Article
Ethics
4 min read

The expectations of an oath: lessons from Hippocrates

M. Çiftçi explores the evolution of a historic and contemporary commitment to protect the vulnerable.

Mehmet Ciftci has a PhD in political theology from the University of Oxford. His research focuses on bioethics, faith and politics.

While surgeons operate in the background a digital display shows numbers in the foreground
Natanael Melchor on Unsplash.

A ‘casual acceptance of infanticide seems to have been not the exception but the rule among both Greeks and Romans in the centuries immediately preceding the birth of Christ.’ That shocking fact about the pagan world’s attitudes towards children, mentioned in David Albert Jones’ The Soul of the Embryo, has been brought to our attention again recently by Tom Holland’s Dominion. Since his book was published, much has been written, even in Seen & Unseen, about the radical alteration of our attitudes towards the weak and vulnerable, especially children, women, and slaves, by the Christian faith’s love for the weak over the strong. The depictions of Christ’s suffering humanity in crucifixes over centuries slowly worked to change the attitudes of even the strong and powerful.  

But to think that the Greco-Roman world was entirely callous towards the vulnerable is not true. There is a minority of voices revealing that, even then, there were some opposed to the killing of children in the womb or after birth. There were some who anticipated the revolution of values that the Judaeo-Christian tradition was about to inaugurate. Within that minority of pagan authors, the writings attributed to Hippocrates (who was roughly a contemporary of Socrates) and to his school, in particular, stand out. Translations of his writings from Greek into Syriac, Arabic, and Latin ensured their influence for centuries over Muslim and Christian physicians. The most well-known one, of course, is the Hippocratic Oath, which explicitly forbids causing an abortion using a pessary.  

Its description of the moral rules and humane ideals that physicians swear to obey, is partly responsible for the honour and prestige that is still, even today, attached to the medical profession. Medical schools around the world, including 70 percent of them in the UK, still use some version of the Oath in their graduation ceremonies, so that the new medics can make their promise to obey a short summary of the ethical ideal that should guide their practice. The revival of interest in the Oath more recently dates from the post-war period, when the appalling example of medical experimentation in the Nazi regime led the then newly founded World Medical Association to draft the Declaration of Geneva in 1948, since revised multiple times, which have in turn inspired many other versions of the Oath to be written. Some of them are banal and frankly silly, such as one version by the poet David Hart: ‘I will not knowingly do harm to those in my care, I will smile at them and encourage them to attend to their dreams and so hear the voices of their inner strangers’.  

Doctors today, in their day-to-day work, rely more often on complex documents detailing their professional obligations. So, what can we and they learn from the Oath? 

The Oath includes general promises to use treatments for the benefit of patients and to protect them from harm and injustice, but more specifically it also promises to not give a deadly drug to anyone if asked, nor to suggest giving one to a patient, including a pessary to cause an abortion as I’ve already mentioned. Later the Oath states:  

‘Into whichever houses I enter, I will go for the benefit of patients, keeping myself free of any intentional injustice or corruption, particularly in sexual matters, involving both female and male bodies, both of the free and of slaves.’  

Already, this tells us, there was an awareness that patients are vulnerable when in the care of another. The physician must not take advantage of their vulnerability, either sexually, or by euthanising them, or by enabling those in despair to commit suicide. A renewed commitment to these rules should be urged, since some doctors continue to abuse their power over patients in these ways, sometimes even with legal permission in countries that permit assisted suicide

That the Oath was written by a pagan points to the possibility of us all finding our way, without appeal to any holy book or revelation, to an agreement about some basic moral rules that should guide doctors. However, Christianity put its own spin on the Hippocratic Oath, as we can see from a Christian version of it dating from the early Middle Ages. Gone is the reference to swearing by Apollo and Asclepius, whose serpent-entwined rod remains a symbol of medicine today. But, more importantly, the Christian oath forbids causing an abortion by any means, making the promise more definite and explicit. This provides further evidence of the argument mentioned at the beginning of Christianity’s preoccupation with defending the most vulnerable from harm.   

Whereas the original Oath envisages belonging to a closely-knit circle of physicians, led by a teacher, from which outsiders are to be excluded, those sections are completely missing from the Christian version. According to W.H.S. Jones, this could be because creating ‘an inner circle of practitioners shows an aristocratic exclusiveness, which is in sharp contrast with the universal brotherhood of Christianity. The relief of pain and suffering … should be tied by no fetters and hindered by no trade-union rules. Christian benevolence should be universal.’ For that reason, Jones thought that the Christian Oath might have been originally written during the earliest centuries of Christianity, when Jesus’ healing missions and the Apostles’ practice of holding all possessions in common had not yet been ‘forgotten or neglected.’  

In Westminster Abbey, last year, we saw at the Coronation that the heart of our political system is an exchange of vows between monarch and his people, vows sworn in the belief that to remain faithful to what was promised are gifts given by something above us and beyond our ability to control. Similarly, the weighty responsibilities of marriage have inspired societies across generations to begin married life by pledging solemn promises. Why should we expect anything less from those who take us into their care when we are struck by disease, or facing death?  

