At the beginning of the oath accorded to him, Hippocrates calls upon the Greek gods Apollo, Asclepius, Hygieia, and Panacea by name as witnesses to his solemn professional vow. Conventional wisdom often credits Hippocrates with naturalizing medicine, that is, of distinguishing the practice of medicine from the practices of magic, superstition, or otherwise religious ritual, which is not incorrect. Such an account does, however, overlook a critical point that concerns the ways in which Hippocrates refigures the relationship between the divine and nature in general and the relationship between religious piety and the practice of medicine in particular. Moreover, the received version of the story also overlooks the way in which the Hippocratic reconstruction of these relationships also provides warrant for a kind of epistemological humility that ought to characterize the practice of medicine altogether.
The problem is not thick religious commitments of the sort that Hippocrates himself actually had. On Hippocrates’ account, such religious commitments are precisely what keep epistemological hubris at bay. Hippocrates, well-versed in the Greek myths, notices how even the thunderings of Zeus do not always have their expected outcomes. For instance, Zeus might declare the destruction of a certain people for whatever reason, but it is not always the case that such destruction occurs. Hippocrates sees in such cases a parallel between divine pronouncement and medical prognosis insofar as in neither case can the outcome be known in advance. Even if either turns out to come true, it was not and could never have been known in advance, and it is the sort of endogenous uncertainty that characterizes the practice of Hippocratic medicine and at the same time indexes what sort of moral responsibility physicians have for their patients.
As a Catholic theologian myself, I have no intention of pretending to be a physician or even of having more than a woefully inadequate knowledge of medicine, biology, physiology, or anything of the sort. What I aim to do in this piece is simply to chart out some of the firm common ground between medicine and theology, between the medical vocation and the life of Christian faith, between tending to the body and tending to the soul. My fundamental question is “What ought we owe Hippocrates?” It is not, to be clear, “What do we owe Hippocrates?” as such debts are often and without compunction disavowed or at best remain contently unpaid. What ought we owe Hippocrates? How might we, in a sense, make good on the Hippocratic legacy? Though we are separated by over two millennia, by culture, and by religion, our respective situations are not entirely different. Human beings remain fundamentally the same: finite, mortal, uncertain.
Nature and Naturalizing Medicine
Perhaps it is best to begin with one of Hippocrates’s most central innovations, namely, his emphasis on prognosis, which of course remains an important part of the practice of medicine to this day. Moreover, Hippocrates is still rightly accorded credit for establishing its permanent importance. Yet, when we look to his treatise on prognosis, his Prognostikon, we find some interesting facets of his account of it that have, over time, become soundly ignored. For Hippocrates, prognosis is a form of fore-seeing and fore-telling, as the Greek etymology of the word suggests. It is a skill that must be cultivated and so cultivated by observation of the patient. Yet, Hippocrates begins his treatise with how the practice of prognosis, precisely because it is the fruit of observation, is first and foremost the means by which a physician gains the trust of her patient, so that the patient will be sufficiently forthcoming with symptomatic and habitual details that she would otherwise prefer to keep private. Hippocrates is well aware that for many of the sick they might accord a divine cause to their sickness, and Hippocrates does not rule that out. But it must be determined to be or not be the case.
In light of his observation and the account of symptoms and habits by his patients, Hippocrates foretells the outcomes of his patients, and the success of his treatments is directly correlated to the degree to which he is able to anticipate the future health conditions of his patients, that is, whether they will live or die. Medical prognosis is like divine prognosis, on Hippocrates’s account, insofar as they both retain their respective degrees of uncertainty, and in neither case are we dealing with an occult science. With respect to both, in fact, our horizon for observation is limited and our prognoses are both made from generalizations: for instance, patients who exhibit a certain constellation of symptoms (sunken eyes, vomiting, black veins, or the like) tend to die within a certain amount of time, and so forth; similar patterns can be observed with respect to the gods: people who behave in this way or that tend to meet this or that fate. Yet such outcomes are not certain. Sometimes symptoms resolve and the patient returns to health, and sometimes the wicked seemingly go unpunished to live long, morally deranged lives. In a way, Hippocrates seems just as weirded out by the patient who with clear and severe morbidities returns to health and lives a long life as the ruthless tyrant who is granted many decades over which to oppress and exploit his subjects only to die peacefully in his sleep at a ripe old age. Thus, beyond the physical suffering it encounters, the practice of medicine also experiences first the kind of existential suffering that comes with uncertainty.
