Introduction

Medicine, as a profession, must communicate to the outside that its members share similar moral principles and ensure compliance. In order to gain trust from patients, the medical profession must convince all, even potential patients, that in case of illness, they can expect a certain behaviour from members due to them practicing a profession, that prioritises the well-being and protection of patients. This necessitates certain binding rules for the members of the profession (Medical Professionalism Project 2002; critical to this role of the profession is Veatch 2012).

For this purpose, the medical profession frequently resorts to the Hippocratic Oath. It does so with some pride as no other academic discipline can refer back to a moral code of comparative age. The Oath is over 2400 years old. For many doctors it still epitomises the profession’s ethos (e.g., Mattli et al. 2016; Marketos et al. 1996; Qidwai 2004). Its validity, however, has come into question and in 1948 the World Medical Association adopted the Declaration of Geneva (The Physician’s Pledge), last amended in 2017. In content and form it undoubtedly places itself in the tradition of the Hippocratic Oath and was even termed “The Modern Hippocratic Oath” by the WMA in the past (World Medical Association). In the following, both documents will be compared in terms of content and origin. Their relevance for current medical practice is investigated. Which status is ascribed to these documents and which status can they reasonably claim to have? In particular, arguments that rely on historical stability or historical origin are being examined. Finally, the question is addressed: should doctors swear the Hippocratic Oath or the Declaration of Geneva?

The Hippocratic Oath

Hippocrates (460–375 bc) contributed to the exceptional importance the Hippocratic Oath has had throughout time, but, most likely, it wrongly bears his name. Scholars assume the Oath was not in fact formulated by Hippocrates (Leven 2018), however, determining its origin more closely is problematic. A frequently cited but not wholly uncontentious theory states that a group of fourth century Pythagorean doctors developed the Oath (Edelstein 1943). In the course of time the Oath was incorporated into the most important medical work of antiquity, the Hippocratic Corpus, where it took pride of place as the opening text. However, the origin and authorship of the Hippocratic Corpus itself is a continued area of research. Hippocrates is, at most, the author of some of the texts only.

Content

The Oath begins by calling upon the gods Apollo, Asclepius, Hygieia, Panacea and all Gods and Goddesses. It details the duties of a pupil towards his profession and prescribes a close teacher–pupil relationship. The oath taker commits to training the teacher’s descendants without fee. It regulates admission to a closed circle. Only those who commit to the ethic of the Oath are granted membership. The duties of the physician towards the sick are of pivotal importance: “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” (Edelstein). The Oath demands confidentiality in matters regarding the treatment of patients. Moreover, it provides a code of conduct aimed at preventing the abuse of power such as sexual abuse of patients.

The Oath not only commits the physician to a particular moral conduct in their practice, but also throughout life. Towards the end, the Oath describes the outcome of a morally good life as a physician: “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” (Edelstein).

Problems of interpretation

The Hippocratic Oath contains sentences which are problematic in their interpretation. To quote Owsei Temkin, it is “a puzzling document” (Temkin 2002, p. 21). In particular the supposed prohibitions on euthanasia, abortion and surgery continue to challenge scholars, especially as the historic interpretations of these proscriptions varied. Thus, many scholars take the Oath to categorically forbid ending a pregnancy. However, on close, critical, philological examination of the text, the termination of a pregnancy is not explicitly forbidden. Different versions of this sentence exist and the original only forbids certain forms of pregnancy termination but not abortions as such. “These metamorphoses of the Oath’s original sentence on abortion indicate that its recipients subjected this paragraph to significant editorial changes and felt compelled to adjust its meaning to conform to a categorical interdiction of abortion” (Rütten 1996, p. 470). The numerous translations and commentaries also reach differing conclusions on the topic of abortion. The commentators were often more interested in the legitimation of their own translations than in the faithful rendition of the Oath (Rütten 1996, pp. 473–474). In light of all this a general prohibition on abortion cannot be derived from the Oath.

