Hippocrates and the problem of medical ethics. Medical ethics and deontology. Medical ethics in the Soviet Union
"Medical Law and Ethics" N 1, 2004
FROM THE ETHICS OF HIPPOCRATES TO BIOETHICS
The European tradition of medical ethics has been uninterrupted for about 2,400 years. The set of books of Hippocrates (V-IV centuries BC) on medical deontology ("The Oath", "Instructions", "On Art", "On the Doctor", etc.) contains ethical prescriptions that are mandatory for a doctor as a representative of secular profession (already finally taking shape at that time in Ancient Greece, along with healers-priests). It is believed that the Hippocratic Oath, the core of his ethical system, goes back to the ascetic ethics of Pythagoras, who lived about 100 years earlier than Hippocrates.
The ethics of Hippocrates is the ethics of virtues. His most important commandments: prohibition of harm to the patient; to euthanasia (and in general, to the transformation of medical art into a means of murder); aiding in suicide; for an artificial abortion; attempts to treat the dying that are senseless from the point of view of medical science (medical art); an intimate relationship with a patient; medical secrecy; careful informing of the patient, allowing him to misinform; correct attitude to colleagues, consulting with colleagues, if necessary; exposure of false doctors, medical charlatans. Using the language of modern medical ethics, the first four commandments of Hippocratic ethics can be defined as the principle of unconditional respect for the patient's life (1, p. 87-130).
From a philosophical point of view, the norms of ethics of Hippocrates are a mosaic of moral precepts that were formed in different historical periods and were influenced by most of the main schools of ancient Greek philosophy. In the Hellenistic era, the doctor's system of ethical values was supplemented and enriched on the basis of Stoic philosophy with the ideas of moral duty, sympathy for the patient, and even love and friendship in the relationship between doctor and patient.
Greek medicine and Greek philosophy mutually nourished each other. Socrates, Plato, and Aristotle used medicine extensively as a teaching tool, especially as a model for the moral use of knowledge. In medicine, they found a source of analogies bringing together the health of the body (medicine) and the health of the soul (philosophy). The closeness between medicine and philosophy was so great that at one time doctors were forced to specifically assert their independence, emphasizing the empirical nature of the medical art.
The first special works on medical ethics in modern times appear in England at the end of the 18th century: J. Gregory "Lectures on the duties and qualifications of a doctor" (1772), T. Percival "Medical ethics" (1797). The appearance of these works should be considered in the context of the rapid socio-economic development of England, its leadership in the industrial revolution, and as a result - earlier than in other European countries, the transition from traditional to industrial society, finally, the earliest of all bourgeois revolutions - " Glorious Revolution "1688, which consolidated the socio-political system of the British constitutional monarchy. And all this was reflected in the development of social consciousness, in the achievements of the era of the English Enlightenment. Here and "New Organon" by F. Bacon (1626) - a kind of manifesto of the experimental scientific knowledge of nature, and great work I. Newton "Mathematical Principles of Natural Philosophy" (1687), and treatises on religious tolerance and government by J. Locke (1690), which laid the foundations of the theory of the rule of law, philosophical and ethical doctrine of human rights (the right to life, freedom and private property) , and, of course, the works of the founders of political economy from "Treatise on Taxes" by W. Petty (1662) to "The Wealth of Nations" by A. Smith (1776).
In the first above-mentioned special works on medical ethics, we find the ethical and normative basis of professional medical activity in the era of early capitalism, when the social position of the doctor, which developed in the Middle Ages and is characterized by the vassal dependence of the doctor on the senior, radically changes: the doctor as the owner of special knowledge and special personal experience, art becomes a participant, a free subject of market relations in society. In these conditions, the deontological code of Hippocrates is enriched, correspondingly, to the spirit of its time. At the same time, the regulation of the competitive relationship of doctors with each other and the institutionalization of this regulation becomes a very important topic of medical ethics. As T. Percival wrote: "The doctors of any charitable institution are to some extent ... the keepers of each other's honor. Therefore, no doctor or surgeon should speak openly about hospital incidents that could harm the reputation of any of his colleagues ... You cannot behave selfishly, trying to directly or indirectly damage the patient's confidence in the doctor or surgeon. However ... there are times when vigorous intervention is not only justified, but also necessary. the patient leads to danger to his life or haste leads to even greater danger ... "(Quoted from 2: p. 34).
If we transfer (in a metaphorical sense) Haeckel's biogenetic law from the field of biology to the field of culture, then the logic of the formation and development of medical ethics in Russia (a kind of "ontogeny") repeats the formation and development of medical ethics in European civilization in general (a kind of "phylogeny") ... Interesting pages in the history of medical ethics in Russian medicine are opened only at the beginning of the 19th century, when, let's say, the university medical education in our country. Elected after 1812 five times as the dean of the medical faculty of Moscow University, M.Ya. Mudrov (1776-1831), reading to students the basics of therapy, pharmacology, dietetics, etc., translated from the ancient Greek book of Hippocrates ("Captivated by the wisdom of Hippocrates ... I decided to spend the nights with Hippocrates ";" This chapter should be read on my knees "). The ethical instructions of M.Ya. Mudrov include not only the commandment about medical secrecy ("Silence in cases of reprehensible diseases ... about heard and seen family disturbances"), the prescription of a wise solution to the problem of informing doomed patients ("Promising healing in an incurable disease is a sign or an ignorant or dishonest doctor "), but also the requirements regarding cleanliness, neatness of clothes, demeanor, exactingness to their speech (3, p. 93-95).
Throughout the 19th century. Russia in many respects remained a feudal society, in which capitalist social relations gradually took shape and the features of an industrial society were formed. The famous doctor Haas (German and Catholic) arrived in Russia in 1806 as the family doctor of Princess Repnina. Under the contract, he was obliged to treat her family and courtyard, but he also had the right to practice in private in Moscow. He later became a legendary doctor, when he transferred to the civil service - the chief physician of Moscow prisons (1829-1853). Usually, the historical role of Dr. Haas is quite rightly seen in an unparalleled, selfless service to the medical profession, which was confirmed in the 1994 initiative of Moscow Catholics appealing to the Vatican about the official canonization of "St. Doctor Fyodor Petrovich" by the Roman Catholic Church. We emphasize here that Dr. Haas created a model of penitentiary medicine, which received international recognition only in the last decades of the 20th century: the professional duty of doctors working in prisons is only medical assistance to prisoners; prisoners as patients should receive medical care without discrimination.
During the XIX century. domestic medicine in many respects has reached the European level. We are talking not only about the rapid progress of medical science (N.I. Pirogov, I.P. Pavlov, I.I. Mechnikov, etc.), but also the corresponding level of ethical consciousness of domestic doctors, nurses, etc. Published for 20 years (1881-1901) under the editorship of Professor V.A. Manassein, the weekly newspaper "Doctor" and the famous book by V.V. Veresaev "Notes of a Doctor" (first edition in the magazine "Peace of God" in 1901) - evidence of such a level of discussion, for example, the topic of biomedical (clinical) experiments on humans as objects, that both of these sources remain very interesting and important in the light of modern medical ethics (4, pp. 56-62).
During the Soviet period in the history of Russian healthcare, the development of professional medical ethics was deeply contradictory. On the one hand, the Soviet health care system, earlier than in many modern Western countries, realized the ideal of universal accessibility of professional, including many types of specialized, medical care to almost the entire population on the scale of such a huge country as the USSR. The real implementation of the right of citizens in the Soviet Union to qualified medical care undoubtedly contained a huge moral potential. In the personal dimension, the social nature of Soviet health care continued with a sufficiently high awareness of professional duty by Soviet doctors and nurses, which ultimately determined the moral climate in domestic medical institutions (while we do not forget about the "double standards" in medicine for everyone and for the elite , primarily for the state nomenclature).
On the other hand, the socio-political nature of the totalitarian society in the Soviet Union (which leveled the role of the human person), the logic of communist ideology in the Soviet version (personal interests should be completely subordinated to the public), the state-bureaucratic organization of the entire medical business, which was managed mainly through the command -administrative "levers" - all this became the reasons for a kind of ethical nihilism among Soviet doctors and paramedics. A vivid manifestation of this nihilism was the position in the 1920s of the first People's Commissar of Health N.A. Semashko, who repeatedly stated that we were on a firm course to renounce medical secrecy (5, p. 364). From our point of view, the underestimation of confidentiality issues in the professional consciousness of domestic doctors still persists.
The most important frontier for the fate of medical ethics in the XX century. became the second world war. Nazi medicine (forced sterilization for eugenic purposes of hundreds of thousands of Germans; forced euthanasia of tens of thousands of patients in German psychiatric hospitals; criminal medical experiments - mainly on prisoners of concentration camps, i.e., in the vast majority, not Germans) has become unprecedented in history falsification of the medical profession ... It is precisely the contempt for the entire ethical system of Hippocrates (and above all for the principle of unconditional respect for the patient's life), which Nazi doctors quite deliberately demonstrated, that explains the unrelenting attention to Nazi medicine of the entire world medical community throughout the second half of the 20th century. Today, when discussing the moral problems of public health, world medicine takes almost all of this experience of Nazi doctors as a kind of "absolute ethical zero."
The attitude to the problems of medical ethics in the USSR in the post-war period remained deeply contradictory as before. On the one hand, Soviet medicine occupied leading positions in many areas of medical science (for example, in experimental transplantology, resuscitation thanks to the works of V.P. Demikhov, V.A. Negovsky, etc.), i.e. domestic medical specialists inevitably faced new moral and ethical problems generated by the development of modern medical technologies. On the other hand, the inertia of ethical nihilism, laid down in the 1920s, was aggravated by the international isolation of the domestic scientific medical and medical community, which sometimes led to elementary ignorance of Soviet doctors and medical scientists about new ethical ideas, ethical approaches in modern medicine, which began to grow like an avalanche from the turn of the 60-70s.
This is confirmed by the fact that the community of Soviet doctors did not have, as in many other countries, a national association of doctors that could join the World Medical Association (WMA). Of course, history does not have a subjunctive mood, so we do not even discuss the issue of the procedural difficulties of Soviet doctors joining the Military Medical Academy, since this latter constantly emphasizes its political neutrality and ideological indifference.
But it was the VMA that did most of the constructive work - the creation of a modern normative ethical base for medicine in the second half of the 20th century. In 1948, the VMA adopted the text of the modern international oath of a doctor - the "Geneva Declaration"; in 1949 - "International Code of Medical Ethics"; in 1964 - a set of ethical rules for conducting biomedical research on humans - the "Declaration of Helsinki"; in 1981 - the minimum international ethical standard of patients' rights - the "Lisbon Declaration" and dozens of similar international ethical documents. Suffice it to add that the first Russian translation of these documents appeared only in 1995 (6).
The norm-setting activity of the VMA has become especially productive in the last 30 years - with the emergence and rapid development of a new science - bioethics. The word "bioethics" became widespread thanks to the works of the American specialist W.R. Potter, in particular - the extremely apt title of his book "Bioethics - a bridge to the future" (7). Most authors identify the concept of "bioethics" with the concept of "modern medical ethics" or "clinical ethics". Retaining a connection with the traditional ethics of Hippocrates (in particular, with its humanistic spirit), bioethics critically evaluates some of the specific provisions of his ethical system.
The principle of respect for life still retains the significance of the philosophical and ethical principle of the entire system of moral values in medicine, however, its concrete interpretation, when it comes to dying patients, seems to split - in society there are many supporters of active euthanasia, but even more supporters of passive euthanasia , requiring difficult from a moral point of view decisions about non-treatment by certain means or methods of some of the dying. Other provisions of the Hippocratic ethics, around which there are heated discussions in the mainstream of bioethics - the boundaries of medical paternalism (disregard of the patient's autonomy by doctors and medical staff); the moral permissibility of abortion, etc. A characteristic feature of these discussions is the active involvement of professional philosophers in this process.
