Do You Know What the Hippocratic Oath Really Says?

People generally seek to make decisions in a manner consistent with their personal philosophy and the normative values of their social group. Although most want to make the "correct" choice, the concept of "correctness" is relative, and there may be many correct choices or none at all. Making the "right" choice often depends on having all the facts, a prerequisite that is rarely met.

Most importantly, "correctness" for an individual may not be similar to "correctness" for society. Morality is the idea (typically of one person) of what is right or wrong; it is often driven by a higher covenant, and it transcends cultural norms. In contrast, ethics refers to communal values, and it is dependent on others for definition. Morality and ethics are distinct concepts.

If ethics is communal, who in the community should guide us in making difficult ethical decisions in our professional lives?

When human social structures were primarily tribal, there was often one person in the group who had an insightful thought process about difficult decision-making. This was often an elder whose memory and integration of vast life experiences allowed him/her to recognize patterns that might be helpful to others. In organized religion, a local religious leader often acted as the expert consultant on life matters.

In Ancient Greece, the high priestess of the Temple of Apollo -- better known as the Oracle of Delphi -- was a sought-after source of guidance. Sadly, the Oracle offered advice only on 9 days of the year and often provided ambiguous answers. Famously, Croesus of Lydia asked the Oracle if he would be successful in his war against Persia. The Oracle predicted that Croesus' campaign would destroy an empire, a prophecy he took as encouragement to launch his military campaign. Croesus lost miserably; the empire that was destroyed was his own.

Throughout most of Medieval Europe, the Catholic Church acted as the primary arbiter of "correctness," but its decisions were largely driven by its desire to maintain its influence over political and financial affairs on both a small and large scale. With the Reformation and the rise of secular institutions, there was a need to establish standards of behavior for groups outside of the province of religion. When physicians emerged as a professional community, they needed a code of ethics.

The Hippocratic Oath is the oldest statement of medical ethics. When Greek and Latin literature was reimported into Europe at the start of the Renaissance, physicians looked to the ancient Mediterranean civilizations for precedence on ethics, and the Hippocratic Oath came into prominence.

Although modern practitioners refer to the Hippocratic Oath constantly, it is the rare physician who has actually read it. It begins with an oath to Apollo (as the god of medicine), and the original Greek text (1) bans the performance of abortions, (2) prohibits physicians from performing surgical procedures, and (3) instructs physicians not to share their medical knowledge with anyone else because they constitute "holy secrets." None of these ethical standards generally apply to the practice of medicine today.

And contrary to common belief, the words "primum non nocere" (first, do no harm) do not appear in the Hippocratic Oath. Versions of this text can be traced to Thomas Sydenham in the 17th century, but the phrase was most likely first written by American physician Worthington Hooker. Hooker's 1847 book Physician and Patient represented the birth of medical ethics in the U.S.

Many allopathic physicians mistakenly believe they take the Hippocratic Oath when they graduate from medical school, but instead, most take an Oath written by Louis Lasagna, MD (later the dean at Tufts Medical School) in 1964. Osteopathic physicians take the Osteopathic Oath, first developed in 1938. But neither Oath represents a code of medical ethics.

A code of ethics for the medical profession was developed in the U.S. by the American Medical Association, coincident with the publication of Hooker's book in 1847. In the U.K., the British General Medical Council's document on Good Medical Practice serves as the code of ethics. But these documents do not provide guidance in ethics for countless issues that physicians are likely to encounter.

Is it ethical to refuse to treat a patient if they do not have insurance? Is it acceptable or mandatory to treat a wounded terrorist? Is it ethical to terminate the pregnancy of a fetus known to have a horrific congenital disease? What happens when a physician's own moral standards are in conflict with their professional ethical responsibilities? The list of unaddressed dilemmas is endless.

For these situations, one might think physicians would benefit from expert guidance. A wise, respected, and thoughtful leader. A person who understands the moral compass of individuals and builds on that standard to guide behavior towards a constructive societal outcome.

Enter the bioethicist. Sargent Shriver claims to have invented the word "bioethics" in 1970, after attending a conference at Georgetown University. Bioethicists can be trained in medicine, philosophy, sociology or law, or political science or theology, but very few have specific training in bioethics. There are only a handful of PhD programs in biomedical ethics in the U.S., and most are highly focused on healthcare policy rather than other ethical domains.

Nevertheless, over the past 20 years, interest in bioethics has grown so that it is now included as a course requirement in many U.S. medical schools.

