The Hippocratic and Other Oaths: Past and Present
Until recently, medicine was practiced in an inherently creedal and covenantal manner. Hence, most allopathic and osteopathic physicians historically used the Hippocratic Oath as a statement of practice. Physicians and patients previously understood that medicine functioned in a "priestly religious role" derived from implicit religious guidelines. Everyone took oaths that involved written promises (creeds and covenants) and statements of practice with sanctions (oaths), as implied agreement on the part of those involved to behave in a specified ethical manner. The advent of "situation ethics" and "outcome-based ethics" (or consequentialism) in its various forms radicalized a previously held community ethos.
Modern culture has taken an objection to the use of creeds and oaths to define one's beliefs and expected ethical behavior. However, our Christian system of beliefs and manner of life are well summarized through the use of these statements. In the Christian faith, history demonstrates a longstanding adherence to the Apostolic and Nicaeno-Constantinopolitan Creeds.' Creeds in the Reformation and post-Reformation period were abundant. Many, such as the Westminster Confession, are still held by many Christians today (as we do). Extreme care and attention were paid to the exact wording of these doctrinal creeds, to render precise and succinct summaries of the immutable truths found in the Holy Scriptures.
Oaths, like creeds, attest to a set of beliefs, but, unlike creeds, usually contain moral obligations or duties incumbent upon the oath-taker with stipulations applying to the persons bound by the oath and sanctions for violating the terms of the oath.
Recent Christian sentiment has objected to oath-taking. The first objection is based on an exegetical reading of Christ's injunction in the Sermon on the Mount as an absolute prohibition to oath-taking (Matthew 5:33-37). This exegesis is erroneous. The second objection is more pernicious, stating that Christian "freedom" from the Law removes moral demands and obligations on the individual. An oath or creed of conduct supposedly removes someone from the "freedom" he has in the Gospel. Such antinomianism has been adequately refuted elsewhere.' The third objection stems from the prevailing lack of moral fortitude found in much of Christendom, leading to resistance to impose stringent rules on the individual when he would have no desire to live by them. Because of these three objections, churches, organizations, and individuals now rarely if ever honestly commit themselves to a solemn oath or pledge of behavior.
Physicians, however, have had a long-standing tradition of abiding by moral creeds and oaths. Some of the earliest medical documents available are none other than medical oaths of conduct, such as is found in the Code of Hammurabi from ancient Sumer. The most remembered and cited medical oath is the Hippocratic Oath, written c. 400 B.C. by a small cult of religious zealots who were known as the Pythagoreans. They were committed to a unique set of gods and maintained strict ethical standards that governed their behavior.' The Pythagoreans wrote and abided by the Hippocratic Oath as a reaction to contemporary Greek culture and medical practices that they considered to be unacceptable. This oath has contemporary relevance, because medical practices and conditions of today paralleled practices and conditions of ancient Greece in the era of Hippocrates.' The usefulness of the Hippocratic Oath is attested to in both Protestant' and Roman Catholic statements. John Paul II in the Evangelium Vitae comments on the] still relevant Hippocratic Oath, which requires every doctor to commit himself to absolute respect for human life and its sacredness."
What is it that makes the Hippocratic Oath still pertinent Why did Christians accept the Hippocratic oath as their medical ethic, even though they knew that the Oath was a covenant to the pagan gods? What are the salient features that give the oath its transcendence and value? How have contemporary versions of the oath denigrated it?
The Sacred Triangle of Medicine
The Hippocratic Oath reflects that medical ethics (or any ethics for that matter) are not simply between the patient and the physician. Rather, every interchange involves the triad of the patient, the physician, and God.' This means that certain individuals are ethically excluded. Yet, today, prolific federal regulations governing how we engage in the practice of medicine, and third-party payors' encroachment on the physician-patient relationship have all but destroyed this triad. And, an ever-increasing number of parties vie for space in the counseling room of the doctor's office.
The triad of God-physician-patient does not try to treat society or groups of people. Public pathology is not addressed in the oath nor is it addressed in the Scriptures. When Holy Writ addresses the sins of a nation, they are sins committed by individuals who comprise that nation. Sometimes, the sin of only one person may lead to judgment on a nation. This link seems unjust to us; yet, it is the Scriptures which perfectly define and prescribe justice-not our personal intuition. The Scriptures are replete with examples of leaders as God's representatives. Moses is seen as the judicial representative for the people of Israel before the Lord (Exodus 18:17-27). The nation of Israel was punished when Saul demonstrated disobedience (I Samuel 15). David's sin against Uriah with Bathsheba caused Nathan the Prophet to predict the sword to "never depart from the house of Israel" (II Samuel 12:9-12). Representatives also bring blessing to the nation, as when the Joseph saved the nation of Israel from destruction (Genesis 41-50) by his faithfulness to the Lord.
History reflects in our century that situations where those nations which rose to power but deemed the value of the individual to have less value than the value of the state uniformly led to mass carnage of human lives. The priority and solidarity of the individual stands at the center of Hippocrates' assumptions. The Pythagoreans must have known well the danger of ascribing value to the state at the expense of individuals.
The Hippocratic Oath never attempts to address what might happen to society because of the outworking of the oath. Perhaps, we may attribute this omission to the naiveté of the Pythagoreans or to irreconcilable cultural and technological differences, but we doubt these arguments. Medical care has always been expensive and a drain on the economic strength of individuals and families. There would have been ample ability for Hippocratic physicians to observe this cost in ancient Athens, yet they make no mention of medical economics in the oath. The focus on the oath refuses to lose sight that care of the patient is never subservient to the care that we offer to our society. This focus is entirely consistent with Christian ethical standards.
Statements of confidentiality in the oath support the notion that others who are outside the cultic community of physicians sworn by the creed must not be involved. In the twentieth century, physicians rarely can practice medicine independent of nurses, technicians, aides, and myriad other health-care workers. It is assumed that these individuals are sworn to similar such oaths.
