Oath Research Paper

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The formal traits of oaths and pledges and the reasons to take them are discussed from a moral philosophical point of view. Some historical examples of medical texts from different cultures are presented and compared with the so-called Hippocratic oath. Genuine oaths are rare but there is considerable agreement about how the ideal physician should behave. The reasons are discussed why medical oaths fade away in modern times. An alternative is suggested which better fits modern ethical requirements.


Physicians are concerned with the functioning body or with the psychophysical organism which forms the natural basis of personal life. So the dependency of patients upon physicians exceeds the dependency on the other professions. To commit one’s body to an expert requires trust, so patients demand trustworthiness from their physicians. Trustworthiness has a significant moral dimension which seems to be even more important now than in premodern times. Oaths as well as less demanding ways of self-binding are expected to secure trustworthiness. Different cultures and different social realities shape different ways to attain this goal. A comparison between texts that express different types of physician’s self-understanding may yield some advice how to deal with modern wants. Therefore, we compare the so-called Hippocratic oath, which is widely known and a well-considered composition with some historical and recent manifestations.

Oaths In General

Thomas Hobbes on oaths: “.. .: which Swearing, or Oath, is a Forme of Speech, added to a Promise; by which he that promiseth, signifieth, that unless he performe, he renounceth the mercy of his God, or calleth to him for vengeance on himselfe.. .. It appears also, that the Oath addes nothing to the Obligation. For a Covenant, if lawfull, binds in the sight of God, without the Oath, as much as with it: if unlawfull, bindeth not at all; though it be confirmed with an Oath” (Hobbes 1991, p. 99–100).

Immanuel Kant confirms the Hobbesian verdict on swearing unnecessarily by God and swearing by other things when he comments on St. Matthew 5: 37: “In the cited passage of Scripture, this kind of attestation is presented an an absurd presumption – wanting to make actual, as though through magic words, things are not within our power. – It is easy to see, however, that the wise teacher, who here says that whatever goes beyond Yea, Yea, and Nay, Nay, in the attestation of truth comes of evil, had in view the bad effect that oaths bring in their train, namely that the greater importance attributed to them almost sanctions the common lie” (Kant 1996a, p. 181, footnote).

Thus, any statement that has been strengthened by unnecessary additional expressions is morally tainted. In spite of these misgivings, Kant justifies swearing before court. “Yet with reference to a court, and so in the civil condition, if one admits that there is no other means than an oath for getting at the truth in certain cases, one must assume that everyone has a religion, so that it can be used as an expedient (in casu necessitatis) for the purpose of proceedings about rights before a court, which regards this spiritual coercion (tortura spiritualis) as a handy means, in keeping with the human propensity to superstition, for uncovering secrets and considers itself authorized to use it because of this” (Kant 1996b, p. 449). In other words, even psychological facts like superstition may be used to reach the right verdict. According to Kant, right is part of morality (Sittlichkeit) and entitled to coerce. Thus, it is part of legal coercion to have persons swear oaths before court. And as perjury is a crime, the efforts to find the truth may be considerable.

Society needs reliability of declarations. It is necessary for persons to give reliable promises, i.e., bind themselves in a trustworthy way. The use of oaths is expected to improve the trustworthiness of persons, the firmness of their resolutions, and thus the reliability of their statements. But this demand is met not only by using oaths in the strict sense according to Hobbes and Kant. There are several types of self-binding act and several types of speech und promise. The evil the swearing person connects with failing to keep his/her promise is decisive, but what counts as evil depends, too, upon societal standards and contexts. A vow (for instance, the vow of poverty) or even a firm resolution (for instance, to stop smoking) is a promise one makes to oneself, and the evil envisioned by the swearing person in case he breaks the vow is the possible loss of self-respect. By taking up an occupation which is publicly regulated, one promises implicitly to the public to act in conformity with those regulations, and the evil experienced is the public criticism. Lying before court after having been sworn in counts as criminal offence and may be punished. Swearing the oath of allegiance during the naturalization process in the United States is performed by a single person in front of a state representative and a flag. In Germany, recruits used to take their oath of office publicly and jointly in a solemn way. In an atheist society, the faith of a person who swears by God would be questionable.

