Reviving the Hippocratic Tradition: Medical Ethics and the Physician's Duty in Modern Medicine

By Jennifer Lahl, MA (Bioethics), BSN, RN

Photo by @mutecevvil from Unsplash

Hippocrates – The Father of Modern Medicine and the Bedrock on which the Medical Profession was Built – The Original Oath:

“I swear by Apollo the physician, and Aesculapius the surgeon, likewise Hygeia and Panacea, and call all the gods and goddesses to witness, that I will observe and keep this underwritten oath, to the utmost of my power and judgment.

I will reverence my master who taught me the art. Equally with my parents, will I allow him things necessary for his support, and will consider his sons as brothers. I will teach them my art without reward or agreement; and I will impart all my acquirement, instructions, and whatever I know, to my master’s children, as to my own; and likewise, to all my pupils, who shall bind and tie themselves by a professional oath, but to none else.

With regard to healing the sick, I will devise and order for them the best diet, according to my judgment and means; and I will take care that they suffer no hurt or damage. Nor shall any man’s entreaty prevail upon me to administer poison to anyone; neither will I counsel any man to do so. Moreover, I will give no sort of medicine to any pregnant woman, with a view to destroy the child. Further, I will comport myself and use my knowledge in a godly manner.

I will not cut for the stone but will commit that affair entirely to the surgeons. Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient; and I will willingly refrain from doing any injury or wrong from falsehood, and (in an especial manner) from acts of an amorous nature, whatever may be the rank of those who it may be my duty to cure, whether mistress or servant, bond or free.

Whatever, in the course of my practice, I may see or hear (even when not invited), whatever I may happen to obtain knowledge of, if it be not proper to repeat it, I will keep sacred and secret within my own breast. If I faithfully observe this oath, may I thrive and prosper in my fortune and profession, and live in the estimation of posterity; or on breach thereof, may the reverse be my fate!” (McCollough Scholars, 2024).      

The Ancient Greek physician and philosopher, Hippocrates (c 460 – 370 BC), is often referred to as the “father of modern medicine” (Grammaticos & Diamantis, 2008). In his early writings, running to more than 70 books, Hippocrates scientifically described many diseases and their treatments. His most familiar maxim is: “As to diseases, make a habit of two things – to help or at least to do no harm.” Primum non nocere, the Latin for, first, do no harm. Much later, Canadian physician, Sir William Osler (1849-1919) was recognized for his important work at Johns Hopkins School of Medicine where he established the field of internal medicine, as well as medical internships and residency programs, still used today, to teach and train new physicians. He was known as a “larger-than-life” person implementing training of student doctors at the bedside of the patient (Barton Team, 2023). Like Hippocrates, he has many quotes still famous today, like, “A physician who treats himself has a fool for a patient”. The works of both Hippocrates and Osler are still relevant and important today.  But Hippocrates is attributed as the founder of modern medicine and is the starting place all medicine has been built upon – the scientific method of diagnosis and treatment, while doing good to, and for, the patient and never harming them.

Hippocrates was heavily influenced by the famous Greek philosophers of his day – Plato and Aristotle to name just two. Discussions between the various philosophers were probably lively during this time, pondering great questions like, “what is the good?”, “what is virtue?” and “how do we know what is good?” or “how do we know who a virtuous person is?” Words used to describe what good meant were words like “virtue” and “excellence” and “beautiful”.  These questions, as medicine was being born in early Greece, surely impacted the view of what makes for a “good” physician.  A virtuous and good physician, according to the Hippocratic Oath, would make a covenant with and swear allegiance to the Greek gods as well as to his patient. It was both a vertical and horizontal covenant: He will not sleep with a patient and will maintain confidentiality between himself and his patient.  He swears to devise the best plan of care, to not hurt or harm the patient, and to refer out when a specialty like surgery is needed, “I will not cut for the stone, but will commit that affair entirely to the surgeons” (National Library of Medicine, 2008).

The physician knew what his fiduciary duty was to his patient as well as the seriousness of his oath sworn to his gods, which served as a guide to practice the art of medicine as a virtuous and good medical doctor.

The purpose of medicine

What is the aim, the purpose, the point, or the goal of medicine?  Simply put, it is the health of the patient.  Health is not just the absence of disease or illness but is defined as the state of your physical and mental health. The natural or normal state of the human body is one of health.  When using the word “normal” it means the natural function of an organ, a system, or the body.  For example, the function of the healthy human heart is to beat and circulate oxygenated blood to the whole body. When this function is impaired due to disease, injury, or aging, the duty of the physician is to return function to the extent possible. Eyes see and ears hear. Kidneys produce urine as they remove waste from the blood to manage fluids and maintain hormone balance. When we are sick, we seek medical care to regain a state of health. As we age, we seek medical care to maintain our health or improve our health if we are not able to return to our previous state of health or proper function.  We seek healing and the restoration of health whenever possible. At its core, the medical profession professes to practice medicine for the good health of their patients through their expert training in medicine and medical ethics. To Aristotle, “the end of the medical art is health” and to Hippocrates his oath was to only enter the home “on behalf of the sick”, and to help or to at least not harm.

