International code of medical ethics adopted by the Third General Assembly of the World Medical Association, London, 1949. Courtesy of the National Library of Medicine. Healing, harming, and Hippocrates Physician-assisted in Roman medicine

Felipe Fernandez del Castillo The author is a member of the Class of 2016 at the University of Massachusetts Medical School. This essay won honorable mention in the 2013 Helen H. Glaser Student Essay Competition.

n the summer of AD 138, the Roman Emperor Hadrian decided his time had come. Likely terminally ill with congestive heart failure, struggling to breathe, and no longer able to cope with gross edema, he had long since begun to pray for a swift death. Eventually he decided to take matters into his own hands.

often he would ask for poison or a sword, but no one would give them to him. As no one would listen to him, although he promised money and immunity, he sent for Mastor, one of the barbarian Iazyges . . . and partly by threatening him and partly by making promises, he compelled the man to promise to kill him. He drew a coloured line about a spot beneath the nipple that had been shown him by Hermogenes, his physician, in order that he might there be struck a fatal blow and perish painlessly.1p463

This passage has been used as evidence of physician as- sisted suicide in antiquity,2 but while it is true that Hermogenes instructed Hadrian in how to achieve a painless death, he drew the line at providing direct assistance. Although the

Bust of Roman Emperor Hadrian, British Museum. SHAUN CURRY/AFP/Getty Images

The Pharos/Autumn 2010 21 Healing, harming, and Hippocrates

physician certainly would not have wanted to be accused of and dearest of all,—what penalty should he suffer? I mean the emperor’s , the narrative hints at more subtle im- the man that slays himself,—violently robbing himself of his plications: the Greeks and Romans of the imperial court were Fate-given share of life, when this is not legally ordered by the ones who refused to stab Hadrian in spite of his promises the State, and when he is not compelled to it by the occur- of money and immunity, leaving the emperor to turn to his rence of some intolerable and inevitable misfortune, nor by barbarian servant Mastor, who, in the end, recoiled from his falling into some disgrace that is beyond remedy or endur- assignment. A resigned Hadrian eventually decided to meet ance,—but merely inflicting upon himself this iniquitous his death by “indulging in unsustainable food and drink” on penalty owing to sloth and unmanly cowardice. In this case, his death bed, shouting out a popular saying: “Many physicians the rest of the matters—concerning the rules about rites of have slain a king!” 1p463 purification and of burial—come within the cognizance of Were the cultural norms of the Greco-Roman world of the . . .8p873 Hadrian’s time responsible for his failure to achieve his sui- cide? What were those norms? Were they widely shared? The caveats of “when he is not compelled to it by the occur- When did they become prominent? rence of some intolerable and inevitable misfortune, nor by The current scholarly consensus on the Hippocratic prohi- falling into some disgrace that is beyond remedy or endur- bition of suicide owes much to a narrative proposed in the late ance,” seem to imply that there were circumstances in which 1940s by the medical historian Ludwig Edelstein.3 Edelstein ar- suicide was considered permissible. gued that the Hippocratic Oath’s prohibitions of abortion and argues in his Nicomachean Ethics that obligation were so contrary to Greek cultural norms of the stems not from religious, but social