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 Title

Hippocrates and Medicine in the Third Millennium

 Synopsis

The Hippocratic Oath - the promise of high standards of behaviour and practice for generations of doctors - is being whittled away or replaced with humanistic codes which exclude some of Hippocrates' most important ideas.

Originally published by the Christian Medical and Dental Society. Republished with the permission of the author.

 Author

John Patrick

 Author Notes

Physician and Professor at the University of Ottawa, Director of Education and Public Policy for the Christian Medical and Dental Society, internationally-known commentator on medical ethics, organizer of the Canadian Registry of Hippocratic Practitioners for physicians who the support the Hippocratic Oath

 Essay - 1/1/1999

Introduction

For most people Hippocrates is a shadowy figure somehow connected to the ethical practice of medicine; they feel vaguely comforted by the supposed fact that doctors take a Hippocratic Oath of practice upon graduation. The truth is that very few take the Oath of Hippocrates; some take a revisionist version, which retains the name but removes the content; many make no commitment to rigorously defined ethical standards. There are many bio-ethicists who argue that the Oath of Hippocrates is irrelevant to our society for reasons which I will make plain shortly.

I do not intend to spend time on the historical Hippocrates, because even his existence is still a topic of contention and my objectives are theological and philosophical rather than historical. I wish, therefore, to focus on the Oath and its implications. The Oath is commonly given as follows;

Oath of Hippocrates

I swear by Apollo Physician and Aesclepius and Hygeia and Panacea and all the gods and goddesses, making them my witness, that I will fulfil according to my ability and judgment, this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brother in male lineage and to teach them this art - if they deserve to learn it - without fee and covenant: to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and taken an oath according to the medical law, but to no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody if asked for it, not will I make a suggestion to this effect. Similarly, I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favour of such men as are engaged in this work.

Whatever house I visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slave.

Whatever I may see or hear in the course of the treatment or even outside the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about.

If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honoured with fame among all men for all time to come. If I transgress it and swear falsely, may the opposite of all this be my lot.

I have gathered a number of Oaths from medical schools across Canada. Not one of them contains several of the essential features of the Oath of Hippocrates. In other words, where the name is used it is used in the modern revisionist sense where the name of Hippocrates is used to make the public feel comfortable. But the reality that he stood for has been removed. Kierkegaard said we would be a passionless century that took the heart of meaning out of the institutions of our world and left the sham edifice standing.

Transcendence

The opening phrase of the Oath of Hippocrates is worthy of deep reflection. The literal form of the Oath cannot be sworn by Christians but they will relate immediately to the intent of Hippocrates and his followers, unlike sophisticated moderns and post-moderns who dismiss it as a mere vestigial marker of cultural superstitions unworthy of a scientific age. Certainly Hippocrates would find little with which to sympathize in the dominant model for the teaching of medicine today, which is founded on the cultural hubris that our categories supersede those of Hippocrates because it presumes that medicine is adequately described by the categories of biology, psychology and sociology. The transcendent dimension is denied. This bio-psycho-social model I usually describe as weighed in the balances and found wanting. The fact that ninety percent or more of medical students do not understand my meaning merely emphasizes my point. Neither do you, dear reader, understand unless the metaphor, "weighed in the balances", was correctly related to the story of Belshazzar's feast.

For modern medical students my dismissal of the bio-psycho-social model is just evidence of my patriarchal, white male, incapacity to deal with the real world, besides which, they are bright so they can fix any minor defects in the model themselves. Such is their pride. If they had been properly educated they would, at least, have recognized that my charge was more serious than merely suggesting that the bio-psycho-social model is a few grams underweight. Belshazzar had profaned the sacred vessels of the Jews when the hand wrote on the wall; "Mene, mene, tekel, uparsin." No one understood until Daniel was sent for. He told them that the words meant that Belshazzar and his kingdom had been weighed in the balances and found wanting and they were consigned to history next morning at the hands of Darius.

My objection to the bio-psycho-social model is that it is profoundly and profanely wrong because it denies that we are all spiritual beings. It has no place in its understanding for the most profoundly moving and significant events which we, as physicians, are ever privileged to witness. I recently heard a beautiful account of an agnostic Jew's description of one such event. She is a physician who carries a pager at all times, in order to give palliative care to her patients in their time of need. Early one morning she was called to a patient, who wished to die at home but he had begun to suffer pain and was convulsing. When she had done all she could, the patient was no better. The unwanted death in hospital seemed inevitable but before the family agreed they called the church music group of which the patient had been a member to come and sing at the bedside. They came and as they began to sing in the small hours of the morning the patient relaxed and ceased convulsing. When they stopped, he deteriorated, when they sang he improved and was comfortable. So for 24 hours they sang until he died peacefully. The agnostic physician simply said to her colleagues; "I tell you this story to remind you that there are things out there we do not understand." It is our job, as those who believe that more than things there is a Person out there who loves us, to witness to these things; to hold our colleagues to their commitment to the facts; to reality; to recognize that it is another form of intolerance that demands that no space be provided for such witness in hospitals.

