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RELEVANCE OF THE HIPPOCRATIC OATH TODAY/ZNACAJ HIPOKRATOVE ZAKLETVE DANAS.

Introduction

The body of literature on the Hippocratic Oath is so large to make an ever-growing library. Although written some twenty five centuries ago, it is still a subject of numerous writings of medical scholars, which can be easily evidenced by Googling. It is sufficient to type "Hippocratic Oath", and the omniscient Google will find almost half a million hits. This number is related only to the amount of relevant information available in English. If we assume that the bibliography in other sixty languages into which the Hippocratic Oath has been translated [1] is also significant, the size of this virtual library becomes really impressive. However, we are going to stay only in the "English Reading Room", i.e. we will focus our attention solely on sources available in English.

If from the above number, those that only mention the term Hippocratic Oath, are excluded, it is plausible to think (but impossible to check out!) that still remains an enormous amount of pertinent literature sources. Thus, the shelves of the reading room of this virtual library are stocked with volumes of books and journals dealing with the Oath. They are mainly from the fields of medical ethics and history of medicine. Among them, there are even three books about this topic published in this century [2-4]. The other books and journals contain whole chapters, review articles, and papers of different length and significance. One should also mention numerous opinions and comments posted on popular social media websites. In the mentioned sources, one can find a wealth of opinions, ranging from those that consider that the Oath's "principles are held sacred by doctors to this day" to those that "some doctors see oathtaking as little more than a pro-forma ritual with little value beyond that of upholding tradition" [5].

It should be pointed out that there are different versions of the Hippocratic Oath, so that it is possible to speak about it in the plural. Namely, apart from the version usually termed 'Classical', there is also one termed 'Modern', and numerous versions written in a similar vein to the Hippocratic Oath. Although they contain the word 'Hippocratic', they are not literal translations of the Oath, but rather its adaptation to suit the values of a particular culture, like the one used by medical students in India [6] and in Russia [7]. Besides, there is opinion that "medical students are free to choose their own oaths" [8]. However, a question can be raised as to whether all these versions can be called 'Hippocratic'.

Let us recall that the Hippocratic Oath is the most widely known medical text of the Greek heritage, authored by Hippocrates, the founder of a school of medicine on the Greek island of Kos, or by his closest associates [9, 10]. It is a code of ethics which "provides first statements of a moral of conduct to be used by physicians" [11], separating medicine from religion. Along this line, the famous American anthropologist Margaret Mead 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. ... 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" [12].

The Oath was originally written in the Ionic Greek, probably in the late fifth century Before Christian Era [1]. Its best known translation into English was done by Ludwig Edelstein, a classical scholar and historian of medicine. This translation is usually called 'Classical version' [13], whereas the (modified) version written by Louis Lasagna is known as 'Modern version' [14]. However, it should be pointed out that there is a significant number of references in which, instead of 'classical', it is called the 'original', which is not correct because there are various translations from the Greek. Therefore, the word 'original' could be appropriate only for the version written in Greek, although it can be rightly supposed that, in its long history, the 'pristine' text could have been subjected to alterations.

Below, we present the full texts of the 'Classical' and 'Modern' versions of the Oath, not only to compare their contents, but also for the purpose of discussing their significance at the present time. In doing so, we will review critically different opinions on the subject matter and also tackle some points which, in our opinion, have not been treated appropriately in the available literature.

Hippocratic Oath: Classical Version [13]

"I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill 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 my life 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 brothers in male lineage and to teach them this art - if they desire 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 have taken an oath according to the medical law, but 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 who asked for it, nor 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 favor of such men as are engaged in this work.

Whatever houses I may 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 slaves.

What I may see or hear in the course of the treatment or even outside of 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 fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored 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."

Hippocratic Oath: Modern Version [14]

"I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those of sound mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help."

A brief comparative analysis of two versions

According to dictionaries, an oath, in its noble meaning, is a solemn promise, often invoking a divine witness, regarding one's future action or behavior. The abandonment of ancient Greek gods and goddesses as witnesses, the Classical version, deprived the Oath of much of its solemnity. Instead of deities, Lasagna's formulation called upon personal virtues of the oath taker (I swear to fulfill, to the best of my ability and judgment, this covenant). While not pretending to be quite serious, one can invoke as a witness something that is neither divine nor personal. Thus, in their poem in prose entitled "Hippocratic oath translated into poetry", R. Philipp and D. Hart say: "I swear by the music of the expanding universe and by the eloquence of the good in all of us that I will excite the sick and the well by the severity of my kindness to a wholeness of purpose" [15].

