The Hippocratic Oath and the Ethics of

Medicine

Steven Miles, MDUniversity of Minnesota

Believed to be the only depiction of Hippocrates.

Hippocratic Medicine and Oath -- 400 BC

• Rejected divine explanations for the cause or treatment of disease in favor of empirical, causal observational science.

• Moved from oral traditions to recorded observations.

• Opened from hereditary occupational families to a mission-professing guild.

Time Line

1000

Deontological works

Oldest OathPapyrus Church

Editing

1st MedicalSchool use

“Hippocratic”MedicalWorks

Fall of Athens

CEBCE

Oath

Columbus Voyage

The Cutting Insertion

1000

Bladder stonesurgical innovation

240 BCE

Oldest OathPapyrus

Fall of Athens

CEBCE 1500

Oath

Surgery separates from

Medicine

I will not cut, and certainly not those suffering from stone, but I will cede this to practitioners of this activity.

Oaths Ethics‘Questions

•Who is the physician?•What is the physician

committed to?•Who is the physician

accountable to?

Who is the physician?

Opening of Oath: An invocation?...

“I swear by Apollo the Physician and by Asclepius and by Hygieia and Panacea and by all the gods as well as goddesses, making them judges [witnesses], to bring the following oath … to fulfillment, in accordance with my power and my judgment;”

… or a genealogy?

• “Is there a man who has not heard of me—Amphitryon of Argos, son of Alcaeus, grandson of Perseus, and father of Heracles. I have lived here in Thebes ever since the crop of Sown Men sprang full grown out of the Earth.”

• From Heracles by Euripides

If genealogy, what does it mean?

The Genesis Story of Medicine I

Apollo CoronisPhysician, prophecy

AsclepiusChiron (a Centaur)Trainer of AchillesMedical education

Apollo: Prophecy & Prognosis

Apollo• God of Reason

• God of Prophecy– Oracle at

Delphi

Physicians• Reason- Natural

Cause and Effect:– Points to cause,

diagnosis, and treatment.

• Prognosis

Prometheus (Foresight)

• A titan who gave humans fire and creativity to invent medicines and imagine a prognosis.

• To prevent despair at foreseeing death in a person who was dying. Prom: I stopped mortals from

foreseeing doom.Chorus: What cure did you discover

for that sickness?Prom: I sowed in them blind hope.

– Aeschylus. Prometheus Bound

The Family of Medicine II

Epione(Hercule

s’ Daughte

r)‘Soothing

’

Asclepius

‘Unceasingly

Gentle’

Pindar’s Verdict on AsclepiusStill, even wisdom yields to hope of profit. And gold induced no less than he [Asclepius] to try to resur-rect a man whom death already had imprisoned…. We must seek from deity the things that fit our mortal hearts, keeping our condition and our destiny in mind. My vital being, do not seek immortal life; exhaust, instead, all possibility. •Pindar. Pythian Odes 3-63.

What does the Apollo Genesis Story of Medicine

Say?• The passion to heal arises

from love and grief.• Physicians must accept

mortality as a boundary for moral work.

• The names of Asclepius and Epione say that healing is not a war but a gentle rebalancing to path to health.

The Family of Medicine III

Asclepius EpioneUnceasingly Gentle Soothing

Hygieia

Health

AigleRadiance

TelesphorusConvalescenc

e

IasoHealers

PanaceaMedicines

Podalirius Machaon

The Family of Medicine IV

Asclepius EpioneUnceasingly Gentle SoothingPodalirius

Hippocrates

Machaon

Each Physician(Hippocrates dies in Larissa)

to regard my teachers as equal to my parents

What is the physician

committed to?

MD in Society Clinical Ethics

Principles

I will use regimens for the benefit of the ill in accordance with my ability and my judgment, but from [what is] to their harm or injustice I will keep [them].

Into as many houses as I may enter, I will go for the benefit of the ill, while being far from all voluntary and destructive injustice,

Examples(2)

1. I will not give a drug that is deadly to anyone if asked, nor will I suggest the way to such a counsel. 2. I will not give a woman a destructive pessary.

