Medical Ethics, History of the Near and Middle East: I. Ancient Near East

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I. ANCIENT NEAR EAST

In its conventional sense the term ancient Near East includes a diverse range of cultures. This article limits its coverage to Mesopotamia from the Sumerian period (beginning ca. 3100 b.c.e.) through the Babylonian period (ending with the Persian conquest in 539 b.c.e.), Egypt from about 3100 b.c.e. to its conquest by Alexander the Great (332 b.c.e.), and Israel from the Exodus (variously dated from 1446 b.c.e. to 1280 b.c.e.) to the destruction of Jerusalem by the Romans in 70 c.e.

In both Mesopotamia and Egypt thriving medical professions existed throughout the period under consideration. In Israel a distinct medical profession appears to have developed very late (second century b.c.e.). If anything that could be called medical literature was produced in Israel, it was at the very end of our period. By contrast a large body of medical literature, some of which has survived, existed in both Mesopotamia and Egypt.

Conceptual Observations

No writer in the ancient Near East appears to have addressed what we call medical ethics as an area of specific discussion. No one seems to have written even on that weak precursor of medical ethics known as medical etiquette. Nevertheless, medical ethics existed as much in the ancient Near East as in any other culture. The medical ethics of any society is generally congruous with that society's moral perceptions. As a subset of its ethical values, medical ethics will be as simple or as complex as any culture is monolithic or pluralistic. An ethical framework exists for the practice of medicine wherever those who treat disease, even in a magico-religious form, administer healing. In seeking to reconstruct the medical ethics of any society, one must understand the broad cultural framework within which healers function in order to appreciate the ethical considerations that directly or indirectly govern the practice of their art. This picture may be supplemented by the incidental illumination of relevant aspects of medical practice gleaned from medical and other literature, as well as by evidence of legal constraints upon the activities of practitioners of the healing arts.

J. V. Kinnier Wilson remarks that "Medically, as in other respects, Egypt, Mesopotamia, and Palestine were three quite different worlds. Each developed along independent lines of thought and was of its own kind" (p. 337). While this statement is essentially correct, Mesopotamia and Egypt are sufficiently similar when contrasted with Israel that they may be considered together, while Israel, because of its unique religious and moral outlook, merits separate treatment.

Mesopotamia and Egypt

THE UNDERSTANDING OF DISEASE AND THE ROLE OF PHYSICIANS. In Egypt and Mesopotamia all aspects of life were molded by religions that were naturalistic and polytheistic, based on the worship of cosmic forces, and steeped in magic. Health and physical wholeness were perceived as being present so long as life remained in harmony with the forces of deified nature, while illness reflected a dissonance between the individual and his or her total environment. It was imperative to identify the cause of sickness in order that the appropriate treatment might be given for the restoration of health. Edwin Yamauchi isolates four main sources of illness, which were not mutually exclusive: (1) a divine source which sent illness as a punishment for sin; (2) a demonic source which indwelt or tormented the individual; (3) a magical source sent from a sorcerer or practitioner of black magic; and (4) a natural source as discerned by experience. The modes of treatment would include: (1) prayer, sacrifice and repentance; (2) the exorcism of demons; (3) counter-magic; and (4) empirical applications of medicine, drugs, or surgery. Quite frequently different kinds of treatment were combined. (p. 99)

In both Mesopotamia and Egypt the treatment of disease attributed to divine, demonic, or magical sources fell within the purview of a class of healers different from those who treated disease attributed to natural causes. In Mesopotamia the latter class (the azu or asû) appears to have emerged much earlier than the former (the āšipu). According to Kinnier Wilson, "In Sumerian times—as it would seem—the azu was the only doctor who was prominent in society. It is only at a later period, in Babylonia, that one meets the āšipu, a specialist in incantations and a kind of medical 'diviner,' capable of reading the 'signs' of suffering or of divine punishment" (p. 349). The two professions were functionally and ideologically distinct, and only the āšipu was a priest. Similarly, in Egypt, the seynu (or swnw), like the Mesopotamian asû, was concerned with the treatment of physical conditions, whether sicknesses or injuries, for which a proximate, natural causality was evident; the heri-ha'ab, the equivalent of the Mesopotamian āšipu, was essentially a magician or exorcist (Kinnier Wilson). In a third category was the wabw, the priest of Sekhmet, lion-headed goddess of war, who both caused and cured epidemics. The wabw often combined features of both the seynu and the heri-ha'ab. Although each constituted a distinct profession, any two or even all three might be combined in the same practitioner.

