sábado, 11 de agosto de 2018

THE HIPPOCRATIC OATH – POETIC, SYMBOLIC AND MORAL INTERPRETATION

THE HIPPOCRATIC OATH – POETIC, SYMBOLIC AND MORAL INTERPRETATION

Author: Helio Angotti-Neto, MD, PhD
Address: Coordination of the Medical School - UNESC, Bloco A. Avenida Fioravante Rossi, 2930. City of Colatina – Espírito Santo. Brazil. CEP: 29703-900
Affiliations: Dean of UNESC Medical School, Member of the Institutional Review Board of UNESC, Editorial Director of Mirabilia Medicinae. Visiting Scholar of the Global Bioethics Education Initiative of the Center for Bioethics and Human Dignity - 2016.

ABSTRACT 
The Hippocratic Oath remains as one of the most loved - or loathed - ethical texts in Medical Ethics and Bioethics. The objective of this essay is to clarify its poetic and symbolic interpretations, searching for the adequate use of the Oath; and to suggest that it remains a useful tool for Bioethics and Medical Ethics inspiration and teaching. Using the Aristotelian Theory of the Four Discourses, we analyze the Oath alongside with an interpretation of its direct, indirect, specific and general moral prescriptions. It is a poetic text, which can be used to cause a powerful impression upon the new physician, helping in his moral education and in his commitment with the moral community of Medicine. 
Keywords: Hippocratic Oath, Hippocrates, Aristotle

INTRODUCTION AND OBJECTIVES
The Hippocratic Oath is one of the many classical texts of the universal literature. It is a product of great medical thinkers from the distant past, in Ancient Greece, whom culture still is one of the pillars of the Western Civilization. As a classic text, the Oath keeps an aspect of transcendence, being capable of communication with many different cultures and periods. Although it is a very short classic text, it remained extremely important not only in Medical Ethics along the centuries, but also in the contemporary bioethical debate and education as a model for the most basic moral commitments in healthcare (Miles 2004, 189-192).
In ancient times, the Hippocratic Oath raised many praises among philosophers and physicians. Scribonius Largus, from Ancient Rome, highlighted its use for the inspiration of young students’ minds and hearts (Pellegrino & Pellegrino 1988, 22-38). And even today, the Hippocratic Oath still raises some praises among contemporary physicians, who recognize in it something morally valuable. On the other side of the question, many bioethicists and physicians question its validity for the contemporary professionals; they exhibit the Oath as something outdated and morally inadequate to contemporary medicine.
Bernard Nathanson acknowledged this fact when he said that:
"It has become fashionable in the circles of the bien-pensants bioethicists to denigrate the Oath: to point with derision at its failures - for example, the omission of any reference to informed consent of the patient. Nevertheless, in a world as savage and primitive as was the island of Cos in the year 450 B.C., the expression of compassion, of respect for one's teachers, for life itself was and remains a monument to the beauty of the human soul and the dignity of the human person. Such monuments should not be hastily abandoned" (Nathanson 1996, 53-54).
How can a short text from an old time raise such disagreement? I argue that there is a significant chance that one “side” of the question is reading the Oath without the necessary literary and symbolic comprehension, or even without that empathic effort needed to reach for their neighbor from the past.
The purpose of this work is (1) to analyze and classify the Hippocratic Oath using the Aristotelian Theory of the Four Discourses[1]combined with an essentialist and symbolic approach; (2) to review some of the positive and negative critiques of the code; (3) to understand contemporary uses for the Oath and its importance; and (4) to offer an adequate method for its interpretation.
A CLASSIC TEXT
The Hippocratic Oath can be considered a classic for many reasons. The main reason is that it is very old and has survived the proof of time, reaching our civilization almost untouched; thanks to the work of ancient copyists from the Middle-Ages.  As a classic text, the Oath has many significations compressed in a small space, and it provides many interpretations according to the intellectual and moral development of its reader. The Oath also has a transcendent and non-temporal quality, containing a narrative that retains elements which are always contemporary in many aspects, appealing to a common morality. Finally, it gives the trained reader the tools to understand reality (Calvino 1999).
As a classic text, the Hippocratic Oath is also part of our collective identity. It is a special cultural foundation for a very influential area in our societies: the exercise of Healthcare. 
Physicians are everywhere in our history, and their counsels dictate for the most part of humanity how one should behave and live to reach a good health or how one must search for a cure - conditions which are necessary for a good life without suffering and severe limitations.

