Archive | Learning from Hippocrates

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Physician Character and Integrity

Posted on 16 August 2015 by Lester Liao (Meds 2016)

Our last post discussed the significance of the oath in Hippocratic medicine and the importance of governing deities to ensure its terms were held.  While colleges serve a similar role in today’s world, the question remains: what if physicians can get away with things without the college noticing? This is where the content of the Hippocratic Oath begins to reveal much of the physician’s character.

Theoretically, in today’s society, if the college does not know you are somehow doing something unlawful and patients never complain, you can get away with anything.  This differs from the Hippocratic worldview that believed in gods that would certainly know what you were up to.  Embedded in the oath was a sentence of punishment for failing to uphold the oath.  Today this punishment may be losing the right to practice medicine.  Yet the college is not omniscient, and doctors today can certainly get away with small, “under-the-radar” practices that could relate to increasing financial gain, poor treatment of patients, and so on.  How is this to be prevented?  Hippocrates, on top polytheism, believed the solution was character.

As mentioned in previous posts, the Oath highlights a serious devotion to medicine and practicing it a certain way.  This assumes already that there is character compatibility between the practice of medicine and the person.   What is less obvious, however, is that this character is to be pervasive.  It is not what we would call “professionalism.”  Physicians were not to act all proper with patients but then to engage in all sorts of shenanigans on their own time.  Physicians were to be proper all the time.  Consider that the physician was to be “pure and holy both [in] my life and my art.”  This was hardly what we call professionalism.  This was integrity.  A physician was always to be a certain kind of person, never fragmented by circumstance or setting.  Regardless of surveillance, monetary gain, personal reputation, or simple convenience, physicians with integrity would act the same way.

The Oath further offers a practical example of how this integrity is supposed to manifest.  Regardless of whether the physician heard something inside or outside of the medical setting, he or she was never to divulge “what should not be published abroad.”  This was an early sort of confidentiality, but it was a confidentiality that developed not as an external restraint but as an internal disposition.  In today’s setting, if a physician is a terrible gossip but maintains patient confidentiality, there are no issues.  The Hippocratic worldview, however, did not hold such a disjointed view of the person.  The activity of the physicians developed from their fundamental characters.

When we consider today how to expect physicians to practice ethically, there are two things we can consider.  First we can ask if the person believes that there are true and real consequences to all his or her actions (even if they can somehow eschew human authorities).  Secondly we can ask what the physician is like as a person.  Surely it comes more naturally to a righteous person to act righteously in the professional and personal settings than for an unrighteous person to act righteously in the professional setting (presumably due to external rules and regulations) while acting unrighteously in all other domains.

We would do well today to learn this lesson from Hippocrates.  The human is a cohesive being that cannot arbitrarily be split into two personalities.  For all actions stem from a person’s heart or core.  Certainly we still have high aspirations and character qualities we laud in theory, but to the average patient seeing a community physician with little surveillance, integrity could be all the difference.   Perhaps recognizing the importance of a high devotion to medicine paired with personal integrity would change the way medicine is practiced today.

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Why the Oath?

Posted on 17 May 2015 by Lester Liao (Meds 2016)

Last time we highlighted that Hippocrates framed his entire oath with the gods as his witnesses.  This provided for him an inherent accountability in the profession of medicine, as wrongdoing could be punished by the gods.  The question remains, however, why an oath?

The Greek term for oath, horkos, is derived from the term for a bound or a limit.  This is telling because it was implied in an oath that what was said in the oath would bind a person and limit him/her from going beyond what was said.  This makes sense to us when we think about it a little.  Today we are unlikely to make oaths (since it sounds too intense) and instead we make promises.  They function in a similar way in that they set out actions to be done and not to be done.  For example, if I were to say, “I promise to eat my vegetables and not to eat my dessert first,” I am setting out actions to do and actions not to do.  I am bound by these words in this promise.

They differ, however, in that promises tend to be made between people and there is no accountability outside of this.  If I eat my dessert first, there are unlikely to be any serious consequences.  We have already seen, however, that Hippocrates frames the oath with the gods as his witnesses.  As he understands, breaking this oath will bring judgment.  He is bound to do no harm, he cannot go beyond this.  Furthermore, Hippocrates stipulates conditions that oath-takers must submit to if they break the oath, namely they must submit to having the opposite of the oath’s blessings – disrepute and no enjoyment of life.  While most people taking the heavily altered Hippocratic Oath today hardly think of the consequences of breaking the oath, for Hippocrates this was of utmost importance.

That this oath was taken with such seriousness is suggested by Scribonius Largus, who was likely a military physician at some point in his lifetime.  He treated the Hippocratic Oath with the same reverence as the sacramentum of the Roman soldier, the oath to defend the emperor and empire even to the cost of life.  What sorts of oaths are taken today with such seriousness?

The oath is significant because it means that medicine was not something to be entered into lightly.  Medicine was for the finest, for the most dedicated people with fine integrity.  It was not for a random group of people, some deciding medicine was a good means to make money and others deciding it could be a cushy job.  Medicine was a serious matter, and because of the oath every person that entered into medicine was to be held to a higher standard.  While we often say this about medicine today, we do not realize the seriousness of medicine that existed in a prior era.  This is certainly a challenge from Hippocrates to us worthy of contemplation.

Are we so committed to medicine that we would put our reputations on the line and live in such a way that is open to the scrutiny of the highest authorities? Some might suggest that the government or colleges serve a similar role.  I would agree with this but with some additional thoughts.  While colleges can punish negative behaviour, what incentive is there to do positive work instead of just “getting by” without being noticed by regulatory bodies?  Or what if someone found a way to play the system without being reprimanded?  These are questions we will examine in our next post with Hippocrates and the oath.

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His Basis For Morality

Posted on 02 January 2015 by Lester Liao (Meds 2016)

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.[1]  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.”[2]  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.[3]

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.

[1] 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.”

[2] From an abridged version of Religious Affections in 1984, edited by Dr. James Houston.

[3] 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.

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Learning from Hippocrates

Posted on 23 November 2014 by Lester Liao (Meds 2016)

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!

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