HIPPOCRATIC ETHICS IN MODERN MEDICINE
EMERITUS PROFESSOR SPYROS G.MARKETOS*
INTRODUCTION
Ethical issues and humanities are indispensable parts of medical practice. In no other profession the ethical principles and the humanities count so much as in medical practice. On the other hand in our times new technology is an important part of our life. The need to combine the ethical precepts of Hippocrates and his concepts of the values of humanities with the technological "imperative" (power) is more necessary than ever, because at present, the patient very often is seen as a disordered mechanism rather than a suffering psychosomatic entity. Modern medicine is expected to solve and not to pose problems, such as de-humanization and de-personalization of suffering.
Today, some of the modern hospitals have lost their compassion. The patient is a machine and medical care is a production line that can forever be speeded up! Furthermore, the enormous biomedical technology has so far contributed little to the traditionally humane fields of psychosomatic disturbances, while posing new dilemmas and threatening ethical problems.
Ancient medical etiquette and Hippocratic ethical concepts are described in eight books of Corpus Hippocraticum, namely the Oath, Ancient Medicine, the Physician, the Law, Precepts, Airs - Waters- Places, Medical Decorum, and in the famous Aphorisms. They explore the ethical attitudes necessary in clinical medicine and underscore the many difficulties inherent in general practice. However, it is very important to bear in mind that many other treatises of the Hippocratic collection are also concerned with medical ethics.
HISTORICAL OUTLINE
Ancient Greek Medicine is based on the co-existence of both Asclepian Art and Hippocratic Medicine and comprises a part of the history of general culture. Rationality is central to Hippocratic principles. The fact that the priestly Asclepian Medicine - which relied on dreams and religious faith - and the rational Hippocratic Medicine co-existed since the 5th c. B.C. reveals that alternative medicine is nothing new 1-8.
Although there is not any evidence to support cooperation between the Hippocratic physicians and the priests of Asclepieia, there is not also any proof to ascertain some kind of hostility between them. Although the medical work of Hippocrates had little in common with that of the priests of Asclepieia the parallels between creativity in Asclepian Art and Hippocratic Medicine were closer than medical historians usually realize. Asclepios' followers respected the tradition, did not reject the old divine status, claimed that they were the descendants of Asclepius and were loyal to the Hippocratic Oath 8-13.
Hippocratic writings teach that rationalism without humanities renders science insufficient, and that a culture based firmly in the humanistic values is as important as clinical education in medical practice. It is also interesting to note that the ascendance of Christianity did not diminish the stature of Hippocratic medicine and that doctors could easily exchange the cult of Asclepios for the worship of Christ. In other words, the profile of Hippocrates ethics, demonstrates the close relationship between medicine, philosophy, cultural education and religion 7,9,12,13.
The centers for followers of Hippocrates, the cults of Asclepios, continued to expand and flourish long after the school of Hippocrates, showing that rational medicine does not exclude a parallel rise of religious medicine in Ancient Greece. There was neither competition nor enmity between the God of the healing art, Asclepios, son of the patron deity of medicine Apollo the healer and father of a large family - most of whom had health and medical functions - and the Hippocratic physician.
The first lines of the Hippocratic Oath are revealing:
I swear by Apollo Physician, by Asclepios, by Hygeia and Panacea and by all the gods and goddesses, making them my witnesses, that I will carry out according to my ability and judgment, this oath and this indenture.
HIPPOCRATIC TRADITION
The "Golden Age" of medical art was born in the Greek island of Kos, near the coast of Asia Minor by Hippocrates the Asclepiad (the Koan) 2,6. His name is connected with the most creative period of medicine in antiquity. He was the most capable to assimilate the accumulated knowledge of the previous centuries for the transition from empirism to rational medicine.
The medical school of Hippocrates gives special emphasis upon the natural course and the prognosis of the illness, the process of the disease, the whole body disturbances, the prevention and the prediction of illness, the philosophy of medicine and the medical ethics. Hippocrates medicine is based on a right way of thinking, on a whole humane (psycho-socio-somatic) approach to the patient (holistic medicine) and on his monumental ethical principle:
"The physician must benefit and do not harm the patient".
Hippocrates observed diseases with the eye of a naturalist and established rules by which the physician would know what to expect and what to go at the right time. He had a profound understanding of human suffering, knowledge the limitations of human life and emphasized on many occasions that:
"The place of the physician is at the bedside of his patient" and that "to restore every sick to complete health is impossible".
Although Hippocrates was more interested in recording his clinical observations than philosophizing, the "Aphorisms" and the "Oath" are exemplary of _ blending of the thoughts of a reflective philosopher and the wisdom of an experienced practitioner. He was respected not only as a great physician and teacher, but also as an inspired philosopher and thinker. Under his leadership the medical school at Kos produced many fine scholars and pupils who added their experience and other writings to the works of the master himself 14.