A POPULAR TEXT
The Hippocratic Oath remains popular, attracting criticism and praises from highbrow scholars and popular culture at the same time.  In the Academy there is a great volume of books, articles and media related to the Oath, and it still remains as an important topic in Bioethics circles.
There are those who would oppose its use, considering it outdated and incomplete (Beauchamp & Childress 2012), or just incompatible with contemporary religious and secular standards (Veatch 2012). From other perspective, there are those who would endorse the use of the Hippocratic Oath for several activities, including moral medical teaching (Cameron 2001; Miles 2004). The fact is that some precautions must be taken before one would use or criticize the Hippocratic Oath text (Joterrand 2005, 107-128).
Perhaps a first step would be the understanding of its form and its final cause, which can be provided by a technique which is both philosophic and literary, as seen in the Aristotelian Theory of the Four Discourses, systematized by the philosopher Olavo de Carvalho in Brazil (2013).

CLASSIFICATION OF THE OATH ACCORDING TO THE ARISTOTELIAN THEORY OF THE FOUR DISCOURSES
The Aristotelian Theory of the Four Discourses can be used to classify, understand and pragmatically apply all kinds of discourse in society departing from a formal and essential identification of the text according to the Metaphysics of Aristotle (Reale 2010). It is a classification with a very broad possibility of being used, even in medical education (Angotti Neto 2014, 151-159).
To better understand this classification, one could start using a negative form of explanation, excluding each one of the classifications that would not apply.
The Oath is not a Logic discourse - although it certainly has some logic in itself - because it does not pretend to offer an apodictic reasoning, and it does not depart from premises to reach unavoidable conclusions.
The Oath is not a Dialectic Discourse because it does not compare two different hypothesis in conflict of what should be medicine. It does not try to reach a more probable conclusion, it only offers a specific vision of what is the right thing to do or understand.
 The Oath is not a Rhetoric Discourse, although it can be used in a rhetoric speech, because it does not demand a decision or a change in mind from the listener immediately; it needs someone who already believes in the statements which are to be invoked. The text is not a rhetoric defense of justice, in Aristotelian terms; it is an explicit exposition of what is good in the practice of medicine.
Finally, the Oath can only be in the Poetic form. It is written to reinforce or to cause an impression, in the form of a narrative of intentions. It is the less rigid form of discourse, but at the same time it is the most impressive one. It doesn’t have the rigid form and thought of logical and dialectical discourses, but it does not need all the intellectual preparation for being understood that a text in logical or dialectical modes would demand, although it needs certain intellectual measures to be approached after more than two millennia. It does not wait for an immediate decision from the listener or from the one who take the Oath, like the Rhetoric discourse. The decision was already made before the invocation, and the Oath remains as a solemn confirmation of what one should believe. 
According to Edelstein, “The Hippocratic Oath originally was a literary manifesto, a programme laid down by one who wished to set matters right in accordance with his own convictions” (Edelstein 1956, 392-418).
In a time when “Hippocratism is in decline, once more the medical faith of a minority”, the use of the Oath “is returning to its original role – that of a manifesto for reform in medical values” (Cameron 2001, 51).
As a Poetic discourse, the Oath has the most uncontrollable results, but at the same time it generates the deepest and longest-term changes in the psyche of the one who reads it or says it aloud before an audience.
Without the comprehension of its form, its objectives and its possibilities, one can hardly proceed to the interpretation of its moral prescriptions.

AN OATH, NOT A CODE
The ancient poetic formulations on Medical Ethics were mainly composed of prayers and oaths, which can be exemplified in the “Prayer of a Physician”, allegedly from Moses Maimonides (1135-1204 DC) and in the Hippocratic Oath (Bird & Barlow 1989).
“It must be clearly understood that the Oath was devised, not as law, but as a precept. Unlike the Code of Hamurabi, it makes no mention of penalties. The Hippocratic Oath was a counsel of perfection; an attempt to set up a high moral standard. For centuries, and indeed until the establishment of such courts as the General Medical Council [in Great Britain], founded in 1858, an appeal to conscience was the only means of elevating the moral tone of the medical profession, and of showing that character was as important as knowledge in the practice of medicine” (Guthrie 1978).
A Code, usually written in the Logic form, has to be more detailed, and has to emphasize norms and laws within a structure of major and minor statements linked by a logical arrangement. Its objective is not focused on values, but on procedures. Codes need to be inclusive and complete, pretending to be a very specific and reliable source for medical conduct; things which cannot be said of a Prayer or an Oath.
When some scholars addresses the Hippocratic Oath as a Code, or criticizes its use as inspirational substance, there is a confusion concerning the understanding and interpretation of different discursive forms, which invalidates the critique in many ways (Veatch 2012).
The Oath, as a Poetic text, outside a correct contextualization, defiled by an unimaginative and vulgar interpretation, certainly will lose its philosophical recommendation value for the listener. It also will never have the scope of a code. The solution is not to attack or just to ignore the Oath for not being a complete and updated code, but to understand it better and to have some empathy to its original developers. These are pre-requisites for accessing and understanding classical culture in general.