Several means other than oaths are used in order to strengthen the reliability of promises. Swearing an oath in public (for instance, by a high representative) confronts the swearing person directly with the expectations of many people; swearing before an official representative during a solemn procedure makes an impression on the swearing person; touching the Bible while swearing appeals to a common faith but is near superstition or even magic. These means are psychological ones, but they can also be interpreted as based on misunderstood or distorted or disguised moral intuitions. Another type of confirmation is used by swearing in concert. Whereas the former tries to emphasize the moral weight of the promise, swearing jointly adds a pragmatic ingredient: The swearing persons unite their forces in order to achieve a common goal; they promise and can expect mutual help (for instance, the Scottish Covenanters). If the procedure is performed not only jointly but also publicly and officially, it inculcates, at the same time, their role in the swearing persons and in the public (for instance, if recruits take their pledge of office).

The Hippocratic Oath

If we demand the traits of an oath in the strict sense, namely, to make a promise, to face a divine power, able to see and to punish anything, and to speak of one’s own free will, perhaps, only the so-called Hippocratic oath may be found.

There is some evidence that this oath originated during the fourth century before Christ and has Pythagorean roots (Edelstein 1943), but there is no consensus about it and it is unknown to what extent the oath was really used. It is part of a collection of medical texts, the Corpus Hippocraticum, but, most probably, is not written by the historical Hippocrates. Notwithstanding, it is impressive because of its perfect composition. By this oath, the future physician promises not only to obey certain rules but also to do so in a morally perfect way; he gives his promise not in public, but before all Gods and Goddesses whose service was part of public life, and he had free choice to enter the family-like alliance of colleagues or to abstain even if he was consanguineous (see item 2):

  1. “I swear, calling Apollo Physician, and Asclepius and Hygieia and Panacea and all gods and goddesses as witnesses, to fulfil this oath and contract according to my ability and discernment.”
  2. “to consider him who teaches me this art equal to my parents and to have him take part in my life; and if he is in need of something to share with him, and to put his offspring on a par with my brothers and to teach them this art if they wish to learn it, without remuneration and contract; to allow to participate in precepts, lectures and all other instruction my sons and the sons of him who has instructed me as well as pupils who have bound themselves contractually and sworn an oath according to medical custom – but no one else.”
  3. “I shall employ suggestions concerning the conduct of life for the good of the sick according to my ability and discernment; but with respect to harm and wrong, in order to keep them away.”
  4. “I shall give no one who asks for it a lethal medicine, nor will I provide any such counsel. In like manner I shall give no woman an abortifacient.”
  5. “Purely and devoutly I shall lead my life and perform my art.”
  6. “I shall not cut, not even in the case of calculosis, but I shall yield to the men dealing with that work.”
  7. “All households into which I come I shall enter for the sake of the sick, refraining from all intentional wrong-doing, from all harm, and especially from lustful acts upon female and male bodies of the freeborn as well as of slaves.”
  8. “Whatever I see or hear about the life of human beings, during or even outside the course of treatment, that one must by no means make public, I shall keep to myself, convinced that it is sacrilegious to talk about such things.”
  9. “If I fulfil this oath and do not weaken it, may it be granted to me to take delight in life and the art, to be honourably held in memory by all human beings for time eternal; if I transgress it and perjure myself, may the opposite of all this be my fate.”

Some Comparable Texts

A translation of the so-called Hippocratic oath can be found in the Arabic book Lives of Physicians by Ibn abi Usayb’ia from 1269 (Jones 1924). This text starts by “Hippocrates said.. .”which does not fit an individually taken oath. It replaces Apollon with “God, the Master of life and death, the Giver of health and Creator of healing and of every treatment,” thus rendering the pagan perspective a monotheistic one.

A Jewish text, possibly from the sixth century, indeed, contains a short promise (Pines 1975):

We will do all that you exhorted and ordered us [to do], For it is a commandment of the Torah, And we must do it with all our heart, with all our soul and with all our might, To do and to obey Not to swerve or turn aside to the right hand or the left. And they [Asaph and Yohanan] blessed them in the name of God most high, maker of heaven and earth.

But this promise takes only a tenth of a long text which describes how Asaph and Yohanan “exhort and adjure their pupils.” It consists mainly in the praise of God, mixed with instructions for acting as a physician, similar to a sermon. So the pupils promise to obey their instructors rather than a self-selected value.

The so-called Oath of Maimonides, probably written 1793 by Marcus Herz, pupil of Immanuel Kant (Friedenwald 1917), is a prayer to God. It is not a promise given before God, but the physician is well aware of his professional role:

The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.

