| Abstract|| |
Hippocrates (460-375 B.C.), an ancient Greek physician considered the "Father of Medicine," constructed the groundwork for the principles of ethics in medicine over 2,500 years ago in his establishment of the Hippocratic Oath. One of the oldest binding documents in history, the text has remained the ethical template for physicians to this day. The changing cultural and social environment of modern society, accompanied by the advancement in scientific knowledge and therapeutic tools, has surfaced the need to reframe ethical perspective in modern medicine. Progress in aspects such as organ transplantation, stem cell technology, and genetic engineering has welcomed a new set of ethical dilemmas. These dilemmas have become intimately intertwined with the impact of commercialization, as seen by the interplay between legislation, health care, and pharmaceutical businesses. This paper seeks to dissect the principles of the original Hippocratic Oath and analyze the template in relation to the ethical dilemmas presented by contemporary medicine. Examination will provide a deeper understanding of the paradigm shift in modern medical ethics. Both the value of the Oath and the level of awareness of modern ethical dilemmas through the lens of American and Indian medical graduates will be assessed.
Keywords: Ethics, Hippocratic Oath, Indian medicine, medical profession, Western medicine
|How to cite this article:|
Jhala CI, Jhala KN. The Hippocratic oath: A comparative analysis of the ancient text's relevance to American and Indian modern medicine. Indian J Pathol Microbiol 2012;55:279-82
|How to cite this URL:|
Jhala CI, Jhala KN. The Hippocratic oath: A comparative analysis of the ancient text's relevance to American and Indian modern medicine. Indian J Pathol Microbiol [serial online] 2012 [cited 2020 Feb 22];55:279-82. Available from: http://www.ijpmonline.org/text.asp?2012/55/3/279/101730
| Introduction|| |
Hippocrates (460-375 B.C.), the "Father of Medicine," was an ancient Greek physician from the island of Cos in the Aegean Sea. Hippocrates was a unique physician in his era. Unlike others, he rejected the superstition and magic of primitive medicine. He developed an oath which established lofty moral principles to govern the conduct of physicians. Those who took the Hippocratic Oath swore to treat the sick to the best of their ability, preserve the patient's privacy, teach the secrets of medicine to the next generation, and respect human life. Hippocrates was the first to establish such an ethical template. To this day, the Oath is almost universally accepted. Its recitation by medical students serves as a rite of passage into physicianship.
The American Scenario
Despite its ancient roots, the Hippocratic Oath is still emphasized by the American Medical Association (AMA) as an expression of ideal modern medical conduct. Today, medical school students at more than 60% of U.S. medical schools swear to some form of the Oath, usually a modernized version.  Worldwide, over 84 national medical associations, which represent some nine million physicians, are members of the World Medical Association (WMA). The WMA has established a publicly professed oath.  Yet paradoxically, even as the modern oath's use has burgeoned, its content has been watered down from the classical doctrine.
To delve into the use and knowledge of the Hippocratic Oath within a modern community of physicians, we interviewed 15 randomly chosen physicians with varied backgrounds from a major tertiary care medical center with excellent repute in the United States. Their specializations included Pathology, Cardiology, Pediatrics, Radiology, and more. Of the 15, six were females and nine were males. The physicians graduated from various medical schools across the United States, including Washington University in St. Louis, the University of Louisville, the University of Alabama at Birmingham, and Galvesten University. The oldest physician interviewed graduated from medical school in 1974 and the youngest in 2007. All of the physicians had background knowledge on the Hippocratic Oath. Two main questions were asked: (1) Do you remember taking the Hippocratic Oath (or some varied form of it) when entering medical school? and (2) Do you remember what it said? Of the 15, 14 remembered taking some form of the Oath when graduating from medical school. However, only one could repeat the Oath's content in full. Four had "more than a general knowledge" of the content, meaning that of the seven main points of the Oath, they could explain three or more. Nine of the physicians had little, if any, knowledge of the Oath's content. When asked, they could name one or two of the Oath's ethical duties such as to "do no harm" or "treat patients with respect."
