For most people Hippocrates is a shadowy figure somehow connected to the ethical practice of medicine. They feel vaguely comforted by the supposed fact that doctors take a Hippocratic Oath of practice upon graduation. The truth is that very few take the Oath of Hippocrates; some take a revisionist version, which retains the name but removes the content; many make no commitment to rigorously defined ethical standards. There are many bioethicists who argue that the Oath is irrelevant to our society. I am not going to spend time on the historical Hippocrates, because even his existence is still a topic of contention; my objectives are theological and philosophical rather than historical.

About 98% of American and 50% of British medical students now swear an oath, either on entry to medical school or on graduation.[1] However, they rarely contain all the essential features of the Hippocratic Oath. It might be argued that where the name of Hippocrates is used today, it is used in a modern revisionist sense to make the public feel comfortable. But the reality that Hippocrates stood for has been removed.

Transcendence

The opening phrase of the Hippocratic Oath is worthy of reflection. The literal form cannot be sworn by Christians because it invokes ancient Greek deities. However, we can relate to the intent of Hippocrates and his followers, unlike some secular commentators who readily dismiss it as a marker of the cultural superstitions of that time and unworthy of our scientific age. Hippocrates would find little with which to sympathise in the dominant model for medical teaching today - the bio-psycho-social model, which completely denies the transcendent dimension, presuming that medicine can be adequately described without theological and philosophical underpinnings.

This bio-psycho-social model can legitimately be described as weighed in the balances and found wanting. The fact that most medical students do not understand that the metaphor 'weighed in the balances' relates to the story of Belshazzar's feast[2] merely emphasises my point. The charge is clearly more serious than just suggesting that the bio-psycho-social model is a few grams underweight: Belshazzar had profaned the sacred vessels of the Jews when the hand wrote on the wall, 'Mene, mene, tekel, uparsin'. No one understood these words until Daniel was sent for. He explained that Belshazzar and his kingdom had been weighed in the balances and found wanting; they were consigned to history the next morning at the hands of Darius. The bio-psycho-social model is profoundly wrong because it denies that we are spiritual beings. It has no place for the most profoundly moving events that we, as physicians, are ever privileged to witness.

I recently heard a beautiful account of an agnostic Jew's description of one such event. She is a physician who carries a pager at all times, in order to give palliative care to her patients in their time of need. Early one morning she was called to a patient; he wanted to die at home but had begun to suffer pain and was on the edge of convulsing. When she had done all she could, the patient was no better.

The unwanted death in hospital seemed inevitable but, before the family agreed, they called the church music group, of which the patient had been a member, to come and sing at the bedside. They came and as they began to sing in the small hours of the morning the patient relaxed and was at peace. When they stopped, he deteriorated; when they sang, he improved and was comfortable. So for 24 hours they sang in relays until he died peacefully. The agnostic physician simply said to her colleagues, 'I tell you this story to remind you that there are things out there we do not understand.' It is our job, as those who believe, to witness to the 'things out there' and especially to the Person 'out there' who loves us.

The significance of the invocation of the gods in the Oath of Hippocrates cannot be overstated. It places patients and their physicians in a world with a transcendental dimension. The physician who believes in transcendence, particularly where that belief includes the ideas of moral consequence and ultimate accountability before judgment, has reason to be ethical because he fears God appropriately. Solomon thought such fear was the beginning of wisdom[3] and great physicians have often agreed. The Christian Medical and Dental Society of Canada takes a wonderful piece of prose by one such physician, Thomas Sydenham, as its vision statement:

It becomes every man who purposes to give himself to the care of others, seriously to consider the four following things: First, that he must one day give an account to the Supreme Judge of all the lives entrusted to his care. Secondly, that all his skill, and knowledge, and energy as they have been given him by God, so they should be exercised for his glory, and the good of mankind, and not for mere gain or ambition. Thirdly, and not more beautifully than truly, let him reflect that he has undertaken the care of no mean creature, for, in order that he may estimate the value, the greatness of the human race, the only begotten Son of God became himself a man, and thus ennobled it with his divine dignity, and far more than this, died to redeem it. And fourthly, that the doctor being himself a mortal man, should be diligent and tender in relieving his suffering patients, inasmuch as he himself must one day be a like sufferer.[4]

Transcendence was still an active concept in the 17th century at the highest reaches of the practice of medicine. Why is it so different now? Would that we had the like of Sydenham leading our profession today!

