!1 Do you think it is fair to speak of Hippocrates’ ‘influence’ in modern times? 1127318 The British Medical Association’s (BMA) handbook of ethical advice, published in 2012, deals with the ethics and morality of a doctor and their relationship with their patients. In describing medical ethics at the start of this book the BMA advises doctors that Hippocratic values ‘remain relevant because doctors generally want solutions that... do not contravene their intuitions about the core purpose of medicine’;1 and that ‘the principles of promoting benefit and avoiding or minimising harms... directly reflect Hippocratic values and tradition codes’.2 That the BMA makes Hippocrates central to its handbook on medical ethics aptly demonstrates the lasting influence of Hippocrates in the modern day. He is the symbolic figure for medical ethics. In this essay I will focus on his ethical legacy; looking at how various groups can use the Oath for their own means, how Hippocrates was used as a response to the severest of medical crimes, and how oaths have become widespread in modern practice. I will also look at how Hippocrates’ observational form of medicine, theory of the humours, and ideas on black bile and melancholia were received. In this essay I will not be seeking to prove the influence of the man Hippocrates, but rather the material we deem as ‘Hippocratic’; and ‘modern times’ will be defined as from the Early Modern period to the present day. ! Hippocrates is a household name due to his Oath, and so it warrants discussion in its enduring legacy in modern medical ethics. The well documented medical atrocities in Nazi Germany committed by men who are meant to ‘either help or do not harm’3 led to speculation over whether physicians were governed by a morality and an ethics above that 1 BMA (2012) 1. 2 BMA (2012) 11. 3 Hippocrates, Epidemics Book 1, 11. !2 of the state.4 These great atrocities A document dealing with the prosecution of such war criminals in 1945 states that, ‘the fact that the Defendant acted pursuant to order of his Government or of a superior shall not free him from responsibility’;5 this document would imply that there is a higher law, a moral law, which each person must adhere to over the law of the state.6 For doctors this meant a medical ethics which the state does not have the power to create or to destroy.7 As happens so frequently throughout history an older, authoritative and canonical source in Hippocrates was used to give credence to a modern action. As the World Medical Association (WMA) say in their own history, they drafted a modernised version of the Hippocratic Oath.8 The solution to potentially the worst medical crimes in history was a return to Hippocrates, which I will now look at. ! This modernised Hippocratic Oath took the form of The Declaration of Geneva and we can see how influential the Oath was in its creation. It requires one to ‘give my teachers the respect’9 they’re due, which recalls the Oath saying ‘to hold him who taught me this art equally dear to me as my parents’.10 The Declaration requires physicians to ‘respect the secrets which are confided in me’,11 a clear restatement of the Oath’s requirement to ‘keep secret’12 things found out in treatment. It requires the physician to ‘maintain... the honor and noble traditions of the medical profession’;13 this reverence 4 Friedlander (2002) 72. 5 ICRC, Agreement... Tribunal. 6 Boozer (1980) 85. 7 Boozer (1980) 94. 8 WMA, History. 9 WMA, Declaration of Geneva. 10 Hippocrates, The Oath. 11WMA, Declaration of Geneva. 12 Hippocrates, The Oath. 13 WMA, Declaration of Geneva. !3 echoes the Oath’s requirement to act ‘in purity’.14 Being of benefit and not harm for the patient is stressed greatly, ‘the health and life of my patient will be my first consideration’,15 can be seen as a reworking of the Oath’s ‘do no harm’, or other translations to a similar effect.16 The Declaration also modernises the Oath: controversial topics such as abortion and euthanasia are not explicitly mentioned and surgeons are not told they cannot use the knife. There is no mention of not having sexual relations with one’s patients, as the likelihood of sexual exploitation may not be seen as a pressing issue in the modern day. The Declaration does not swear to any deity but rather upon ‘my honor’;17 which reflects a multi-faith modern society and the removal of varying religious values from the ‘higher law’ of Hippocrates inspired medical ethics. And finally we see in the Declaration that there should be no prejudices in the treatment of the sick on the grounds of ‘religion, nationality, race, party politics or social standing’.18 This modernised Oath is itself modernised, as by 2005 it` has been expanded to cover ‘any... factor to intervene between my duty and my patient’.19 This shows the incredible influence of Hippocrates on modern medical ethics. Close consultation with the Oath created a new standard of medical ethics and a higher law for physicians, in the face of the worst medical crimes the world has ever seen. Since the Geneva Convention of 1948 the role of oath taking in medical schools has flourished. Half of UK medical schools20 and nearly all of US medical schools now require students to make a formal oath as part of their study;21 compared to 19% of American 14 Hippocrates, The Oath. 15 WMA, Declaration of Geneva. 