The alleged necessity to introduce a new, binding oath has been suggested and a discourse started.1 It is argued that current problems of medical practice, mainly the phenomenon of economization, call for such anew oath. At the same time attempts have been made to downplay the significance of the Hippocratic oath and to characterize it as irrelevant for our time. The Hippocratic Society Switzerland confirms the unaltered relevance of the Hippocratic oath and explains in this article why that should be the case.
For almost 2500 years the Hippocratic oath has been regarded as one of the most important foundations of medical practice. The values which it represents are independent of time and have endured various historical eras of most different kinds. Therefore the oath constitutes an enormous normative power. It is neutral to religion and embodies the central values of medicine. Every practitioner of medicine should know these foundations, take them to heart and act accordingly. That is why we would like to remind our readers of text and meaning of this highly relevant document. (see box).
The Hippocratic Oath is a moral self-commitment of the physician. The invocation of the gods underscores seriousness and unconditional validity of the code of conduct. The commitment rests firmly on the principle of “nihil nocere”: to improve the condition of the patient and never cause harm. At the centre lies the prohibition to kill, the unconditional protection of life as the cornerstone of any medical practice. The physician has to be absolutely certain about the question of Reverence for Life, otherwise no relationship of mutual trust can be built with the patient. Another indispensible foundation of this relationship is the clear obligation to keep the medical secret.
The oath obliges the physician to always act with absolute care. He needs to know his limits and must not act hazardously. This is reflected by the promise, never to operate on patients suffering from bladder stones, since this was not part of the medical education in those days. The oath also demands of the physician that he be a role model in his behavior and personal conduct. This included, even then, the prohibition of sexual abuse of the patient. For Hippokrates, the personal relationship between the medical student and his teacher is of utmost importance. The respect and loyalty to the experienced doctor who teaches him the art of medicine and its ethics is compared by Hippokrates to the relationship with one's own parents. The oath views the medical profession as a mission in the sense of a life-long commitment, which should be approached with utmost respect and responsibility.
After this brief summary of the crucial contents of the Hippocratic oath we continue with a broader characterization of the Hippocratic medical conduct, as it is defined by further texts from the Corpus Hippocraticum:3
According to Hippocratic teaching the medical practitioner meets his patient as a fellow human being, who interacts with him on equal footing and forms a mutual relationship of trust. Therefore he is more than just a knowledgeable expert, who fulfils his duties by applying the information he has been given, teaches and performs acts and techniques, always doing the right thing in the right time as an expert would. The human being is regarded as more than the sum of highly specialized organs working together. The philosophy which defines him as the undestructable unity of body, mind and soul goes far beyond that. This is the reason why every illness attacks and concerns the human being not only as physical or mental suffering of some partial entity, but always in the completeness of his existence.
From this insight follows necessarily: Who wants to really help suffering fellow human beings has to approach them in their entirety: embrace their personality in all its dimensions, engaging fully in an I -You relationship. The good doctor throws his own existence in for his profession. He does not just function. His character, his honesty, his good will and his life conduct all turn into healing factors in the process of the patient getting better.
From this viewpoint of wholeness some fundamental aspects of medical conduct become understandable and explainable:
The medical practitioner serves Life. In the core part of the Hippocratic oath Reverence for Life is rooted as the most important value. In the Greek original phrasing we find a four-fold negation of any kind of killing in this context:
This builds the foundation of the trust in the doctor, which takes for granted that he will under no circumstances harm the patient knowingly – the principle of “nihil nocere”.
All these requirements - that the doctor should lead his life in a trustworthy manner, never put up with injustice, only advance the good without exception, cut the sphere of sexual desire out of his professional life, and finally the absolutely essential necessity never to talk about what had been subject of the conversations at the patient’s bed – all these point towards this one aim: the human environment of the therapeutic dialogue should build on the foundational value of trust.
Trust has something to do with dedication, with good-will, empathy and helpfulness, all things the patient is entitled to expect. With Hippokrates he may know for sure: My doctor understands me in a deep sense, with my whole environment, and all I will encounter with him is good-will. Even if he might inflict pain and not fulfill my wishes – still I will never have to have feelings such as fear in this relationship.