The second part of both versions is concerned with the relations between the physician and his teachers, as well as the students he will be teaching one day. In the Modern version, the respect to the seniors and readiness to share the knowledge "with those who are to follow" are clearly stated in a succinct way. In the Classical version, this matter is more elaborated, and the corresponding sentence is much longer. The oath taker declares that he is obliged to his teacher as much as to his own parents, and promises to give him material support in case of need. This high regard and readiness to help extends also to the teacher's offspring. The neophyte physician is ready to teach them the art of medicine ("if they desire to learn it") the same way as his own sons. This implies that medical professionals could be primarily members of the family's male lineage. This holds for Hippocrates himself, whose father was also a physician, whereas his two sons and son-in-law were his pupils [1]. Although this was quite normal in the time of Hippocrates, by the modern views it is neither acceptable nor compliant with reality. Namely, the percentage of female physicians is growing in many countries. For example, in the United States of America, they made only 9.7 % in 1970 and 32.4% in 2010 [16].

It seems that the tradition of practicing medicine, mainly reserved for the members of 'medical clans', has survived to the present day. On the one hand, this may be a desirable trend, as the members of younger generations grow up in a favorable milieu, which could be beneficial for the medical profession. However, this tradition can be criticized on the grounds that some gifted young people may be thus hindered or prevented from learning the art of medicine. True enough, there is a possibility for "pupils who have signed the covenant and have taken an oath according to the medical law, but no one else". One can understand that from this stems the requirement for a 'medical license' at the present time.

The rest of the sections are concerned with the physician-patient relationship, stating that the physician, although being aware of his limitations, will always act in the patient's best interests. This is a typical paternalistic attitude, since the physician assumes the role of the parent (father), who knows best what suits his patient (child). However, this is not consistent with fundamental principles of modern medical ethics, by which the physician-patient dyad should function in a cooperative way [17, 18].

The following part of the classical text "... I will keep them from harm..." may be considered only as a hint of the well known principle "First, do no harm" ("Primum non nocere"), which is often (wrongly) associated with the Hippocratic Oath. In fact, it has been stated in the collection of medical writings called 'Hippocratic Corpus' (in the book "Epidemics") [19].

Obviously, the above principle is one of the core obligations of every physician. However, as pointed out by Robert H. Shmerling from the Harvard Medical School: "The fact is that when difficult, real-time decisions must be made, it's hard to apply the "first, do no harm" dictum because estimates of risk and benefit are so uncertain and prone to error" [20]. It is quite probable that many medical practitioners had to face such a situation. The most important thing is that they must not inflict harm intentionally!

The strong readiness of the physician to do everything "for the benefit of the sick" (mentioned twice in the classical and once in the modern text) means more than "do no harm". In contrast to the old version, in which the physician's empathy for his patients is not stated explicitly, Lasagna expressed it in a beautiful way as "warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug".

Abortion, euthanasia ("physician-assisted death"), and surgery are the three issues that have been most frequently in the focus of attention of medical ethicists and other interested authors. While in the classical text the physician swears not to practice abortion ("I will not give to a woman an abortive remedy") and euthanasia ("I will neither give a deadly drug to anybody who asked for it"), these life-and-death issues, though not mentioning explicitly either abortion or euthanasia, Lasagna worded with subtle care ("Most especially must I tread with care in matters of life and death...But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God."). Abortion and euthanasia are topics of hot debates among not only medical ethicists and healthcare professionals, but also among law and religious authorities, as well as people from all walks of life. While abortion has been legalized in many countries, euthanasia is allowed only in a few European countries (Netherlands, Belgium, Luxembourg, Switzerland), and in some states of the United States of America [16, 18].

As far as surgery is concerned, one may understand that the oath taker was not going to practice it ("I will not use the knife ... but will withdraw in favor of such men as are engaged in this work."). By this, the physician admits his incompetence in the art of surgery, and there is no mentioning of the possible specialization. Hence, a question arises as to how then the surgeons were trained, since there is evidence in the Hippocratic Corpus that "Greek doctors were in fact aggressive surgeons" [21]. In both versions, the oath taker declares to respect the privacy of his patient, and this confidentiality principle is also contained in the majority of modified versions. Thus, according to a survey of the contents of oaths in United States of America medical schools in 2000, the principle of "Protecting patient confidentiality" is ranked first, as it was present in 91% of the oaths, followed by the "Loyalty to colleagues, profession and teachers" (87%), while "Avoiding sexual misconduct" (2.8%) and "Prohibition of abortion" (0.7%) were at the end of the list in the oaths that "maintain ethical values in the traditional Hippocratic oath" [22]. Such low percentages of the oaths addressing the last two issues may seem somewhat surprising.

