Catholic Medical Quarterly Volume 64(3) August 2014
Did a medical ethic arise spontaneously in a single civilization or were there cross-cultural communications?
Physicians’ oaths of the major human civilizations demonstrate remarkable similarities in their core values.
In summary, they all acknowledge
- a transcendent power,
- a doctor-patient covenant,
- a covenant between colleagues and students,
- the need for propriety, and
- a recognition of the sacredness of life.
Content of Physicians oaths
1) Acknowledgment of a higher power
2) Healing covenant with a sick person
3) Covenant with colleagues and students
5) Respect for life
These, in one form or another, are reflected in the core contents of all the ancient medical oaths.
One must ask the question: why the similarities? Was there communication over time between the medical thinkers of the geographically disparate cultures or are these medical values innate to the human conditions of life, illness and how mankind deals with these fundamental realities?
We will attempt to briefly review the various threads that over time have resulted in medical oaths that are so similar.
There are two threads to be followed here. The first is the similarities in medical oaths across cultures. Is there a common geographical, or temporal, origin for their core contents? The second, but related question, did Greek medicine assert more influence on Indian and Chinese medicine or did ideas flow more from east to west?
It is difficult to simplify this complex topic but let us try. The three main cultures under consideration, Greek, Indian, and Chinese flourished at a time when communication between them was difficult and these societies were self-absorbed.
There are similar core principles in the various medical codes. Are these commonalities inherent in nature, natural law, and medicine? Given the inevitability of sickness and death, all human cultures have had health care systems and physicians to diagnose and treat the sick members of these various societies. Considering the importance of medicine, with its life and death implications for society, is it surprising that medical ethical codes have developed to which the medical profession and society adhere? These oaths are often taken upon graduation from medical school and are honoured in society.
A review of medical creeds of the major civilizations; Western: Greek, Jewish, and Moslem and Eastern: Indian and Chinese, suggests that there are core aspects of these codes common in all cultures. The question arises as to whether one or other of the aforementioned cultures took the lead in articulating the various components of the medical ethic. Or did this common ethos spring spontaneously over time from the “human condition.” Did man realize that his frailty, mortality, and dependence ultimately rested on a higher power? We shall expand on these concepts.
There have been many varied scientific influences on medicine as documented in the ongoing historical records. As medicine has developed scientifically there have been profound recent (last 200 years) advances especially since the development of what we can characterize as modern medicine: anaesthesia and antisepsis. The scientific and clinical developments in medicine change constantly.
The philosophy and ethics of medicine is another story. The moral character of medicine can be seen in its ethical codes which have remained constant. We shall review two aspects of medical codes. 1) Early cultural influences on medical codes of the major cultures: Greek or Western (to include the Jewish and Moslem cultures) and Eastern: Indian and Chinese. 2) The similarities of the various medical ethical codes suggest a universal human ethic regarding physicians and their sick and suffering fellow humans.
We are familiar with the traditional doctor’s oath of Western medicine, the Hippocratic Oath. But most human societies consider medicine, and its practices, societally important and have devised other indigenous codes for their young doctors to recite when they commit themselves to the honoured practice of medicine. This is the case for Eastern as well as Western cultures.
The common elements of most codes include, as mentioned, 1) acknowledgment of the “gods,” 2) commitment to a doctor-patient healing covenant, 3) covenant with colleagues and students, 4) decorum and 5) acknowledgment of the sacredness of life.
Given this universality, the question arises as to whether there was a
direct communication between cultures or are these aspirations inherent in
the practice of medicine as it is part of the human condition?
As Toynbee described them, there were 21 major civilizations  but for our purpose we will limit ourselves to these cultures: Western (Greek, Jewish, Moslem) and Eastern (Indian and Chinese). There are several theories about how medical ethical philosophies arose and spread in human societies. While individual scholars headed East to West and vice versa in the first millennium BC, there is no body of evidence to suggest the contention that ideas from either direction, East or West, predominated over the other.
Medicine began as religious medicine practiced by the shaman of the tribe and is, as Sigerist says, “timeless.”  As medicine became experience based, those with proven clinical skills dealt with the patients’ physical illness and the shaman invoked the spirits.
Garrison has suggested an Indoeuropean semitic background originating 3500-2500 BC as the origin of fundamental medical ethical theory. These concepts, he believed, subsequently influenced 1) the Euphrates civilization, 2) Aryan India 3) Greek Mediterranean society and 4) Egypt. This would coincide with the ideas expressed in Code of Hammurabi (1750 BC) and the Ebers papayri (1550 BC). The Code of Hammurabi delineated punishment for medical errors and the Ebbers papayri (1550 BC) delved into specific medical treatments. These documents indicate that there were professional guidelines for physicians from an early date.
We shall begin with perhaps the most accepted theory of the origin of the Hippocratic Oath, and that is Edelstein’s contention that the Hippocratic oath was influenced by Pythagorean beliefs. The Pythagorians (circa 500 BC) were a Greek cult with Gnostic backgrounds, much influenced by mathematical theory, who lived strict virtuous lives and foreswore abortion and euthanasia. They had a profound respect for life. Were they the origin of “primum non nocere?” (First, do no harm). Other have suggested that the Pythagoreans were in turn, influenced by Hindu philosophers who had earlier travelled to the Mediterranean area. This contention is unsettled. India, previously Buddhist, until about 300 BC, subsequently became predominantly Hindu.
