Book Review

Medicine, Society, and Faith in the Ancient and Medieval Worlds

N Engl J Med 1997; 336:883-884March 20, 1997

Article

Medicine, Society, and Faith in the Ancient and Medieval Worlds
By Darrel W. Amundsen. 391 pp. Baltimore, Johns Hopkins University Press, 1996. $39.95. ISBN: 0-8018-5109-2

The debate about assisted suicide arouses such passion on both sides that it is difficult to know what the argument is really about. Some believe that it is wrong for physicians to participate actively in the deaths of their patients, no matter what the degree of the patient's suffering or whether the patient requests assistance. In this view, the classic duty of physicians is to prolong life, so that assisting in the death of a patient contravenes the traditions of the profession. On the other side, it is argued that the physician's duty to relieve suffering reaches back to antiquity and overrides other considerations and that in the modern world, the suffering of some patients has reached degrees not previously known. In addition, some say, assisted suicide has been a fact of physicians' lives from the beginning. How are such arguments to be resolved? We often have disagreements about the care of patients, but good clinicians look to the literature to resolve their differences. And in one of the most important medical advances of our time, the quality of the evidence that can be brought to bear on clinical disputes has become, for the most part, excellent. What evidence will convince the disputants here? Perhaps there is nothing that can resolve deep moral differences.

Many of us know, however, that the continued success of our pluralist society rests on understanding conflicting beliefs and finding a way for them to coexist. Where do we, the majority, go to find the evidence that will help us through a dispute? History. Darrel Amundsen's wonderful book is an example of the kind of historical resource that can be used to understand how certain ideas that today are extremely influential got their start. Let me make it clear that just as good science rests on painstaking investigation, Amundsen's historical evidence comes from meticulous scholarship that is often a joy to read. His interpretations of the original medieval and ancient documents are convincing precisely because he is so obviously careful, even picky at times. Even those of us who are not historians know the danger of choosing only the historical evidence that will support the author's presuppositions. R.G. Collingwood, a British philosopher of this century and a historian of antiquity, wrote that one could not really make sense of historical writings unless one knew both the intended audience and what questions the author was trying to answer. Amundsen is extremely helpful in telling us not only, for example, what Augustine had to say about suicide but also whom he was addressing and why. This is extremely important when it becomes clear that in their current form, Catholic prohibitions against suicide, and assisting the suicide of others, go back to the writings of Augustine in the fourth and fifth centuries and even some of the earliest patristic authors.

Amundsen's discussion of the origins of the belief in the physician's obligation to prolong life is also interesting, because he attempts to situate his reader in the era under discussion as an antidote to the tendency to idealize the past — particularly the time of the Hippocratic writings — in the service of the present. For example, he points out that the oft-quoted (by me, among many others), lofty statement from the Hippocratic Corpus, “Where there is love of man, there is also love of the art,” appears in the context of a discussion about fees. If historical evidence is to be useful in the resolution of modern dilemmas, then the issues have to be carefully spelled out. Amundsen is helpful here also, because he is a clear thinker. He opens his chapter on the duty to prolong life by asking what we mean by that phrase. He speculates that

a physician in classical antiquity . . . might reasonably ask whether, by prolonging life, we mean increasing longevity generally; preserving health by prophylaxis; combating curable diseases and injuries; temporarily prolonging the unhealthy life of a terminally ill patient; or refusing to assist in terminating the life of any man with or without his consent, whether healthy or ill, and if ill, whether with a painful but curable or an incurable ailment.

And what do we mean by life? And by duty: “Duty to whom: to the patient, even against the patient's wishes? to the medical art or profession? to public opinion, to the state, to religion? to his own conscience, simply as a man, or as a physician?” In the same chapter, Amundsen casts doubt on the origins of the Hippocratic Oath, saying, “Few (if any) scholars today hold that the Oath that bears his name was written by the historically elusive `father of medicine.' ”

Interesting chapters deal with issues ranging from the attitudes of the early church toward medical practice (which were generally but not universally favorable) to canon law and medical practice by the clergy, with absorbing discussions that make it clear that some ethical problems in medicine have remained virtually unchanged over the millennia. Amundsen's final chapter, “The Moral Stance of the Earliest Syphilographers,” has obvious application to AIDS. He quotes Thomas Sydenham's reply, in 1673, to those who believed that syphilis should not be treated, in order to frighten the unchaste or punish the afflicted:

If we reject all cases of affliction which the improvidence of human beings has brought upon themselves, there will be but little room left for the exercise of mutual love and charity. God alone punishes. We, as we best can, must relieve. Neither must we be too curious in respect to causes and motives, nor too vexatious in our censorship. Hence I will state what I have observed and tried in the disease in question; and that not with the view of making men's minds more immoral, but for the sake of making their bodies sounder. This is the business of the physician.

Henri Bergson said, “The present contains nothing more than the past, and what is found in the effect, is already in the cause.” Perhaps nothing demonstrates Bergson's insight more than medical science, in which every advance is dependent on previous research. Yet this scientific era of medicine has been curiously ahistorical, as though the past began a decade or so ago. To what is that past a prologue? A medicine that has only faint memories of its great physicians and their achievements and shallow roots in its long traditions. No surprise, then, that it is also a medicine in which physicians' acts and physicians themselves, divorced from their traditions, have come to be viewed as interchangeable commodities in the marketplace — each the same as all the others, with experience disvalued. It would be simplistic to say that books like this one provide a solution to our difficulties, but medicine's history is a vital part of its present that should remain in front of our eyes. Darrel Amundsen's book is a valuable witness to that fact.

Eric J. Cassell, M.D.
Cornell University Medical College, New York, NY 10028

Citing Articles (1)

Citing Articles

1. 1

   Ira Byock. (1998) Hospice and Palliative Care: A Parting of Ways or a Path to the Future?. Journal of Palliative Medicine 1:2, 165-176
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