Pitfalls with the Hippocratic Oath and the Woke Oath
My friend Ted Levy, a retired doctor, told me over the phone this week that it’s not just the latest Woke Oath for doctors that is problematic; the traditional Hippocratic Oath is no prize either.
So I encouraged him to write up his point in two posts. The first takes on both the Hippocratic Oath and the Woke Oath. That’s below. The second is his preferred substitute, which he came up with. Here’s Part I, his criticisms:
Medical oaths have been in the news lately. Some conservatives have expressed dismay about a woke oath that has made the rounds, lamenting that society is moving away from the traditional Hippocratic Oath. In fact, that move happened quite a while ago. And the Hippocratic Oath has its own problems. So I thought it might be fun to analyze both the traditional oath and the recent woke oath, and perhaps compare them to what we’d want to see in a medical oath that libertarians could embrace.
The Hippocratic Oath
Hippocrates of Kos was a Greek physician practicing around 400 BC, traditionally referred to as the “Father of Medicine.” The Hippocratic Oath is named after him. It is often thought to contain the famous phrase, “First, do no harm.” It does not. It is often thought to be an altruistic oath in which physicians pledge to do their best for the patient and for humanity. It is not. A simple economic analysis indicates that much of it was designed to maintain a medical guild capable of garnering supra-market profits by limiting competition.
Let’s consider some aspects of the Oath.
Early on, after swearing to Apollo—the God of, among other things, medicine—the young physician says he will “hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him.”
That is, doctors in training guarantee to provide financial security to academic physicians and, as needed, provide them with a sinecure. Nice work if you can get it.
But a physician-in-training must do even more for those masters who train him to enter the guild. The trainee must consider his master’s sons as his “own brothers, and to teach them this art, if they want to learn it, without fee or indenture.” Today, Ivy League schools are often condemned for offering “legacy admissions.” That’s the practice of a college giving preferential admissions treatment to the children of its alumni. As you can see, it’s not a new idea. The medical guild of Hippocrates’ time wrote it into its oath. Legacies don’t need to have any demonstrated competence. They are automatically accepted and they get training for free. Good deal if you can get it. But the nature of guilds is, unfortunately, that most people can’t get it.
The Hippocratic Oath continues with a pledge “to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the Healer’s oath, but to nobody else.” It’s hard to get clearer than that. The medical guild supporting the oath wants to restrict practitioners not to those who best perform medical skills to benefit patients, but as much as possible to their own families, friends, and loved ones. BUT TO NOBODY ELSE.
The oath then delves into two issues that, thousands of years later, remain hot button topics. Ancient practitioners pledged not to engage in euthanasia or abortion. You may well oppose both procedures today. Many do. But notice that in both cases the oath opposes patient autonomy, a value and principle not in evidence in ancient times but that has become pre-eminent in modern medical ethics.
Here’s yet one more example of how guilds function. The Hippocratic Oath includes a passage sounding odd to modern ears: “I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein.” In modern times a surgeon is a type of doctor. In ancient times a surgeon was an alternative to a doctor. Doctors treated what ailed their patients with potions, powders, ointments, and advice. Surgeons (who were also barbers) cut the patient open. The Hippocratic Oath (where “stone” refers to kidney stones or gallstones, horribly painful conditions for which surgery is generally warranted) tells doctors to do nothing in such cases but instead to send them to a surgeon/barber. In other words, they must uphold professional jurisdictional rules. Neither the medical nor the surgical guild competes with the other, to the benefit of both.
You may think, “That’s good. People with kidney stones should see a surgeon.” But, as any modern surgeon can tell you, sometimes they are sent patients on whom they could operate but who would do just as well with non-surgical treatment. In ancient times, such patients didn’t get the best treatment; they got the treatment based on the way the guilds divvied things up.
Medical guilds, protecting their members more than the public, have historically been the rule rather than the exception. Historian Ronald Hamowy, in his article “The Early Development of Medical Licensing Laws in the United States 1875-1900,” appearing in the Journal of Libertarian Studies 3 (1):73-119 (1979), noted that from its origin in 1847 the American Medical Association spared no effort at restricting medical supply, largely via licensing. The AMA’s code of medical ethics, based on and expanding from Hippocrates’ Oath, contained a variety of principles not based on patient care but on physician avarice. For example, one edition of the AMA’s Code of Medical Ethics stressed the impropriety of “A wealthy physician [giving] advice gratis to the affluent.” Why? Because it decreases the “common funds” of the guild, thereby “defrauding” fellow doctors.
