Book Review: Hippocrates’ Oath and Asclepius’ Snake: The Birth of the Medical Profession

This is a small book but packed with outstanding background and detailed discussion of two historical items that have come to define the profession of medicine: the snake/rod of Asclepius the oath of Hippocrates. It is revealing that the book’s cover art depicts the scene from Euripides’ Telephus, depicting the healing of Telephus by Achilles, who had originally inflicted Telephus’ festering wound. Telephus was advised by the oracle of Apollo at Delphi that “the wounder will heal” his wound. This theme of “wounder as healer” along with the opposite “healer as wounder” theme is woven throughout the book, with many examples of how physicians incorporate both themes in daily practice.

Cavanaugh’s first chapter offers a fascinating discussion of how the snake and rod of Asclepius became a symbol of the medical profession. The association of snakes with healing arose from their molting process symbolizing regeneration and their assumed familiarity with hidden healing properties of the earth. He notes that the caduceus, with two snakes surrounding a staff, and now commonly associated with medicine, originally was the wand of the Greek god Hermes, messenger of the gods. This symbol was used in the early days of printing to emphasize the messenger role of printed material and became a standard printer’s mark. In the United States, early medical textbooks that came from Europe were thus marked with the caduceus symbol, and this was soon (incorrectly) interpreted and adopted as a medical symbol. The staff of Asclepius, on the other hand, is a walking staff, such as used by ancient physicians, with a single intertwined snake. It is speculated that the intertwined snake might also represent coiling of the parasitic guinea worm around a stick as it is extracted from a patient. The concept of snake as wounder and healer is cited in the Old Testament in Numbers 21:4–9, which notes the image of a snake on a pole that healed those bitten when they gazed on it. The New Testament applies this concept to the crucified Jesus in John 3:14–15, where eternal life is offered to those who believe in Him. Cavanaugh then discusses the medical–ethical problem of role conflation, where physicians deliberately harm. This is a significant concern since physicians possess both the skill to heal and to sicken. This ethical dilemma is addressed by separating healing practices from those of deliberate wounding or killing, as outlined in the Hippocratic Oath. This is presented in greater detail in a later chapter.

The book’s second chapter covers the Hippocratic Oath. Cavanaugh starts with historical information about Hippocrates and how the oath was attributed to him. One of the many interesting tidbits is that Hippocrates deviated from the tradition of only teaching medicine to male sons. He not only taught medicine to unrelated men but also assessed fees for their education. This radical approach resulted in increased numbers of medical practitioners. With the inception of this novel process, concerns arose on ensuring benefit for both teacher and student. These concerns then led to the creation of a promissory oath, which was a common practice in ancient Greece. The etymology for oath in Greek is interesting, as the word for oath, horkos, is related to the word for fence, herkos, highlighting the boundaries imposed by the oath. The Hippocratic Oath is then dissected and each segment discussed, starting with preliminary statements and moving into the oath proper. Regimens are to be used for the benefit of the sick and not for harm. The oath taker pledges to not providing lethal drugs or such counsel and also pledges not to provide abortive agents. The oath has an unusual statement that is asynchronous with the rest of the document and appears to prohibit the use of surgery except “to practicing men in this doing” (i.e., surgeons). Cavanaugh opines that this statement is felt to have been added at some later point and is not in keeping with the oath or its tradition. The next segments of the oath pledges against injustice and corruption (particularly sexual indiscretions) during encounters and against publicly discussing any sensitive information obtained during caregiving. These proscriptions allayed patient fear of physician impropriety and thereby facilitated therapeutic interaction. The oath concludes with the promise of good fortune to physicians who follow its tenants and the opposite to those who transgress it.

Following this discussion, the next chapter deals with the subject of wounding, which has two opposing aspects. The positive aspect is any wounding that occurs during the treatment process. Although this produces hopefully temporary adverse effect, the overall intent is for healing. This approach exemplifies the Hippocratic physician, as noted in the oath’s statement on using treatment regimens for the benefit of the sick. The contrary negative aspect is the physician using their skills for intentional harm, which Cavanaugh labels as injuries. Physicians who follow the tenants of Apollo or Asclepius are regarded more as technicians who can use their skills to harmful ends such as assisting with executions. An example of the Apollonian approach is illustrated by the story of Drs. Guillotin and Louis with their involvement in proposing and developing an instrument used for capital punishment. Currently, the Apollonian approach is exemplified by physician-assisted suicide, physician-performed euthanasia, and, of course, physician participation in abortions. There are many reasons for physicians to avoid killing, and five are presented in detail. By killing the sick, physicians undermine the trust placed in them by patients. To assist with suicide or actively kill a terminally ill patient who prefers death to loss of autonomy, physician involvement makes the patent’s existential distress into a medical issue. The author goes on to explain that lack of control over the time and manner of one’s death partially defines the human condition, and it is a fundamental error to regard this lack as a disease in need of treatment. In responding to requests for assisted suicide or euthanasia, physicians render other vulnerable individuals susceptible to these processes. By adopting these practices, advancement in medicine will actually be retarded, as there would be less incentive to develop therapies to treat diseases for which such practices would be felt indicated. The last concern presented notes the danger of a slippery slope where medical skills are used more broadly for the purpose of killing. Examples of this are unfortunately all too easily found in physician involvement with experimentation and executions in Nazi Germany and in our current climate of legalized abortion, assisted suicide, and euthanasia.

The final chapter deals with the oath as part of the medical profession and discusses the subject of professional autonomy. A profession involves unique ethical commitments that are not necessary for purely technical occupations. Professing an oath captures this aspect. Reasons for taking a public medical oath include the gravity of subjects covered by medicine that warrants a solemn oath, the public nature of an oath emphasizing commitment to its tenants, the (hopeful) assurance that promises will be kept, a subsequent focus on deliberation, facilitation of advancement of the practice, a means of explaining and justifying conduct, and to realize professional autonomy. This last point of professional autonomy is further developed. Society acknowledges this because it serves the public good. The axiom of primum non nocere, or as stated by Galen, “be useful or do no harm,” certainly benefits the public good. Interestingly, Galen wrote that he thought this maxim was insignificant at the start of his career (perhaps many newly minted modern physicians also think so), but with practice experience, learned its profundity. Professional autonomy involves self-governance and includes the need to educate the nonmedical public regarding ethical limits on requests for assistance such as physician participation in executions. Unfortunately, contemporary medical oaths have deviated from the original Hippocratic version, to the range of incorporating language permitting physicians to take a life, or allowing oaths fashioned by the individual student for their personal use.

It was fortuitous that this book review coincided with reading two recent publications on medical professionalism (Byyny, Papadakis, and Paauw 2015, 2017), both of which address the Hippocratic Oath in the context of contemporary medicine. Cavanaugh’s text was a fine companion to these monographs. In summary, this book will be of interest to anyone wanting a “back to basics,” in-depth look at these fundamental subjects.