At the start of the oath accorded to him, Hippocrates calls upon the Greek gods Apollo, Asclepius, Hygieia, and Panacea by identify as witnesses to his solemn skilled vow. Typical knowledge typically credit Hippocrates with naturalizing drugs, that’s, of distinguishing the follow of medication from the practices of magic, superstition, or in any other case spiritual ritual, which isn’t incorrect. Such an account does, nonetheless, overlook a important level that issues the methods wherein Hippocrates refigures the connection between the divine and nature typically and the connection between spiritual piety and the follow of medication specifically. Furthermore, the acquired model of the story additionally overlooks the way in which wherein the Hippocratic reconstruction of those relationships additionally supplies warrant for a type of epistemological humility that must characterize the follow of medication altogether.
The issue is just not thick spiritual commitments of the type that Hippocrates himself truly had. On Hippocrates’ account, such spiritual commitments are exactly what preserve epistemological hubris at bay. Hippocrates, well-versed within the Greek myths, notices how even the thunderings of Zeus don’t all the time have their anticipated outcomes. As an illustration, Zeus may declare the destruction of a sure individuals for no matter cause, however it’s not all the time the case that such destruction happens. Hippocrates sees in such instances a parallel between divine pronouncement and medical prognosis insofar as in neither case can the end result be identified upfront. Even when both seems to come back true, it was not and will by no means have been identified upfront, and it’s the kind of endogenous uncertainty that characterizes the follow of Hippocratic drugs and on the identical time indexes what kind of ethical accountability physicians have for his or her sufferers.
As a Catholic theologian myself, I’ve no intention of pretending to be a doctor and even of getting greater than a woefully insufficient data of medication, biology, physiology, or something of the type. What I purpose to do on this piece is just to chart out among the agency frequent floor between drugs and theology, between the medical vocation and the lifetime of Christian religion, between tending to the physique and tending to the soul. My elementary query is “What ought we owe Hippocrates?” It isn’t, to be clear, “What do we owe Hippocrates?” as such money owed are sometimes and with out compunction disavowed or at greatest stay contently unpaid. What ought we owe Hippocrates? How may we, in a way, make good on the Hippocratic legacy? Although we’re separated by over two millennia, by tradition, and by faith, our respective conditions usually are not completely totally different. Human beings stay basically the identical: finite, mortal, unsure.
Nature and Naturalizing Medication
Maybe it’s best to start with considered one of Hippocrates’s most central improvements, particularly, his emphasis on prognosis, which after all stays an necessary a part of the follow of medication to this present day. Furthermore, Hippocrates continues to be rightly accorded credit score for establishing its everlasting significance. But, after we look to his treatise on prognosis, his Prognostikon, we discover some attention-grabbing aspects of his account of it which have, over time, turn out to be soundly ignored. For Hippocrates, prognosis is a type of fore-seeing and fore-telling, because the Greek etymology of the phrase suggests. It’s a talent that should be cultivated and so cultivated by commentary of the affected person. But, Hippocrates begins his treatise with how the follow of prognosis, exactly as a result of it’s the fruit of commentary, is at first the means by which a doctor positive factors the belief of her affected person, in order that the affected person will likely be sufficiently forthcoming with symptomatic and ordinary particulars that she would in any other case favor to maintain non-public. Hippocrates is properly conscious that for lots of the sick they could accord a divine trigger to their illness, and Hippocrates doesn’t rule that out. However it should be decided to be or not be the case.
In mild of his commentary and the account of signs and habits by his sufferers, Hippocrates foretells the outcomes of his sufferers, and the success of his remedies is straight correlated to the diploma to which he is ready to anticipate the longer term well being situations of his sufferers, that’s, whether or not they are going to dwell or die. Medical prognosis is like divine prognosis, on Hippocrates’s account, insofar as they each retain their respective levels of uncertainty, and in neither case are we coping with an occult science. With respect to each, in truth, our horizon for commentary is proscribed and our prognoses are each constructed from generalizations: for example, sufferers who exhibit a sure constellation of signs (sunken eyes, vomiting, black veins, or the like) are likely to die inside a sure period of time, and so forth; comparable patterns will be noticed with respect to the gods: individuals who behave on this approach or that have a tendency to satisfy this or that destiny. But such outcomes usually are not sure. Typically signs resolve and the affected person returns to well being, and typically the depraved seemingly go unpunished to dwell lengthy, morally deranged lives. In a approach, Hippocrates appears simply as weirded out by the affected person who with clear and extreme morbidities returns to well being and lives an extended life because the ruthless tyrant who’s granted many a long time over which to oppress and exploit his topics solely to die peacefully in his sleep at a ripe outdated age. Thus, past the bodily struggling it encounters, the follow of medication additionally experiences first the type of existential struggling that comes with uncertainty.