The significance of the invocation of the gods in the Oath of Hippocrates cannot be overstated. It places patients and their physicians in a world with a transcendental dimension. The practical value of such an enculturated understanding is that a physician who believes in transcendence, particularly where that belief includes the ideas of moral consequence and ultimate accountability with judgment, has reason to be ethical because he fears God appropriately. Solomon thought such fear was the beginning of wisdom and who are we to argue with him? Great physicians have often agreed. The Christian Medical and Dental Society of Canada takes a wonderful piece of prose by one such physician, Thomas Sydenham, as its mission statement.

"It becomes every man who purposes to give himself to the care of others, seriously to consider the four following things:-First, that he must one day give an account to the Supreme Judge of all the lives entrusted to his care. Secondly, that all his skill, and knowledge, and energy as they have been given him by God, so they should be exercised for His glory, and the good of mankind, and not for mere gain or ambition. Thirdly, and not more beautifully than truly, let him reflect that he has undertaken the care of no mean creature, for, in order that he may estimate the value, the greatness of the human race, the only begotten Son of God became himself a man, and thus ennobled it with His divine dignity, and far more than this, died to redeem it. And fourthly, that the doctor being himself a mortal man, should be diligent and tender in relieving his suffering patients, inasmuch as he himself must one day be a like sufferer."

Thomas Sydenham (1642-1689)

Transcendence was still active in the 17th century at the highest reaches of the practice of medicine. Why is it so different now? Would to God that we had the like of Sydenham leading our profession today.

The best that the bio-psycho-social model can offer is an unpredictable utility, without any guarantee that the dominant utility will be that of the patient rather than the economist, administrator or the physician. Those who deny the existence of objective truth and say that we create our own values have no basis for collegial laws. At the heart of medical ethics, as opposed to bio-ethics, lies the privileged relationship between the physician and the patient; a privilege which can be and is, on occasion, abused. Its control is not susceptible to simple bureaucratic measures. Ultimately, as Sydenham understood, it is only submission to God and God's truths which protect the patients. In the worst case scenario the main witness is dead and the documentary evidence written primarily by the physician. A physician is only required to display appropriate attitudes to pass with honours in the modern medical school. The current evaluation of medical students concerns itself with their attitudes rather than their character. At the end of our lives it is not beautifully presented attitudes that we need but formed character that will strengthen us and accompany us to the gates of death without illusions. But if values are subjective they are not consistently predictable. Oaths only make sense when God is at the heart of what people believe to be true. Codes are all that is left to a people who have lost their God. Character on the other hand is what a man is and habitually does.

Oaths and Codes

One of the greatest horrors of the second world war was that the physicians of one of the most cultured nations of Europe not only did not protest against the eugenic and racist killings of the Nazis but co-operated with them. The first gas chambers were designed by psychiatrists and the concentration camps maintained the fiction of "medical" selection for the gas chambers by having physicians in charge of those selections. The Nazis merely extended the logic of the eugenics already incorporated into the beliefs of the profession of medicine. (The process is being repeated as we accept the results of molecular biology which consistently allow the detection of "malformed or diseased" children in utero but rarely lead to cures. The main result will be an increase in eugenic abortions.)

The debate after the war was intense and led to the promulgation of the World Medical Association's Code of Ethics.

I solemnly pledge myself to consecrate my life to the service of humanity; I will give to my teachers the respect and the gratitude which is their due; I will practise my profession with conscience and dignity; The health of my patient will be my first consideration; I will respect the secrets which are confided in me; I will maintain by all the means in my power, the honour and the noble traditions of the medical profession; My colleagues will be my brothers; I will not permit considerations of my religion, nationality, race, party politics or social standing to intervene between my duty and my patient; I will maintain the utmost respect for human life from the time of conception; even under threat I will not use my medical knowledge contrary to the laws of humanity; I make these promises solemnly, freely and upon my honour.

The change from oath to code denotes that the problem of Nazi behaviour was not dealt with. The code is a rationalistic document, without the invocation of transcendence. The medicalized killings in Germany and subsequently in Russia were rational killings. It is a question of whose rationality is dominant. The Oath involved transcendence and drew the physician into a covenantal relationship. The richness of the idea of covenant compared to the poverty of the modern concept of code or terms of contract is illustrated by the prose Paul Ramsey uses to describe it:

"Justice, fairness, righteousness, faithfulness, canons of loyalty, the sanctity of life, hesed, agape or charity are some of the names given to the moral quality of attitude and of action owed to all men by any man who steps into covenant with another man."