commitments. Aristotle’s time that the oath must have been written by and for followers primary objection to suicide is that it weakens the polis of the pre-Socratic philosopher Pythagoras. When Christians through the loss of potentially arms-bearing citizens.9 In his found certain aspects of Pythagorean morality consonant with Eudemian Ethics, Aristotle also condemns as cowardly those their own, the Hippocratic Oath became institutionalized.3 who commit suicide out of a desire to avoid pain, even while Most modern scholars reject Edelstein’s specific thesis noting that it is a common practice.10 of Pythagorean authorship, but the essential elements of Whatever the original teachings of and Aristotle, his thesis are widely accepted. They continue to shape both there is considerable evidence that later Platonists and classical scholarship4,5 and current politics,6 and have led Aristotelians tolerated suicide and even praised the practice many to assume that physician was practiced as courageous.3,5 Other philosophical schools of the time, in- indiscriminately in the classical Greco-Roman world. An as- cluding the Stoicism fashionable in Rome during the first cen- sumption that combines the theory of the esoteric origins of turies AD, followed suit. One of the best sources concerning the Hippocratic Oath with concrete evidence of the permis- Roman views on suicide comes to us in the Letters to Lucilius, sive views of suicide expressed in Greek and Roman sources in which the prominent Stoic Seneca describes the suicide of ignores or dismisses evidence that some physicians adhered Tullius Marcellinus, a “quiet soul” battling a disease “by no to the Hippocratic Oath well before the institutionalization means hopeless . . . but protracted and tiresome.” 11¶5 Although of Christianity in the Roman Empire. The refusal by these uncertain what to do, he eventually takes the advice of “a man physicians to practice physician assisted suicide and abortion of courage and vigor” 11¶6 (not his doctor) who recommends: stemmed not from moral beliefs but from a commitment to a professional identity rigidly defined by the Hippocratic axiom Do not torment yourself, my dear Marcellinus, as if the “Medicine is the science of healing, not of harming.” 13p26 question which you are weighing were a matter of impor- tance. It is not an important matter to live; all your slaves Ancient perspectives on suicide live, and so do all animals; but it is important to die honour- While both Plato and Aristotle objected to suicide, they ably, sensibly, bravely. Reflect how long you have been doing based their objections on concepts unlikely to have been the same thing: food, sleep, lust,—this is one’s daily round. invoked by a doctor confronted with a suffering patient. In The desire to die may be felt, not only by the sensible man Plato’s Phaedo, argues that: “Any man who has the or the brave or unhappy man, but even by the man who is spirit of philosophy, will be willing to die, though he will not merely surfeited.11¶6 take his own life, for that is held not to be right.” 7¶33 Even when “a man is better dead,” 7¶40 the decision to end life is the Marcellinus starves himself to death with his friend’s exclusive prerogative of the , since the relationship be- assistance. tween the gods and man is one of ownership. In Plato’s Laws, Seneca proposes suicide as a means to end the meaning- he reiterates this: lessness of “one’s daily round.” 11¶5 Thus the decision to end life may be made not just by the chronically ill or suffering, Now he that slays the person who is, as men say, nearest but by anyone who feels the pleasures of life no longer make

