Reciting the ancient Hippocratic Oath was once the high point of any medical school convocation. Now, the noble pledge of traditional medical ethics is being altered or even suppressed to accommodate modern prejudices and taboos. Interim associate editor Tony Gosgnach tells us why.

Once upon a time, it was unthinkable that a physician would perform an abortion, or cause harm to his or her patient. Prohibitions against such conduct were inspired largely by the Hippocratic Oath, a treatise on medical ethics dating back more than 2,000 years and never seriously questioned or ignored – except for two periods of time.

The Nazi era in Germany.

And now, throughout the Western world.

The collapse of the Hippocratic legacy in Nazi Germany was rapid and largely unopposed by German psychiatrists. Most of the psychiatrists chose of their own free will to co-operate in the murder of mental patients and handicapped children. The Nuremberg Code was a restatement of medical ethics embodied in the Hippocratic Oath.

Since then, however, there has been another descent from high ethical standards in medicine to a point where almost anything goes, guidelines are hazy and mutable, and no unchanging frame of reference exists.

All of which serves as a horror story to conscientious members of the medical profession, as well as members of groups that could be, if they are not already, victims of the new ethos.

“Most countries don’t even take an oath anymore. Britain hasn’t for a long time,” observes Dr. John Patrick, an associate professor of biochemistry and pediatrics at the University of Ottawa and a member of Canadian Physicians for Life. Patrick has performed research into the matter of the Hippocratic Oath and its use (or disuse) today.

Other jurisdictions retain the title of the Hippocratic Oath, while altering its contents. “My own university was calling something a Hippocratic Oath, when it wasn’t,” says Patrick. “That’s what they all do. As far as I know, only Baylor University’s medical school in Texas uses the Hippocratic Oath.”

“The secularization of the state and the legalization of abortion have made it necessary (to alter traditional medical oaths),” he adds. “Otherwise, there would be no one around to fulfill the laws that the state had passed.”

Patrick says that what are currently being called Hippocratic Oaths differ from the original version in “totally predictable ways.”

“The traditional oath opens with an appeal to transcendance,” he says. “Modern ones are secular – they vow ‘on their own honour,’ whatever that means.

“Secondly, Hippocrates had an absolute commitment to the sanctity of life, specifically saying that he would neither perform an abortion, nor assist with suicide, or counsel to that effect. That, too, has been removed now.

“Thirdly, Hippocrates said he would teach medicine only to those who accepted those principles.

“And fourthly, he insisted that collegiality be part of medicine. In other words, a student was to look upon his teacher as part of his family. There was a degree of collegiality in the medical profession that didn’t exist in the other professions. That, too, is gone now.”

Patrick reiterates the point that the decline in medical ethics, particularly with regard to human life, is more a product of the influence of the secular state, than any desire to change on the part of the medical profession. The medical profession “hasn’t been that eager to follow,” he says. “For example, they’re having great difficulty gettings residents to train to do abortions. Nobody likes doing it.”

Patrick charges that the misuse of Hippocrates’s name in modern medical oaths is designed to make the public feel comfortable, while the reality that he stood for is removed.

Patrick isn’t the only one who has noticed changes in medical oaths in recent years. Professor Paul R. McHugh, writing in the May 1996 edition of Nature magazine, said that changes in medical oaths reveal a confusion in the medical profession about its ethical aims.

“I became aware that the version of the Hippocratic Oath recited by graduating students was changing and, in particular, that as the years passed, its ethical prescriptions were phrased less sharply, more vaguely.”

McHugh noted that alterations to the oath included: omitting the invocation of pagan gods and lifetime, family partnerships with teachers; excluding prohibitions against abortion and use of “the knife;” and replacing the Hippocratic aim – the benefit of the sick – with “the service of humanity.”

“As a goal, the service of humanity is not only more imprecise, it may, occasionally, conflict with the benefit of the sick, particularly if sick people are identified as burdens,” said McHugh.