It is interesting to see how the Oath is treated in legislation, i.e. how the breaches of the Oath's principles are sanctioned. Dimitrios Gakis observed that "in ancient Athens if somebody was treating inappropriately a supplicant, the penalty was death!" [23]. In general, this statement does not tell what behavior is referred to as inappropriate treatment. In today's healthcare practice, there may arise many specific situations, especially in the domain of the very sensitive physician-patient relationship, abortion, euthanasia, etc., that may lead to court cases. There is an interesting opinion that "the Hippocratic Oath exerts a powerful influence on modern legal controversies implicating medical ethics, leading courts to adopt an overly doctor-centered view of these disputes" [24]. This questionable statement is supported by the presumed dignification of the medical profession and by the opinion that "the Oath treats the patient as subordinate to the physician." In their book, Pel-legrino and Thomasma [25] put the focus on the patent's autonomy. This matter is formulated in the form of the principles known as "Pellegrino's Precepts". In the linguistic sense, this shift from the term 'oath' to 'precept' can be understood as a weakening of the obligation of the physician to stick strictly to the pledge.

On the contemporary relevance of the Oath

As pointed out in the Introduction, the literature search shows that the Hippocratic Oath is a very controversial subject. Generally, opinions range from warm approval to total disapproval. It seems that every single bit of the Oath has been subjected to detailed analysis and interpretations. The majority of objections are related to the Classical version, which is claimed to be outdated, although at the time it was, supposedly, 'modern'.

Below, we are going to discuss some pros and cons related to the Oath, while trying to formulate our own position in this matter. The choice of topics selected for discussion is very limited as it was made with the only purpose to illustrate the diversity of views of a number of authors.

One of the starting points in a significant number of writings on the subject is concerned with the formulation of the oath opening, i. e. with the choice of the oath witnesses. While D. Graham says: "To invoke the gods and goddesses as witnesses to an oath is certainly a more serious undertaking than making a pledge to a personal conscience that can easily be ignored" [26], H. Herrell's opinion is that "few students today would take swearing by Apollo and Asclepius seriously" [27]. On the other hand, H. Kantarjian and Steensma [21] put it this way: "Today, we face (and may swear by) old and new deities, including one perhaps more powerful and capable of extremes of good and evil than any other: money." It is true that nobody can deny that money is a powerful incentive, but one would like to believe that humanistic values will prevail, at least in certain situations.

In his article, "The Myth of the Hippocratic Oath", Robert H. Shmerling has expressed his opinions (some of which may seem a bit contradictory) on a number of relevant issues, and, among the others he stated the following: "In fact, the modern-day Hippocratic Oath covers only a few issues relevant to the ethical practice of medicine" [20]. Although this observation is true, it is possible to criticize it on the grounds that one should not expect that an oath, bearing in mind its specific character, is supposed to address the whole multitude of ethical issues that a physician can encounter in his/her practice. All these aspects, including those concerned with medical research, are appropriately covered in the corresponding declarations of the World Medical Association [18, 28].

In her long and well articulated article, Emily Woodbury [29] stated that "the importance of a unique medical morality cannot be understated." She also points out that "this myriad of interpretations" concerning the Hippocratic Oath and medicine in general "necessitates a unified philosophical grounding for medicine and an agreement within the medical professional community on ethical constraints". She concluded that "the Hippocratic Oath fails to meet those demands", so that it should be abandoned, announcing thus a "post-Hippocratic era". It is interesting to note that although advocating strongly the replacement of the Oath with Pellegrino's Precepts, Woodbury proposes to discard two (the 5th and 11th) of the 13 precepts. This is evidence on how difficult it is to take a clear stand on a controversial topic.

A similar opinion that the Hippocratic Oath is outdated and that it should be replaced with Pellegrino's Precepts has been recently expressed in an online article [30]. The author claims that "the Oath sees the patient as a subordinate to the doctor" and advocates for taking patient's opinion into consideration. Although not giving the source of data, the author gives the following statement: "as of the year 2016, all (100%) of students swear upon some version of an oath upon graduating from medical school".