On the identical time, that uncertainty is just not itself absolute, which is to say that solely precisely one factor is for certain: demise. I believe this perception offers us some perspective on the Hippocratic aversion to euthanasia: “I’ll give no lethal drugs to anybody if requested, nor recommend any such counsel,” as it’s put within the oath. However we must get there. Fairly often we’re informed that the Hippocratic Oath commits the doctor to a sure moral stance or to uphold sure moral commitments, however for Hippocrates himself such commitments are metaphysical earlier than they’re moral. Hippocrates not solely believed, like practically all historic Greeks, that human beings had been created by the gods, he additionally believed that drugs was a present from the gods, the very ones one invokes when taking the oath. It may appear, at first look, that such perception is an element and parcel of historic Greek piety, however in actuality, Hippocrates’s perception is definitely revolutionary. The frequent perception of his predecessors and contemporaries was that the gods had been the causes and events of sickness and illness, not their treatment. In his remedy of the Divine Sickness, a medical treatise on epilepsy, a illness which was considered a visitation of the divine, Hippocrates argues that the so-called divine sickness isn’t any extra divine than every other sickness; it’s a manifestation of a compromised physiology fairly than of divine company.
It’s value pausing right here, only for a second. Attempt to think about the type of theological paradigm shift this represents, and it’s undoubtedly value noting that Hippocrates attracts out a theological implication from his medical expertise. He begins together with his commentary and remedy of epileptics, determines epilepsy’s physiological origins after which causes to a theological conclusion. He might need contemplated, “If epilepsy is just not a divine visitation or affliction however is fairly a illness of the physique, then what do the gods must do with it?” He might need continued to muse, “But, I’m able to deal with this illness. The physique of my affected person is intelligible to me. I can observe it, examine it, diagnose it, and at the least typically heal it.” The conclusion that Hippocrates reaches is that it’s the therapeutic that has divine origins, not the illness. The gods are within the enterprise of therapeutic, not cursing.
Furthermore, within the oath, the therapeutic gods are invoked as witnesses, not as brokers of therapeutic themselves. Once more, this configuration is itself additionally revolutionary. For Hippocrates, if illness is a pure phenomenon with pure, physiological causes, then it will make little sense to aim to deal with it with magic, ritual, or superstition. By invoking the gods as witnesses, Hippocrates is making a correctly theological declare, in truth a sequence of them. The gods don’t want us hurt; they don’t curse with sickness; nor do they heal provided that the correct ritual is carried out, or observance made. Fairly, they’ve given us, like Prometheus with fireplace, the present of having the ability to heal the sick ourselves. They’ve given us the present of medication. In different phrases, it’s not the case, as is commonly instructed of Hippocrates, that he banished the divine from the world of pure drugs in any respect. As a substitute, he presents a brand new imaginative and prescient of the connection between faith and drugs altogether, and from that he goes on to characterize the medical occupation, its greatest practices, and the moral responsibility its practitioners have with respect to it.
Furthermore, Hippocrates can be credited with revising the frequent understanding of the organic composition of the human physique. Granted, we’re speaking a few historic second at which we have now not but drawn clear distinctions between physiology and anthropology, so these historic views of the human particular person, her nature and physiology, tended towards the philosophical or in any other case mystical. Earlier than Hippocrates, the human particular person was considered a unity of the primordial parts: fireplace, water, wind, or earth. Hippocrates was not satisfied. His physiology, nonetheless, seems nonetheless fairly unusual and maybe simply as esoteric. He understands the human particular person to be composed of 4 balanced “humors” or bodily fluids: blood, yellow bile, black bile, and phlegm. A wholesome particular person is one for whom these humors or fluids are “balanced” or are in correct proportion with respect to at least one one other; in an unhealthy particular person, alternatively, the humors are imbalanced. As unusual (and gross) as this appears, it is very important observe that Hippocrates develops his physiology straight from his expertise dissecting cadavers. Reduce open a physique, and also you do in truth discover these fluids, in addition to tissues that might plausibly be understood to be composed of them. The follow of Hippocratic drugs, then, is to revive steadiness of those humors, at the least when attainable. Hippocrates’s strategy is fairly attention-grabbing. He acknowledges that the identical illness can have many cures, exactly as a result of pure issues will be affected by any variety of issues. If it may be correctly mentioned that Hippocrates naturalizes drugs, that is what we should imply.
