450 BCE to 380 BCE. He was a physician, and the writings of the Corpus
Hippocraticum provide a wealth of information on biomedical
methodology and offer one of the first reflective codes of
professional ethics. Though Plato (a contemporary) makes reference to
Hippocrates (Phaedrus 270a and elsewhere), it is generally believed
that most of the writings in the Corpus Hippocraticum are actually the
work of a number of different writers. By convention of time, place
and general approach a common name of 'Hippocrates' was assigned to
the lot (without distinguishing those of the historical Hippocrates).
Hippocrates and the other associated writers provide the modern
student with a number of different sorts of insights.
On the biomedical methodology side, these writings provide the most
detailed biomedical observations to date in the Western world. They
also offer causal speculations that can be knitted together to form a
theoretical framework for diagnosis and treatment. On the ethical
side, their code of professional ethics is so well structured that it
continues to stand as a model for other professions.
1. Biomedical methodology
One way to parse the groups of Hippocratic writers revolves around
their geographical origins: Cos vs. Cnidos. Though this classification
is controversial, it is useful (whether one accepts the literal
geographical demarcation) to mark some clear distinctions in the
Hippocratic body of writing. It appears to be the case that the Cos
writers sought to create general biomedical "laws" that for the most
part would give the explanation for why someone was sick. Any
physician might make reference to these "laws" and thereby have an
etiology for the disease, and by extension a strategy for treatment.
a. The Four Humors
The most historically prominent theoretical scheme of the Coan writers
was the doctrine of the four humors of the body: blood, phlegm, black
bile, and yellow bile (or sometimes serum). Health was defined as the
balance of the four humors. Disease was defined as the imbalance of
the humors. When imbalance occurred, then the physician might
intervene by making a correction to bring the body back into balance.
For example, if the individual were too full of phlegm (making her
phlegmatic or lethargic), then the phlegm must be countered. Citrus
fruit was thought to be a counter-acting agent. Thus, if one feels
lethargic, increasing one's citrus intake will re-create balance. The
treatment is, in fact, generally effective. Moderns might describe the
therapy differently by ascribing the effect to vitamin-C, phosphorus,
and natural sugar. This example illustrates the scope of the
Hippocratic physician in this context: something like a cross between
the modern roles of an herbalist dietician and a personal trainer.
Nonetheless, the cures that were dictated by the four humor theory
seemed to work well enough for this theory to extend to the nineteenth
century (in various guises).
b. An Ancient Debate: Are General Causal Theories Beneficial?
Other biomedical writers–some say from Cnidos–held that strict
empirical principles did not allow scientists to go far beyond the
data. It was a better methodology for the biomedical practitioner to
stay as close as possible to the data that were before him. This meant
that each patient would be seen in her particularity. Such a method
required careful trial and error observation and only slight
manipulation of the patient in the form of treatment.
There was a great conflict in the ancient world concerning the status
of observational conclusions (the empirically concrete). Should they
be given in their specificity and remain as disparate, individual
accounts, or should they be grouped and more general principles drawn
from them? In this instance it was very much in dispute whether it was
better to set out individual reports of particular illnesses (case
studies) or to try to draw general rules from the particulars.
Take, for example Epidemics III:
THE MORTIFICATION OF THE GANGRENE. If the gangrene mortifies itself
there is a head pain and frequently a scratchy throat; the sick limb
loses sensation, a feeling of cold comes to the head and the affected
limb sweats. He suddenly loses his speech and blows blood from his
nose as he becomes pale. If the disease takes hold of the patient with
a weak force, he recovers the discharged blood. If the disease takes
him with a strong force, he dies promptly. In this case one induces
sneezing by pleasant substances; one evacuates by the upper and lower.
Alternatively those odors will be a little active. The soup will be
light and hot. Wine is absolutely forbidden. (Epidemics III, Littré 7,
p. 123) In this passage one is left merely with symptoms and
treatment. But when one practices medicine in this way there are
severe restrictions. For the disease is seen as a collection of
symptoms. The cure can only be guessed at unless it has been
previously written down in a manual. When a physician is confronted
with a novel disease he must find a similar set of symptoms and use
that treatment. This aspect of the "trial and error" method brought
harsh rebuke from Galen. The point is that they [the Cnidians] looked
at the varieties of symptoms which change for many reasons and failed
to consider the specificity of the dispositions, as did Hippocrates,
who used for their discovery a method only by using which, one can
find the number of diseases . . . . Hippocrates censures the Cnidian
physicians for their ignorance of the genera and species of diseases,
and he points out the divisions by which what seems to be one becomes
many by being divided. (Corpus Medicorum Graecorum 5.9.1, pp. 121-22;
Claudii Galeni De Placitis Hippocratis et Platonis, ed. I. Mueller
(Lipsiae, 1874), p. 776)
c. Prognosis and Treatment
What was it that made the Cnidians different from the Coan writers?