It is obvious that bioethics is a phenomenon of a civilizational order, as the philosopher (and doctor in basic education) P.D. Tishchenko wrote about earlier, describing the last third of human history as an "ecological turn of mankind" and "bioethical turn of mankind" (8). It is worth remembering that earlier doctors-philosophers, be it Alcmaeon or Empedocles in Dr. Greece, J. Locke or W. James in modern times practically did not touch upon the issues of professional medical ethics. K. Jaspers devoted two essays in an informal style to the relationship between a doctor and a patient, but he did not publish a single work in which a scientific analysis of medical ethics was carried out.
Social preconditions for the emergence of bioethics in the last third of the XX century. are taking shape with the formation of post-industrial society in Western countries and the corresponding evolution of the health sector - the growing role of "consumer stereotypes" in public consciousness, the growth of ethnic self-awareness, the spread of feminism, the growth of respect for individual rights, the development of civil society institutions (with a relative decrease in the role of state bodies) ... During these years, the rapidly developing newest medical technologies have become the reason for the complication and increase in the number of ethical problems in medicine. In the context of depersonalization of rendering medical services traditional ethical values in medicine began to be questioned, there was a need for alternative systems of medical ethics, which were in demand both in the practical work of doctors and in the process of teaching students.
On the one hand, bioethics fulfills the functions of traditional medical ethics, since it prescribes ethical standards for the attitude of doctors, nurses to the patient (dying patient, donor, recipient, etc.), on the other hand, bioethics becomes the mainstream of in-depth philosophical research. The fact is that the new socio-cultural prerequisites for the functioning of the health care system, which were discussed above ("consumer stereotypes" of public consciousness, increased respect for individual rights, etc.), with a simultaneous crisis of the "canonical" ethics of Hippocrates, turned into a temptation to substitute ethics exclusively legal regulation of a medical case or the choice of decisions based only on economic feasibility, or, finally, replacing a generally valid professional ethics the arbitrariness of the moral positions of individual doctors and specialists. Serious philosophical research in the field of bioethics was the answer to these challenges and dangers. In the form of bioethics, medical ethics, preserving the humanistic spirit of Hippocrates' ethics, was revived at a new qualitative level.
Several stages can be distinguished in the more than thirty-year history of bioethics. The first stage can be called the “stage of principledism”, associated, first of all, with the fundamental book of American specialists T. Beachamp and J. Childress, “Principles of Biomedical Ethics,” which was reprinted many times (9). Philosophers have brought to medicine the tradition of rigorous analysis of complex moral dilemmas, taking into account pluralism, social heterogeneity (primarily in religious, ethnic terms) modern society.
Beechamp and Childress identify four fundamental principles in the foundations of modern biomedical ethics - no harm; good deeds ("Your duty is to strive only for the good of the patient, to act only in his highest interests!"); respect for individual autonomy; justice. Methodologically, Beachamp and Childress proceeded from the theory of prima face moral principles developed by the American philosopher Ross (literally, this Latin expression means "in the first place"). When analyzing the complex ethical dilemmas of medical practice, each of these four principles does not have an unconditional, absolute moral force, but in a certain situation we can first of all rely on one of them (prima face). For example, solving the dilemma of informing severe, especially terminal, sick, the doctor deals with the contradiction of the principles of "no harm" and "respect for the autonomy of the individual." If a doctor deliberately took the path of limiting truthful information (i.e. limiting autonomy), then he must have sufficient grounds for such tactics, such a choice. He must reasonably substantiate that he is forced in this particular situation prima face to rely on the principle of non-harm (10, p. 16-17).
Beechamp and Childress were aware that it is extremely difficult to build a unified, consistent theory of medical ethics, and therefore, such a theory was based on four particular principles, the need to follow which is axiomatic. This tetrad of principles was immediately adopted to address the ethical dilemmas of clinical practice by both bioethical theorists and medical practitioners. By the way, the first Russian manuals on bioethics to a certain extent also followed this tradition (11; 12).
The attractiveness of the "new ethical thinking" for clinicians was determined by the fact that the degree of uncertainty and subjectivity in the debate on moral problems of medicine decreased. Clinicians saw in modern medical ethics (bioethics) an approach that is somewhat similar to the approach in solving medical problems of diagnosing and treating diseases - both here and there a specific solution algorithm was developed. It was also important that the prima face moral theory in a bioethical context made it possible to avoid direct confrontation on such problems as abortion and euthanasia.
Two of the four principles, according to Beacham and Childress, "do no harm" and "good deeds" are quite consistent with the Hippocratic ethical system. It is no coincidence that both of these principles have been known from time immemorial to many generations of doctors thanks to catch phrases"Primum non nocere!" (First of all - do not harm!) And "Salus aegroti - suprema lex!" (The well-being of the sick is the highest law!). But two other principles of "respect for autonomy" and "justice" turned out to be completely new, not fitting into the ethical system of Hippocrates.
The principle of respect for the patient's autonomy came into direct conflict with the paternalism of Hippocratic ethics. The Hippocratic Oath says: "I will direct the regime of the sick to their benefit, in accordance with my strength and my understanding ..." (1, p. 87). That is, the patient is completely excluded from the decision-making process regarding his health, life, and maybe death. Recognizing the role of the principle of respect for patient autonomy was difficult, as it was associated with the violation of two other principles rooted in the very archetype of medical consciousness - harmlessness and good deeds. The principle of respect for autonomy, in the end, was recognized by the medical community, but the main role here was played not by philosophical arguments, but by general cultural trends in health care and society in general in the West, by virtue of which clinical practice began to be based on the informed consent of patients. As you know, for the first time in the modern sense, the concept of "informed consent" (implying the completeness of informing patients, especially with regard to the risk of alleged medical intervention) was actively discussed in the American media back in 1957 - in the "case of Martin Salgo v. Stanford University." It was about a patient who became disabled as a result of a complication after an invasive medical intervention, and during the judicial investigation of this case, the prosecution focused precisely on the patient's lack of information about the possibility, the degree of probability of such a complication (by the way, the patient won this case).
The patient's autonomy has become entrenched in medical practice because the lifestyle in modern post-industrial countries has become more individualistic, and independence and independence have become the credo of the individual.
Without a doubt, the principle of respect for autonomy and the resulting criticism of medical authoritarianism and paternalism have become the main factor in the evolution of the value system of modern medical ethics (bioethics). When in 1998 the first domestic educational program in bioethics was created (approved by the Ministry of Health of the Russian Federation in 1999), the idea was discussed among the "developers" of the Program - to begin the presentation of the principles of bioethics precisely from the principle of respect for autonomy. At the same time, there are clinicians (especially in modern domestic health care) who doubt that patient autonomy should really be considered as a fundamental principle of medical ethics. The criticism of the principle of patient autonomy usually boils down to the following: this principle can destroy the mechanism for making optimal decisions, contribute to the alienation of the doctor from the patient, and even become a factor causing harm to the patient.
The principle of justice became completely new for the system of ethical values of Hippocrates. Although for Plato and Aristotle the problem of justice is one of the central ones in their moral and political philosophy, this did not have a noticeable effect on the ethics of Hippocrates; the good of the individual patient is at the center of the ethics of Hippocrates. Here in the book "Instructions" Hippocrates advises the student: "You should not worry about establishing reward, since we believe that paying attention to this is harmful for the patient, especially in acute illness: the speed of the disease, which does not give an occasion for delay, makes a good doctor look not for benefits, but rather for gaining fame ... And I advise you not to behave too inhumanely, but to pay attention to the abundance of funds (from the patient) and their moderation, and sometimes heal for nothing ... " (1, p. 120-121). Of course, in such an ethical position of a doctor there is also an element of social justice, however, the principle "The doctor's duty is to strive only for the patient's welfare!" Dominates here.
Historically, the idea of social justice began to play an increasingly prominent role in medicine with the development of social medicine and the solution of public health problems in the 19th century. In the last decades of the XX century. As medicine has become increasingly saturated with modern technologies, the availability of which is often limited to all patients in need, the problem of social justice in health care has come to the fore.
Sometimes the birth of modern bioethics is directly related to an event that took place in 1968 in Seattle: at that time there was only one artificial kidney machine and about ten patients with chronic renal failure who could be saved by using renal hemodialysis. Doctors at a clinic in Seattle faced a difficult choice - which of these patients should have an artificial kidney in the first place, while other patients were almost certainly doomed to die. A specially created public commission compiled a dossier for each of the patients (gender, age, social status, etc.), after which it became convinced that in such a formal way it is impossible to develop an algorithm for a fair solution to this ethical dilemma and, perhaps, a random sample (for example, by lot ) will be the fairest.
In the subsequent years of the development of bioethics, a whole spectrum of philosophical theories of social justice appeared, the authors of which consider them to be the most appropriate for solving the dilemmas of distributive (distributive) justice in modern healthcare.
First, there is the theory of justice by the American philosopher Rawls. The greatest social justice is achieved in a society that follows the following principles: the principle of granting each member of society the most equal freedoms for all; the principle of equality (subject to the same levels of ability) for employment and public office; the principle of differentiation, according to which society (if it respects the two previous principles) seeks to maximize the availability of social benefits to the poor.
Secondly, this is also a very popular radical liberal theory of the American philosopher Nozick. Continuing the tradition of the father of modern liberalism, John Locke (who first proclaimed the sacredness of private property), Nozick considers public health systems as a whole unjust, as it is mainly the state bureaucracy that benefits from them.
Thirdly, this is the concept of social justice of the German philosophers Apel and Habermas, who believe that a balance of equality and inequality acceptable for society will be the result of the participation of all members of civil society in a public discussion (for example, on the problem of health), for which society should create necessary communicative prerequisites (13, p. 58-68).
In theoretical terms, the main drawback of the tetrad of bioethical principles of Beachamp and Childress was that these principles do not have any hierarchical core. Bioethics as an applied ethics is, in practice, situational ethics, and the main difficulty of moral choice in a particular clinical situation is associated with the conflict of the above principles with each other (autonomy and justice, justice and beneficence, etc.).
The second stage in the history of bioethics can be called the stage of anti-principleism.
The prevailing position at this stage is as follows: at least a tetrad of bioethical principles requires a deeper substantiation with the help of some traditional great ethical teaching. The principles of bioethics must be "placed" in the context of the general philosophical theory of morality. And yet, the main criticism of principleism in bioethics came not from philosophical, but from professional medical circles: the principles are too abstract, too rationalistic, far from the psychological environment in which a real moral choice is made, they ignore the character of a person, gender, the upbringing he received. ... In other words, the very circumstance that contributed to the recognition of the tetrad of bioethics principles by physicians (the algorithmicization of moral choice by analogy with the “algorithmicization” of the doctor's diagnostic thinking) has now acted as a negative factor: principleism in bioethics means, as it were, a mechanistic method of making moral decisions.
In modern medicine, one of the alternative systems of medical ethics claims to be the so-called "compassion" ethics. The adepts of this theory argue that in specific situations ethical decisions, female doctors are more likely to be empathetic than male doctors. Women are mainly interested in maintaining good relations, and not in self-affirmation, are more inclined to establish cooperation than confrontation. Of course, there can be no objections to the fact that such virtues as sympathy and compassion are important for a doctor and even more so for a nurse, but this very concept of sympathy is extremely subjective, i.e. again, it requires a conceptually grounded rationalization, identifying sufficient grounds for one or another optimal decision. And yet, this line of criticism of principleism in bioethics requires us not to discount such an additional factor as the psychology of morality.