So, to return to euthanasia, the prohibition in opposition to it’s not merely moral, that’s, to say that euthanasia is dangerous, so you shouldn’t do it, even when somebody asks properly. Fairly, given his pure understanding of pathology and physiology, euthanasia couldn’t presumably be thought-about drugs, exactly as a result of it doesn’t search to revive steadiness to the humors. In keeping with Hippocrates, we owe the therapeutic gods at the least that a lot, to follow drugs and never one thing else. The moral stance has a pure rationale. It attends to the pure physique and the advanced constellation of pure components that impacts it and is affected by it. We invoke the therapeutic gods, it will appear, first, as an expression of gratitude, for each the present of medication and for the present of the pure world which incorporates our physiological our bodies. Thus, I believe we come to our first cause that we, and particularly these in or contemplating the medical occupation, ought to owe Hippocrates, particularly, for the perception that locations the follow of medication inside nature and demonstrates for us that God or the gods needn’t and ought not be a casualty of the naturalization of medication.
Prognosis and Prognostication
We must always now have the ability to see extra clearly what Hippocrates means by prognosis. When you recall, prognosis is the fore-seeing or fore-telling of a particular medical end result born of cautious, knowledgeable commentary. Prognosis causes from observable phenomena to what’s prone to come about. The presentation of this or that symptom tells us one thing, which for Hippocrates is all the time put by way of proximity to demise, what immediately we’d name morbidity. But, even a wholesome particular person, who presents no troubling signs, stays proximate to demise. That’s the solely certainty. What’s fascinating to me is how Hippocrates takes that uncertainty into consideration as he describes the duty and obligations of the doctor. This level is one thing that the oath maybe overlooks or at the least oversimplifies: “First, do no hurt.” But, I believe Hippocrates means one thing extra subtle than a comparatively uninspiring prohibition in opposition to hurting one’s sufferers. The potential for each hurt and well being are current far upfront of any administration of cures or therapies, exactly on the first second of encounter. Our relationship to demise is for certain. We are going to die. The small print of how that certain certainty unfolds, nonetheless, are unsure.
For Hippocrates, it’s this unsure certainty and sure uncertainty that characterize not solely the patient-physician dynamic but additionally a elementary facet of human expertise. Hippocrates speaks typically of the shortness of life. Within the first entry within the assortment of his aphorisms he writes, “Life is brief, and artwork (techne) lengthy, alternative fleeting, experimentation perilous, and judgment troublesome.” That life is brief, Hippocrates is saying, casts all of what follows right into a sure sharp reduction. The shortness of life renders the acquisition of talent (techne), the seizing of alternative, the success of experiments, and the making of judgments pressing. In fact, Hippocrates had this expertise as a doctor. The accuracy of his prognoses, the effectivity of the remedy of his sufferers, the honing of his medical expertise—all of this stuff race in opposition to time. But Hippocrates is conscious that his sufferers all have the identical expertise no matter their current state of well being. They arrive to him with each the notice that life is brief and the concern that no matter symptom that prompted a go to to the physician may make it shorter.
In one other aphorism, Hippocrates offers this recommendation to his fellow physicians: “Treatment typically, deal with typically, consolation all the time.” Consolation all the time. Having rehearsed all that we have now established thus far, such recommendation ought to strike us with a recent profundity. Hippocrates prioritizes comfort even over remedy and treatment. In different phrases, a doctor ought to anticipate to offer remedy and to manage a treatment ought to the circumstances warrant it, however there would by no means be a circumstance wherein comfort is just not acceptable. Or, to place it much more concisely, the human situation as such calls for comfort insofar as it’s basically ordered towards demise. Hippocrates is adamant; a situation could be handled, illness could be cured, however there’s neither remedy nor a treatment for our mortality. Within the Prognostikon, Hippocrates defines prognosis because the means by which demise is predicted. I believe this definition is extremely attention-grabbing, truly. What I take Hippocrates to be saying is that demise is always-already implicit in any description, medical or in any other case, of the state of a human being. The medical prognosis is exclusive insofar as that implicit thanatonic dimension is correlated to the presence or absence of a sure symptom or signs.