Interestingly, the physicians retaining the most extensive knowledge of the Oath were the oldest. The one individual who could recite the Oath's content in full was the 1974 graduate. The four physicians with "more than a general knowledge of the content" graduated in 1976, 1984, and 1985. The relatively recent graduates, including those from 2006 and 2007, had the least amount of knowledge on the Oath, despite having taken it most recently. A possible explanation for these discrepancies may be the fairly recent incorporation of medical ethics courses in the medical schools. These courses integrate modern-day medical issues in clinical and research settings with ethical principles. This teaching collides in many instances with the older ethical framework of the Oath. Current students, therefore, understand the core concepts of "do no harm" on a deeper level through the academic study of ethics. They retain little from the administered oath at their graduation ceremony. The Oath itself is mostly viewed as a rite of passage or ritual of reminder. For older graduates, this type of coursework was unavailable, making Hippocrates's ethical template the primary source for establishing a moral conduct framework. This study provided preliminary insight into the argument that the Hippocratic Oath, while an important framework of moral guiding principles, has grown to become obsolete in today's medical field.
The Indian Scenario
In contrast to the United States, the system in India to acquaint young medicos with the principles of medical ethics is new and weak. As Dr. Anshu, Professor of Pathology of the Mahatma Gandhi Institute of Medical Sciences Sevagram, notes, "In the past, ethics was often given short shrift in the Indian MBBS curriculum, and consigned to a few forgotten pages in textbooks of forensic medicine. These mostly dealt with legal ethics; clinical and research ethics hardly ever found their way into classroom teaching." Only recently has there been a movement to begin integrating the study of ethics more deeply into the medical curriculum. The governors at the Medical Council of India (MCI) established the Vision 2015 document on March 29, 2011, calling for the entire reconstruction of the Indian medical curriculum. The proposed changes included plans to "integrate ethics, attitudes and professionalism into all phase of learning…[to] enable the Indian Medical Graduate to function professionally and ethically." While in the United States there has been a two-fold ethics module to help medical graduates formulate an ethical template (the strong medical ethics curriculum in medical school and the Hippocratic Oath at the completion of medical school), in India, there has been neither; this is slowly changing. Already, a few universities have taken heed of incorporating ethics education. However, the movement has yet to gain enough momentum to be considered universal in the Indian medical education system. 
Changing Concepts of Physicianship from the 19 th Century to the 21 st Century
In light of the above understanding it is important that we recognize the genesis of the code of ethics as we know it today. The first modern national code of ethics, written in 1847 by the American Medical Association, was hailed as being as revolutionary as the Declaration of Independence. It was the first document to establish a three-part social contract with reciprocal obligations between physicians and patients, physicians and their peers, and physicians and their communities. For example, in the physician-community relationship, a physician is "required to expose his health and life for the benefit of the community (and) he has just claim in return, on all its members, collectively and individually, for aid to carry out his measures." In regards to the physician-patient relationship, physicians were to "be ready to obey the calls of the sick." Simultaneously, patients were to select only properly trained physicians and to "faithfully and unreservedly communicate to their physician the supposed cause of the disease." The Oath also advocated that "the obedience of a patient to the prescriptions of the physician should be prompt and implicit."  The current medical framework has led to the disintegration of this three-part social contract and to the creation of a one-part social contract in which autonomous physicians retain complete authority. To understand how this has changed the meaning of the Hippocratic Oath, it is important to evaluate relevant historical trends.
In the original context of the Oath, a kind, nurturing, and open student-teacher relationship was imperative to the medical profession. The Oath taught medical students to treat their physician mentors as equal to their own parents. For example, the Oath advocated that students regard their mentor's offspring as equal to their own brothers. Simultaneously, to teach the art of medicine without fee and covenant, and to give guidance to sons and to sons' sons was part of the medical law established by the Oath. Sustaining this type of medical community was key in the progress and development of medicine.
