A refresher of our approach – humility and an open mind. Don’t reject it because it is bizarre – this is poor scientific thinking and lacks inquisition. Germ theory turned out to be right after all! Don’t jump onto it because it is new – this is foolhardy. Just because aseptic surgery has been developed don’t go cutting everything out of the abdomen! Both are dangers. And remember to keep our chronological snobbery in check. They were not idiots “back then.” Not all epilepsy was attributed to the demonic. Just take a look at what Matthew wrote in his Gospel close to two thousand years ago about distinguishing between those oppressed by demons and those who were epileptics (Mt 4:24)! If you thought that was what they thought back then, it may be a good indicator that you’re actually the ignorant one! Let’s always be willing to learn.
Now let us continue to set up the groundwork for learning from Hippocrates. We need to recognize our own worldviews and how they inform how we understand practicing good or bad medicine. How we understand moral knowledge is informed ultimately by our worldview. Our worldviews inform four fundamental questions: What is my origin? What is the meaning of my life? How should I live my life? What is my destiny? Whether you believe in God or gods or nobody or do not know, whether there is life after death, whether there exists truth or not, and so on, will inform your answers to these fundamental questions. How you understand morality (or the third question) then is also influenced by worldview. For the sake of learning from Hippocrates, we will focus on the morality issues.
Some readers might now be shaking their heads and saying, “Oh but morality is totally subjective! It is relative!” If you hold this view, you must recognize that this is actually one of the views prevalent amongst people in our day and was not popular in the past. Moral relativism has many faces, but broadly speaking it is an untenable position in reality. Sure it may sound interesting and humble in theory (apart from the incoherent declaration that it absolutely says all things are relative and says it is right about that), but it brings problem into the practice of medicine. If there is no set standard by which physicians should practice, how can we be “good” physicians apart from just feeling like we are? Where is our moral standard coming from? There are a few popular answers to this question in our day, and I will very briefly address three of the common ones with critiques that philosophers and scientists have offered. I will focus specifically on morally relativistic views because these are the furthest from Hippocrates and his worldview. These are not intended to cause you to abandon your viewpoint but to force you to think critically and rationally. In line with all we have discussed, any viewpoint, including absolutist viewpoints (e.g. Kant’s categorical imperative, natural laws, divine precepts), will have critiques, and good thinkers must be able to appreciate critiques and re-evaluate accordingly. Ultimately this will help us connect with Hippocrates’ understanding of morality.
The first position holds that morals are socially conditioned; it is our cultural structure that we agree upon that determines what is right or wrong. When we consider the law and democracy, most of us can agree to this to some degree. One major difficulty with this position, however, is presented by societies that have committed atrocities. Is what is right or wrong just a matter of what people agree on? Or what most people “vote” is correct? Nazi Germany often serves as the litmus test for this position. If social conditioning is where morality comes from, Nazi Germany must be understood as being right for that culture and it would not be our place to tell them otherwise. Similarly, any society that accepted to mutilate, sexually abuse, and then kill babies would be “moral” if this was the cultural milieu. This probably doesn’t jive too well with us innately. So while there certainly is an element of culture to what we see as right or wrong, many argue social conditioning cannot be our ultimate arbiter of right and wrong.
The second position appeals to a form of evolved morality. We have evolved with moral capacities because it has helped us survive as a species over the ages. This too sounds tenable initially but historically many issues have been raised with this train of thought. If morality is evolved, it means it is an arbitrary product of chance (just like we could have evolved with three arms instead of two – neither is “right” or “wrong”). The naturalist mindset renders everything meaningless because everything is a matter of chemicals mixed a certain way. They are fascinating accidents, but they are still just chance occurrences. To say that one way of thinking is right or wrong would be like saying that the way one pop can fizzes versus another is right or wrong. Additionally, the nature of this morality must be consistent with natural selection, but this has difficulties as well. If morality is only about reaping returns and passing on genes, a simple situation should challenge us. We would expect that we should never help an unrelated, dying lady with no money and nobody around to see our good deed if she needed someone to help her cross the street. After all, why expend our resources for someone that will never increase the chances I will pass on my genes? Yet this is an act we praise. Finally, Darwin chillingly noted in The Descent of Man that if natural selection is the true driver behind morality, “the civilized races of man will almost certainly exterminate and replace throughout the world the savage races.” This racist and eugenic mindset was the driving force of Nazi Germany, but if they were simply acting consistently with natural selection, we could not call their actions “wrong.” I have designated this a relativist position because it has difficulty calling things truly right or wrong. Many people in medicine will likely espouse this view and will be surprised to learn that there are atheistic/agnostic (unlike dear Hippocrates) scientists and philosophers that do not hold this view. David Berlinski and the late David Stove are two well-known names critiquing this position.
