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With purity and with holiness I will pass my life and practice my Art.
Almost everyone has heard of the Hippocratic Oath, the ancient pledge sworn by newly minted physicians. Few people know just what the Oath says and even fewer know that many medical schools no longer require their graduates to take the Oath. Since the ethics expounded in the Oath have shaped the course of Western medicine for over 2,500 years, it is important for us to understand something of the history and contents of the Oath. We must also understand the challenges physicians face-especially Christian physicians-as they try to maintain fidelity to the principles and virtues outlined in what may be called the "Hippocratic consensus" in medicine. Biomedical ethics did not rise phoenixlike from the ashes of the twentieth century. In fact, like medicine, biomedical ethics has ancient beginnings.
Some form of medicine has existed since at least 9000 B.C. The historical evidence suggests that the first physicians were really priestly magicians whose treatments and cures arose from their cultic practices rather than scientific research. The practice of medicine consisted largely of spells, incantations, charms, and a few natural drugs given to patients as part of a spell to rid them of an ailment. Many of these treatments may have been helpful, though one must wonder whether some of the patients might have been better off without treatment.
In Mesopotamia three classes of physicians existed: the diviners (who interpreted omens and foretold the course of diseases), the exorcists (who cast out the evil spirits believed to have caused the disease), and the physicians (who performed surgery and administered drugs). The Code of Hammurabi (ca. 2000 B.C.), an ancient law code, spelled out some of the protocols to be followed in Babylonian medicine. For example, if a physician treated a nobleman for a severe wound or for an abscessed eye and the nobleman either died or lost his eye, the physician's hands should be cut off! These laws, no doubt, made the idea of becoming a doctor less attractive to prospective physicians. The Code included little, if anything, that could be described as ethics.
Early Western Medicine
Western scientific medicine really began with the Greeks. Though some Egyptian medical practices were transferred to Greece, Hellenistic culture can be credited with much of our early knowledge of anatomy, physiology, and the genesis of our medical terminology. Even the symbol of medicine, the caduceus-the familiar serpent entwined on a rod-probably owes its origin to the Greek deities Aesculapius and Hermes, as well as the cult of the serpent in Minoan religion. Other Greek giants such as Aristotle, Galen, and Hippocrates shaped medicine in innumerable ways.
Hippocrates of Cos (ca. 460-ca. 370 B.C.) was the son of a physician and practiced as an itinerant doctor in Thrace, Thessaly, and Macedonia. Plato mentions Hippocrates in the Phaedrus, where Socrates appeals to the empirical observations of Hippocrates and the Asclepiad, the cult of Aesculapius. Plato also calls Hippocrates "a professional trainer of medical students."
The written works attributed to Hippocrates are of various origins. Some are doubtless the works of Hippocrates himself. Prognostics and Joints are usually thought to be original. Other works were written under his name either by individuals or by the so-called Hippocratic school. The Hippocratic corpus of some sixty written works is rich and varied. His Aphorisms, for instance, begins: "Life is short, and the Art long; the occasion fleeting; experience fallacious, and judgment difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals co-operate."
The Hippocratic Oath
Hippocrates is perhaps best known to most of us through the Oath that bears his name. What has become known as the Hippocratic Oath was probably written after his death by the Hippocratic school. Nevertheless, the Oath is universally held to reflect accurately the ethics of Hippocrates himself.
Originally the Oath was not recited in medical schools. Rather, it was administered in family guilds of physicians or used to form a pact between a teacher and his pupil.
Jews, Christians, and Muslims adopted the Oath as their own, changing the names of the Greek deities to the names of Yahweh and Allah, respectively, thus making the Oath monotheistic rather than polytheistic.
The purpose of the Oath
When thinking about the purpose of the Oath, it is important to remember that in Hippocrates' day there were no medical schools, examination boards, or professional organizations that offered credentials to physicians. No training was required, no licensure was necessary, and no one could, therefore, remove a physician from practice. Medicine was considered a craft and the physician was a craftsman.
Anyone could (and did) hang out a shingle, as it were, and call himself a physician. (In the ancient world physicians were, almost without exception, males.) As we have noted, not only were some of the physicians the equivalent of sorcerers, but there were plenty of charlatans who took advantage of the sick for their own profit. The patient had to be able to distinguish the charlatan from the true physician.
The Hippocratic school was probably like a crafts guild. A Hippocratic physician demonstrated mastery over a particular set of skills. Many of the works that bear the name of Hippocrates outlined those skills. The Hippocratic physician was also held to high ethical standards. These standards are expounded clearly in the Oath itself.
I swear by Apollo the physician and Aesculapius, and Health, and All-heal, 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 offspring 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 to 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 labouring 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.
The Oath divides neatly into two parts: the first specifies the duties of the pupil toward his teacher, and the second provides a brief summary of the ethics of medicine. In the first part it is evident that being a physician was much like being any other kind of craftsman.
Certain duties were required of the learner of a craft toward his teacher. First, upon entering training for medicine, the student was to treat the master as he would his own father, even supporting the teacher should that become necessary. This was a form of indenture, but a more intimate form than others in the ancient world. For in this indenture, the offspring of the teacher were to be regarded as siblings of the student. Moreover, the student pledged to teach the master's children the art of medicine should they wish to learn it.
Surprisingly, the student also covenanted to teach other pupils who signed the indenture and swore the Physicians' Law (another term for the Oath), "but to none other." As Nigel Cameron has pointed out in his very helpful volume, The New Medicine: Life and Death After Hippocrates, "The Oath explicitly forbids the physician to pass on his clinical knowledge to anyone who has not already committed himself to the Hippocratic values." The skills of clinical medicine were only to be taught to those who would embrace the ethics of medicine.