The best ethics that the bio-psycho-social model can offer is an unpredictable utilitarianism, without any guarantee that the dominant utility will be that of the patient rather than the economist, administrator or physician. The privileged relationship between the physician and the patient should be at the heart of medical ethics. Sadly this can be abused: I am glad that many of my colleagues practise better ethical medicine than could be rationally deduced from their beliefs about a world where only genes compete. Those who deny the existence of any objective truth or benchmark for morality and say that we create our own values have no basis for moral laws.

A physician is required only to display appropriate 'attitudes' to pass with honours in the ethical evaluations of the modern medical school. Any trained actor could finesse this aspect of the course but, at the end of our lives, it is not beautifully presented attitudes that we need, but formed character that will strengthen us and accompany us to the gates of death.

If, however, values are subjective, they are not consistently predictable. Oaths only make sense when God is at the heart of what people believe to be true. Codes of ethics are all that is left to a people who have lost their God. Character, on the other hand, is what a man is and habitually does.

Oaths and codes

One of the greatest horrors of the Second World War was that physicians not only failed to protest against the Nazis' eugenic and racist killings, but co-operated with them. The first gas chambers were designed by psychiatrists for 'defective' children. The concentration camps maintained the fiction of 'medical' selection by having physicians in charge of those selections. The Nazis merely extended the logic of the eugenics already incorporated into the beliefs of the profession of medicine. Today the process is being repeated as we accept the results of molecular biology, which consistently allows the detection of prenatal defects in utero, but rarely provides cures.

The debate after the Second World War was intense and led to the promulgation of the World Medical Association's Code of Ethics. The change from an oath to a code is significant, and it does not invoke any form of transcendence. The killings in Germany were rational if there is no God and the only absolute is the desires of those in power. The Hippocratic Oath involved transcendence and drew the physician into a covenantal relationship. Thus the physician accepted the responsibility to be with his patient throughout an illness or up to death. This commitment was embodied by the best physicians; patients tacitly understood this and responded with loyalty. To turn from this to modern codes and contracts is like turning the Ten Commandments into the ten guidelines.

Trust and morality

Medicine is a moral activity because it is based on trust and its central function is to help the patient decide what he or she ought to do. In much of the western world, we are in the midst of a rapid decline in certain forms of trust, as exemplified by the proliferation of security devices. There are two reasons for this. Firstly, the reductionist, truth-denying character of the modern university is becoming the ethos of society, leaving only the 'hermeneutic of suspicion', which is corrosive of the common good. Secondly, we now live not in communities of distinctively Christian character where trust flourished, but in anonymous loose associations of people who meet briefly on Sunday morning in cities and suburban deserts. Postmodern living spaces are places in which theft and disregard for people are commonplace. Walk-in clinics and progressive commercialisation are medical examples of the loss of communities of character. The Hippocratic Oath gave substance to a vision of a medical community with a predictable character of high ethical standards that could support justifiable trust between physician and patient with all the therapeutic benefit this produces.

Sanctity of life

The main reason for the modern dismissal of the Oath of Hippocrates by those who know its content is its commitment to the absolute sanctity of life. Neither abortion nor assisted suicide find any place in the thought of Hippocrates. Why was this commitment so central? Margaret Mead, the anthropologist, clearly understood when she wrote;

For the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world, the doctor and the sorcerer tended to be the same person. He with power to kill had power to cure, including specially the undoing of his own killing activities… With the Greeks, the distinction was made clear. One profession, the followers of Asclepius, were to be dedicated completely to life under all circumstances, regardless of rank, age, or intellect - the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child… [T]his is a priceless possession which we cannot afford to tarnish, but society always is attempting to make the physician into a killer - to kill the defective child at birth, to leave the sleeping pills beside the bed of the cancer patient… It is the duty of society to protect the physician from such requests.[5]

This tradition is never more important to us individually than at that extraordinary point in life when we choose to become patients. When we are ill, we need someone we can trust to do what is best for us: sick people want someone else to handle the difficult problems. You may be a client when you choose who will fix your hernia but you are not a client when you have septicaemia and renal failure. This is where Hippocrates changed the direction of medicine. Ancient and modern pre- and post-Hippocratic physicians were and are willing to kill for a price, whether financial or ideological. In contrast, the followers of Hippocrates who took his Oath committed themselves to a practice that removed this fear of death at the hands of the physician. This generated a substantial trust and consequently they became the physicians of choice. It was patient choice and the desire to have an income, not the intrinsic nobility of the medical community, which forced the medical profession to adopt the higher ethical standards of the Hippocratic community.

