Appendix: A Classic Perspective on the Hippocratic Oath (C. Everett Koop)
We have recently seen the ambivalent manner in which society deals with physicians who assist patients in committing suicide.
I have always defined euthanasia as “death by someone’s choice,” someone who considers the life in question no longer worth living. There is a difference between helping a person live all the life he is entitled to and prolonging the act of dying. There is also a difference between letting nature take its course in a dying life and speeding the death of an individual by whatever means and for whatever purposes, no matter how well intended.
Thirty years ago and earlier, the debate about euthanasia centered around pain that could not be relieved. Today, when it is possible, in almost every case, to relieve pain and suffering, the debate has shifted to ending the lives of those despairing of their situation, who don’t want to die of their diagnosis, who know they are incurable, or who have lost self-command, dignity, or quality of life.
We have overemphasized curing, compared to caring, to our detriment. The medical tradition that has served us so well for more than two thousand years came from Hippocrates and his disciples. They had very little to offer patients except care and integrity. Among other things, the Hippocratic Oath states, “I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them.”
The Hippocratic Oath has been the most enduring ethical legacy of the practice of medicine, being passed on from teacher to student, from physician to new physician, from generation to generation. The Hippocratic Oath and the tradition surrounding it became the medical ethics and the value system that made Western medicine the art that it has become. Only recently, since the Second World War, has this noble tradition been threatened. The function of the Oath in today’s society is the same as when it was first spoken. The Oath calls physicians to a higher ethical standard than that of society in general.
In the society that produced the Hippocratic Oath, the lines between physician, witch doctor, and magician had become blurred, as had the line between physician and executioner. The laws of the society in which the first Hippocratic physicians took that Oath allowed them to kill, allowed abortion, and allowed them to abuse the privacy of their relations with patients.
The Oath called on physicians not to change the laws of society—that was not their function—but to commit themselves to a higher ethical standard.
The Oath was trying to say, “I [that is, we of the school of Hippocrates] am above such things. Though others who call themselves physicians do these things, I will not. You can count on my being a responsible physician.”
You will be well on your way to understanding the Hippocratic tradition when you understand its basic premise: the physician is a healer. Perhaps the most important aspect of the Hippocratic Oath is that it does not at any time or in any way speak of the doctor’s role in the relief of human suffering. The ancient doctor of those days could cure practically nothing, and it is self-evident that he did what he could within the framework of “do no harm.”
With few medications or procedures in his armamentarium, the ancient physician often succumbed to the temptation to kill, to assist in suicide, and so to alleviate suffering by ending it with death. This, however, was not for Hippocrates. Alleviate suffering, to be sure, but never if it threatened the sanctity of human life, the basic premise of the healing physician.
I went to medical school to learn how to save lives and alleviate suffering. I saw no tension between those points of view, because I was a Hippocratic physician. There was an absolute proscription on the taking of life. If I could heal or cure, I would do it, but in doing that or failing that, I would relieve the suffering of my patient.
Hippocratic medicine does not require that the act of dying ever be prolonged. If my patient has received all that I can do for him, and if healing is not possible, I can alleviate his suffering and still stay well within the bounds of “do no harm.”
C. Everett Koop, MD,
United States Surgeon
General (1982–1989)