I swear by Apollo, the Hippocratic Oath is obsolete.

Harold Smith is a 67-year-old retired business executive in excellent health except for easily controlled mild hypertension. Harold plays tennis regularly, takes the steps in his three-story house two at a time, and has never been sick a day in his life.

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However, Harold's grandfather died suddenly at the age of 64 and his father suffered a massive fatal heart attack at age 66. Harold's doctor is Ben Conrad, an excellent internist who is also a favorite clinical instructor at the local teaching hospital.

Harold won't go to Ben for regular annual checkups, but Ben makes Harold come see him at least once a year before he will refill Harold's prescriptions.

Last week, Ben again urged Harold to get a stress test, clearly indicated because of Harold's family history. "I'm not getting on that slippery slope," Harold told Ben.

"You find something questionable in the stress test so you order another one; still don't know, so let's do an angiogram ... Charlie got a heckuva big hematoma from that procedure. Basically, you want to keep me alive so I can pay three thousand dollars a month to some nursing home? No thanks. Go peddle your wares elsewhere."

On teaching rounds, Ben tells this story to residents in training to prepare them for the many difficult patients they will encounter. "We try to do what's best for them," he tells the impressionable young doctors, "but sometimes they just won't let us."

Taking the oath

The central theme of the Hippocratic Oath is that a physician must strive to do what he or she thinks is best for a patient. That basic premise is now under fire. So are several other features of the oath.

One reason the oath escaped criticism for so long is that many who take it are unfamiliar with its contents.

For example, the famous medical dictum "first do no harm" is often attributed to the oath even though it contains no such language. Galen, a Roman physician, probably originated primum non nocere.

Modernizing the language of the Hippocratic Oath satisfies some 21st century objections to it, but the oath's fatal flaw is not merely a matter of semantics.

Actually, it would be a mistake to consider the entire Oath of Hippocrates either current or irrelevant. It is a hodge-podge combination of ageless ethical principles and obsolete specific ideas.

Practicing doctors still serve as mentors to medical students, but medical schools do not offer medical education "without fee or stipulation." Physicians still exhibit the collegiality urged by Hippocrates. But how many doctors do you know who pay off a colleague's debts if he or she gets in a tight spot?

The distinction between physicians and surgeons required in the oath is alive and well. Some internists--with tongue only slightly in cheek--love to characterize themselves as thoughtful doctors and their surgeon friends as merely cutters and probers.

Hippocrates' reference to house calls is out of touch with reality and has been for several years. But his admonition that having sex with a patient is unethical is current. Confidentiality of a patient's personal medical information was important to Hippocrates. But in his day physicians were much like priests. They were expected never to reveal a patient's confidences.

In today's world, even the HIPAA regs acknowledge appropriate times to share information collected in the course of patient care. The Hippocratic Oath is not the only time-honored school of ethical and moral thought to be discarded because of inflexibility. Rules stated as always or never are sooner or later discredited by failure to withstand the "Yes but, what if ...?" questions.

The oath's didactic references to abortion and euthanasia are too simplistic to be useful to those seriously debating the professional, political, ethical and religious aspects of these complex topics. Perhaps it is not necessary for a pledge of professionalism to be so specific. If it is necessary, then Hippocrates fails us by omitting mention of stem cell research and genetic engineering.

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Secret oath?

The first section of the oath is similar to vows taken by pledges of secret societies whose members must carefully protect closely guarded secrets.

Many physicians deny that the oath has any such meaning. But at a minimum, the oath's language encourages physicians to preserve the values of an exclusive collegial group. So the oath encourages those doctors who believe that a circle-the-wagons strategy is the best reaction to encroachments on professionalism by impersonal policies and practices in profit-driven health care organizations. Physician executives know that a more effective strategy is to become part of the policy-making team.

The first part of the oath is also similar to a religious rite, and that is exactly what the oath might be. Hippocrates was Pythagorean. He may have intended the oath to be a code of behavior for Pythagorean physicians, not a generally applicable definition of medical professionalism. (1)

Indeed, that view prevailed in Roe v. Wade, the famous 1973 U.S. Supreme Court Case. Attorneys for Wade claimed that since the Oath of Hippocrates prohibits "providing a pessary to a woman for the purpose of abortion," abortion is unethical.

But attorneys for Roe persuaded the court to view the oath as a religious credo, not a statement of ethical principles. So the attempt to play the oath card failed. (2)

The religious nature of the oath is still clear, although modern versions of the oath are sworn to Almighty God rather than to Apollo and other gods. The religious nature of any oath is controversial these days.