Thus the physician accepted the one-sided responsibility to be with his patient throughout an illness or up to death, and this commitment was embodied by the best physicians although they never expressed it with Ramsey's precision. Patients tacitly understood this and responded with loyalty. To turn from this tacit transcendentalism to modern codes and contracts is like turning the ten commandments into the ten guidelines.

Trust

Anthropologists are well aware that levels of trust vary between societies. Here in Canada we are in the midst of a rapid decline in levels of trust for two reasons. First, because the reductionist, truth-denying character of the modern University is becoming the ethos of the whole society. Second, because Christians are changing from communities of distinctive character where trust can flourish, such as the Mennonite prairie communities of the early twentieth century in which theft was a rarity, to anonymous loose associations of people who meet briefly on Sunday morning in our cities and suburban deserts. For those without any spiritual support these post-modern, characterless living spaces are places in which theft and disregard for people are commonplaces. Walk-in clinics and the progressive commercialization of medicine are medical examples of the loss of communities of character. What the Hippocratic Oath gave substance to was a vision of a medical community with a predictable character of high ethical standards which could support justifiable trust between physician and patient with all the therapeutic benefit which such a community produces. Such communities only flourish where the shared story which gives meaning is transmitted in childhood by members and particularly by parents, who inhabit the same story. In Central Africa today, traditional healers still practice pre-Hippocratic medicine. They have real abilities but they are feared not loved for reasons which I will now describe.

Sanctity of Life

The main reason for the modern dismissal of the Oath of Hippocrates by those who know its content is its commitment to the absolute sanctity of life. Neither abortion nor mercy killing find any place in the thought of Hippocrates. Why was this commitment so central? Margaret Mead, the libertarian anthropologist, clearly understood, when she wrote;

For the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with power to kill had power to cure, including specially the undoing of his own killing activities. ... With the Greeks, the distinction was made clear. One profession, the followers of Asclepius, were to be dedicated completely to life under all circumstances, regardless of rank, age, or intellect - the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child. ... [T]his is a priceless possession which we cannot afford to tarnish, but society always is attempting to make the physician into a killer - to kill the defective child at birth, to leave the sleeping pills beside the bed of the cancer patient. ... [I]t is the duty of society to protect the physician from such requests. [1]

This tradition is never more important to us individually than at that extraordinary point in life when we choose to become patients. At this point a profound psychological event occurs. Even physicians, on becoming patients will recognize this reality. When one is ill, one needs someone whom one can trust to do what is best for us. No amount of verbal papering over the cracks by substituting client for patient will change the reality that sick people want someone else to handle the difficult problems. You may be a client when you choose who will fix your hernia but you are not a client when you have septicaemia and renal failure. This is where Hippocrates changed the direction of medicine. Ancient and modern pre- and post-Hippocratic physicians were and are willing to kill for a price, whether financial or ideological. There is, as Gerald Manley Hopkins put it, "a death dance in our veins"; Kevorkian illustrates this for anyone with eyes to see. Thus when you go to such physicians you must always worry whether someone else has paid more for your death than you have for your life. Those followers who took the Oath of Hippocrates removed this fear, generated a substantial trust and consequently became the physicians of choice. It was patient choice and the desire to have an income, which forced the medical profession to adopt the higher ethical standards of the Hippocratic community not the intrinsic nobility of the medical community.

The adherents of a great tradition are largely unaware of their own premises, which lie deeply embedded in the unconscious foundations of Practice... if the citizens are dedicated to certain transcendent obligations and particularly to such general ideals as truth, justice, charity and these are embedded in the tradition of the community to which allegiance is maintained, a great many issues between citizens, and all to some extent can be left - and are necessarily left - for individual consciences to decide. The moment however a community ceases to be dedicated through its members to transcendent ideals, it can continue to exist undisrupted only by submission to a single centre of unlimited secular power. [2]