On this level, Hippocrates sounds a bit like a Benedictine. In chapter 4 of his Rule, St. Benedict admonishes us to “preserve demise day by day earlier than our eyes.” As a normal non secular follow, that is after all sound recommendation. Memento mori. Keep in mind that you’ll die. Mirror upon your mortality. Make choices within the full consciousness that you’ll die at some point having made this or that individual determination. Once more, nice non secular recommendation. But I believe there’s extra right here than may meet the attention. For our Benedictine Hippocrates, comfort (or giving consolation) is the primary job of the doctor—“Consolation all the time.” We’re mortal, dealing with the inevitability of a sure demise, nonetheless unsure the situations of our personal respective deaths stay. The follow of Hippocratic drugs is based upon this brute reality. But, Hippocrates leads us to an attention-grabbing inference: any and each act of comfort or giving consolation to any mortal creature, human or in any other case, is always-already itself an act of consoling the dying. A easy act of kindness to a stranger, being current to a pal, soothing a fussy toddler, even giving a canine a superb scratch behind the ears, all in their very own approach mark moments of reprieve from the press of our mortal situation. Each such encounter has the potential to speak to its recipient the modest dignity of reassurance that, “Sure, you’ll die, however you’ll not have died with out having been cherished, with out having been handled kindly, with out having skilled your individual dignity that transcends the immanent body of your mortal life.” Any act of comfort is to console the dying.
But, fairly than relativizing the distinctive significance of the medical practitioner by figuring out the comfort of the dying as one thing elementary to and potential in all human interplay, the follow of medication will be seen on this mild as a elegant expression of that common human exercise. As we have now talked about, Hippocrates’s treatise on prognostication does foreground the significance of the ethical high quality of the doctor and the significance of her studied attentiveness to her affected person, however the precedence of the textual content is to show its reader how one can interpret signs and render medical assessments. What do sure inflammations point out? The pains in sure joints. Intestinal unpleasantness, to place it politely. Hippocrates even describes and classifies the totally different sorts of sweats a affected person might need, which I’ll quote primarily for comedic impact:
These sweats are the very best in all acute ailments which happen on the important days, and fully carry off the fever. These are favorable, too, which going down over the entire physique, present that the person is bearing the illness higher. However these that don’t produce this impact usually are not helpful. The worst are chilly sweats, confined to the pinnacle, face, and neck; these in an acute fever prognosticate demise, or in a milder one, a prolongation of the illness; and sweats which happen over the entire physique, with the characters of these confined to the neck, are in like method dangerous. Sweats attended with a miliary eruption, and going down concerning the neck, are dangerous; sweats within the type of drops and of vapor are good. One must know your complete character of sweats, for some are related with prostration of energy within the physique, and a few with depth of the irritation.
It’s fascinating studying, really, but it surely additionally offers an thought of how Hippocrates causes from signs to prognostications. In any case, Hippocrates sees the doctor because the one with probably the most perception into demise, exactly as a result of she is aware of its causes, its incremental actualization within the dwelling particular person, the myriad methods wherein demise negotiates with the physique by means of its advanced interplay with the immune system and medical remedies. This information is way more than a technical data, although technical data is important. The practitioner of medication maybe is aware of demise greatest as a result of she is aware of demise by acquaintance with out dying.
The Greco-Roman physician and admirer of Hippocrates, Galen, dwelling within the century after the time of Christ, additionally wrote a treatise on prognosis, however his may be very totally different. Galen’s On Prognosis is weirdly autobiographical. In it, he roughly offers an account of why he’s so good at making correct prognoses. In case you are accustomed to Galen already, you may already know that he’s his personal greatest fan. The textual content of his On Prognosis accommodates treasured little medical info, however fairly offers an account of how he turned the very best within the enterprise. He describes his upbring and schooling, his medical coaching and expertise, and on and on. As foolish as this may strike us, there’s something to it. He’s in the end explaining that the eye given to the particularity of the affected person also needs to be directed to the particularity of the doctor. Granted, it’s surmised that on this textual content, Galen is making the play to be the private doctor to Marcus Aurelius, however I believe the purpose stands. Galen offers us a way to correlate medical commentary and private reflection.
Within the Christian custom, we’d name this correlation between commentary and reflection discernment and the thing of that discernment vocation. For each Hippocrates and Galen, comfort is a elementary a part of medical follow, exactly in advantage of the truth that medical follow is part of a broader life that features particular person human beings in their very own particularity beset by all method of infirmity. This recognition of the significance of comfort is itself the results of discernment, not commentary alone. Between the time of Hippocrates and Galen, we see an attention-grabbing improvement in Greco-Roman literature, the formation of comfort right into a literary style. These literary consolations had been usually moral or in any other case philosophical treatises on how one can grieve correctly or keep away from grief altogether, fairly often commending such recommendation to grieving buddies. Cicero wrote notable consolationes, as did Seneca, Plutarch, and others. Galen did, too.
