Providing medical assistance to patients is a deeply noble act imbued with ethics. Researcher of medical deontology P. Peiro says: “One cannot live without a moral principle that governs our actions.”
In fulfilling the duties of a physician, one must make decisions that can affect human freedom or life. They must solve problems that depend not only on their professional knowledge, but also on their beliefs and humanistic convictions. Awareness of one’s own limitations, respect for human dignity, and the ability to put oneself in the position of the patient will greatly contribute to medical assistance.
History of Medical Ethics
The history of medical ethics is the history of the ideals and values that influence medical practice. These ethical ideals were developed and codified by the most renowned physicians in each era, creating rules that those practicing medicine had to adhere to. Since the beginning of humanity, religion has intertwined with medicine. Therefore, it is not surprising that religious beliefs and principles have influenced the development of medical ethics throughout history. It is emphasized that religious ethics has a special place in medical deontology. Likewise, doctors have also discovered the medical and social application of ideals taught by philosophers and thinkers such as Pythagoreans, Stoics, and others.
Throughout historical periods and social circumstances in which humanity found itself, deontology has changed its role. Because of such instability, humans have sought to establish a permanent deontology.
This is just a fleeting look at the history of deontology and its development in the past, present, and future. We cannot accurately determine the moment when medical deontology emerged, as we encounter a continuous process that is directly related to the evolution of the human race. The development of medical deontology is primarily marked by a series of historical medical codes.
The Code of Hammurabi
In Mesopotamia, during the reign of King Ur-Nammu (2050 BC), a series of medical-legal regulations were enacted, which some authors consider the first code. The code of ethics known to mankind. This code, written in twenty-one columns, was found in Suzi. One of the reliefs shows us the Babylonian king receiving these rules from the hands of the sun god.
The Code of Hammurabi, which relied heavily on the provisions of the Code of Ur-Nammu, was the first legislative legal regulation of medicine, and it mentions medical compensation as well as the prescribed punishment in case of an error in therapy. In general, this code regulates the relationships between physicians, patients, and society.
The Council of Asclepius
Less known than the Hippocratic Oath, the Council of Asclepius, intended for medical students, presents a magnificent text about the fundamentals and motivations of the medical profession. It thoroughly examines the duties, sacrifices, and satisfactions that medical practice brings.
It is a collection of highly surpassable deontological regulations.
Do you want to be a doctor, my son? It is the aspiration of a noble soul, the yearning of a knowledge-hungry spirit. Have you thought carefully about what your… Life? You will have to give up your life.
While most of your fellow citizens can retreat after finishing their tasks, far from those who come at the wrong time, your doors will have to be always open for everyone.
If you love the truth, you will still have to keep it silent. You will have to hide the severity of some patients’ illnesses from them, and the insignificance of others, because this truth could hurt them. Don’t strive to enrich yourself with this profession. I told you: a doctor is a priest and it is not fitting for you to give importance to earning like some oil or wool merchant.
You will be alone when you’re sad, alone when you’re learning, surrounded by human selfishness.
If you consider the relief you bring to a mother, the smile of someone who no longer suffers, as a reward, then… become a doctor, my son.
Hippocrates (around 460 BC – 380 BC) – the most famous ancient Greek physician
Hippocratic Oath
The statement that “except blind forces of nature, everything that lives or dies comes from Greece,” the work The term “deontologija” can be applied to medical ethics. Greek understanding of medical practice dominated the Mediterranean in ancient times and has its roots in Minoan, Assyrian-Babylonian, and Egyptian civilizations.
As W. Jaeger wrote in his Paideia, the 6th and 5th centuries BC represent an exceptional moment in history from the perspective of ethics and social application of medicine. A physician of the Hippocratic tradition treats based on certain ethical principles grounded in their love for science and humanity. Where there is love for humanity, there is also love for science. (Propisi, 6).
The most obvious texts with ethical content are the Oath, Propisi, On the Physician, and On Integrity.
From Constantinople in the 10th century (when Byzantine humanism was at its peak) to Venice in the 14th century (the first printed edition of the text), from the Quod jusicurandum bull of Pope Clement VII in 1531 to the World Medical Association (1948), the Oath is the most famous text of the Corpus Hippocraticum. All deontological norms that … The principles that are present in this text have a common foundation and purpose: to help the patient and protect their personal integrity. On the other hand, the fact that these principles were prescribed in general norms reflects an inherent element of ancient medicine: the belief that the doctor and patient are equally important beings, that their relationship is crucial for the practice of medicine, and that the well-being of the patient is of utmost importance.
