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 suicide 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 murder, 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 god . .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 Aristotle argues in his Nicomachean Ethics that obligation euthanasia 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 Plato 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 assisted suicide 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, Socrates 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 gods, 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.