BOSTON -- The Hippocratic oath, uttered for decades by new doctors at medical school graduation rites, is nearing extinction because it is outdated and at odds with some modern medical practices.
The oath, attributed to the Greek physician Hippocrates about the fourth century B.C., is being shunned in favor of alternative oaths nationwide.
There is no quibble with the oath's pledge to do no harm and maintain patient confidentiality. But objections have grown over the years to the oath's paternalistic tone and to its outdated references to the apprentice system of training doctors.
Lately, the biggest -- and perhaps fatal -- problem with the Hippocratic oath is its prohibition of abortion and references throughout to "brothers," "sons" and "men," a sexual bias that some would like purged.
"It's very sexist. The oath makes it sound like only men can be physicians," said Joan Hoffmann, associate dean for student affairs at the University of Massachusetts Medical Center in Worcester, who noted that 50 percent of its graduating doctors are women and that students have chosen to recite a different oath. "It's just very outdated."
The Hippocratic oath has never been a requirement; it simply became a part of the ritual of medical school graduations, a moral commitment undertaken by those about to enter the profession.
While not legally binding, the oath has, through the years, provided a sense of tradition and ethical foundation for doctors, according to Arthur Caplan, director of the Center for Biomedical Ethics at the University of Minnesota.
"It's held up pretty well, primarily because of the 'do no harm' principle," Mr. Caplan said. "It serves as a conservative force of ballast for people who want to get into the latest technology or fad or the latest drug. It keeps a handle on the physician's power in dealing with some very vulnerable people. And it acts as a brake on using people for research."
About 15 years ago, however, many medical schools started questioning the Hippocratic model and modified it or replaced it with other oaths. Several left the choice to students as to whether to swear an oath at all.
Much of the Hippocratic oath was seen as too outdated; its references to maintaining close ties with one's teacher, for example, are irrelevant to modern medical training, which has long abandoned the single mentor-apprentice model. There was also a problem with the oath's reference to the unilateral judgment of the doctor.
"From a philosophical point of view, the Hippocratic oath is based on paternalism; that's basically gone by the boards," said George J. Annas, director of the Law, Medicine and Ethics Program at the Boston University School of Medicine. "There's nothing in it about the patient."
These days, the credo is that "the doctor should do what's best but with the patient's informed consent," Mr. Annas said.
Those who take the Hippocratic oath must also swear not to perform an abortion and not to provide any "deadly medicine" -- references that have become particularly problematic with the continuing debate over abortion and euthanasia.
But the death knell for the Hippocratic oath may well be the absence of any reference to women and its failure to say anything about the broader obligations of physicians to public health.
"It doesn't tell me what my social obligations are," Mr. Caplan said.
For all these reasons, many medical schools have all but stopped using the full Hippocratic oath and are instead allowing students to choose alternatives.
The most popular substitutes include the Prayer of Maimonides, a series of pious vows attributed to the 12th-century physician and philosopher; the Declaration of Geneva, an ethical guideline written by the World Medical Association in 1948; and an oath written in 1964 by Dr. Louis Lasagna, now dean of the Sackler School of Graduate Biomedical Sciences at Tufts University in Medford, Mass., that speaks of humility and sympathy and the "special obligations" of the doctor in society.
Merry Touborg, a spokeswoman for Harvard Medical School, said students vote each year on what oath they want to take and have not been choosing the Hippocratic oath very often. Harvard stopped using the Hippocratic oath as its official oath 15 years ago.
But, given the increasing ethical dilemmas facing the profession, Mr. Caplan said, "There are those who would say we should cling to the oath more than ever."
"There is some value to the code. I see it lived day-to-day, even though people may not be thinking it," Mr. Caplan said. "It does have a presence in the ethos of health care."