22 The Pharos/Spring 2014 life worthwhile. Refuting Socrates’ argument of obligation to the gods and Aristotle’s argument of obligation to the state, About Felipe Fernandez del Castillo Seneca reasons that the individual who commits suicide is I graduated from the University “deserting no duty; for there is no definite number estab- of Chicago in 2011, and now am a lished which [he is] bound to complete.” 11¶19 It is tempting to medical student at the University of read this as an early articulation of the principle of autonomy, Massachusetts. I live in Cambridge with but while Seneca supports Marcellinus’ decision to commit my wife, Lisa. suicide, this is less because he believes in personal rights than because of his belief in stoicism. Seneca sees the desire to avoid death as complacency, and his letter contains severe language on the subject of those who lack “the courage to show, an abortifacient drug to a pregnant woman. In this die” 11¶15 and cling childishly to life. way, Hippocrates long ago prepared his students’ hearts and Seneca’s belief in the permissibility of suicide was shared minds to learn humane feelings [humanitatem].13p26 by many Romans. Cicero and Pliny the Elder (writing in the last century BC and the first AD respectively) are among the Scribonius establishes the oath’s importance in the phrase chorus of voices asserting suicide’s validity both for those suf- “our sworn oath,” but further tells us that Hippocrates wrote fering from incurable diseases, and for those suffering from “long ago,” implying that it is a well-established part of the other kinds of adversity. There is also evidence that consulting medical profession. He leaves us with the impression that a physician when making the decision to commit suicide was medical practice in Rome was not monolithic, but that physi- common, and there are at least three examples from first- and cians felt free to act according to their own ethical priorities, second-century Roman literature of physicians supplying poi- consistent with other accounts of ancient medicine.4 This son requested by their patients.2,3 preface implies an audience of physicians who, like Scribonius, are “bound by the sacred oath of medicine not to give a deadly What did doctors think? drug, even to an enemy.” 13p26 Scribonius’ adherence to the The acceptance of suicide does not mean that physicians oath may mark him as an iconoclast or a radical, but we know were universally or even commonly eager to assist in the sui- at least that he was not alone. cides of their patients. Although primary references establish Scribonius was probably a physician to the court of the that physician assisted suicide occurred, they say nothing Emperor Claudius, since the Compositiones was dedicated to about how doctors understood their role at the deathbed. The a powerful member of the imperial household. Thus he and Hippocratic writings are silent on the subject of active eutha- his oath-taking colleagues were likely prominent physicians nasia. Neither Galen nor Celsus say anything about the ethical depending on the patronage of the imperial government. content of the Hippocratic Oath, although they speak highly Two pre-Christian sources refer to the ethical content of of Hippocrates himself.12 Nevertheless, there is primary evi- the oath. In the first, the novelist Apuleius, a contemporary of dence that the oath and its contingent prohibition of physician Galen, in Book 10 of his novel The Golden Ass,14 tells a con- assisted suicide were well established in parts of the medical voluted tale about an attempted murder, in which a physician, community in first-century Rome.* “a senior councillor, a man noted for his integrity and a highly The Hippocratic Oath clearly held a place in Roman medi- respected doctor,” provides testimony: cine. The earliest known reference to the oath occurs in the preface to a treatise on pharmacology written between AD Finally the doctor spoke out: “No, I will not allow it, I 44 and 48 by the Roman physician Scribonius Largus, the will not allow you to punish this innocent young man and Compositiones Medicatorum. let this fellow escape the penalty for his crime and make a mockery of justice. I will give you a clear proof of the real Hippocrates, the founder of our calling, transmitted state of affairs. When this rascal was so eager to buy a deadly the beginnings of this discipline in the form of our sworn poison, I thought it improper for one of my profession to oath, which ordains that no physician should give, or even provide anybody with the means of death. I had been taught that medicine had been invented to save life, not destroy it. However, I feared that if I declined to give it to him, I should merely be aiding and abetting his crime and do more * Note that I assume that the Hippocratic Oath’s injunctions that harm than good by my refusal; he would acquire his deadly “nor shall I give a deadly drug to anybody if asked, nor shall I give potion from somebody else or in the last resort carry out advice leading to that end” refer to physician assisted suicide, not murder, as is the consensus of historians.3,4,5,12 I further assume that his abominable plan with a sword or some other weapon. doctors who accepted the Hippocratic prohibition of abortion would So I gave him his ‘poison’; but it was a soporific draught of also have accepted its injunctions against physician assisted suicide. mandragora, a proven narcotic, as you know, which induces