16 Hippocrates, The Oath. 17 WMA, Declaration of Geneva. 18 WMA, Declaration of Geneva. 19 WMA, Declaration of Geneva 2005. 20 BMA (2012) 747-8. 21 Tyson, The... Today. !4 schools in 1928.22 The Oath of Hippocrates itself is rarely found however. An Academy of Medicine study on oaths being used in the US in 2000 found that only one school used an unmodified version of the Hippocratic Oath, 59 used a modified version, while 63 others use a variety of oaths from the Declaration of Geneva to an oath crafted by the institution themselves.23 Whether the oaths sworn today are the original Oath of Hippocrates or not is irrelevant. What matters is that a ‘Hippocratic tradition’ has developed which sets out demanding ethical standards to which a doctor is asked to pledge themselves to. As the BMA say this has contributed to the ‘understanding of... doctors’ potential to act for good or bad in their patients’ life’.24 Hippocrates is influential in the modern day for what he stands for more so than what he said. His words may be twisted, updated and changed to fit various standpoints and changes in modern ethics; but no matter how abstracted Hippocrates becomes, his legacy of medical ethics remains. Hippocrates is also a symbol of ethics for the non-medical world. ! We should also look at how the Oath can be interpreted in various ways to fit the needs of a group or an individual. The two most heated debates in medical ethics in the modern day are arguably abortion and euthanasia. Groups campaigning for or against these issues often utilise the reputation and authority of Hippocrates as a means of giving a stronger, ancient, backing to their point of view. If we first look at abortion, the Oath states that ‘I will not give... a pessary to cause an abortion’.25 The Pro-Choice Action point out that the Oath only prohibits the use of a pessary, a method of abortion that may have been more dangerous to women than other methods. In addition the fact that other works in the Hippocratic corpus advocate methods of abortion (presumably a reference to The Nature of the Child 13 in which the author helps a woman perform an abortion) is used as 22 Wooton (2006) 5. 23 O’Reilly, Only 1... Oath. 24 BMA (2012) 748. 25 Hippocrates, The Oath. !5 further evidence that the Oath does not forbid abortion.26 In comparison the pro-life Faith and Freedom Network does not see the use of ‘pessary’ as selective prohibition on abortion but instead states that the Oath ‘did not permit doctors to take the lives of the unborn’.27 On the issue of euthanasia, the Oath says ‘to do no harm or injustice and ‘I will not give a lethal drug’.28 The Death with Dignity National Centre argues that what is considered ‘harm’ is subjective: ‘harm for some patients could be forcing them to die according to how their bodies decide instead of how they decide’.29 While the second quotation may not even be involved with the issue of euthanasia; but may rather be addressing Classical Greek fears of physicians collaborating with political figures to murder rivals.30 On the other hand the American Medical Association’s (AMA) stance on euthanasia being ‘fundamentally incompatible with the physician’s role as healer’31 is ‘derived from the Hippocratic tradition’.32 The National Catholic Bioethics Center (NCBC) redefined the stance on euthanasia: ‘I will neither prescribe nor administer a lethal dose of medicine to any patient even if asked nor counsel any such thing nor perform act or omission with direct intent deliberately to end a human life’.33 This removes the ambiguity of the Oath and is clearly against all forms of euthanasia. The NCBC must feel that harkening back the Oath adds credence to their new document; else this would not be named a ‘restatement’. This perfectly demonstrates how the ethical code in the Oath can be read in different ways and repurposed to match varying sets of modern values. The Oath, and thus Hippocrates, is so influential in modern society that many organisations feel they need to use it to validate their standpoint. 