Furthermore, the Oath takes a strong position on euthanasia which does not conform to the reality of the ancient world. Killing upon request or assisting suicide were by no means always seen as unethical. Furthermore, the prohibition of surgery presents particular difficulties of interpretation: “I will not use the knife, not even on sufferers from stone, but will withdraw in favour of such men as are engaged in this work” (Edelstein 2018). The question of why the Oath forbids surgery remains unanswered as it was not untypical for doctors in the ancient world to perform surgical procedures. There is no consistent interpretation of this prohibition, and no good historical reason can be found for the ban on surgery, often interpreted as forbidding the removal of bladder stones (Leven 2018, p. A-1167). The Hippocratic Oath was largely unknown in antiquity. None of the other texts of the Hippocratic Corpus which deal with ethical aspects of practising medicine refer to the Oath, and neither does Galen (~ 129–216 ad). Certainly, it was not the case that all ancient physicians adhered to the Oath. At most, this was true of a small proportion. The importance of the Oath is a product of its later reception: it gained significance in the Christian and Islamic cultures of the Middle Ages and this significance was further heightened in the Renaissance. Even today, its widespread reception continues. (Leven 2018, p. A-1167).

The Declaration of Geneva

The Pledge begins with the oath taker committing to dedicate their life—not only their professional life—to the service of humanity. Similarly, to the Hippocratic Oath, it commits the oath taker to place the “health and well-being” of the patient first. The term well-being was added in 2017. A new addition of great significance to the 2017 version of the Declaration is a commitment to respect the autonomy and dignity of the patient. Further additions include paragraphs obliging doctors to attend to their own health and well-being in order to be able to care for others, and to share knowledge “for the benefit of the patient and the advancement of healthcare.” The Declaration demands “the utmost respect for human life” (World Medical Association 2017).

The Declaration of Geneva details and forbids any type of discrimination of patients and stresses the importance of confidentiality. It commits teachers, physicians and students to mutually respect one another. The Declaration also requires respect for the history and tradition of medicine: “I WILL FOSTER the honour and noble traditions of the medical profession” (World Medical Association 2017). Doctors are required not only to act conscientiously and carefully but also according to “good medical practice”, that is, on the basis of scientific knowledge. Moreover, the Declaration obliges doctors not “to violate human rights and civil liberties, even under threat” (World Medical Association 2017).

Hereby it recognises a different moral and legal code which does not have its origin in the Declaration and is in no way confined to the medical profession. It ends with the oath: “I MAKE THESE PROMISES solemnly, freely, and upon my honour” (World Medical Association 2017). There is no reference to God in the Declaration of Geneva.

Comparison of content

On comparison the two documents present a number of similarities: both are specifications for members of a particular group who take an oath. Both documents regulate the behaviour of the oath taker towards patients as well as other oath takers. Both documents emphasize the duty of the oath taker to uphold patient welfare and confidentiality. Both demand mutual respect amongst physicians. Both expect a certain manner of conduct, not just professionally but also privately.

Naturally the two documents also contain differences: the maxim of non-maleficence is explicitly stated in the Hippocratic Oath whereas it is at best implicit in the Declaration of Geneva. The Hippocratic Oath prohibits abuse, whilst the Declaration of Geneva prohibits discrimination. Unlike the Hippocratic Oath, the Geneva Declaration does not make arrangements for descendants of the oath takers. It contains no reference to God, no prohibition of surgery, no explicit restrictions on euthanasia or abortion, but simply a commitment to “the utmost respect for human life”. The Hippocratic Oath on the other hand contains no references to history and tradition, to an obligation to exchange knowledge, or the duty to care for one’s own health as a prerequisite for practising good medicine. The 2017 version of the Geneva Declaration mentions patient autonomy for the first time. The Declaration also accepts norms prescribed by others—human rights and civil liberties. Thereby, it highlights the importance of an external moral point of reference.

