New Mexico, Albuquerque (Fall 2009)
From my early years in medical school, I recall the reverence with which my teachers talked about Hippocrates. The great Indian physicians, Charaka and Shushruta, who worked and wrote several hundred years before Hippocrates, were mentioned only in passing. The Hippocratic Ethics, the Hippocratic Oath, and the clinical observations made by Hippocrates were central to the teaching of ancient medical history. I vividly recall learning about the various assessments attributed to Hippocrates, including the Hippocratic facies (the gaunt and blank look of a patient that predicted impending death) and the succussion splash, a sign of hydro-pneumothorax. We did not take a formal Hippocratic Oath, but the Oath was written on a marble slab and prominently displayed in the hallowed halls of the medical school Administrative Building.
Only later in life did I begin to question the high place that the medical world accorded to Hippocrates. After further reading, I drew a very different picture from that which I was told as a young student. I realized that Hippocrates was not one person and that the writings ascribed to him had been written over a span of 100 years in different parts of the Aegean world. Thus the reverence accorded to a personified pioneer and a model human is somewhat misplaced. The Oath of Hippocrates, as taken until recently by young physicians, is also troubling in the context of today’s social and medical expectations and norms. What was sworn to in the sixth and fifth centuries before Christ no longer fits the standards of today, and what was acceptable then would not be acceptable today. The world of the ancients was different, an unequal society that did not strive for egalitarianism, divided starkly between the haves (the citizens) and the have-nots. The have-nots’ were by far the most numerous, consisting of two tiers: the freemen without property or votes (metics), and the slaves, estimated to have comprised 70 to 80 percent of the population of the cities of ancient Greece.
For a modern society, which places a high value on an equitable distribution of health services, the selection of patients by physicians in Hippocrates’ time would have been problematic. It was the common practice of physicians of the day to limit their practice essentially to the citizens (those who had power), to accept the metics occasionally, and to exclude the slaves from mainstream care. This exclusion is no longer ethically acceptable in our day. Of course, it must be noted that in many poor countries, and even in the United States, there is a discrepancy between the types of health care available to the rich and the poor. What is available to the poor is inferior to what is routinely provided to the more educated and well-to-do citizens. Still, in theory at least, there is a goal of egalitarianism all over the world.
The physicians of the Hippocratic era had a fail-safe system of making a contract with their patients before accepting them into their practice. They were thus assured that they would receive their fees and did not have to worry about unpaid bills. It is unclear whether such a contract was linked to a guarantee of success, but it has been suggested that the physicians preferred patients with self-limiting disease and a better prognosis in order to enhance their reputation.
The Oath and the accepted norms of ancient society raise other issues as well. Communication with the patient and his family was limited, restricted to generalities and giving instructions. Physicians gave out just enough information to ensure that the patient followed their instructions. Discussion of prognosis and sharing of concerns do not appear to have been common practice.
Another problematic norm of medical care dating from that period occurs with the practice of eugenics. Society, for reasons relevant to those times, encouraged the creation of a superior class of people. Though not specifically addressed in the Oath, these practices reveal the values of the society that produced the Oath. In Sparta, weak or “defective” babies were allowed to die in order to reduce the burden on society, and the breeding of superior men with desirable women was encouraged in order to produce healthier soldiers. The irrelevance of the Oath to current medical practice is most obvious when one realizes that the practitioners who took the Oath were allowed neither to practice surgery, considered to be a separate field, nor to teach others unless they were in the same school or students of the same teacher.
Also proscribed by the Hippocratic Oath were abortions (even though some were performed in that period), which was understandable when the population was small and every male baby was a potential soldier. In today’s world, with population pressures and many mothers’ desire to control family size, many people would view such a ban as unacceptable or less than desirable.
The Hippocratic corpus of work and the changes it brought about in the principles and practice of medicine were revolutionary and pioneering. Systemic observation of circumstances, signs and symptoms of disease, and their correlation with outcomes are the foundations of many basic principles of medicine. Furthermore, these observations led to a greater understanding of anatomy and physiology, which in turn lead to the development of pathophysiology and clinico-pathological correlation. These were major changes in the approach to disease. Prior to this new development in Greek medicine in the fifth century BC, the Greeks of the Homeric period (8th century BC); the ancient Egyptian healers; and the healers from West, South, and East Asia; while making significant observations and developing many important medical and surgical treatments, did not understand or make use of these principles to the same extent. The systematic observations and correlations made by the Greek physicians of the fifth century BC have had a far-reaching impact that is still relevant today.
No one questions the value of many of the contributions that Hippocrates and others have made to the development of modern medicine. What remains at issue is whether or not the ethics of an ancient world are relevant to medical practice in the 21st century, when the involvement of patients in the management of their illness is emphasized and attempts are being made to provide equitable medical care to all.
Thus questioning the relevance of the Hippocratic Oath and putting it in the social and medical context of the day is a useful exercise. Questioning current beliefs and practices has frequently led to improvements in medical care. It is my hope that revisiting our trust in the Hippocratic Oath will lead us to a more modern ethics that matches the values of today’s world.
AROOP MANGALIK is a medical oncologist at the University of New Mexico Cancer Research & Treatment Center in Albuquerque. He has an interest in history and history of medicine. He was brought up in India in a medical family. His father was also interested in History of Medicine.
Highlighted in Frontispiece Fall 2009- Volume 1, Issue 5