At the same time, that uncertainty is not itself absolute, which is to say that only exactly one thing is certain: death. I think this insight gives us some perspective on the Hippocratic aversion to euthanasia: “I will give no deadly medicine to anyone if asked, nor suggest any such counsel,” as it is put in the oath. But we will have to get there. Very often we are told that the Hippocratic Oath commits the physician to a certain ethical stance or to uphold certain ethical commitments, but for Hippocrates himself such commitments are metaphysical before they are ethical. Hippocrates not only believed, like nearly all ancient Greeks, that human beings were created by the gods, he also believed that medicine was a gift from the gods, the very ones one invokes when taking the oath. It might seem, at first glance, that such belief is part and parcel of ancient Greek piety, but in reality, Hippocrates’s belief is actually revolutionary. The common belief of his predecessors and contemporaries was that the gods were the causes and occasions of illness and disease, not their cure. In his treatment of the Divine Illness, a medical treatise on epilepsy, a disease which was thought to be a visitation of the divine, Hippocrates argues that the so-called divine illness is not any more divine than any other illness; it is a manifestation of a compromised physiology rather than of divine agency.
It is worth pausing here, just for a moment. Try to imagine the kind of theological paradigm shift this represents, and it is undoubtedly worth noting that Hippocrates draws out a theological implication from his medical experience. He begins with his observation and treatment of epileptics, determines epilepsy’s physiological origins and then reasons to a theological conclusion. He might have pondered, “If epilepsy is not a divine visitation or affliction but is rather a disease of the body, then what do the gods have to do with it?” He might have continued to muse, “Yet, I am able to treat this disease. The body of my patient is intelligible to me. I can observe it, study it, diagnose it, and at least sometimes heal it.” The conclusion that Hippocrates reaches is that it is the healing that has divine origins, not the disease. The gods are in the business of healing, not cursing.
Moreover, in the oath, the healing gods are invoked as witnesses, not as agents of healing themselves. Again, this configuration is itself also revolutionary. For Hippocrates, if disease is a natural phenomenon with natural, physiological causes, then it would make little sense to attempt to treat it with magic, ritual, or superstition. By invoking the gods as witnesses, Hippocrates is making a properly theological claim, in fact a series of them. The gods do not wish us harm; they do not curse with illness; nor do they heal only if the proper ritual is performed, or observance made. Rather, they have given us, like Prometheus with fire, the gift of being able to heal the sick ourselves. They have given us the gift of medicine. In other words, it is not the case, as is often suggested of Hippocrates, that he banished the divine from the world of natural medicine at all. Instead, he presents a new vision of the relationship between religion and medicine altogether, and from that he goes on to characterize the medical profession, its best practices, and the ethical duty its practitioners have with respect to it.
Moreover, Hippocrates is also credited with revising the common understanding of the biological composition of the human body. Granted, we are talking about a historical moment at which we have not yet drawn clear distinctions between physiology and anthropology, so these ancient views of the human person, her nature and physiology, tended toward the philosophical or otherwise mystical. Before Hippocrates, the human person was thought to be a unity of the primordial elements: fire, water, wind, or earth. Hippocrates was not convinced. His physiology, however, appears still quite strange and perhaps just as esoteric. He understands the human person to be composed of four balanced “humors” or bodily fluids: blood, yellow bile, black bile, and phlegm. A healthy person is one for whom these humors or fluids are “balanced” or are in proper proportion with respect to one another; in an unhealthy person, on the other hand, the humors are imbalanced. As strange (and gross) as this seems, it is important to note that Hippocrates develops his physiology directly from his experience dissecting cadavers. Cut open a body, and you do in fact find those fluids, as well as tissues that could plausibly be understood to be composed of them. The practice of Hippocratic medicine, then, is to restore balance of these humors, at least when possible. Hippocrates’s approach is rather interesting. He acknowledges that the same disease can have many cures, precisely because natural things can be affected by any number of things. If it can be properly said that Hippocrates naturalizes medicine, this is what we must mean.
