“Above All, Do No Harm” Notes on Hippocrates and the Hippocratic Oath

There is a body of work, mainly ancient medical writings, that have come down to us as the central teaching of Hippocrates. We know very little about the mythic man, Hippocrates. Plato refers to him twice in the dialogues, most prominently in the Protagoras in which Hippocrates is called an “Asclepiad” – or perhaps better known as a follower of Asclepius, the god of the healing art. Hippocrates is similarly referenced in Plato’s Phaedrus.

Hippocrates likely founded a small medical school at Cos (an island in the southeastern Aegean), and he traveled widely throughout the ancient Mediterranean, teaching the healing art for a small profit. He lived perhaps a generation before Plato, and after his death, during the age of Hellenism, rumors and legends abounded as to his life. Aristotle refers to Hippocrates as a great physician-teacher, though small in stature (in the Politics). A vast compilation of medical works from the ancient world were brought together at the Library of Alexandria, and they were collectively referred to as the Corpus Hippocraticum. Hippocrates became the symbol for all ancient medical writing. The story of early medicine is a biography of one man, even though the texts of the corpus are all anonymous.

The collected works in the Hippocratic Body are fascinating – there is the Epidemics, which discusses the weather and related diseases, a series of treatises called Diseases, and all manner of theories and compositions about the body, its organs, its health, and its relation to the natural world. There was also an odd fictional work called The Embassy which linked Hippocrates’s family with the city of Cos and important cultural events that took place, as well as imagined letters between Hippocrates and the king of Persia, as well as letters between Hippocrates and Democritus, the famous pre-Socratic “atomist.” Of course, the most famous of the early texts was the “Hippocratic Oath” – the moral code for physicians that is still in effect today. In our time, approximately sixty texts from the Hippocratic Corpus have survived, including the famous oath. Some are short, lasting only a paragraph in length, and others are extensive volumes. Many of the texts identify the classical Four Humors: melancholic, sanguine, phlegmatic, and choleric. These were the foundation for European and classical Arabic understanding of maladies until the modern era. References to the Four Humors can be found in the writing of Shakespeare. The fourfold nature of humors ran parallel to Empedocles’s fourfold essential elements of the cosmos: earth, air, fire, and water.

A 3rd century papyrus fragment of the Hippocratic Oath written in Koine Greek.

Thanks to the work of the librarians at Alexandria, the field of medicine underwent a revolution with Galen of Perganum in the 2nd century.

I recently surveyed some of the texts from the Hippocratic Corpus:

One of the earliest texts is “On Ancient Medicine” (perhaps written around 400 BC) – a polemical text that argues against the idea of “hypothesis” and defends medicine as a necessity, discovered for the health of man. In the same way that gymnasts grow stronger in training, so do people improve their strength and body by eating and drinking certain things. Bad and commonplace physicians are like poor pilots who lose their ship in a storm. Strong constitutions are preferable to weaker constitutions that are subject to disease. In reading this text I was reminded of Aristotle’s and Plato’s arguments for a natural harmony within the body, when all parts are healthy and fulfilling their particular virtue in excellent balance.

In the text called “On the Sacred Disease” we receive the conflict between ancient superstitions and the need for people to discover or “comprehend” the cure for a disease, regardless of its divinity. The text contains a fascinating observation of what appears to be epilepsy as temporary fits of madness.

Some of the texts are about the process, such as early empirical observations or rationalist interpretations, and others are simply arguments or treatises. There are texts like On Fractures, The Physician’s Establishment or Surgery, On Injuries of the Head, On Ulcers, On the Eighth Month’s Foetus, On Dreams, On Internal Affections, On the Glands, On the Veins, On Vision, and so on. Within the corpus there are also several texts attributed to Polybus, the son-in-law and pupil of Hippocrates on Cos, as attested by Aristotle in his History of Animals.

On the Hippocratic Oath

A 12th century script of the Hippocratic Oath.

The oldest surviving text of the Hippocratic Oath dates to sometime in the 2nd or 3rd century. Bioethics has long been a topic of concern. There are several different versions of the oath that have been found throughout the world, however the most frequently cited is the Koine Greek translation as featured in the Loeb Classical editions:

I swear by Apollo Physician, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.

(Interestingly, despite the conflict between Physics and Theology that is so pervasively prevalent in the Hippocratic Corpus, the oath begins with a pledge of allegiance, calling forth the witnesses of Apollo, Asclepius, Hygieia, and Panacea (followed by all the gods and goddesses).

To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the physician’s oath, but to nobody else.

(The first pledge of the oath is to honor and care for the pupil’s teacher as if he were a parent and to share money with him as needed. In turn, the pledge is to become a teacher to his own pupils as if they were sons, as well.)

I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly I will not give to a woman a pessary to cause abortion. But I will keep pure and holy both my life and my art. I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein.

(This section of the pledge is the most important. It defines medicine as an essentially noble art. Medicine is not a-moral, but requires ethical guidelines. Medicine is power over the infirm, therefore one with the knowledge of healing also has the knowledge of disease and poison and so on. The medical practitioner is dangerous – and even the idea of abortion is specifically called out as evil in the oath. Instead the oath asks the physician to keep his art “pure” and “holy.” The physician is a healer, not a warrior, thus he will not use the knife as a weapon).

Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.

(Abstaining from wrong-doing or harm is the essential crux of the oath. Sometimes the oath is simplified to: “First do no harm” (or in Latin: Primum non nocere). However, this likely dates much later. Goodness, in the Hippocratic medical writings, is associated with helping or improving the balance of mankind. Wrong-doing, or poison or deliberate attempts to obstruct the health of the body, are considered evil. Indeed the secrets of the medical community are sworn to be “holy secrets” in the oath, as well. Medical knowledge is dangerous in the wrong hands).

Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I break it and forswear myself, may the opposite befall me.

(If the oath is honored, the swearer requests a noble reputation both for his own personal life and the fruits of his art, however if broken he prays for the opposite – namely a sour reputation on his life and his art, as well. The final portion of the oath deals with rewards and punishments).

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