Relevance of the Hippocratic Oath today: attempts at legitimation

The question arises as to what meaning the Hippocratic Oath has for medicine today. The Oath itself gives us no insight as to why one should take the pledge. “The oath does not justify itself. It does not say why it is right and proper for a healer to swear it” (Temkin 2002, p. 27). The Oath has a long history and has been subject to interpretation throughout that history. After all, the text lends itself to interpretation, especially in its numerous versions and translations. It is undoubtedly a “text whose meaning and implications are far from being self-evident” (Rütten 1996, p. 477). The discrepancy that there are multiple different interpretations for this apparently so self-evident text is frequently overlooked (ibid., p. 468). With the result that “a cultural hero has been constantly invented and reinvented; constructed, deconstructed, and reconstructed; molded and remolded, according to the cultural, philosophical, social, and political context, or the private and moral background” (Gourevitch 2003, p. 418; see also Cantor 2002). Moreover, the Oath is frequently employed in an emblematic fashion without citation of the text used (Leven 2018).

Despite its countless and quite varied interpretations the Oath still represents a binding pledge for many doctors today. “The Hippocratic Oath still has great significance and makes complete logical sense even today” (Punjabi 2015, p. 610). But in contemporary discussions on medical ethics, can the Oath be regarded as an authority, as “a paradigm of the highest standards of ethical behaviour” (Robin and McCauley 1995, p. 1422)? In order to affirm this, various strategies are employed.

The Oath is given a special authority and legitimacy by being attributed to Hippocrates. Those who defend this argument see him as the Father of Medicine and epitome of a physician. Despite the fact that there is very little reliable information about the historic figure of Hippocrates and that there is no evidence for his authorship, we frequently find claims to contrary. However, Hippocrates’ (supposed) authorship does not grant the Oath validity today. Even if the Oath had been written by Hippocrates, this gives the Oath no current validity.

Other attributes of Hippocrates are also used to bolster the authority of the Oath. Current relevance is justified with reference to Hippocrates’ position in the history of medicine: “Hippocrates was the first who referred to ethical principles” (Askitopoulou and Vgontzas 2018, p. 1483). Firstly, there is no proof for this statement. And, even if it were true, it does not follow that the ethical principles Hippocrates is supposed to have laid down first, would still be relevant today. The argument that the original somehow equals the truth is naïve in terms of history of philosophy. Empirical evidence about the beginnings is always so thin that interpretations are manifold. By-gone eras lend themselves beautifully to being used as flippant projections of one’s own theories, and the Hippocratic Oath is no exception. Moreover, the existence of certain attributes at the start of a historic development says nothing about their present relevance. Why should the beginnings represent the true ethics of medicine? What we find at the beginning of a development needs not be valid forever. Rather, the essence of the physician’s ethos could be refined over time (Wiesing 2012). The step between supposed existence at the beginning and validity today will always require a separate justification.

Claims regarding the importance of the Oath are also based on the idea that it represents the morality of a glorious age. “The Hippocratic Oath constitutes a synopsis of the moral code of Ancient Greek medicine” (Antoniou et al. 2010, p. 3075). However, this statement is factually incorrect too: certain acts which the Hippocratic Oath forbids were common and permissible in the ancient world. The Oath was far from being the sole ethical groundwork in antiquity but is most likely to have been largely unknown and irrelevant. Moreover, this idea cannot give the Oath legitimacy: even if the Oath were a faithful representation of morality in Ancient Greece (which it is not), this by no means grants it any validity today. In short, even if the Hippocratic Oath had been written by Hippocrates, and even if Hippocrates had been the first to concern himself with these ethical principles (both of which we have no evidence for), even if he represents the morality of a great era (which is not the case), none of this would justify claims for current validity. The well-known difference between genesis and validity is often forgotten in this context.

Paradoxes of the Hippocrates cult

On close examination, references to Hippocrates and the Hippocratic Oath as a moral authority in medicine are full of contradictions. The Hippocratic Oath is often bound up with the idea that the ethos it describes is immutable and transcends time, it is timeless (Mattli et al. 2016, p. 854) and therefore always relevant, including in the present. Firstly, this is factually inaccurate as the Oath has been changed (Rütten 1996). More than the invocation of Greek gods was transformed in the Christian Middle Ages. More fundamentally however, because the Oath lacks respect for patient autonomy it cannot represent an immutable, enduring physicians’ ethos. The interpretation of the Oath as a “timeless” basic law for all physicians is unjustified and historically inaccurate. If this were the case our historical search would lead us to an event that transcends history: historical research into the beginnings, especially regarding the historical beginnings or the “Father of Medicine”, thus paradoxically produces results outside the realm of history. But this is impossible. History can be examined to find out what has remained constant over time. Historical research, however, cannot uncover that which is outside of history, which transcends history, and which has not merely remained constant in the past but will always remain constant. Historical research does not possess the requisite methodology for this task (Wiesing 2012).