People outside of the Hippocratic cultus have no right to enter, and we are remiss to allow them to do so. As an example, it is not right for physicians to contract with third-party payors, as that is a contract between the third-party payor and the patient alone. Patients are often unaware of the contractual relations that a physician has made with their insurance company that may significantly affect the type of care that they receive. Unfortunately, it is extremely difficult to escape the moral environment constructed for us.
Increasingly, individuals in the health-care community are operating outside the ethically defined community. A study recently published in The New England Journal of Medicine showed that 6 percent of all intensive care nurses confessed in a recent study to euthanizing a patient in their care without any suggested order from a physician.
Hippocrates would not have approved of such assistants!
Medicine as a Covenantal Relationship
The Hippocratic Oath attests to the nature of the interchange between the physician and the patient as one of covenant, not contract. A Covenant recognizes the imbalance of power, especially when a patient is sick. Autonomy, as such, is not an ethical issue but only states a deference of the patient's ethical principles above that of the physicians'. Medical practice in the spirit of Hippocrates depends on the ethic of the physician. The only true answer to the question of autonomy is in the orthodox, Trinitarian view of man. Cornelius Van Til writes of the Father, Son, and Holy Spirit."
Each is as much God as the other two. The Son and the Spirit do not derive their being from the Father. The diversity and the unity in the Godhead are therefore equally ultimate: They are exhaustively correlative to one another and not correlative to anything else.
The triune God is the embodiment of the "one and the many." Van Til states categorically:
"Using the language of the One-and-Many question, we contend that in God the one and many are equally ultimate. Unity in God is no more fundamental than diversity, and diversity in God is no more fundamental than unity. The persons of the Trinity are mutually exclusive of one another. The Son and the Spirit are ontologically on a par with the Father. It is a well-known fact that all heresies in the history of the church have in some form or other taught subordinationism. Similar, we believe, all heresies in apologetic methodology spring from some form of subordinationism.
If there is not an ontological trinity to allow man the ability to be worthy as an independent being with value as being made in the image of God (Imageo Deo), then the state absorbs the individual and reduces him to meaninglessness. As such, Andrew Hacker points out that concepts such as informed "consent," "obligation," and "free" all have different meanings.
"The upsurge of mass-conditioning in this century has spelled the demise of the autonomous man who has been so enthusiastically proclaimed by the liberal theorists. Autonomy may still be reality for the small minority who operate the conditioning processor who manage to escape it. But because the vast bulk of community passively receives the attitudes which are implanted in them, it is necessary for us to recast our thinking about the `individual' in politics. If his mind is not `his own,' the notions which we have inherited from liberal theory must be overhauled or even discarded. Conceptions such as `consent,' `obedience,' `obligation,' `leadership,' `public opinion,' `representative government,' `majority rule,' and even `freedom' must take on new meanings. The traditional definitions which spring from liberal theory may perhaps still hold true for those who plan the conditioning of others. But they are gross malaprops for those whose minds are on the receiving end. And this latter group contains the vast majority of us."'3
So, "in God's being there are no particulars not related to the universal and there is nothing universal that is not fully expressed in the particulars."
Thirdly, as a corollary to the second point, the Hippocratic Oath does not seek a negotiated ethic, nor does it make any attempt to provide medical care in a context or culture that diminishes the ethic of the physician. The Reformed orthodox Trinitarian view of man sees God as sovereign and operates in relationship from covenants. Written creeds and oaths derived from Scripture carry immense importance. The radical discontinuity of God as the omnipotent, absolute ruler of the universe versus His creation is declarative in Scriptures. "God said to Moses, `I am who I am"' (Exodus 3:14).
This covenantal relationship between man and God provides the bedrock upon which the orthodox faith rests as inherently ethical, creedal, and concrete. It is not a negotiated ethic that allows us to change views with majority rule, culture, or attitude. Therefore, the presupposition for the physician (as expressed in his oaths) are manifestations of how he ought to act, and not merely how he writes and speaks. Implicit in the covenantal relation is the notion that if one "breaks covenant," self-maledictory sanctions will be applied. These sanctions rest with God and are not to be nullified by the state. The state should have no interference between the orthodox Christian and his patients. The state is not Messiah.
Sanctity of Human Life
The Hippocratic Oath recognizes the immense value of human life from conception to death. We may wonder how the Pythagoreans clearly saw the dangers of abortion, yet they did. Opposition to abortion in the 1970s is usually attributed to religious zealotism of the Christian faith, yet it was Hippocrates that codified the ethical error of abortion entirely outside of the context of the Judeo-Christian faith. The Oath is consistent with Psalm 139:14-16, where David notes that before his conception or birth he was precious in the mind of God. "All the days ordained for me were written in your book before one of them came to be." The implications of these pregnant words of God are immerse. We see that each person is immanent in the mind of God before his conception, development, and birth. Each day of life is sanctified, ordained, and ordered by the omnipotent God of the universe. God reserves the right to Himself to "write" our days in His own book.
His declaration negates abortion, infanticide, suicide, and euthanasia, because all seek to abrogate God's solitary prerogative of ordering our days for us. The ultimate sin is the idolatry of "becoming like God" seeking to overturn His written days commanded for our lives. Hippocrates was right. Godly physicians must not murder their patients.
Cultus of Physic
The Hippocratic Oath established a cultus of physicians sworn and bound by it. The oath was taken as one entered medical school, not when one completed it. It impelled the physician-asteacher to instruct only those students sworn to uphold the oath. It was restrictive and intolerant of ethical variance in the medical community. We may see the parallels in the Christian medical ethic with the covenantal nature of the relationship with Israel (Deuteronomy 27 and 28).
"However, if you do not obey the Lord your God and do not carefully follow all His commands and decrees I am giving you today, all these curses will come upon you and overtake you" (Deuteronomy 28:15).
The Israelites demonstrated their love of God by obeying His law. They made "covenant" with God in Deuteronomy 26 (offerings), Deuteronomy 27 (blessings and cursings), and Deuteronomy 29 and Joshua 24 (renewal). Moses and Joshua stood as the national representatives before God, demonstrating the transcendence of God as sovereign, His hierarchy with Godly leaders being shepherds of the flock, His law as His immovable ethics, His invocation by the people of the self-maledictory oath (Joshua 24:14-27), and His sanctions for His people who refused to obey (Deuteronomy 27 and 28).
