Another delve into the annals of history; this time we travel back to ancient Greece and the island of Kos. In the year 460 BCE the father of medicine Hippocrates is born. Hippocrates learned his craft from his father and grandfather and would go on to revolutionise medicine in the ancient world, but not without controversy. Hippocrates is credited as the first person to remove superstition and religion from medicine, instead attributing ilness to natural causes. “Men regard its nature and cause as divine from ignorance and wonder, because it is not at all like to other diseases.” Hippocrates attributed diseases and their progression to the four humours; black bile, yellow bile, phlegm, and blood. While we’ve moved on from these ideas somewhat, back in their day they were at the forfront of cutting edge ideas. As well as these works, one of Hippocrates most famous works is the Hippocratic oath. An Oath in some regard taken explicitly or implicitly by clinicians for thousands of years. Interestingly the phrase “first do no harm” doesn’t actually come from the Hippocratic oath, while it’s not part of the Hippocratic oath, its probaly worth discussing at somepoint whether or not it can be achieved. Anyway onward to the translated oath.

The Hippocratic Oath

1. I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea and all the gods and goddesses as my witnesses, that, according to my ability and judgement, I will keep this Oath and this contract:
2. To hold him who taught me this art equally dear to me as my parents, to be a partner in life with him, and to fulfill his needs when required; to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract; and that by the set rules, lectures, and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to students bound by this contract and having sworn this Oath to the law of medicine, but to no others.
3. I will use those dietary regimens which will benefit my patients according to my greatest ability and judgement, and I will do no harm or injustice to them.
4. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.
5. In purity and according to divine law will I carry out my life and my art.
6. I will not use the knife, even upon those suffering from stones, but I will leave this to those who are trained in this craft.
7. Into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or corruption, including the seduction of women or men, whether they are free men or slaves.
8. Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.
9. So long as I maintain this Oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of all men for all time. However, should I transgress this Oath and violate it, may the opposite be my fate.

Hippocratic Oath by Hippocrates of Kos, Translated by Michael North National Library of Medicine 2002

So does the oath hold water today. Should we stick to it or abandon it entierly or cherry pick from it the parts that fit our personal philosiphy and fill in the rest? Well lets pick it apart. Section 1 I don’t personally think there is anything inherently wrong with swearing an oath to a god/gods what ever you believe in, however thats not for me. I dont think you have to swear on anything to commit to something and actions in my opinion speak louder than words, I want my commitment to doing the best for my patients to be reflected in their outcomes and quality of life.

Section 2 I think the wording here is somewhat old-fashioned and I kind of disregard the family thing in a professional setting, I think there needs to be boundaries at work. I also think fulfilling needs as required, is a bit vague completing tasks without question or thought creates a working culture of good Germans also, following the established rules stagnates necessary change, clinging to the edifices of old regimes doesn’t help us progress, but progress shouldn’t be made for the sake of progress it should be done meaningfully with evidence to back the need for change. There’s also stuff around working for free which is a very grey area, I personally think people should get paid for their work and it should be a liveable wage. The last part I think is vitally important we should absolutely share our knowledge if nothing more than to get others to challenge it, there’s an old adage that those who can’t, teach! Well I think everyone should be a teacher and a student throughout life, share your ideas freely because you never know who will benefit from it. On a slight side note to this, I am always happy to answer questions I may not know the answer, but I’m always happy to talk through ideas.

Section 3 I think “to the greatest of my ability and judgement” is really important we are in fact humans and in that we are fallible, we make mistakes, but we should use our best judgement and ability to help our patients, and part of this is looking at the latest research keeping up to date with CPD, and understanding our own limits. We may think we are superman, but sometimes life gets in the way (family issues, sleep deprivation due to newborns, death etc. pick your poison), we need to understand when we are in a position where we can’t use our best judgement or do our best for a patient, and when to step back from this. I had a week off sick this year, the first time I’ve been off sick in ages, it started out as a tickly cough and ended up as full-blown flu. I called in sick, I knew I couldn’t risk giving my patients or other staff members what I had. I think there’s a part of me when I was calling in sick that felt a bit guilty, the appointments would need to be cancelled and rearranged delaying treatment or other staff members would need to pick up the slack, but I dismissed this guilt because actually it would have been worse for patients and staff members for me to go into work and pass on what ever bug I had caught. We cannot provide good quality care if we do not look after ourselves first.

On the other point which needs a bit more picking apart “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan” There are two parts to this the first is giving a lethal drug in general we use toxins, radioactive materials, steroids, opioids the list goes on for the weird and wonderful treatment options that have inherent risks of death for example we use Botulinum toxin on a daily basis, but this can cause paralysis. We have to weigh the risks the interventions have with the benefits this brings. The second part of this section is the use of treatment to assist with dying, again I am pro-choice I think that if the time came where I was in the position of having some degenerative disease that I knew would end in a painful undignified death that I would want to be able to set my affairs in order and go out on my terms. I think this can be done with appropriate safeguarding in place and would alleviate a lot of suffering in certain patient populations on an individual basis.

Section 5 completely ignores it I don’t think the divine exists and most religious laws are utter rubbish I don’t think religious law and doctrine has any place in healthcare apart from when the patient has wishes and I think these need to be accepted there’s a conversation to be had about capacity and best interest, but I don’t think it’s one for here.

Section 6 I couldn’t agree more with the theme of this, what Hippocrates is saying here. He’s saying that he’s not a trained competent surgeon, so he will not attempt surgery, and this should in my opinion be one of the fundamental principles for every clinician. Know your limitations and unless you have been trained, supervised and deemed competent, you should not provide the treatment.

Section 7 Again I couldn’t agree more with Hippocrates we should always conduct ourselves professionally, this doesn’t mean we have to be robots or doctors in white coats we are human after all and our patients want to deal with human beings that actively listen and respond to their issues with care, compassion and warmth.

Section 8 This is superseded by the need to safeguard, absolutely patient’s condition and information should be kept private and consent should be obtained to share information with other professionals this however is superseded by safeguarding policies and regulations which require disclosure to appropriate bodies.

The final section I guess it does in a way still hold up we don’t want outside sources to influence our medical decisions, we want to make decisions on the evidence with the patient’s input, and in that we need to have a process for dealing with pharma and tech companies trying to sell their wears and an awareness that the thing you’re being sold as the miracle cure to all ailments may be appropriate for some things and not others or could be complete sake oil. I also think that helping people is in its self a noble pursuit in life, and we shouldn’t lose sight of what is at the centre of that pursuit is the patient, and we should understand that while we are the expert in the room we must take into account the patient’s wishes.

There is a modern Hippocratic oath which I think I identify more strongly with. It talks about treating a patient with sympathy and warmth, and the combination of art and science, it identifies the need for reflection and understanding our limitations, and that we will at some point need to ask for help and accept that others have strength and knowledge in areas we do not. There is also an acceptance that death while being the thing we are trying to prevent is inevitable and should be accepted as a natural part of life and that patients who are facing it should be treated with the dignity they deserve. It warns us not to become detached from society or desensitised to the ailments we are treating, I think this is to prevent us from becoming cold and detached from our patients and to encourage us to keep searching for better solutions to the issues our patients face. I think for me this oath holds much better to the tenants of healthcare I have seen so far in the colleagues I have worked with: compassion, warmth, understanding patients, a wholistic approach that looks at not just the immediate issue but the impact it has on all aspects of a patient’s life, and a drive to do what is right by the patient, treating them as an individual not a piece to be fitted into a system.

Most services, colleges, professional bodies have moved away from the Hippocratic oath to their own professional standards which aren’t as set in stone.