Another alternative to the dominance of principalism in bioethics has been the revival of interest in the theory of "precedents", which is attractive to clinicians due to its concreteness. According to this theory, it is necessary to find typical cases (incidents) regarding which there is a consensus of professionals and society (or at least more or less complete agreement) in the application of ethical principles. In less clear cases, the method of analogies should be applied, while developing the rules of limitation. Criticism of this direction of bioethics primarily points to pluralism in modern society, emphasizing that casuistry is a product of a predominantly medieval culture, where there was agreement on the dominant values. The theory of precedents is especially characteristic of Catholic moral theology, but in modern society there is no consensus on many moral issues, even among the followers of the Roman Catholic Church.
The development of a new foundation of medical ethics is extremely complicated by the crisis state of modern philosophy and ethics with the spread of nihilism and skepticism in them. The philosophy of postmodernism relativizes the interpretation of truth in general, which calls into question the possibility of a rational approach to issues of ethics and morality.
In addition, as modern bioethics spreads in countries outside the Western world, there is more and more talk of "cultural hegemony" in moral matters. According to this concept of "cultural hegemony", medical ethics, which began its countdown from Hippocrates and was transformed into bioethics, is a product of exclusively Western civilization. The core idea of bioethics about patient autonomy is especially criticized. As soon as Western medical ethics comes into contact with other cultural traditions, all controversial issues immediately intensify.
Noting the difficulties (of a philosophical, cultural nature) in the development of bioethics, it should be further said that it is precisely in modern medical ethics that an interesting dialogue of various religious doctrines, cultural traditions, socio-political programs and philosophical concepts takes place. In view of the universality of the phenomena of health and disease, the general proximity of the strategic and tactical tasks of medicine around the world, the possibility of a reliable substantiation of the principles, norms and standards of behavior of medical specialists is by no means an insoluble problem.
The most promising direction for the further development of bioethics is "clinical ethics". Clinical ethics focuses on the clinical reality of moral choice, taking into account the role of all participants in this process (doctors, patients, as well as nurses, etc.). Based on empirical research, clinical ethics poses specific questions: "Is the imminent death of this particular patient inevitable?" "How does public acceptance of euthanasia affect the psychology of doctors, nurses and patients?"; "What is the fate of ethics and morality if the decision of doctors to prescribe a particular treatment for a patient is dictated primarily by financial considerations?"; "Is the patient's autonomy always in his best interest?" etc.
In the development of clinical ethics, doctors and nurses are, as it were, doomed to dialogue with philosophers. Medical ethics is too important for doctors, patients and society as a whole, and it should not entirely depend, on the one hand, on the philosophical "fashion", and on the other - on the superficial judgments of clinicians in matters of ethics.
LITERATURE
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Professor of the department
philosophy of RAMS
A. Y. IVANYUSHKIN
Medical ethics is a form of professional ethics. Historically, professional ethics has developed primarily in medical, legal; teaching professions, in which the central place is occupied by helping a specific person and, therefore, interacting with him, as with a patient, client, student (student). The specificity of moral assessments, moral regulation in these areas is determined by the fact that such interactions directly affect the most significant values: human life and health, his fundamental freedoms, rights, etc.
In the process of mastering the principles and norms of professional ethics, physicians simultaneously comprehend the mission of their profession in society. The full-fledged professional thinking of a doctor, nurse, pharmacist always includes an ethical component. At the same time, professional medical ethics, organically included in practice, is designed to ensure the prevention of damage that can be caused to an individual or society, as well as to the authority of the medical profession as a result of incompetent, careless or reprehensible actions of any of its representatives.
Medical ethics Hippocrates
The history of medical ethics available to us in the written language is more than three thousand years old. In ancient India, doctors took an oath as early as 1500 BC. e.
For European medicine, the ethics of the ancient Greek physician is of lasting importance. Hippocrates(about 460-370 BC), especially his famous "Oath". After in the sixteenth century. in different countries (Italy, Switzerland, Germany, France) published works of Hippocrates ("Hippocratic Corps"), the growth of his authority among European doctors can be figuratively called the "second coming" of Hippocrates. Already at that time, doctors who were receiving their MD degrees from the Faculty of Medicine of the University of Paris were required to give a "Faculty Promise" in front of the bust of Hippocrates. It is known that when F. Rabelais received his doctorate in medicine in Montpellier, according to the custom of that time, he was not only handed a golden ring, a gold-embossed belt, a black drape cloak and a crimson cap, but also a book of Hippocrates' writings. In the second half of the XIX century. The "Faculty Promise", which is based on the "Hippocratic Oath", was introduced in the medical faculties of Russian universities. By analogy with the "Hippocratic Oath" at the beginning of the XX century. was compiled nursing "The Oath of Florence Nightingale", named after the founder of the independent nursing profession, who opened in 1861 in England the world's first school of nursing. In the second half of the twentieth century, especially since the formation of bioethics at the turn of the 60s-70s, many of the provisions of the "Hippocratic Oath" (and the "Hippocratic Corps" in general) found themselves in the midst of stormy philosophical, theological, legal disputes. which largely determines the heightened current interest in Hippocratic ethics.
The ethical views of the great physician are set forth in the books "The Corps of Hippocrates": "The Oath", "Law", "On the Doctor", "On Decent Behavior", "Instructions", "On Art", "Aphorisms" and others. Historians have long argued over which of the named books belonged to Hippocrates himself. Thus, the point of view, first proposed by the American historian L. Edelstein, is quite widespread, according to which the "Oath" was created by the Pythagorean school. One of the arguments in favor of this statement is that the "Oath" puts forward significantly stricter norms than those that were proclaimed in Greek legislation, in the ethics of Plato or Aristotle, and those that were characteristic of the then medical practice. Although the question of the authorship of Hippocrates is of great scientific value, the content of the books of the Corpus of Hippocrates, their significance and role for the history of medical ethics, as well as their general cultural significance can be considered independently of the solution of this question.
The first part of the "Oath" contains a description of the relationship within the medical profession, in particular, between teacher and student. The person entering the profession actually became an adoptive member of the teacher's family, and his strongest commitments lie precisely with the teacher and the teacher's family. Primary are the requirements that prohibit the disclosure of medical knowledge to those who have not taken the oath, and to protect the ranks of professionals from unworthy penetration. The medical community that existed at that time appears to us as a very closed social organization, which could be designated by words such as order or clan. hippocrates medical humanity
In the field of the relationship between a doctor and a patient, Hippocrates proclaimed the principles of humanity, philanthropy, mercy. Ethics is based on the idea of respect for a sick person, a patient, the obligatory requirement that no treatment should harm him: "I ... will refrain from causing any harm ...", - says the "Oath". Modern medicine has a huge arsenal of means and methods, the irrational or careless use of which can cause serious damage to health (iatrogenic pathology) and, in general, the well-being of the patient. For clarification, we note that these circumstances prompted the famous Russian clinician E.M. Tareeva to conclude that the ancient rule "first of all, do no harm" retreats before the requirement modern principle well calculated risk. In modern clinical medicine, there is still a mandatory requirement of Hippocratic ethics: the expected benefit (benefit) from a medical intervention must exceed the risk associated with the intervention. Moreover, the importance of this principle of medical ethics increases with the increasing aggressiveness of medical interventions in the field of human health.
The ideas of humanity and respect for the patient's human dignity are concretized in many teachings of the "Corpus of Hippocrates", in particular, in those that relate to the patient's family life. The ethical prohibition of intimate relations between a doctor and a patient should be especially emphasized. The "Oath" says: "Whatever house I enter, I will enter there for the benefit of the sick person, being far from everything intentional, unrighteous and harmful, especially from love affairs with women and men, free and slaves." In the books "On the Doctor" and "On Decent Behavior" you can find the development of this topic: "A doctor has a lot of relationships with patients; after all, they entrust themselves at the disposal of doctors, and doctors at all times deal with women, with girls and with property a very high price, therefore, in relation to all this, the doctor should be abstinent. " "When you come to a patient, you should remember ... about outward decency, ... about brevity, about ... to sit down with the patient right now, showing attention to him in everything."
Medicine, which in certain situations presupposes the need for visual and even tactile examination of a patient by a doctor of the opposite sex, as it were, destroys the corresponding moral barriers, “neglects” the cultural context of the relationship between the sexes in society. It is this aspect of medical practice, as well as the special depth of emotional contact, the doctor's influence on the patient (and even power over him) that contain the possibility of abuse.
The problem posed by Hippocrates retains its practical relevance for modern medicine. For example, in 1991, the Committee on Ethical and legal issues The American Medical Association, having considered the ethical aspects of the relationship between doctors and patients, made a special decision: intimate contacts between a doctor and a patient that occur during the period of treatment are classified as immoral.
The most famous commandment of the ethics of Hippocrates is his prohibition to divulge medical secrets. This ethical requirement is contained in the "Oath": "Whatever during treatment - as well as without treatment - I see or hear about human life from something that should never be disclosed, I will keep silent, considering such things a secret ". In the book "On the Doctor", the enumeration of the moral qualities of the doctor begins with "prudence", the first (and even self-evident) confirmation of which is called the ability to remain silent. And this fragment of the book "On the Doctor" ends with a summary: "So, with these valor of the soul ... he must be different." This attribution of medical secrecy to the "valor of the soul" is especially valuable in the context of the entire subsequent history of medical ethics, especially those stages when attempts were made to abandon the rule of confidentiality altogether.
Perhaps, none of the ideas of Hippocrates' ethics evokes today, in the 21st century, more interest (not only in the professional medical environment, but also in society as a whole) than the idea of respect for human life. All the huge modern literature devoted to the problems of euthanasia and abortion, in a sense, boils down to the polemics of supporters and opponents of the position of Hippocrates: pessary ". This position of the "Oath" does not allow the doctor to interrupt the patient's life, even if he is terminally ill and doomed. In the modern literature on bioethics, this problem is referred to as "active euthanasia". Hippocrates was also fundamentally opposed to the practice of "assisting suicide", the topic of which has been extremely widely discussed in recent years.
The "Oath" contains a ban on the participation of a doctor in an abortion. However, Hippocrates himself, judging by some sources, was sometimes forced under the pressure of the need to allow deviations from this norm. So, considering the issue of providing medical care to slaves in Ancient Greece, the researcher of antiquity T.V. Blavatsky, in one of her works, mentions the story of Hippocrates about how he terminated the pregnancy of a young slave flutist. In general, the historical evidence available today suggests that the real medical practice of the time of Hippocrates was more tolerant of abortion and euthanasia than the prescriptions of the "Oath". American medical historian D. Amundsen argues that both prohibitions, as a rule, are not fixed in the ancient medical and ethical literature.
Of undoubted interest is Hippocrates' interpretation of the topic of informing patients. In the book "On Decent Behavior" young doctor advice is given: "Everything ... must be done calmly and skillfully, hiding much from the patient in his orders ... and not informing the sick of what will come or have come, for many sick people for this very reason, that is, through the presentation of predictions about what comes or after what happens will be brought to an extreme state. " In the book "Instructions" the last thought is clarified: "But the patients themselves, due to their deplorable situation, in despair, replace life with death." It is with this that Hippocrates justifies the requirement to hide the true state of affairs from the patient, if it is very deplorable and, all the more, hopeless: the doctor should not take away the patient's hope of recovery. The further course of the disease is often unpredictable and unknown even to the doctor, and Hippocrates knew about the influence of a person's state of mind on his recovery: often the strength of mind and confidence in recovery allows the patient to cope with the most serious illnesses, and despair deprives him of strength and creates favorable conditions for the aggravation of the disease.