Physicians sworn to an oath could be relied on to be trustworthy. However, we are now considered to be guilty until proven innocent. Medicare and insurance companies ask physicians to define the patient's disease (ICD-9 code) and their professional interaction with a patient as simply a number that quantifies the intensity of the event (CPT code). This quantification misses entirely a substantive portion of the physicianpatient interchange. To accidentally mis-codify such an interchange can now be deemed medical fraud punishable by imprisonment. With such impositions, Islam seems rather kind when they offer the punishment of upper extremity amputation for untoward results-at least one could then collect disability insurance! Without an ethical code, physicians cannot be assumed to maintain personal integrity and must be assumed to be guilty.
Encouragement of Specialization
The Hippocratic Oath established realms of competence that supported the art of subspecialization. Note the statement that the physician would not practice surgery, but yield to those competent in that art. The authors are both subspecialty physicians and believe that our practices must not exceed that of our own comfort or range of expertise. Today, however, physicians are often compelled to exceed their general level of competence for the sake of saving costs. With capitated care, any referral to a specialist leads to decreased reimbursement for the referring physician. Thus, there is reservation in seeking the assistance of those physicians known to possess greater expertise in a given area of medicine.
The oath carried anathemas against those physicians who violated the oath. Oath violators were excluded from the cultus of physicians and thus lost their means of livelihood. This penalty forced the practitioner to realize that he was being held under the surveillance of a greater judge; that is, the judge of the universe. Those things done in secret eventually would eventually become known! In the Bible, Nathan the Prophet rebuked David and let him know that his secret sin of adultery and murder soon would become public knowledge (11 Samuel 12). Absalom publicly displayed his contempt for the Law of God and His father by having sex with his father's concubines in full view of Israel (II Samuel 16:21-22). The sins of a leader bring tragedy on the whole nation with civil war, murder, and intrigue.
Christian Medical Ethics: What is it?
What is the purpose of ethics? Why do we feel morally compelled to act in an "ethical" fashion? Why are there numerous textbooks detailing fine minutiae about our moral obligations and restrictions? What does the Christian want to accomplish when he thinks about ethics? The Christian ethic should be quite different than a secularly derived ethic, as the basic goal for a Christian is to please and serve God. This commitment results in a different starting point, a different process, and a different ending point for the Christian than the secular ethicist.
Ethics do not exist in a vacuum. Any ethic presumes a certain cosmology and epistemology. If our world view considers the "cosmos as all there is, or ever will be,''' an ethic will reflect that limitation. If epistemologic presuppositions state that it is impossible to know universal absolutes, that ethic will be quite different from one that supposes absolute truth to be knowable.
Professional ethicists have the distinction of providing lengthy, verbose, obtuse, and terminologically obscure wording to their answers of right or wrong. Yet, these explanations are often rationalizations that prevent the inquisitive person from probing deeper and harder as to how one knows whether a certain action is right or wrong. Is it ultimately a societal convention? Is it nothing more than the "gut-feeling" of a trained ethicist? Can ethics be discovered solely by rational inquiry? Are there innate "natural laws" that govern our sense of morality and must be followed Or, does ethics demand a propositional statement from an absolute and infinite being?
The "natural law" argument suffers from just that problem. The attempted synthesis of Christianity with classical (Aristotilean or Platonic) logic and ethics pollute the purity of the Word of God. Thomas Aquinas attempted to reconcile the writings of the pagan philosophers by "Christianizing" them in different terms. Unfortunately, when attempts are made to mix the leaven of humanism with the leaven of Christ, we end up with a spoiled loaf.
The answer to the ultimate question of "how do we know what is right and wrong" centers again on presuppositions. Paul writes "For since the creation of the world God's invisible qualities-his eternal power and divine nature-have been clearly seen-being understood from what has been made, so that men are without excuse" (Romans 1:18-32). The created world around man cries out that God is sovereign creator. His laws, written in His Word, form the objective basis upon which to develop an ethic. In 11 Timothy 3:16, Scripture is described as being "God-breathed and is useful for teaching, rebuking, correcting and training in righteousness, so that the man of God may be thoroughly equipped for every good work." How else do we know what Christian ethics are or what good works are? We orthodox physicians must have the full knowledge of the Word of God as our immutable, perspicuous source of truth in a world wont to be blown about by each whim and fancy that comes its way.
Perhaps, a critical review of some contemporary solutions for "doing ethics" will be helpful.
Critique of Beauchamp and Childress
Beauchamp and Childress" offer us a broad summary of the current secular'' ethical systems at large in the introductory chapters of their text on medical ethics, now in its fourth edition. The various ethical theories covered include utilitarianism, Kantian-deontological theory, character ethics, rights-based theory, ethics of caring (feminist ethics), casuistry, and principle-based, common-morality theories. Beauchamp and Childress state themselves to be eclectics, using each of the various theories as they are deemed most appropriate to a given ethical dilemma. The authors contend that they have derived general ethical principles which are self-evident and will provide guidance to select the best ethical system for the moment. They state, "We start in ethics, as elsewhere, with a particular set of beliefs-the set of considered judgments (also called self-evident norms and plausible intuitions) that are acceptable initially without argumentative support."" They discuss the need to have some sense of internal logical consistency to their theory (coherence) and universalizability to their ethical system. One then "specifies" which principles are applicable to a given moral dilemma. When various principles are in conflict, one "balances" various conflicting norms to derive a specific ethical judgment.
What are the problems with the system of ethics of Beauchamp and Childress? First, they assume that there really are self-evident ethical principles that universally govern mankind. They are not proposing a natural law ethic, as they do not even discuss natural law ethics. Their universal "laws of mankind" differ from that of the natural law ethic in that the ethical principles of Beauchamp and Childress are not inviolate--contrary to natural-law ethics. But, as they proceed to propose universal innate principles of ethics, they do not state either the nature nor character of these self-evident principles.