Explainer
Biology
Culture
Ethics
8 min read

Inheritance and environment's impact on ethics

Once discounted insights are now found important and have ethical consequences. Andrew Davison concludes his series on biology’s current developments.

Andrew works at the intersection of theology, science and philosophy. He is Canon and Regius Professor of Divinity at Christ Church, Oxford.

A wall tile shows a 1940s woman tend a stove below a washing line.
A commemorative tile honours Dutch woman who made 'something out of nothing. during the hunger winter.
Peter de Wit (FaceMePLS), CC BY 2.0, via Wikimedia Commons

There’s no more exciting work in biology at the moment than thinking about organisms in terms of their environment. That’s a crucial part of the lively current scene in evolutionary thought (which I described in my previous article), and part of how a new generation of fascinating writers is urging us to throw off the overly narrow perspectives of the twentieth century. It’s not that Darwin’s fundamental insights were wrong, just that some of his followers took them to rule out, or discount, features of biology that turn out to be real and important.  

In fact, Darwin was often ahead of the game here. He was more interested in cooperation between species, for instance, than many writers who went on to champion his ideas. He wrote brilliantly about the relationship between moths and orchids, for instance, and between plants and earthworms. Similarly, as Jessica Riskin has recently pointed out, he never dropped the idea that what organisms do during their lifetime affects what they pass on to their offspring (what he called ‘use and disuse’). For much of the twentieth century, that idea, of passing on of acquired characteristics, was biological heresy, but today it’s making a comeback. 

The excitement in contemporary evolutionary biology can usefully be gathered under two headings. Alongside ‘organism and environment’, there’s also ‘extended heredity’, although the two are closely related on some points. They’re both important as part of the sort of discussion presented on this site – run in conjunction with the Church of England, of all things – not just because it’s good for religious institutions to demonstrate enthusiasm for science, but also because they’re full of ethical consequences.  

 Passing on to the progeny 

Take ‘extended inheritance’: extended, in the sense that there’s so much more that’s inherited from parent to child than just a DNA sequence. For one thing, every organism bequeaths a world to its progeny, which means a world that’s at least somewhat adapted: at least a little (as with some bacteria, although others are adept at ‘ecosystem engineering’) or massively, as when a beaver completely changes its surroundings by building a dam, or when human beings cover the Earth with marvellous and terrible things. The transformed landscape of the beaver and the human being, even of the bacterium, is part and parcel of what they each pass on to their progeny, and therefore part of biological inheritance. That really puts the environment back at the centre of our thinking about organisms and evolution. 

Taking a wider view than genes-are-all-you-pass-on has no lack of consequences. In their accessible and endlessly fascinating 2018 book Extended Heredity, Russell Bonduriansky and Troy Day show that narrow-mindedness on that front has had terrible consequences. They see it behind the Thalidomide birth defect tragedy, for instance, and the strange unwillingness of medics, in the middle of the twentieth century, to take the dangers of foetal alcohol syndrome seriously. If it’s a matter of scientific dogma that all that matters is what genes parents give to their offspring, other factors – like bothering to monitor what effects alcohol have on pregnant women and developing child, or the effects on them of a new medicine – don’t look as important as they should.  

Genes aren’t everything, especially in the developmental phase (from conception through childhood and adolescence). Throughout that period, in particular, genes and environment dance an intimate tango, with genes turning on and off in response to its experience of its environment, before and after birth. Moreover, recent science shows that what happens to you during your lifetime can even be passed onto your offspring, and even to their children after them.  

That flies in the face of the idea that all you have to pass on is the genetic hand of cards you were delt at conception (or its equivalent, for instance for a plant). On that hallowed view, the most that life has to offer from that moment on is testing your ‘fitness’, to see whether you manage to pass those genes on, or not, or how abundantly. But that’s far too limited a picture. We don’t just pass on genes; we also pass on the pattern of how genes are tagged to be turned on or off, and that is changed by the conditions the organism has experienced.  

 Hunger lessons 

The most striking, but gruesome, example involving human beings is the ‘Dutch Hunger Winter’ of 1944­–45, when occupying German forces starved the Dutch population in retaliation for resistance victories. Children conceived during that period grew up with poor metabolism (or, to be more accurate, metabolism that would be good at surviving starvation, but was not well-adapted to healthier post-war life nutrition, which is fascinating in itself). So much for genes being everything. More startling still was the observation that their children also had poor metabolism: the grandchildren of the starved pregnant women. We can pass on acquired characteristics, which really puts the cat among the twentieth century Darwinian pigeons. As the prophet Ezekiel put it, ‘The parents have eaten sour grapes, and the children’s teeth are set on edge’. This is full of ethical freight. The way we treat other people, and ourselves, affects those who come after us: yes, socially and culturally, which is significant enough, but even in how their bodies are programmed to develop. 

A stimulating environment 

There’s a similar ethical charge to what is perhaps my favourite part of the newly boisterous world of biology: phenotypic plasticity. That’s the simple idea that the same genes (the ‘genotype’) will produce a differently structured organism (the ‘phenotype’) in response to different environments. In one sense, it’s obvious enough. If I go to the gym for a year – a particular kind of environment – I’ll look different afterwards than if I’d spend an equivalent length of time on the sofa.  