Nowadays numerous modified versions of what is still called the Hippocratic Oath are taken by medical graduates (for an overview see Veatch 2012, pp. 36–38). Admitting that the wording of the Oath has been repeatedly changed, one could argue that the original Oath still passes on an unchangeable core of ethical principles (e.g., Pellegrino 2001). This raises the question of what constitutes the core. Why are some principles considered to be part of this unchangeable core and others not? To answer this question, we would need to devise criteria which are derived neither from Hippocrates nor the Oath. This method is also unable to explain, whether or not respect for autonomy is part of the core ethic.

The attempt to bolster the authority of the Oath by associating it with or even attributing it to a specific person, namely Hippocrates, leads to another paradox: Whilst Hippocrates was responsible for a scientific development whereby only objective reasons count, ethics seems to rely on the personal authority of an individual—Hippocrates. On the one hand, Hippocrates is celebrated for elevating medicine to a new level of rationality (which is true of the Hippocratic Corpus rather than Hippocrates himself). This scientific character of medicine led to dynamic development. According to the projection, Hippocrates has triggered a process which in the course of time has surpassed his own teachings. Because he introduced scientific thinking to medicine we now practice a very different kind of medicine than the Hippocratic medicine. He stands for a development in medicine which Max Weber, speaking about science in general, describes as follows: “We cannot work without hoping that others will advance further than we have.” (Weber)

Ethics, on the other hand, takes the opposite view: here Hippocrates is celebrated for saying that which is timeless, which becomes timeless because it was said by him, the Father of Medicine, and which cannot be superseded.Footnote 1 A dynamic development of the kind that we find in medical science, triggered by Hippocrates, does not therefore exist in the field of ethics, only the concept of an immutable truth or “time-enduring messages” (Antoniou et al. 2010, p. 3075). It is certainly paradoxical that Hippocrates (without any historical evidence) is considered responsible for both a dynamic scientific development surpassing his own teachings and an unchangeable moral truth. Both the development of medical science and medical ethics rely on very different perceptions of Hippocrates, although we know little about his true contribution to either field. Furthermore, we are left with the question of why a rational, progressive development should be impossible in the realm of morality.

Another paradox is worth mentioning: medicine also achieved its scientific progress through the basic virtues of scepticism and doubt. Scientific findings are always subject to discussion and debate. If new and better knowledge is gained, the old becomes irrelevant. Yet, when it comes to Hippocrates and the Oath, a very different approach is often apparent: rather than scepticism and criticism, observance and affirmation, paired with romanticism, are the sought-after virtues. Critical historic research about the Oath, its authorship and variations, is simply ignored. In this respect the ethical foundation of medicine, if it roots itself in the Hippocratic Oath, is taking a highly uncritical stance.

Why is the Oath, and its romanticised ideal, so popular, and why is it the most well-known text of ancient medicine? The concept of the Oath as the unchangeable basic law of medical practice may be unconvincing as an argument but has apparent merits: it removes the need for further reflection as once we have discovered the eternal moral norm of physicians. The moral quest has come to an end. Furthermore, the concept of the unchanging ethos bestows stability on a time marked by instability and rapid change—it is eternal and there is no danger of it ever changing (Eva 2014). Conveniently, medical ethics can be left to the historians: let them decide which is the most authentic, the primordial Oath! This may be a comfortable option, but it is not a convincing one.

The different portrayals of the Hippocratic Oath are also a projection of different cultural and historic needs for identity and self-reassurance (Leven 2011, p. 307). They are attempts to provide moral stability for oneself by referring back to a legend. This may be understandable, but it is not legitimate as a rational argument for a medical  ethics.