As you can see, many essential features of the "paternalistic model" of the relationship between a doctor and a patient were formed in the time of Hippocrates. The physician's patronizing style of behavior is also recommended by many other fragments of The Hippocratic Corps.
Attention and affection should be combined with the doctor's perseverance and severity. In some cases, the doctor does not trust the patient (after all, "many often deceived in accepting what was attributed to them"), and therefore Hippocrates recommends that a sufficiently experienced student be assigned to the patient, "who would observe that he fulfilled the prescriptions on time." In the conclusion of the book "On Decent Behavior" there is such advice: "About everything that is done, in advance, announce to those who need to know it." Thus, the paternalistic position here acquires its completeness: the restriction in informing the patient himself is complemented by the requirement to inform third parties, moreover, without the consent of the patient himself.
Hippocrates assigns a significant place in his ethical writings to the regulation of the relationship of doctors with each other: "There is nothing shameful if a doctor who is in some difficulty with a patient ... asks to invite other doctors." At the same time, "doctors who examine a patient together should not quarrel with each other and ridicule each other." Doctors should not be like "their craft neighbors in the square," "a doctor's judgment should never arouse the envy of another." When faced with a colleague's mistake, it is necessary to remember that you are also a human being, and you too can be wrong, "for there is a lack in all abundance." Professional dialogue should not turn into mutual accusations, it should be constructive, businesslike, and its goal should always be the patient's benefit, and not the doctor's own ambitions.
The theme of the doctor's attitude to his profession runs through the ethical writings of The Corps of Hippocrates as a red thread. Caring for the authority of the medical profession leaves a kind of imprint on the pedagogy of medicine and determines the direction of efforts to educate and self-educate a doctor. Here is the beginning of the book "About the Doctor": "The doctor is informed by authority if he is of good color and well-fed, according to his nature, for those who themselves do not have good looking in their body, the crowd is considered incapable of taking proper care of others. "Further, the young doctor is given advice" to keep yourself clean, have nice clothes"which should be" decent and simple "and dressed" not for excessive bragging, "but in order to make a pleasant impression on the patient and his relatives and to inspire their confidence in the doctor. The doctor's face should not be stern, but also the opposite extremes should also be avoided: "The doctor who pours out in laughter and excessively cheerful is considered heavy."
The moral and ethical instructions of Hippocrates instruct the doctor to keep under moral control not only his own professional activity, but also his entire way of life: in private life, he must follow moral rules, since he is a public person. Hippocrates makes such high moral requirements to the doctor that the question arises whether such a person can do this. Good fame in medicine is given dearly, at the cost of constant self-control and self-restraint: "I will live my life purely and immaculately." "To me, indestructiblely fulfilling the oath, may it be given ... the glory of all people for eternity." Hippocrates proclaims the high authority of the medical profession: "Medicine is truly the noblest of all arts."
The problem of the authority of medicine has another very important aspect in Hippocrates - this is the assessment and criticism of the activities of "pseudo-doctors". In the book "The Law" he writes about doctors: "There are many of them by rank, but in reality they are just as few as possible." The book "On Decent Behavior" speaks of those who, "possessing professional dexterity, deceive people ... Everyone can recognize them by their clothes and other adornments." As for true doctors, then, having many positive qualities("they are demanding of disputants, prudent in making acquaintances with their own kind", etc.), they also "give in general information everything that has been taken from science. "However, in the light of the text of the Oath, we are talking, apparently, about a narrow circle of selected professionals.
Consider the moral aspects of the real relationship between the doctor and society in ancient Greece. The society highly appreciated and encouraged the dedication of doctors. Historical sources have brought to us many examples of contempt for dangers, personal courage of doctors during epidemics, wars, earthquakes. Some of the doctors died in the process. However, another thing is no less important: how fair was the assessment of such work-ministry. In the temples, steles were erected in honor of the doctors, listing their merits. When a decree was issued in honor of the special merits of a "foreign policy" doctor, a copy of the decree was sent (sometimes with a solemn delegation) to his native city. Various gifts and generous rewards for doctors in such cases are mentioned in many historical sources.
Very high on the scale social values in the ancient Greek society was the disinterestedness of doctors. More than once, doctors who were in the public service, in difficult times for the policy, refused completely or for a certain period of the salary due to them. It is appropriate to recall here that in ancient Greek mythology, philanthropy was a characteristic feature of the patron saint of medicine, Asclepius. And if we now return to one of the most important ideas of Hippocrates' ethics, according to which the life of a doctor must correspond to his art, then we can understand this idea deeper: not only professional activity doctor, but his life itself must be inherent in philanthropy.
We come to an interesting and important problem - healing and reward for it. The work of a doctor was paid highly in Ancient Greece (better, for example, than the work of architects). The bulk of the doctors lived off the fees received from the patients. The author of the "Instructions" advises his student: "If you first start the matter of remuneration - after all, this also has a bearing on our entire business - then, of course, you will lead the patient to the idea that if the agreement is not made, you will leave him or you will be neglectful of him and will not give him advice at the moment. makes a good doctor look not for profit, but rather for gaining glory. Better to rebuke the saved than to rob those in danger in advance. "
Here, an attempt is made to resolve the age-old dilemma: on the one hand, the doctor's work must be fairly paid, and on the other, the humane nature of the medical profession is emasculated if the relationship between the doctor and the patient is reduced exclusively to monetary ones. The relationship between a doctor and a patient cannot be characterized in economic terms alone, because it is very difficult for a patient to assess the quality of the services offered to him. Enrichment cannot be not only the only, but also the most significant motivation for professional activity. When the author of the book "On Decent Behavior" says that medicine and wisdom are closely interconnected (and even identical), then the first manifestations of wise life position he calls the doctor "contempt for money, conscientiousness, modesty."
The words "contempt for money" must, however, be understood in light of the entire context of the ethical writings of The Corpus of Hippocrates. So, the author of "Instructions" advises his student, when it comes to fees, to differentiate approach to different patients: "And I advise you not to behave too inhumanely, but to pay attention to the abundance of funds (in the patient) and their moderation , and sometimes he would heal for nothing, considering a grateful memory higher than momentary glory. If an opportunity presents itself to provide help to a stranger or a poor man, then in particular it should deliver it ... "
The fairness of society's attitude to the activities of doctors has another side. In ancient Greece, only in relation to doctors there was a special punishment "adoxia" (dishonor). These are doctors who have committed serious professional errors or are guilty of abuse. According to T.V. Blavatsky, historical sources have not preserved factual information about the adoxia procedure itself or its consequences. But there is reason to believe that this punishment was quite harsh and effective in the fight of the policy against false doctors and ignoramuses. At the very least, adoxia meant a loss of trust and respect for fellow citizens. It probably also meant a loss of practice, a loss of a source of income for the doctor. Perhaps she was even accompanied by a partial defeat in the rights of an unscrupulous doctor.
Summarizing all that has been said, we note that the ethics of Hippocrates is a system of moral commandments, requirements, prohibitions that regulate the practice of healing and determine the doctor's attitude to the patient, to other doctors, to his profession in general, as well as the doctor's attitude to society. Its main principle is the principle of "first of all do no harm" (primum non nocere). She had a tremendous impact on the moral consciousness of doctors in ancient Greece and Rome.
Ethics: lecture notes Anikin Daniil Alexandrovich
1. Bioethics and medical ethics. Oath of hippocrates
Bioethics is a significant point of philosophical knowledge. The formation and development of bioethics is closely related to the process of changing traditional ethics in general, as well as medical and biological ethics in particular. It can be explained, first of all, by the significantly increased attention to human rights (in particular, in medicine, these are the rights of the patient) and the creation of the latest medical technologies, which give rise to a lot of problems requiring urgent solutions from the point of view of both law and morality.
In addition, the formation of bioethics is determined by colossal changes in the technological support of modern medicine, great advances in medical and clinical practice, which have become acceptable due to the success of transplantology, genetic engineering, the emergence of new equipment to support the patient's life and the accumulation of practical and related theoretical knowledge. All these processes have made the most acute moral problems that now confront the doctor, relatives of patients, nurses.
Are there boundaries for the provision of medical care, and what should they be in maintaining the life of a terminally ill person? Is euthanasia acceptable in modern society? From what time should the onset of death be counted? From what moment can a human embryo be considered a living being? Is abortion legal? These are some of the questions that arise before the doctor, as well as before society at the current level of development of medical science.
Bioethics is an interdisciplinary research area that emerged around the late 1960s and early 1970s. The very term "bioethics" was introduced by VR Potter in 1969. Today its interpretation is very heterogeneous. Sometimes attempts are made to equate bioethics with bio-medical ethics, limiting its content to ethical problems in the doctor-patient relationship. In a broader sense, bioethics includes a number of social problems and problems that are associated with the health care system, the relationship of man to animals and plants.
And also the term "bioethics" says that it is focused on the study of living beings, regardless of whether they are used in therapy or not. Thus, bioethics is guided by the achievements of modern medicine and biology when substantiating or solving moral problems that arise in the course of scientific research.
In the past, there were various models and approaches to the issue of morality in medicine. Let's consider some of them.
Hippocratic Model ("Do No Harm")
The principles of healing, which were laid down by the "father of medicine" Hippocrates (460-377 BC), are at the origins of medical ethics. The famous healer in his well-known "Oath" formulated the duties of a doctor to a patient. Its main position is the principle “do no harm”. Even though centuries have passed since then, the "Oath" has not lost its vitality, moreover, it is the standard of construction of many modern ethical documents. In particular, the Oath of a Russian Physician, which was approved at the 4th Conference of the Association of Russian Physicians in Moscow in November 1994, contains positions that are close in spirit and even in formulation.
Paracelsus' model ("do good")
A different model of medical ethics was formed in the Middle Ages. The most distinctly her postulates were set forth by the physician Paracelsus (1493-1541). In contrast to the Hippocratic Oath, when a doctor by his attitude wins the patient's social trust, in the Paracelsus model, paternalism acquires the main importance - the emotional and mental contact between the doctor and the patient, on the basis of which the healing process is built.
In the spirit of the Middle Ages, the relationship between the doctor and the patient can be compared with the relationship spiritual mentor and a novice, since the concept of “pater” (Latin - father) in Christianity extends to God. The essence of the relationship between the doctor and the patient is determined by the doctor's good deed, and the good, in turn, has a divine origin, for all good comes to us from above, from God.
The deontological model (the principle of "observance of duty") Was formed later. It is based on the principle of "observance of duty" (from the Greek. Deontos - "due"). It is based on strict adherence to the prescriptions of a moral order, adherence to a certain set of rules that are established by the medical community, society, as well as the doctor's own mind and will for their mandatory implementation. Each medical specialty has its own “code of honor”, non-observance of which is punishable by disciplinary sanctions or even expulsion from the medical con- dition.
Bioethics is also understood as the principle of “respect for human rights and dignity”. Modern medicine, genetics, biology, corresponding biomedical technologies have come very close to the problem of control and forecasting of heredity, the problem of life and death of organisms, control of many functions of the human body even at the tissue, cellular level.
For this reason, as never before, the question of the observance of the rights and freedoms of the patient as a person has become acute. Respect for the patient's rights (the right to information, the right to choose, etc.) is entrusted to ethical committees, which have actually made bioethics a public institution.
The considered historical models can be considered “ideal”. Today, in practice, there are more realistic models that include some of the legal aspects of the described relationship.
Sometimes most of the problems appear in medical practice where neither the patient's condition nor the procedures prescribed to him give rise to them by themselves. In daily contacts with patients, there are generally no morally unusual situations.
