The Hippocratic Oath and the Ethics of Medicine

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The Hippocratic Oath and the Ethics of Medicine Steven Miles, MD University of Minnesota

The Hippocratic Oath and the Ethics of Medicine Steven Miles, MD University of Minnesota Believed to be the only depiction of Hippocrates.

Hippocratic Medicine and Oath -400 BC • Rejected divine explanations for the cause or

Hippocratic Medicine and Oath -400 BC • Rejected divine explanations for the cause or treatment of disease in favor of empirical, causal observational science. • Moved from oral traditions to recorded observations. • Opened from hereditary occupational families to a mission-professing guild.

BCE Oath “Hippocratic” Medical Works 1000 Fall of Athens Time Line CE Oldest Oath

BCE Oath “Hippocratic” Medical Works 1000 Fall of Athens Time Line CE Oldest Oath Papyrus Deontological works Columbus Voyage Church Editing 1 st Medical School use

Oath CE Oldest Oath Papyrus Surgery separates from Medicine Bladder stone surgical innovation 240

Oath CE Oldest Oath Papyrus Surgery separates from Medicine Bladder stone surgical innovation 240 BCE 1500 BCE 1000 Fall of Athens The Cutting Insertion I will not cut, and certainly not those suffering from stone, but I will cede this to practitioners of this activity.

Oaths Ethics‘Questions • Who is the physician? • What is the physician committed to?

Oaths Ethics‘Questions • Who is the physician? • What is the physician committed to? • Who is the physician accountable to?

Who is the physician?

Who is the physician?

Opening of Oath: An invocation? . . . “I swear by Apollo the Physician

Opening of Oath: An invocation? . . . “I swear by Apollo the Physician and by Asclepius and by Hygieia and Panacea and by all the gods as well as goddesses, making them judges [witnesses], to bring the following oath … to fulfillment, in accordance with my power and my judgment; ”

… or a genealogy? • “Is there a man who has not heard of

… or a genealogy? • “Is there a man who has not heard of me—Amphitryon of Argos, son of Alcaeus, grandson of Perseus, and father of Heracles. I have lived here in Thebes ever since the crop of Sown Men sprang full grown out of the Earth. ” • From Heracles by Euripides If genealogy, what does it mean?

The Genesis Story of Medicine I Apollo Physician, prophecy Asclepius Chiron (a Centaur) Trainer

The Genesis Story of Medicine I Apollo Physician, prophecy Asclepius Chiron (a Centaur) Trainer of Achilles Medical education Coronis

Apollo: Prophecy & Prognosis Apollo • God of Reason • God of Prophecy –

Apollo: Prophecy & Prognosis Apollo • God of Reason • God of Prophecy – Oracle at Delphi Physicians • Reason- Natural Cause and Effect: – Points to cause, diagnosis, and treatment. • Prognosis

Prometheus (Foresight) • A titan who gave humans fire and creativity to invent medicines

Prometheus (Foresight) • A titan who gave humans fire and creativity to invent medicines and imagine a prognosis. • To prevent despair at foreseeing death in a person who was dying. Prom: I stopped mortals from foreseeing doom. Chorus: What cure did you discover for that sickness? Prom: I sowed in them blind hope. – Aeschylus. Prometheus Bound

The Family of Medicine II Epione (Hercules’ Daughter) ‘Soothing’ Asclepius ‘Unceasingly Gentle’

The Family of Medicine II Epione (Hercules’ Daughter) ‘Soothing’ Asclepius ‘Unceasingly Gentle’

Pindar’s Verdict on Asclepius Still, even wisdom yields to hope of profit. And gold

Pindar’s Verdict on Asclepius Still, even wisdom yields to hope of profit. And gold induced no less than he [Asclepius] to try to resurrect a man whom death already had imprisoned…. We must seek from deity the things that fit our mortal hearts, keeping our condition and our destiny in mind. My vital being, do not seek immortal life; exhaust, instead, all possibility. • Pindar. Pythian Odes 3 -63.

What does the Apollo Genesis Story of Medicine Say? • The passion to heal

What does the Apollo Genesis Story of Medicine Say? • The passion to heal arises from love and grief. • Physicians must accept mortality as a boundary for moral work. • The names of Asclepius and Epione say that healing is not a war but a gentle rebalancing to path to health.

The Family of Medicine III Asclepius Epione Unceasingly Gentle Iaso Panacea Healers Medicines Soothing

The Family of Medicine III Asclepius Epione Unceasingly Gentle Iaso Panacea Healers Medicines Soothing Telesphorus Convalescence Hygieia Aigle Health Radiance Podalirius Machaon

The Family of Medicine IV Asclepius Epione Podalirius Machaon Unceasingly Gentle Hippocrates Each Physician

The Family of Medicine IV Asclepius Epione Podalirius Machaon Unceasingly Gentle Hippocrates Each Physician Soothing to regard my teachers as equal to my parents (Hippocrates dies in Larissa)

What is the physician committed to?

What is the physician committed to?