According to Hippocratic tradition medical practice must be direct by observation, by the nature of art and by a high respect for the patient and his or her relatives.
No account of Hippocrates� philosophical background would be complete without referring to his first aphorism:
"Life is short; and the art long; and the right time an instant; and treatment precarious; and the judgment difficult. It is necessary for the physician not only to provide the needed treatment but provide for the patient himself and for those beside him and to provide for his outside affairs".
HIPPOCRATIC ETHICS
Ethics deals with right and wrong in human behavior. Medical ethics deals with right and wrong in the behavior of physicians during their professional lives. Ethics in medicine, is particularly concerned with relations between patients and physicians in recognition of the special state of sickness and its threat. It is obvious that medicine without ethics is a potentially dangerous profession. Furthermore, it is well known that during the Hippocratic era (5th century B.C.) there was - for the first time in the history of the world - a complete separation between killing and curing (for example the pledge not to perform euthanasia and abortion).
The Hippocratic Oath 12-18 teaches the importance of responsibility in diagnosing patients and emphasizes the professional dignity. It represents a promise to patients to make their health as the first priority. That promise, in turn, fosters the trust between physician - patient relationship. It is, therefore, a promissory Oath divided into four parts:
- First part (Invocation): The gods and goddesses are evoked to witness the oath taking.
- Second part (Duties to profession): It is a long acknowledgement of the gratitude students' entering into the practice of medicine feel toward their teachers.
- Third part (Duties to the patients): The text is separated into two sections. In each of them the central tenet and the goal of medical practice is repeatedly specified on the sentence "benefit to the sick".
"I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing".
In addition the use of the future time (I will ...) indicates that the Oath was to be taken by medical students or young physicians before entering their medical careers. Many of the precepts and proscriptions contained in it still recognized as relevant today. The highest positive statement and the main ethical principle for the physicians is centered in two keys-words:
"Purity" and "holiness"
"I will keep pure and holy both my life and my (medical) art".
- Fourth part (Epilogue): The Oath closes by decreeing the consequences on physician who fail to live as promised.
It is evident that the three fundamental elements of the Hippocratic tradition are included in the Hippocratic Oath. First, the triple covenant with deity, teacher and patient. Second, the double ethical principle concerning the young physician's dedication to proper treatment and the importance on the interests of the individual patient. Third, the wise precept:"Help or at least do not harm"
Hippocratic Oath is an ethical guide for those who practice medicine. It is a one-page text about which hundreds of thousands of pages have been written through out the ages 17. It was written "to inspire human feelings in the mind of the students and the younger physicians", as firstly stated by the Latin author Scribonius Largus.
It is useful to understand what the Oath is not. It is not a legal text with a limited life span and therefore cannot deal with the ethical issues raised by human experimentation and by modern medical technology. It is often quoted in a segmentary way misunderstood as a unified whole by some revisionists 8,12,13.
It is a mistake to read it closely as a list of rules! It is not only an apocryphal text based on secrecy. On the other hand, confidentiality has been considered rightly to be a basic element of the doctor-patient relationship worldwide since the Hippocrates' time.
The properties of the Hippocratic Oath that contributed to its longevity can be classified as either inherent or acquired. The former are its beauty of prose and its clear-cut simplicity and validity in expressing higher abstract humanistic values.
Hence, these properties guaranteed the support of those who value traditional aesthetics and ethics. The latter group, the acquired characteristics, includes its antiquity and its elevation to the status of a symbol, and both can be seen as mixed blessings. In historical periods when seniority was revered and tradition was the vehicle for the intellectuals of the day to feel justified and contented, the very antiquity of the Hippocratic text symbolizes the ethos of classical Greece plus the ideals of philanthropy, honesty and love for mankind.
"For where there is love of man, there is also love of medical art"
(Excerpt from "Precepts")
At the start of the 21st century medical ethics is dealing with a great number of new and difficult ethical cases. Although the Hippocratic Oath does not attempt complete coverage of medical ethics Hippocratic physician can practice medicine in any current healthcare system.
The precepts of Hippocratic ethics continues to serve as a cornerstone of the professional behavior and will continue to be the "nucleus" of all medical ethics. For example, the Declaration of Geneva (1948), the Nuremberg Code (1968), the Declaration of Helsinki and its latest revision (completed in October 2000) include almost half of the ethical principles most of which resemble the fundamental precepts 14-18 outlined in the Hippocratic Oath.
ENVIRONMENTAL ETHICS
Hippocratic writings consider and discuss the great importance of environmental factors in human health. The belief in the balance between the human being and the environmental compartments (air, water, soil) is clearly evident in the Hippocratic book on "Airs, Waters, Places". It constitutes the first known systematic endeavor to present the causal relationship between environmental changes and disease.