If there are self-evident principles that are not culturally or religiously influenced, are universal, and are plain to all men, then, what are they? List them! They do not reveal the nature or character of these self-evident principles. They do not admit that there would be no universal agreement as to exactly what these basic intuitive ethical principles are, nor exactly how they are derived. In essence, they take an "emotive" stance, the tacit assumption that they themselves are the ultimate reference point for basic principles. The real problem with Beauchamp and Childress is their intellectual dishonesty and unwillingness to define exactly how they derive their ethic. Somehow, we believe that right and wrong are unknowable, indefinable, and not absolute but that we'll know right and wrong when we see it. Their position smacks of "outcome-based ethics" where the outcome result is based on what or how you feel about a moral action. Realistically, this approach makes as much sense as attempting to say that "gravity is unknowable" so we can treat it anyway we want. So, if you jump off that cliff, all that matters is how you feel about gravity when it affects you. Christ on the other hand is quite clear when He says, "If you hold my teaching, you are really my disciples" (John 8:31).
The reluctance of Beauchamp and Childress to admit their dilemma is understandable. Alisdair MacIntire states
"What emotivism however did fail to reckon with is the difference that it would make to morality if emotivism were not only true but also widely believed to be true... Emotivism [implies] a theory of meaning-that the prestige derives from the fact that the use of `That is bad!' implies an appeal to an objective and impersonal standard in a way in which `I disapprove of this, do so as well!' does not. That is, if and insofar as emotivism is true, moral language is seriously misleading and, if and insofar as emotivism is justifiably believed, presumably the use of traditional and inherited moral language ought to be abandoned."19
The second problem with the ethics of Beauchamp and Childress is their inability to form a solitary principle of ethics. The appeal for eclecticism states only that individual judgment remains the over-arching ethical agent which determines which "subsystem'' of ethics will be used in a particular situation. But, what principles, laws, facts, or guidelines govern this judgment? Eclecticism is an unacceptable means of hiding the fact that there is some greater principle or system in operation that gives one the ability to choose the type of ethics he will use in a particular situation. They continually speak of a "common morality" and a basic "convergence" across the various ethical theories, but we are never left with a formal basic universal unifying ethical theory that would govern our actions.
The third and most serious problem with the ethic of Beauchamp and Childress relates to their complete silence on the possibility of a transcendent ethic. It is not that the authors are unaware of any existent transcendent theoriesChildress edited an encyclopedia of Christian ethics. Yet, the words "God," "theistic ethic," "Christian ethic," "Biblical ethic," "Ten Commandments," or any of the words that would define the formerly prevailing Western ethic, whether it be Jewish, Christian, Muslim, or Hippocratic, are entirely missing. Why this oversight? We consider it intentional deceit that any form of transcendent ethic was not even mentioned in the text of this book. For a Christian, transcendence must be, and we repeat, MUST be our starting point. The Christian ethicist posits that a natural ethic (natural law) is itself derived from God and is universal, while it is incomplete (rather, we should say, fallen, and often either in error or not entirely revealing our total moral duty), but subservient to a revealed ethic, as found in the Scriptures of the Bible.
Critique of Hauerwas
Stanley Hauerwas20 provides us a different approach to ethics. He argues for a Narrative ethic, in which the stories that define a culture provide the moral basis for actions, and subsequent actions seek to remain true to the narrative base of that community. Thus, in Christian culture, we have the narratives of the Bible to provide us with examples of love, community, altruism, and caring that would allow us to create similar narratives in today's society. Hauerwas shies away from calling any particular narrative as normative. The narratives only witness to what a good person or a good community would do in similar circumstances. Hauerwas would not legitimately be classified as a casuistrist, as he would argue that ethical principles develop out of various narrative cases, which is something the theory of casuistry would object to.
Is it possible to be a strict Biblicist" and yet provide contemporary answers to problems that never existed even a few years ago, such as the issue of in vitro fertilization? We contend for an ethic derived entirely from a Biblical base." While rational means alone is entirely inadequate to achieve moral guidance, but rational dunking from a Biblical base is the ultimate in ethics. Thus, when many Christian ethicists attempt to derive an ethic based on intuitive virtues, natural law, or the like, they are giving an incomplete and unreliable statement as to what is morally good. How does one balance the various virtues? What really is a virtue? Why is it a virtue, for example, to be courageous? Courage can be costly at times! What about the most important commandment that Christ gave, to love God with all of your mind, soul, and strength? Is love for God irrelevant to the moral life of an individual? The Bible provides details of proper Christian character, but these characteristics all center around the steadfast obedience to the revealed moral law-patience, longsuffering, self-control, Godliness and other desirable Christian characteristics, all of which cannot be interpreted independent of a prevailing moral law. For example, what is the meaning of self-control? It is abstaining from various moral sins as defined by statements God Himself has made concerning what is morally offensive to Him. What is Godliness? It is adherence to behaviors defined in moral laws obtained by propositional revelation.
Why is there a necessity for obedience to a moral law in the "age of grace"? Much confusion stems from the appeal for a qualitative or quantitative difference between God's actions and expectations for man in the New Testament as compared to the Old Testament. The Reformers rightly noted that God's demands and interactions with man were no different in either Testament. His command to be "holy as He is holy" states His desire for mankind to behave in a fashion consistent with the intrinsic ontologic nature of Who He is. The character of God is only partly revealed in nature. God must otherwise tell us about himself and describe His character. This fact can come only from revealed knowledge communicated to man from God, and this claim is exactly the one made by the Scriptures. Since the character and ontologic nature of God has not changed between the Old and New Testaments, we should neither presume that our manner of behavior is expected to be any different.
Might a Christian get guidance from ethical systems other than a strictly Biblical ethic? Can we serve as eclectics and glean from the best of various secular ethical systems? Can we provide a Christian basis for a secular ethic and thus give secular ethics a proper Christian orientation? Can we speak of consequentialism in the light of a Christian ontology? Does the "caring" that comes from feminist ethics resemble that of Christian "love"? We would answer in the negative to all of these questions, for reasons we gave previously. There is such a cataclysmic difference in the way we and secular ethicists would proceed that the areas of similarity are only coincidental, and not substantive.
