Clinical Medical Ethics series

Paul J. Carrick

• Publisher: Georgetown University Press
• Year: 2001
• ISBN:
  9781589018617
• Topic: Medicine
• Subtopic: Ethics in Medicine

In this book Paul Carrick charts the ancient Greek and Roman foundations of Western medical ethics. Surveying 1500 years of pre-Christian medical moral history, Carrick applies insights from ancient medical ethics to developments in contemporary medicine such as advance directives, gene therapy, physician-assisted suicide, abortion, and surrogate motherhood. He discusses such timeless issues as the social status of the physician; attitudes toward dying and death; and the relationship of medicine to philosophy, religion, and popular morality. Opinions of a wide range of ancient thinkers are consulted, including physicians, poets, philosophers, and patients. He also explores the puzzling question of Hippocrates' identity, analyzing not only the Hippocratic Oath but also the Father of Medicine's lesser-known works.

Complete with chapter discussion questions, illustrations, a map, and appendices of ethical codes, Medical Ethics in the Ancient World will be useful in courses on the medical humanities, ancient philosophy, bioethics, comparative cultures, and the history of medicine. Accessible to both professionals and to those with little background in medical philosophy or ancient science, Carrick's book demonstrates that in the ancient world, as in our own postmodern age, physicians, philosophers, and patients embraced a diverse array of perspectives on the most fundamental questions of life and death.

PART I
THE SOCIAL AND SCIENTIFIC SETTING

1
The Status of the Physician

History is philosophy teaching by example.

— DIONYSIUS OF HALICARNASSUS

TO FULLY PENETRATE the values and conduct of the ancient Greek physician, it is necessary first to examine certain fundamental elements of his historical setting. Thus, I have selected three areas of initial inquiry that hold the key to comprehending the cultural framework within which the ancient physician practiced his craft. These three areas are best introduced in the form of three questions. First, who was the Greek physician? Second, what were some of the leading theories of health and disease that guided his care of patients? And third, what were the dominant attitudes and theories of his culture regarding death and the afterworld?

In Part I, I shall develop answers to these three important questions, with the present chapter restricted to the first among them. My primary focus throughout will be centered on cultural developments in and around the Greek mainland between the sixth through fourth centuries B.C. My secondary focus will include selected features of the Greco-Roman world up to the time of Galen in the second century A.D.

TYPES OF PHYSICIANS

Who was the ancient physician of fifth-century-B.C. Greece? What was his social rank? Ludwig Edelstein asserts that “whatever the situation may have been in prehistoric Greece, in Homer’s time [ca. 725 B.C.], the physician was already the member of a lay craft; he was ‘a worker for the common weal’ like the maker of spears, the singer, the seer. He remained throughout antiquity a craftsman, an artist, a scientist.”¹ As such, like all Hellenic craftsmen (demiourgoi), the physician was seen to be in the possession of the technical body of knowledge peculiar to his craft alone. He was not ordinarily confused with other tradesmen, nor was the physician equated in the public’s mind with the exorcist or magician, who were common enough figures in the ancient world. Hence, by the fifth century one is hardly surprised to find the playwright Sophocles asserting that, “It is not a learned physician who sings incantations over pains which should be cured by cutting.”² Centuries later, Roman law established that any physician who practiced by exorcisms or incantations could under no circumstances sue his patients for unpaid fees, for such methods were judged not to belong to the bona fide craft of medicine.³

Nor is it likely that medicine in Greece originated in the temples of the deified hero-physician, Asclepius. By the time Asclepius rose to the status of a god and temples were erected to celebrate his powers and promote his cures (most notably at Epidaurus), the physicians (iatroi) of Greece were already firmly established as independent, secular craftsmen.⁴ The honorary title of “Asclepiad,” by which physicians were sometimes addressed, had been a source of long-standing confusion among historians attempting to sort out the cultural roots of the Greek practitioner. But it is now emerging from the available evidence that this title did not refer to the god or to a formal religious corporation.⁵ Rather, it referred to certain guilds or families of physicians who handed down medical knowledge from father to son, or master to apprentice.⁶ The title of Asclepiad was, it seems, a well-chosen indirect reference to the admirable deeds and personal compassion associated with the heroic founder of medicine, Asclepius. The legacy of Asclepius was such that contemporary fifth-century physicians sought a share in it as distant descendants or “sons,” as they sometimes called themselves.⁷ Indeed, few physicians wished the public to lose sight of Homer’s oft-repeated judgment that “a healer is man worth many men….”⁸

