Is First do no harm really part of the Hippocratic Oath?

When Professional Responsibility class began, I was most excited at the idea of not having to sit through another lecture on proteins and cell transport.

I was also looking forward to the class where we would be using clickers from the Library to poll audience responses during the lecture, as doing something while listening to someone talking has a much higher success rate in getting me to pay attention for 50 minutes straight. Our first class did not disappoint, or crush my high expectations. It included a history lesson about the Hippocratic Oath, and this, I found incredibly interesting.

The Hippocratic Oath is as follows:

“I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement: To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art. I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion. But I will preserve the purity of my life and my arts. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.”

After reading the oath out loud, our professor then asked us the same question that I will ask you now (doubtfully in the exact words): Knowing that this oath is what popular culture has come to represent physician-hood by (you can purchase t-shirts, posters, throw blankets, and even vacation packages, related to it), what are your thoughts when you read this, many of you, in its actual language, for the first time?

If you are like many of my classmates, swearing that as doctors, we would not perform physician assisted suicide or an abortion would be bothersome. You might also be wondering why surgery would be considered a lesser profession, why we would need to swear to “keep [ourselves] from all intentional ill doing and seduction”, or why we would need to share our goods with our medical professors (as if most people being in a debt to the government or to the school was not enough, now, we must also be indebted financially to our professors and their sons). Even still, you might wonder why we would be making the oath to the Greek Gods anymore, when most of us do not even know who each of these Gods actually is or what he is supposed to do.

However, if you are like my Professor (and a much more seasoned, astute observer), the first thing that you will notice is that the oath does not, anywhere, contain the words “First do no harm,” a phrase that has become synonymous with this oath in popular, and even medical, culture. I must admit that when he first said this I reread the words over and over hoping to find something he missed, as I could not believe that this omission was possible. While even my Professor could not explain the root of this almost rumor-like association, I feel like someone invented those particular words for the oath because well, unlike some of the other phrases in the oath, they actually made sense.

Knowing what the oath literally says, I am excited by the fact that when I graduate I will get to spend time with my classmates writing our own oath, one that is relevant to us, but yet, an important promise nonetheless. While I do not think we need to promise something so obviously outdated as the real oath is to current medical practice, entering a field of service, and of duty, I do believe some semblance of a ceremonial rite of passage into the profession and an acknowledgement of all that it entails, is necessary. For now, as I go on this medical school journey, I will simply swear to do my best for myself and eventually for my patients, to learn with every opportunity that I have to do so (from my teachers, my classmates, and my patients), and to never lose my humanity, my humor, or myself, in this long, tiresome, and grueling training process. Amen (to all the Gods wherever) for that.

Jessica Gold is a medical student.

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  • http://www.sufficientscruples.com Kevin T. Keith

    This sounds like a useful and insightful discussion. Good to hear!

    The issues with the Oath are many, and much-discussed. It was written for a particular group of people at a particular place and time, thousands of years ago. Much of it is obviously outmoded; much of it is morally questionable. Almost no ethicists today regard it as having moral authority; few regard it as even of symbolic importance.

    A brief survey of the issues is given here: http://sufficientscruples.com/blog/58/

  • Don Harting MA ELS CCMEP

    Interesting article Jessica! Thanks for writing it!

  • http://natickpediatrics.net Rob Lindeman

    Just because those words wont appear in the oath you pronounce when you graduate, doesn’t mean they should not guide you through your professional life. On the contrary. they should.

    BTW, it occurs to me that Hippocrates never could have said “primum non nocere” as he spoke Greek, not Latin.

  • JF Sucher, MD FACS

    In fact, there has been much written on this topic. No one truly knows it’s origin, but it has been attributed to Hippocrates because the oath contains the phrase “..never do harm to anyone.”. Certainly not an exact match, but pretty darn close.

  • http://www.sufficientscruples.com Kevin T. Keith

    A better match is from Hippocrates’s “Epidemics”, which includes the line: “As to diseases, make a habit of two things—to help, or at least to do no harm.”