The most important problem of modern medical ethics is that health protection should be a right of every person, and not a privilege for a limited number of people who can afford it. Nowadays, as, indeed, in the past, medicine does not follow this path, although this norm as a moral requirement is gaining more and more recognition today. Two revolutions played an important role: biological and social. Thanks to the first revolution, health protection became a right of every person. All members of society should be treated as equal in that which is combined with their human qualities - dignity, freedom and individuality. According to the human right to health protection, the historically established models of moral relationships "doctor - patient" and the state of modern society, the following synthetic models of the relationship between doctor and patient can be considered acceptable.
Model "technical" type
One of the results of the biological revolution is the emergence of the physician-scientist. The scientific tradition commands the scientist to be "impartial." His work must be based on facts, the doctor must avoid value judgments Only after the creation of the atomic bomb and medical research by the Nazis, when no rights were recognized for the subject (we are talking about experiments that were carried out on prisoners of concentration camps) , humanity has become aware of the danger of such a position.
A real scientist cannot be above universal human values. When making important decisions, he also cannot avoid judgments of a moral and other value nature.
Sacred type model
The paternalistic model of the “doctor-patient” relationship has become polar to the model described above. Sociologist Robert N. Wilson characterized this model as sacred.
The main moral principle, which formulates the tradition of the sacred form, reads: "Providing help to the patient, do not harm him."
In the works on medical sociology, one can find the position that between the patient and the doctor, images of a child and a parent invariably arise.
Although paternalism in the range of values deprives patients of the ability to make their own decisions, transferring it to the doctor. Thus, for a balanced ethical system, it is necessary to expand the range of moral standards that doctors must adhere to. These are the basic principles that a doctor should follow according to this model.
1. Benefit and not harm. No one can relieve a moral obligation. The physician should only benefit the patient, avoiding harm entirely. This principle is perceived in a broad context and constitutes only one element of the entire mass of moral obligations.
2. Protect personal freedom. The fundamental value of any society is personal freedom. The personal freedom of both the doctor and the patient must be protected, even if it seems to someone that it could be harmful. The judgment of any group of people should not serve as an authority in deciding what is beneficial and what is harmful.
3. Protect human dignity. The equality of all people in their moral principles presupposes that any of us has the main human dignity. Personal freedom of choice, complete control of one's body and one's own life contribute to the realization of human dignity.
4. Speak the truth and keep promises. A physician's moral obligation to tell the truth and keep promises is as reasonable as it is traditional. But one can only regret that these bases of interaction between people can be made minimal in order to observe the principle of "do no harm".
5. Observe and restore justice. The social revolution heightened public concern about the equity in the distribution of basic health services.
Thus, if health is a right, then it should be for everyone. The negative feature of this model is that the observance of all these principles is entrusted only to the doctor, which requires him to have the highest moral qualities.
Unfortunately, now a similar approach in the provision of medical services is very difficult to implement due to the high level of discrimination on different grounds (material, racial, gender, etc.).
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The influence of Hellenic culture on the entire course of the subsequent development of mankind is extremely great, and this statement is also true in relation to medicine. Without dwelling in detail on the presentation of the history of medicine in ancient Greece, we note some points that are important for illuminating the subject of interest to us - the sources and forms of medical ethics of that period.
Important role in the formation of the consciousness of the people, the system of its religious and mythical beliefs plays. For ancient Greece, it was a pagan religion that brought together legends, beliefs, real historical events and the wisdom of many peoples who inhabited the Aegean Sea basin. In the vast pantheon of Greek gods, there was a place for the healer-god Asclepius, whose prototype historians tend to consider a real healer who lived during the Trojan War (7th century BC). According to legends, considered the son of Apollo, the god of music, poetry and sunlight, Asclepius learned the art of healing from the wise centaur Chiron and soon surpassed the teacher, since he not only healed the sick, but also revived the dead, causing the anger of the god of the underworld, Hades. Having settled on the island of Kos, Asclepius founded there a center of medical knowledge and a family of Asclepias, descendants of Asclepius. The immediate children of the god were considered Hygieya - the goddess of health, Panakeya - doctor with medicines (they are mentioned in the text of the "Oath") and other famous healers. The introduction of healers into the pantheon of gods laid the foundations of a tradition alternative to the usual empirical healing or the practice of healers, which of course took place among the Hellenes earlier. This new tradition, which has flourished over the centuries, is temple healing.
The first sanctuaries dedicated to Asclepius were erected around the 6th century. BC, originally on the island of Kos. Subsequently, this practice became so widespread that ancient sources speak of more than 300 Asclepion (temples of the god Asclepius) in the territory of ancient Greece. These sanctuaries varied in scale, and the richest of them were of amazing organization. As a rule, they were built not just in fertile, but special places, where there were mineral springs with healing waters, cypress groves, the sanctuaries themselves were majestic and beautiful buildings dedicated to the gods mentioned above. It is clear that we can speak at least about the presence of components of sanatorium-resort treatment, especially since historians note the presence on the territory of the sanctuaries of a bath, a library, a stadium and a gymnasium for sports, and sometimes a theater.
Healing in the Asclepion combined empirical and magical techniques. In addition to hydrotherapy, gymnastic exercises, and the use of medicinal herbs, a special sacred ritual was used to remind one of the more ancient traditions of healer and magical healing. This ritual called encomisis(translate the Greek word Enkoimesis as "incubation" or "incubation sleep"), was an artificial or hypnotic sleep, in which large groups of people suffering from cure were immersed. The procedures were carried out in the majestic halls of the sanctuary, the method of immersion in sleep could be both the use of substances with a narcotic effect, and methods of psychological influence. The techniques of theatrical performances with the apparitions of the gods were used, and publicly performed surgical interventions could also be used to immerse oneself in a trance. The healing effect of such rituals was so significant that crowds of sufferers flocked to the temples, bringing huge incomes to the Asclepion.
It is interesting to note that there was no single payment for treatment, however, everyone who came for help made a sacrifice to the gods as far as possible, and, in addition, made a vow of another sacrifice in favor of the temple, if the treatment was successful. When the desired result is achieved, such votive(sacrificial) offerings went to the temple. This is evidenced by numerous images of hands, feet, ears and other parts of the body that were healed in this temple, found during excavations of temples, along with surgical instruments. The fact that the material from which such offerings were made varies (from gold and silver to marble and gypsum), as well as their size, makes it possible to assert adherence to the principle of voluntary donations and their volume. It is also important from an ethical point of view that donations were brought upon the fact of healing, by those patients who received the expected effect. However, there were other traditions in the temples, more dubious from an ethical point of view, for example, there was a rather strict preliminary selection of patients, when those suffering from incurable diseases threatening close death, as well as women in labor, were not allowed into the temple as unclean.
Healing in ancient Greece was not limited only to temple practice, empirical, secular healing was also widespread, and they cannot be completely delimited one from the other. This is evidenced, for example, by the practice of itinerant doctors who move from city to city, at the invitation of both temples and private individuals. This movement of physicians contributed to the spread of medical knowledge and the creation of medical schools. Healing for a long time remained a family tradition, protected from the uninitiated by tradition, but later, by the 5-4th century. BC, the scope began to expand somewhat, and medical schools (Cnidus, Croton, Sicilian, Kos, etc.) began to accept students from outside, not from the families of this medical family.
Preserving the traditions of temple healing, the schools were distinguished by their closeness to knowledge from related fields, including the philosophical views of that period. The latter were quite variegated, it is not for nothing that Greece is considered the ancestor of almost all philosophical traditions of our time. In the classical period of the history of ancient Greece, two main classical systems of philosophy were formed: the natural-scientific (materialistic) atomistic doctrine, formulated in the works of Democritus, and objective idealism, created by Plato. The formation of specific sciences, including medicine, was inseparable from philosophy. The Ionian natural-philosophical tradition turned out to be especially significant, which opened the way to the study of the main causes of diseases and the disease process itself, and the tendency to systematize knowledge contributed to the development of systematization in medicine, led to the creation of theories of disease and the emergence of independent directions. Why is it important? Because the disease was no longer viewed as the result of the punishment of the gods, but began to be interpreted as arising from natural causes affecting the body. This tradition was fully supported by Hippocrates, who is considered the great healer of ancient Greece and formulated the ethical code of the doctor of that period that interests us.
For a long time, medical traditions in ancient Greece remained secret, closed from the uninitiated, and if not family, then clan. For several centuries, advanced medical schools have developed, which in the classical period were located mainly outside the Balkan Peninsula, outside Greece itself, in its overseas settlements. Without dwelling on the history of the schools mentioned above, their similarities and differences, we note that they were characterized by a natural philosophical tradition, empiricism in the acquisition of knowledge, human health and diseases were thought in close connection with the surrounding world. Attention was paid to the body's natural healing powers, for the stimulation of which certain procedures were also proposed. The highest merit of the doctors of ancient Greece is the systematization of information of a medical nature, the creation of the first written sources for the transfer of medical knowledge.
Hippocrates II the Great (c. 460 - c. 370 BC), whose legendary name is a symbol of medical art in ancient Greece, was a representative of the medical school on the island of Kos. There are few reliable information about his life. The very first biographies of Hippocrates were written several centuries after his death, their authors were more likely guided by orally transmitted information that had developed into legends. So, accept to consider that born on about. Kos Hippocrates belonged to the ancient and noble family of Asclepion, that is, he was a direct descendant of the god of healing Asclepius. Having studied healing on his native island, he subsequently did not live in one place, but, on the contrary, traveled a lot, healing in different regions of Greece and beyond. As a wandering healer, Hippocrates thereby spread both knowledge and his own fame in different parts of the country, and became literally a legendary man. At the same time, we emphasize that a certain stamp that calls Hippocrates "the father of medicine" is not accurate. In his great time, he was the head of an outstanding medical school, personifying the best achievements of ancient Greek medicine, but medicine itself, as we have already noted, has a noticeably more ancient history.
Our attention to Hippocrates is due to understandable reasons, since there is no more well-known ethical document in medicine than the medical code called "The Oath", the authorship of which is attributed to Hippocrates. We consider it fair to say that it is difficult to recognize probably the authorship of Hippocrates in relation not only to the "Oath", but also to other works. Peru Hippocrates is credited with a very large number of them, collected around 300 BC. in the "Hippocratic collection" (Latin: "Corpus Hippocraticum"). The opinion of many researchers in the history of medicine, the authorship of Hippocrates asserts for such works as "Aphorisms", "Prognostics", "Epidemics", "On the air, waters, localities", "On ancient medicine" and some others. Most of the essays relate, of course, to practical medicine, describe the methods of examining the patient, medical, dietary instructions for the treatment of internal diseases, surgery and obstetrics. Thus, the "Hippocrates Collection" is an encyclopedia of ancient Greek medicine of the classical period, which lists more than 250 herbal medicines and 50 animal products. Our main interest is the ethical aspect of medical practice. It can be found in a number of Corpus writings, such as The Oath itself, as well as On the Doctor, The Law, On Art, On Decent Behavior, and Instruction. It is important for us that in the Code, Hippocrates speaks about a number of features of teaching medical science, and suggests not only to assimilate knowledge of medicines, methods of their preparation and correct use, but also to learn a certain set of techniques and rules of behavior.
The main ethical document, of course, is the Oath. If you look at its text (see Appendix 1), then already from the first phrases it is clear that the rules proposed in it are based on strict corporate ethics not just a profession, but rather a religion, a system of views and beliefs of some rather closed clan. This is evident from the requirement for a special, equal respect for parents, attitude towards teachers and respectful towards colleagues, like other initiates. The clan nature of the profession also sounds in the prohibition on the dissemination of medical knowledge outside a narrow circle of initiates, confirmed by the high requirements for the behavior of doctors, higher, as historians of medicine write, than just the ethical and legal requirements of that time. In essence, the ethics of Hippocrates is the ethics of commandments, rules or strict prescriptions, that is, deontological ethics, moreover, for persons speaking on behalf of a respected deity, and thus standing, as it were, above other people.