The Ethics of the Oath
What are Hippocratic ethics? In another place in the Hippocratic literature Hippocrates says, "The medical art has to consider three factors, the disease, the patient, and the physician. The physician is the servant of his art, and the patient must cooperate with the doctor in combating the disease." These three factors-the disease, the patient, and the physician-clearly inform the moral requirements of being a physician.
First, the Oath is written against the backdrop of the patient's disease. The patient is sick. The patient has a disease that requires the physician's skills to treat. Following the outline of the Oath, the disease may require a change of diet, the administration of drugs, or surgery. In the application of all these treatments, the primary concern is for the good of the patient. He or she is the focus of the Hippocratic physician's art. The physician serves his art to the end that the patient's sickness is relieved.
Also, note carefully that the Oath enjoins the physician to employ his skills "for the benefit" of the patient and in such a way as not to be "deleterious and mischievous." It is a well-known axiom that the first principle of medical ethics is primum non nocere (first, do no harm). After that, the physician is also to seek to do good for his patient by skillfully and competently treating the patient's illness.
Doing no harm means, among other things, that the physician will not give a poison to anyone or even make a suggestion to that effect. Physician-assisted suicide is beyond the pale of "purity and holiness" for the Hippocratic physician.
Similarly, doing no harm means that the physician will not give an abortion-causing drug to one of his female patients. Abortion was not uncommon in the Graeco-Roman world. Nevertheless, the Hippocratic physician was to set himself apart from this practice, no matter how common it might be. Interestingly, in one Christianized version of the Oath the language is even more explicit, stating that the physician will refuse to perform an abortion "from above or below." This would prohibit both the use of drugs or surgery for the purposes of abortion-once again underscoring the fact that early Christians knew abortion to be a common cultural practice.
Further, the Hippocratic physician pledges not to practice beyond his competence. Thus, he swore that he would refer patients with a "stone" to a surgeon. Here we have an ancient testimony to the emergence of specialties in medicine. Apparently there were already what we call internists and surgeons.
Next, we should observe that the Hippocratic physician was a "professional." That is to say, there was no dichotomy between his "life" and his "art." A professional is ideally a thoroughly integrated individual who is on the inside just what one sees on the outside.
Professionalism means that he will keep himself from wrongdoing, including sexual immorality of either a heterosexual or homosexual nature. Sexual sin is especially heinous where a person of considerable power (in this case the physician with his special set of skills and expertise) is in a position to exploit a person who is weaker (in this case due both to the presence of an illness and by the social structures of the day).
Moreover, the professionalism of the physician means that he will keep confidential any information about the patient and/or information learned during the treatment of the patient. Patient confidentiality is no less important today for some of the same reasons it was important in Hippocrates' era. Patients can easily be discriminated against based on their diagnoses and prognoses. If someone does learn of a patient's condition, it should not be, says the Oath, from the physician.
Finally, the Oath ends with a sanction showing its utter seriousness. The consequences of keeping the Oath were to be a life of flourishing and respect. If the physician violated his covenant, he called down misery and disapproval on himself.
Evidence of the sober nature of the Oath was that it was pledged in the name of the gods. While Christians obviously will not name the pagan deities when they pledge the Oath, they nonetheless recognize, as Hippocrates recognized, that the practice of medicine is transcendent in nature.
Human beings are not merely creatures of flesh and blood; they are spiritual and "soulish" creatures. Moreover, the universe is more than a merely physical universe. So the task of caring for patients compromised by illness must be performed in light of realities that go beyond the physical.
The Costs of Ignoring the Oath
The Hippocratic Oath enshrined the ideals of medical practice in the Western world. Much of what we think of as medicine and medical ethics is derived from the Hippocratic tradition. Christians modified the Oath in important ways. They did not, however, dilute the Oath. They only strengthened it. Today, medicine is changing. We are jettisoning many of the Hippocratic, not to mention Christian, ideals. We do so at our own peril and, more importantly, at the peril of those who are sick.
In a very important survey of medical schools in North America in the mid-1990s, Robert Orr, M.D., and his colleagues found that only one medical school of the 157 surveyed used the original Hippocratic Oath. Sixty-eight schools used some version of the Oath, but only 8 percent of those oaths prohibited abortion and only 14 percent prohibited assisted suicide and euthanasia.
Excerpted from Does God Need Our Help? by John F. Kilner and C. Ben Mitchell Copyright ©2003 by John F. Kilner and C. Ben Mitchell. Excerpted by permission.
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|Introduction: Why All the Fuss?||xi|
|Part I||Tools: Distinguishing Right from Wrong|
|1.||It Started with Hippocrates||3|
|2.||Then Along Came Bioethics||17|
|3.||Does the Bible Address Bioethics?||35|
|Part II||Health Care: Across the Lifespan|
|4.||Embryonic Ethics: Stem Cell Research, Abortion, and Beyond||61|
|5.||Life on the Line: End-of-Life Treatment and Resource Allocation||85|
|6.||Breathtaking Decisions: Assisted Suicide and Euthanasia||115|
|Part III||Biotechnology: Shaping the Human Race|
|7.||Thirty-eight Ways to Make a Baby||137|
|8.||Send in the Clones?||155|
|9.||Who's Splashing in the Gene Pool?||171|
|10.||Remaking Humans: The New Utopians versus a Truly Human Future||191|
|About the Authors||233|