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Hippocrates of Cos was said to have lived sometime between 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.
Table of Contents (Clicking on the links below will take you to those parts of this article)
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: - 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.
- I will help the sick according to my skill and judgment, but never with an intent to do harm or injury
to another.
- 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.
- I will not engage in surgery--not even upon suffers from stone, but will withdraw in
favor of others who do this work.
- 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).
- 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
- A specific listing of common
abuses.
- A few general guidelines that tie behavior to the mission of the profession.
- 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, viz., 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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