But now, in the 21st century, only about 15 percent of American physicians are members of the AMA. The dramatic growth of third-party, largely governmental, payments to physicians in the second half of the 20th century achieved the AMA’s long sought goals of limiting supply and increasing physician revenue and thereby ironically diminished its membership among now satisfied private practice doctors. Instead, as government rules, regulations, and restrictions became a more substantial part of the physician’s practice, and had to be stressed in medical education, academic medical faculty and administrators became more important among AMA members. And academic medical faculty, of late, tend to be woke.
A Woke Oath
In December 2022, Robert Englander, MD, MPH, Associate Dean of Undergraduate Medical Education at the University of Minnesota school of medicine, led the first year medical students in their White Coat ceremony. That’s a traditional ceremony in the move from layperson to medical professional, where students first get to wear the symbolic “white coats,” garb they will continue to don throughout their medical school, internship, and residency. But Dr. Englander’s words, dutifully repeated by the first years, was anything but traditional. He had re-written the medical oath to, in his vision, fit the times.
He began by noting that the medical school was “located on Dakota land,” referring to land owned by the Dakota Indian tribe. He added:
“[T]his acknowledgment is not enough. We commit to uprooting the legacy and perpetuation of structural violence deeply embedded within the healthcare system. We recognize inequities built by past and present traumas rooted in white supremacy, colonialism, the gender binary, ableism, and all forms of oppression.”
So it seems clear that when Englander (how appropriate a name for someone recognizing his role in white supremacy and colonialism!) said the medical school was “located on Dakota land” he didn’t mean “purchased from the Dakota Indians.” He meant illegitimately taken from them. Yet for all his expressed willingness to end the “perpetuation of structural violence” and recognize the inequities rooted in white supremacy, colonialism, the gender binary, ableism (in a medical school??, a place devoted to training people to aid the sick and infirm??), and “all forms of oppression” Englander never mentioned his willingness to give the stolen land back. I can’t speak for Native Americans, of course, but I’d be willing to bet that given the choice of getting their land back or dealing with the traumas associated with the gender binary, they’d take the land.
Englander and his woke oath were nowhere near finished, though. It went on to pledge “healing our planet.” As Alex Epstein has noted in his book Fossil Future, environmental pleas to heal the planet involve demands to minimize if not eliminate human impact on the environment. Thus the need to reduce energy use as much as possible. Does Englander have any idea how much energy modern hospitals use? Maybe that’s why his pledge also commits to “honor all Indigenous ways of healing that have been historically marginalized by Western medicine.” Granted, acupuncture and medicinal herbs use much less energy than CT scanners and extracorporeal lithotripsy units.
The Woke Oath also contains a vow “to embrace our role as community members and strive to embody cultural humility” yet also to “learn from the scientific innovations made before us and pledge to advance and share this knowledge with peers and neighbors.” The Woke never see the contradictions in their visions. Many communities in America, we’ve learned in the last few years, are concerned about vaccines. Should the white coats learning about Jenner’s past scientific innovation “share this knowledge” with community neighbors? Or should they “embody cultural humility” and not bring it up, instead recommending “indigenous ways of healing…historically marginalized” in the past?
A reading of this version of a medical oath on YouTube led to much consternation. FIRE, the Foundation for Individual Rights and Expression, sent the medical school a letter of concern and received confirmation from the dean that no one was forced to attend the White Coat ceremony or take the oath. But if you get sick in the Minnesota area in the future, be sure to remember that you have indigenous and historically marginalized, as well as Western, medicine options to choose from. Well, maybe not all Western medical options, but at least the culturally humble ones.
The picture above is of Hippocrates.
Next up: Ted Levy’s suggested pro-medical liberty replacement.
Dec 16 2022 at 12:46pm
Do pledges impact behavior? The states of Vermont, Wyoming, and Hawaii do not require the pledge of allegiance; are their citizens less patriotic in any measurable way? Pledges and oaths are part of many epics and sagas, but epics and sagas are fictions. I have been to graduations for me and others where prayers were said and oaths recited. I don’t think that I am the only person who sat through that stuff bored and hoping that they would get on with the ceremony. In 1955 we began requiring “In God We Trust” on our money; have we become godlier as a result?
