Ethics Codes in Medicine

Foundations and Achievements of Codification Since 1947

Ulrich Tröhler, Stella Reiter-Theil, Eckhard Herych

• Publisher: Taylor & Francis
• Year: 2019
• Print ISBN: 9781138334823
• eBook ISBN: 9780429814310
• Edition: 1
• Topic: Philosophy
• Subtopic: Medical Theory, Practice & Reference

First published in 1998, this volume considers the Nuremberg Code in light of new ethical grey areas which have become evident due to recent scientific advancements, particularly the questions of DNA and cloning. The contributors reflect in 26 articles on the impact of the Code, events which prompted it including Japan, and more recent ethical issues raised. The book contains the results of two European/American preparatory workshops for the First World Conference on Ethics Codes in Medicine and Biotechnology (October 1997 Freiburg, Germany) supported by the leading national institutions in the field. It aims to stimulate research about codes, the effects of codification and other forms of implementing ethics. It breaks new ground with interdisciplinary and international discourse on the subject, emphasising the need for a complete collection of codes for systematic research and evaluation and filling the gap in literature on the subject to date.

Ethics Codes in Medicine: Historical, Legal and Philosophical Aspects

1

The Invention of Hippocrates: Oath, Letters and Hippocratic Corpus

Karl-Heinz Leven

In 1948, the World Medical Association, which had been founded two years before in London, was given an ethical code¹ called the “Declaration of Geneva”, which was formulated in both English and French. Its subtitle in French, “Serment d’Hippocrate, formule de Genève”, clearly shows the intent to have it associated with the Hippocratic Oath in terms of form and content. The myth of Hippocrates had proved once again to be an integral element of the image that doctors had of themselves. The idealized vision of Hippocrates that is behind all this goes back to antiquity, as will be demonstrated below. During the first half of the 20th century, a historical critique on the philological aspects of Hippocratic medicine and a nostalgic view of history both led to die formulation of rather unusual misunderstandings which have an impact on the ethical discourse still today.

Hippocrates in Geneva and Nuremberg

The “Declaration of Geneva” was expressed in the Hippocratic tradition partly to show that the Hippocratic Oath, when formulated in modem terms, could serve as the basis for medical ethics in the 20th century. This was held to be all the more true since the Nuremberg trials against Nazi doctors (1946-47) had shown what ethical crimes modem medicine was capable of.² These trials dealt with the cruel and often deadly experiments that German doctors had conducted on prisoners of war and inmates of concentration camps - acts held by the tribunal to constitute murder and crimes against humanity. The defense tried to relativize and play down the atrocities perpetrated by the defendants by citing cases in the international medical literature that were ostensibly comparable. The prosecution and the tribunal thus were faced with the unexpected difficulty of finding a generally acceptable standard with which to judge the crimes of the Nazi doctors. At the same time, the judges realized that ethical guidelines had to be drawn up for regulating and keeping in check any future medical research. The Nuremberg tribunal met both of these needs, but not by applying the Hippocratic Oath. Instead, it created a new ethical guideline, the Nuremberg Code (1947).

Although the prosecution had initially accused all of the Nazi doctors of having violated the Hippocratic Oath, which they had sworn to uphold, it did not quote any parts of the Oath.³ Later, two witnesses for the prosecution who served as experts on medical ethics, the German medical historian Werner Leibbrand (1896-1974) and the American physiologist Andrew C. Ivy (1893-1978), did make reference to the Oath. When cross-examined by the defense, they mentioned specific passages of the Oath. Leibbrand stood for, as he himself put it, an uncompromising “Hippocratic” standpoint, dismissing any experiments on humans that did not serve the needs of the subjects themselves as being unethical. Ivy, on the other hand, made a distinction “between the doctor as a therapist, the healer, and the doctor as a researcher”. Different sections of the Hippocratic Oath should be applied to one or the other type, but Ivy did not specify which sections he meant.⁴ Later on in the trial, the defendants also referred to the Hippocratic Oath. Karl Brandt, one of those responsible for Nazi “euthanasia”, tried to justify the medical crimes as being a modem interpretation of the Hippocratic Oath.⁵ The tribunal did not accept this interpretation of the Hippocratic Oath, though it did not try to disprove it either. As Alexander Mitscherlich, one of the attendants of the trials, put it, the Oath had proved ineffective as an ethical standard of modem medicine.⁶

In 1947, with the aid of prosecution witnesses Andrew Ivy and Leo Alexander, the tribunal created and included in its decision a new ethical standard that was independent of the Hippocratic Oath and is now known as the Nuremberg Code, a ten-point statement delimiting permissible medical experimentation on human subjects.⁷ The World Medical Association appeared to take no notice of this “breach with Hippocrates”, when in 1948 it drew up a set of pledges serving as ethical guidelines for doctors throughout the world one year after the trial had ended. Confronted with accusations that members of their profession had backed the Third Reich, representatives of the German Medical Association also were keen on espousing the Hippocratic Oath as an argument for their own benefit.⁸ The prosaic Nuremberg Code thus easily fell victim to the victorious myth of Hippocrates.

