The principle of justice (non-discrimination in healthcare and equitable distribution of resources) was not the rule in the ancient times.¹

Hippocratic oath does not include these principles. In its many translations, different words are used for equivalent Greek terms—for example, some translations use the word “injustice” to translate the term “adikíé”, others use other terms—for example, Jones^2–5 uses the words “injury” or “harm” instead. The translations that include the word injustice are based on the study by Edelstein,⁵ who in the first instance translates,


 I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

In the second instance,


 Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

This author justifies the use of the word “injustice” as a principle pertaining to the Pythagorean school, among others. With regard to the association existing between these rules and sexual relationships, pythagoreans consider it to be unfair because the man who is unfaithful to his wife is unfair to her; similarly, the doctor is unfair when he misuses the patient’s vulnerability. Another pythagorean feature is the non-discrimination by sex and social class in regards to the prohibition of this relationship.⁵

The clause that states the prohibition of sexual relationships in the Hippocratic oath has not been studied adequately. Campbell⁶ points out some reasons for this: it is obviously not important and is a taboo subject. Despite this, at present, research shows the frequency of these relationships in publications on psychiatry, obstetrics, gynaecology and other subjects.^7–9 Studies analysing the ethical and legal consequences associated with this type of relationship are also available.¹⁰

Currently, medical schools try to ensure that their members are committed to their careers by making them take oaths. This is shown by studies in the past decades that analysed the use and contents of the oaths in the US, Canada and Argentina.^11–15

As the prohibition of a sexual relationship between a doctor and a patient has not been studied in other oaths⁶ and schools continue to bind their graduates through oaths, it is interesting to analyse this clause in the formulas that were used during different periods.

Consequently, the first objective of this study was to determine whether this prohibition of sexual relationships between doctors and patients that was manifested in the Hippocratic oath was preserved in the formulas of different periods and in versions of the original oath. The second objective was to assess the variations in the expression of the prohibition in the oaths of different times in comparison with the manifestations in Hippocrates’ oath.

MATERIAL AND METHODS

To analyse the expression of the prohibition of the doctor–patient sexual relationship, 50 oaths found in publications were assessed. These were selected considering their historical context and not its practice.

With regard to the time of formulation, texts were grouped as old–medieval (n = 13) and modern–contemporary (n = 37). Of the 50 texts, 19 were versions of the Hippocrates’ oath (table 1).

For analysis, oaths were divided into those that indicated prohibition and those that did not, on the basis of the following characteristics: expression of the prohibition of sexual relationships or other manifestations that refer to any sexual aspect, also taking into account all the paragraphs that start in the same manner as Hippocrates’ oath (“Whatever houses I may visit, I will …”).⁵

With the objective of pointing out the clause, the work consisted of noting each idea that may refer to these aspects, to compare them in terms of their formulation and to determine their similarities with and differences from Hippocrates’ oath.

Significant differences between the manifestation of this commitment and the oaths of different times and the versions and non-versions of the Hippocratic oath, were assessed by using the proportion comparison test (z).⁴⁴

RESULTS

Of the 50 oaths analysed, 24 (48%) stated the prohibition of sexual relationships between doctors and patients, or made similar statements or a paragraph that began similarly to Hippocrates’ oath; and 26 (52%) neither referred to it nor included such a paragraph (table 1).

When analysing the relationship between the time of formulation and the statement of this prohibition, 8 of the 13 (62%) old–medieval and 16 of the 37 (43%) modern–contemporary oaths expressed it; thus we found no significant differences (z = 0.813; p = 0.416). Also, with regard to a version or non-version of Hippocrates’ oath, we found no significant difference: 12 of the 19 (63%) versions and 11 of the 30 (37%) non-versions expressed this prohibition (z = 1.517; p = 0.129).

Four texts, versions of Hippocrates’ oath, expressed the sentence almost verbatim, except that the expression “sexual relations” was changed to “fornication” (according to Hippocrates, as sworn by a Christian²), “with other transaction or in regard to sexual relations” (Covenant laid down by Hippocrates²), “casual love affair” (from Perotti’s translation¹⁸ of Hippocrates’ oath) and “sexual intercourse” (from Read’s translation of Hippocrates’ oath).²¹

Lombardi’s translation¹⁸ of Hippocrates’ oath modified this expression by omitting the prohibition: “… I shall exercise my art in men and women, either servants or lords …”.

The other two texts, versions of Hippocrates’ oath, refer to the prohibition of “sexual relations” (of the Russian physicians²⁷) or “seduction” (ad 1995 Restatement of Hippocrates’ oath³⁰), but towards the patient only, without specifying man, woman, free or enslaved. Another modification of the Hippocratic oath (from Lowe’s translation²¹) notes the prohibition, but without mentioning with regard to whom.

The Hebrew paraphrase¹⁹ of Hippocrates’ oath prohibits only “coveting” the patient’s “wife, daughter or maid”. And all three remaining versions (of Doctor in Medicine,²⁵ Modern Hippocratic,¹³ and Hippocratic oath—The Johns Hopkins’ version²⁹) modified the expression, beginning the paragraph as “… aloof from wrong, from corruption and from the tempting of others to vice …”.

This clause is also expressed in a similar manner in four other texts that are not versions of Hippocrates’ oath (of the Montpellier School of Medicine (Doctorate),¹⁷ the Buenos Aires School of Medicine,²³ the Sao Paulo School of Medicine²⁴ and the La Plata School of Medical Sciences).²⁶ These oaths begin as Hippocrates’ oath does, eliminating the clauses of prohibition of sexual relationships, abortion and euthanasia and generalising the expression “… neither corruption of the customs nor favoring crime …”.

