Exploring roots of the Hippocratic Oath

"First do no harm."

It is perhaps the most famous medical text of all time, attributed to the master physician, an oath the swearing of which transforms students into doctors.

"I'm joining a fraternity of other physicians, a sacred community that I am blessed to be a part of," a visibly moved Eitan Kimchi said Friday after reciting it during Jefferson Medical College's commencement at the Kimmel Center.

Yet the origins of the oath are shrouded in mystery - the date of its writing unknown, its authorship in considerable doubt - and the words have been revised again and again to suit modern sensibilities.

What began as "I swear . . . by Apollo" became ". . . in the presence of the Almighty" and, in most current versions, ". . . by that which I hold most sacred."

To teach "without fee" may now be rendered as "impart a knowledge of the art of medicine to others." The original's directive against abortion is gone.

It's a good bet that no new doctor today will recite the words - from an authoritative translation of the ancient Greek by Heinrich von Staden of the Institute for Advanced Study in Princeton - about abstaining, when visiting the houses of the ill, "from sexual acts both upon women's bodies and upon men's, both of the free and of the slaves."

Still, the myth of a unique document endures, said Steven Peitzman, a professor of medicine who teaches the Hippocratic Oath at Drexel University College of Medicine.

"What shocks people is that it doesn't begin with 'first do no harm,' " Peitzman said. "It begins with, first, honor your teachers, and if your teachers are having a hard time, support your teachers. . . . It doesn't get to patients for quite a while."

But the oath powerfully conveys the concepts of honoring the art and the science of medicine, he said, and places doctors-to-be within a long tradition of healing.

"I want them to perceive that the lofty values that are in the oath reflect high standards of human behavior," said Peitzman, who compares the different versions in order to encourage his students to think analytically. "It has been rewritten to reflect the values of the time, and that is OK."

Little is actually known about Hippocrates, who is believed to have been born on the Greek island of Kos in the fifth century B.C. A series of writings by different authors over more than 100 years shared what Peitzman refers to as a naturalistic and "results-based" practice of medicine.

The treatises, aphorisms, and case studies of the time are grouped together as the Hippocratic Corpus. While the words "first do no harm" never appeared in the oath, the theme is clear and the directive is elsewhere.

Versions of the oath were known in the Middle Ages and Renaissance. In 1928, a survey found only about 20 percent of medical schools in the United States and Canada used it in ceremonies. Among them was Woman's Medical College (now Drexel), which Peitzman said used the most classic version.

Horror at Nazi doctors' experimentation on prisoners in concentration camps led to a post-World War II reemergence of the oath as the medical profession sought to emphasize humanistic values and prevent future atrocities. Recent surveys show some version is administered at more than 90 percent of North American medical school commencements.

While much of the language is different, it is true to many of the key themes that were first written on papyrus: Loyalty to the profession. Living and practicing in an honorable way. Refusing to give drugs or treatments for a criminal purpose, even if requested by a patient. Confidentiality.

All five medical schools in the Philadelphia region administer an oath, each slightly different.

The oldest of them, dating to 1954, was recited yesterday at the Academy of Music when 270 medical students received their degrees from the Philadelphia College of Osteopathic Medicine.

The Osteopathic Oath contains the same core themes but adds words that reflect its branch of the profession, calling on osteopathic doctors to be "keeping in mind always nature's laws and the body's inherent capacity for recovery."

Drexel students got to vote on nine versions before their commencement two weeks ago.

Among the rejects: the oath written for the classes of 1975 (". . . may all patients regardless of race, politics, sex, or social standing be regarded by me as a fellow human in pain . . .") and 1994 ("May I be motivated . . . not by financial issues or self-interest . . . "), as well as the Oath of Maimonides ("Thy eternal providence has appointed me to watch over the life and health of Thy creatures . . .") and the Declaration of Geneva ("I Solemnly Pledge Myself to Consecrate My Life to the Service of Humanity . . .").

Drexel's overwhelming winner, at least 10 years in a row, is based on a succinct "modern" version of the Hippocratic Oath that maintains a bit of the original flavor.

In a medical journal commentary last year, Larry N. Smith, a retired physician in Florida, criticized some attempts to create a "socially benign oath." He posed the question: "Should physicians hold themselves responsible to a higher position than the selfish needs of society, or are we just a reflection of society's needs?"

At Jefferson, students are asked to consider all angles. At the start of orientation, first-years are introduced to the oath, discuss it in small groups, and are assigned to write their own. But they recite the common "modern version" when receiving their white coats - at the traditional ceremony that begins their education as doctors - at the end of the week.

The personalized versions are put on file to be discussed in a third-year class, by which time many have encountered difficult clinical situations such as drug abusers and battered children.

Revisiting those oaths, some in the form of poetry, most brimming with altruism and hope, "reminds them not to be cynical, not to be hardened, but to maintain the compassion, empathy and humility in their practice of medicine," said Charles A. Pohl, a professor of pediatrics and associate dean.

Eitan Kimchi, 29, who is heading to the University of Maryland Medical Center to begin a residency in psychiatry, remembers well his experience of writing an oath.

He had taken a few years after college to travel, teach, and work as a therapist with autistic children, and was reading books about different religions. He tried to incorporate Jewish, Muslim, and Christian beliefs into his oath. He also emphasized his feeling that by putting "my loved ones first and taking care of myself I will be a better physician because I will be more whole."

Before administering the "modern" oath to Kimchi's Jefferson Medical College Class of 2009 on Friday, William D. Kocher, a clinical associate professor, invited the faculty to recite it along with the students.

"The actual piece," Pohl said earlier, "when you all stand up, it kind of gives you a chill."

Compare ancient and modern interpretations of the Hippocratic Oath, and the versions recited at medical schools around the region: http://go.philly.com/healthEndText