So, to return to euthanasia, the prohibition against it is not merely ethical, that is, to say that euthanasia is bad, so you should not do it, even if someone asks nicely. Rather, given his natural understanding of pathology and physiology, euthanasia could not possibly be considered medicine, precisely because it does not seek to restore balance to the humors. According to Hippocrates, we owe the healing gods at least that much, to practice medicine and not something else. The ethical stance has a natural rationale. It attends to the natural body and the complex constellation of natural factors that affects it and is affected by it. We invoke the healing gods, it would seem, first, as an expression of gratitude, for both the gift of medicine and for the gift of the natural world which includes our physiological bodies. Thus, I think we come to our first reason that we, and especially those in or considering the medical profession, ought to owe Hippocrates, namely, for the insight that places the practice of medicine within nature and demonstrates for us that God or the gods need not and ought not be a casualty of the naturalization of medicine.
Prognosis and Prognostication
We should now be able to see more clearly what Hippocrates means by prognosis. If you recall, prognosis is the fore-seeing or fore-telling of a specific medical outcome born of careful, informed observation. Prognosis reasons from observable phenomena to what is likely to come about. The presentation of this or that symptom tells us something, which for Hippocrates is always put in terms of proximity to death, what today we might call morbidity. Yet, even a healthy person, who presents no troubling symptoms, remains proximate to death. That is the only certainty. What is fascinating to me is how Hippocrates takes that uncertainty into consideration as he describes the task and responsibilities of the physician. This point is something that the oath perhaps overlooks or at least oversimplifies: “First, do no harm.” Yet, I think Hippocrates means something more sophisticated than a relatively uninspiring prohibition against hurting one’s patients. The potential for both harm and health are present far in advance of any administration of cures or therapies, precisely at the first moment of encounter. Our relationship to death is certain. We will die. The details of how that sure certainty unfolds, however, are uncertain.
For Hippocrates, it is this uncertain certainty and certain uncertainty that characterize not only the patient-physician dynamic but also a fundamental aspect of human experience. Hippocrates speaks often of the shortness of life. In the first entry in the collection of his aphorisms he writes, “Life is short, and art (techne) long, opportunity fleeting, experimentation perilous, and judgment difficult.” That life is short, Hippocrates is saying, casts all of what follows into a certain sharp relief. The shortness of life renders the acquisition of skill (techne), the seizing of opportunity, the success of experiments, and the making of judgments urgent. Of course, Hippocrates had this experience as a physician. The accuracy of his prognoses, the efficiency of the treatment of his patients, the honing of his medical skills—all of these things race against time. Yet Hippocrates is aware that his patients all have the same experience irrespective of their present state of health. They come to him with both the awareness that life is short and the worry that whatever symptom that prompted a visit to the doctor might make it shorter.
In another aphorism, Hippocrates gives this advice to his fellow physicians: “Cure sometimes, treat often, comfort always.” Comfort always. Having rehearsed all that we have established so far, such advice should strike us with a fresh profundity. Hippocrates prioritizes consolation even over treatment and cure. In other words, a physician should expect to provide treatment and to administer a cure should the circumstances warrant it, but there would never be a circumstance in which consolation is not appropriate. Or, to put it even more concisely, the human condition as such demands consolation insofar as it is fundamentally ordered toward death. Hippocrates is adamant; a condition might be treated, disease might be cured, but there is neither treatment nor a cure for our mortality. In the Prognostikon, Hippocrates defines prognosis as the means by which death is predicted. I think this definition is incredibly interesting, actually. What I take Hippocrates to be saying is that death is always-already implicit in any description, medical or otherwise, of the state of a human being. The medical prognosis is unique insofar as that implicit thanatonic dimension is correlated to the presence or absence of a certain symptom or symptoms.