The use of secular terms in a Christian ethic runs a
great risk of confusing matters. For, does concern about the future, such as
our desire for Heaven make our thinking consequentialist in nature? It is true
that we speak of final consequences of our actions, but without an eschatology,
consequentialism deteriorates. Our actions are not calculated in terms of proximate
outcomes, but rather in terms of duty to the one who defines and commands those
actions. To state it another way, our motive is to glorify God, not to achieve
favorable outcomes. Thus, consequentialism has a subservient role in the Christian
ethic. We worry about ultimate outcomes, but behavior is not defined consequentially.
A review of some contemporary oaths gives perspective to a Biblicalmedical ethic. There have been several attempts to put the Hippocratic Oath into a modern parlance or to provide an alternative to the Hippocratic Oath. Because of the large number of oaths and modifications of previous oaths, we cannot address all the ethical formulae in existence. We even purposefully leave out some older oaths, such as the Oath of Maimonides, not because it is irrelevant, but because it doesn't contribute to the current thrust of this paper and is not as widely used by any major medical group as the ones we have selected for discussion.
Medical Oath of Geneva
The Oath of Geneva was written following World War II as a reaction to Nazi atrocities, including the termination of the lebenunwertes Leben or "life unworthy of life." These "unworthy" lives included the mentally handicapped, insane, and genetically inferior peoples, but also developmentally handicapped infants and people who lacked serious potential for the "good" of society.
This oath lacks dimension and ethical tenacity, as compared to the Hippocratic Oath that fathered it. The Oath of Geneva is an entirely secular oath, with no obligations of the physician or the patient to an infinite, personal Christian God. Instead, loyalty is pledged to "humanity," the twentieth-century god. The triad of God, patient, and physician becomes the triad of patient, physician, and society. This Oath supports the notion that the work of the physician is to treat societies rather than individuals, encountering the problem of the one and the many again.
The Genevan Oath insists on an utmost respect for human life, but the meaning of that is left arbitrary. Physician-assisted suicide, abortion, euthanasia, and other immoral activities of physicians fail to be proscribed overtly in the Genevan ethic. Can utmost respect for life be interpreted ending the suffering of my mother with a deadly cocktail? In this oath, it might be. There is a plea not to act contrary to the "laws of humanity," without giving one a clue as to what those laws may be. The Genevan Oath certainly is not an appeal to the idea of a natural law nor to the Laws of God. It fails to identify a transcendent ethic into which patients and physicians can enter.
Most importantly, the oath lacks color. This is a complaint I'm going to wage against other oaths under discussion. Words are important, and how we say our creed must be crafted with extreme care. It is typical of human nature to find the loopholes or exceptions to an ethical statement to justify a behavior. Our fallenness can never produce an ethical statement of the color, succinctness, or nature of the Holy Scriptures themselves. Our summaries must be written with extreme care so as not to allow what the Word of God itself does not allow. The natural read of the Hippocratic Oath, the sense of elegant prose, and consistent but definite terminology is not used in the Oath of Geneva. It is too terse. There is not the deliberate prose of "my colleagues will be my brothers" in the Hippocratic Oath, which forces one to view the oath in a wholistic, inclusive manner. The breath, pulse, and life of the Hippocratic oath were mortified in this pallid statement of humanitarian thought, however well-intentioned!
AMA Principles of Medical Ethics
An ethically reduced version of the Genevan Oath can be seen in the document the "American Medical Association (AMA) Principles of Medical Ethics." It is difficult to say much about this "oath" since it deviates far from both Scriptural principles and from ethical standards of the Hippocratic Oath. The AMA readily acknowledges an unwillingness through this Oath to declare any absolute proscriptions. Indeed, a brief glimpse through the oath demonstrates that nothing is absolutely forbidden. Virtue is prescribed in principle, but not as a law or duty. Evidently, this oath is an overt attempt to achieve a pure rule, not based upon acts, but principles of love and caring. It fails to proscribe acts of dishonesty, immorality, and incompetence. By so doing, it leaves the creedal adherent open to any possible act. For example, if the "best interest" of the patient is for the physician to tell a lie to him, not lying would be immoral for the physician. It is essentially a nonethic.
Principle II asks for exposure of those physicians who are deficient in character. We have never met a physician not "deficient in character," save for the Great Physician. There is no explanation which "character traits" would be lacking to cause a physician to be deficit or to what extent these character traits might influence our practice as physicians. Is the AMA suggesting that there are certain virtues that are demanded to be a physician of "character"? If so, name them!
Principle IV asks physicians to "respect the rights of patients." Which rights? The right to an abortion? The Hippocratic Oath never addresses the rights of the patient nor takes any consideration for patient autonomy. The AMA oath establishes the patient as the defining source of the ethic in any medical interchange, but physician moral principles must not play to the will and whim of the patient.
Compare the AMA Principle IV dictum to "safeguard patient confidences within the constraints of the law," versus the Hippocratic dictum that "whatever, inside or apart from connection with my professional practice, I see or hear in the life of men that ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret." Which physician would you be more likely to trust with confidential information, the AMA physician or the Hippocratic physician? The AMA script places medical ethics subservient to laws of the land. But, those laws are often wrong, since state laws are never perfectly consistent with the laws of God." Hippocrates did reference the Athenian courts to establish his ethic. He saw his ethic as derivative of higher powers, the law of "the gods." We must reference God Himself through His Word.
Principles III and VI seem to be concerned about government al interference with our practice of medicine. Again, we would hope that a medical ethic would transcend any political dogma and be just as applicable in mainland China or Cuba as it would be in the United States of America. The AMA has trivialized their ethic by politicizing the content of the medical ethic and has erased the timeless domain of the Hippocratic Oath by reducing medical ethics to contemporary political concerns. If God is not God, then only the state remains as our Messiah.