What we have to come to terms with now is that this consensus no longer exists and it is our failure to appreciate this that lies at the heart of our problems. A small episode before the United States senate illustrates the modern realities. Martha Nussbaum is a Professor of Philosophy, Classics and Comparative Literature with an international reputation. In the Colorado Supreme Court Amendment 2 case, the homosexual community attempted to claim that the people could not pass an amendment which prohibited laws making "gay, lesbian or bisexual conduct a ground for minority status, or claim of discrimination." In order to do this they needed to show that in pre-Christian times homosexuality was not considered shameful, so that they could claim that current opinions are merely the products of Christian bigotry. Several scholars claimed that Socrates, Plato and Aristotle actually held the same view as traditional Christians. Nussbaum in a written rebuttal, which is not subject to the laws of perjury, claimed that they were guilty of poor scholarship but to substantiate this she misquoted her own book, which is in agreement with the other scholars. In doing so, Nussbaum, like other scholars, was making a distinction between her behaviour as a citizen concerned to achieve particular legal ends and her behaviour as a scholar concerned with accuracy. In this context, ends justified means including mis-representation of your own work! In this world we must expect to face opposition which has an entirely different hierarchy of goods from those that were historically associated with Christian culture and does not necessarily place truth telling at the top of the list.

The Physician Patient Relationship

In this narcissistic era where individual autonomy is always first it comes as a surprise to realize that patient rights have no place in Hippocrates' thinking. That, say the modern generation of bio-ethicists, is good reason to dismiss Hippocrates. But is it? Hippocrates lived in a pagan ethos where life was cheap and promises easy. His time did not have two thousand years of Christian thought anchoring it down. In such times patient autonomy was meaningless because the relationship was intrinsically unbalanced. All the power lay in the hands of the physician. The patient's safety therefore lay in the ethics of the physician. If the physician took the Oath of Hippocrates he swore to do no harm, to recognize the limits of his competence and refer appropriately, he swore to honour his profession by not abusing his opportunities for sexual gratification and he swore to treat all men equally. The patient's safety lay in doing everything to preserve the physician's integrity, to avoid even subtle coercion to kill or to abort. Remarkably there is little evidence that European culture did other than encourage physician integrity to the Oath of Hippocrates until the last century where once again rationalistic hubris began to erode this cultural gift. Now, as a result, we have College courts trying to enforce the unenforceable and killing a few innocent sheep in the process. "The best" said Yeats, "lack all conviction, while the worst are full of passionate intensity." How right he is.

Conclusion

These days many writers are comparing our times to those of the sack of Rome. MacIntyre puts it like this:

It is always dangerous to draw too precise parallels between one historical period and another; and among the most misleading of such parallels are those which have been drawn between our own age in Europe and North America and the epoch in which the Roman empire declined into the Dark Ages. Nonetheless certain parallels there are. A crucial turning point in that earlier history occurred when men and women of good will turned aside from the task of shoring up the Roman imperium and ceased to identify the continuation of civility and moral community with the maintenance of that imperium. What they set themselves to achieve instead - often not recognizing fully what they were doing - was the construction of new forms of community within which the moral life could be sustained so that both morality and civility might survive the coming ages of barbarism and darkness. If my account of our moral condition is correct, we ought also to conclude that for some time now we too have reached that turning point. What matters at this stage is the construction of local forms of community within which civility and the intellectual and moral life can be sustained through the new Dark Ages which are already upon us. And if the tradition of the virtues was able to survive the horrors of the last dark ages, we are not entirely without grounds for hope. This time, however, the barbarians are not waiting beyond the frontiers; they have already been governing us for quite some time. And it is our lack of consciousness of this that constitutes part of our predicament. We are waiting not for a Godot, but for another - doubtless very different - St. Benedict. [3]

If a Barbarian is someone who does not know and celebrate his own history then we are Barbarians and the question is, who will be our St. Benedict to give us a rule to order our lives? We might do far worse than to commence by addressing ourselves to finding out who are the Hippocratic physicians who will fore swear killing and join company with them so that when the Barbarians come to remove that bulwark we can retreat into a sector of medicine where that virtue can be kept alive. My suspicion is that we constitute more than enough to demand and achieve a legitimate and continuing sector of Hippocratic medicine in this pluralistic society. The old consensus has gone but no new one is yet dominant therefore we have a right to practice medicine in the Hippocratic way as long as we serve a significant proportion of the population. The new medicine has no right to totalitarian power although if we are not alert it may usurp it. I guarantee that no school of medicine offers a course on Christian ethics but only of that oxymoron secular ethics which should be called "secular behaviour". In the meantime we must talk about the necessity of transcendence, of a commitment to the sanctity of life, to training within a moral ethos, and to the critical importance of the preservation of the moral integrity of the physician even over illegitimate claims of patient autonomy, if medicine is to be preserved.

NOTES

1. Paul Ramsey, The Patient as Person, Yale University Press, 1970

2. Margaret Mead, as quoted in Rita L. Marker et al., "Euthanasia: An Historical Overview", Maryland Journal of Contemporary Legal Issues 2, 1991, 257-298

3. Alasdair MacIntyre, After Virtue, Notre Dame University Press, 1983


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