“ THE PROHIBITION OF EUTHANASIA ” AND MEDICAL OATHS OF HIPPOCRATIC STEMMA

It has been debated whether the Hippocratic Oath’s commitment referring to not administering poisonous/ deadly drugs prohibits: euthanasia, assisted suicide or murder. The first goal was to analyze if the prohibition of administering poisonous/deadly drugs was kept and how it changed in medical oaths of Hippocratic stemma of different time periods and religious orientations. The second aim was discern what is forbidden: euthanasia, assisted suicide or murder. Seventeen medical oaths: 4 Medieval, 2 Modern and 11 Contemporary oaths were studied and divided into those expressing the commitment like the original, those that may include it depending on the interpretation and those that do not mention it. Medieval and Modern oaths express it similarly to the Hippocratic Oath, possibly due to religious and Hippocratic/Galenic influences. What they forbid cannot be inferred. Contemporary oaths maintaining the commitment tend to include phrases regarding active euthanasia and assisted suicide. Other contemporary oaths may generalize it. It would be advisable that medical oaths would contain clear and specific premises regarding this commitment depending on the country, school and the student body’s idiosyncrasies.


Introduction
Many physicians have considered the commitment of the Hippocratic Oath in reference to the administration of harmful drugs as the prohibition of euthanasia (1,2).However, its true original meaning is not yet clear.Authors like Jones translated this commitment as: I will not give poison to anyone though asked to do so, nor will I suggest such a plan (3:11).
While others like Edelstein declare: I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect (Tödliches Medikamente) (4:7).Deichgräber, at the same time, translates it as: I will not perform, even if asked, a deadly action (Tödlich Wirkende) (5:9).
While Von Staden does it as: I will not give a drug that is deadly to anyone if asked (for it) (6:407).
We must note, however, that according to definitions, a poisonous drug is not necessarily deadly.It depends on the dosage.For this reason, when the term is translated as poison they're also making reference to cause no harm, therefore, to the principle of non-maleficence.
There are different interpretations about what the prohibition of administering poisonous or deadly drugs in the Hippocratic Oath actually means.Some authors understand it as referred to assisted suicide.Others think it's related to euthanasia and a few assert that is not committing murder.
Due to these discrepancies and trying to analyze the evolution of this concept expressed in medical oaths, the first goal of this work was to analyze if the prohibition of administering poisonous/ deadly drugs was kept and how it changed in medical oaths with Hippocratic influence of different time periods and within different religious orientations.The second aim was, when possible, discern what is forbidden: euthanasia, assisted suicide or murder.The intention of this study was not by any means to analyze current bioethical positions regarding euthanasia, neither to provide a new translation or interpretation of the Hippocratic Oath.The Hippocratic Oath and its discussion by scholars is merely mentioned to introduce the topic to the reader and provide a needed theoretical framework for analyzing subsequent oaths.

Materials and methods
Seventeen oaths of Hippocratic stemma were studied when analyzing the prohibition of administering poisonous/deadly drugs.They were selected according to their historical significance and representativity regarding time period, geographical location, renowned medical schools, ideology and/or religion, and importance and reliability of the sources.The oaths were selected from different sources: original articles, anthologies, encyclopedias, or sent by authorities of medical schools.In Table 1 the names of the oaths, historical periods when they were written and religion (if applies) can be found (Table 1).
The relation to the Hippocratic Oath would be represented by the name of the oath when it includes the word Hippocratic or because the authors recognized having based their oaths on the Hippocratic Oath.The different texts were grouped according to the time period in which they were written: 4 Medieval, 2 Modern and 11 Contemporary (Table 1).
For the analysis, they were divided into those that express the commitment the same or similarly to the Hippocratic Oath.Those with commitments that could include or not the prohibition of administering poisonous/deadly drugs depending on the interpretation, and those that express nothing about it.
With the aim of pointing out this commitment, we examined when it was referenced in each oath.The goal of this task was to determine similarities and differences between themselves and with the Hippocratic Oath.
The first two authors analyzed the oaths, pointing out words or phrases that referred to not administering poisonous/deadly drugs, as well as commitments that could include this prohibition.
Primarily, the work was done individually.When the authors compared their results, there was a discrepancy of 5%.In the second instance, all authors worked together and reached a consensus in the expressions where they had previously disagreed.