Sir William Osler (1849-1919) reflected the purpose of the 19 th - century medical society in his writings. He viewed medical societies as the "fertile grounds upon which physicians grew." He stated, "You cannot afford to stand aloof from your professional colleagues in any place. Join their associations, mingle in their meetings, gathering here, scattering there but everywhere showing that you are faithful students, as willing to reach as be thought."  Talcott Parsons, an American Sociologist from Harvard, suggested that people who became doctors during this time tended to be less driven by money and more by a desire to share scientific knowledge with their peers.  For medical leaders in particular, participation was seen as a core altruistic duty to the future of the profession. According to Osler, "No physician [had] a right to consider himself as belonging to himself, but all ought to regard themselves as belonging the profession, in as much as each is a part of the profession."  In fact, when Osler was asked by a medical student whether he (the student) should attend a local medical society meeting, Osler responded, "Do you think I go for what I can get out of it, or what I can put into it?"  The medical society was a cohesive, peer-driven community. Participation in professional associations was an ethical obligation that fostered humility in the field of medicine.
Hippocrates' original emphasis on humility had been based on the awe of God's powers over human life and a belief that physicians would be guilty of hubris if they meddled in God's plans. Later generations of physicians saw the human body as mechanistic; as acquiescent to scientific scrutiny for the purpose of learning.  While the shift to a more mechanical perception of the human body served well to fuel scientific discoveries, it was those same discoveries that stripped the physician of his or her humility. As medical discoveries led to triumphs over disease and suffering, so too did the physician's ego conquer modesty. This led to a diminishing respect for the transparency of knowledge within the medical community. Individual progress began to be valued over collective achievement.
Thus, the modern medical framework is less centered on bilateral relationships between the physician, medical community, and patients. Increasingly, the individual mind-set has been amplified by the intertwining of business concepts in health care. A capitalistic medical revenue field has led to competition propagated by the lowest percent errors along with the greatest percent innovation. Physician credibility in academic settings is gauged by the amount of publications and presentations in research. Physician credibility in private practice settings is gauged by greatest amount of patients. Whereas in the academic setting, monetary compensation is fueled by innovation, in private practice, monetary compensation is fueled by quality of care. In either instance, revenue is key for advancement.
Thus, there shows a transition away from the idea of patient and community-based medicine to revenue-based medicine. In relation to the Hippocratic Oath, Dr. Knapp van Boagart of the Department of Family Medicine at the University of Limpopo further explains, "The current emphasis on autonomy and distributive justice has changed the relationship to such an extent that one might argue that the Oath has become irrelevant."  Modern translated versions of the Oath seek to revive many of the original concepts in regards to establishing a community of modest physicians. For example, a widely used modern version states, "I will not be ashamed to say 'I know not,' nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery." The conscious construction of such concepts in modern Oath translations indicates that medical boards have recognized the negative effects of the transition away from physician humility and physician communities.
Ethics in Modern Medical Research as a Lens for Evaluation
Deteriorating ethical behavior in medicine can be attributed to a variety of pressures, the most prominent of which include those that come from (1) universities whose revenues depend on research-affiliated funding and (2) companies whose successes are solely based on profit.
The South Korean cloning scandal is the greatest example of a departure from Hippocratic ideals. The medical research community witnessed the rise and fall of Professor Hwang Woo-Suk and his team of researchers, who claimed to have successfully developed the first human embryonic stem cell line. In March 2004, Hwang's team reported using the process of somatic cell nuclear transfer (SCNT) to generate a line of human embryonic stem cells (ES) that were identical to the donor nucleus.  Nearly a year later, in June 2005, Hwang's team published another article claiming that genetically identical cell lines had been generated from patients with spinal cord injuries and other diseases. By January 2006, however, the Investigations Committee of Seoul National University concluded that the articles published by Hwang were fabricated and that his team of researchers had engaged in scientific misconduct. 
The fraud sparked controversy around the globe. Many bioethics analysts began to question how a scandal of such a magnitude could originate in a medical research laboratory. A study done by the University of Pittsburgh showed that scientific misbehavior, even in heavily regulated research environments, was more common than previously thought. In a survey of researchers at the National Institutes of Health, 1.5% admitted to falsifying or plagiarizing data. Luk Van Parijs, who was fired by the Massachusetts Institute of Technology after admitting to fabricating and altering research papers in order to support grant applications, explained the motivation behind such misbehavior.  In research-funded settings, pressure to publish mounts, causing some researchers to start the publication process before they have results that support their assertions.  Such medical misconduct can be fatal. Clinical researcher Paul Konark altered patient medical records in order to facilitate their enrolment in drug trials from which they should have been omitted due to preexisting conditions. When one of these patients died, Konark was jailed for criminally negligent homicide. 