But while the physician of Hippocratic times (ca. 450-300 B.C.) was, by definition, one who engaged in the art of preserving or restoring health, evidence exists in the writings of the philosophers Aristotle and Plato that invites the judgment that the social status of physicians varied significantly according to their training and methods. Aristotle, for example, says that “the term ‘physician’ means both the ordinary practitioner, and the master of the craft, and thirdly, the man who studied medicine as part of his general education.”⁹

It is difficult to know whether Aristotle here intends a faithful description of well-recognized social groups within Greek medicine, as such, or whether he is supplying us with a personal evaluation of the sorts of physicians one usually encountered in the Greek city-state. I think he is rendering an evaluation. The context of his remark is a large discussion in which he is seeking to evaluate how much power a political majority should exercise over the technical affairs of the state. His mention of levels of skill among physicians is thus seen as part of a useful analogy: just as some physicians do not practice their art but acquire it as part of their general education and thereby know something about medicine, so too many citizens know something of the affairs of state though they do not personally practice the art of rulership. Additionally, when one considers the medical knowledge possessed by such pre-Socratics as Empedocles, as well as by the later sophists and generalists of Greece and Rome, it is not at all difficult to account for Aristotle’s third definition of the generally educated physician.

But then, what of Aristotle’s remaining distinction between “the ordinary practitioner” as opposed to “the master of the craft”? Does this refer to two distinct social classes of physicians, one the scientist-theoretician, the other the leech-practitioner?

The plausible answer is that it does not. At most it attests to Aristotle’s awareness that some physicians, like Diocles of Carystus, appeared as masters of their craft in the sense that they could explain why their treatments worked. Others could not, though they still may have gotten helpful medical results. The former were masters, the latter ordinary practitioners. This difference in the practitioners’ level of understanding, at once both detectable and significant for a theorist of knowledge like Aristotle, almost certainly constituted the basis for his threefold grouping here. This interpretation is all the more credible since, in fact, anyone in the ancient world could practice medicine; there were really no formal educational class distinctions as such. To practice medicine was a right, not a privilege. Physicians were not in the least certified or categorized by the state.

Furthermore, it is pertinent to mention that Plato distinguishes two social ranks of physicians in his Laws. He speaks on the one hand of the free-born physician and on the other of the slave-physician. The free-born physician “for the most part attends free men, treats their diseases by going into things thoroughly from the beginning in a scientific way”; the slave-physician generally treats fellow slaves and never gives a patient any account of his complaint.¹⁰ He is “innocent of the theory,” whereas his free counterpart can be found “talking almost like a philosopher, tracing the disorder to its source, reviewing the whole system of human physiology….”¹¹

Yet, despite Plato’s words, it would be overly hasty to conclude that the social difference between slave and free doctors made a decisive difference in the quality of their medicine. Owsei Temkin points out that slave doctors were a known institution throughout antiquity. Highly educated persons could become slaves when they or their defeated armies became captives. So there is little warrant for supposing that physicians belonging to this slave class were automatically of inferior skill or knowledge.¹² In view of these facts, I am prepared to conclude from the Laws that Plato, like Aristotle, felt it instructive to distinguish those healers who studied nature in such a way that they deduced their treatments from universal principles from those less rigorous healers who acquired their skills mostly by imitation and rote. The latter were bereft of a theoretical causal framework for their medicine. The former alone were “almost like a philosopher” and stood for both men as exemplars of their craft.