MEDICAL ETHICS. The ethics of healers reflected an environment in which the understanding and explanation of reality were thoroughly religious: All aspects of life, including sickness and healing, received their meaning from religion (see Amundsen and Ferngren). The therapeutics employed by the asû and the seynu in dealing with acute diseases and injuries seem rational when compared with the predominantly magico-religious techniques of the āšipu and the heri-ha'ab. But the words of Owsei Temkin are cogent here:

To be historically comprehensive, medicine cannot be defined as a science or the application of any science or sciences. Medicine is healing (and prevention) based on such knowledge as is deemed requisite. Such knowledge may be theological, magic, empirical, rationally speculative, or scientific. The fact that medicine in our days is largely based on science does not make other forms less medical—though it may convince us that they are less effective. (1977, p. 16)

Those ancient Near Eastern practitioners who seem to have been more rational than their magico-religious colleagues were not more ethical. Theirs were complementary, not competitive, professions. We do not have here a case of medical rationalism vying with superstition. Within their cultures neither approach was more or less rational than the other. Both perceived the causality of disease within an epistemological context in which spiritual, magical, and natural categories were not clearly distinguished. Hence, in this environment, the ethical obligations of healers must be appreciated in terms of their role as interpreters of sickness and healing within the broader cosmological realities and social values of their community. Within this general framework we can glean from the primary sources some specific, although fragmentary, aspects of medical ethics of the ancient Near East.

TO TREAT OR NOT TO TREAT. The Egyptian physician, as revealed by the medical papyri, made a prognosis before undertaking treatment. If the prognosis was favorable, the physician's comment was "an ailment that I shall treat"; if it was uncertain, "an ailment that I shall combat"; and if the prognosis was unfavorable, "an ailment not to be treated." The Edwin Smith Papyrus (a sixteenth-century b.c.e. copy of an earlier text that was probably written between 3000 and 2500 b.c.e.) contains the record of fifty-eight examinations, each followed by either treatment or a decision not to treat (Breasted). The author recommends treatment in forty-two cases and leaves sixteen untreated. In three of the hopeless cases (6, 8a, and 20), some alleviating treatment is indicated. In the Papyrus Ebers (Ebbell), which dates from roughly the same period, a small number of cases are regarded as untreatable (e.g., cols. 108–110), and in one hopeless case there is an attempt to relieve the patient. That specific alleviatory instructions are given only in a minority of hopeless cases does not necessarily indicate a lack of compassion. Incidental remarks in these papyri suggest that physicians carefully and gently treated their patients and showed kindness to the ill, injured, and maimed.

In Mesopotamia āšipus were prognosticators whose medical repertoire consisted mostly of incantations and charms, occasionally supplemented by ointments and purgatives. They did not hesitate to withdraw from cases that they regarded as hopeless. Their colleagues, the asûs, who administered medicines, performed some surgery, and seldom used incantations, seem only rarely to have refrained from treating hopeless cases, but continued with treatment to the end. This difference may be due in part to the fact that the āšipu treated primarily chronic illnesses, while the asû usually dealt with acute diseases and injuries (Ritter).

EUTHANASIA AND ABORTION. There is no direct evidence pro or contra regarding the ethics of euthanasia. It appears that in both Mesopotamia and Egypt those who committed suicide were regarded as having cut themselves off from the gods. A touching dialogue between a man contemplating suicide and his ba (soul), survives from Egypt, dating from the end of the third millennium b.c.e. (Pritchard). Although the man is not considering suicide owing to illness, the psychological struggle portrayed reveals a culture in which suicide was not accepted simply as a personal option without moral and religious compunctions, although the text suggests that it was not uncommon. Whether physicians assisted in suicide or viewed active euthanasia as opprobrious is unknown.

Prescriptions for induced abortion are found in the Egyptian medical papyri, but its legality remains unclear. In Mesopotamia, Middle Assyrian laws (fifteenth century b.c.e.?; Pritchard, 1969) stipulate that if a woman has an abortion by her own act, whether or not she survives the ordeal, she is to be impaled on a stake and left unburied. The purpose here (as in much other ancient law prohibiting abortion) is not to protect the fetus but to protect the husband's right to have the child he fathered. There is no mention of the involvement of physicians in abortion.