Finally, Principle VII states that a medical ethic must take into account society at large. It gives no account as to how the physician weighs the importance of the individual in relation to the importance of society, especially when the two are at odds with each other. The abrogation of the individual's ethics in principle VII leaves patients and physicians at the mercy of the state. Again, there is the problem of the "one and the many" rearing its head again with the State as savior. How may ethics exist when solely defined by the expediency of the society and not by the unchangeable Word of God? Of necessity, the presuppositions which undergird society's laws and codify its ethics must define the behaviors that a society will and will not tolerate. If the laws themselves are not based on inviolate principles, how may the physician know what is legal for the patient is also "good" for the patient? How may we talk about individuals if their beliefs may be trivialized and ignored by the arbitrary might and will of the State? The Hippocratic Oath recognizes no obligation to society at large except to train progeny who will also ply the trade of medicine with strict ethical principles.
Oath of the Christian Dental and Medical Society
Religious groups have also considered replacement oaths. One example is the oath of the Christian Medical and Dental Society, a group of (mostly Protestant) Christian physicians in the United States and Canada. While this oath maintains merit for calling physicians to a medical practice founded on Biblical principles, there are several dominant weaknesses to the oath compared to the Hippocratic Oath.
First, sanctions are missing. There are no consequences for violating the stipulations of this Oath. This oversight is in keeping with modern attempts to blunt the negative aspects of any moral statement, keeping the overall tenor of the moral injunction in a positive light, hoping to encourage the prescribed behaviors.
Second, as with the AMA ethic, this oath implies a contractual relationship to society at large, a situation which is inappropriate for the special relationship a physician must maintain with his patients. The CMDS oath contains an ill-defined contract to care for the poor and lonely. The oath asks us to be concerned about societies' resources, which suggests that we must approach every patient with the effort to reduce services in a rationed fashion. The concept of rationing and preservation of resources that are renewable and expandable is contradictory. This concept of rationing might apply to transplantation, where there are a limited number of available organs. It does not exist in most of medicine, where the only limiting factor for care is economics. Concern for the poor should be present in everyone, yet, it is not relevant to the care of a an individual patient. It should not be mentioned in an oath.
Third, the CMDS Oath, while in some sense resembling the Hippocratic Oath, betrays sense of a cultus of physicians. For example, it omits proscriptions against matters such as confidentiality and sexual involvement with patients. These omissions leave the CMDS Oath with a sense of incompleteness. It is not an Oath that encompasses all of the dominant ethical problems of medicine.
Finally, reading the CMDS Oath against the Hippocratic Oath demonstrates a missing literary and cognitive dimension. The CMDS oath fails to maintain the bite and punch of the Hippocratic Oath necessary to be a convincing statement of resolve demanded of an oath.
In 1995, the Value of Life Committee engaged the assistance of a number of scholars to produce an oath that we will call the "Value-of-Life Committee" Modification of the Hippocratic Oath (VLCMHO). While this version is an excellent example of a modern change in the oath, there are still certain problems.
First, is it not strange that such an oath is copyrighted We are sure that Hippocrates gave no thought to copyrighting his oath. Does the committee intend to profit off of the success of this statement that is legitimately valid universally because it is an ethic that is transcendent, founded on an infinite deity? Do they expect that copyrighting the oath will protect it from perversions? We do not know the answers to these questions.
Second, there is a lack of clarity to the oath. 1) The oath is directed to a generic god (the Almighty). Are we offended by insisting on the Biblically revealed God as the only designation of Gods Do we really feel that inclusiveness of pagan deities is necessary to accomplish our statement Would Elijah on Mount Carmel have any issue with sweet-sounding statements of generic gods (I Kings 18:1640)? Our unwillingness to state clearly that our ethic demands an infinite personal God found only within the confines of the Scriptures of the Old and New Testament will truly be our undoing.
2) Statements on medical research lack clarity. In particular, the oath suddenly calls for patient autonomy. Autonomy is foreign to the Hippocratic Oath and to Christian ethics. "I will neither treat any patient without the valid informed consent of the subject or the appropriate legal protector thereof' implies that we can render truly informed consents. But, those who work in research understand that you could never do that legitimately. Does the patient understand fully and comprehensively the nature of the experiments? What degree of understanding does a patient require to make a decision to enter a research protocol? Can a patient make an autonomous decision during a life-threatening illness that leads him to consider a research protocol? Does such a statement hold the physician ethically bound to offer research protocols for the alleged benefit of future patients? We are not attempting to denigrate medical research, but we are implying that (in the spirit of Hippocrates) physicians should engage in medical research only under the aegis of a cultus of doing the best for the patient. When the physician does not know what is best, he should so inform the patient and propose a treatment, even though it be formulated by a random method. The short statement in the VLCMHO does injustice for a full ethic of research in a Hippocratic tradition.
Third, the oath is unclear on endof-life issues. This oath was formulated, in part, as a reaction to various contemporary attempts to state the oath in a manner that accepts abortion, euthanasia, and physicianassisted suicide. Yet, "omission with direct intent deliberately to end a human life" attempts to define clearly ethical areas that are not so simple in real life. Do they deny the possibility that a physician may withdraw treatment to allow a patient to die naturally? Are we as physicians allowed to turn off a ventilator when we see no hope for the patient maintained on one? Are we allowed to withhold treatments when all we do is prolong comatose or exceedingly painful life? Hippocrates was silent on such issues for good reason. The Christian faith maintains that all life is in God's control, and thus is not ours to determine. Yet, we are not ethically bound to medically maintain the life of a patient. We must assume only that withdrawal of treatment in hopeless circumstances is done, not for the sake of society, or for means of purposely terminating a life for no other reason. The Value-of-Life Committee probably meant to include the possibility of "passive euthanasia" yet failed to do so.
Fourth, the VLCMHO contains undefinable statements, when interpreted outside of a Christian culture. An example is the word "beneficence." Do they assume a common good, true to all people? Do they assume that common law intrinsically defines what is good and bad? If so, there would be no need for the Hippocratic Oath, or any oath for that matter. Since the purpose of an oath is to define what the "good" is, to desire the beneficence of a practitioner of medicine is a failure to understand that purpose.
Finally, like many of the other restatements of the Hippocratic Oath, it lacks the literary color, transcendence, and timeless wording of the original oath. It changes too much of the original oath to be a legitimate restatement of it.