On this basis we cannot derive any relevance of the Hippocratic Oath for the present. If certain principles are still binding today, then not because they are contained within the Oath but because there are good arguments for their validity.

The Declaration of Geneva and its claim to validity

The historic development of the Declaration of Geneva is less hazy: it was first adopted in 1948 by the second General Assembly of the World Medical Association. It is the pivotal ethical document written by the WMA, after its foundation the previous year and in light of the medical crimes committed in particular after 1933. Since then it has been revised several times, most recently and comprehensively in October 2017. It does not claim enduring validity. The Declaration is not a document written by a subgroup of doctors, but the World Medical Association, the global and self-governing, professional organisation. However, the practical dissemination falls short of the document’s self-conception (Rheinsberg et al. 2018).

Moreover, the development of the Declaration is a transparent process: the 2017 revision involved a public debate. The WMA published a provisional version online with a call for commentary and criticism. The General Assembly then voted on revisions to the Declaration making these binding for its member national medical associations. Between the title and actual text of the pledge the Declaration of Geneva refers to when it was adopted and revised. It documents the formal process of approval by the World Medical Association and thereby underpins its legitimacy.

The vague commitment in the Declaration to “the utmost respect for human life” points to a fundamental problem such documents have (Arras 2001): they cannot solve some highly controversial ethical problems. More than ‘respect for human life’ cannot be demanded from a document that is supposed to convey the attitude of any member of the profession. To include an explicit prohibition of abortion or assisted suicide in such a document would not find a majority as these are controversial topics even in the World Medical Association. The wording is a tribute to the realistic approach the Declaration of Geneva takes.

The Declaration refrains from referring to God. It commits doctors to caring for their “noble traditions” but does not seek to derive legitimacy from history. A small criticism remains: through its title The Modern Hippocratic Oath (World Medical Association) the Declaration does seek historicizing self-stabilization. This is neither justified nor necessary. This reference, however, can no longer be found in the 2017 version (World Medical Association 2017). Here the WMA speaks of a “modern successor to the Hippocratic Oath for physicians around the world” (World Medical Association).

Conclusion

Even if both documents show similarities in terms of function, in that their aim is to promote patient trust in the profession, and display some similarities in content, the verdict as to their present-day validity is divisive. The Hippocratic Oath is a remarkable historic document, which contains important elements still relevant for medical ethics today. The commitment to patient welfare, non-maleficence, confidentiality, as well not taking advantage of the patient’s need are amongst these. But that doesn’t mean that these principles are valid today because they are part of the Hippocratic Oath. Furthermore, it also contains norms whose validity can no longer be upheld and lacks norms which are needed for a justifiable twenty-first century medical ethos. Its interpretation as a timeless medical code is unfounded. The historical arguments, that should justify its validity, are untenable. The ethos of the medical profession has changed, which is seen most clearly in the fact that patient autonomy has been added to the Declaration of Geneva. The origin of the Oath is largely unknown. The retroactive and erroneous association of the Oath with the famous name Hippocrates cannot form the basis of any obligation, but rather serves to uphold a romanticised myth. A document cannot gain legitimacy through historic fame and wrongly attributed authorship. If certain principles are still binding today, it is not because they are written in the Oath but because good arguments exist for their adoption.

The Declaration of Geneva was written under completely different circumstances. It can justifiably claim to be binding for the currently 114 national medical associations which form the World Medical Association. After all the WMA General Assembly adopted the revised Declaration unanimously in 2017. The Declaration of Geneva, and not the Hippocratic Oath, can legitimately claim to come close to representing the most important principles of professional medical conduct in today’s globalised world. In modern society validity can only be achieved through arguments and transparent, democratic processes. A discipline whose special status is built on its rationality cannot violate these standards of rationality in attempting to legitimise itself ethically and must not fall prey to gratuitous historic romanticising. It should also identify and respect the limitations of such a document. A professional code of conduct can regulate important elements of the doctor–patient relationship, but it cannot solve all the problems of medical ethics.