The principle of “acting for the benefit, not to harm” clearly expresses the philosophy of Hippocratic medicine, which seeks to restore health through its skills. This professional attitude and fundamental ethics can be found in physicians with a Hippocratic orientation.
Instructions for acquiring virtues such as purity, dedication, and justice express the entire ethics of a physician’s life. This concept does not allow for the paradoxical existence of dual moralities, one private and one professional, because as the text says: “my life is my art.”
In the work “On Dignity,” we return to the question of the ideal image of a physician. Although they are obtained However, the fee for treatment and education, doctors insisted on suppressing the desire for possession and profit, according to the ethics of Hippocrates.
Unfortunately, today we can only state that a large part of Hippocrates’ teachings exist only theoretically.
Asaph’s deontological sermon
Asaph Ben Berachiach (6th century), a Jewish disciple of Hippocrates, valued his moral oath. His code was widely accepted in medical schools in Alexandria and Palestine. Asaph considered medicine a priestly and religious calling. He founded a school that only those who met certain criteria, among which moral order was the most important, could attend. His Oath is very similar to Hippocrates’.
Medieval Codes
With the fall of the Roman Empire, medicine split into two branches: Arabic as a cultural and scientific phenomenon, and the one practiced in medieval times. The Benedictine and Franciscan monasteries were the first medical institutions. These two branches would merge five centuries later in Salerno. There, medicine would undergo restructuring in terms of knowledge and teaching methods, as well as the behavior of physicians in their profession.
During the Middle Ages, the ethics of the medical profession merged with Christian, Jewish, and Muslim traditions. The deontological codes of Lafranc and Arnaldus de Villanova illustrate the influence of Christianity on Western medieval medical ethics. Religious norms and Christian moral sentiments oblige physicians to provide free assistance to the poor, to which they had to swear an oath.
In the Islamic world, in addition to its influence on social and economic organization and the inclination towards specialized knowledge, religious life and the regulations of the Quran constituted the foundation of ethical principles.
Muhammad said, “Of all sciences, theology is the first, the guardian of the soul, and medicine is the second, the guardian of the body.”
Abu Bakr Muhammad ibn Zakariya al-Razi (around 865 AD – around 925 AD) – renowned Persian physician.
Harun al Rashid, who is most deserving of the opening of hospitals, ordered that hospitals and care centers be built next to every new mosque, as such merciful treatment of patients is prescribed in the Quran. These orders and the adaptation of Hippocrates’ oath to the Islamic faith have made Arab physicians apply a more demanding ethic.
Maimonides’ (Moshe ben Maimon Rambam) Physician’s Prayer, edited in the late Middle Ages, is a prayer in which the physician seeks inspiration to fulfill their duty in a dignified and proper manner.
One of the first works of medical ethics in the Arab world is the work of Ishag Ibn Ali al Ruhawi, called Practical Ethics of the Physician (Adab al Tabib). The work strives to find a way of medical practice that would transcend the conflict between the philosophical ideals of the Greeks and the Islamic prophets.
Isaac Israeli, a contemporary of al Ruhawi, practiced as a physician in Egypt and Tunisia. His works were translated into many languages and were used by physicians in the Middle Ages.
From the 15th to the 18th century
Incipit vita nova2
The Renaissance brought about a rebirth of classical Greek and Roman culture, as well as an attempt by human thought to transcend the limitations imposed by the church and state, with the aim of enabling experimentation, observation, and unbiased conclusions.
Despite the fact that in 1750 there was still a rule that “a physician had to be a Christian”, “and what young Parisian doctors were collectively taking an oath to defend the Catholic faith in Notre Dame Cathedral, from the 15th to the 18th century, a slow but increasingly evident secularization can be observed, as well as a transition towards philanthropic morality. This phenomenon, combined with the growing power of civil authority and the transformation of social life, enables the development of legal medicine and medical rights, which will reach its peak in the 19th century.