Within the framework of this deontological ethics, a clear and unambiguous solution of a number of particular issues is proposed. Thus, the Oath clearly states: a ban on the appointment of a "lethal agent" (that is, a ban on euthanasia), abortion, personal, and especially intimate, relations between a doctor and patients, and the rule of confidentiality is rigidly formulated. "Refraining from causing any harm and injustice" is also singled out as a separate principle, which later, during the Roman Empire, will receive an even more orthodox sound: "First of all, do not harm" ("Primum non nocere"). The ideas of humanity and respect for the patient's human dignity are concretized in many of the teachings of the "Corpus of Hippocrates", in particular those concerning the patient's family life. The already mentioned ethical prohibition concerns the intimate relations of a doctor and a patient: "Whatever house I enter, I will enter there for the benefit of the patient, being far from everything intentional, unrighteous and harmful, especially from love affairs with women and men, free and slaves." , “A doctor has a lot of relationships with patients; after all, they entrust themselves at the disposal of doctors, and doctors at all times deal with women, with girls and with property of a very high price, therefore, in relation to all this, the doctor should be abstinent "," When you come to a patient, you should remember ... about outward decency, ... about brevity, about ... to immediately sit down to the patient, showing attention to him in everything "(" The Oath "," About the Doctor "," About Decent Behavior "). The most famous commandment of the ethics of Hippocrates is his prohibition on divulging medical secrets. . This ethical requirement is also contained in the "Oath": "Whatever during treatment - as well as without treatment - I neither see or hear about human life from what should ever be disclosed, I will keep silent, considering such things secret "(quoted by TS Sorokina, 1994).
The ideas of Hippocrates were in many ways ahead of their time, but this is especially true of the idea of respect for human life. it is reflected in two themes - euthanasia and abortion, and with regard to the resolution of these topics, Hippocrates is short and categorical: “I will not give anyone the lethal remedy I ask for, and I will not show the way for such a plan; Likewise, I will not give an abortion pessary to any woman. "
The development and continuation of the formulated theses, some explanations to them, can be found in other works of Hippocrates. So, in the work "On Decent Behavior" it is said about the need for a doctor to educate himself, developing "contempt for money, conscientiousness, modesty, ... decisiveness, neatness, an abundance of thoughts, knowledge of everything that is useful and necessary for life, aversion to vice, denial of superstitious fear of the gods, divine superiority. " The last words that set the position of the doctor, unusually high, Hippocrates explained by the fact that "The doctor-philosopher is equal to God," and here we see the source of this position as the religious, superhuman foundations of healing that we had indicated earlier.
It was necessary to build relationships with patients in a special way. The doctor is obliged to make a positive and worthy impression on the patient, and for this to monitor his appearance: "The doctor is informed by authority if he is of good color and well-nourished, according to his nature, for those who themselves do not have a good appearance in their bodies are considered by the crowd to be unable to take proper care of others." It is recommended to "keep yourself clean, have good clothes and rub yourself with fragrant ointments, for all this is usually pleasant for the sick ..." Such advice about the image (as we are now talking about) is evidence of concern for the authority not so much of one doctor as of the profession as a whole, the profession of which he is a representative. An indication of avoiding both excessive severity and gaiety is one of the analogous status restrictions ("About the doctor").
The type of role-based (again in accordance with modern terminology) relationship with the patient recommended to the doctor is, of course, the type of “paternalistic model”. This conclusion is obvious due to the instructions to the doctor to combine "attention", "affection" with "persistence", "severity" in relation to the patient. So, it is necessary to visit the patient often and carefully observe, and "everything should be done calmly and skillfully, hiding much from the patient in his orders, ordering with a cheerful and clear gaze what should be done, and turning the patient away from his wishes with persistence and severity." ("On Decent Behavior"). Thus, it is the doctor who decides what needs to be done, what are the pros and cons for the patient, the opinion of the latter is not taken into account. It is also recommended not to completely trust the patients and, if necessary, you can assign to the patient a sufficiently experienced student, "who would watch that the patient obey the instructions on time." At the end of the book "On Decent Behavior" there is a piece of advice: "Announce everything that is done in advance to those who need to know it." Thus, the paternalistic position here acquires its completeness: the restriction in informing the patient himself is complemented by the requirement to inform third parties (without the patient's consent!).
The question of the doctor's remuneration did not go unanswered. The author of the "Oath" wrote that while worrying about the patient's health, the healer should not start by worrying about his reward, since "paying attention to this is harmful to the patient." Moreover, it was pointed out that it was sometimes necessary to heal without reward, for nothing, “considering grateful memory higher than momentary glory. If the opportunity presents itself to provide assistance to a stranger or a poor man, then such in particular should deliver it. " And also: “It is better to rebuke the saved than to plunder in advance those in danger” (“Instructions”). Hippocrates made an attempt to resolve the age-old dilemma: the doctor's work must be fairly paid, but the relationship between the doctor and the patient cannot be characterized in only economic categories, since then the humanistic nature of the medical profession suffers. In the book "On Decent Behavior" the author says that medicine and wisdom are closely interconnected (and even identical), and he calls the first manifestations of the doctor's wise life position "contempt for money, conscientiousness, modesty."
Finishing his studies, the future healer gave the "Oath" orally and in writing, and later was obliged to unbreakably follow it throughout his life, for "whoever succeeds in the sciences and lags behind in morality is more harmful than useful." The laws of medical ethics in ancient Greece were strictly followed and were the unwritten laws of society, for "where there is love for people, there is love for your art." The "Oath" given by the healer protected patients, being a guarantee of high medical morality, and provided the healer with the confidence of society. In the works of Hippocrates, one can find references to another interesting aspect of the professional ethics of doctors - their attitude towards unscrupulous colleagues. Thus, it is directly indicated that there are "pseudo-doctors" who "possessing professional dexterity, deceive people ..." The last distinctive feature is once again intended to emphasize the philanthropic nature of medical practice. The relationship of doctors with each other was also subject to ethical regulation. So, "doctors who examine a patient together should not quarrel with each other and ridicule each other", they should not be like "neighbors in their craft on the square", and "the doctor's judgment should never arouse the envy of another." In addition, Hippocrates believed that "there is nothing shameful if a doctor who is in difficulty in a patient's case ... asks to invite other doctors" (ibid.).
It is safe to say that the ethics of Hippocrates, on the one hand, was the result of the medical practice of that period, the practice of temple (and later secular) healing, on the other hand, it was much ahead of its time. She set the tone for the ethical component of the medical profession for many centuries to come, and had a tremendous impact on the moral consciousness of physicians in ancient Greece and Rome.
Ibn Sina
The scientific and practical activities of Ibn Sina, who is one of the greatest scientists of Central Asia, who have enriched world science with achievements of paramount importance, played a huge role in the development of medicine. The works of Ibn Sina and his great contemporary Abu Rai Khan Beruni marked the highest stage in the development of science in the medieval East.
Ibn Sina's father, Abdallah, was from Balkh. During the reign of the Samanid emir Nukh ibn Mansur (976-997), Abdallah moved to Bukhara, where he was appointed head of tax collection from the village of Khurmitan, near the city of Bukhara. Then he lived for some time in the village of Avshana, where he married a girl named Sitora. At the beginning of the month of Safar in 370 AH (the second half of August 980), their son Hussein was born (this is Ibn Sina's own name). Hussein was about 5 years old when the family moved to the capital city of Bukhara, which was then one of the largest centers East. The boy was sent to school.
From early childhood, Ibn Sina studied the Koran and adab (this included grammar, stylistics and poetics), and by the age of 10 he had reached perfection in both areas. In addition, he studied arithmetic and algebra, and then under the guidance of his home teacher Abu Abdallah an-Natili began to study logic, Euclidean geometry and Ptolemy's "Almagest". However, soon al-Natili was forced to admit that he had exhausted his educational material and was no longer able to satisfy the boy's cognitive interest, and Ibn Sina continued his teaching on his own. He enthusiastically took up the study of natural sciences, and above all medicine. At the same time he was engaged in medical practice - he treated patients free of charge. At the age of 17 Ibn Sina. how the doctor achieved such fame that he was invited to the court of Nukh ibn Mansur, who had been ill for a long time, and the court doctors who treated him could not help him in any way. Ibn Sina succeeded in short term to heal the ruler, and in gratitude for this, the young scientist received permission to use the palace library, which was one of the best and richest libraries in the entire Middle East. As a result, he expanded his scientific knowledge to grandiose proportions.
Having thoroughly mastered logic, natural science, medicine and other sciences, Ibn Sina moved on to metaphysics, which was then considered one of the main branches of philosophy. The conquest of Bukhara by the Karakhanids, the fall of the Samanid dynasty (999) and the feudal civil strife that followed these events did not allow Ibn Sina to continue his scientific studies in Bukhara. His father died in 1002. All this prompted Ibn Sina to leave native city and go to Khorezm, to Urgench, where the political situation was more favorable. Then, for political reasons, he was in about 1010 - 1011. secretly left Khorezm and went to Khorasan. He arrived in Gurgan, a feudal principality on the southeastern coast of the Caspian Sea. In Gurgan, Ibn Sina resumed his scientific work and medical practice. He began the first book of his main work on medicine - "The Canon of Medicine." In 1014 Ibn Sina left Gurgan and lived for some time in Rhea and Qazvin. Then he arrives in Hamadan, where, as a court doctor, and then a vizier, he wrote many of his works, began work on the multivolume philosophical encyclopedia Kitab ash-sifa (The Book of Healing).
In 1023 Ibn Sina moved to Isfahan and completed the Kitab ash-Sifa there, created other works, including his brief philosophical encyclopedia in Persian “Danish-name” (“The Book of Knowledge”).
Almost continuous wanderings in the cities of Maverannahr and Iran, constant hard work, sleepless nights, multiple imprisonments broke the scientist's body. He suffered from colitis, from which he died in Ramadan in 428 (June 1037) at the age of 57. Ibn Sina was buried in Hamadan, his grave has survived to this day.
As a true scientist - encyclopedist, Ibn Sina worked with great success in almost all areas of knowledge. The sources mention over 450 titles of his works, and the number of works that have come down to us is about 240. They cover such areas of science as philosophy, medicine, logic, psychology, "physics" (ie, natural science), astronomy, mathematics, music, chemistry, ethics, literature, However, Ibn Sina became famous mainly due to his works on philosophy and medicine. Ibn Sina used everything of value that was developed by his predecessors in the field of natural science and philosophy and created a philosophy that became the pinnacle of the development of theoretical thought in the countries of the Near and Middle East in the early Middle Ages. Despite the contradictory nature of certain provisions, the philosophical teachings of Ibn Sina played a progressive role under the conditions of feudalism. It clearly shows the materialistic tendency, the desire to oppose religion with scientific knowledge based on experience and logical evidence. Ibn Sina also left a significant mark in the field of poetry. He wrote many of his scientific treatises in poems in the amount of rajaz. In addition, he wrote several works that had a noticeable influence on subsequent Persian-language literature.