26 Arthur, Hypocrisy... Oath. 27 Randall, Hippocratic... Death. 28 Hippocrates, The Oath. 29 Death with Dignity, Physicians’... Questions. 30 Miles (2005) 73. 31 AMA, Euthanasia. 32 CEJA, Report C. 33 Stanton, Restatement... Hippocrates. !6 ! Hippocratic writings on melancholia greatly inspired Early Modern writers on the subject. Robert Burton, in his The Anatomy of Melancholy, 1621, had not rejected the Hippocratic humoural system in his analyses of melancholia; in fact the Hippocratic theories on melancholia were very much alive at this time.34 In the Hippocratic corpus ‘black bile or melancholy’ is mentioned numerous times.35 Burton, describes melancholia as ‘cold and dry, thick, black, and sour’;36 this is a direct transmission of what Hippocrates says of black bile, that it prospers in the ‘dry season’ when the body begins ‘to cool’.37 Melancholia itself was viewed as being one where the ‘brain must be affected’,38 this is something confirmed by Hippocrates, as the brain is believed to be the ‘seat of madness and delirium’.39 The brain is effected thus due to it being in a ‘cold and dry condition’ which Burton says ‘Hippocrates confirms’;40 and as a result those inflicted by melancholia tend to be ‘of a cold and dry constitution’.41 Hippocrates tells us that excess black bile can give a fever of ‘chronic character and difficult resolution’, that has an ‘association...with melancholy,42 this longstanding nature is emphasised in the Aphorisms where melancholia is linked with a ‘fear or depression of long standing’.43 Burton tells us the exact same thing about melancholia; to him it ‘is a habit...a chronic... disease, a settled humour’.44 Hippocrates tells us that to treat an excess of black bile, and thus an imbalance of the humours, ‘black bile can be eliminated’ by ‘cut[ting] the body so as to 34 Jackson (1978) 369. 35 Hippocrates, Airs, Waters, Places, 10. 36 Burton, The Anatomy of Melancholy Part 1, 130. 37 Hippocrates, The Nature of Man 7. 38 Burton, The Anatomy of Melancholy Part 1, 153. 39 Hippocrates, The Sacred Disease 17. 40 Burton, The Anatomy of Melancholy Part 1, 153. 41 Burton, The Anatomy of Melancholy Part 2, 36-7. 42 Hippocrates, The Nature of Man, 15. 43 Hippocrates, Aphorisms, 7,23. 44 Burton, The Anatomy of Melancholy Part 1, 128. !7 form an open wound’, so ‘it bleeds’.45 Burton says, ‘I conclude with Areteus, “before you let blood, deliberate of it,” and well consider all circumstances belonging to it’.46 Burton thus recommends careful thought before letting blood, but still considers Hippocratic blood-letting a course of treatment for melancholia. Boerhaave meanwhile, a physician writing in the late 17th and early 18th centuries, said that melancholy was a ‘Disease [that] arises from the Malignancy of the Blood and the Humours which the Antients have called Black Choler’.47 And although this later author did not espouse humoural theory, as he saw black choler as an infectious agent rather than as one of the four humours of Hippocratic theory, he did still use the words and imagery of Hippocrates in discussing melancholia.48 Robert Burton’s theories on melancholia stemmed from the humoural theory of Hippocrates; and through this influential text Hippocrates lived on in the Early Modern period. Whilst he was less influential for the ideas of Boerhaave, the imagery and language of Hippocrates still left a lasting impression- which we find in the modern day through the dark and mysterious language depression and melancholy are discussed through. ! Another key area we can see Hippocrates’ influence is his style of observational, bedside medicine. The Epidemics show us thorough bedside observations of diseases by the naked eye with symptoms, attempted remedies and possible causes noted down. In the first of the fourteen cases in Epidemics Book 1 the author noted daily changes in health, from ‘sweating’ in day one, ‘more pronounced’ symptoms on day two, and urine is examined on day four. We also find attempt at treatment with ‘the administration of an enema’ on day one and the ‘giving of a suppository’ on day five.49 This notion of bedside 45 Hippocrates, The Nature of Man, 5. 46 Burton, The Anatomy of Melancholy Part 2, 189. 47 Jackson (1986) 119. 48 Jackson (1986) 120. 