the breathing was rare and large" is an apt description for Cheyne-Stokes respiration. This vividness of the depiction was the hallmark of Hippocrates. Further, he was able to forecast how symptom would develop and whether a fatal issue is likely. An extract from one of his greatest works "prognostic" summarizes it well. It says, "I hold that it is an excellent thing for the physician to practice forecasting… he will carry out treatment best if he knows beforehand from the present symptoms what will take place later."
Hippocrates made little use of drugs in the treatment. He probably knew that most of the diseases have a tendency of natural cure and believed that "the natures are the physicians of our diseases." Nevertheless, he did not refrain from even surgical treatment when it was needed. His description of surgical practices ranged from the use of tar for wounds as an antiseptic method to the instructions for trainee surgeons. In his short book entitled "In the surgery," he wrote "the nails neither to exceed nor come short of the finger tips. Good formation of fingers, with thumbs well opposed to forefinger. Practice all the operations, with each hand and with both together." While he had an illustrious career as a physician and surgeon, he was courageous enough to report his successes and failure with equal ease. He did not refrain from reporting high mortality of 60% out of 42 cases that he described in the book "epidemics." Thus, he set an example of record keeping.
In addition to many firsts in the field of medicine, Hippocrates is credited with the use of aphorisms (Greek aphorismos) - an original thought presented in a concise and memorable fashion. One such aphorism worth mentioning is "do not disturb a patient either during or just after a crisis, and try no experiments, neither with purges nor with other irritants, but leave him alone." Similarly, he remarked that "it is better to give no treatment in cases of hidden cancer; treatment causes speedy death, but to omit treatment is to prolong life." These aphorisms may not be true in the current era of emergency medicine and advanced oncology but was in probabilities appropriate for physicians then. He advised the doctor to be prepared for the right thing at the right time, in which patient, attendants, and the external circumstances must co-operate. Thus, while he was concerned about physicians' behavior toward their patients, he was vigilant enough to express his expectations from the patients and their relatives. In summary, he contributed in all aspects of medicine and laid the foundation for their growth over centuries. This is his expertise in preclinical, clinical as well as surgical specialties of medicine that has earned him a title of "father of medicine."
| Hippocratic Oath|| |
According to Webster dictionary, Oath is a noun that literally means "a formal and serious promise to tell the truth or to do something." The Oxford dictionary defines this noun as "a solemn promise, often invoking a divine witness, regarding one's future action or behavior." The Oath is emphasized so much in recent times that it seems to have become a reflection of the gold standards of any profession. And why not, when in the current era moral and ethical values are eroding rapidly this sacred set of promises is expected to be taken equally by all the stakeholders. Almost all medical professionals cherish the moment of their Oath ceremony and feel proud to be associated with such a tradition. Unfortunately, while expectations and enthusiasm regarding Oaths are high this much celebrated Hippocratic Oath is questioned for its relevance in the current era. As has been mentioned before, contrary to the expectations historians do not know for sure who wrote it. The notion that this might not have been written by Hippocrates himself stems from the fact that some of its contents contradict the concepts in other text believed to be composed by Hippocrates. As little is known about the original Oath, it remains unclear what relevance did it have in the Greek era. In fact, some scholars speculate that there may have been other Oaths at that time, of which the Hippocratic Oath is the sole survivor. There is almost no mention of the Oath during first 1500 years after its composition. The first recorded use of the Oath was in the University of Wittenberg, Germany, in 1508.  This literary silence of almost one and half century and its resurgence in the middle age, possibly explain the inclusion of some of the vows that seem to have reflection of Christian ideology. The Hippocratic Oath was translated in English in 18 th century, and it is increasingly being used in medical schools in Europe and the United States, albeit in modified form. ,
The Hippocratic Oath not only contradicts other Hippocratic texts, but also contradicts ancient Greek practices. For Plato, life began from birth and Plato as well as Aristotle advocated abortion and infanticide, not only for medical reasons but also for a variety of reasons. In this respect, the Oath might rather be a reflection of Pythagorean philosophy that argued in favor of beginning of life at conception. Further, if Edelstein is to be believed the separation of medical and surgical specialties as the Oath might suggest is also the result of Pythagorean influence. Edelstein made a rather strong conclusion when he claimed that the Oath was a Pythagorean manifesto and not the expression of an absolute standard of medical conduct.  Other historians, however, do not agree with this interpretation and believe that the Oath is in general sync with the then existing Greek philosophy. Interestingly, contrary to the common belief the well-known phrase "first do no harm'' from Latin "primum nonnocere" is not part of the Oath. Hippocrates wrote in Greek and not Latin, and this phase were most likely introduced by Thomas Inman in 1860. 