The Pharos/Spring 2014 23 a sleep indistinguishable from death. . . . if what the boy the beginnings of this discipline in the form of our sworn drank was really the drink that I compounded, he is alive oath, which ordains that no physician should give, or even and sleeping peacefully, and soon he will shake off his torpor show, an abortifacient drug to a pregnant woman. In this and return to the light of day. If, however, death has claimed way, Hippocrates long ago prepared his students’ hearts and him, we must look for the cause elsewhere. minds to learn humane feelings [humanitatem]. How much The old man’s speech carried conviction, and not a mo- more evil would this man, who thought it wrong to destroy ment was lost in hastening to the tomb where the boy’s body even the tenuous possibility of a man, judge the harming of had been laid. . . . It was the father himself who removed a living human being!13p26 the lid of the coffin with his own hands; and at once the boy shook off his deathlike lethargy and sat up, risen from Rather than relying on the arguments of Socrates and Aristotle, the dead. Scribonius embraces the concept of humanitas, as institution- alized in the Hippocratic Oath. Although a fictional account, The Golden Ass certainly re- flected the attitudes of the medical profession of Apuleius’ If, on the other hand, [doctors] have experienced the util- time. Suffering patients must have approached doctors for ity of drugs, yet still reject their use, they are all the more poisons, probably with some confidence of success. Thus, as culpable because they are subject to bias, an evil that should in Compositiones, The Golden Ass hints at the stature given a be despised in every living creature, especially physicians. physician who adhered to the oath. The doctor’s respectability All gods and men should hate the doctor whose heart lacks is a key to the story’s plot. compassion [misericordia] and the spirit of human kindness In the second, Soranus, a prominent Greek physician who [humanitas].13p26 spent part of his life practicing in Rome during the first and early second century AD, illustrates a dilemma common to Scribonius seems to say that doctors who are “subject to mankind in the interpretation of the oath: bias” are equivalent to those who lack humanitas, that failure to treat patients effectively is a violation of the same profes- But a controversy has arisen. For one party banishes sion-defining principle as failure to adhere literally to the abortives, citing the testimony of Hippocrates who says: Hippocratic Oath. Humanitas appears to be a term describ- “I will give to no one an abortive”; moreover, because it is ing an attitude of what we might call today professionalism: the specific task of medicine to guard and preserve what treating patients to the best of one’s ability, with compas- has been engendered by nature. The other party prescribes sion and kindness, and in accord with the Hippocratic Oath. abortives, but with discrimination, that is, they do not pre- Humanitas in this sense thus summarizes the Hippocratic scribe them when a person wishes to destroy the embryo axiom that “medicine is the science of healing, not of harm- because of adultery or out of consideration for youthful ing,” 13p16 an axiom that he embraced. He urged his readers to beauty; but only to prevent subsequent danger in parturition work “conscientiously, even reverently in accordance with this . . . And they say the same about contraceptives as well, and maxim.” 13p26 we too agree with them.15p63 Further analysis of Scribonius’ writing reveals that humani- tas is not a moral issue for him, but instead stands for a rigid It seems that physicians in the second group, with whom professional code. Soranus strongly identifies, were flexible about strict adher- ence to the oath in the face of challenging ethical dilemmas. These very qualities [humanitas and misericordia], after all, Whether this flexibility extended to physician assisted suicide preclude the physician, bound by the sacred oath of medi- is unknown. cine, from giving a harmful drug even to an enemy—yet the physician will attack that same enemy, when occasion Humanitas, healing and harming demands, in his role as a soldier and good citizen.13p26 Medical historian Oswei Temkin used the body of evidence presented above to establish the existence of “a tradition Thus it is clear that Scribonius’ ethics are not shaped by “re- which, in its uncompromising form, did not sanction any spect for life,” but by a belief that a physician inflicting any limit to the respect for life” 16p5 in ancient medicine. However, form of harm contradicts the meaning of medicine. Killing an “respect for life” seems to have played only a small role in enemy, morally acceptable for a “good citizen,” is forbidden to Scribonius’ acceptance of the Hippocratic Oath’s moral in- that same citizen acting as a physician, which provides a useful junctions. His embrace of the oath apparently has more to do insight into how a doctor who shared Scribonius’ Hippocratic with professional identity than personal morality. He writes: commitments would have understood physician assisted sui- cide. This understanding of humanitas dictates that the physi- Hippocrates, the founder of our calling, transmitted cian is a “healer,” not a “harmer”; assisting in suicide is harm,