On this point, Hippocrates sounds a bit like a Benedictine. In chapter 4 of his Rule, St. Benedict admonishes us to “keep death daily before our eyes.” As a general spiritual practice, this is of course sound advice. Memento mori. Remember that you will die. Reflect upon your mortality. Make decisions in the full awareness that you will die one day having made this or that particular decision. Again, great spiritual advice. Yet I think there is more here than might meet the eye. For our Benedictine Hippocrates, consolation (or giving comfort) is the first task of the physician—“Comfort always.” We are mortal, facing the inevitability of a certain death, however uncertain the conditions of our own respective deaths remain. The practice of Hippocratic medicine is predicated upon this brute fact. Yet, Hippocrates leads us to an interesting inference: any and every act of consolation or giving comfort to any mortal creature, human or otherwise, is always-already itself an act of consoling the dying. A simple act of kindness to a stranger, being present to a friend, soothing a fussy infant, even giving a dog a good scratch behind the ears, all in their own way mark moments of reprieve from the press of our mortal condition. Every such encounter has the potential to communicate to its recipient the modest dignity of reassurance that, “Yes, you will die, but you will not have died without having been loved, without having been treated kindly, without having experienced your own dignity that transcends the immanent frame of your mortal life.” Any act of consolation is to console the dying.
Yet, rather than relativizing the unique importance of the medical practitioner by identifying the consolation of the dying as something fundamental to and potential in all human interaction, the practice of medicine can be seen in this light as a sublime expression of that universal human activity. As we have mentioned, Hippocrates’s treatise on prognostication does foreground the importance of the moral quality of the physician and the importance of her studied attentiveness to her patient, but the priority of the text is to teach its reader how to interpret symptoms and render medical assessments. What do certain inflammations indicate? The pains in certain joints. Intestinal unpleasantness, to put it politely. Hippocrates even describes and classifies the different kinds of sweats a patient might have, which I will quote mainly for comedic effect:
Those sweats are the best in all acute diseases which occur on the critical days, and completely carry off the fever. Those are favorable, too, which taking place over the whole body, show that the man is bearing the disease better. But those that do not produce this effect are not beneficial. The worst are cold sweats, confined to the head, face, and neck; these in an acute fever prognosticate death, or in a milder one, a prolongation of the disease; and sweats which occur over the whole body, with the characters of those confined to the neck, are in like manner bad. Sweats attended with a miliary eruption, and taking place about the neck, are bad; sweats in the form of drops and of vapor are good. One ought to know the entire character of sweats, for some are connected with prostration of strength in the body, and some with intensity of the inflammation.
It is fascinating reading, truly, but it also gives an idea of how Hippocrates reasons from symptoms to prognostications. In any case, Hippocrates sees the physician as the one with the most insight into death, precisely because she knows its causes, its incremental actualization in the living person, the myriad ways in which death negotiates with the body through its complex interaction with the immune system and medical treatments. This knowledge is much more than a technical knowledge, though technical knowledge is essential. The practitioner of medicine perhaps knows death best because she knows death by acquaintance without dying.
The Greco-Roman doctor and admirer of Hippocrates, Galen, living in the century after the time of Christ, also wrote a treatise on prognosis, but his is very different. Galen’s On Prognosis is weirdly autobiographical. In it, he more or less gives an account of why he is so good at making accurate prognoses. If you are familiar with Galen already, you might already know that he is his own biggest fan. The text of his On Prognosis contains precious little medical information, but rather gives an account of how he became the best in the business. He describes his upbring and education, his medical training and experience, and on and on. As silly as this might strike us, there is something to it. He is ultimately explaining that the attention given to the particularity of the patient should also be directed to the particularity of the physician. Granted, it is surmised that in this text, Galen is making the play to be the personal physician to Marcus Aurelius, but I think the point stands. Galen gives us a means to correlate medical observation and personal reflection.
In the Christian tradition, we might call this correlation between observation and reflection discernment and the object of that discernment vocation. For both Hippocrates and Galen, consolation is a fundamental part of medical practice, precisely in virtue of the fact that medical practice is a part of a broader life that includes individual human beings in their own particularity beset by all manner of infirmity. This recognition of the importance of consolation is itself the result of discernment, not observation alone. Between the time of Hippocrates and Galen, we see an interesting development in Greco-Roman literature, the formation of consolation into a literary genre. These literary consolations were typically ethical or otherwise philosophical treatises on how to grieve properly or avoid grief altogether, very often commending such advice to grieving friends. Cicero wrote notable consolationes, as did Seneca, Plutarch, and others. Galen did, too.