Since medicine’s aim is health and the practice is guided by evidence, meaning the centrality of evidence that directs what the physician will prescribe as a treatment to restore the health of their patient, the physician’s treatment should not be directed by the wants, desires, or wishes of their patients.  Certainly, these desires and wants of the patient ought to be listened to and considered when a physician is diagnosing and prescribing treatment for the patient, but these desires are secondary to his duty to use his expert knowledge to work to restore or improve the health of his patient.  For example, a particular drug is needed to treat an illness, but while taking this drug, the side effects will not allow the patient to eat a type of food they enjoy.  The doctor may be able to prescribe an alternative drug, that will treat the patient, while still allowing the patient to eat a favorite food. But, if there is no substitute medication, the physician’s prescribed treatment should take precedence over any dietary preferences, for the sake of the health of their patient.

Today, it seems, medicine is no longer oriented toward the health of the patient but has been moved into the role of what I often refer to as the technician or that of being a service provider. Physicians today often feel their practice is dictated by the desires of their patients, the insurance companies’ coverage of services, the administrators of our hospitals and their medical centers, regulatory agencies, accrediting bodies, financial incentives, and attorneys.  Even the training of physicians has reduced their role to keeping the customer satisfied, and their performance is routinely graded by customer satisfaction surveys.  Tell us about your experience.  Do you feel your physician listened to you? Did your physician answer your questions and address your concerns?  All this is well and good if the primary aim of medicine is directed to the health of their patient, and secondarily, that the patient felt cared for and listened to. But when the practice of medicine is graded on patient satisfaction, the goal of “do no harm” subtly shifts. The physician shifts his duty from the best interests of his patient to preserve and restore their health, to keeping patients and hospital administrators happy and lawyers at bay.

The ancient oath of Hippocrates has been amended over the years and in some ways has been watered down; new ethical theories such as utilitarianism, consequentialism, and deontology have altered the practice and the art of medicine.

Utilitarianism promotes the “greatest good for the greatest number” which means the focus is not on the individual but the collective whole. Utilitarian ethics are often reflected in decisions around resource allocation. We don’t have endless medical resources, so how do we “deliver” and allocate resources so that healthcare is delivered to the greatest number?  Consequentialism focuses on available treatment options and possible outcomes (Savulescu & Wilkinson, 2019).  If the outcome is good, say the patient lived, but we lied to them about a treatment option, consequentialism holds that lying was acceptable because it led to a good outcome.  Also, focusing on outcomes can be limited as we don’t know with certainty what an outcome might be. In deontological ethics, the focus is on the duties and obligations of the physician toward their patient and emphasizes mutual respect for one another’s decisions. Deontological ethics is more patient-centered, while utilitarian ethics are more society centered. (Tseng, & Wang, 2021).   But a con of deontological ethics lies in its rigidity in allowing for the physician to nuance his practice.  Duty and obligation supersede flexibility.  This is often illustrated with examples of those who lied and hid Jews to save their lives.  The duty to never lie, to only speak the truth, can sometimes cost people their lives, when the first principle is to do no harm.

Perhaps though, a newer and more influential ethical theory today that has replaced the Hippocratic Oath and is guiding medicine would be Tom Beauchamp and James Childress’ book, “Principles in Biomedical Ethics”, where they outlined four principles of medicine: non-maleficence, beneficence, autonomy, and justice (Page, 2012). It is the view of Beauchamp and Childress, that these four principles, held together can guide, direct, and ensure that medicine is aimed at the health of their patient.

·       Non-maleficence is to do no harm to your patient. 

·       Beneficence requires the physician to seek the good for his patient.

·       Autonomy allows for the patient to have ultimate say in his care and treatment, even if that means refusing life-saving care.

·       Justice seeks to treat each individual patient fairly, instead of having biased care as is often seen in minority or economically disadvantaged populations.