T’ao Lee (1943) collected eight texts on medical ethics in ancient China (sixth century to seventeenth century). These texts do not contain oaths or even promises. God or “Providence” is mentioned, but divine power is seen as a prerequisite of healing and as a source of reward for virtuous behavior by the physician (see below), and there is no prayer. Sun Ssu-miao (581–673 A.D.) is an example:

A great doctor, when treating a patient, should make himself quiet and determined. He should not have covetous desire. He should have bowels of mercy on the sick and pledge himself to relieve suffering among all classes. Aristocrat or commoner, poor or rich, aged or young, beautiful or ugly, enemy or friend, native or foreigner, educated or uneducated, all are to be treated equally. He should look upon the misery of the patient as if it were his own and be anxious to relieve the distress, disregarding his own inconveniences, such as night-call, bad weather, hunger, tiredness, etc. Even foul cases, such as ulcer, abscess, diarrhoea, etc., should be treated without the slightest antipathy. (Lee 1943, p. 269f.)

Filliozat (1964) and Barnes (2007) deal with traditional Indian texts. These contain physiological and anatomical theories as well as prescriptions and recommendations for therapy, but do not discuss the role of the physician.

The World Medical Association issues the Declaration of Geneva (last version in 2006). This document has, linguistically, the form of an individual promise, although the WMA is a collective agent and unable to bind any individual agent. It does not mention divine power; the evil envisioned by the imaginated swearing individual is loss of “honor”, but loss of honor may be indistinguishable today from loss of trustworthiness, as the real danger of being hurt or even killed in duel has ceased:

At the time of being admitted as a member of the medical profession:

I solemnly pledge to consecrate my life to the service of humanity;

I will give to my teachers the respect and gratitude that is their due;

I will practise my profession with conscience and dignity;

The health of my patient will be my first consideration;

I will respect the secrets that are confided in me, even after the patient has died;

I will maintain by all the means in my power, the honour and the noble traditions of the medical profession;

My colleagues will be my sisters and brothers;

I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;

I will maintain the utmost respect for human life;

I will not use my medical knowledge to violate human rights and civil liberties, even under threat;

I make these promises solemnly, freely and upon my honour. (WMA 2006)

So the Declaration of Geneva is an unusual promise and not an oath in the strict sense. But the first phrase points to its real meaning: It is an attempt to identify the medical profession as far as an agreement can be reached among the physicians of the world.

The Good Physician

Although the physician’s role is rarely rigidified by formal oaths its content seems to be widely agreed upon. If one compares the texts cited above with the Hippocratic oath (HO), the broad concordance as well as the differences and the different cultural and historical perspectives are obvious. From the perspective of moral theory, the HO entails three elements: The center of the text (item 5) deals with virtue, item 3 with positive duties, and items 6–8 with negative duties or omissions. All these elements are present in the texts cited above, but their shares differ according to cultural preferences . All Chinese texts emphasize virtue and character. The instruction of Asaph and Yohanan consists mainly of negative commandments (21 items where the HO has only 6). And the Declaration of Geneva, compared to the oath, gives the impression of shallowness. This may be due to the fact that only two negative duties are mentioned and that their content is rather broad.

The HO places the relationship between physicians even before the details of medical practice. The specific bond to the teacher expresses high appreciation of knowledge as well as a kind of loyalty towards one’s colleagues, as all physicians share this bond. All Chinese texts and the prayer of Maimonides stress scholarship explicitly, the Chinese texts reject slandering colleagues, and the Geneva declaration calls other physicians brothers and sisters. All texts agree in that the good physician gives priority to the needs of his patients. The HO, Sun-Ssu-miao, and the Geneva Declaration mention this idea explicitly among the positive duties; the Jewish texts include it in the relationship to God. The HO puts killing and abortion under verdict as do some Chinese texts and the instruction of Asaph and Yohanan. Similar to the HO (item 5), all texts stress the virtuous life of the physician. The HO, the Chinese texts, and Asaph and Yohanan disapprove of sexual relations. The duty to keep patient’s secrets which is justified twice in the HO is echoed in the Geneva declaration and in Asaph and Yohanan.

But the HO is unique in some respects. The oath taker refuses cutting without condemning it. Perhaps, there is a certain parallel in Asaph with the physician who warns about using blood, iron instruments, and fire. On the other hand, the refusal of sorcery, mentioned by Asaph and Yohanan and by the Chinese text of Chang-Lu, written in 1695 (Lee 1943) is lacking in the oath. Furthermore, if one interprets the oath as saying that the physician wants to keep away harm and wrong from patients not only done to them by other persons but also done to them by themselves, there is nothing similar in the other texts. Similarly, the last paragraph of the oath distinguishes precisely – in both the positive and in the negative case – the outer observance from the inner attitude.