METHOD FOR INTERPRETATION OF THE HIPPOCRATIC OATH
After the understanding of which one is the discourse form of the classic Oath, we will analyze its matter with a teleological approach, which seems to be the more proper way, since its intentional creator had specific uses and effects in mind. To better understand the Oath, we will divide its statements in four different categories:
(1)          General Context Information – aspects of the general Classic Greek culture which are exposed in the Oath as background for moral prescriptions;
(2)          Specific Context Information – aspects which were specific of the Greek Hippocratic physicians and are exposed as background for moral prescriptions;
(3)          Indirect Moral Prescriptions – specific attitudes and actions of the ancient Greek physicians which reflects an underlying value, principle or moral prescription;
(4)          Direct Moral Prescriptions – prescriptions of principles, values or specific morality behaviors by the Hippocratic physicians.
However, we will not try to make an extensive and very detailed analysis, which one can find in several works in the Medical Ethics and Bioethics fields of study (Angotti 2016). I will detain myself in a few examples of each kind of statement for the instruction of the reader, who can use the same tools along with the study of Classical Culture so one can better understand the whole Hippocratic Oath.
A possible use of this classification is to validate or criticize any critique against the Oath. Only a critique directly made to direct moral prescriptions can be deemed proper without some elaboration. Every other kind of direct critique must face some restrictions to avoid what is commonly known as a strawman argument.
A critique against a General Context Information, for example, is not a critique against the Oath itself, or against the Hippocratic physicians. It is a critique against Ancient Greek culture in general.
A critique against a Specific Context Information should comprise the cultural and contextual elements of the text, trying even to do a symbolic understanding of the cultural value of the text for ancient Greeks. Specially for Greek Hippocratic Physicians.
A critique against the Indirect Moral Prescriptions should not be directed to the action per se, but should be addressed to the underlying moral value.
If a reader is not openminded enough to judge a text in the best context possible, as the author of any text would like to be judged, the critique probably will not be valid, it only would be a denigration of the original text and its original intent.

THE ORIGINAL HIPPOCRATIC TEXT
The classic translation by Edelstein from the Attic Greek (Edelstein 1987)[2]is reproduced here so the reader can look directly in the text for the statements and their contexts:
“I swear by Apollo the Physician and Asclepius and Hygieia and Panaceia and all the gods, and goddesses, making them my witnesses, that I will fulfill 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 the oath according to 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 guard my life and my art. I will not use the knife, not even on sufferers from stone, but will withdraw in favor 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 intentional 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 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 myself holding such things shameful to be spoken about. If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored 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.

GENERAL CONTEXT INFORMATION
There are some elements in the original text that just describe general aspects from the Ancient Greek society, and have no prescriptive value, functioning only as background to better understand the existential context of the Oath.
One could, for example, try to accuse the Hippocratic Oath of “sexism” appealing to the passage translated by Edelstein (1987) in which the author mentions male teaching exclusivity, telling us that: 
“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…”
However, this accusation does not stand against the Hippocratic Oath and the Physicians themselves, it stands against all society and the role which women had at that time. Later, such things would gradually change, even with several reports of female physicians in the Roman Empire (Israelovitch 2015, 70-86).
Another common accusation against the Oath is that it is completely outdated because it mentions slavery (Jones 1923, 289-302): “I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free.” It is plainly obvious that a text with more than two thousand years will contain much anachronic information, but the core of this fragment is not the mention of slavery, it is the respect for both slaves and free people, man and women.
Finally, one cannot judge all the classics from the past according to its adherence to contemporary customs and accidental rules. This would be a strange kind of temporal solipsism. 
A true effort is needed to understand the common moral aspects and values that keep the Oath and many other classics always interesting, despite the great time lapse between the texts and our age.

