by Dr Petros Bouras-Vallianatos
Wellcome Trust Research Fellow in Medical Humanities, King's College London
The Hippocratic Oath, which is commonly dated to around the late fifth or early fourth century BC, is perhaps the single most influential ancient Greek text nowadays. It is often mentioned in current debates on medical ethics and the original or modern versions of it are still sworn by medical graduates across several countries, including the UK. It is, however, rather bizarre to learn that Hippocrates was most probably not involved in its composition and that whether the Father of Medicine or any of his disciples ever took this oath is unknown. Intriguingly, we know nothing about its early reception and impact among medical professionals of the Classical and Hellenistic eras. It is noteworthy that the earliest surviving fragment of a version of the Oath, i.e. a papyrus originating in Egypt, dates to the third century AD (see Fig. 1).
The text is just 250 words long (an English translation is provided at the end of this article); yet the aphoristic nature of the text has often caused different interpretations. The Oath is of fundamental importance since it is one of the first texts in history which attempted to establish an ethical code for medical practice. In fact, it outlines what is part of the art of medicine and what is not, including both the private and the professional life and activities of the physician. The Oath does not have any legal repercussions for the swearer, but it has strong religious and social implications. The content could be divided into two main parts: the first deals with the duties of the oath-taker in connection with the transmission of medical knowledge and the second concentrates on the obligations of a physician related to medical practice and, the relationship between physicians and their patients and to society at large.
The Oath opens with an emphatic first-person singular declaration on the part of the physician who swears by gods and goddesses. The swearer first invokes Apollo, a significant Greek deity and patron of the Delphic Oracle, who is connected inter alia with music and prophecy, and also considered inventor of the art of medicine. Apollo is not only connected with healing abilities but he can also inflict a disease, as in the case of the plague visited on the Greek camp in Troy which caused the death of several soldiers, a story told in the first book of the Iliad. The Oath continues with an invocation to Asclepius, himself a hero and god of medicine and, according to one tradition, son of Apollo; Asclepius is credited with giving mankind medical knowledge. We can also see a reference to his two daughters, Hygeia (health) and Panacea (all-healer), both goddesses of cures and the physician’s ancestors, and finally to the entire Greek pantheon, all the Olympian deities. The invocation should not be seen as a prayer, but as a contract with gods and goddesses who play the part of witnesses in the act of swearing the oath. As we can see from the conclusion, the text has a substantial moral twist. It closes with the promise of reward in terms of personal and professional reputation (doxa) for those keeping the vow, while punishment and presumably loss of reputation would attend the backslider. The reference to moral judgement by ‘all human beings for time eternal’ embraces the wider society, emphasises the substantial social role of the physician, and reminds us of the significance of posthumous eternal fame and immortality in Greek thought and culture.
The first section of the Oath refers to the teacher(s) of medicine, the oath-taker and his sons, and also the sons of his teacher(s). The closely-knit system described in the Oath allows the transmission of the art of medicine only to members of a certain circle who have taken the oath and signed a written covenant. The physician would be trained in a form of medical apprenticeship and was obliged to transmit his knowledge to the next generation of physicians without fee and even consider the children of his master as part of his family and treat them as his own sons. This sort of lifelong commitment is quite unique and was not usual in other trades or vocations in antiquity. The text may reflect a contemporary context during a transitional period in which an earlier system of medical education embedded in a strong family-guild tradition is succeeded by a new era in which the art of medicine gradually became available to all those who wanted to learn it. On the other hand, the existence of a strong family tradition is not unusual in antiquity; Hippocrates himself claimed descent from Asclepius, while even nowadays many medical students come from families of physicians.
The second section deals with both clinical and social medical ethics, laying down what the oath-taker should and should not do. In the first instance, the physician promises to recommend to his patient therapeutic agents in order to protect them from harm and also from ‘injustice’, emphasising once again a strong sense of respect for moral traditions, which is in line with the religious tone of the Oath. In this context, in particular, it might also incorporate a provision to keep his patients away from harmful wrongs committed by other practitioners. Afterwards, we can see two of the most popular but also highly controversial phrases of the Oath dealing with ‘deadly’ drugs and abortifacients respectively. Medicine is the art of restoring and preserving health; thus, if a physician administers a poisonous drug or gives advice on the subject that could lead to murder, it would certainly be contrary to this ideal and considered a criminal act in antiquity. The passage has often been cited in modern discussions on physician-assisted suicide and voluntary or non-voluntary euthanasia, but the text, in fact remains silent on issues of assisted suicide. It is noteworthy that there is no sufficient evidence to suggest that physicians in Classical Greece practised euthanasia in its modern sense, i.e. a rational request to die made by the patient. Next is the interdiction on administering an abortive vaginal tampon. The provision is significant in respect of history of abortion and contraception. The passage seems to have caused problems of interpretation even in antiquity and a version of the text omitted the specific reference to ‘vaginal pessary’ in an attempt to embrace a wider group of abortifacients. In fact, ancient physicians used other agents for abortion as well, including potions and pills. It is intriguing that we can find references to early interruption of pregnancy even in Hippocratic works, such as On the Nature of the Child.