Ibn Sina's achievements in the field of medicine are especially great. He is rightly considered one of the greatest medical scientists in human history. According to various sources, the total number of medical works of Ibn Sina reaches 50, but about 30 of them survived. However, the main medical work Ibn Sina, who brought him centuries-old fame throughout the cultural world, is the "Canon of Medicine". This is a true medical encyclopedia, in which everything related to the prevention and treatment of diseases is presented with logical harmony. Ibn Sina not only combined the scattered experience of the past and supplemented it with the results of his own observations, but also formed a number of fundamental provisions related to the conduct of the first systematic medical tests. Ibn Sina connected the development of medicine with the development of rational pharmacy, with the use of drugs obtained by chemical means, he described many new drugs of plant, animal and mineral origin
Among the innovations related to ethical issues, the scientist recommended the practice of clinical trials on animals in order to test the effect of new substances, as well as a special approach to assessing the harm, side effects of drugs, determining the mutual enhancement and mutual weakening of the effect of drugs in their joint appointment. In fact, he asserted the natural-scientific essence of medicine as a field of scientific and practical activity and a special, also natural-scientific, status of a doctor. It was a speech against the superstitions that reigned in contemporary medicine, astral notions, magical cypherology, indications of the healing properties of precious stones, conspiracies, and amulets. Within the framework of such a practice, doctors of that period often did not claim real treatment, entrusting their patients to the will of Allah, to which the great Ibn Sina opposed rational means of diagnosis, therapy and hygiene. Even in relation to mental disorders, he looked for rational causes associated with the influence of the environment or bodily disorders, thereby rejecting demonological views on this type of suffering.
Objectively speaking, Ibn Sina did not create his own code of ethics, but his practice, broad erudition, experimental, scientific method became a model for many generations of doctors, and generalizing encyclopedic works largely contributed to the preservation and development of the achievements of ancient medicine (ancient, Hellenistic, Indian, Iranian , Central Asian), comprehension and synthesis of their rich practical experience and theoretical concepts. The Canon of Medicine was translated into European languages, and for several centuries became the most popular of the medical books written in the East. He was the main study guide in European universities, having a huge impact on the level of special knowledge of doctors in medieval Europe. The work, which immortalized the name of the author, was translated into many European languages many times, was published about 30 times in Latin and for more than 500 years served as a mandatory guide to medicine for European universities and medical schools in the Arab East.
We do not have the opportunity to dwell on the content of the "Canon", we will only note the breadth and representation of various aspects of medicine in this work (from human anatomy, clinical description of disorders, to their systematization, treatment methods, teachings about nutrition, hygiene, with prophetic ideas about infectious diseases, the doctrine of poisons, the relationship of mental illness with the state of soma, pharmacopoeia, exercise, etc.)
Paracelsus.
The personality of Paracelsus is so surrounded by fiction that it is impossible to establish biographical events with certainty. The sources for the biography of Paracelsus are, first, his writings, in which autobiographical data are very often found; secondly, the memoirs of his contemporaries and the compositions of his followers and opponents. However, his own compositions, written in an exaggerated boastful tone, overflowing with obviously incorrect data, can only be material for indirect judgments. As for the works of his contemporaries, they, too, written by friends or enemies in the heat of a fierce polemic struggle, give a vivid idea of the storm caused by the activities of Paracelsus, characterize the strength of his personality, fiery temperament, but in no way can they claim historical impartiality. How unreliable our information about Paracelsus is, can be judged at least by the fact that the surviving 35 of his portraits are very little like one another. Legends have surrounded Paracelsus (real name Philip Aureol Theophrastus Bombast von Hohenheim) since his birth in 1493. Biographers differ as to who his father was. Most likely, he was the legitimate son of Wilhelm Hohenheim, a physician and alchemist. Moreover, the name Theophrastus was given to him in honor of the famous disciple of the great Aristotle, in commemoration of a great future and the path of a healer. Paracelsus did not receive a classical education, his first teacher was his father, who taught him alchemy, therapy and surgery. Recall that at that time these two sciences and practices were usually separated, the latter was considered "dirty" work and was the lot not of doctors with university degrees, but representatives of the workshop of poorly educated bath attendants, barbers and midwives.
In his writings, Paracelsus also calls his teachers, in addition to his father, a number of persons, however, chronological data refute his statements, tk. they lived before he was born. It is difficult to say whether he was well-read, whether he knew the international language of medieval science - Latin, he never used it. But Paracelsus successfully compensated for the lack of classical education by long travels, during which he acquired his undoubtedly extensive knowledge. He traveled a lot, according to him, he visited higher schools Germany, Italy, France, traveled to Spain, Portugal, England, Moravia, Lithuania, Poland, Hungary, Wallachia, Transylvania, the Netherlands, Denmark, Finland, Lapland. He even assures that he has been to Asia and Africa. Even if this list is an exaggeration, it is known that Paracelsus traveled for many years. During his travels, he visited doctors and healers, warlocks and barbers, gypsies and even executioners. He earned food for himself with the help of his medical and alchemical knowledge, but this, as we now know, was not limited to this.
In 1526 Paracelsus, after long wanderings, arrives, accompanied by the glory of a skillful doctor, in Basel. Here his successful practical activity makes a strong impression: he enters into the mercy of influential people and gets a place as city doctor and professor of medicine at the university. The path to the position of professor was opened by the Reformation for Paracelsus: a number of departments were empty at that time at the University of Basel due to the removal of Catholic professors. The change of religion and the recommendation of Erasmus of Rotterdam made it easier for him to access the pulpit. Thus, a person who did not have a doctorate received, contrary to the well-established tradition, a professor's place at the University of Basel.
In his program, Paracelsus announced that he would purify medicine from the "barbaric leaven" and restore it to its primitive purity, that he would reject the ideas of the ancients and adhere to the instructions of nature itself, his own discoveries and his long experience, that doctors are grossly mistaken, because blindly follow Hippocrates, Galen, Avicenna and other authors. He also believed that not medicine, but chemistry can form true doctors, that neither academic degrees, nor eloquence, nor erudition acquired by reading, nor knowledge of the language will make them skilled doctors, but only deep knowledge of things, the study of secrets hidden in the depths nature - which is what all sciences are about. In his opening lecture, Paracelsus, repeating the gesture of Luther who burned the papal bull, burned the works of Galen and Avicenna in front of his listeners. Like Luther, who translated the Bible into German, Paracelsus did not deliver his lectures in Latin, but in German - a courage unheard of at that time. These are the outward manifestations of the upheaval wrought by Paracelsus. The boldness of his speeches, as well as the revolutionary (sometimes too risky) methods of treatment that he used, make literally all the doctors of his day turn against him. Paracelsus, with all the fervor of violent temperament, enters the struggle. Both sides do not spare each other and do not show much discrimination in the means, as well as in the expressions in which the controversy is conducted. It is easy to imagine what irritation Paracelsus caused in the camp of his enemies. They begin to persecute him. The University of Basel unexpectedly, a year after Paracelsus was appointed professor, demands from him the presentation of his doctoral degree. Paracelsus appeals to the council of the city of Basel and in a letter that has survived to this day, asks "to order his enemies to stop attacks against the university professor and not to prevent him from reading the course with offensive language and low accusations with which they shower him." The clash ended in victory for Paracelsus.
The struggle started by him continues after his death. The essence of his reform lies in the fact that he prioritizes chemistry and instead of herbal medicines begins to use chemical preparations, including potent ones. A new direction in medicine and pharmacy is rapidly spreading and, being one of the manifestations of the Reformation, is gaining an increasing number of supporters and adherents in the Protestant states. At the same time, the Catholic Church introduces the works of Paracelsus in the list of prohibited books, and the Paris parliament in 1566 prohibits the use of the funds of Paracelsus and at the same time expresses condemnation of all innovations in medicine.
Paracelsus' views on medicine are a consequence of his general worldview. He proceeds from the idea of the world as a single whole, consisting of the same basic principles and governed in all its parts by the same laws. Human body- chemical laboratory; disease - a violation of the correct activity of this laboratory, resulting from a lack or excess of any substances; the doctor's task is to restore the correct ratio by introducing the necessary chemicals into the body. In this way bringing medicine and chemistry closer together, Paracelsus gives the latter a new direction. Not the transformation of metals into gold, but the preparation of medicines should, according to Paracelsus, be the goal of chemistry. At first glance, it seems that this assumption of Paracelsus does not consist of a coup, but remember that for a millennium the efforts of alchemists were aimed at realizing a specific purpose that all the content of science was seen precisely in this and that alchemical theories are entirely built on the concept of the transformation of metals (see Jung K.G., 1992).
Paracelsus not only did not express a negative attitude towards the alchemical doctrine, he was a Kabbalist and a mystic, he considered the brain a microcosm, representing the macrocosm of the environment. He assured that he knows the secret of the "Philosopher's Stone" and knows how to transform metals, as evidence of which he demonstrated the "transformation" of iron into copper when a knife was immersed in a solution copper sulfate(in this case, the iron goes into solution, displacing copper from the latter, which is deposited on the surface of the blade). It is possible that, on the part of Paracelsus, this tolerance of alchemy was a tactic: he wanted to focus the fire of his attack on medicine and, in addition, benefited from the belief of his contemporaries in the transformation of metals. Since the time of Paracelsus, thanks to the unification of chemistry with medicine and pharmacy he made, a new period in the history of chemistry begins - the iatrochemical period.
For us, it is most important to mention that Paracelsus asserted a completely different attitude not only to teaching medicine, but also to medicine in general. For ordinary people, whose treatment he never disdained, he was something like Robin Hood: the rich had to pay him in full, and the poor could get treatment for free. He said that "mercy is the mentor of doctors", "mercy ... should be innate in a doctor", "where there is no love, there is no art." Displeasing the mighty of the world and the church, he also opposed the practice of using medical art in the service of the Inquisition and wrote: "a doctor can be neither a torturer, nor an executioner, nor a servant of an executioner."
He was, in relation to that time, inappropriately tolerant of the mentally ill: “In practice, it is much more important to heal the mentally ill than to cast out demons, because the mad are sick people, and, besides, our brothers, and therefore we should treat them with sympathy and gentleness ... After all, it may happen that we ourselves or our brothers will suffer the same evil fate ”(cited from Y. Kannabikh, 1994) ..
He studied the diseases of simple artisans, and constantly repeated that "it is not a title, not an oratory, not reading books that creates a doctor, but the only knowledge of things and forces of nature", "the theory of a doctor is experience." Even on his grave it is indicated that “he possessed magical knowledge and gave good to the poor,” it is not for nothing that the place of his burial in Salzburg has been revered and visited by those in need of healing for many centuries.
The "Paracelsus Model" is a form of medical ethics in which the moral relationship with the patient is understood as a component of the doctor's therapeutic behavior strategy. If in the Hippocratic model the social trust of the patient's personality is won, then it is important to take into account the emotional and mental characteristics of the individual, to recognize the depth of her emotional contacts with the doctor and the involvement of these contacts in the treatment process. This, of course, is also paternalism, but which is characterized by positive psycho-emotional attachments and social and moral responsibility, "healing", "divinity" of the very contact between the doctor and the patient. The main principle that is formed within the boundaries of this model is the principle of “do good”, good, or “create love,” benevolence, mercy. Healing is this organized realization of good. Paracelsus wrote: “The strength of a doctor is in his heart, his work should be guided by God and illuminated by natural light and experience; the most important basis of medicine is love. "
- 81.50 KbIntroduction
The history of medical ethics available to us in the written language is more than three thousand years old. For European medicine, the ethics of the ancient Greek physician Hippocrates (460 - 370 BC), in particular his famous medical "Oath", remains relevant to this day. After in the XVI century. the first published works of Hippocrates ("The Hippocratic Corpus") were published in Europe, the growth of his authority among European doctors can be figuratively called the "second coming" of Hippocrates. Already at this time, doctors who were receiving their doctor of medicine at the Paris Medical Faculty were obliged to give a "Faculty Promise" in front of the bust of Hippocrates.
The purpose of this study is to explore the main ideas underlying the ethics of Hippocrates, historically the first European form of medical ethics.