SPECIFIC CONTEXT INFORMATION
Along with general aspects of Greek society, there are also specific aspects of Ancient Greek Medicine in the Oath, which can be seen in the opening of the text when the applicant conjures the Greek gods, especially Apollo, Hygeia, Panacea and the demi-god Asclepius.
The Oath opening is perhaps the most condensed and enigmatic part for those who don’t know Greek Mythology and those who neglect the characteristics of a Poetic discourse. The deference to a specific pantheon of gods is a demonstration of commitment for specific values by the Hippocratic physicians. The calling of the gods meant basically three things for the Greek: (1) the notion of immortality; (2) the character of sacredness of the polislinked to the gods; and (3) manifested human possibilities according to the mýthoi– their stories – as exemplified by the gods (Marías 1970, 27).
Apollo represents reason and the capacity of making prognosis. Hygeia stands for the good habits which can bring health: hygiene. Panacea is the goddess of medicines: pharmacological therapy. Asclepios was the father of all physicians, the gentle and caring god (Miles 2004).
A critique directed to the superstitious evocation of the Pagan gods is superficial, considering that there are many existential aspects depicted in the selection of deities which was made by the author of the Oath. The best way to criticize this specific element of Greek culture would be to attack the principles of action involved, like the use of the prognostic art when one invokes Apollo. However, such an attack would dismantle medicine’s identity and practice completely, for therapy (Panacea), prognostication and diagnosis (Apollo), and prevention (Hygeia) are still the basic foundations for the desirable medical practice.

INDIRECT MORAL PRESCRIPTIONS
Most part of the Hippocratic Oath is composed of indirect moral prescriptions by ordering several specific actions and by prohibiting others. 
Perhaps, one of the most easily attacked fragments of the Oath is the statement that “I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work” (Edelstein 1943). The easier form to comment this part is to say that it is completely inadequate and anachronic, considering that in our days the physicians would have no qualms against doing surgery. However, to put things this way completely misses the point in a context of underlying values and virtues’ prescriptions.
There are several explications for why the Hippocratic physicians would not perform great surgeries, which were performed back then with a modest rate of success. There is the hypothesis that they would not touch human blood risking the life of the patient, according to the practices of some esoteric schools like the Pythagoreans, or that they simply avoided surgeries because they choose to focus on therapeutic and less invasive arts (Arbagin 1987, 159-181). But there is a necessary and unavoidable interpretation: physicians were recognizing their own limits concerning their capacity or disposition in doing good for their patients, and were sending those patients in need for others who could better attend them and their disease with surgical procedures. More than a matter of doing or not surgery, this part of the text shows underlying virtues such as humility, self-knowledge and cooperation with other healers for the good of the patient. 
Another interesting segment of the Oath that we can use as an example has negative prescriptions of moral actions, denying the possibility to make abortions or to practice assisted suicide. In a very different fashion, when comparing with the previously analyzed segment, here the physician would not send the patient to anyone, he would just vow to avoid such things. Underneath these negative prohibitions, there is a very direct perception that human life was precious and should be protected against intentional harm.
A critique directed against the action without bear in mind the underlying values or virtues should be considered inadequate. One must read “between the lines” and understand the core virtues or values presented in the text, and only then proceed to a valid critique.

DIRECT MORAL PRESCRIPTIONS
Perhaps, the most accessible parts of the Oath would be those with the direct prescription of virtues and values. At the same time, these would carry the broadest possibilities of application in the physician’s life, and also would be the vaguest, what just reinforces the necessity of knowing the Ancient Greek context before trying to interpret the text.
A very direct statement says that “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” (Edelstein 1943). This is a direct prescription of virtues like benevolence, non-malevolence and justice. 
There can be some scholars who will attack benevolence directly, for example, opposing it to the patient’s autonomy and integrity (Veatch 2012) in the frame provided by the well-known work of Beauchamp and Childress (2012). However, this frame of conflicting prima facieprinciples does not offer the best justification for such an attack, and other forms of interpretation and framing of the question can be seen, such as in the work of Edmund D. Pellegrino, who opposes patient’s autonomy to paternalism, and keeps benevolence and integrity as higher virtues which should guide the physician-patient relationship (Pellegrino & Thomasma 1988). This last virtue-based approach is also more compatible with the morality of that ancient time (Macintyre 2008).

CONCLUSIONS
The Hippocratic Oath is an ancient symbol of morality for the medical profession since ancient times. It must be interpreted in an adequate way, considering its form and essence, which is Poetic according to the Aristotelian Theory of the Four Discourses. Considering its statements, one can find general aspects from Ancient Greek society, specific aspects of the medicine practiced in Ancient Greece, prescriptions of actions which presuppose underlying values or virtues, and direct prescription of values and virtues. Each one of these different forms of expression demands different approaches when one tries to criticize the original text. Although very ancient and sometimes obscure to the unprepared reader, the text retains many valuable moral aspects which can still be used and comprehended by Healthcare professionals, remaining as a very old thorn in Bioethics’ hide (Koch 2013, 75-88).
The reading of ancient texts will not teach us Science. However, these old texts can help us in learning what does it mean to be a good physician for our patients. Through the use of empathy and cultural studies one can still find good models in the history of Medicine who will help in the shaping of a benevolent physician, which is a necessity that should guide, in a teleological form, all the technical and scientific teaching and practices.
 We believe that the teleological interpretation under the comprehension that the Oath is a Poetic text can offer a good opportunity to better understand its essence and its possibilities concerning actual medical education and ethics.

