What are the issues at stake in revising the Hippocratic Oath?

Historians know little about the origin of what we now call the 'Hippocratic Oath', and little about its use in antiquity. It came from Greece around 400 BC, and was probably associated with the 'school' of Hippocrates rather than with one physician alone.

The general public today believes mistakenly that all doctors swear the Oath on graduation, and are bound by high ideals ever afterwards. In fact, while few swear it, perhaps rather more swear by it. The Hippocratic tradition has been popular and has undoubtedly been a conservative yardstick for medical ethics.

There are different forms of the Oath around in modern use: Ludwig Edelstein's translation [1] reads:

I swear by Apollo Physician and Asclepius and Hygeia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfil according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but to no one else.

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.

I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guide my life and my art.

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.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intention-al injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about. If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honoured 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.

At its Annual Representative Meeting in 1995, the British Medical Association called for an updated version of the Hippocratic Oath for all doctors to take on graduation, to ensure that ethical standards were maintained in a rapidly changing world with many new pressures.

A 'Draft Revision of the Hippocratic Oath', the text below, was published by the BMA this spring. Their plan is for a final version to be accepted by the World Medical Association in 1998, so this could potentially affect healthcare all around the world.

The practice of medicine is a privilege which carries important responsibilities. All doctors should observe the core values of the profession which centre on the duty to help sick people and to avoid harm. I promise that my medical knowledge will be used to benefit people's health. They are my first concern. I will listen to them and provide the best care I can. I will be honest, respectful and compassionate towards patients. In emergencies, I will do my best to help anyone in medical need.

I will make every effort to ensure that the rights of all patients are respected, including vulnerable groups who lack means of making their needs known, be it through immaturity, mental incapacity, imprisonment or detention or other circumstance.

My professional judgment will be exercised as independently as possible and not be influenced by political pressures nor by factors such as the social standing of the patient. I will not put personal profit or advancement above my duty to patients.

I recognise the special value of human life but I also know that the prolongation of human life is not the only aim of health care. Where abortion is permitted, I agree that it should take place only within an ethical and legal framework. I will not provide treatments which are pointless or harmful or which an informed and competent patient refuses.

I will ensure patients receive the information and support they want to make decisions about disease prevention and improvement of their health. I will answer as truthfully as I can and respect patients' decisions unless that puts others at risk of harm. If I cannot agree with their requests, I will explain why.

If my patients have limited mental awareness, I will still encourage them to participate in decisions as much as they feel able and willing to do so.

I will do my best to maintain confidentiality about all patients. If there are overriding reasons which prevent my keeping a patient's confidentiality I will explain them.

I will recognise the limits of my knowledge and seek advice from colleagues when necessary. I will acknowledge my mistakes. I will do my best to keep myself and colleagues informed of new developments and ensure that poor standards or bad practices are exposed to those who can improve them.

I will show respect for all those with whom I work and be ready to share my knowledge by teaching others what I know.

I will use my training and professional standing to improve the community in which I work. I will treat patients equitably and support a fair and humane distribution of health resources. I will try to influence positively authorities whose policies harm public health. I will oppose policies which breach internationally accepted standards of human rights. I will strive to change laws which are contrary to patients' interests or to my professional ethics.

This draft has been praised for being a religion-free, non culture-specific, contemporary statement of ethics which includes community and international considerations. It has also been criticised: it is not an Oath, it is ambiguous, it mixes principles with guidelines for practice, it is dangerously weak on 'pro-life' issues, it no longer explicitly prohibits sexual relations with patients . . .

In a back-to-back comparison, what do you think?

What oath, if any, would you support?

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