According to the Hippocratic tradition the key concept of the environment is inherently anthropocentric. Hippocrates emphasizes, "the dominant factor is nature" (Decorum) and that "all excess is hostile to nature" (Aphorisms). _nterest, therefore, in the relation of environmental factors to health and disease, goes back to Hippocrates. According him, man is a part of nature and should not be a manipulator of it!
On the other hand, in post-Hippocratic years, there is a failure to stress the links between nature and human health and to support various fundamental aspects of the humans-nature ethics. For example, pollution of air, water and soil, as well as unlimited consumption steadily increase, resulting is an urgent need to prevent their threatening effects on human health.
It is obvious that environmental Hippocratic principle has been badly neglected - particularly in Western countries - and that ignoring the consequences of environmental degradation in health represents one of the major failure of the modern medicine.
MODERN MEDICINE
According to the high ethical standard of Hippocratic tradition the physician promises to act primarily for the benefit and not for the harm of patients, to protect their confidences, to refrain from performing abortion and euthanasia and from having sexual relations with patients or their families and to lead a professional life of moral values. On the other hand, the naturalistic healing of the Hippocratic physician and his remarkable observations concerning the relationship between human health and environmental changes remains a vital concern for the modern medicine.
At the start of the 21st century, rapid changes of environment and deleterious climatic conditions, the water supply, which according to Hippocrates is the most important factor for the health, the chemical and nuclear pollution (chemical and radioactive carcinogens), the dangerous effect of radiation on health, the chemicals accumulated through unsuitable eating, drinking and hazardous habits, such as smoking and drug abuse, the cloned sheep and the genetically modified foods, are some of the serious recent problems.
In modern times millions of people suffer the effects of an array of chronic disease, such as malnutrition syndromes, gastro-intestinal, pulmonary and heart diseases, hypertension, diabetes and various cancers, which have a substantial nutritional basis.
There is an urgent need to protect global and local environment, to prevent a further degradation of it and to emphasize that a healthy life-style has a tremendous individual, social, economic, psychological, cultural and vital value. It is evident that there is a pressing necessity to minimize the stress of the environment and to rediscover the long-forgotten Hippocratic principles regarding healthy behavior, the quality of life and the healing power of nature.
The ethical issues raised by modern medical technology are very complicated. For example, the question of the ethical permissibility of placebo controls when an effective treatment for a disease exists or the business of human organs for transplantations affects the traditional fiduciary relationship between physician and patients. There is a general feeling that biomedical technology has ignored the psycho sociologic aspect, treating the patient more or less as a disease and not as a unique human entity.
Depersonalization of the patient and a lost sense of his or her individuality can be confronted by keeping the Hippocratic humanistic values in perfect balance with progress in technology. Dedication to the same vital principles is needed in medical research, which should be designated to serve humankind and not technology itself.
The complicated ethical dilemmas posed by advances in biomedical technology, the tendency to reduce illness only to individual bodily processes and the danger of creating a medical system not orientated to the patient has made Hippocratic (humanistic) education more important and more necessary than ever16.
In the age of the triumphant Western technology medicine feels the need to combine more than ever the ethical principles of Hippocratic medicine with the enormous power of technological progress. The driving force of biomedical technology so far has contributed little to the traditional human fields of psychosomatic and/or functional disease and patient suffering. It is evident that modern medicine cannot be considered synonymous with the impersonal high technology and the business of medical care. The great value of Hippocratic medicine lies in the perennial humanistic lessons and the highest ethical standards deriving from it. Today the young physician still can learn from the Hippocratic heritage and will still need to be an expert Hippocratic physician, ever more humane and competent, in the use of the new biotechnological achievements.
SUMMARY AND CONCLUSIONS
Medical ethics in the midst of the biological and social revolution is dealing with a great number of new ethical conflicts. Hippocratic Medicine - which is created in the Greek island of Kos, at the crossroads between Occidental and Oriental Civilization - acts as a bridge between East and West and a symbol for the need to combine both the anthropocentric experience of the traditional (Eastern) and the bio-technological trends of the modern (Western) medicine.
At the start of the 21st century Hippocratic ethical principles are more valuable than ever. Although formulated about 2,500 years ago will continue to be the "nucleus" of all medical ethics in clinical practice.
The fact that Ancient Greek Medicine was based on the co-existence of both Asclepian (religious) and Hippocratic (rational) medicine historically and culturally reveals that the "marriage" of both modern medical systems (the biotechnological and the biopsychosocial) and their bond with the ethical Hippocratic model is necessary in order to overcome the threatening biomedical problems of the modern and/or the so-called "post-Hippocratic" or �post-modern" era.
The domain of medicine requires special rules but modern medicine needs to maintain its own internal compass based upon the perennial Hippocratic messages for health, healthcare and disease.
NOTES
* Athens University Medical School Athens, Greece and Honorary President International Hippocratic Foundation, Kos, Greece
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