Hippocrates and Hippocratic Corpus

Although knowing the date when they were written is relatively trivial for most historical documents, not knowing when the Hippocratic Oath was written does lead to a number of problems. The Oath is to be seen in the context of the works associated with Hippocrates’ name - the Hippocratic Corpus. In medieval manuscripts, the Oath takes up the first page of the Corpus, a practice which often has been maintained in modem editions and translations.⁹

The approximately 60 writings (counting methods vary) contained in the Hippocratic Corpus cover all topics in medicine; they are not, as was realized as far back as antiquity, written all by one author named Hippocrates. Not only the breadth of topics, but also obvious contradictions and fundamental oppositions show that the work was done by various authors. In addition, there are the “differences in quality” of the writings that have been perceived in various ways throughout the ages. The Corpus originated over a period extending from the end of the 5th century B.C. until the late Hellenistic Age. Some texts may have been written in the postChristian era. The body of writings was apparently first compiled under the author’s name, Hippocrates, in Hellenistic Alexandria,¹⁰ which is also the birthplace of Hippocratic exegesis. The latter used the literaiy form of commentaries on specific texts in the Corpus and was instrumental in creating the Hippocrates lexica. The earliest commentaries mentioned in the sources were probably written by Herophilus (approx. 330/320-260/250 B.C.); his pupil Baccheius of Tanagra (approx. 275-200 B.C.) created the first lexicon on the Hippocratic treatises.¹¹ The earliest existing commentary has been written by Apollonius of Citium (1^st cent. B.C.). Commentaries were written then on the Hippocratic treatises partly in order to make them useful to contemporary medicine. This was still true of the last complete edition of Hippocrates by the French doctor and philologist, Émile Littré (1801-1881), published from 1839 to 1861.¹² Apart from the practical considerations, by espousing Hippocratic ideas doctors have been able to furnish themselves a quality seal for their own views, doing so ever since and far beyond the Hellenistic age. In an age of medicine which drew its authority from tradition, the adjective “Hippocratic” was especially attractive. In debates among various medical sects in antiquity, for instance between the “Herophileans” and the “Empiricists”, one tried to prove that one’s own ideas were “Hippocratic” while those of the others were “un- Hippocratic”. In doing so, it was important to refer to the “real” Hippocrates - or at least to the author who was believed to be the real one.

The Greek doctor, Galen of Pergamon (approx. 129-210 A.D.), contributed greatly to the image of Hippocrates and stylized himself as the purist “Hippocratic” physician. In doing so, in a sense he invented Hippocrates, and his interpretation rendition of the master from Cos has remained with us to this day.¹³ For Galen, as well, it was obvious that not all of the writings in the Hippocratic Corpus, which had been edited again at the time of the Roman emperor Hadrian (117-138 A.D.), could possibly be written by one and the same author. For Galen, Hippocrates’ fundamental doctrine was to be found in the treatise “On the Nature of Man” (De natura hominis). Ever since, Hippocrates has unquestionably been held as the father of the doctrine of the four humours, which was first touched upon in the aforementioned treatise.

The question involving the “authenticity” of single Hippocratic treatises is closely tied in with conjectures about the origins of the Hippocratic Corpus. The traditional view handed down to us from antiquity, which Galen also subscribed to, held that Hippocrates had founded a school on the island of Cos. The master himself was said to have written the best treatises of the Corpus. Among these high-quality texts are Epidemics, Aphorisms, On the Sacred Disease and Prognosticon, just to name a few. His pupils and successors were said to have draped garlands of “unauthentic” texts around this core of the Corpus. All texts were assumed to have been located on the island of Cos, where they constituted the “Library of the Doctors”, From there, sometime during the early Hellenistic period, the omnibus of treatises was said to have found its way moved to the center of knowledge, the library of the newly founded city of Alexandria. There scholars allegedly catalogued and published the writings under the name of the main author, Hippocrates. The Corpus has thus been held to consist of some “genuine” texts by Hippocrates and some falsely attributed to him.

This widespread “traditional” theory, which has endured from antiquity to the present, is supported by several factors, some of which are inherent to the context of the treatises, others of which are extrinsic in nature. To begin with the inherent factors mentioned first, the treatises of “high quality” (Epidemics I, III, Prognosticon etc.) were written during Hippocrates’ lifetime (around 400 B.C.). In the 20^th century, the German classical philologist, Karl Deichgräber, was foremost in proving how these treatises are linked to each other and, in view of their historical background, when they were written.¹⁴ Among the extrinsic arguments supporting the “traditional” theory, one states that the island of Cos was under the sphere of influence of the Ptolemaic kings of Egypt, who actively supported the doctors and scholars of Alexandria. Ptolemy II Philadelphus (reigned 283/82-246 B.C.) was bom in the Ptolemaic winter quarters at Cos in 308 B.C. during a naval operation.¹⁵ It is thus possible that the Ptolemaic kings, who in antiquity were notorious for their craving for books,¹⁶ also transported the medical library from Cos to the capital. Galen, too, held this opinion, though none of the sources explicitly mentions the transfer of the Hippocratic books to Alexandria.¹⁷

Galen took his contemporaries’ criticism of the authenticity of the Hippocratic writings seriously. This is obvious from the difficulties he had in justifying himself: Aristotle had attributed the treatise “On the Nature of Man”, which Galen claimed was genuine “Hippocratic”, to a certain Polybus (Aristotle, Historia animalium III 2; 512 b 12).¹⁸ A later source, one of the so-called “Letters of Hippocrates” (which we will return to shortly) called this Polybus a son-in-law of Hippocrates,¹⁹ while Aristotle did not mention...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Foreword
• Introduction of the Editors
• Ethics Codes in Medicine: Historical, Legal and Philosophical Aspects
• The Paradigm Shift in Medical Ethics: Patients’ Rights, Education, Institutions
• Ethics and Medicine for the 21st Century: The Quest for New Codes
• Appendix