Hippocratic Oath
Different hypotheses have been proposed through time trying to explain the meaning of the Hippocratic Oath's commitment traditionally translated as not administering poisonous/deadly drugs.For Edelstein, the prohibition is against suicide, clarifying that it wasn't forbidden in Ancient Greece and that it was justified if it was committed due to illness.He asserts that the Platonists, the Cynics and the Stoics allowed the suicide of the ill and that even some philosophers considered this act as the major triumph of man above destiny.According to his view, only Pythagoreans condemned suicide for considering it a sin against God: 'who allocated to man his position in life as a post to be held and to be defended'.This is one of the reasons why Edelstein considers the Hippocratic Oath to belong to this group (4:11).It should be mentioned that although Edelstein's hypothesis was influential during its time, in the subsequent decades its validity decreased (7).Authors like Prioreschi, for example, contradicts him, mentioning other schools that also condemned suicide: Academics, Peripatetics and Epicureans (8).
For Edelstein it would make no sense that the commitment refers to poisoning, as many others assured, because there were already laws about it in those times that forbid it.There would be no reason to repeat them in the Oath (9).On the contrary, Carrick asserts that many oaths back then were influenced by legislation; therefore it wouldn't have been an inconvenience that the Hippocratic Oath would repeat existing laws.This author considers that the prohibition literally refers to not poisoning.He says that the physicians in Greco-Roman times who were skillful in Prohibition of administering poisonous/ deadly drugs
Table 1: Prohibition of administering poisonous/deadly drugs and Medical Oaths of Hippocratic Stemma.
healing were also skillful in killing and that Plato had already mentioned it in The Republic.Also, ancient Greeks had no way to know through chemical analysis if somebody had died of poisoning, which would be another reason to include the prohibition in the Oath (9).
According to Miles, the term suicide did not exist in Ancient Greece in the time that the Hippocratic Oath was supposedly written.It appeared years later, and even then it did not refer to end one's life to escape suffering or illness, but to heroic deaths or out of shame.He affirms that in those times, similar to today, the wish to end one's life was considered a symptom of depression (7).
According to Van Hoff, the term euthanasia appeared during the IV and III Centuries B.C and was used for the first time by Greek comedy writers.He asserts that in former times, the polis and its welfare were the most important things for a person.After the rising of great powers, like Macedonia, this wasn't as important.People started to value private life and also their own deaths to a greater degree.It's in this context that the term euthanasia could have originated (10).Von Engelhardt however mentions that the term euthanasia was already in use and that Suetonius used it to describe Augustus conception of an ideal death (11).
Miles also defends this idea, but states that the word euthanasia didn't appear until the 280 A.D., and that it didn't refer to assisted death but referred to death without agony.It wasn't until 1869 that the historian William Lecky gave it the actual meaning of 'intentionally ending life in order to end suffering from disease'(7:68).It's for these reasons that Miles, as well as Van Hoff, considers that the prohibition of administering deadly drugs cannot be referred to in the Hippocratic Oath as euthanasia.He asserts that it is murder, since in Ancient Greece it was common that physicians, who knew about poisons, would participate in crimes for economic reasons (7).However, other authors like Von Engelhardt affirm that the first person to use the term euthanasia similarly to the current interpretation was Francis Bacon, in a text from 1.623 titled De dignitate et augmentis scientiarum.Bacon referred to heroic deaths as inner euthanasia.Asking doctors to end the suffering of patients without hope was described as external euthanasia (12).
Summarizing, the meaning of this Hippocratic Oath's compromise will always be subjected to readers' interpretation.However, it is not only important the influence that the Oath had on ancient Greek physicians, but also how it affected other countries' medical oaths through times.

Analysis of medical oaths of Hippocratic stemma
Out of the 17 oaths, 9 of them include explicitly the prohibition of not administering either poisonous or deadly drugs, making one of them reference to both (Hebrew Paraphrase of the Hippocratic Oath).All Medieval and Modern oaths and three Contemporary oaths analyzed fall into this category.Seven contemporary oaths contain expressions that could be interpreted by the reader as referring to euthanasia, assisted suicide or murder.One oath does not contain any commitment regarding the subject nor that could be interpreted as such (Oath of Hippocrates, University of Ottawa) (Table 1).