What is the Physician Committed to? MD in Society Clinical Ethics Principles I will

What is the Physician Committed to? MD in Society Clinical Ethics Principles I will use regimens for the benefit of the ill in accordance with my ability and my judgment, but from [what is] to their harm or injustice I will keep [them]. Into as many houses as I may enter, I will go for the benefit of the ill, while being far from all voluntary and destructive injustice, Examples (2) 1. I will not give a drug that is deadly to anyone if asked, nor will I suggest the way to such a counsel. 2. I will not give a woman a destructive pessary. 1. especially from sexual acts both upon women's bodies and upon men's, both of the free and of the slaves. 2. About whatever I may see or hear in or without treatment…-- things that should not ever be blurted outside --I will remain silent, holding such things to be [profane to speak of].

What does the Physician Promise to Society? I will not give a drug that

What does the Physician Promise to Society? I will not give a drug that is deadly to anyone if asked, nor will I suggest the way to such a counsel. • Capital punishment? • Euthanasia? • Homicide?

Medically-Assisted Executions • Executions were common in ancient Greece. • No record of Greek

Medically-Assisted Executions • Executions were common in ancient Greece. • No record of Greek physicians striving to make executions more effective or “humane” as in United States’ use of lethal injections. • Physician engagement in such a role is best dated to 1789 when the French physician-legislator, Joseph-Ignace Guillotin, successfully promoted an antitorture law that required that all executions be carried out by means of a “machine that beheads painlessly. ”

Hemlock Euthanasia 320 BCE, Theophrastus noted that Thrasyas of Mantineia had discovered, “a plant

Hemlock Euthanasia 320 BCE, Theophrastus noted that Thrasyas of Mantineia had discovered, “a plant which produces an easy and painless end; he used the juices of hemlock poppy. … For the effect of this compound there is absolutely no cure… death is made swift and easy. ” Does not describe who used hemlock, nor for what purpose. Greek medical treatises do not describe the use of hemlock to induce death. It was used for executions. Euthanasia “good death” was not coined until 280 BCE, more than a century after the Oath was written. “Of those things that a man [human] prays for from the gods, nothing is better to meet with than an easy (happy) death. ” This coinage referred to a natural death without agony--not to assisting death. 1869, William Lecky redefined euthanasia as intentionally ending life in order to end suffering from disease.

I will not give a drug that is deadly to anyone if asked, nor

I will not give a drug that is deadly to anyone if asked, nor will I suggest the way to such a counsel. Suicide in Greece of 400 BCE Was in relation to moral honor, shame Not in relation to suffering caused by disease. No medical discussion of physician assisted suicide or euthanasia. If medically assisted euthanasia been part of ancient Greek medicine, it probably would have been discussed in the treatises, just as abortions by midwives were discussed.

“I will not give a drug that is deadly” addresses fear of physician poisoner.

“I will not give a drug that is deadly” addresses fear of physician poisoner. • Murder was commonly used when the Oath was written to topple civic leaders, municipal figures and settle family disputes. In addition to loyalty or fear, physicians were under economic pressure from the collapse of the Athenian economy and cutbacks in the position of cityphysicians. Tensions between civic medicine and medical ethics were widely discussed. • 345 BCE, Plato wrote that a physician who administers a poison with the intention of causing death should be executed as such deeds are acts of terror Plato. Laws 933.

What does the Physician Promise to Society? I will not give a woman a

What does the Physician Promise to Society? I will not give a woman a destructive pessary. • Antiabortion? Pro-life? • Anti-trespass in a woman chattel society? • Pessaries are dangerous.

BCE Oath Lethal Pessaries CE 1000 Oldest Oath Papyrus Hardening Church Position Against Abortion

BCE Oath Lethal Pessaries CE 1000 Oldest Oath Papyrus Hardening Church Position Against Abortion Fetus as alive. Church Editing of Oath 1 st Medical School use

What Does the Physician Promise to the Patient? 1. . . especially from sexual

What Does the Physician Promise to the Patient? 1. . . especially from sexual acts both upon women's bodies and upon men's, both of the free and of the slaves A clinical ethics of being a guest.

What Does the Physician Promise to the Patient? 2 About whatever I may see

What Does the Physician Promise to the Patient? 2 About whatever I may see or hear in or without treatment… -- things that should not ever be blurted outside – I will remain silent, holding such things to be [profane to speak of].

Who is the physician accountable to?

Who is the physician accountable to?

If I render this oath fulfilled, and if I do not blur and confound

If I render this oath fulfilled, and if I do not blur and confound it may it be to me to enjoy the benefits both of life and of techne (art and science), being held in good repute among all human beings for time eternal. If, however, I transgress and perjure myself, the opposite of these.

Oath’s Vision of Medical Ethics Genesis: respect for love and grief, bounded by mortality.

Oath’s Vision of Medical Ethics Genesis: respect for love and grief, bounded by mortality. Empirical A community to transmit knowledge and values Physician in Society Personal Integrity In a pure and holy way, I will guard my life and my art and science. Clinical Ethics Judgment of history. Moral Beneficent, Just

Summary • Oath conforms to the medical practice and rhetoric of Classic Greece. •

Summary • Oath conforms to the medical practice and rhetoric of Classic Greece. • Roles: education, compiling knowledge, and treatment. • Ethics: beneficence and acting justly (dike) in public and clinical spheres. • Progressive and historically accountable rather than deontologically, deistically accountable.

Steven Miles MD miles 001@umn. edu

Steven Miles MD miles 001@umn. edu