Dec 22 2022 at 3:35pm
Oaths may not dictate behavior, but they set a tone. Prospective NCOs regurgitate the NCO Creed every day in the military with no real understanding of anything they’ve saying. But, many of them grow into it over time. Not all, by any means. But many.
Dec 16 2022 at 4:08pm
Graduated from Penn in early 80s. Wife graduated from Univ of Texas same period. Neither of us did the Hippocratic oath. We each did some oaths the details of which we dont remember. There are some good parts to it, like keeping patient info confidential and agreeing to not behave with impropriety or try to use their position to seduce people. (The oath caused issues for Christians also as you are swearing by Apollo and all of the Gods.) All that said even those who took the oath in the 50s and 60s when it was still a thing just ignored the parts of the oath that didnt make sense or really apply.
I have a hard time seeing the woke oath affecting much that doctors will do. Have talked this over with some med students and residents. The Dakotas owned the land in the past? Ok, will that decide which labs you order? The only part that might actually affect how people work is the indigenous healing part, but again I think this will mostly be ignored or people will tell pts its ok to engage in their own healing as long as they also follow modern standards.
Cultural humility? That’s a tough one. I occasionally ask pts why they didnt get vaccinated. I am not supposed to do that as it is deemed culturally insensitive and might hurt their feelings. Definitely not politically correct. However, I am retiring soon, I chair the department and I dont care. My sense is that very few of those not vaccinated are due to cultural reasons. I think it is more because of their tribal affiliations or they spend their time on conspiracy sites. They tell me that the vaccines have killed more people, a lot more, than the disease. That just doesnt seem to be a cultural thing.
Dec 16 2022 at 4:28pm
Excellent post, Dr. Levy. Licensure, regulatory capture, ESG and woke are anathema.
Dec 16 2022 at 4:34pm
What a delightful post! I’d never heard any of this.
But regarding the admonition to impart instruction to certain people, “but to nobody else”: A better translation would say “AND to nobody.else.” That was my maiden name.
Dec 16 2022 at 5:47pm
The defiant insistence that the land is – present tense – ‘Dakota land’ (when really it hasn’t been Dakota land for generations) is amusingly irredentist and nationalistic, on behalf of the Dakota peoples. The wars that tore up Europe for centuries were often justified by a similar logic: some land was inhabited by our ethnic group a long time ago, but they were (often brutally) displaced, killed, or subjugated, but in some innate sense, it still belongs to “us,” so we’re going to take it “back” from the people who “stole it” (but really, descendants who’ve lived there all their lives and who’s great grandparents lived there all their lives). One of the key reasons Europe has been so peaceful the last 80 years is it has embraced realism with respect to its borders, accepting that borders and people should generally be left alone as they are, rather than violently restructured in accord with who lived where hundreds of years ago. Though I’m sure Dakota irredentism isn’t a threat to Minnesota, it’s still a bad idea to breathe life into this nationalistic conception of ethnic land ownership.
Dec 17 2022 at 12:40pm
<p>I never knew the original oath had that much to it.</p>
<p>I’m not sure “But notice that in both cases the oath opposes patient autonomy” is right. I’ve never heard a baby give permission for its abortion.</p>
Dec 17 2022 at 10:57pm
Hippocratic oath is pertinent in the sense it talks of things relevant to the profession and the patients. You may not agree as the ancient opinions clash with modern dogma of abortion and euthanasia. But the oath has underlain western medicine for 2500 years. Were it not for prohibition against abortion, how many Western people would exist now? To quibble about patient autonomy.
Guide restrictions are well in their own place and are probably necessary in absence of strong central authorities.
Dec 28 2022 at 7:50pm
Patient autonomy is one of the cornerstones of modern medical ethics, along with beneficence, non-maleficence, and justice.
To so brazenly ignore it, while throwing a straw man about abortion, shows a clear lack of understanding about the issue at hand.
Dec 18 2022 at 11:41am
David (and Ted): I find this post especially interesting as it contradicts what I thought I understood from reading parts of Jacques Jouanna’s Hippocrates (John Hopkins University Press, 1999) and of Ludwig Edelstein’s Ancient Medicine (John Hopkins Press, 1967) two decades ago. In these books, you get the idea of the Hippocratic Oath not as justifying a guild (in the medieval or modern hidden sense), but as brand name on a free market. Jouanna writes (p. 77-78):
Edelstein suggests the same idea:
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