The Modern Situation

Two Types Of Alliance

The HO – and, perhaps, its Arabic version – is unique in that it creates a specific alliance. The quasi-familial obligations to which the oath taker commits himself (see item 2) are directed neither at the patron of a clientele nor at the chairperson of any association, and not even at a blood relative per se – but at his teacher. The son of a teacher who does not wish to learn “the art” does not belong to the alliance, whereas one who is not related but pays for the instruction and has sworn the oath does belong. The same loyalty which the oath taker shows his teacher will be shown to him by future pupils after he has become their teacher, for he knows that they have sworn to this. The content of the oath does not indicate that there is only a single teacher, and it is hardly possible for all pupils to have the same teacher. For this reason, we must assume, if in fact the oath was ever of practical relevance, that there were many teachers. In any case, it is the teaching which is handed down by the consecutive teacher-pupil relation-ships fashioned by the oath.

What is handed down, it is not only knowledge and skills. The oath taker wants to regard his teacher just as he does his parents, in other words, to recognize his authority and to provide him support in case of material need. Beyond that he also wants to allow the teacher to “take part in his life”(bίou koinώsasyai). “Life” (bίoB) means conduct of life, i.e., behavior with respect to morality, not only biological life. How far this solidarity goes remains unclear to us, but it is certain that there are commonalities in the teacher’s and pupil’s conduct of life and that these also must relate to the religio-moral sphere. Tradition, which is created by the quasi-familial, exalted teacher-pupil relationship which never ceases handing things down, thus also comprehends, besides knowledge and skills, a certain attitude. The oath binds both things together: conduct and cast of mind or technology and morality. The adept who wishes to learn “the art” receives only both of them; he who is not prepared to do so remains excluded. The alliance which emerges in this way has no constitution, no public representation, and no missionary aspirations. It comes into being by means of the creed-like resolution of many individuals. In everyday treatment, the alliance has no function beyond eventual mutual encouragement and reassurance as the single physician remains personally responsible for his use of the knowledge and the experience that he has amassed from, and which has been passed down to him by, his teacher. He is limited by what he is able to carry with him or store in his own house. This type of physician’s alliance can be called a “proto-profession”(Heubel 2015).

The professional alliance of today is substantially more: Physicians practice a kind of division of labor, the development of which is continuously fostered by the accumulation of technical means, whose mastery requires specialized skills. Members of the profession utilize only the basics of what has been handed down to them by their teaching colleagues; beyond that, however, they apply the knowledge and experience relevant to their own areas – plus specialized equipment. Unlike in antiquity, they make themselves, along with their respective abilities, available to all of their colleagues. All physicians are thus part of a diagnostic-therapeutic alliance upon which every physician draws, regardless of whether he is a GP or a clinician. Physicians use and serve one another simultaneously as a means of medical praxis. In so doing, they are mutually co-responsible for the medical actions of their fellow professionals. This charges the profession with an additional responsibility. The profession as an organized body is expected to organize the division of labor between physicians and to grant the professional standards. This task can be entrusted to nobody else because it is the physicians who hold the uncontested right to make diagnoses.

Fading Oaths

The Hippocratic oath originates in Greek antiquity. Medical therapy at those times was not based on physiology, anatomy, and biochemistry in our contemporary sense; there were no pharmaceutic and technical equipment industries, no difficult and extremely expensive operations, no controlled trials, and no “evidence-based medicine.” This does not mean that the work of physicians was not effective. Dietary measures – how to live one’s life – played a major role, and there were what we call “minor procedures” (Gordon 1949). But there was no rational system of diagnoses connected with proven therapeutic options and calculable costs comparable to the modern diagnosis-related groups (DRGs). Therefore, although the Greek city states had functioning legal systems, legal claims to specific medical measures and a publicly controlled health-care system could not emerge. And all the more important was the oath which was connected to the divine world which figured as a public institution.