REGULATION OF THE MEDICAL PROFESSIONS AND LEGAL PROTECTION OF PATIENTS. The first recorded attempt to protect the patient from the incompetent physician is from Babylonia, in the Code of Hammurabi (ca. 1750 b.c.e.; Pritchard). There it is specified that if a physician performs a major operation with a bronze lancet on a member of the nobility that results in the patient's death, or an operation with a bronze lancet on his or her eye that results in its loss, the physician's hand will be cut off. If an operation with a bronze lancet results in the death of a commoner's slave, or if the operation causes the loss of the slave's eye, the physician is to pay half the slave's value in silver. No punitive regulations are extant governing medical procedures other than surgery. This is understandable, particularly in a culture permeated by magical beliefs. The unsuccessful use of incantations or sympathetic magic (the administration of medicinal herbs may be included in this category), in which the healing role of the practitioner is nearly passive because of the supernatural agents at play, stands in marked contrast to the active immediacy of the physician in surgery. The Code of Hammurabi also establishes fees for surgery. The amount is determined by the social status of the patient, indicating the intention of the legislator to peg medical fees to the patient's economic means.

Little is known about the regulation of healers in Egypt. Although there appears to have been no system of medical licensure, medical procedure became rigidly prescribed over the centuries. A Greek historian, Diodorus Siculus (first century b.c.e.), whose material on Egypt was derived from the sixth-century-b.c.e. Greek geographer Hecataeus, writes that Egyptian physicians gave treatment in accordance with ancient written procedures. If their patients died, the physicians were absolved from any charge. If they deviated from traditional methods in any way, they were subject to the death penalty, on the assumption that few physicians could be wiser than the physicians of old. In the Politics, Aristotle describes a slightly more flexible situation in Egypt, in which physicians could alter their prescriptions after four days; if they altered them earlier, they did so at their own risk.

Little evidence exists from the ancient Near East regarding experimentation with novel procedures. In a letter to the Assyrian king (seventh century b.c.e.?), a physician suggests that a particular prescription be tested on members of the domestic staff before being administered to a member of the royal family. While cesarean section is known to have been performed in Mesopotamia in the second millennium b.c.e. as a last resort to save the infants of dying women, the evidence suggests that the procedure was used only on slaves. These examples suggest the fear of risk involved in novel procedures. But there were other hindrances to therapeutic experimentation: the tendency of empirical physicians to rely on traditional procedures; the existence of a written tradition of medical knowledge and procedures in both Mesopotamia and Egypt; and the fact that medicine was often allied ideologically with religion. These factors are likely to have inhibited innovation that deviated from accepted practice even in late Egyptian medicine. Although evidence is lacking for Mesopotamian attitudes to novel procedures, they are not likely to have been more positive.

Ancient Israel

The basic difference between the worldview of the Hebrews (ca. 1300 b.c.e.—70 c.e.) and that of their ancient Near Eastern neighbors was one of religious outlook. Israel's religion was monotheistic, while that of its neighbors was polytheistic, focused on the worship of natural forces, particularly those associated with fertility. In the Hebrew Scriptures, the cosmos is perceived as being under Yahweh's direction. Although there is a personal force of evil (Satan), he is subordinate to Yahweh and poses no significant challenge to his authority. While polytheism imposed no absolute moral standards, the ethical beliefs of Israel were grounded in the character of Yahweh, who was regarded as the transcendent creator and sustainer of the world. Religion and ethics were inseparable, since both were derived from Yahweh, who was holy and required holiness of his people. Yahweh's absolute character gave authority to his revelation to Israel, and his holiness provided the ethical basis of Israel's laws. The law of Israel, the Torah, grew out of Yahweh's covenant with the Hebrews, which made them his special people. As a requirement of maintaining the covenant, Israel was to reflect the moral character of Yahweh in its national life.

THE HEBREW UNDERSTANDING OF DISEASE AND HEALING. In the Hebrew scriptures illness is viewed in its moral and spiritual dimensions rather than as a merely physical phenomenon. A close relationship between sin and illness was believed to exist at two levels: (1) Physical evil, including illness, entered the world as a consequence of sin; and (2) illness was sometimes visited upon both individuals and nations because of their sin. Hence disease and injury were a consequence of sin, but they were also within the realm of God's control. Yahweh says, "I kill and I make alive; I wound and I heal" (Deut. 32: 39). Disease, as a manifestation of God's wrath against sin, could be seen on both an individual (e.g., Num. 12: 9–12; 2 Kings 5: 25–27; 2 Chron. 21: 11–18) and a national level (e.g., 1 Sam. 5: 6–12). Yahweh promises health and prosperity to his covenant people if they are faithful to him, and disease and other suffering if they spurn his love (e.g., Exod. 15: 26; Lev. 26: 14–16; Deut. 28: 21–22, 27–28, 59–61; Ezek. 14: 21; Hos. 6: 1).