This can be found by examining the two steps in any medical practice:
Prognosis and Treatment. In the Coan work, On Prognosis, the writer
suggests that prognosis consists in knowing the patient's condition in
the past, present, and the future. Now how could a physician know
this? Well, this could also have been part of a handbook catalogued
through similar case studies. The practitioner could memorize each
individual description. Next, the practitioner could add to this his
own experience. But the problem is that each case is individual. It
possesses "nature" only in the sense of possessing a unique set of
properties. The practitioner would not be in a good position to treat
novel cases. When confronted with a novel case, the practitioner is
left with seeking similar cases. The implied premise is that similar
cases call for similar remedies. The more the experience, the more
refined the practitioner can be in balancing similar cases with the
remedies.
Obviously, much rides on the word, 'similar.' Is a rich body of
knowledge enough? Is it not also requisite to have a classification
procedure, which itself implies rules of classification. And how does
one select and justify such rules? It would seem that we are pressed
backwards toward archai, starting points for some axiomatic system (à
la Aristotle's Posterior Analytics, I, i-ii).
Such an alternative to the empiricist program aims at establishing a
theory of causes that underlie individual cases. These causes such as
the "hot," "cold," "wet," and "dry" or "the four humors" are more
general because they seek to describe a different sense of the nature
of disease. 'Nature' in this context refers to the sort of condition
that comes from observations based upon the individuality of actual
patients. For here we are interested in the genera and species of the
disease in question. Such an exercise creates a classification of
types of diseases.
But for this classification not to be based upon accidental
characteristics, it is requisite that it include the causal factors
that operate to bring about the disease in the first place. This is
really the foundational or causal network that is responsible for the
disease's very existence. Such an understanding of "nature" moves away
from individuals and their "similarities" toward the theoretical.
Understood in this way, the nature of disease is a regulating factor
upon the prognosis of the physician. This nature must be understood in
order to offer treatment. In this sense, nature is the overarching
principles that give an account of the mechanism of the disease. What
made the Coan writers so attractive to Galen was that they
investigated various senses of nature while the Cnidians confined
themselves only to the data as they presented themselves.
d. The Hippocratic Writings and Hellenistic Medicine
The Hippocratic writings were influential in the development of later
biomedical practitioners. The three principal Hellenistic schools:
Dogmatists, Methodists, and the Empirics all hearken back in various
ways to the Hippocratic writings. Many debates in the Hippocratic
writings (such as the "preformation" vs. "epigenesis" debate) are
picked-up again and given a twist according to the predilections of
the Hellenistic schools. Galen, himself, often cites Hippocrates, aka
"the Hippocratic writers," as the point of departure for his own
theory building. Thus, it would be fair to say that not only were the
Hippocratic writers the first systematic biomedical writers in the
Western tradition, but also the most influential to later writers.
2. Ethics
In the time of Hippocrates (and the other associated writers) there
were many who wanted to pass themselves off as physicians. These
individuals had not gone through an apprenticeship and thus had no
specialized (professional) knowledge. Because of this, these con men
went about fleecing customers. This created a problem for those who
entered the study of medicine the traditional way. These more careful
practitioners had to distinguish themselves from the charlatans. The
way most professions try to deal with this sort of problem and the
legitimate problems that arise during practice is to create codes of
conduct and structures of accreditation. The most famous of these in
the biomedical tradition is: The Oath of Hippocrates.
a. The Oath
By Apollo (the physician), by Asclepius (god of healing), by Hygeia
(god of health), by Panacea (god of remedy), and all the gods and
goddesses, together as witnesses, I hereby swear that I will carry
out, inasmuch as I am able and true to my considered judgment, this
oath and the ensuing duties:
1. To hold my teacher in this art on a par with my parents. To make
my teacher a partner in my livelihood To look after my teacher and
financially share with her/him when s/he is in need. To consider
him/her as a brother/sister along with his/her family. To teach
his/her family the art of medicine, if they want to learn it, without
tuition or any other conditions of service. To impart all the lessons
necessary to practice medicine to my own sons and daughters, the sons
and daughters of my teacher and to my own students, who have taken
this oath-but to no one else.
2. I will help the sick according to my skill and judgment, but
never with an intent to do harm or injury to another.
3. I will never administer poison to anyone-even when asked to do
so. Nor will I ever suggest a way that others (even the patient) could
do so. Similarly, I will never induce an abortion. Instead, I will
keep holy my life and art.
4. I will not engage in surgery--not even upon suffers from stone,
but will withdraw in favor of others who do this work.
5. Whoever I visit, rich or poor, I will concern myself with the
well being of the sick. I will commit no intentional misdeeds, nor any
other harmful action such as engaging in sexual relations with my
patients (regardless of their status).
6. Whatever I hear or see in the course of my professional duties
(or even outside the course of treatment) regarding my patients is
strictly confidential and I will not allow it to be spread about. But
instead, will hold these as holy secrets.