Whatever may be the truth behind its composition, authorship and its exact timing, the persistence of this Oath is impressive. Ceremonial and nonobligatory, the Hippocratic Oath can be compared to that taken by a judge, president or other politician when he or she is sworn into office. To understand the message embedded in the Oath, it is necessary to have a detailed analysis of the Oath. Many historians have provided interpretations of the Hippocratic Oath. Michael North  interpreted and translated the Oath [Figure 2]. According to Orr et al.  the content of this traditional version Hippocratic Oath can be divided into 12 items:
- Covenant with deity: "I swear by Apollo, the physician…"
This is an invocation of the Greek gods of healing. Apollo is invoked as a physician or healer. Asclepius is the legendary father of medicine and physicians. Hygeia and Panacea were the two most famous of Asclepius' daughters. Medicine was a craft commonly passed from father to son; medical families sometimes claim to be descended from Asclepius himself. This was true of Hippocrates, and this is probably the reason why Plato called him an "Asclepiad."
When on one hand, they are credited with incorporating science in place of philosophy in the understanding the health and disease invocation of the Gods seems contradictory. In all probabilities, prominent physicians are invoked as patrons, witnesses and judges who will determine whether the contract is ethically followed and not as Gods. The invocation of the gods, like swearing on the Bible in a court of law, brings a solemnity and supernatural sanction to the Oath, which is precisely what makes it an Oath (as opposed to a promise or a declaration). If they have been fulfilled, the gods will grant fame and honors, but if they have been transgressed, the gods will ensure ill fortune and disgrace.
The very concept of inviting Gods is not in line with the Christians and Muslims philosophy, as it seems to involve worshipping or at least acknowledging the existence of false gods. This problem might explain delayed acceptance of Hippocratic Oath nearly 2000 years after its composition. Furthermore, this portion of the Oath has undergone greatest degree of alteration over the ages. Nevertheless, it is remarkable that the Oath was adapted and used both by Christians and Muslims. One of the many versions has not only replaced the pagan gods with Christ, but also adapts the Oath to become a declaration; there is no "I swear" but it begins instead by saying "Blessed to God the Father of our Lord Jesus Christ, who is blessed for ever and ever; I lie not." Other newer versions of the Oath simply allow one to swear by "whatever I hold sacred." ,
Similarly, the Islamic translators rendered the Oath safe and acceptable by putting it in the mouth of Hippocrates and also by making a number of subtle changes to the Oath. One of such Oath begins by saying "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." 
- Covenant with teachers: Pledge of collegiality and financial support.
- Commitment to students: Promise to teach those who swear the Oath.
These two paragraphs are controversial. When used in its near original form, this section is often omitted as it seems obsolete in the current era. According to Edelstein, the practice of quasi-adoption of the pupil was again a pointer toward Pythagorean influence. It seems difficult to understand as to why the teaching of medicine is confined to those who take the Oath? This could be a way to protect the power and exclusivity of the medical elite. The exclusion of those who will not abide by the physicians' law is, of course, a sociological method of control, and a means to establish the reputation and prestige of those within the fellowship of the Oath. Such mechanisms once again are not unique to the ancient world. Like any other method of control or licensing it must have been a way to separate the reliable from the unreliable and the trustworthy from the untrustworthy. These paragraphs of the Oath also stress the importance of passing on the knowledge of medicine and of ethical practice to the next generation. In the current days of institutions, formal education and statutory exams this is no longer a part of the relationship of a physician and his apprentice. However, the importance of passing on medical knowledge and of impressing upon students the importance of standards of behavior and of competence cannot be overemphasized.
- Covenant with patients: Pledge to use "ability and judgment."
- Appropriate means: Use of standard "dietary" care.
- Appropriate ends: The good of the patient, not the physician.
This section is the soul of the Oath. It immediately follows the section on the structures of medical education and sets out the fundamental role of medicine. The physician promises to use a treatment for the benefit of those who are sick, according to his or her ability and judgment. The physician is also directed to refrain from doing harm or injustice. The typical Hippocratic method of treatment was to prescribe a particular regime of diet and exercise with or without change in the environment. Only if this failed, there was a need of drugs. The role of the physician was to assist nature in restoring this balance. "Nature is the physician of diseases."
- Limits on the ends: Originally proscribed abortion and euthanasia.