We should never forget one thing with Hippokrates: The relationship of mutual trust is indispensible for the whole endeavor of healing. His aims are not merely practical norms or social time-dependent standards – ethics of medical practice according to Hippokrates aims at the very basic values of human existence. In the historical context the holiness of Life is guaranteed by the powerful relation to the gods beyond time. Albert Schweitzer refers to that later in his term “Reverence for Life”.5
The frightening aspects of the history of medicine in the 20th century point to the opposite direction: As soon as human life – understood both in its entirety and as the singular human fate – stops being inviolable for the medical practitioner, as an axiom beyond any discussion, but subjected to the changeable norms of morals – there he enters into the realm of guilt.
What happens in such a case, when the doctor ceases to be dedicated to the Reverence for Life entirely, is that he is burdened with a responsibility and expectations of competence which he can never bear: as a custodian of “worth to live” or “not worth to live”, of human resilience, human fate, as a judge over life or death, who on top of that has to enforce his own judgment himself. And whenever physicians, lacking the unconditional reverence for the mystery of life, succumbed to the demands of some political or social ideology they sooner or later crossed the line to being criminal. The following list may exemplify this: race doctrine, eugenics, euthanasia, the judgment of someone being “not worth to live”,6 genocide by means of sterilisation, vivisection, “human guinea pigs” against their will for the sake of scientific progress.7
The physician who, on the other hand, takes the basic values of his mission seriously and respects the inviolability of human life beyond any juridical laws and scientific regulations will with Hippokrates not only safe his own life from the pressure of guilt, but will become a true trusted guardian for his patients.
Reconsidering Hippocratic ethics
History is full of circumstances when human foundational values as they are outlined in Natural law and constitute the basis of our democratic states were disrespected. During the world wars it became apparent to a gruesome extent where inhuman medicine might lead to.7
Today we have to face utilitaristic constructions which were developed in an Anglo-American context under the label of bioethics. Again, the inviolability of human life is questioned, again disputable reflections serve as pretext to violate the dignity of individuals for the alleged sake of the many, again economic and ideological aspects are mingled with ethics.
We cannot support the notion of a new, according to professional rules even legally binding oath,1,8 which would no longer contain the prohibition to kill but through the back-door promote the rules of economics in medicine to the ranks of ethical requirements.
Why should today’s generation of medical doctors not reconsider Hippocratic ethics which has served as the ethical foundation of medicine for more than two millennia and fulfill their duties of care and dedication to their patients yet again according to its teachings? •
First published in: Schweizerische Ärztezeitung – Bulletin des Médecins Suisses – Bollettino dei
Medici Svizzeri 2016; 97(23): 854–856; Tribüne Standpunkt 856
1 Giger, M. Ein Eid für heutige Ärztinnen und Ärzte. Schweizerische Ärztezeitung 2015; 96(25): 930–4
2 see also Höffe, O. Philosophische Ethik: Fahne im Wind oder Fels in der Brandung. In: Schweizerische Ärztezeitung 2010; 91(32): 1199–202
3 This text is based on the lecture “Will Hippokrates survive?” by Jakob Gehring and Josias Mattli, presented at the 1. Symposium Medizin und Ethik. Davos 1998
4 Im Griechischen wird die besondere Bedeutung durch eine vierfache Verneinung hervorgehoben: “Ich werde aber nicht und ganz und gar nicht (und) niemandem als (dazu) Gebetener ein todbringendes Mittel geben, und ich werde auch nicht einen solchen Ratschlag vorzeigen”, Translation Gehring und Mattli
5 Schweitzer, A. Die Ehrfurcht vor dem Leben.
Verlag C. H. Beck 2003.
6 Binding, K., Hoche, A. Die Freigabe der Vernichtung lebensunwerten Lebens. Ihr Mass und ihre Form. Leipzig 1922
7 see also: Müller-Hill, B. Tödliche Wissenschaft. Die Aussonderung von Juden, Zigeunern und Geisteskranken 1933–1945. Reinbek: Rowohlt 1984
8 Wils, JP. et al. Wir müssen über einen neuen Ärzteeid diskutieren. Schweizerische Ärztezeitung 2016; 97(10): 381–3
(Translation Current Concerns)
(Übersetzung von Axel W. Bauer)
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