But what does "ethics training" in medical schools actually look like? A course in bioethics might include a single lecture about horrific medical practices in the past. But classes in bioethics typically consist of discussion groups that encourage medical students to think about a range of morally complex situations. The discussion groups do not instruct the students as to what is right or wrong. Instead, their purpose is to stimulate a thoughtful, wide-ranging, and interactive discussion. It is hoped that these discussions will raise awareness and shape physician character, but no one knows whether these lofty goals are actually accomplished.

To be sure, bioethics training must be distinguished from the teaching of medical professionalism. Medical professionalism focuses on how individual physicians fulfill their social contract with patients. Professionalism focuses on the commitment of practitioners to patient respect and personal accountability, trustworthiness, excellence, and scholarship. These elements are certainly influenced by moral character, but none lie within the realm of bioethics.

Bioethicists seek to understand the interface of moral principles, societal stability and justice, and biomedical issues. Many are highly focused on creating a conceptual framework for the consideration of controversial subjects, e.g., human experimentation, gene therapy, healthcare delivery, or underserved populations. These bioethicists typically avoid proffering opinions on very specific circumstances. (The weekly New York Times column "The Ethicist," authored by the prominent cultural theorist, Kwame Anthony Appiah, is an exception, but it sadly reads like an entertaining "Dear Abby" personal advice column, rather than a framework for ethical understanding.)

But that does not mean that bioethicists do not get involved -- voluntarily or involuntarily -- with highly specific issues.

About 20 years ago, I was asked by Claude Lenfant, MD, the head of the National Heart, Lung, and Blood Institute (NHLBI) at the time, to provide advice concerning a difficult situation with an NIH-funded investigator who was causing considerable consternation among the NHLBI leadership. Lenfant assembled an advisory group, presumably with the intent of getting support for a decision he had already made. I was asked to provide the perspective of the clinical investigator, and Ezekiel Emanuel, MD, PhD (then head of Bioethics at the Clinical Center) was the designated bioethicist. When presented with the facts of the matter, I was impressed when Emanuel refused to offer an opinion. To paraphrase his response: "This is a problem in politics not ethics, and it needs a political solution. I am a bioethicist, and I cannot help you." Interestingly, Emanuel subsequently became the primary architect for President Obama's Affordable Care Act.

Last week, I wrote an essay that concluded that pharmaceutical giants should cease their investments in Russia and abandon their drug manufacturing facilities, which were built to support a specific Putin agenda. I cited many egregious examples where the desire for corporate profits led companies to support a destructive totalitarian regime. Unbeknownst to me, Arthur Caplan, PhD (head of Medical Ethics at New York University) simultaneously authored an editorial that advocated a more extreme stance, suggesting that pharmaceutical companies should cease the shipment of life-prolonging medicines and writing, "the Russian people need to be pinched not only by the loss of cheeseburgers and boutique coffee but by products they use to maintain their well-being." I did not agree with Caplan's position, and many readers of his article objected vociferously to his views. Caplan's career achievements are impressive, but he has taken many very controversial stances, and in 2000, he was sued for his professional bioethicist role, as a result of his involvement in a gene therapy trial that resulted in the death of a research subject (he was subsequently dropped from the lawsuit). In other instances, Caplan has been criticized for his "hands-on philosophy" and for this enthusiastic engagement with the media. His response: "the whole point of doing ethics is to change people, to change behavior." In my view, such a mission statement should be identified as social activism rather than bioethics.

By anyone's measure, bioethics is still in its infancy. Bioethicists are seeking to form the foundational principles for their discipline and develop a body of knowledge that represents their expertise. At the same time, bioethicists are debating how best to interact with those who have a vested interest in biomedical affairs.

But in our search for ethical wisdom in the current era, no physician should look longingly to Ancient Greece. No modern practitioner seeks the blessings or insights of Apollo or practices medicine according to principles of Hippocrates. Physicians can address most ethical issues by relying on their own moral character. The complexity of many difficult medical choices is driven by politics and healthcare policy, and not ethics. Those who intentionally violate professional standards and defraud the public have a severe character flaw, which will not be rectified by experts in ethics.

In the final analysis, there are no moral answers; there are only moral questions. The Oracle of Delphi proclaimed there was no man wiser than Socrates. Why? Because Socrates questioned others who had a reputation for wisdom, and unlike them, he did not claim to know what he did not know.

All physicians -- and all bioethicists -- should take note.

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