The paragraph which immediately follows concerns the provision of deadly drugs and of abortive pessaries. This paragraph is placed here because these actions are seen as archetypal acts of transgression, betraying the aim or meaning of medicine as outlined in paragraph 4. These prohibitions are thus central to the very understanding of medicine. Giving a lethal drug or in lethal doses, for whatever reason, contradicts the meaning of medicine, understood as the fostering of physical health. Destroying the body (either of the sick patient or of the fetus) is contrary to the very nature of medicine. Thus since these actions in some way contradict the most fundamental aim of medicine and rather than assisting nature and bringing health, they bring death and destruction, these actions are prohibited by Hippocrates.
The debate on the use of abortifacients is not new. Although it invokes death and destruction of the fetus it brings health to the mother immediately and in times to come especially if it is associated with ill health of the mother or is an unwanted pregnancy. The relief of physical and mental sufferings of the mother then should be the first goal as a physician. Therefore, taking a balanced view this statement must be taken as a guide to use harmful drugs with caution.
- Limits on means: Originally proscribed surgery for renal stones, by deferring to those more qualified.
The paragraph about surgery (paragraph 7) is obscure, but it is at least clear that it does not involve the same sort of objection as the prohibition of poisoning or abortives-for in the case of surgery the physician is allowed to make way for a specialist physician, the surgeon to carry out these actions. Although it may be a reflection of an element of self-protection, it also emphasizes the role of specialization. Interpreted very broadly as a prohibition against practicing beyond the limits of one's competence, this is probably more relevant today.
- Justice: "Avoiding any voluntary act of impropriety or corruption."
- Chastity: Originally proscribed sexual contact with patients.
- Confidentiality: Not to repeat anything seen or heard.
- Accountability: Prayer that the physician be favored by the gods if the Oath is kept, and punished if it is not kept.
In these paragraphs, emphasis is broadly on the physician-patient relationship that is becoming more and more talking point in the current era of modern medicine. The Oath is an ethically acute and thoughtful document in this regard. It is this ethical aspect of the Oath that has made it relevant in a long history of more than two centuries.
In addition to the opening proclamation, many institutions have modified the remaining content of the Hippocratic Oath. The most common changes are the removal of the proscription of sexual contact with patients, the ban against using abortive agents and the agreement to be accountable for keeping the Oath. While close to 50% of schools have chosen to continue to use the Hippocratic Oath with some modification or modernization substituted to make it more consistent with their own values, other institution have chosen to administer a different medical Oath.
| Medical Oath in Current Era|| |
There are many modern versions of the Oath. The declaration of Geneva that was written by the World Medical Association in 1948 after World War II is most popular of these. This was later amended in 1968, 1984, 1994 and underwent two editorial revisions in 2005 and 2006. Unlike the Oath, the declaration of Geneva does not invoke the presence of Gods and is only a statement of promise. However, it is not a pact between individuals nor is it agreement to abide by institutional rules. Other version commonly used is written by Louis Lasgna, the dean of Tufts University in 1964.  Similarly, British Medical association has suggested modified version of the Oath. , Many medical schools and Universities have composed their own Oaths or declarations, at times allowing the student bodies to be part of the team preparing these documents or even instructing each student to write his or her own personal Oath. 
In 1994, of the 27 medical schools in the United Kingdom, three used the Hippocratic Oath, four used the declaration of Geneva and seven used other Oaths or declarations. A similar pattern is found in the United States. Whereas, in 1928, only 24% of US medical schools administered an Oath, in 1958 this had risen to 72% and by 1989, the proportion had reached a staggering 98%. Of these medical schools, nearly half use some version of the Hippocratic Oath and a quarter uses the declaration of Geneva. ,, Similar to the trend worldwide, there is no uniformity of the Oath in India. The Oath being used at All India Institute of Medical Sciences, New Delhi is believed to be written by Charak [Figure 3].
|Figure 3: Oath being pledged at All India Institute of Medical Sciences, New Delhi, India.|
Click here to view
Nevertheless, while the number of schools using an Oath or declaration has risen consistently through the twentieth century, albeit with more and more changes in the original content of the Hippocratic oath. In short, more and more medical students were swearing to do less and less with the concerns during the Oath ceremony shifted from physician's behavior to the requirement to respect the stated wishes of patients.
| Conclusion|| |
The contributions made by Hippocrates are immense in every field of medicine. The Hippocratic Oath although controversial in some aspects is still relevant to modern day physicians and forms the basis of a majority of the medical Oaths being sworn in medical schools across the globe.
| References|| |
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[Figure 1], [Figure 2], [Figure 3]