Passages often considered messianic offer the hope of healing, physical as well as spiritual (e.g., Isa. 53: 4–5; Mal. 4: 2). When the Messiah comes, "No one in Jerusalem will say 'I am sick'; the people who dwell there will be forgiven their iniquity" (Isa. 33: 24). The mental and physical anguish that accompanies the guilt of a person smitten and disciplined by Yahweh for sin is spoken of repeatedly in the Psalms (e.g., Ps. 38: 3, 5, 8), while to acknowledge and repent of sin is said to bring healing (Ps. 32: 3–5). Forgiveness and consequent healing were not viewed as the result of appeasing a hostile deity through ritual and offerings (see, e.g., Ps. 51: 16–17). Suffering in general, and sickness in particular, represented Yahweh's chastisement of his people, which was corrective rather than retributive. This theodicy, however, did not make suffering easier to endure for those who searched their hearts but could find no specific sin to be confessed (e.g., Ps. 88; Job, passim). The righteous sufferer must acknowledge God's inscrutable ways and ultimate goodness (e.g., Ps. 94: 12; Prov. 3: 11–12).

PHYSICIANS AND MEDICINE. The judgment upon King Ahaziah for consulting the god of Ekron concerning his illness (2 Kings 1: 2–4) resulted from the same kind of sin for which Asa, king of Judah, was condemned. Asa was seriously ill, "yet even in his disease he did not seek the Lord, but sought help from physicians. And Asa slept with his fathers" (2 Chron. 16: 12–13). Asa is not condemned for resorting to secular medicine as such but, rather, for consulting physicians who were probably Mesopotamian or, less likely, Egyptian. The procedures practiced by these physicians, even if empirical, would have been magico-religious. There is no evidence that priests functioned as physicians or surgeons in Israel. Their only involvement in matters pertaining to health was in the enforcement of a highly developed code of personal and social hygiene (Lev. 12, 13, 15, 21). Were there healers in Judah whom Asa could have consulted, whose practices would not have violated Jewish religious scruples? This question cannot be answered with certainty since there is no evidence in the Hebrew scriptures of the existence of a distinct medical profession.

The Hebrew word for healer or physician is the participle of the verb rapha, the original meaning of which appears to be "one who sews together" or "one who repairs." Its first participial occurrence is found in Gen. 50: 2, where Egyptian physicians are said to have embalmed Jacob. The verb itself is often used literally in the sense of healing from disease or injury (e.g., Gen. 20: 17; Num. 12: 13; 2 Kings 20: 5–8). When Jeremiah (ca. 645–ca. 575 b.c.e.) writes, "Is there no balm in Gilead? Is there no physician there?" (Jer. 8:22), although he is speaking metaphorically, he attests the existence of both balm, as a therapeutic substance, and some kind of healers. The Israelites, of course, had knowledge of the rudimentary treatment of wounds and of herbs that could be used to treat various ailments traceable to natural causes. The Torah stipulates that if a person injures another in a quarrel and the injured party survives, the assailant is to be held financially liable "for the loss of his time, and shall have him thoroughly healed" (Exod. 21: 18–19). This passage implies that the expense both for medicines and for healers to dispense or apply them was to be borne by the guilty party. Several incidental references suggest the existence of binders of wounds (Isa. 3: 7), knowledge of the setting of fractures (Ezek. 30: 21), and the use of various therapeutic substances (Isa. 1: 6; Jer. 51: 8).

Although the Hebrew scriptures represent Yahweh as the only healer (e.g., Exod. 15: 26) and command Israelites to refrain from resorting to magical or pagan healing practices (see, e.g., Ezek. 13: 17–23), the use of natural or medicinal means is not discouraged, but is resorted to even in ostensibly miraculous healings (e.g., 2 Kings 20: 7). Medical knowledge may have been limited to folk remedies, however, and there probably were no systematized therapeutics, much less medical practitioners who were distinctively Hebrew. Not until the second century b.c.e. is there evidence of a Jewish medical profession. Contact with Greek civilization in the Hellenistic age provided Jews with something that neither Mesopotamia nor Egypt could contribute: a religiously neutral theoretical framework for a rational understanding of disease and healing that allowed the coexistence of both divine explanations of ultimate causality and natural processes of proximate causality within Yahweh's created order.