Consequently, medical oaths have changed in their significance today. The warrant of the physician’s liability has been shifted a considerable amount from individual trustworthiness to public and professional regulation. Professions are now occupations which are publicly supervised but are granted a certain autonomy. They are expected to play their role as an irreplaceable part of a healthcare system no matter how complex it may be organized. Thus, by entering his publicly regulated profession, the physician gives an implicit promise to comply with those standards and expectations. And they can be sanctioned. The evil of God’s disgrace, which is typical for broken oaths, has been replaced by professional reproof or even lawsuits. Thus, the necessity to rely on oaths was diminished. Additionally, in secular societies, swearing to a divine power may elicit scepsis rather than trust.

Credibility Of The Profession

Of course, patients still demand personal trustworthiness from their physicians. This demand persists in spite of secured legal claims and is rooted in the specific vulnerability of human beings who present the bio psychological basis of their lives to an expert. Basically, trustworthiness of the individual physician depends upon the physician’s own conduct. But it is conferred to them to a significant degree by the trustworthiness the public ascribes to the medical profession as a whole. The medical profession conveys some trust in advance; this facilitates seeking help. Again, trustworthiness depends upon conduct: The conduct the medical profession as a collective agent shows to the public. Allsop (2006) has found for Great Britain that a discrepancy exists between trust to individual physicians and trust to the organized profession: Mistrust towards medical professional boards is growing and professional self-regulation is under political pressure. In part, this may be explained by the difference between the legal and the political system. The misconduct of a single physician may be a matter for the judicial process; failure of the medical profession as a whole to administer itself, systematic misconduct, and systematic disincentives are grounds for legislative action. Legislative action is in principle called for when a lack of self-discipline in the medical profession as a whole puts into question its own credibility and thereby the credibility of its supervision. But this type of action is slow and its urgency is difficult to assess.

According to the Hippocratic oath, the dedication of the physician is complete if he cares for his patients as promised. As a physician, he had no duties towards other persons but his patients, except the specific relationship to his teacher. But to the amount health care depends upon adequate division of labor, the commitment of physicians acquires a new element. Then, they have duties towards the profession. That is to say, they should engage for the integrity of the collective therapeutic instrument which is made up by themselves and their fellow physicians. Seemingly, this commitment removes physicians and patients from each other but, in fact, service is improved. However, many organizational steps are required, and the individual physicians have to decide about their effort according to their different interests, capabilities, and necessities. So what is needed is rather a confession to be obliged than a promise to fulfill distinct obligations. Such a confession would be similar to an oath but, morally, is already included in the implicit promise which is given through entering the profession by registration as a physician.

The adequate way, then, to improve and protect the profession’s credibility is to formulate specific types of action which can be recognized by professionals and the public and the performance of which can be assessed by them. This is what the charter on medical professionalism (2002) intends. The first paragraph of its preamble reads:

Professionalism is the basis of medicine’s contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession. (Medical Professionalism in the New Millennium 2002, p. 243)

And the last of ten commitments reads:

Commitment to professional responsibilities. As members of a profession, physicians are expected to work collaboratively to maximise patients’ care, be respectful of one another, and participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards. The profession should also define and organise the educational and standard-setting process for current and future members. Physicians have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance. (Medical Professionalism in the New Millennium 2002, p. 246)


In order to be perceived as trustworthy, a person should show moral strength, i.e., other people should be able to perceive the person as one who resists generally known temptations. To resist temptations is easier if failure to resist is followed by punishment. Punishing requires an authority which is able to register failure and to connect it with an evil. In taking oaths, this authority is divine power. The more reliability other promises gain, the easier any break of promise is detected and answered by a group of experts. This is what an alliance of physicians is able to achieve. By supervising the conduct of its members, it reduces the effort the promising physician has to summon up as well as the expenditure the public needs to assess the promise’s reliability. The Hippocratic oath is the only document among those mentioned above to create such control. The Chinese texts refer the public only to the virtue of the single physician and the Jewish ones to the physician’s faith. Strictly speaking, even the Hippocratic oath is not an oath in the full sense as it does not ground reliability exclusively on fear of divine punishment.

Still, the demand for trustworthiness has to be met today. But the conditions have changed. Social control by experts has been completed by and sometimes replaced with the legal system. There is no contract any more between physicians and their teachers as in the Hippocratic oath. Instead, physicians practice division of labor and, therefore, are co-responsible for their colleagues. The alliance has to organize itself as a profession. To care for trustworthiness is now expected from the medical profession as a corporate body, not only from the single physician. This body cannot take an oath. But the profession can publicly define their standards and control their performance in a way that is visible to the public. Probably, this provides more credibility than any oath could deliver today.

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