In this regard, it seems necessary to consider the following issues:
Consider the Hippocratic Oath and analyze its provisions on the basic values of the immoral norms of the relationship between the doctor and the patient;
Show how the ideas of Hippocrates were developed in Europe in the works of Paracelsus and Percival;
Show the role of Hippocrates' ideas in modern medicine.
1.Hippocratic oath on the basic values and moral standards of the relationship between doctor and patient
Around 400 BC. e. Hippocrates, the ancient Greek physician, who is called the father of medicine, drew up the text of the medical oath, expressing the fundamental moral and ethical principles of the physician's behavior.
Hippocrates believed that the oath of medicine was of particular importance. As one of the founders of medicine, Hippocrates asked doctors to swear an oath:
“I swear by Apollo the doctor, Asclepius, Hygieia and Panacea and all the gods and goddesses, taking them as witnesses, to fulfill honestly, according to my strength and my understanding, the following oath and a written obligation: to honor the one who taught me on an equal basis with my parents, to share my wealth with him and, if necessary, help him in needs; consider his offspring as his brothers, and this art, if they want to study it, teach them free of charge and without any contract; instructions, oral lessons and everything else in teaching to communicate to his sons, the sons of his teacher and students, bound by obligation and oath under the medical law, but to no one else. I will direct the regime of the sick to their benefit in accordance with my strength and my understanding, refraining from causing any harm and injustice. I will not give anyone asked of me a deadly remedy and will not show the way for such a plan; Likewise, I will not give an abortive pessary to any woman. I will pursue my life and my art purely and immaculately. In no case will I make cuts in patients with stone disease, leaving it to the people involved in this business. Whatever house I enter, I will enter there for the benefit of the sick person, being far from everything intentional, unrighteous and harmful, especially from love affairs with women and men, free and slaves.
So that during treatment - as well as without treatment - I neither see nor hear about human life from something that should never be divulged, I will keep silent, considering such things a secret. I, who unbreakably fulfill my oath, may be given happiness in life and in art and glory with all people for eternal times; and the one who transgresses and takes a false oath, let the opposite of this be done ”1.
The god Apollo mentioned here is the patron saint of doctors in ancient Greece and Rome (and the god of music, poetry, divination and the founding of cities). Asclepius, son of Apollo, was considered a special god - the patron saint of doctors. Hygieya (Hygiene) - the goddess of health, Panakeya (Panacea) - the goddess-healer of all diseases - the daughter of Asclepius.
The philosophy reflected in this document rather corresponds to the ideas of the Pythagoreans of the 4th century BC. BC, who preached the sanctity of life and were reputed to be opponents of surgical intervention 2.
The "Oath" of Hippocrates is based on the idea of respect for the patient, the patient, the mandatory requirement that any treatment does not harm him.
Medical ethics requires from a specialist not only not to do evil, but also to perform good deeds. “Whatever house I enter, I will enter there for the benefit of the patient,” says the Hippocratic Oath.
A curious moment of the oath is the prohibition of intimate relations between the doctor and the patient.
The most famous commandment of the ethics of Hippocrates is his prohibition to divulge medical secrets. The medical community, thus, appears before us as a very closed social organization, which could be designated as an order or clan.
Finally, it should be noted that the society in ancient Greece highly appreciated and encouraged the dedication and disinterestedness of doctors. In ancient Greek mythology, philanthropy was a feature of the patron saint of medicine, Asclepius. The work of a doctor was paid highly in Ancient Greece (better, for example, than the work of architects). But Hippocrates advises his student, when it comes to fees, to differentiate between different patients: “And I advise that you do not behave too inhumanely, but that you pay attention to the abundance of funds (in the patient's) and their moderation, and sometimes heal it would be a gift, considering a grateful memory higher than momentary glory. If the opportunity presents itself to provide assistance to a stranger or a poor man, then such in particular should deliver it ”3.
Hippocrates saw a deviation in the doctor's moral behavior from the everyday practice of human relations, first of all, in the fact that it should not be focused on the personal individual good of the doctor and the search for ways to achieve this good (be it material, sensual, etc.).
The behavior of the doctor, both from the point of view of his internal aspirations and from the point of view of his external actions, should be motivated by the interests and welfare of the patient. “Whatever house I enter, I will enter there for the benefit of the patient, being far from everything intentional, unrighteous and harmful,” wrote Hippocrates.
He rightly noted the direct relationship between philanthropy and the effectiveness of a doctor's professional activity. Philanthropy is not only a fundamental criterion for choosing a profession, but also directly affects the success of medical practice, largely determining the measure of medical art. "Where there is love for people, - said Hippocrates, - there is love for your art"
2. Development of the ideas of Hippocrates in European medicine in the 16-18 centuries.
2.1 Paracelsus' model of medical ethics
The second, after Hippocrates, historical form of medical ethics was the understanding of the relationship between a doctor and a patient, which developed in the Middle Ages. Paracelsus (1493-1541) was able to express it especially clearly. K. Jung wrote about Paracelsus in the following way: “In Paracelsus, we see not only a founder in the field of creating chemical drugs, but also in the field of empirical mental treatment” 4.
The Paracelsus model is a form of medical ethics in which the moral attitude towards the patient is understood as one of the most important components of the doctor's therapeutic behavior strategy. If in the Hippocratic model of medical ethics, first of all, the social trust of the patient's personality is won, then in the Paracelsus model the emphasis is placed on taking into account the emotional and mental characteristics of the personality, on recognizing the importance of emotional contact with the doctor and the involvement of such contact in the treatment process.
Within the boundaries of the Paracelsus model, paternalism (from Lat. Pater - father) is fully developed as a type of relationship between a doctor and a patient. The true meaning of the paternalistic approach lies in the fact that the connection between the doctor and the patient reproduces not only the best examples of consanguineous relations, which are characterized by positive psycho-emotional attachments and social and moral responsibility, but also a kind of “divine healing” of the contact between the doctor and the patient 5.
This "divine healing" is determined and set by the doctor's virtue, the direction of his will for the patient's welfare. It is not surprising that the main moral principle that forms within the boundaries of this model is the principle of doing good, good, or do love, good deed, mercy.
Paracelsus taught: “The strength of a physician is in his heart, his work should be guided by God and illuminated by natural light and experience; the most important basis of medicine is love. "
2.2. Peculiarities of medical ethics of Percival
In 1803, the English physician T. Percival published the book "Medical ethics, or a set of established rules in relation to the professional behavior of doctors and surgeons" (surgeons in those days did not belong to doctors) 6. If you get acquainted with these rules, you can see that they can be used for office instructions for doctors and nurses of the 20th century:
"Hospital doctors and surgeons should treat patients in such a way that they get the impression of the importance of their service; that the peace, health and life of those who are entrusted to their care depend on their skill, attention and dedication. They must also learn that in their demeanor should combine tenderness with firmness, condescension with authority in order to awaken in the minds of their patients feelings of gratitude, respect and trust.The feelings and emotions of patients in critical circumstances should be known and taken into account no less than the symptoms of their illness. incorrect assessment can reinforce real evil (disease) or create imaginary, no discussion about the nature of the disease is permissible in the presence of patients either with a doctor (surgeon), or with hospital students or other physician invited to the hospital. to speak about their complaints in such a tone of voice that they cannot be heard by those around them. cost, must be strictly observed. And women should be treated with the most scrupulous delicacy. It is cruel to neglect or laugh at their feelings ... No precautions in admitting patients suffering from incurable diseases, or contagious in nature, or tending to aggravate in an unclean atmosphere, can not eliminate the evil that comes from cramped wards and false economy. Distinguishing diseases with which admission to the hospital, the state of the air, nutrition, cleanliness, medications - all this should be carefully checked at certain periods of time. "
If in the ethics of Hippocrates the doctor must put the needs of the patient above his personal interests, serve the patient day and night with all his heart and with all his soul; do not indulge in crimes, drunkenness and adultery; keep professional secrets secret. Then in the ethics of Percival we see a slightly different attitude towards patients. Percival's doctor acts as a philanthropist who brings them the benefit and receives from them the appropriate gratitude. In his opinion, the doctor should behave with patients "delicately, balanced, condescending and authoritative."
Percival was the first to recognize the physician's obligation to not only patients, but society as well.
3. The role of Hippocrates' ethical ideas in modern medicine
The principles of modern medical ethics for the most part remain adequate to the ethics of Hippocrates: harmlessness, mercy, justice, but with the recognition of the patient's autonomy.
In the ethics of Hippocrates, the doctor-patient relationship was built on the basis of “strong” and “weak”, laying a model for a paternalistic approach in medicine. The dilemma of the paternalistic and non-paternalistic is now “cross-cutting” in the ethics of modern medicine. The paternalistic model is based on the asymmetry of the nature of the moral relationship between the doctor and the patient - the doctor assumes all (or almost all) responsibility for making clinical decisions. On the contrary, the non-paternalistic model of the doctor-patient relationship proceeds from the priority of the patient's moral autonomy, due to which the category of the patient's rights becomes the key category of this approach.
The basic moral principle of modern medicine is the principle of respect for human rights and dignity. Under the influence of this principle, the solution to the main issue of medical ethics is changing - the question of the relationship between a doctor and a patient. Today, the question of the patient's participation in making a medical decision is acute. This is far from secondary - participation is taking shape in a number of new models of the doctor-patient relationship. Among them - informational, advisory, interpretation. Each of them is a kind of protection of human rights and dignity.
In Russia, the overwhelming majority of doctors still adhere to the traditional paternalistic model of relationships with patients, in particular, professing the conviction of ethical justification in the context of healing the doctrine of “holy (saving) lies”. When Sigmund Freud learned from the doctor that he had cancer, he whispered: "Who gave you the right to tell me about this?" The great fighter against all self-deception in the field of sex did not find the strength to face another biological truth - inevitable death. Is it possible to reveal a "terrible" diagnosis to a patient or family, or should it be kept secret? Is it advisable to tell the patient a less traumatic diagnosis, and what should be the measure of truth? We often choose not to know the details of the treatment ahead of us and the associated risks. According to surveys, the number of patients who are not interested in obtaining information on these topics reaches 60% in Russia 9.
However, even in America, where for most people it is a matter of course for most people to know the truth about their condition, doctors take cultural factors into account. A young doctor tells a 68-year-old Chinese patient that he has cancer. From the point of view of a doctor, he does everything right - he realizes the patient's right to truthful and accurate information about his condition. But the patient's son is outraged: he believes that the doctor should have first talked with the patient's family members, and then they themselves would have decided whether to tell their relative the truth and in what form. In Chinese culture, the ethical basis of decision-making is Confucianism and Buddhism, which emphasize the values of consent and submission to authority. This tradition is in direct opposition to the Western model of the independent personality, in which hiding information is viewed as a violation of fundamental rights of the individual 10.
Description
The history of medical ethics available to us in the written language is more than three thousand years old. For European medicine, the ethics of the ancient Greek physician Hippocrates (460 - 370 BC), in particular his famous medical "Oath", remains relevant to this day. After in the XVI century. the first published works of Hippocrates ("The Hippocratic Corpus") were published in Europe, the growth of his authority among European doctors can be figuratively called the "second coming" of Hippocrates. Already at this time, doctors who were receiving their doctor of medicine at the Paris Medical Faculty were obliged to give a "Faculty Promise" in front of the bust of Hippocrates.
Content
Introduction 3
1.Hippocratic oath on the basic values and moral standards of the relationship between doctor and patient 4
2. Development of the ideas of Hippocrates in European medicine in the 16-18 centuries. 7
2.1 Paracelsus' Model of Medical Ethics 7
2.2. Peculiarities of medical ethics of Percival 8
3. The role of Hippocrates' ethical ideas in modern medicine 10
Conclusion 13
References 15
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