The largely Stoic context of those works was largely to dissuade individuals from grieving, to console them so they might not must grieve. Galen follows swimsuit, but with an attention-grabbing nuance. In his consolatio, which is translated as “On the Freedom from Misery” or “On the Avoidance of Grief,” Galen is responding to the cultural devastation of the lack of the Palatine libraries in Rome in AD 192, which included not solely his personal private assortment however many works in numerous states of progress; however he begins with noting the physiological results of emotional misery on those that had been in grief. In keeping with Galen, to supply comfort means at first the alleviation of dangerous, even lethal signs; he claims that considered one of his buddies truly died from his grief over the fireplace. In a short time, nonetheless, he goes on to elucidate why he skilled no such misery by detailing his personal childhood and upbringing. Galen is important of the Stoic program of philosophical impassivity within the face of tragedy as a matter of precept insofar because it overlooks one’s particularity, particularly, their psychological composition and their private historical past, and the way such issues impart an individual’s system of evaluative beliefs. In different phrases, the reply to emotional misery or grief can’t be an axiom, however fairly requires each private reflection and the psychological coaching to train these proper evaluative beliefs in occasions of disaster. Once more, it’s a matter of commentary and reflection. Typically misery is affordable. Furthermore, we should always anticipate these events, rehearse them upfront so we aren’t laid low with their shock. We must always search comfort not within the useless hope of avoiding them, however fairly in our skill to deal with respect to them, which we discern by means of cautious self-observation and self-reflection.
As we start to conclude, we should always return to our query of what we ought to owe Hippocrates—and Galen, too, I suppose. Maybe it is so simple as quoting Hippocrates himself and to commit ourselves to his maxim: consolation all the time. For individuals who deal with typically and treatment typically, as he goes on to say, comfort will imply one thing fairly particular in particular person medical follow; but for all of us, to console each other is maybe one of the crucial profound methods to boring the sting of demise, to take care of the dying at no matter stage of demise they’re. Furthermore, maybe a method wherein we’d preserve St. Benedict’s rule of conserving demise day by day earlier than our eyes is to convey others—the mortal and so dying capital-O Different—earlier than our eyes, to treat others of their constitutive mortal vulnerability as worthy of tenderness, compassion, and love.
Thus, having spent a lot time ruminating upon consoling the dying, we’re left with a closing theme: demise itself as a comfort. In a single sense, maybe a bit grim, demise is the alleviation of that situation that we name life, which as all of us properly know consists of unbelievable struggling. St. Paul within the Letter to the Romans, writes about how the legislation of sin workouts its dominion in demise, but by our demise we’re free from sin. Paul appears to take this as proof of sin’s inherent weak spot in contradistinction to the grace we obtain by means of religion in Christ Jesus which ends up in everlasting life, however I believe we’re properly inside our proper to search out some comfort additionally within the freedom from sin that may come by means of our personal deaths. In one other sense, nonetheless, we’d discover comfort in demise, in its fittingness as the top to our mortal lives. Certainly one of my favourite biblical reflections on demise, Sirach 41:1-4, speaks to this fantastically:
O demise, how bitter is the reminder of you
to at least one who lives at peace amongst his possessions,
to a person with out distractions, who’s affluent in every thing,
and who nonetheless has the vigor to get pleasure from his meals!
O demise, how welcome is your sentence
to at least one who’s in want and is failing in energy,
very outdated and distracted over every thing;
to at least one who’s opposite, and has misplaced his endurance!
Don’t worry the sentence of demise;
bear in mind your former days and the top of life;
that is the decree from the Lord for all flesh,
and how will you reject the great pleasure of the Most Excessive?
Whether or not life is for ten or 100 or a thousand years,
there isn’t a inquiry about it in Hades.
This admonishment to not worry demise is—or needs to be—consoling. I believe it’s not completely consoling, however I additionally suspect that it’s not as a result of we deal with that admonition as an axiom and never because the fruit of commentary and reflection. To be freed from the worry of demise is a matter of discernment. We should come to know and expertise our personal mortality as a present from God, not simply our life. Even the Christian hope within the resurrection doesn’t stand in demise’s approach. The hope within the resurrection does, nonetheless, converse past it, to the far shore of our mortality the place by God’s grace we could be raised with Jesus Christ, who’s the Nice Doctor, to eternal life.
EDITORIAL NOTE: This paper was initially offered on the Hippocratic Society of the College of Notre Dame, 28 April 2024.