The scenarios mentioned above all have a central shared attribute: greed for success, whether it is through prestige, power, or revenue. Professor Julian Savulsecu, Director of the Oxford Centre for Practical Ethics at the University of Oxford, explained the capitalistic framework of the medical field. She stated, "The majority of funding comes from governments, companies and private investors. Companies have a specific interest in funding research that could improve their profit margins."  In reference to bioethical violations that result from this capitalistic structure, Savulsecu noted that Hwang may have felt the pressure to present positive results in order to garner honor for his nation and those who funded his research. Cases like this show how rivalry fueled by revenue and prestige can move the scientific world to a place where ethics, once part of the game, stays benched on the sidelines. The biomedical research arena, so closely tied with medical advancement, has failed to preserve the ethics sanctified by the original Hippocratic Oath. Because of this, many researchers in the global medical community believe that a "gold standard" of ethical procedures is needed.
Ethics in India's Medical Education System
The rapidly growing commercialization of medical education in India is resulting in a multiplicity of ethical issues. As the chief aim of medical education becomes a lust for lucre, a growing distrust of physicians increases throughout society. In medical schools, the merit of money too often has taken precedence over the merit of scores. Today, if you have sufficient monetary assets, you can get a medical education regardless of your academic credentials. This is occurring at both the graduate and undergraduate levels. Simultaneously, the quality of education is deteriorating quickly. Currently, many commercialized medical institutions have inadequate teaching materials, equipment, facilities, and staff. Dr. Pandya of the Department of Neurosurgery at the Jaslok Hospital and Research Centre provides a small example from the slew of instances available of how the quest for financial profit negatively affects medical teaching. He notes in a study, "Municipal medical colleges in Mumbai have demonstrated once again the ill-effects of permitting full-time teachers to indulge in private practice. All guidelines are openly flouted. Senior teachers are seen in private hospitals in the mornings and afternoons, attend several private hospitals, and divert patients from their teaching hospitals for personal profit." 
Medical graduates in India enter the field with a handicapped background, although having spent a large sum of money for that education. Those that benefit are the organizations sponsoring the education. Oftentimes, the goal of medical education by capitalistic organizations is to gain greater return on investments at a faster rate. If a student pays the full price of medical school for an education that costs the university half the amount to build, then a net benefit of revenue is incurred. Patients expect medical certifications to mean healing power, not buying power. Such factors will inevitably lead to society's declining trust and respect for the once noble medical profession. It is our responsibility to rejuvenate the glory and pride of the medical profession in our communities by declaring and enforcing the ethical principles of Hippocrates for both individuals and institutions.
| Conclusion|| |
The 1940 general assembly of the World Medical Association constructed one of the most commonly used set of medical ideals:
Ethics in the medical profession has always been and will continue to be of great importance. It is the profession's link to the amelioration of human sickness and suffering. Due to the phenomenal rise of consumerism, commercialization, and economic liberalization, a materialistic wave has overtaken the medical community. The high tide of this flood is resulting in the decline of ethical standards and the deterioration of the doctor-patient relationship. The philosophy of "awareness equals prevention" has been well engrained in societal and academic movements. Following the footsteps of the Western medical system, it may be beneficial for higher regulatory authorities (from medical institutions and state governments to the national government of India) to fortify and universalize the steps being taken to introduce foundational courses in medical ethics into the medical curriculum in order to counter the declination detailed above.
- I shall dedicate my life in the service of humanity.
- I shall practice my profession with conscience and dignity.
- The health of my patient will be my first consideration.
- I shall maintain by all means in my power the honor and noble tradition of the medical profession.
- Even under threat, I will not use my medical knowledge contrary to the laws of humanity.
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Khushboo N Jhala
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Source of Support: None, Conflict of Interest: None