Another three formulas, non-modifications of the original, changed this prohibition: “well being and modesty of the ill” (of the Basle Doctor²⁰), “bad or immoral purposes” (of the University of Berlin (Bird and Barlow,²²)) and “any deed that stains the eyes of God” (from Doctor, Kuwait Code of Medical Ethics).¹⁶

The Imhotep oath,²⁸ a non-version of Hippocrates’ oath, states, “… I shall refrain from sexual practices with my patients and others under my guard …”.

The expression in the three remaining texts, Caraka,¹⁶ Asaph¹⁶ and Amato Lusitano,¹⁷ refers to different aspects of the Hippocratic oath. The Caraka oath prescribes a life of celibacy, avoiding adultery and not accepting gifts from a woman without her guardian’s consent.¹⁶

The Asaph oath¹⁶ expresses, “… Refrain from lustfully coveting beautiful women ….Do not wish wealth or possessions that come from assisting in or carrying out sexually vicious acts …”.

The Amato Lusitano oath¹⁷ specifies, “… in my consultations and feminine visits I did not practice the least blunder, never did anything that a judicious and distinguished physician would be ashamed of …”.

In summary, this prohibition of having sexual relationships with patients has been maintained in almost half of the studied oaths, some quoted verbatim from Hippocrates’ oath, some changing the words and others using a more general terminology associated with other commitments.

DISCUSSION

The Hippocratic oath expressed the prohibition of sexual relationships between doctors and men or women, free or slaves. This text was subjected to different translations, modifications or elimination of commitments.¹⁸ Also, in other versions of the Hippocratic oath, the same concept was expressed in other words. In summary, the oaths analysed in this study may be the result of interpretations rather than translations.^3,4

As previously discussed, Edelstein⁵ considered the Hippocratic oath as pertaining to the Pythagorean school. Therefore, this prohibition of sexual relationships between doctors and patients was considered to be a rule sustained by this school, which judged the sexual relationships to be unfair. Edelstein relates this sentence to the concepts of sanctity and purity manifested in the Oath in regards to the way the professional would live and practise his art. Another peculiarity was that Pythagoreans considered that members of the different sexes and social classes were equals.

Campbell⁶ studied this clause of the Hippocratic oath, pointing out different reasons for its inclusion:

1. A legal reason, as infidelity of the woman, seduction and abduction were legislated

2. An economic reason, as physicians following Hippocrates’ oath defended the reputation of their profession

3. Sexual relationships with guest relating to exchange of goods were prohibited at that time

4. A social reason, as this prohibition carried a protection towards the sexual integrity of women and slaves, ultimately to defend the relationship between doctors and patients

5. The existing difference between the doctor’s power and the patient’s vulnerability.⁶

Despite this, the sexual relationships between a doctor and a patient, adultery and concubinage were common practices in old times, among heterosexuals as well as homosexuals.^1,6

This prohibition is maintained in almost half of the analysed texts, and, although we found no marked difference, the old–medieval texts are the ones that point it out most frequently. This may be because of the greater influence of the Hippocratic oath on the first formulas.

Of the five articles that analysed the use and contents of the oaths used in Medical Schools in the US, Canada and Argentina,^11–15 only two point out similar subject matter. The first one mentions chastity (3%)¹³ and the second one specifically indicates this prohibition (3%).¹⁵ Results of these studies are very different from those of our study. These studies analysed texts from the same place and historical time, whereas ours analysed formulas from different eras. Also, the classification of the commitments was different. In summary, these studies showed that the prohibition has been abandoned in present medical oaths.

The formulas that modified their wording in regards to Hippocrates’ oath showed general commitments and used different terminology. It can be said that they used the wording from the oath of the Montpellier School. According to this School, the three prohibitions mentioned in the Hippocratic oath—namely, sexual relations, abortion and euthanasia—were generalised by the expressions “wrong, vice, and corruption”.

The different versions of Hippocrates’ oath changed the parties committed to the prohibition of sexual relationships. Only one version of Hippocrates’ oath mentions women represented by the patient’s wife, daughter and maid (Hebrew Paraphrases).¹⁹ Another two texts, also Hebrew-oriented, point out women only. The Asaph oath went further by prescribing that these types of relationships should not lead to gaining goods or wealth. This text followed many statements of the Hippocratic oath and the rest were based on passages from the Bible.¹⁶ The oath by Amato Lusitano mentions any type of offence against a woman. This formula is a moral testimony of the medical life that reflects its Judaism. Therefore, the religious orientation of these formulas may have influenced the fact that the prohibition affects only women related to the patient. Nowhere in the texts were women considered patients, except in the last oath. The Christian and Arab formulas maintain the same wording as Hippocrates’ oath, because their ethical principles followed the rules of these religions.²

Other oaths mentioned patients, without differentiating sex. This expression is much more logical at present. Nowadays, the number of female professionals and other sex orientations suggest not specifying sex in regards to the doctor as well as the patient.

The remaining texts that are not versions of Hippocrates’ oath showed this clause in a different light. The Caraka oath reflects the Indian tradition at the time. Throughout their learning period, men were committed to leading an ascetic life and being celibate.⁴⁵

The seven texts that are versions of Hippocrates’ oath, which do not mention the prohibition, have preserved the word “Hippocratic” as a tradition and not because they are derived from the original. They might have used generalisations in their clauses because of this. Also, the absence of this commitment in the Declaration of Geneva could be due to its general context. The Declaration of Geneva was formulated to advise on its use at medical schools pertaining to different cultures and religions.¹⁶

Sexual relationships between doctors and patients were common in Hippocrates’ times. This practice has not been abandoned at present^7,8,9,10 and is a subject of legal and ethical analysis.¹⁰ Therefore, medical associations and schools should evaluate whether to include the prohibition of sexual relationships in their medical oaths.