It is interesting to note that there are few articles concerning the opinions of physicians about the influence of the Hippocratic Oath on their personal attitude towards the professional practice. This was the subject of a recent extensive polling on the impact of medical oaths and other professional codes on the "physicians' professional formation and practice", carried out by Antiel et al. [31]. The survey included 1032 United States practicing physicians who returned a completed questionnaire, and the data were analyzed by taking into account a number of factors. Practically all respondents (97%) participated in the ceremony of taking the oath, which was a version of the Hippocratic Oath in 85% of cases. To the question on the extent to which their practice was influenced by the oath, the answers were as follows: "a lot" (26%), "somewhat" (37%), "not very much" (24%), and "not at all" (13%). It is also interesting to note that in relation to other sources of moral guidance the respondents marked "personal sense of right and wrong" (92%), "great moral teachers" (35%), and "specific traditions" (28%).

The argument that "today's doctors face a number of important ethical issues that are not included in the

Hippocratic Oath" [20], although being true, cannot be used as a basis for making it more complete. That would result in a very long text which could not serve its purpose any more. Anyway, one cannot expect that a small number of ethical guidelines could address all possible aspects of the physician's practice.

Although the wordings of the statements that are sworn by the physicians may differ to a great extent, they always express very positive attitudes about the physician's work. The awareness that their colleagues all over the world attend similar ceremonies and pronounce similar words can induce the feeling that they are members of a wholesome fraternity (Gens una sumus). Although this may seem an exaggeration, we would like to believe that there is a grain of truth in this premise.

This short review of the pertinent literature indicates the existence of a great variety of opinions about the relevance of the Hippocratic Oath. Despite of this, it appears that the tradition that graduate students take a medical oath--different versions of the Hippocratic Oath or the oaths composed in a similar vein--is nurtured at (almost) all medical schools over the world. So, to make a choice from this rich menu is not an easy task. If one is inclined to respect tradition that has passed down to us throughout so many centuries ("Tradition means obligation!"), he will choose the Classical version, despite the right criticisms related to the attitudes towards some crucial aspects (abortion and euthanasia). The Modern version, could be recommended as the "most appropriate", while Pellegrino's Precepts are less acceptable because of the fact that the replacement of the term "oath" with "precepts" may seem as weakening the obligation. Finally, all those "self-composed" and jocular versions could not be considered to be a valid substitute for the Oath.

Conclusion

In conclusion, the shortest answer to the question in the title of the paper is a big "yes". The Hippocratic Oath is alive and well today, and will, hopefully, be so in the future.

References

[1.] Jotterand F. The Hippocratic oath and contemporary medicine: dialectic between past ideals and present reality? J Med Philos. 2005;30(1):107-28.

[2.] Miles SH. The Hippocratic oath and the ethics of medicine. New York; Oxford: University Press; 2004.

[3.] Tallis R. Hippocratic oaths: medicine and its discontents. London: Atlantic; 2004.

[4.] Dossetor JB. Beyond the Hippocratic oath. Edmonton: University of Alberta Press; 2005.

[5.] Tyson P. The Hippocratic oath today [Internet]. 2001 [cited 2019 Jan 13]. Available from: www.pbs.org/wgbh/nova/article/hippocratic-oath-today/?utm_source=promourl&utm_medium=direct&utm_campaign=nova_2019.

[6.] Pai SA, Pandya SK. A revised Hippocratic oath for Indian medical students. Natl Med J India. 2010;23(6):360-1.

[7.] Tishchenko PD. Resurrection of the Hippocratic oath in Russia [Internet]. 2008 [cited 2019 Jan 13]. Available from: http://www.zpu-journal.ru/en/articles/detail.php?ID=330.

[8.] Bailey M. So long Hippocrates. Medical students choose their own oaths [Internet]. 2016 [cited 2019 Jan 13]. Available from: http://www.statnews.com/2016/09/21/hippocratic-oath-medical-students.

[9.] Carrick P. Medical ethics in the ancient world. Washington, D.C.: Georgetown University Press; 2001.

[10.] Bjelica A. A short journey through the history of medical ethics. Med Pregl. 2017;70(3-4):119-22.

[11.] Oath and law of Hippocrates/Physician/Oath - Scribd [Internet]. 2016 [cited 2019 Jan 13]. Available from: https://www.scribd.com/document/Oath-and-Law-of-Hippocrates.