24 The Pharos/Spring 2014 no matter what the patient desires. 3. Edelstein L. The Hippocratic Oath: Text, Translation and Examination of the sources presented earlier upholds this Interpretation. In: Temkin O and Temkin CL, editors. Ancient view. Apuleius’ doctor, for example, says nothing about his Medicine: Selected Papers of Ludwig Edelstein. Baltimore (MD): own beliefs regarding suicide. For him, it is “improper” for a The Johns Hopkins University Press; 1967: 3–64. physician to assist anyone to die because medicine exists to 4. Nutton V. Ancient Medicine. Oxford: Routledge; 2004. preserve, not destroy, life—or at least that’s what he learned 5. Amundsen DW. The physician’s obligation to prolong life: from his teachers.14 Neither a handsome price offered nor a a medical duty without classical roots. Hastings Cent Rep 1978; 8: plea that the patient is suffering enormously can overcome 23–30. this prohibition. Doctors cited by Soranus furnish similar 6. Amundsen DW. The Significance of Inaccurate History in arguments. Abortion is wrong “because it is the specific task Legal Considerations of Physician-Assisted Suicide. In: Weir RF, of medicine to guard and preserve what has been engendered editor. Physician-Assisted Suicide. Bloomington (IN): Indiana Uni- by nature.” 15p63 Soranus’ disagreement with this Hippocratic versity Press; 1997: 3–32. dogmatism appears to be a disagreement with how the ethic 7. Plato. The Apology, Phaedo and Crito. Volume II, Part 1. should be applied, not the ethic itself. The understanding Jowett B, translator. The Harvard Classics. Eliot CW, editor. New that the physician’s role was to heal, not harm, and that this York: P.F. Collier & Son; 1909–14. Available at http://www.bartleby. precluded physician assisted suicide had, by the mid-second com/2/1/31.html. century AD, become well established among doctors. 8. Plato. Laws, Volume II: Books 7-12. Bury RG, translator. Loeb Classic Library No. XX. Cambridge (MA): Harvard University A hypothesis and a word of caution Press; 1926. Available at http://www.perseus.tufts.edu/hopper/te In facing difficult bioethical dilemmas today, most of us xt?doc=Perseus%3Atext%3A1999.01.0166%3Abook%3D9%3Apage think in terms of morality rather than professional identity. %3D873 Why and when did this change come about? 9. Rackham H, editor and translator. Aristotle in 23 Volumes. Two factors sharply distinguish the perception of physician Volume 19. Cambridge (MA): Harvard University Press; 1934. Avail- assisted suicide in the early centuries AD from that of today. able at http://www.perseus.tufts.edu/hopper/text?doc=Perseus%3 At that time there was little that a physician could do for a Atext%3a1999.01.0054%3Abekker+page%3D1138a%3Abekker+line seriously ill patient. Doctors of the time commonly refused %3D1. to treat seriously ill patients at all.5 And it is noteworthy that 10. Rackham H, editor and translator. Aristotle in 23 Volumes. Romans were comfortable with the idea of suicide, even in Volume 20. Cambridge (MA); Harvard University Press, Harvard cases where cures were considered possible. University Press; 1981. Available at http://www.perseus.tufts.edu/ Taken together, these two factors suggest that requests to hopper/text?doc=Perseus%3Atext%3A1999.01.0050%3Abook%3D3 physicians for assistance in committing suicide must have %3Asection%3D1229b. been quite common. Indeed, the emphasis writers place on 11. Seneca. Epistles 66–92, Volume II. Gummere R, translator. the prohibitions of the Hippocratic Oath—which comprise Loeb Classical Library No. 76. Boston: Harvard University Press; a small fraction of its content—suggests that they were not 1920. Available at http://en.wikisource.org/wiki/Moral_letters_to_ universally observed. Doctors willing to practice physician Lucilius/Letter_77. assisted suicide may have risked seriously compromising their 12. Temkin O. Hippocrates in a World of Pagans and Christians. professional identity as healers, and thus their livelihoods. Baltimore (MD): Johns Hopkins University Press; 1991. I began writing this paper in response to a ballot initia- 13. Pellegrino ED, Pellegrino AA. Humanism and ethics in Ro- tive to legalize physician assisted suicide in Massachusetts. I man medicine: translation and commentary on a text of Scribonius expected in my research to find echoes of the current debate. Largus. Lit Med 1988; 7: 22–38. Instead, I found a literature that invoked entirely different 14. Apuleius. The Golden Ass. Kenney EJ, translator. London: principles than those we use today. While historical sources Penguin Classics; 1998. can provide perspective in tackling difficult contemporary 15. Soranus. Gynecology. Temkin O, translator. Baltimore (MD): problems, the use of them is even more difficult than their John Hopkins University Press; 1956. interpretation. 16. Temkin O. Respect for Life in the History of Medicine. In: Barker SF, editor. Respect for Life in Medicine, Philosophy, and the References Law. Baltimore (MD): Johns Hopkins University Press; 1976: 1–23. 1. Dio Cassius: Roman History: Books 61-70. Carey E, trans- lator. Loeb Classical Library No. 176. Boston: Harvard University The author’s address is: Press; 1925. Available at http://penelope.uchicago.edu/Thayer/E/ 94 Central Street Roman/Texts/Cassius_Dio/69*.html. Auburndale, Massachusetts 02466 2. Gourevitch D. Suicide among the sick in classical antiquity. E-mail: [email protected] Bull Hist Med 1969; 43: 501–18.

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