At the beginning of the 19th century, Percival’s code appeared, which represents the first code of the modern era in the history of medical deontology.
The separation of religious and civic duties, initially slow, becomes evident and decisive in the 18th and 19th centuries. From that moment, two forms of ethical behavior emerge within medical practice: religious doctors and secular doctors. The latter, through their efforts to provide a rational foundation for medical ethics, gradually displaces religious medicine.
In 1803, Thomas Percival publishes his
Medical Code.” ethics. It explains in a simple way how a doctor must behave towards his colleagues and how certain principles can enhance the idea of serving the patient and society. Truly, this code is a practical guide for solving problems and concrete situations, those in the field of hospital treatment, but also private; it includes legal provisions and defines relations with pharmacists. The American Medical Association’s Code of Ethics (1847) was largely inspired by it.
20th century
In the 20th century, there will be a technological and scientific progress with some problems and situations that, ethically speaking, grow into many extremely difficult dilemmas that have shaken medical deontology, poor in philosophical and moral foundations.
Scientific and technological progress highlights the need for some clear ethical norms about what is right and what is wrong, about the limits of our freedom of action. This need is more prominent when, as it is now, science and technology are developing faster than legislation. The enforcement of the appropriate legal provisions is crucial. Ethics, which has been pushed to the back due to the irresistible impulse of technology over time, is now more necessary than ever.
Today, some believe that the Hippocratic Oath is no longer relevant, although it is difficult to improve or replace it. The World Health Organization adopted the Geneva Declaration in 1948, which translated the Greek oath into modern language, and in 1949, the Third Assembly of the World Medical Association adopted the International Code of Medical Ethics, divided into three parts: the mutual duties of physicians, the general duties of physicians, and the duties of physicians towards patients.
The problem of questionable ethics
Percival’s medical principles can solve some ethical problems of our time, but they are undoubtedly insufficient given the speed of scientific progress. The avalanche of circumstances and ethical dilemmas arising from research in the last decades has caught legislation off guard. Here are a few examples: “The secret of medical language and spreading of information, conducting hypnosis and sophrology therapy, voluntary termination of pregnancy or right to life, clinical research, incorrect therapy, ethics and the pharmaceutical industry, poor practice and negligence, strikes of doctors and unionism, ethics in wartime, ethics of professional formation, artificial insemination, euthanasia, informatics and deontology, professional development, organ and sperm banks, prenatal adoption, gender reassignment, advances in genetics or identifying a group of people with special traits, use of pharmacological products that can alter human behavior, eugenics, production of microbes… ”
“Instead of solving global problems, scientific ambitions seem to be busy creating new ones,” says Duellwe. Recent research has overwhelmed the slow and sluggish legislative machinery to such an extent that there are no laws that could encompass them all. “Is science slipping out of our hands?” H. Commoner wonders. Man finds himself in a dangerous situation. ich: Like Prometheus, he found heavenly fire and that fire can do him a lot of good, but it can also destroy him.
Van Deusselaer talks to us about “dangerous knowledge” and defines it as “knowledge that accumulates much faster than the wisdom that could use it beneficially.”
We have reached a point where it seems difficult to assess whether scientific and technological development is good or bad. The gap between scientific power and the principles that enable its prudent application is becoming more pronounced.
Religions and philosophies guided by ethical consciousness lead us to the question of whether the existence of universal or natural medical ethics is possible. It would be a deontology that would respect human nature, accepted by all people of goodwill and applicable in all historical and social circumstances.
Whatever the area of the doctor’s action, his goal will always be the same: to help the patient. The principles of medical ethics will continue to serve us as a guide to determine what is ethically correct and what is not in various situations. This is best for the patient, the doctor themselves, and their profession. (Dwight C. Wilbur, American Medical Society)
So, is it necessary to have permanent standards related to the dignity of doctors, an expression of eternal ethics, far beyond social-historical circumstances?
Medicine is more than just the combination of knowledge and action. Medicine is science, it is economy and politics, it is art in the sense of Hippocrates, it is ethics and religion: four driving forces that propel it and give it authentic value. Therefore, deontology must unite these elements to become a timeless value.
1 Deontology – the study of the correctness and duty of various professions.
2 “A new life begins,” translation note.
3 The science of methods for improving individuals’ physical and mental characteristics.