The largely Stoic context of these works was largely to dissuade people from grieving, to console them so they would not have to grieve. Galen follows suit, yet with an interesting nuance. In his consolatio, which is translated as “On the Freedom from Distress” or “On the Avoidance of Grief,” Galen is responding to the cultural devastation of the loss of the Palatine libraries in Rome in AD 192, which included not only his own personal collection but many works in various states of progress; but he begins with noting the physiological effects of emotional distress on those who were in grief. According to Galen, to offer consolation means first and foremost the alleviation of harmful, even deadly symptoms; he claims that one of his friends actually died from his grief over the fire. Very quickly, however, he goes on to explain why he experienced no such distress by detailing his own childhood and upbringing. Galen is critical of the Stoic program of philosophical impassivity in the face of tragedy as a matter of principle insofar as it overlooks one’s particularity, namely, their psychological composition and their personal history, and how such things impart a person’s system of evaluative beliefs. In other words, the answer to emotional distress or grief cannot be an axiom, but rather requires both personal reflection and the psychological training to exercise those right evaluative beliefs in times of crisis. Again, it is a matter of observation and reflection. Sometimes distress is reasonable. Moreover, we should anticipate those occasions, rehearse them in advance so we are not stricken by their surprise. We should seek consolation not in the vain hope of avoiding them, but rather in our ability to cope with respect to them, which we discern through careful self-observation and self-reflection.
As we begin to conclude, we should return to our question of what we ought to owe Hippocrates—and Galen, too, I suppose. Perhaps it is as simple as quoting Hippocrates himself and to commit ourselves to his maxim: comfort always. For those who treat often and cure sometimes, as he goes on to say, consolation will mean something pretty specific in individual medical practice; yet for all of us, to console one another is perhaps one of the most profound ways to dull the sting of death, to attend to the dying at whatever stage of death they are. Moreover, perhaps one way in which we might keep St. Benedict’s rule of keeping death daily before our eyes is to bring others—the mortal and so dying capital-O Other—before our eyes, to regard others in their constitutive mortal vulnerability as worthy of tenderness, compassion, and love.
Thus, having spent so much time ruminating upon consoling the dying, we are left with a final theme: death itself as a consolation. In one sense, perhaps a bit grim, death is the alleviation of that condition that we call life, which as we all well know includes incredible suffering. St. Paul in the Letter to the Romans, writes about how the law of sin exercises its dominion in death, yet by our death we are free from sin. Paul seems to take this as evidence of sin’s inherent weakness in contradistinction to the grace we receive through faith in Christ Jesus which leads to eternal life, but I think we are well within our right to find some consolation also in the freedom from sin that will come through our own deaths. In another sense, however, we might find consolation in death, in its fittingness as the end to our mortal lives. One of my favorite biblical reflections on death, Sirach 41:1-4, speaks to this beautifully:
O death, how bitter is the reminder of you
to one who lives at peace among his possessions,
to a man without distractions, who is prosperous in everything,
and who still has the vigor to enjoy his food!
O death, how welcome is your sentence
to one who is in need and is failing in strength,
very old and distracted over everything;
to one who is contrary, and has lost his patience!
Do not fear the sentence of death;
remember your former days and the end of life;
this is the decree from the Lord for all flesh,
and how can you reject the good pleasure of the Most High?
Whether life is for ten or a hundred or a thousand years,
there is no inquiry about it in Hades.
This admonishment not to fear death is—or should be—consoling. I suspect it is not entirely consoling, but I also suspect that it is not because we treat that admonition as an axiom and not as the fruit of observation and reflection. To be free of the fear of death is a matter of discernment. We must come to understand and experience our own mortality as a gift from God, not just our life. Even the Christian hope in the resurrection does not stand in death’s way. The hope in the resurrection does, however, speak beyond it, to the far shore of our mortality where by God’s grace we might be raised with Jesus Christ, who is the Great Physician, to everlasting life.
EDITORIAL NOTE: This paper was originally presented at the Hippocratic Society of the University of Notre Dame, 28 April 2024.
