Learning from Hippocrates

Before we can delve into this wonderful journey of learning from Hippocrates, we must confront prejudice! Some of you may be thinking – Learning from a dead guy that was born two and a half millennia ago? He thought disease was a matter of humors! He didn’t know about germs! What can be learned? That is a good question. And I will point out two things before we continue. Firstly, if you had at all a similar reaction that followed my little script, you have belied your own ignorance as to what medicine consists of – as if knowing about germs is all it takes to make you a good doctor! But secondly, and more importantly, what can be learned from a dead guy (like over two thousand years dead!) requires us to challenge this age we live in of unprecedented chronological snobbery. That is the brilliant C.S. Lewis’ way of describing the “uncritical acceptance of the intellectual climate common to our own age and the assumption that whatever has gone out of date is on that account discredited.” In other words, because we’re so advanced today we think we are so much smarter than everyone that has lived before us. Anybody acquainted with history should have a jumpstart on avoiding this double trap of arrogance and folly. Certainly people have made mistakes in the past, and if we were in their shoes we likely would have made similar mistakes. Ironically, we have easier access to volumes of history than ever before, but it has served us little in humbling us. We must remember that great minds are great minds whether from two thousand years ago or from today. If we remember this, we can be good learners. This first blog post is dedicated precisely to that. Let’s lay down the groundwork on how to think so we can have a proper approach to Hippocrates when we come together again.

To understand Hippocrates well we must understand him in his context and not our own. This also means we need to understand how our own understanding and views are influenced by our own context. The best way to learn about this is to read some history and particularly the history of thought! Is how we think of medicine today the same way medicine was thought of fifty years ago? Five hundred years ago? Two millennia ago? While we cannot know it all, this will surely help us to read more accurately. If there is one thing we do well in our world, it is eisogesis. We import our own meanings into what others say and fail to let them speak as they intended. We chop up their words and take what we like and leave out other important parts. Sound like something you might see on TV in the news? Think again. We have done it with the Hippocratic Oath. If you went through the white coat ceremony at Schulich, you likely recited the “Hippocratic Oath.” Let’s see if you remember saying this:

I SWEAR by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation-

to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required;

to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation;

and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others.

I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.

I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art.

I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work.

Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves.

Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.

While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!*

(I reformatted the translation found at http://classics.mit.edu/Hippocrates/hippooath.html)

*It is worthwhile to comment that whether Hippocrates himself or his followers were responsible for this oath is not entirely clear. For our purposes, we’ll focus more on the content than its historical validity.

Now this is probably the first time you have actually read the full Hippocratic Oath and if not, even better! But a cursory read presents many problems to the present-day Canadian reader reared in a culture of political correctness and championed secularity (see how I pointed out some of our context and how it influences how we read?). Many of us, however, would readily be able to appreciate that our writer intended no malice with these words. We can begin to appreciate that our mindsets were not his paradigm, and this should enable us to read “coolly” without huffing and puffing at whatever we do not like. So first, let’s take a look at our own influences before tackling Hippocrates.

It is not surprising that the oath recited at the white coat ceremony is so far from this ancient oath. There are things in this original oath that modern people disagree with (although this is hardly a reason to hijack the Hippocratic Oath – either let Hippocrates speak as he spoke without twisting his words or stop calling it the Hippocratic oath!). But what is interesting to note is that these disagreements are hardly medical. Hippocrates delves little into technical medicine. The oath revolves more around how to practice medicine and to be moral physicians. We must note here a difference between moral and technical knowledge.

An important distinction between moral knowledge and technical knowledge is that the latter cannot be employed in medicine without the former. We cannot go from “this drug cures cancer” to “give this drug to those with cancer” without a moral injunction. Moral knowledge, which in this case dictates it is good to give a dying patient cancer medication to save his/her life, cannot be found purely in technical data. Some might say it is good to charge an exorbitant price for this drug to make us rich. Others might say it it is good to take a trillion dollar bribe from the man that wants all cancer patients dead instead of offering up the cure. Science does not say it is good to give the drug; it says giving the drug will remove the cancer. What the drug does is technical, but what should be done with the drug is moral, and that takes place at the patient-physician interface called practicing medicine. In other words, science can lead us to the discoveries of new technologies and medicines, but it cannot tell us what to do with what we learn. For some reason it has become popular nowadays to think science can do precisely this, but empirical evidence and theory will never take you there. Remember the humanist optimism of the 19th and 20th centuries that accompanied scientific progress? Remember how it came crashing down with the world wars and we realized technical advancement is not correlated to morality? Giving the cancer cure to dying patients requires moral injunctions.

Furthermore, what makes moral knowledge different from technical knowledge is that the latter changes but the former does not. When we say that medicine has changed over the years, we normally refer to technological and medical advancements. This change does not, however, apply to the moral practice of medicine. Of course there have been different approaches to medicine, such as paternalistic models or counseling models, but at the core what largely makes a good physician today is what made a good physician then. This is why we are able to draw from the Hippocratic Oath at all. Recognition of this distinction between moral and technical knowledge should open us up to learning from all ages about the former (this is not to say it is useless to learn technical knowledge from our predecessors – there is a different kind of merit to this, but that’s another topic!). If we consider what we now understand as massive moral atrocities of societies before us, we should recognize that we are the same biologically with the same propensity for error. We are not superior as people. This will help us learn.

So we have been primed. I will leave it to readers to mull over our approach to Hippocrates (and any history or view different from our own). Real learning actually requires us to think things over and not just amass information – especially when we are dealing with matters of virtue and wisdom, which take decades to properly foster. Sit on this methodology (or blatantly reject it and read no more) and consider your own prejudices a while as I go and consider mine! Let’s be reasonable and honest. More than likely there will be disagreements (and by all means let’s talk about them together in a civil fashion), but good learners will always have an open mind, even to things they initially find bizarre and strange (I wonder how many important things learned in history were initially thought of as bizarre and were initially ridiculed?). This is, after all, the true spirit of genuine and inquisitive science – all questions are up for grabs. Hippocrates was not without his own issues that we will explore next time, but in humility we should consider our own ways of thinking before we consider his. But now that we have established this foundation, the next post can jump into how Hippocrates frames the entire oath and the question of morality… by appealing to all the gods and goddesses!

P.S. If you just had a “Wow, Hippocrates must’ve been a whacko” moment, go back to the beginning of this post and reread everything about what I said about having a good and humble approach!