1. especially from sexual acts both upon women's bodies and upon men's, both of the free and of the slaves. 2. About whatever I may see or hear in or without treatment…-- things that should not ever be blurted out outside --I will remain silent, holding such things to be [profane to speak of].

What is the Physician Committed to?

What does the Physician Promise to Society?

• Capital punishment?• Euthanasia?• Homicide?

I will not give a drug that is deadly to anyone if asked, nor will I suggest the way to such a counsel.

Medically-Assisted Executions

• Executions were common in ancient Greece.

• No record of Greek physicians striving to make executions more effective or “humane” as in United States’ use of lethal injections.

• Physician engagement in such a role is best dated to 1789 when the French physician-legislator, Joseph-Ignace Guillotin, successfully promoted an anti-torture law that required that all executions be carried out by means of a “machine that beheads painlessly.”

Hemlock Euthanasia

320 BCE, Theophrastus noted that Thrasyas of Mantineia had discovered, “a plant which produces an easy and painless end; he used the juices of hemlock poppy. … For the effect of this compound there is absolutely no cure… death is made swift and easy.”

Does not describe who used hemlock, nor for what purpose.

Greek medical treatises do not describe the use of hemlock to induce death.

It was used for executions.

Euthanasia “good death” was not coined until 280 BCE, more than a century after the Oath was written. “Of those things that a man [human] prays for from the gods, nothing is better to meet with than an easy (happy) death.” This coinage referred to a natural death without agony--not to assisting death.

1869, William Lecky redefined euthanasia as intentionally ending life in order to end suffering from disease.

I will not give a drug that is deadly to anyone if asked, nor will I suggest the way to such a counsel.

Suicide in Greece of 400 BCE Was in relation to moral honor, shame

Not in relation to suffering caused by disease.

No medical discussion of physician assisted suicide or euthanasia.

If medically assisted euthanasia been part of ancient Greek medicine, it probably would have been discussed in the treatises, just as abortions by midwives were discussed.

“I will not give a drug that is deadly” addresses fear of physician poisoner.

• Murder was commonly used when the Oath was written to topple civic leaders, municipal figures and settle family disputes. In addition to loyalty or fear, physicians were under economic pressure from the collapse of the Athenian economy and cutbacks in the position of city-physicians. Tensions between civic medicine and medical ethics were widely discussed.

• 345 BCE, Plato wrote that a physician who administers a poison with the intention of causing death should be executed as such deeds are acts of terror Plato. Laws 933.

What does the Physician Promise

to Society?

• Antiabortion? Pro-life?• Anti-trespass in a

woman chattel society?

• Pessaries are dangerous.

I will not give a woman a destructive pessary.

1000

Oldest OathPapyrus

ChurchEditing of Oath

1st MedicalSchool use

Fetus as alive.

CEBCE

Oath

Lethal Pessaries

Hardening ChurchPosition Against Abortion

What Does the Physician Promise to

the Patient? 1

A clinical ethics of being a guest.

. . . especially from sexual acts both upon women's bodies and upon men's, both of the free and of the slaves

What Does the Physician Promise to

the Patient? 2

About whatever I may see or hear in or without treatment…-- things that should not ever

be blurted out outside –I will remain silent, holding such things to be [profane to speak of].

Who is the physician

accountable to?

If I render this oath fulfilled, and if I do not blur and confound it may it be to me to enjoy the benefits both of life and of techne (art and science), being held in good repute among all human beings for time eternal. If, however, I transgress and perjure myself, the opposite of these.

Oath’s Vision of Medical Ethics

Judgment of history.

Genesis: respect for love and grief, bounded by mortality.

Personal IntegrityIn a pure and holy way,

I will guard my life and my art and science.

Physician in Society

Clinical Ethics

MoralBenef

i-cent, Just

Empirical

A communi

ty to transmit knowledg

e and values

Summary

• Oath conforms to the medical practice and rhetoric of Classic Greece.

• Roles: education, compiling knowledge, and treatment.

• Ethics: beneficence and acting justly (dike) in public and clinical spheres.

• Progressive and historically accountable rather than deontologically, deistically accountable.

Steven Miles MD

miles001@umn.edu