Perhaps the safest conclusion to be drawn about the status of the Hellenic physician, one fully consistent with the above testimony, is that his personal status was variable. Naturally, if his cures were known to be successful and if he thereby gained a reputation as a highly capable practitioner, he would enjoy a measure of fame and status exceeding that of his more average competitors. Then, as now, there existed the country doctor, the city doctor, and the regal court physician. When the Greek physician Galen was practicing in Rome in the second century A.D., he complained that physicians treated their patients differently depending on the physician’s origins, his training, and the perceived social standing of a given patient. Patients, in turn, reacted differently toward their physicians depending on the physician’s perceived authority and his high or low reputation.¹³

But as to the average physician taken as a stereotype of fifth-century Greece, particularly Attica, I am in full accord with Edelstein’s characterization:

The Hippocratic physician is a craftsman. As a craftsman, he practices either as a resident or as an itinerant; he may also settle for awhile in some town, leave again, work in another town, or wander all over the country. When he is in a town, he works in his shop or in his patient’s home. The shop is a place in which today one person, tomorrow another, plies his trade—not a hospital, not a consulting room in the physician’s house. Sick people come to the shop for examination and treatment, or the physician goes to his patient’s home. An itinerant physician works in the patient’s house or has a booth set up in the marketplace of the town, or elsewhere, and practices there.¹⁴

Elsewhere, Edelstein has aptly summarized the social situation for doctors down to the time of the Roman Empire:

About the basic social situation there can be no doubt. The medical practitioner, working for a livelihood and working with his hands, preparing drugs or performing operations, was to the ancients a craftsman and, as such, belonged to the lower strata of the social order. And this was true throughout antiquity. It did not help his standing that in the Classical and in the Hellenistic era he was usually a migratory worker, an ‘out-of-towner,’ and in Roman times a foreigner; in the Rome of Cicero no citizen had yet gone into medicine, while he would not scruple to become a lawyer. Nor should one forget that in the empire probably more physicians were slaves than had even been the case in Greece.¹⁵

Finally, it is relevant to ask: was there anything like our modern medical specialties in classical antiquity? The simple answer is no. For there was no profession as such in today’s terms, and no board certification or other licensing system. But practically speaking, it may be admitted that, while there was no division between medicine and surgery (the latter then including operative surgery, setting bones, reduction of dislocations, and cauterization), evidence suggests that some physicians may have practiced surgery exclusively.¹⁶ But if so, the trend toward specialization was for the most part a matter of personal convenience rather than based on any deep-seated ideological split within the craft of medicine, as some have assumed.¹⁷

EGYPTIAN INFLUENCES

In contrast to the comparatively unified approach to healing characteristic of fifth-century-B.C. Greek medicine (Fig. 1), the Greek historian Herodotus writes of the Egyptian physicians that “medicine is practiced among them on a plan of separation; each physician treats a single disorder, and no more: thus, the country [Egypt] swarms with medical practitioners, some undertaking to cure diseases of the eye, others of the head, others again of the teeth, others of the intestines, and some those which are not local.”¹⁸ This account raises the question: to what extent was Greek medicine influenced by the Egyptians?

To begin with, Herodotus’s report of Egyptian specialization suggests that the state of the medical art in Egypt was quite advanced by ancient standards. In antiquity Egyptian physicians were much sought after in foreign lands. Indeed, the Greeks expressed admiration toward Egyptian medicine, particularly their effective use of drugs. A rich variety of these is prescribed throughout the best-preserved Egyptian medical papyri now in our possession.¹⁹ Moreover, we know for a fact that the Greeks cop...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Dedication
• Contents
• List of Illustrations
• Preface
• Acknowledgments
• Introduction
• Part I The Social and Scientific Setting
• PART II The Rise of Medical Ethics
• Part III Abortion and Euthanasia
• Appendix A: Principles of Medical Ethics
• Appendix B: A Patients Bill of Rights
• Appendix C: Declaration of Geneva
• Appendix D: Code for Nurses
• Appendix E: Animal Use in Biomedical Research
• Appendix F: Historical Chronology: Ancient Medicine and Culture
• Select Bibliography
• Index