Finally, a third position suggests that morality is purely subjective and depends on the self alone. Personally I think this is the least tenable of the positions (the most relative). If morality is subjective, then your position doesn’t matter anyway because anybody can disagree and feel him/herself to be right! Nobody is right. Either that or tell me it is still subjective and valid after someone slaps you in the face ten times and says they just feel like it is the right thing to do.
Each of the positions above has been very briefly critiqued – and I leave it to you to think them over (by all means contact me if you find Berlinski’s writing unconvincing!). So what then of Hippocrates? What was his conception of morality? While much critique of his thought can be offered, we will first focus on his foundations. We must remember that Hippocrates frames the entire oath and the question of morality by appealing to all the gods and goddesses of his day! His appeal was to the transcendent. This is foreign to many people today, but the rationale of it must be carefully considered for its implications on morality. Hippocrates began his oath by making himself accountable to transcendent beings. These were not only colleagues that had no real authority over him or a society that could grow corrupt. These were divine beings with a higher level of authority and power to judge him for his actions. This does not appeal to us today but we must think from Hippocrates’ perspective. If there were people who believed in gods that would judge you for every morally wrong action in medical practice versus people who believed there was no punishment for wrongdoing, who would you trust to do the right thing more? As the famous philosopher-theologian Jonathan Edwards says of the judgment, reality, and certainty of divine things, “those who are convinced of the certain truth of these things will be governed by them in their practice.” While not entirely the equivalent, we could think of the law as functioning in a similar manner – there are punishments to those who act outside of what is determined to be right or wrong.
Hence we see two major factors in Hippocrates’ understanding of morality based in his polytheism. Firstly, it provided for a foundation to morality that was beyond human opinion because the gods determined what was right or wrong, and hence it was something that everyone would be subject to. Secondly, these gods would then have the ability to judge those who acted in a manner inconsistent with that morality, so there were actual consequences to acting outside of this morality.
Regardless of whether you believe in a plurality of gods or not, it becomes apparent that such a belief had significant impact on what you believed was right or wrong and whether or not you lived consistently with that. Some make this the distinction between ethics and morality, the latter being the practical branch of the former. This distinction is helpful insofar as it is recognized that simply holding a belief of what is right or wrong does not guarantee actions consistent with that belief. In other words, being a formal ethicist does not necessarily correlate with a moral lifestyle.
For those interested, however, it is worth noting that etymologically the two words derive from words conveying the same ideas in different languages. ‘Morals’ comes from the Latin term moralis while ‘ethics’ derives from the Greek equivalent ethikos, both of which were drawn from root terms referring to manners and customs. The former was translated from the latter by Cicero. Hence our current distinction is more of an ideological development than it is a definite, literal one.
Random trivia aside, we see that we have begun to see the worldview of Hippocrates and how it informs how the oath is written. We have also begun to consider our own worldviews and concerns raised against them. Next time we will continue with Hippocrates’ framework and the significance behind the very idea of an oath.
 This is a wide topic, but one final note is worthwhile. A difficulty of purely evolutionary morality is its implications on the deliberation process itself. Thoughts would be accidental products themselves, and we would be using these accidents to make sense of the world of accidents. As C.S. Lewis says, “I see no reason for believing that one accident should be able to give me a correct account of all the other accidents. It’s like expecting that the accidental shape taken by the splash when you upset a milk jug should give you a correct account of how the jug was made and why it was upset.”
 From an abridged version of Religious Affections in 1984, edited by Dr. James Houston.
 This assumes the law addresses every moral conundrum and is itself moral. It is not uncommon, however, that the laws of a land actually appeal to the divine as the standard by which practical laws are then made.