Over 2500 years ago, the ancient Greek medicine has laid the foundation of modern medical ethics that bound the responsibilities of a doctor to a patient. Since the formulation of the Hippocratic Oath, it has lived through time as it is still recited by medical students as their pledge to pursue medicine as a profession. Greeks used this oath to ensure the community receives the highest standards of care and to prevent doctors abusing the trust and power granted to them by the community. Thus, modern physicians are now aware not only in relationship to patients but also in relationship to other physicians comes to the relationship with faith in the physician, presuming that the physician is a person of discretion.
The author of this oath is Hippocrates, who was born on the island of Kos in Greece during 460 BC (Sakula, 1984). He was responsible for the beginnings of a scientific approach to medicine through his teaching and practice of medicine in Greece. He forthrightly rejected the magic and sorcery of the priest healers of the Asclepeion school. Hippocrates’ teachings covered all branches of medicine and included the moral and ethical requirements of an ideal physician which were subsequently epitomized in the Hippocratic Oath. His writings are collected into the Corpus Hippocraticum which comprises 70 books, many of which were probably written by his disciples many years after his death (Breen, Plueckhahn & Cordner, 1997, p. 3).
What is the context during the ancient Greek era that compelled Hippocrates to develop a code for medical practitioners? How did the people during his time accept the necessity and the plausibility of having the Hippocratic Oath? In this paper, we will try to delve behind how the Hippocratic Oath became one of ancient Greek medicine’s greatest contributions to the advancement of biomedical ethics in our time. Although it will not be attempted to impose some exhaustive historical or philosophical analysis of the thinking of Hippocrates and his followers, but we will link the most important Hippocratic influences that is still apparent in our contemporary medicine.
Before the Hippocratic Oath
During the dawn of the Greek civilization, medicine is deemed to have a vital role in society because being in the pink of health is considered to be “status symbol” because this amounted to having a maximum potential as a citizen of the state. This is why ancient Greek culture espoused such a high priority upon healthy lifestyles because healthy individuals meant they are productive enough to contribute in their society. Medical practice in ancient Greece depended much on their religious beliefs. In fact, the Cult of Asklepios grew in popularity and became a notable provider of medical care. This cult developed old theories and introduced several treatments that are quite comparable to the modern alternative medicine.
At the end of the fifth century BC, Asklepios emerged to become as a Panhellenic god. Asklepios (in Latin Aesculapius) had little mythological background, his province was healing and his ethics were professional. His principal sanctuary was near Epidaurus, and there a long series of inscriptions by grateful visitors testify to the efficacy of faith and good medical advice. The oracles had lost most of their political influence — after all, Delphi had backed the Persians in 480 B C — but private custom flourished and even Socrates, who spent so much of his time exposing hypocrisy, seems to have been impressed by an oracular statement that he was the wisest of men (Cook 1962, p. 139).
Found as a character in Homer’s Odyssey, Asklepios was associated with the powers of the ancient world as the serpent-hero. He built his cult in the asklepieia — establishments that were part hospitals, part sanctuaries and the most celebrated in the classical period being that located in Epidaurus. They were administered by doctor-priests, or soothsayer-doctors, who were called Asklepiads, as supposed descendants of Asklepios; and these men passed on from father to son their natural gifts and the traditions of the profession, as well as their clientèle of patients and devotees (Mireaux 1959, p. 94).
According to Homer, Machaon and his brother Podalirius come from a medical family and their knowledge of drugs descends, via their father Asklepios, from Chiron the Centaur. But in the Iliad both Machaon and Podalirius are portrayed in the first instance as warriors, chieftains leading their contingent from Tricca, Ithome and Oechalia, and playing their part in the fighting like other heroes (Saunders, 1999). Machaon, like his father Asklepios, is called a ‘faultless’ healer, an adjective frequently applied to warriors in epic poetry, and his role in leading his men as ‘shepherd of his people’ is not dependent on his medical abilities alone.