    Even that isn’t quite the same thing. It really isn’t a Hippocratic precept (which is to his credit, since, taken literally, it would prohibit virtually all forms of care, and taken in a more general sense provides no explicit guidance).

  • James

    While the sentence “First, do no harm” does not appear in this classical version of the Oath, the final clause of the second principle that follows the preamble is: “never do harm to anyone”. It is not the same words, but it is the same concept.

    It is not the first element of the oath, but is given a high priority, preceded only by the idea of honoring your teacher and his family as your own, or in modern terms sticking together with and up for other physicans against the State, insurance companies, hospitals, laywers, and patients.

    Most of the sentences in the oath that follow “never do harm” are describing specific prohibitions that follow from the general principle; do not cut for stone (or by corralary perform any surgery or procedure) unless you are a specialist in that art, do not euthanize, do not abort, do not betray the trust (by sleeping with them) or the secrets of your patients, do not take sides in politics. Are not all of these concepts enshrined in some form of modern medical ethics? What are Doctors without Borders, the Red Cross, doctor-patient confidentiality, and malpractice for patient-doctor sex or for performing procedures outside your speciality, but specific enactments of the principles identified in this oath?

    • http://paynehertz.blogspot.com Payne Hertz

      “…or in modern terms sticking together with and up for other physicans against the State, insurance companies, hospitals, laywers, and patients.”

      Interesting list of adversaries you have there. Us against them. I suspect the idea behind the oath is to stick up for your patients and do them no harm even if it means running afoul of your colleagues, not professional loyalty particularly where your colleagues may have harmed others or violated the law.

  • supastaru

    This is just nitpicking.No, wait, it’s just wrong!
    You’ve got “never do harm” in there! Which logically includes in itself “first do no harm”. Just like it includes say “do no harm in the middle of it” or “last, do no harm” etc.

  • http://www.sufficientscruples.com Kevin T. Keith

    Regarding specific precepts in the Oath, it is not at all clear that the various prohibitions are intended as examples of not “doing harm”. Breach of confidentiality is expressly described, in the standard translation, as a matter of “shame” to the doctor, not harm to the patient (they are not the same). The prohibition on sexual relations seems to have a similar motivation, being something that doctors just don’t do, not something that is harmful in itself; at any rate, “trust” is not mentioned, and breach of trust and harmdoing are again not the same thing.

    The usual interpretation is that the opening section defines moral obligations between members of the profession, and to “keep [patients] free of all harm” is a general moral precept defining the relationship between doctors and patients. The various specific treatments that follow are kind of thrown in as being especially relevant at that time (e.g., pessary abortions; lithotomies), each for its own reason. (If they are all no more than instantiations of a broad clinical-ethical precept, there would be no reason to list them separately, and no explanation why any of the many other possible forms of harmdoing a doctor might fall into are not mentioned.) There is much more to medical ethics than harmdoing – which is one thing, at least, that the Hippocratic Oath gets right.

    As for doctors “sticking together . . . against the State, insurance companies, hospitals, laywers, and patients” (and *patients*?), well, that’s a new interpretation of the Hippocratic Oath, at the very least!

  • Lil A

    I looked the Hippocratic Oath on Wikipedia (I know, not the best source and definitely one I stay away from when writing research papers for college) and there is now an updated version of the Hippocratic Oath, and even a Physician’s Oath that some medical school students take. I generally like both of them and allow a lot of the concepts in them to shape the way that I think about medicine.

    And I think you are right about creating your own sort of oath. I like yours, short sweet and to the point and pretty close to the one that I have written myself. I totally agree with it, as that is what I strive to do. Mine, however, goes into a little more detail on the things I value. I think it’s important for physicians to know what they value and to treat patients accordingly (I know that there are times where your beliefs will be challenged, but those times are meant to make us stronger and better able to care for those we call our patients). I guess it’s a constant battle that requires the physician to always weigh several choices before making a definitive decision. Sometimes we are handed dilemmas, or situations in which no matter what is done, there will always be some good and evil done and some good left undone. I guess the correct decision in these times is really based of what the physician values and what the physician feels will suit the patients desires and needs the best.