Table 1: Prohibition of administering poisonous/ deadly drugs and Medical Oaths of Hippocratic Stemma
The commitment of not administering poisonous/ deadly drugs is expressed in most Medieval and Modern oaths analyzed, similar to the Hippocratic Oath: Neither will I give poison to anybody though asked to do so (Oath according to Hippocrates in So Far as a Christian May Swear It)(3:23); To not give poisonous drugs to the human body (Doctorate Oath of Schola Medica Salernitana)(13:24);

And I will not give them [to my patients] any poisonous drug if they ask for it, nor will I advise them thus (Oath of the Covenant laid down by Hippocrates) (3:31);
I will never give a deadly drug, nor advice such thing (Giovanni Lombardi`s translation of the Hippo-cratic Oath)(15:480); Neither shall the requests and petitions of any man be they never so earnest, so much prevade with me to give to any person to drinke, neither will I give my counsel or consent theretos (sic); (Oath of Hippocrates, text of John Read)(16:216).
It's improbable that Medieval and Modern oaths, which constitute the majority of the oaths analyzed that maintain the commitment of the Hippocratic Oath expressed in a similar way, would refer to euthanasia as it is conceived nowadays.It must be noted that in the Middle Ages, medicine was still influenced by Hippocratic and Galenic treatises (27).Therefore, it wouldn't be surprising that they would reproduce the Oath's compromises with little or no changes.In Medieval times, which were heavily influenced by religion, suicide was equal to murder, being an offense to God.Secular writings of this period condemned suicide.Also, societies tend to use the text that adapt best to their idiosyncrasies, thus the prevalence of the Hippocratic Oath.Veatch and Mason also assert that in contrast with Hippocratic medicine that did not offer lineages on how to behave with the dying, the Christian morals encouraged to accompany them, although not necessarily to do everything possible to preserve life (28).
Moreover, religious influence encouraged people to not escape from suffering, as Christ didn't, and to gracefully accept death.There were even books in the Middle Ages like Ars Moriendi, that gave advice on how to die well according to Christian precepts.The concept of transcendence is also introduced during these times (11).For Christianity, death is transformation: 'Life is not taken away, it transforms' (29:220).
Sometimes these oaths, vary the form of expression depending on the translation and in occasions it tends to be an interpretation.For example, the Hebrew Paraphrase of the Hippocratic Oath declares: And he will take great care not to give instructions in the preparation of a potion causing death or injury, nor should he [become involved in a procedure] causing weakening to the patient if he feels [this to be distasteful], or if he is induced to do such an evil deed(14:400-441).
Even though this text is an oath of Hippocratic stemma, there is the possibility that it was written by a student in some school of medicine as notes, making reference mainly to the principle of nonmaleficence.This can explain why there are differences and additions compared to the original.We must note that this text points out something common in that time: physicians were in charge of giving instructions to boticaries or similar for the preparation of different drugs.This concept is also expressed in the Oath of Asaph, the first known Hebrew medical oath.It wasn't strange in those communities that physicians took part in crimes.Also, although during the Middle Ages death was supposed to be accepted, during the Renaissance, it begun to be conceived as the loss of the self, putting emphasis in funerary rites (29).The Oath of the Physicians of Russia was created as a combination of the Hippocratic Oath and the prerevolutionary university 'Faculty promise'.It attempted to leave anachronisms aside.This oath would replace the non-Hippocratic 'The oath of the Soviet Physicians'.It expresses:

I will never give anyone a fatal drug if asked nor show ways to carry out such intentions(17:50).
The A.D 1995 Restatement of the Oath of Hippocrates, endorsed by 35 interfaith ethicists, asserts: I will neither prescribe nor administer a lethal dose of medicine to any patient, even if asked nor counsel any such thing nor perform act or omission with direct intent deliberately to end a human life (18:4-5).
These two oaths are clearly manifesting themselves against active euthanasia and assisted suicide.
The Oath of the Physicians of Russia tried to restore old values that were absent in the Soviet Union, making the oath, in Tichtchenko's opinion, sometimes anachronical (17).In relation with the A.D 1995 Restatement of the Oath of Hippocrates, although the debate over euthanasia and assisted suicide exist in secular societies, all major religions condemn them.According to James G. Anderson, traditional religious beliefs oppose euthanasia due to: 'resistance to playing God, the commandment not to kill and the potential spiritual benefits of suffering' (30:106).
The oaths with expressions that could imply not committing murder, not participating in assisted suicide or not performing euthanasia depending on the interpretation, are all contemporary.
The Declaration of Geneva was written in 1948 by the World Medical Association (WMA).This organization was created after the Second World War to replace l'Association Professionnelle Internationale des Médecins, a previous international association of physicians created in 1926 that had suspended its activities during the war (31).The original and subsequent versions until 1994 expressed: I will maintain the utmost respect for human life, from the time of its conception, even under threat; I will not use my medical knowledge contrary to the laws of humanity (20)(21)(22).