Mireaux (1959) explained that these asklepieia were widely distributed throughout Greece and were generally established on some site near a grotto, or wood, or sacred spring. Before any consultation took place, there were certain rites to be observed, such as fasting, bathing, ablutions, anointing and other forms of purification. The next step was for the sick man to offer up a sacrifice; and he was then prepared to undergo the decisive treatment known as the “incubation”. For this, the sick man had to spend the night lying on the skin of his victim, under the portico of one of the subsidiary buildings; and here, in silence and darkness, amid the sacred and familiar serpents gliding between the sleepers and uncoiling themselves over the floor of the sanctuary, the patient was visited by dreams and visions, and listened to the words of the god; which visions and sayings were. On the following day, the visions that the sick man saw will be appropriately translated by the Asclepiads into prescriptions.
Moreover, the sacrifices and payments accompanying these propitiatory ceremonies were obviously a regular source of income to the sanctuary and its ministrants. The gratitude of patients who were cured sometimes took the form of substantial gifts. Thanks were also expressed on votive tablets which gave the symptoms from which the patient had suffered and also the saving remedies; so that every asklepieion had a store of medical archives which came in time to contribute materially to the advancement of medical science (Mireaux 1959, p. 96). After his arrival of the Cult of Asklepios have dominated the healing business in Athens, but this did not monopolize it, as numerous cults to other deities emerged from the fourth century BC.
However, Greek philosophers began to question the validity of the cures offered by these asklepieia because they practitioners only categorized medical practice by lists of drugs and therapies. They raised theoretical as well as practical problems while seeking to establish some of the fundamentals of medicine and often range widely in their argumentation. They employ sophisticated reasoning, and, for the most part, within the sphere of medicine as they define it there is no place for divine causation or divine cures (Lloyd, 1987). Also, critics have questioned the consensus of the Greeks before Troy that illnesses were the result of divine anger because this does not prove that Homer and his audience attributed all illnesses to the gods. The assumption that Apollo, Artemis, Zeus or some other god might have sent a sickness on to a community or on individuals is certainly one that was widely shared during their time and the philosophers want to disprove this.
One of these philosophers is Alcmaeon of Croton, who flourished in the late sixth century BC and tradition claimed him as a pupil of Pythagoras “in his old age”. Alcmaeon’s interests and the sophistication of some of his methods are better suited to the later date. His medical interests can be best seen in his theory of health, which deserves quotation at length, even though its wording may not be entirely his own:
What preserves health is the equal distribution of its forces – moist, dry, cold, hot, bitter, sweet, etc., – and the domination of any one of them creates disease: for the dominance of any is destructive. Disease comes about on the one hand through an excess of heat or cold: on the other hand through surfeit or lack of nutriment; its location is the blood, marrow or brain. Disease may also sometimes come about from external causes, from the quality of the water, local environment, overwork, hardship or something similar. Health, by contrast, is a harmonious blending of the qualities (Longrigg, 1993).
Longrigg (1993) figured that Alcmaeon’s medical interests extended further into embryology and sex differentiation, and into a practical investigation of sensation. He concluded that the sense organs were linked directly to the brain by channels, and that loss of sensation could be the result of these channels becoming blocked, an insight that has drawn the approval of many historians, although they would not accept his further contention that the blockage was most often caused by the brain itself shifting its position.
Another medical philosopher appeared in the later fifth century, he was Democritus of Abdera, who had an even more considerable and longer-lasting influence on medicine than any other medical philosophers. An Alexandrian catalogue of his writings includes works on prognosis and on dietetics, and one intriguingly called Medical Opinions, although whether the opinions were his own or those of others which he collected or criticised is uncertain. He had medical followers well down into the period of the Roman Empire. Democritus had an interest in animal anatomy – although this need not have involved actual dissection – is evident from a report that he believed that animals could produce many young at once because they had multipartite wombs, a theory that was later applied to the formation of human twins by a Hippocrates. Like Alcmaeon, Democritus wrote about vision, dreams and sensation, and, although firmly believing in a world whose ultimate constituents were atoms and void, he attached great importance to pneuma (or air) as the vehicle of life, transmitted in semen (Longrigg, 1993).