But it goes much further than that. Various plants will produce different sorts of leaves, for instance, depending on whether they grow in more or less shady situations. Sometimes, one species can be mistaken for two, as happened with fish, called cichlids, in Lake Tanganyika (between Tanzania and the Democratic Republic of Congo). What scientists had thought to be separate species, because their jaws are so different, turned out to be the same species. If a fish grows up at the bottom of the lake, it develops one mouth shape, with large, strong jaws, for munching shellfish; if a it with the same genes grows up at the top of the lake, it develops delicate jaws, useful for eating other kinds of food.  

Again, the repercussions of ethics are enormous, and that brings us back to the ugly subject of eugenics, mentioned in the first of these articles. At root, eugenics is based on the assumption that some people just are healthy, and others just are sick, because some have ‘good genes’, while others have ‘bad genes’. You are either blessed with the former, or doomed with the later, and that’s set in stone, from conception. It’s then (supposedly) the ‘right thing’ to promote the former when it comes to reproduction and, at its most horrific, to restrain, sterilise, or even slaughter the latter. Eugenics cast its shadow over more of the twentieth century than we might like to admit. At one time or another, it was the darling of both the political right and the political left. It hasn’t gone away. 

Before we say anything else, there’s a moral flaw in thinking that concern for the gene pool trumps concern for suffering individuals. More than that, though, the biology shows eugenics to be flawed even on its own, supposedly scientific, terms. We aren’t just blessed or doomed by the genetic hand of cards we’re delt at conception. Like those plants, growing in sunlight or shade, what our genes will mean is also determined by our setting. Like those African fish, our genes can run more than one programme, so the environment matters.  

Eugenics presents the all-to-convenient picture that the sick will be sick, the weak will be weak, and that’s that. But we’re not just doomed or blessed by genes. It matters, for instance, what sort of housing we have, how we’re fed, and whether we have access to fresh air and places for exercise, and to stimulus for the mind, and companionship. Putting people into groups (healthy and sick, or worthy and unworthy), then writing off one of those groups might be politically and economically convenient, but it’s bad science, as well as bad morals. 

Reason to be curious 

I started this series by mentioning how important the theology and philosophy of the Middle Ages has been for me, in working between theology and science. In one of his little read works, Thomas Aquinas (1224–1274) defended having the expansive curriculum used in training Dominican friars like himself. (It helped that this curriculum was being drawn up, in part, by Albert the Great – perhaps the greatest polymath of his century, and later patron saint of scientists.) One should be open to knowing about everything, Aquinas argued, because you never know what will come in useful later on. We have an excellent, and timely example of that, in how something as obscure as phenotypic plasticity bears on eugenics, and the eminently practical question of proper housing. 

Recently, in fact, the Church of England has been working hard on housing. The Bishop of Chelmsford, Guli Francis-Dehqani, has the new housing brief among the bishops. The church’s council for Mission and Public Affairs has also been busy, not least with the publication of Coming Home: Christian Perspectives on Housing in 2020. What might have seemed like rather abstract wranglings among biologists, over where to put the emphasis in their theories about nature, turns out to show how right it is to be passionate about good housing (and, it turns out, about keeping abreast of biology). 

  

Suggested Further Reading 

Brown, Malcolm, and Graham Tomlin, eds. 2020. Coming Home: A Theology of Housing. London: Church House Publishing. 

Day, Troy, and Russell Bonduriansky. 2018. Extended Heredity: A New Understanding of Inheritance and Evolution. Princeton, NJ: Princeton University Press. An engaging introduction to a broadened picture of inheritance. 

Jablonka, Eva, and Marion Lamb. 2020. Inheritance Systems and the Extended Synthesis. Cambridge University Press. A short discussion of many of the more expansive aspects proposed for contemporary evolutionary thought. 

Jablonka, Eva, Marion J. Lamb, and Anna Zeligowski. 2014. Evolution in Four Dimensions: Genetic, Epigenetic, Behavioral, and Symbolic Variation in the History of Life. Revised edition. Cambridge, MA: MIT Press. One of the most substantial discussions of the new perspective. 

Laland, Kevin, Tobias Uller, Marc Feldman, Kim Sterelny, Gerd B. Müller, Armin Moczek, Eva Jablonka, et al. 2014. ‘Does Evolutionary Theory Need a Rethink?’ Nature 514 (7521): 161–64. A short two-sided piece, asking whether a transformation in evolutionary thinking is under way.  

Lyons, Nathan. 2019. Signs in the Dust: A Theory of Natural Culture and Cultural Nature. Oxford: Oxford University Press. A fascinating presentation of the idea that something like ‘culture’ is present throughout nature, for instance in what organisms make and pass on.  

Riskin, Jessica. 2016. The Restless Clock: A History of the Centuries-Long Argument over What Makes Living Things Tick. Chicago: University of Chicago. Places recent tussles in biology in a longer historical context. 

Sultan, Sonia E. 2015. Organism and Environment: Ecological Development, Niche Construction, and Adaptation. Oxford: Oxford University Press. A magnificent survey of the importance for science of studying organisms in relation to their environments.