[12.] American Hippocratic Registry - History and meaning of the oath [Internet]. 2016 [cited 2019 Jan 13]. Available from: www.ahregistry.us/history-and-meaning-of-the-oath.html.

[13.] Edelstein L. The Hippocratic oath: text, translation, and interpretation. Baltimore: Johns Hopkins Press; 1943.

[14.] Lasagna L. Hippocratic oath: modern version [Internet]. 1964 [cited 2019 Jan 13]. Available from: https://www.pbs.org/wgbh/nova/doctors/oath_modern.html.

[15.] Philipp R, Hart D. An ethical code for everybody in health care: Hippocratic oath translated into poetry. BMJ. 1998;316(7142):1460.

[16.] Strasser AR. Despite growing number of female doctors and lawyers, women's pay still lags behind [Internet]. 2012 [cited 2019 Jan 13]. Available from: https://thinkprogress.org/despite-growing-number-of-female-doctors-and-lawyers-womens-pay-still-lags-behind-9b43f25c0335/.

[17.] Emanuel EJ, Emanuel LL. Four models of the physicianpatient relationship. JAMA. 1992;267(16):2221-6.

[18.] Bjelica A. An outline of medical ethics. Novi Sad, Serbia: Faculty of Medicine; 2015.

[19.] The Internet Classics Archive. Of the epidemics by Hippocrates [Internet]. [cited 2019 Jan 13]. Available from: http://classics.mit.edu/Hippocrates/epidemics.html.

[20.] Shmerling RH. First, do no harm [Internet]. 2015 [updated 2015 Oct 14; cited 2019 Jan 13]. Available from: https://www.health.harvard.edu/blog/first-do-no-harm-201510138421.

[21.] Kantarjian H, Steensma DP. Relevance of the Hippocratic oath in the 21st century [Internet]. 2014 [cited 2019 Jan 13]. Available from: http://www.ascopost.com/issues/october-15-2014/relevance-of-the-hippocratic-oath-in-the-21st-century.aspx.

[22.] Kao AC, Parsi K P. Content analyses of oaths administered in U.S. medical schools in 2000. Acad Med. 2004;79(9):882-7.

[23.] Gakis D. The Hippocratic oath today. MOJ Surgery. 2016;3(2):35.

[24.] Hasday LR. The Hippocratic oath as literary text: a dialogue between law and medicine. Yale J Health Policy Law Ethics. 2002;2(2):299-323.

[25.] Pellegrino ED, Thomasma DC. For the patient's good. New York: Oxford University Press; 1988.

[26.] Graham D. Revisiting Hippocrates: does an oath really matter? JAMA. 2000;284(22):2841-2.

[27.] Herrell H. The Hippocratic oath: a commentary and translation [Internet]. 2000 [cited 2019 Jan 13]. Available from: http://utilis.net/hippo.htm.

[28.] Volkmer S. International ethics applicable to health care professionals [Internet]. 2010 [cited 2019 Jan 13]. Available from: https://www.law.berkeley.edu/files/IntlMedlEthicspaper (final)11June10.pdf.

[29.] Woodbury E. The fall of the Hippocratic oath: why the Hippocratic oath should be discarded in favor of a modified version of Pellegrino's precepts. Georgetown University Journal of Health Sciences. 2012;6(2):9-17.

[30.] Dalvidap. Hippocratic oath [Internet]. 2016 [cited 2019 Jan 13]. Available from: https://rampages.us/univ200hippocraticoath/author/dalvidap.

[31.] Antiel RM, Curlin FA, Hook CC, Tilburt JC. The impact of medical school oaths and other professional codes of ethics: results of a national physician survey. Arch Intern Med. 2011;171(5):469-71.

Rad je primljen 21. I 2019.

Prihvacen za stampu 21. I 2019.

BIBLID.0025-8105:(2019):LXXII:1-2:5-10.

Artur BJELICA (1,2)

University of Novi Sad, Faculty of Medicine, Novi Sad (1)

Clinical Center of Vojvodina, Novi Sad

Clinic of Obstetrics and Gynecology (2)

Corresponding Author: Prof. dr Artur Bjelica, Klinicki centar Vojvodine, Klinika za ginekologiju i akuserstvo, 21000 Novi Sad, Branimira Cosica 37, E-mail: artur.bjelica@mf.uns.ac.rs

https://doi.org/10.2298/MPNS1902005B
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