While the version of 2006 asserts:
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 (23).
Given that this declaration tried to be applied to the worldwide community despite their cultural and religious diversity, none of its versions would specifically refer to euthanasia.This was probably because of the controversy of the topic.Another reason could be due to the different beliefs and laws of the existent countries (32).Even though the way in which this commitment is written could give place to various interpretations, the WMA declared in 1987 its unfavorable position to active euthanasia because they considered it unethical (33).Understanding active euthana-sia as 'to perform a procedure to end the patient's life' (34:89).In the World Medical Assembly of 1992, WMA expressed its opposition to medically assisted suicide and, in its resolution of 2005, they reaffirmed, 'its strong belief that euthanasia is in conflict with basic ethical principles of medical procedure' (31).It is common that medical schools base their own oaths in the Declaration of Geneva.Examples would be the Hippocratic Oath, Faculty of Medicine, University of Zaragoza and the Oath of the School of Medicine of the University of San Diego, California, expressing: 'I will maintain the utmost respect for human life and its quality' (24:381).Some oaths from the United States make reference to criminality.The Oaths of the School of Medicine, University of Toronto and the School of Medicine and Health Sciences, George Washington University expresses: [I] will give no drugs and perform no operation for a criminal purpose and far less suggest such a thing (24:381).
The scope of this prohibition and the interpretation on what would be considered a criminal purpose is controversial and depends on the reader's interpretation.Parallelisms could be drawn between not to give drugs with a criminal purpose and the prohibition of the Hippocratic Oath to not administrate poisonous/deadly drugs, as well as with Edelstein's interpretation to not give abortive remedies (4:7).It is also debatable if these oaths would be referring to euthanasia, to assisted suicide, to murder (of a person who has already been born), or to abortion.Since in the early 20 th century this last one was mentioned in literature as a criminal operation (United States) or an illegal operation (United Kingdom) (35).The reference to crime may be traced back to an oath with no Hippocratic origin nor religious orientation: the Doctorate Oath of the Montpellier School of Medicine (1881) which states 'my status shall not serve to correct morals or forward crime' (20:35).But that has been very influential throughout history.It's also one of the oldest western oaths known that does no mention the prohibitions of abortion and of administering poisonous drugs explicitly like the Hippocratic Oath.making the sample less representative.Also, there could be oaths mentioning the term "Hippocratic" in their name out of tradition but not necessarily recognizing its influence.

Conclusion
All Medieval and Modern oaths keep the commitment of the Hippocratic Oath of not administering poisonous/deadly drugs mentioning it similar to the original.Possibly this is due to religion and to Hippocratic/Galenic medicine being influential during those time periods.However, it is not possible to infer if it refers to euthanasia, assisted suicide or murder.In contemporary times, the commitment was generalized, and its scope was as well subject to reader's interpretation.Only in a few cases they include phrases that clearly state that they are referring to active euthanasia and/or assisted suicide.It would be advisable that medical oaths would contain clear and specific premises regarding this commitment depending on the country, school and the student body's idiosyncrasies, since the commitment loses its meaning when it is generalized and subject to reader's interpretation.
Another contemporary oath with a similar concept but a slight variation is the Version of the Hippocratic Oath of the School of Medicine, John Hopkins University, which affirms: [I] will give no drug… and perform no operation… without a justifiable purpose... far less suggest it... (25:508).
Here the scope of the prohibition might be even wider.
A Physician's Oath, by the Mayo Clinic, states: I will honor the wishes and needs of the patient, recognizing that death is not always an enemy.I will do no harm (24:381).This oath could be interpreted as somehow supporting passive euthanasia.Understanding this one as 'perform medical procedures so the patient is as comfortable as possible but by no means perform anything to improperly prolong their life' (34:89).
The Oath of Hippocrates, University of Ottawa (24) does not express any commitment expressing nor that could be interpreted as prohibiting poisonous/deadly drugs.
Possible limitations of this study are the small number of oaths utilized.Also, there might be medical oaths of Hippocratic stemma but not stated by the authors or not mentioned in the title.Therefore due to this fact they were excluded, Three contemporary oaths analyzed, explicitly mention the prohibition of not administering poisonous/deadly drugs: the Oath of the Physicians of Russia, The A.D 1995 Restatement of the Oath of Hippocrates and The Hippocratic Oath -Autonomous University of Madrid.The latter uses the original version of the Hippocratic Oath almost entirely, possibly due to tradition, as many other universities around the globe.