Christian Version of the Hippocratic Oath: Authors' Modifications
The need for a substantive Christian oath is apparent, leading us to write a Christian version of the Hippocratic Oath. It was desired to maintain the wording of the Hippocratic Oath as closely as possible, while rewriting it within a Christian context. The reasons for this are several. First, the Hippocratic Oath is a universally familiar oath and so needs no explanation in the secular medical community.
Second, the oath maintains a wording and sense of dignity which transcends time. Indeed, it is so well written that Christians still heartily ascribe to it, even though originally written in a pagan context.
Third, the oath establishes a creedal community, clearly defining the behavior of physicians abiding by the oath versus those outside the community.
Fourth, it is an ecumenical oath, applicable to all Christian orthodox confessions, whether Roman Catholic, Eastern Orthodox, or Protestant. It is deliberately exclusive of non-Christian faiths. With minor modifications, it might be applicable to non-Christian confessions as a common ethic for medical care. Though we appreciate the co-belligerency of non-Christian enthusiasts of a Christian morality, the nature of ethical truth demands an orthodoxy that, if altered, will irreparably alter the derivative morality.
Finally, it is an oath with punch. The reader is left no doubt about the commitment of the oath-taker to a moral, upright practice of the art of medicine in the Christian tradition.
The Hippocratic Oath was modified in order to keep the substance and meat of the original oath, while restating the oath from a Christian mindset and worded to obtain contemporary cultural relevance. All aspects of the oath could be sworn to without reservation or explanation by those of a Christian persuasion. There are four specific modifications. First, the Oath addresses the One Triune God. Second, various medical practices are reworded to reflect modern medicine, such as using a pessary to induce an abortion.
Third, the original Oath restricted instruction in medicine to those sworn by the oath. The modified Oath recognizes that it would be difficult and undesirable to separate Christian physicians from academic pursuits in secular institutions, but it demands that the physician teach the Hippocratic ethic along with instruction in the art of medicine. We are not saying that we don't desire medicine to someday be practiced in the community with a closed ethic. This situation may be forced upon Christian physicians whether we desire it or not.
Finally, the modified oath recognizes that the treatment of the body from the treatment of the soul cannot be separated. Thus, the oath encourages the physician to lead the patient into a greater reverence for the Creator and giver of life.
The Evangelium Vitae calls health-care personnel to the unique responsibility of being the guardians and servants of human life. The batde to which we are engaged is argued in the encyclical letter as paramount in importance, since our society has lost all sense of value for human life. As Christian physicians, our statement must clearly state that human life is a most special gift of God, since each person is made in God's own image. Secular society has so trivialized the medical oath as to reduce it to an irrelevant status. It is no wonder that few medical schools now call on their graduates to say an oath of ethical intent. If an oath is used in American medical schools, it is most commonly the Oath of Geneva or a derivative of the same. We propose that the modified Hippocratic Oath serve the purpose of uniting the Christian health-care community under a common creed in support for life.
Dr. Kenneth A. Feucht is a surgical oncologist and ethicist from Puyallup, WA.
Dr. Byron Calhoun is a maternalfetal medicine/high-risk obstetrician and ethicist from Tacoma, WA, and president of Association of Pro-Life Obstetricians and Gynecologists.
Special thanks to Rev. Dick Bouma for constructive criticisms of the text.
AMA Principles of Medical Ethics
Preamble - The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility not only to patients but also to society, to other health professionals, and to self. The following Principles adopted by the American Medical Association are not laws but standards of conduct which define the essentials of honorable behavior for the physician.
I. A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity.
II. A physician shall deal honestly with patients and colleagues and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception.
III. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
IV. A physician shall respect the rights of patients, of colleagues, and of other health professionals and shall safeguard patient confidences within the constraints of the law.
V. A physician shall continue to study, apply and advance scientific knowledge, make relevant information available to patients, colleagues and the public, obtain consultation, and use the talents of other health professionals when indicated.
VI. A physician shall, in the provision of appropriate patient care except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services.
VII. A physician shall recognize a responsibility to participate in activities contributing to an improved community.
Oath of Geneva
I solemnly pledge myself to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude which is their due;
I will practice 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 honor and the noble traditions of the medical profession;
My colleagues will be my brothers;
I will not permit considerations of 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 honor.
CMDS Christian Physician's Oath
With gratitude to God, faith in Christ Jesus, and dependence on the Holy Spirit, I publicly profess my intent to practice medicine for the glory of God.
With humility, I will seek to increase my skills. I will respect those who teach me and who broaden my knowledge. In turn, I will freely impart my knowledge and wisdom to others.
With God's help, I will love those who come to me for healing and comfort. I will honor and care for each patient as a person made in the image of God, putting aside selfish interests.
With God's guidance, I will endeavor to be a good steward of my skills and society's resources. I will convey God's love in my relationships with my family, friends, and community. I will aspire to reflect God's mercy in caring for the lonely, the poor, the suffering, and the dying.
With God's blessing, I will respect the sanctity of human life. I will care for all my patients, rejecting those interventions which either intentionally destroy or actively end the lives of the unborn, the infirm, and the terminally ill.
With God's grace, I will live according to this profession.
Passed by the CMDS House of Delegates May 3, 1991, Chicago, Illinois.
Original Hippocratic Oath
I swear by Apollo the Physician, by Asclepius, by Hygeia, by Panaceia, and by all the gods and goddesses, making them witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.
To regard my teacher in this art as equal to my parents: to make him partner in my livelihood, and when he is in need of money to share mine with him; to consider his offspring equal to my brothers; to them this art, if they require to learn it, without fee or indenture; and to impart precept, oral instruction, and all the other learning, to my sons, to the sons of my teacher, and to pupils who have signed the indenture and sworn obedience to the physician's Law, but to none other.