A consensus of meaning

The swearing of the Oath was not optional and it was required before training could begin, not at the commencement of the practice of medicine. It therefore set the ethos within which learning could take place. The importance of this is set out by Michael Polanyi:

The adherents of a great tradition are largely unaware of their own premises, which lie deeply embedded in the unconscious foundations of Practice...if the citizens are dedicated to certain transcendent obligations and particularly to such general ideals as truth, justice, charity and these are embedded in the tradition of the community to which allegiance is maintained, a great many issues between citizens, and all to some extent can be left - and are necessarily left - for individual consciences to decide. The moment however a community ceases to be dedicated through its members to transcendent ideals, it can continue to exist undisrupted only by submission to a single centre of unlimited secular power.[6]

This consensus no longer exists and it is our failure to appreciate this that lies at the heart of our problems. For the modern world ends justify means. We must expect to face opposition that has an entirely different hierarchy of goods from those that were historically associated with Christian culture, and does not necessarily place truth telling at the top of the list. Frequently we see demands for loyalty to institutions, loyalty that is not trumped by truth. This necessarily will lead to growing incompetence.

The doctor-patient relationship

In this era, where autonomy is always placed first, it comes as a surprise to realise that patient rights have no place in Hippocrates' thinking. That, say the modern generation of bioethicists, is good reason to dismiss Hippocrates. But is it? Hippocrates lived in a pagan ethos where life was cheap and promises easy. His time did not have 2,000 years of Christian thought anchoring it down. Patient autonomy was meaningless because the relationship was intrinsically unbalanced; all the power lay in the hands of the physician. The patient's safety was therefore in the ethics of the physician. If the physician took the Oath of Hippocrates he swore to do no harm, to recognise the limits of his competence and refer appropriately. The patient's safety lay in doing everything to preserve the physician's integrity, to avoid even subtle coercion to kill or to abort.

Conclusion

Today many writers are comparing our times to those of the sack of Rome. Alasdair MacIntyre puts it like this:

It is always dangerous to draw too precise parallels between one historical period and another; and among the most misleading of such parallels are those which have been drawn between our own age in Europe and North America and the epoch in which the Roman Empire declined into the Dark Ages. Nonetheless certain parallels there are. A crucial turning point in that earlier history occurred when men and women of good will turned aside from the task of shoring up the Roman imperium and ceased to identify the continuation of civility and moral community with the maintenance of that imperium. What they set themselves to achieve instead - often not recognising fully what they were doing - was the construction of new forms of community within which the moral life could be sustained so that both morality and civility might survive the coming ages of barbarism and darkness. If my account of our moral condition is correct, we ought also to conclude that for some time now we too have reached that turning point. What matters at this stage is the construction of local forms of community within which civility and the intellectual and moral life can be sustained through the new Dark Ages which are already upon us. And if the tradition of the virtues was able to survive the horrors of the last dark ages, we are not entirely without grounds for hope. This time, however, the barbarians are not waiting beyond the frontiers; they have already been governing us for quite some time. And it is our lack of consciousness of this that constitutes part of our predicament. We are waiting not for a Godot, but for another - doubtless very different - St Benedict.[7]

If a Barbarian is someone who does not know and celebrate his own history, then we are Barbarians and we must ask who will be our St Benedict to give us a rule to order our lives. My suspicion is that we constitute more than enough to demand and achieve a legitimate and continuing sector of Hippocratic medicine in this pluralistic society. The old consensus has gone, but no new consensus is yet dominant. Therefore we have a right to practise medicine in the Hippocratic way as long as we serve a significant proportion of the population. The new postmodern medicine has no right to totalitarian power although, if we are not alert, it may usurp it. Patients are individuals and must be treated as such.

Until this democratic necessity is generally accepted, we must talk about the necessity of transcendence, of a commitment to the sanctity of life, to training within a moral ethos, and to the critical importance of the preservation of the moral integrity of the physician even over illegitimate claims of patient autonomy, if medicine and the doctor-patient relationship are to be preserved.

This article is based upon a fuller paper, available on the CMDS Canada website at www.cmds-emas.ca/documents/hipporates bkl2.doc.