Now if I carry out this oath and not break its injunctions, may I
enjoy a good life and may my reputation be pure and honored for all
generations. But if I fail and break this oath, then may the opposite
befall me.
Within this oath are both a moral code for the profession of medicine
and the outlines of a system of accreditation for new physicians via
an apprenticeship. These two functions went a long way to establishing
medicine as a profession that ordinary people could trust.
b. The Oath and Modern Codes of Conduct
In the modern world there are many professional codes of conduct. One
could look at the American Medical Association Code, the American Bar
Association Code, et al. However, the Hippocratic Oath set the
standard of what a professional code is. A few key features that will
tell why one should accept or reject such codes as solutions to the
problems that have been outlined.
It is this author's opinion that among professional codes, the
Hippocratic Oath is a good one. It balances between very specific
prohibitions such as not administering poison or not having sexual
relations with one's patients, to more general principles such as "I
will concern myself with the well being of the sick." and "do no
harm." These general principles are very useful because they govern a
larger domain than simply prohibiting a particular action. These
principles are not set out without context. Instead they are put into
the context medicine's mission.
Beginning in #1 the tone is set that medicine is an art that is "given
by the gods." It is an esoteric art that is to be reserved for those
who are willing to commit to the provisions of the code. Thus, it is
not open to everyone. This fulfills the condition of specialized
knowledge mentioned earlier. It is for the sake of doing good to
others and always avoiding harm. This fulfills the condition of
providing a service for others.
Thirdly, the code ties itself to the larger moral tradition, "I will
commit no intentional misdeeds." Whereas "harm" has a direct link to
manner in which medicine is practiced, "misdeeds" links the physician
to the larger moral tradition. There is no possible hiding in the
shared community perspective alone.
These three factors are the basis of any good professional code.
A Good Professional Code Should Contain
1. A specific listing of common abuses.
2. A few general guidelines that tie behavior to the mission of the
profession.
3. A link to general theories of morality.
Where codes of professional ethics fail is in overemphasizing one of
these elements too highly or in ignoring an element entirely. If codes
of ethics exist in order to remedy the "inward perspective" problem
described above, then they must create links to more general "shared
worldviews." This would put them in the realm of common morality.
This is the most important point from my perspective. So often the
"practice" of the profession defines its excellence in an
introspective way such that the achievement of these functional
requirements is all that matters-divorced from any other visions,
namely, moral visions.
In the modern arena, many professional codes have evolved from a legal
perspective. The practitioners of the profession do not want to go to
jail or to be sued. Thus, they create certain codes that will make
this possible situation less probable. These sorts of codes are
defensive in nature and stand at the opposite end of the spectrum from
the Hippocratic Oath. Their mission is not to set internal standards
and link to common morality, rather they seek to "shave" as close as
possible to maximizing an egoistic bottom line at the expense of the
pillars of professionalism: one's specialized education and one's
mission to serve others.
Any code that takes as its basis merely a negative approach designed
to protect the practitioner from going to jail or being sued is
fundamentally inadequate. This is not where one should set her sights.
Rather, we should dream about what the profession may be-in the best
of all possible worlds. The Oath of Hippocrates thus properly sets the
mission that should drive all codes of ethics.
3. References and Further Reading
Primary Sources
Littré, E. Oeuvres complète d'hippocrate 10 vols. (Paris: J. B. Billière, 1851).
The standard edition. Corpus Medicorum Graecorum (Berlin:
Akademie-Verlag, on-going).
New editions of selected texts with excellent notes and apparati by
various editors. Secondary SourcesBourgey, Louis, Observation et
experience chez les médecins de la collection hippocratique. (Paris:
J. Vrin, 1953).
A fine connection to principles in the philosophy of science.
Edelstein, Ludwig Ancient Medicine. (Baltimore, MD: Johns Hopkins
University Press, 1967).
Still the best single treatment of ancient biomedical
practitioners.Jouanna, Jacques. Hipporcrate Translated as Hippocrates
by M. B. DeBevoise (Baltimore, MD: Johns Hopkins University Press,
1999).
A broad and speculative treatment. Jouanna, Jacques. Hippocrate: pour
une archéologie d l'école de Cnide. (Paris: Belles Lettres, 1974).
A fine detailed analysis. Lloyd, G.E.R. Early Greek Science: Thales to
Aristotle. (New York: Norton, 1970).
An overview for the student interested in an introduction. Lloyd,
G.E.R. Magic, Reason, and Experience. (Cambridge: Cambridge University
Press, 1979).
Perhaps Lloyd's best analytical work by one of the finest
practitioners of ancient scientific history. Smith, Wesley. The
Hippocratic Tradition. (Ithaca, NY: Cornell University Press, 1979).
A solid overview by an excellent scholar. Temkin, Owsei. Hippocrates
in a World of Pagans and Christians. (Baltimore, MD: Johns Hopkins
University Press, 1991).
A wide-ranging work that stimulates in the tradition of the history of ideas.
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