The earliest mention of a Jewish medical profession is in the Wisdom of Jesus Ben Sira (also known as Ecclesiasticus), composed in Palestine early in the second century b.c.e. Ben Sira urges his readers to honor the physician as a servant of God, who gives him his skill. Dependence upon God is essential for the patient, because it is God who heals. The physician, too, must depend upon God, "for also he supplicates God that he may make his diagnosis successful and his treatment to save your life" (38: 1–15, Noorda's translation[1979]). In spite of an occasional critic like Philo Judaeus (an Alexandrian Jew of the early first century c.e.), who scathingly condemned fellow Jews who trusted in medicine without reference to God and turned to him only as a last resort (Temkin, 1991), Hellenistic Jews accepted rational medicine based on the Greek model as fully compatible with their faith. Apart from the available medical resources, which were limited, healing could come only from Yahweh by confession of sin, supplication, and prayer (e.g., Job 33: 19–30).

MEDICAL ETHICS. Central to understanding Hebrew and Jewish medical ethics is the concept of the image of God (imago Dei). In the Genesis account of creation, Yahweh is depicted as having created man and woman in his image (Gen. 1: 26–27). Endowed with rationality, self-consciousness, and volition, the human personality in Hebrew thought was represented as mirroring Yahweh's image. Persons are spiritual beings, created to have communion with God, and responsible for their own moral actions. The concept of the imago Dei had implications for the protection of human life, which was believed to possess intrinsic value, and hence to be sacred. Even human beings with physical defects are said to bear God's image. Yahweh asks Moses, "Who has made man's mouth? Who makes him dumb, or deaf, or seeing, or blind? Is it not I, the Lord?" (Exod. 4: 11).

As a result of the Hebrew view of humanity as possessing intrinsic worth, the Torah exhibits a greater humaneness than other codes of the ancient Near East (e.g., the Code of Hammurabi). There are, for example, provisions that protect the rights of the blind and the deaf (e.g., Lev. 19: 14). The fetus was regarded as having been created by Yahweh and designed for a specific purpose (Ps. 139: 13–16; Jer. 1: 5; Isa. 49: 1). Yet abortion was not explicitly forbidden by either the Torah or later rabbinic Judaism. In fact, in the Talmud it was permitted in some circumstances. Whether the practice was acceptable in the pre-Christian era is disputed. The accidental destruction of the fetus was not a capital offense, but required monetary compensation (Exod. 21: 22–25). The newborn child, however, was regarded as fully human and deserving of the same protection as an adult. Infanticide, a common practice in the surrounding Canaanite culture, was expressly prohibited (Lev. 18: 21, 20:2), and the exposure of newborn children was also condemned (see Exod. 1: 17–21; Ezek. 16: 5). Castration, sometimes practiced by Canaanites for religious purposes, was also forbidden, and eunuchs were excluded from Hebrew religious life (Deut. 23: 1).

The Hebrew scriptures provide no information regarding the behavior expected of Jewish physicians. Mesopotamian and Egyptian physicians had an enormously varied repertoire of religious and magical techniques of propitiation and manipulation, as well as of natural therapeutics, from which to choose. They also had the freedom to be imaginative, active participants in processes in which the lines between what we call the natural and the supernatural were blurred. By contrast, Jewish physicians, working with and through natural means and processes, and eschewing any techniques involving magic or the demonic, were, along with their patients, to depend upon the Creator, from whom alone all true and licit healing came (Deut. 32: 39). Given the emphasis in the Hebrew scriptures on the compassionate nature of the God who heals, and the importance that Ben Sira assigns to the physician as an agent of God, it would be surprising if Jewish physicians were not encouraged to emulate the divine compassion in their treatment of the ill. This attitude would be especially compatible with the new emphasis on the meritorious nature of charity that is found in the Apocrypha (Jewish religious writings dating from third century b.c.e. to about 100 c.e. that were not included in the Hebrew scriptures). It is in the postexilic period (after 605–582 b.c.e.), too, that one begins to see a tradition of caring for the ill that makes the sick person no longer an object of stigmatization (e.g., Job 19, esp. 13–20; Ps. 42: 4–10), but a person deserving of special care, like widows and orphans (e.g., Sirach 7: 35; 2 Macc. 8: 28). This specific concern for the sick within the community of Israel is a theme that is extended and developed in the Talmud.

darrel w. amundsen

gary b. ferngren (1995)

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Medical Ethics, History of the Near and Middle East: I. Ancient Near East