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[1]CARVALHO, Olavo de. Aristóteles em Nova Perspectiva: Introdução à Teoria dos Quatro DiscursosCampinas: Vide Editorial, 2014.
[2] Ὄμνυμι Ἀπόλλωνα ἰητρὸν καὶ Ἀσκληπιὸν καὶ Ὑγείαν καὶ Πανάκειαν καὶ θεοὺς πάντας τε καὶ πάσας, ἵστορας ποιεύμενος, ἐπιτελέα ποιήσειν κατὰ δύναμιν καὶ κρίσιν ἐμὴν ὅρκον τόνδε καὶ συγγραφὴν τήνδε· ἡγήσεσθαι μὲν τὸν διδάξαντά με τὴν τέχνην ταύτην ἴσα γενέτῃσιν ἐμοῖς, καὶ βίου κοινώσεσθαι, καὶ χρεῶν χρηΐζοντι μετάδοσιν ποιήσεσθαι, καὶ γένος τὸ ἐξ αὐτοῦ ἀδελφοῖς ἴσον ἐπικρινεῖν ἄρρεσι, καὶ διδάξειν τὴν τέχνην ταύτην, ἢν χρηΐζωσι μανθάνειν, ἄνευ μισθοῦ καὶ συγγραφῆς, παραγγελίης τε καὶ ἀκροήσιος καὶ τῆς λοίπης ἁπάσης μαθήσιος μετάδοσιν ποιήσεσθαι υἱοῖς τε ἐμοῖς καὶ τοῖς τοῦ ἐμὲ διδάξαντος, καὶ μαθητῇσι συγγεγραμμένοις τε καὶ ὡρκισμένοις νόμῳ ἰητρικῷ, ἄλλῳ δὲ οὐδενί. διαιτήμασί τε χρήσομαι ἐπ᾿ ὠφελείῃ καμνόντων κατὰ δύναμιν καὶ κρίσιν ἐμήν, ἐπὶ δηλήσει δὲ καὶ ἀδικίῃ εἴρξειν. οὐ δώσω δὲ οὐδὲ φάρμακον οὐδενὶ αἰτηθεὶς θανάσιμον, οὐδὲ ὑφηγήσομαι  συμβουλίην τοιήνδε· ὁμοίως δὲ οὐδὲ γυναικὶ πεσσὸν φθόριον δώσω. ἁγνῶς δὲ καὶ ὁσίως διατηρήσω βίον τὸν ἐμὸν καὶ τέχνην τὴν ἐμήν. οὐ τεμέω δὲ οὐδὲ μὴν λιθιῶντας, ἐκχωρήσω δὲ ἐργάτῃσινἀνδράσι πρήξιος τῆσδε. ἐς οἰκίας δὲ ὁκόσας ἂν ἐσίω, ἐσελεύσομαι ἐπ᾿ ὠφελείῃ καμνόντων, ἐκτὸς ἐὼν πάσης ἀδικίης ἑκουσίης καὶ φθορίης, τῆς τε ἄλλης καὶ ἀφροδισίων ἔργων ἐπί τε γυναικείων σωμάτων καὶ ἀνδρῴων, ἐλευθέρων τε καὶ δούλων. ἃ δ᾿ ἂν ἐν θεραπείῃ ἢ ἴδω ἢ ἀκούσω, ἢ καὶ ἄνευ θεραπείης κατὰ βίον ἀνθρώπων, ἃ μὴ χρή ποτε ἐκλαλεῖσθαι ἔξω, σιγήσομαι, ἄρρητα ἡγεύμενος εἶναι τὰ τοιαῦτα. ὅρκον μὲν οὖν μοι τόνδε ἐπιτελέα ποιέοντι, καὶ μὴ συγχέοντι, εἴη ἐπαύρασθαι καὶ βίου καὶ τέχνης δοξαζομένῳ παρὰ πᾶσιν ἀνθρώποις ἐς τὸν αἰεὶ χρόνον· παραβαίνοντι δὲ καὶ ἐπιορκέοντι, τἀναντία τούτων.