49 Hippocrates, Epidemics Book 1, Fourteen Cases i. !8 care is discussed in the Decorum, ‘on entering bear in mind...bedside manners, care’,50 students are told to ‘add anything necessary’,51 which tells shows us that observation must lead to varying treatment rather than there being strict treatment regardless of specific cases. And in On Ancient Medicine the author is hostile to those who do not follow this empirical basis of medicine, ‘I am utterly at a loss to know how those who prefer these hypothetical arguments...ever cure anyone’.52 We can see this Hippocratic stance having direct influence on physicians from the Early Modern period. Thomas Sydenham studied epidemics and fevers in order to build up information that could be bring a greater benefit to all in preventing further illness; much like the case notes in the Epidemics of Hippocrates.53 Sydenham also felt it proper that observation of disease ought to be done via eyesight observation, as we find exampled in the Epidemics and Decorum; saying that ‘by diligent research... and by careful scrutiny’ we may attain better knowledge of the body to help improve our medical understanding.54 He also criticises ‘new chemical inventions of our day’ as being distractions from the pure observational nature of medicine as Hippocrates espouses: he claims they are tantamount to those more interested in theory than observation as outlined in On Ancient Medicine.55 Interestingly Sydenham also seems to believe in Hippocratic humoural theory as he says that an ‘affection arises from some humour falling on the nerves’ requires the physician to ‘bleed and purge’.56 To Sydenham then Hippocrates influenced the method of his medicine; it was through reading Hippocrates that Sydenham settled on his empirical methods of observation. We find similar things in the figure of Andres Piquer. Piquer was highly influenced by Hippocrates and Sydenham. He translated the Epidemics of Hippocrates into Spanish and believed 50 Hippocrates, Decorum, 12. 51 Hippocrates, Decorum, 17. 52 Hippocrates, On Ancient Medicine, 15. 53 Nutton (2006) 359. 54 Sydenham, A Treatise on Gout and Dropsy, 171. 55 Sydenham, A Treatise on Gout and Dropsy, 172. 56 Sydenham, Schedula Monitoria, 199. !9 study of ancient medicine was the only way to progress.57 Piquer, like Sydenham, believed that observation of phenomena that we can describe, rather than seeking remote causes and hypothetical reasons, was the way of understanding disease.58 He believed Hippocrates to be the ‘main author of experimental medicine’,59 and his Epidemics to be of enduring value by the virtue of not relying on modern technology or abstract theories.60 This informed his opinion that naked eye observation and subsequent experimentation was superior to technology such as the thermometer to achieve this. The case-histories, such as on an outburst of disease at a village on the outskirts of Valencia in 1739, that Piquer wrote remind us of those we see in Hippocrates’ Epidemics.61 Piquer, like Sydenham, took Hippocrates as his guide for an observational, experimental, medicine; and used the Epidemics as a beacon of medical practice that allowed him to reject modern technologies. ! We have seen then that Hippocrates has an enduring influence on modern medicine. He is the prominent figure in medical ethics. He was cited as the starting point of the Declaration of Geneva, which aimed at giving a medical ethics above the law of any state following the medical atrocities during the Nazi regime. This led to a range of different oaths which were employed far more than ever before. His Oath is so revered that having an ethical issue validated by it, or proving a standpoint does not contradict it, is a crucial step in legitimising many modern viewpoints on topics such as abortion or euthanasia. He was also fundamental in the thinking of many physicians during the Early Modern period. We see how his humoural theory persists; and we specifically see how Burton’s, and to a lesser extent Boerhaave’s, theories on melancholia were informed by Hippocrates. We have also seen how the observational method of Hippocrates inspired and 57 Espinós (2010) 465. 58 Espinós (2010) 468. 59 Espinós (2010) 467. 60 Von Staden (1989) 706. 61 Espinós (2010) 464. !10 was taken up by Sydenham and Piquer. Hippocrates carried on influencing medical thought in the Early Modern period; and in the modern day he is still a shining beacon to be called upon when concerns of medical ethics arise. That the world called upon him to prevent the recurrence of the evils of the Second World War, that he informed the theories of a seminal work such as The Anatomy of Melancholy, and that the idea of physicians swearing the Hippocratic Oath instils a sense of comfort and confidence in the general public, shows the relevance and influence Hippocrates still has in modern times. ! ! ! ! ! ! ! ! ! Bibliography: Primary Sources: Hippocrates, Airs, Waters, Places, trans. J. Chadwick & W.N. Mann (Harmondsworth: Penguin 1978) Hippocrates, Aphorisms, trans. J. Chadwick & W.N. Mann (Harmondsworth: Penguin 1978) Hippocrates, Decorum, trans. W.H.S. Jones (London: Heinemann 1959) Hippocrates, Epidemics