There was also communication between India and Persia (500 BC), then the site of Zoroastrian monotheistic beliefs. Chinese medicine, somewhat isolated until the Silk Route was established (400 AD- 1700 AD), was influenced by three major religions: Buddhism, Confucianism and Daoism. Garrison has noted that Chinese medicine was “authoritarian, petrified and formalistic.” China may, in turn, have been influenced by the Nestorians.
The Nestorians were an influential group that had been declared heretical in 428, expelled from Constantinople, settled in Edessa, before migrating eastward to Baghdad, where they introduced Greek philosophy and medicine. They eventually brought Christianity to China in 781. Their medicine was essentially Hippocratic.
Returning to the original question: is the commonality of medical oaths the result of direct communication between the medical communities of the various cultures or is their commonality the result of basic aspirations inherent in the human condition?
The lack of a clear cut origin of fundamental medical ethical tenets may suggest that medical principles are inherent in medicine generally and not identified with a specific time or place. The Hippocratic tradition could be a candidate. There is also evidence that Eastern ideas may have influenced the Mediterranean and even Pythagorean thought.
It appears that core medical ethical tenets 1) acknowledgment of the gods, 2) doctor-patient healing covenant, 3) covenant with the profession, 4) propriety, and 5) life is sacred, are more likely inherent in the human condition. In all societies, a competent physician treats a suffering patient.
An overview of medicine can be explained by Eliade’s explanation of the human experience in terms of the sacred and the profane. Eliade expounds on Otto’s insightful study, “The Sacred: humanities knowledge of reality beyond the material.” Men intuit the pervasive presence of the sacred (God) in their lives and existence. They also realize that much of day to day life is profane and ordinary. Medicine is analogous. Life is sacred and the physician must respect and preserve it. There is also much suffering which must be treated and alleviated.
The ethos of medicine has not really changed in the past 2500 years. A review of medical codes suggests a commonality of content items across cultures. First, there is an acknowledgment of a transcendent power, be it God or nature. They may reflect Eliades’ sacred sphere. Second, there is a covenant between a competent physician and a sick patient to engage in a healing act. Third, there is also a bond between physicians and their students. Eliade articulates, as medicine seems to as well, a reverence for life and the need to pursue and embrace it. Fourth, a professional decorum is to be maintained to protect the societal reputation of medicine. Fifth, there has always been a respect for life.
Medical oaths are among the most solemn and important proclamations men (and women) can profess. The core contents of medical oaths have similarities across human cultures. These commonalities were incorporated before there was effective communication between cultures. The most reasonable conclusion then is that these ideas arose from human nature or the human condition. The profession of medicine touches the sacred as it deals with human suffering, life, and death.
The many cultural influences on medical codes are varied and difficult to pinpoint. In general, they all acknowledge a divine power and the imperative that the physician be competent and exercise compassion for his suffering patient.
In summary, it may be impossible to sort out all of the various influences on the major physician’s oaths. There would appear to be a universal ethic (perhaps a variant of the Golden Rule) that requires medicine to respect life and alleviate human suffering.
A one on one doctor-patient relationship has been the hallmark of medicine. Whether or not, given modern communications and government medicine, this will change, remains to be seen. Let us hope and pray that it does not. The original question, was there a single geographical or historical origin for medical ethics, probably has to be answered in the negative. Medical ethics comes from a physician’s concern for his fellow suffering patients.
- Toynbee, Arnold. “A Study of History.” Oxford University Press, 1972. p. 72.
- Sigerist, Henry. A History of Medicine, Volume II. Oxford University Press. New York, 1961. p. 44.
- Garrison, Fielding (WZ 40 G292 R 1 1929) “An Introduction to the History of Medicine.” Philadelphia, 1929.
- Hammurabi. New Encyclopedia Britannica. Encyclopedia Britannica Inc. Chicago, IL. 1982. Vol. IV. p. 878.
- Ebers http://en.wikipedia.org/wiki/Ebers_Papyrus
- Edelstein, Ludwig. Ancient Medicine: Selected papers of Ludwig Edelstein. Edited by Temkins. Johns Hopkins University Press. Baltimore, 1967.
- Menon, I.A. and Hiberman, H.F. The medical students oath of ancient India. Med. 14:295-297. 1970.
- Radhakrishnan, S. Eastern Religion and Western Thoughts. Oxford University Press, London. 1940.
- Woodfield, Roderick; Woodfield, Susan; Agrien Neville. Art history on the Silk Route. Getty Conservation Institute, Los Angeles.
- Ibid. #3 p. 70.
- Nestorians. Encyclopedia Britannica. Encyclopedia Britannica Inc. Chicago, IL. 1982. Vol. VIII. p. 209.
- Unschuld, Paul. “What is Medicine: Western and Eastern Approaches to Healing.” University of California Press, 2009. p. 151.
- Eliade, Mircea. The Sacred and the Profane. Harvest Books. New York, 1959.
- Otto, Rudolph. The Idea of the Holy. London. 1923.