I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them. I will not give poison to anyone though asked to do so, nor will I suggest such a plan. Similarly I will not give a pessary to a woman to cause abortion. But in purity and in holiness I will guard my life and my art. I will not use the knife either on sufferers from stone, but will give place to such as are craftsmen therein. Into whatsoever house I enter, I will do so to help the sick, keeping myself free from all intentional wrong-doing and harm, especially from fornication with woman or man, bond or free. Whatsoever in the course of practice I see or hear (or even outside my practice in social intercourse) that ought never to be published abroad, I will not divulge, but consider such things to be holy secrets.
Now if I keep this oath and break it not, may I enjoy honor, in my life arid art, among all men for all time; but if I transgress and forswear myself, may the opposite befall me.
(Taken from January 1996 First Things)
I SWEAR in the presence of the Almighty and before my family, my teachers, and my peers that according to my ability and judgment I will keep this Oath and Stipulation:
TO RECKON all who have taught me this art equally dear to me as my parents and in the same spirit and dedication to impart a knowledge of the art of medicine to others. I will continue with diligence to keep abreast of advances in medicine. I will treat without exception all who seek my ministrations, so long as the treatment of others is not compromised thereby, and I will seek the counsel of particularly skilled physicians where indicated for the benefit of my patient.
I WILL FOLLOW that method of treatment which according to my ability and judgment I consider for the benefit of my patient and abstain from whatever is harmful or mischievous. I will neither prescribe nor administer a lethal dose of medicine to any patient even if asked nor counsel any such thing nor perform act or omission with direct intent deliberately to end a human life. I will maintain the utmost respect for every human life from fertilization to natural death and reject abortion that deliberately takes a unique human life.
WITH PURITY, HOLINESS, AND BENEFICENCE I will pass my life and practice my art. Except for the prudent correction of an imminent danger, I will neither treat any patient nor carry out any research on any human being without the valid informed consent of the subject or the appropriate legal protector thereof, understanding that research must have as its purpose the furtherance of the health of that individual. Into whatever patient setting I enter, I will go for the benefit of the sick and will abstain from every voluntary act of mischief or corruption and further from the seduction of any patient.
WHATEVER IN CONNECTION with my professional practice or not in connection with it I may see or hear in the lives of my patients which ought not be spoken abroad I will not divulge, 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 and science of medicine with the blessing of the Almighty and respected by my peers and society, but should I trespass and violate this Oath, may the reverse be my lot.
Value of Life Committee, Inc.
Christian -Hippocratic Oath
I swear by Almighty God, creator of heaven and earth and creator of man in His own image, that according to the ability and judgment given to me by Jesus Christ His Son through the Holy Spirit, I will keep this Oath and its stipulation. I will reckon him who taught me this Art dear to me. By precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art of Medicine, entreating my pupils by word and example to practice medicine bound by this oath and its stipulation.
I will only practice medicine commensurate with my skill and training, and will seek to continue to improve my knowledge and skills to best serve my patients.
I will follow that system of regimen which, according to the ability and judgment granted to me, 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 prescriptions or treatments which produce an abortion, save for the life of the mother.
With purity and with holiness according to the Holy Scriptures I will order my life and practice my Art into whatever circumstance I enter or wherever I encounter those seeking my care, I will go for the benefit of the sick, and I will abstain from every voluntary act of mischief and corruption; and, even further from the seduction of either females or males.
I will always seek to promote a reverence for the Creator of Life in the lives of my patients, prescribing for them the need to love God in all circumstances and to obey His ordinances and commandments. Whatever, inside or apart from connection with my professional practice, I see or hear in the life of men that 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 the Lord God grant me the power to enjoy life and to practice this Art respected by all men, in all times. But should I trespass and violate this Oath, may the converse be my lot.
1. Kelley J.N.D, Early Christian Creeds (Longman, New York- 1972
2. Schaff, Philip, Creeds of Christendom (Baker, Grand Rapids 1931).
3. Hendriksen, William, The Gospel of Matthew (Baker, Grand Rapids: 1973), pp. 306-309.
4. See the Westminster Confession of Faith, Chapter XVI.
5. Copleston, Frederick, A History of Philosophy (Doubleday, New York 1946), pp. 29-37.
6. There is some debate as to the actual existence of Hippocrates, Such a discussion is irrelevant to the thesis of this paper. We will simply assume the historicity of such a person. If Hippocrates as a person did not exist, it would not diminish the argument, since the Pythagoreans all embodied the Hippocratic ideals.
7. Payne, Franklin E., "The Oath of Hippocrates: Ls It Relevant?," Medical Sentinel, March-April 1998, pp. 49-56.
8. John Paul II (Vatican City, Lib. Ed. Vat., 1995)
9. DeCameron, Nigel M., The New Medicine (Crossway Wheaton, Illinois: 1991).
10. Asch, DA, "The Role of Critical Care Nurses in Euthanasia and Assisted Suicide," The New England Journal of Medicine, 334:1374, 1996.
11. Cornelius Van Til, Apologetics, (Philadelphia Presbyterian and Reformed Publishing Co, 1953), p. 8.
12. Cornelius Van Til, The Defense of the Faith (Philadelphia: Presbyterian and Reformed Publishing Co, 1955), p. 42
13. Andrew Hacker, "Dostoyevsky's Disciples: Man and Sheep in Political Theory," The Journal of Politics, November 1955, p. 613.
14. Van Til, Defense of the Faith, p. 43.
15. Taken from Carl Sagan in his Cosmos series.
16. Beauchamp, Tom, and Childress, James, Principles of Biomedical Ethics (Fourth Edition), (Oxford U. Press, New York: 1994).
17. Childress claims to be a Christian ethicist. We define secular ethics by its starting point, whether it be of origin in the mind or in the Scriptures.
18. Ibid., p. 24.
19. MacIntyre, Alasdair, After Virtue, (Notre Dame Press, Notre Dame: 1984
20. Hauerwas, Stanley, A Community of Character (Notre Dame Press, Notre Dame: 1981).
21. A person who bases ethical systems
strictly on Biblical grounds.
22. We would not specifically call it a "Christian" ethic, since any ethic applies to all people, everywhere, at all times.
23. Lifton, Robert J. The Nazi Doctors (Harper Collins, New York 1986.
24. State law and God's law should co-inside, but they do not.
Copyright © 2003 BMEI, Inc.