Book 1, trans. J. Chadwick & W.N. Mann (Harmondsworth: Penguin 1978) Hippocrates, Epidemics Book 3, trans. J. Chadwick & W.N. Mann (Harmondsworth: Penguin 1978) Hippocrates, Nature of Man, trans. J. Chadwick & W.N. Mann (Harmondsworth: Penguin 1978) Hippocrates, On Ancient Medicine, trans. J. Chadwick & W.N. Mann (Harmondsworth: Penguin 1978) Hippocrates, The Nature of the Child, trans. I.M. Lonie (Harmondsworth: Penguin 1978) Hippocrates, The Oath, trans. M. North (National Library of Medicine 2002) !11 Hippocrates, The Sacred Disease, trans. J. Chadwick & W.N. Mann (Harmondsworth: Penguin 1978) Robert Burton, The Anatomy of Melancholy, (Ex-classics Project 2009) Thomas Sydenham, A Treatise on Gout and Dropsy, trans. R.G. Latham (London: The Sydenham Society 1850) Thomas Sydenham, Schedula Monitoria, trans. R.G. Latham (London: The Sydenham Society 1850) World Medical Association, Declaration of Geneva (1948) ! ! Secondary Sources: Boozer, J.S. (1980) ‘Children of Hippocrates: Doctors in Nazi Germany’ in Annals of the American Academy of Political and Social Science 450: 83-97. Espinós, J.A. (2010) ‘Andrés Piquer and the Neo-Hippocratic Teaching of Medicine in Eighteenth Century Spain’ in Hippocrates and Medical Education: selected papers read at the XIIth International Hippocrates Colloquium, Universiteit Leiden, 24-26 August 2005, ed M. Hortsmanshoff (Boston: Brill) 461-474 Frewer, A. (2010) ‘Human Rights from the Nuremburg Doctors Trial to the Geneva Declaration. Persons and institutions in medical ethics and history’ in Medicine, Health Care and Philosophy 13: 259-268 Friedlander, H. (2002) ‘Physicians as killers in Nazi Germany: Hadamar, Treblinka, and Auschwitz’ in Medicine and Medical Ethics in Nazi Germany: origins, practices, legacies, ed F.R. Nicosia & J Huener (New York: Berghahn Books) 59-76 Gibson, T. (2009) ‘The Code of Ethics in Medicine: Intertextuality and Meaning in Plato’s Sophist and Hippocrates’ Oath’ in Critical Interventions in the Ethics of Healthcare: challenging the principle of autonomy in bioethics, ed S.J Murray & D Holmes (Farnham: Ashgate) 183-198 Jackson, S.W. (1986) Melancholia and Depression: from Hippocratic times to modern times (London: Yale University Press) Jackson, S.W. (1978) ‘Melancholia and the Waning of the Humoral Theory’ in Journal of the History of Medicine and Allied Sciences 33: 367-376. Levine, E.B. & Levine, M. E. (1965) ‘Hippocrates, Father of Nursing, Too?’ in The American Journal of Nursing 65: 86-88. Miles, S.H. (2005) The Hippocratic Oath and the Ethics of Medicine (Oxford: Oxford University Press) Nutton, V. (2013) Ancient Medicine (New York: Routledge) Nutton, V. (2006) ‘Medicine in the Greek world 800-50 BC’ in The Western Medical Tradition: 800 BC to AD 1800, ed W.F. Bynum et al (Cambridge: Cambridge University Press) 11-38 Porter, R. (2006) ‘The Eighteenth Century’ in The Western Medical Tradition: 800 BC to AD 1800, ed W.F. Bynum et al (Cambridge: Cambridge University Press) 371-476 !12 Porter, R. (1997) The Greatest Benefit to Mankind: a medical history of humanity from antiquity to the present (London: HarperCollins) The British Medical Association (BMA) (2012, 3rd edn) Medical Ethics Today: The BMA’s handbook of ethics and law (Chichester: Wiley-Blackwell) Von Staden, H. (1989) ‘Review of Las epidemias de Hippócrates: Con observaciones prácticas de los antiquos y modernos by Andrés Piquer’ in Isis 80: 707-707. Wear, A. (2006) ‘Medicine in Early Modern Europe 1500-1700’ in The Western Medical Tradition: 800 BC to AD 1800, ed W.F. Bynum et al (Cambridge: Cambridge University Press) 215-362 Wooton, D. (2006) Bad Medicine: Doctors doing harm since Hippocrates (Oxford: Oxford University Press) ! 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Jones, The Hippocratic Oath II – http://www.cmq.org.uk/CMQ/2006/hippocratic_oath_ii.html (28th April 2012) Accessed 6th March 2013. K.B. O’Reilly, Only 1 Medical School uses classic version of Hippocratic Oath – http://www.amednews.com/article/20060220/profession/302209962/6/ (20th Feb 2006) Accessed 5th March 2013. G. Randall, Hippocratic Oath vs. The Abortion Industry ---- Life vs. Death – http://blog.faithandfreedom.us/2011/01/hippocratic-oath-vs-abortionindustry.html#.UT4i4hyeN7x (24th Jan 2011) Accessed 6th March 2013. !13 J.R. Stanton, Restatement of the Oath of Hippocrates – http://www.catholicculture.org/culture/library/view.cfm?recnum=749 (1st Oct 2008) Accessed 6th March 2013. P. Tyson, The Hippocratic Oath Today – http://www.pbs.org/wgbh/nova/body/hippocratic-oath-today.html (27 Mar 2001) Accessed 2nd March 2013. WMA, History – http://www.wma.net/en/60about/70history/ (4th Dec 2010) Accessed 25th February 2013.