Evangelical politicians in high places ignore George Washington's wise distinction between addressing a sovereign deity and pledging to uphold the specific beliefs of some institutionalized religion. As a result, even the religious significance of the Pledge of Allegiance to the flag is controversial. By the way, Islamic physicians swear to Allah. (3)

The oath's fatal flaw is its requirement that a physician express caring and compassion by assuming an authoritarian role. According to Hippocrates, the ethical physician imposes his or her judgment on the patient, who is thereby presumed incapable of understanding and using information about disease and treatment choices. Today, that notion is definitely obsolete.

Patient care

The issue is not doing what is best for patients. The issue is doing what the doctor believes is best for the patient.

Sometimes, but not always, the patient knows better than the doctor what is best for the patient. Patient participation does not mean that if a mother says to the pediatrician, "My child needs penicillin," the pediatrician should say, "OK, how many units?"

But Harold Smith wants to defy conventional wisdom and practices of modern Western medicine. He wants to take his chances without a stress test. Harold wants to let nature take its course.

The ethical physician in the 21st century is the doctor who will respect Harold's right to make that choice. Dr. Ben Conrad calls people who reject his advice "difficult." But he is not unethical; he is merely a traditionalist.

It is not surprising that there are still many Dr. Conrads. After all, the doctrine of informed consent is only 50 years old.

So, is the Oath of Hippocrates obsolete?

Much of it is. However, its essential features are still the gold standard for medical professionals. Recently suggested alternative medical oaths are either too vague, already obsolete themselves, share the shortcomings of the oath, or are more attuned to political agendas than to professional principles. (4)

The best efforts to frame new professional guidelines factor out of the Hippocratic Oath those ideas that account for the oath's longevity, update them, and leave statements about social justice to another committee. (5)

Eventually, some colleague of Hippocrates will craft a new Pledge of Medical Professionalism that will withstand the test of 21st century reality if not time eternal.

Anyone is welcome to try. So, raise your right hand and repeat after me.

1. I will be a safe physician.

2. I will continually update my clinical knowledge and skills and apply them carefully and with equal thoughtfulness to each patient.

3. I will put the patient's interests ahead of my own.

4. I will be a good listener, and will not reject a knowledgeable suggestion from a patient about his or her own care.

5. I will honor each patient's expectation that information conveyed to me is confidential, except when, in my judgment, such action can be construed as conspiring with the patient to allow harm to others. My patient must respect primum non nocere, too.

6. I will be much more to my patients than a prescriber of drugs and treatments. For example, when one of my patients faces difficult choices regarding reproductive biology or life's end, I will support and assist the patient's decision-making process in legitimate ways considered desirable by us both.

7. I will, in all my dealings as a medical professional, be trustworthy and dependable to the best of my ability.

References

1. Edelstein, L. The Hippocratic Oath: Text, translation, and interpretation. Johns Hopkins Press. Baltimore. 1943.

2. Roe v. Wade, 410 U.S. 113 (1973) at 132.

3. The Oath of a Muslim Physician. www.islam-usa.com/im2.html.

4. Johansen, J. The Charter on Medical Professionalism: The New Hippocratic Oath? http:\\www.pregnantpause.org/ethics/medprof.htm.

5. Pelligrino, ED and Thomasma, DC. The Virtues in Medical Practice. Oxford University Press. New York. 1993. pp. 65-78.

RELATED ARTICLE: The Hippocratic Oath

The Oath of Hippocrates is not the only oath used in medical school graduation ceremonies. Others include the Oath of Maimonides, the Declaration of Geneva, and originals created by local faculty or student groups. (1)

For 2,500 years the Oath stood unamended and unchallenged. But today, is Hippocrates passe?

I swear by Apollo the physician, and Aesculapius, and Hygieia, and Panaceia, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation ...

To reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his off-spring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others.

I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.

I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art.

I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work.

Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves.

Whatever, in connection with my professional service, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.

While I continue to keep this oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times. But should I trespass and violate this Oath, may the reverse be my lot.

1. Oath Registry. American Medical Association. http://www.ama-assn.org/ama/pub/category/5573.html. This is a list of U.S. medical schools by state, giving the name and text of the medical oath currently used in graduation ceremonies at each university.

Richard E. Thompson, MD, is adjunct instructor of ethics at Drury University, Springfield, Mo. and president of Thompson, Mohr and Associates. Previously, he was an adjunct instructor of ethics at the Ethics Institute, St. Petersburg College, St. Petersburg, Fla. He can be reached by phone at [phone] or by e-mail at [e-mail]

By Richard E. Thompson, MD