These principles may sound very good and could serve as an ethical guide for the practice of medicine, but without a shared vision or meaning of these words, the principles are lacking or simply fall apart. In today’s debate around gender affirmation therapy, it is seen as doing harm to your patient if you don’t affirm a new gender identity and “treat” with puberty blockers, cross-sex hormones, and reproductive surgeries.  Similarly, to do good, would be to offer these as therapies, even though they are not based on any medical evidence that they treat or cure any distress. And the autonomy of the patient means that the patient’s wishes and desires are driving the practice of medicine. Finally, the pillar of justice, is again distorted, by claims that marginalized groups, like those who identify as trans receive “biased” care and are treated unjustly.

Looking at these various ethical theories we can see that there are limitations. For example, what about the patient who has a rare form of cancer, and the treatment plan is experimental and very expensive. A utilitarian ethicist would argue that giving resources to this one patient will take resources away from many other people also in need of care.  The consequentialist might argue against pursuing this treatment since it is experimental, which is often expensive (utility argument) and the outcome can’t be known. The deontological approach would not allow for the physician to have nuance in his duty bound do no harm treatment for his patient.  The patient may live, or the patient may die whether he decides for or against agreeing to be part of the experimental treatment. The Beauchamp and Childress model breaks down because of lack of shared meaning to the four principles as stated above.  Doing good, not harming, autonomy, and justice, without shared meaning of these principles will allow for a patient directed model of medical care.

While this is not an exhaustive list of ethical theories and their strengths and limitations, these examples illustrate how the physician may be hindered in caring for and treating his individual patient according to these more modern ethical approaches.

Today, because we have no shared or common vision for what it means to practice medicine while doing good and not doing harm, or what autonomy looks like, or who decides what is just, medicine is often viewed as an industry where bottom line profit motives and patient customer satisfaction surveys dictate the practice of medicine. If we ascribed to the Hippocratic Oath today, these words would have clear meaning, but we don’t. The Oath has been displaced, so that medical students today write their own oaths (Bailey, 2016). Some medical schools now include climate change and “indigenous ways of healing” in their medical training (Harvard Research, 2024; Why evolution is true, 2022). The Hippocratic Oath has been said to be “irrelevant in modern medical practice because it does not address ethical issues that are relevant today” (Sritharan , 2001), but if medicine is aimed at health, it is clear what would be good and just medicine, in all situations, past, present, or future. But today, what is good medicine or bad medicine is in the eyes of the individual, or the insurance provider, or hospital administrator, or even the patient, who often has no medical expertise or training.  One might argue that gender affirming healthcare is a good, and to not provide access to this type of care would cause harm, not be just, and certainly deprive the individual of their autonomy to direct their own personal medical care.  The fact is that, with many of these ethical theories, we can see how medicine can be quickly aimed at many things, like poverty, or climate change, or any other political debates of the day which are often not at all connected to restoring the patient’s health. The utilitarian ethicists will deny a costly and necessary treatment for an individual patient in order to stretch limited financial resources aimed at others. 

Medicine today

It might be helpful to state what medicine is not or should not be.  Medicine should not mean over medicalizing every complaint a patient presents.  It should not lead to the over-diagnosing, over-prescribing, and over-treating of patients. It should not be directed by patient wishes and desires.  With all the regulations, mandates, restrictions, and concerns of litigation being placed on physicians, and the lack of an ethical framework such as the Hippocratic Oath used to provide, it is no wonder doctors have moved more into the role of service provider or technician.  At the same time, and likely as a result, morale is so low that physicians are burning out and leaving their profession before retirement age. The Association of American Medical Colleges “projects that there will be a shortage of up to 124,000 physicians by 2034. Beyond the impending shortage is the urgent need to address physician burnout” (Berg, 2023). In “The Way of Medicine: Ethics and the Healing Profession” Curlin and Tollefsen write, “Medicine has lost its way because it lacks clarity about where the way should lead. We no longer have a shared public understanding of what medicine is for or what the end of medicine is or should be. Rather, medicine has substituted for its once clearly recognized purpose something amorphous, subjective, and shadowy. Consequently, the norms that medical professionals and professional ethics bring to medical practice are devoid of objective content and radically deficient for guiding doctors and protecting patients” (Curlin & Tollefsen, 2021).

In light of the lack of clarity and consensus on what medicine is, and competing medical ethical frameworks, let’s turn to some medical issues facing us today and address the proper role of medical management of these patients.