MDs Robert D. Orr and Norman Pang, in a content analysis of oaths administered in U.S. and Canadian medical schools in 1993 written for theJournal of Clinical Ethics, noted in their summary statament that “the oaths used and the content of those oaths have changed with time.”

Orr and Pang surveyed 157 medical schools and found that, although there has been a progressive and marked increase in the percentage of medical schools administering oaths over the past 65 years (98 per cent in 1993 versus 26 per cent in 1928), only one school used the text of the classical Hippocratic Oath, while 68 others reported they used other “versions” of that oath.

Only 43 per cent of medical school oaths bound graduates to be accountable for their actions, 14 per cent included a prohibition against euthanasia, 11 per cent invoked a deity, just eight per cent foreswore abortion, and three per cent forbade sexual contact with patients.

“There has been a steady increase in the percentage of medical graduates who swear an oath during this century. At the same time, there has been a steady decrease in the inclusion of content items found in the classical Hippocratic Oath,” Orr and Pang concluded.

A draft revision to the Hippocratic Oath by the British Medical Association presented to the World Medical Association includes provisions for “an ethical and legal framework” for abortions “where abortion is permitted.” The draft also recognized “the special value of human life” while acknowledging that “the prolongation of human life is not the only aim of health care.”

At the same time, the association also paradoxically considered requiring its doctors to agree to oppose policies that breach “internationally accepted standards of human rights.”

Francis J. Milligan, a family physician in New Hampshire who served in the U.S. Army, says that when he graduated from medical school in 1961, it was decided that the taking of the Hippocratic Oath was no longer necessary. “But when my son graduated in 1988, they allowed us to come back to say the oath … When I looked carefully at it, it was not the same oath. They had changed the clause on abortion … They merely said you should follow the law, whatever the law is.”

“The application of medicine is becoming a very different thing from what it once was,” he adds. “More and more, ‘social factors’ are being used to direct the legislation of medical directives and administration of (medicine’s) delivery … If enough physicians do not stay anchored and the body of medicine continues to drift, the tradition that has been preserved for over 2,000 years will unravel, for the principal thread will have been lost.”

P.J. King, a registered nurse and member of Ohio Right to Life in the U.S., says the moral commitments of a physician are integral to his or her claim to being a member of a profession, rather than merely holding a particular occupation. “Most physicians still regard the heart of medicine as a moral commitment,” says King. “Those who would break with this tradition must recast medicine as technique and the practitioners thereof as mere technicians.”

King adds that a strength of the classical Hippocratic Oath was its context in theism, making the pledge a “solemn covenant,” rather than just an assertion of ethical principles.

According to Nigel M. Cameron, in his book The New Medicine, those who are drafting reformulations of Hippocratism “have turned the principles of medical ethics into one long composite motion to be debated year on year at representative medical assemblies.”

An example of the confusion that surrounds medical oaths these days can be found in the experience last year of 64 graduates of the University of South Carolina’s medical program. They were asked to take an oath that excluded pledges not “to give a deadly drug to anyone if asked for it,” nor “give to a woman an abortive remedy.”

“We take the oath so seriously that we don’t want to swear to something we don’t fell comfortable upholding,” said Kellee Frogge, a medical student and a member of the committee that chose the oath’s wording.

Jeff Morgan, another graduate, said he was comfortable with the wording in the classical version of the oath. “Because of my personal religious beliefs, I’m never going to perform an abortion procedure, and I’m never going to assist in anyone’s suicide,” he said.

The sorry state of current medical ethics leads one to ask what can be done to restore principles more in keeping with the classical Hippocratic Oath. According to Patrick, one avenue of hope may lie in the Christian Medical and Dental Association’s embarking on a project to establish a registry of Hippocratic physicians.

“I hope that will develop into something significant and get perhaps half the medical profession to identify themselves as such – meaning they will not do assisted suicides or abortions,” says Patrick.

The CMDS, which includes chapters in Canada and the U.S., is launching the effort, but the intention is to spread the effort worldwide.