The last clinical provision is with regard to the practice of surgery. The oath-taker should not make use of the knife even for minor operations such as lithotomy, that is the removal of little stones from bladder or kidney. Although a strict distinction between dietetics and pharmacology on the one and the performance of surgery on the other hand does not exist in other Hippocratic works, here there is a straightforward advice to the oath-taker to leave the practice of surgery to those who were more expert in this field. It is tempting to set this passage in a context in which there was a distinction between general practitioners and surgical specialists. For example, the house of a surgeon dated to the Roman period (ca. second half of the second century AD) was recently found in the Italian city of Rimini; the collection of surgical instruments unearthed numbers 150 pieces. Another example from a much later period and a different context shows a further interesting analogy with our text. We know, for example, that in the foundation charter (ca. AD 1134) of the Byzantine hospital (xenon) of the Pantokrator in Constantinople, in addition to the physicians and medical assistants, there is a reference to a part-time specialist in hernia surgery.
From clinical practice the Oath moves on to the code of behaviour for the physician, thus defining his social relationship with his patients. The doctor must refrain from sexual relations not only with his patients but also with all members of their household, male or female, free or slave. This reference to slaves is worth noting and shows once more a concern for a broader perspective, incorporating issues for which contemporary law rarely made provision. The last obligation of the oath-taker is to respect the patient’s confidentiality in respect of information that s/he has provided and details regarding their medical condition. The importance of confidentiality in the relationship between patient and physician is of central importance nowadays as well, and this applies not only to physicians but also to pharmacists or nurses and other paramedical staff, who may come into contact with a patient’s medical history.
The Hippocratic Oath was received and adopted in different contexts throughout history showing its continuous importance to various audiences. For example, a Christian version replacing Greek Gods with an invocation to Jesus Christ appeared in a medieval Greek environment (see Fig. 2). The Oath’s popularity today goes back to its reception in the Renaissance during the fifteenth and sixteenth century. The Declaration of Geneva, first adopted by the World Medical Association in 1948, is in fact a revision of the Hippocratic Oath taking into account modern society’s needs and morality.
Figure 1. Papyrus of the Hippocratic Oath (3rd c. AD), Oxyrhynchus 2547 = Wellcome MS.5754, Courtesy of the Wellcome Library, London.
Figure 2. Christian version of the Hippocratic Oath in the form of a cross, Vaticanus Urb. Gr. 64, f. 116r (10th/11th century), Courtesy of the Wellcome Library, London.
‘I swear by Apollo the Physician, by Asclepius, by Hygeia, by Panacea and by all the gods and goddesses, making them witnesses, to bring the following oath and written covenant to fulfillment, in accordance with my power and my judgment:
To regard him who has taught me this art as equal to my parents, and to share, in partnership, my livelihood with him and to give him a share when he is in need of necessities, and to judge the offspring coming from him equal to my male siblings, and to teach them this art, should they desire to learn it, without fee and written covenant, and to give a share both of rules and of lectures, and of all the rest of learning, to my sons and to the sons of him who has taught me and to the pupils who have both made a written contract and sworn by a medical convention but by no other.
And 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. And I will not give a drug that is deadly to anyone if asked for it, nor will I suggest the way to such a counsel. And likewise I will not give a woman a destructive pessary. And in a pure and holy way I will guard my life and my art. I will not cut, and certainly not those suffering from stone, but I will cede this to men who are practitioners of this activity. Into as many house as I may enter, I will go for the benefit of the ill, while being far from all voluntary and destructive injustice, especially from sexual acts both upon women’s bodies and upon men’s, both of the free and of the slaves. And about whatever I may see or hear in treatment, or even without treatment, in the life of human beings – things that should not ever be blurted out outside – I will remain silent, holding such things to be unutterable sacred, not to be divulged.
If I render this oath fulfilled, and if I do not blur and confound it making it to no effect, may it be granted to me to enjoy the benefits both of life and of art, being held in good repute among all human beings for time eternal. If, however, I transgress and perjure myself, the opposite of these.’
(English translation: Heinrich von Staden, “‘In a pure and holy way’: Personal and Professional Conduct in the Hippocratic Oath?,” Journal of the History of Medicine and Allied Sciences 51 (1996): 404-437, at 406-8, modified)