Gender Dysphoria and Body Dysmorphia

The Mayo Clinic states that gender dysphoria, “is the feeling of discomfort or distress that might occur in people whose gender identity differs from their sex assigned at birth or sex-related physical characteristics” (Mayo Clinic, 2024). And body dysmorphia is defined as “a mental health condition in which you can't stop thinking about one or more perceived defects or flaws in your appearance — a flaw that appears minor or can't be seen by others. But you may feel so embarrassed, ashamed, and anxious that you may avoid many social situations“(Mayo Clinic, 2022). While there may be some overlap in these two conditions, e.g. someone who is distressed by their sexed body, can also be ashamed and anxious about what they may perceive about their appearance, such as, “I’m too fat and I also have discomfort about having breasts”.  There is also the condition of apotemnophilia, where the person has the desire to remove their healthy limbs and feels they should have been born in a “limbless body”.  The distress that each of these conditions and mental disorders causes is real and requires medical expertise, specifically from psychiatrists and or clinical psychologists who can help the patient return to a state of health, in this case, mental health. In these cases, the state of health that the physician is tasked with is to help one to become comfortable in their given body.  As is often said, we don’t offer liposuction to someone dangerously thin to help them feel comfortable in what they perceive to be an overweight body.  Similarly, we shouldn’t offer to amputate healthy arms or legs so that a person who has distress over their limbs feels better. Both the gender dysphoric and apotemnophiliac person may harbor feelings of distress from a perception of having been “born in the wrong body” or they may gain attention and praise for claiming a special “identity”. Many have heard of the child who lacks friends or might have been bullied; but when they announce that they have decided to “transition,” they are celebrated and achieve instant popularity. Similarly, the apotemnophiliac may seek surgery because they “want amputation as a way to gain sympathy from others” (Elliot, 2000). The ethical issues for the physician caring for these types of decisions of individuals will vary depending on how they order their ethical decision-making. Would the utilitarian refuse to amputate healthy limbs or organs in order not to waste medical resources? Or would he see this is a growing patient population of people with dysphoria or dysmorphia, who would benefit from surgical intervention and could be justified for the greater good? Would the consequentialist refuse these therapies since the given outcome cannot be predicted to be successful in alleviating the patient’s distress or would they be convinced by weak evidence that these therapies do good?  Autonomy and justice certainly can be distorted to allow for and even give an ethical gloss of good standards of care when the patient requests or demands such interventions and any denial is seen as taking away patient autonomy and a matter of injustice.

The Red Herring – Plastic Surgery

One often hears, when making the case of what medicine is or is not, the “what about plastic surgery” argument?  If doctors aren’t supposed to surgically remove healthy limbs, breasts, or genitalia, what about the woman who gets breast augmentation or a person who gets a facelift, nose job, or a tummy tuck?  First, if medicine is to be aimed at a person’s health, there is a role for plastic surgery in cases where, for example, a baby is born with a cleft palate and or cleft lip.  These repairs need to be done to restore normal function and allow a baby to eat, get nourishment, and grow, and this is in the domain of the well-trained experts in plastic surgery. The same is true for plastic surgeons who deal with trauma or burn patients.  The aim is to restore health as much as possible and to return loss of function to a state of better or full function.  Botox, cosmetic surgeries, and procedures are not the aim of medicine as there is no state of disease or illness.  This is purely for cosmetic purposes and not restorative reasons. If one argues that these people have body dysmorphia and are distressed by the size of their breasts or their sagging skin due to natural aging processes, then this person may benefit from counseling or therapy to help them come to terms with the body that they have. To rebut the claim that plastic surgery for cosmetic purposes is the same as surgery for sexual reassignment, one just needs to explain what the purpose of medicine is and is not.  Medicine is not consumer-driven care.  It is an art aimed at the health of the individual. Not removing healthy limbs, organs, or tissue because we feel uncomfortable with our body and its appearance.

What we face now is a time where people are building their identity around a desire, a wish, or a want, to alleviate personal stress or discomfort, and this rebuilding of one’s identity has reduced the profession of medicine from a healing art down to a that of a wish granter. Make my nose smaller.  Make my breasts bigger. Remove my penis and make me a vagina, otherwise you are harming me, not doing good by me, you are not respecting my autonomy, and this is an injustice since my doctor is here to do that which I ask of him.

The Way Back

If we, as a society, don’t sort this out soon, and restore medicine back to its sole aim, that of the mental and physical health of the patient, there will just be another “thing” which comes along.  Will physicians begin transplanting uteruses into men so that they can fulfill their desire to go through pregnancy and delivery of a baby?  Or gestating babies into artificial wombs, so that one is not burdened with a nine-month pregnancy?  There will be no bottom to these sorts of scenarios if the patient is a consumer of medical services and the physician is just the technician who is tasked to provide for the wants and desires of the individual. With so much at stake, let’s return to the roots and vision of Hippocrates.

Acknowledgments

The author wishes to acknowledge Kallie Fell, Gary Powell, and Joe Burgo, for careful reading of early manuscripts providing helpful comments.

References

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