AMA Journal of Ethics^®

...I will use my power to help the sick...Hippocratic Oath

There is a standard technique in the study of moral reasoning that makes use of stories and asks for judgments as to whether or not the actions depicted are right or wrong in the moral sense. In one such story, a gravely ill woman can be saved only by a medicine that costs more than her husband can afford. The pharmacist refuses to provide the medicine unless it’s paid for in advance and in full. After the pharmacy has closed, the woman’s husband breaks in, steals the medicine and administers it to his wife, whose life is saved. In some respects, this story is paradigmatic of the long history of medical practice. It is a history that includes noble purposes, the constraints of law, the physician’s own personal needs, and the values of that larger society whose judgments are often dispositive.

Economic considerations have long been an integral part of the practice of medicine. In 283 BC, impelled by a mixture of superstition and science, the authorities of ancient Rome looked to medicine as a defense against the plague. Guided by prophecy, they brought the fabled serpent of Aesculapius to Rome as part of the establishment of a center for treatment. Victims of the plague were cared for in an Aesculapiumthat occupied most of the Tiber Island. Projects of this sort depend on the growing confidence of the community in the power and promise of medical therapy, as well as on a degree of wealth that permits the construction of such facilities. Who paid for all of this? In Rome, responsibility was borne by the head of the family. The best doctors in what we would call private practice were Greek, and it is clear from contemporary writing that their fees were very high indeed. But the Aesculapium was a public facility whose treatments were extended freely to those in need. Private contributions supported much of the venture, with the treasury of the Roman Republic financing a balance.

Romans were serious about good health. If they looked to Greece it was because of its advanced state of medical training. We learn of the famous Greek surgeon Archagathus in the third century BC who was quickly granted citizenship, comfortable housing, and an office to establish his practice in Rome. Supporting such celebrated specialists were cadres of apprentice-residents, nurses, pharmacists, and the occasional woman doctor, along with midwives, valets, and slaves. We see, then, that a population at once rich and health-conscious will attract specialists and create facilities not unlike what we find in today’s developed nations.

The gifted physicians of antiquity, however, were celebrities. They were not only treated honorably, but were expected to abide by that aspect of the Hippocratic oath that calls upon the physician to be exemplary in all respects. In other words, the economics of the situation never reduced doctors to the status of employees. The physician’s duty was to heal and do no harm. The poor would be charged next to nothing, while the rich would find themselves reluctant patrons. The doctors of highest repute were extremely wealthy. Suits for malpractice were rare and seldom successful. The doctor faced a greater legal liability for assessing excessive fees for failing to heal or making a bad situation worse. At the risk of a misleading simplification, this picture from the ancient Roman record is surprisingly close to what some of us recall of the 1950s.

A radically different picture emerges in the early medieval period. Sickness at that time was often judged to be a punishment and evidence of evil. Superstition overcame the prevailing “science,” and medicine took on the character of a cult. Ancient medical education in the West had been largely Hippocratic, emphasizing pragmatic standards. Theory was not absent, but it invariably yielded to observation and clinical experience. Medieval medicine in the West reversed this. Only much later, with systematic and refined approaches to medical education, was there at least a partial recovery of the ancient tradition. Central to these developments was the medical school at Salerno, founded in the 11th century. Only graduates of this program were permitted to practice in the court of the holy Roman Emperor; royalty had chosen science over superstition.

Something of a slander is committed by Boccaccio in his introduction to the Decameron. He charges the doctors of Florence with running away from those suffering from the plague lest they compromise their own health. He laments their indifference to suffering. The horrors of the Black Death, he says, should excite the human virtue of compassion. As a matter of fact, the Florentine physicians, as best as we can tell, performed admirably in the face of the truly overwhelming catastrophe. I mention Boccaccio not to discredit his account but to record the fact that doctors were held to a very high ethical standard. Their own lives should be of lesser concern to them than the lives of those who need them.

There is a very important historical document by Paolo Zacchias who was physician to the Pope. The work, Quaestiones medico-legales, is a compendium of the relationship between law and medicine, with a particular focus on public health. His inquiry stretches from ancient writings to his own era in the 17th century. A significant part of the treatise deals with the fees paid to doctors and expected by them. Given the moral and spiritual rewards of medical practice, Zacchias asks the otherwise unthinkable question, should fees be assessed at all? He offers the example of Hippocrates’ refusing to accept pay on the grounds that it would make him a slave to his paymaster. Moreover, the noble physician is not a mere craftsman who bargains with an employer—one does not barter with a dying man.

Read in a certain light, Zacchias provides at least the intimation of the concept of a right to treatment. It is a right that arises from the physician’s duty, rather than something possessed inherently by those who are ill. In other words, it is not a matter of others having a claim on the doctor, it is that the profession of medicine itself imposes special obligations.

This article is painted with a broad brush. I’ve touched upon four historical periods, each more complex than a brief characterization can honor. The ancient world, the early and later medieval epoch, and the Renaissance bring to light practices that are coextensive with the idea of the doctor. Every age regards what it takes to be medical knowledge as integral to life itself. It is not just another kind of knowledge, but one able to relieve suffering and forestall death. Those who possess this knowledge are prized, but much is expected of them. No matter how great their wealth or celebrity, it is the life of the patient that must matter most to them. At the risk of being controversial, I should say that the notion of physician-assisted suicide, not to mention withholding treatment solely on the grounds of old age, cannot be reconciled with the idea of doctoring throughout its long history.

Every age has faced the problem we refer to as the high cost of medicine. Unlike those in earlier ages, we do not face the Black Death. We know the difference between science and superstition. We know the structure of life in its most minute details. We have the example of cultivated people allowing their leaders to treat life as expendable. In all, then, we should be able to create or re-create a therapeutic ethos that liberates the profession to perform that mission for which the office was created in the first instance. If we make our doctors the hourly employees of the state, we surely cannot expect them to behave as saints and heroes. And if we expect saintly and heroic conduct, we must be prepared to accord them the highest respect, the deepest admiration, and, yes, the right to a rich life during the few hours that can be spared. Medicine is not a wheel that needs to be reinvented. We know a good physician when we see one.