Only 1 medical school uses classic version of Hippocratic Oath

In the eight years since Antonio M. Gotto Jr., MD, took over as dean of the Weill Medical College of Cornell University in New York, he has met with graduating students the day before commencement to get down the proper pronunciation of their names and run through a recitation of Cornell's version of the Hippocratic Oath.

Some of the language was so archaic that students, who had little prior exposure to the oath, found it humorous.

"[Students] would laugh at certain parts," Dr. Gotto said. "Then I'd give them dire threats that I wouldn't graduate them the next day if they laughed during the ceremony."

Student reaction prompted Dr. Gotto to form a 20-member committee of faculty and students to rewrite the oath. June 2005 marked Cornell's first commencement in which students recited the new version, still dubbed the Hippocratic Oath.

No one laughed during the ceremony. But along with the laughter, some of the precepts Hippocrates laid down 2,500 years ago also are missing when modern-day medical students take their oaths.

In fact, with the State University of New York Upstate Medical School in Syracuse the only U.S. medical school that still administers the classical Hippocratic Oath, the vast majority of graduating medical students don't swear to avoid performing abortions, assisting suicides or having sex with patients as a part of their oath.

An Academic Medicine study of the 141 allopathic and osteopathic school oaths in use in 2000 found that:

• One explicitly prohibited abortion.
• Four urged physicians to avoid sexual relationships with patients.
• Twenty-five explicitly prohibited physician-assisted suicide. Among those, 19 were schools using the Osteopathic Oath.

Kayhan J. Parsi, PhD, co-author of the Academic Medicine study, pointed out that many contemporary oaths feature ethical precepts absent from the classical Hippocratic Oath, such as putting the patient's welfare first, respecting patient autonomy, avoiding bias and advancing a just society.

But conservative critics of the move away from the classic Hippocratic Oath charge that while oath-taking has become more widespread as a symbolic gesture, its substantive value has been diminished.

Though the Hippocratic Oath is millennia old, widespread use of oaths in North American medical schools is relatively new. As recently as 1928, fewer than a quarter of medical schools in the United States and Canada used an oath, says a 1997 study in The Journal of Clinical Ethics.

"The practice of giving an oath to graduating medical students has increased dramatically in the last 100 years," said Robert D. Orr, MD, who co-authored the article and is director of clinical ethics at the University of Vermont College of Medicine. "At the same time, the content has been diluted. We're sort of at cross-purposes. The profession is saying, 'Yes, it's important to pledge honor to something,' but in order to make it more universal and acceptable to a broader number of people, it's been watered down."

This so-called dilution of the Hippocratic Oath has led groups to push back. For example, each year more than a thousand graduating medical students take the Christian Physicians' Oath in separate campus ceremonies, vowing to "care for all my patients, rejecting those interventions which either intentionally destroy or actively end the lives of the unborn, the infirm and the terminally ill."

Officials at Cornell and elsewhere argue that changes to the classic oath are necessary to engage students and accommodate a more contemporary understanding of medical ethics. Cornell's previous version of the Hippocratic Oath did not include prohibitions of abortion or physician-assisted suicide, and the 21st-century iteration also purposely steers clear of those hot-button issues, according to Joseph Fins, MD, who led the school's oath committee.

"Those are contentious issues," said Dr. Fins, chief of Cornell's division of medical ethics and a professor of medicine and public health. "Do you want to impose an oath on students that probably half of them could not agree to?

"The prescriptive oath, in a sense, is one that purports to have all the answers," he added. "This breaches the notion of a community. What should mark the professional community today is the willingness to engage ideas and be reflective, all in the service of advocating for patients."

One medical ethicist says much of the debate over the oath is misguided. In The Hippocratic Oath and the Ethics of Medicine, Steven Miles, MD, a bioethics professor at the University of Minnesota Medical School, argues that what are read today as prohibitions of assisted suicide and abortion were actually injunctions against providing poisons to assassins and a particular type of abortive suppository known even then to do irreparable damage to women.

"When you read a document like the Hippocratic Oath," Dr. Miles said, "you have to read what it was saying to its time and judge how fair it is to extrapolate it to the problems in our time."