As medicine had flared up a series of debates involving doctors and non-doctors from all over the Greek world, Hippocrates thought of writing something that would “standardize” medicine as a profession. As a person with an obscure background, people depicted Hippocrates as a wise sage, called in to cure Democritus of madness – and then refraining from intervention because he found him sane; a patriot who refused to take Persian gold to serve their king, the enemy of Greece; and a wonderfully versatile doctor, capable of treating both a monarch’s lovesickness and the great plague of Athens, which Thucydides had deemed incurable. These stories in turn became part of the picture of the historical Hippocrates, so that, for instance, they played the dominant role in shaping the understanding of the behavior of the ideal physician.
Hippocrates in Focus
The anthropologist Margaret Mead pointed out that prior to the Hippocratic tradition, the physician and the sorcerer tended to be the same person, and she credits the Greeks of the fourth and fifth centuries with forever making clear the distinction between the two (Bulger & Barbato, 2000). The pre-Hippocratic practitioners of medicine were empiricists who used treatments indiscriminately or mystics who claimed control over nature through magic and ritual. Hippocratic medicine for the first time introduced a new approach based on reason in the natural order of things and a framework of scientific knowledge. As Pedro Lain-Entralgo (1969) characterized it, Hippocratic doctors needed to know the illnesses they were treating, what remedy would cure the illness, and why the remedy worked. Along with this historic transition in the practice of medical skills evolved the concept of medicine as a technical “art”, a body of scientific study to be mastered, taught, expanded, and documented.
Bulger and Barbato (2000) revealed that Hippocrates insisted on careful observation and the keeping of notes. He believed that the interaction of nature, the patient, and the physician determined the outcome of the illness. Contrary to what became central Judeo-Christian belief, Hippocrates did not believe that God placed the earth and nature at humanity’s disposal or that humans were lords of the earth. Rather, he felt deeply that humanity worked within the confines of nature and must collaborate with it to achieve the best health and to avoid disease. He had in fact a remarkably broad concept of health and disease that is not now widely appreciated.
Thus, the collected writings of the Hippocratic corpus comprise a kind of running textbook of medicine, carefully describing diseases and known treatments. Hippocrates detailed his treatment failures so that others would not repeat them. He followed his patients until the disease had run its course, even if it took months. He treated all comers, whether free or in bondage, and he describes the need to treat each person with dignity and the diseased body as still sacred. Instead of incantations or prayers, the physician’s art, his technique, required careful observation, clear thinking, and useful intervention without doing harm.
In fact, Bulger and Barbato (2000) noted that it is the prohibition against medical harm that particularly sets the Hippocratic tradition apart. Certain injunctions are specifically spelled out in the oath (abortion, euthanasia, use of poisons). But a general instruction is found in Epidemics: “As to diseases, make a habit of two things–to help or at least to do no harm”. This dictum is central to the ethos that emerges from the Hippocratic writings and formed the basis of the physician-patient relationship. By virtue of his knowledge and skill the physician was presumed to act as a benevolent authority in both technical and moral matters. He was to decide what was best for his patients and to make those decisions on the basis of competence. This formulation of a moral and technical prescription for doctors was not uniformly held by the body of Greek physicians. It represented a departure that set medicine and medical practice on a new course and it is reflected until now.
In studying the development of ancient Greek medicine, we will realize that it was a process of debates until they had realized that something has to be done to professionalize the career of a doctor as a healer. Today’s physicians value the Hippocratic Oath as a link to the profession begun more than 2,500 years ago, and which has prospered progressively since. Despite differences in philosophic detail with their predecessors in early Greek civilization, Western physicians at the beginning of the third millennium A.D. find meaning in the concurrence of their ethos and aspirations with those of their earliest professional forebears. In a fast-paced world in which institutions and even nations come and go with startling rapidity, there is great appeal to things of more abiding nature; and we sense that the tradition of the scientific healing initiated by Hippocrates is one of these abiding things. To many within the profession and within the society at large, this abiding tradition is embodied and best represented in the Hippocrates Oath. Thus, we realize how the ancient Greek medicine clearly represented the medical profession in its relationship to the society at large. They issued a nature of a social contract between physicians and their patients by committing physicians to serve patients to the best of their ability, such that the patient’s benefit takes precedence over the physician’s self-interests.
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