Hippocratic and Ideological Medicine (Part II)

by Angelo Fiori

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Even if it must be recognized that ideological medicine has assumed new ways of being and acting today, there are. however, symptoms of dangers even greater, perhaps, than those that characterized the dark ages.

These new features of ideological medicine are obviously of particular interest, because they are the heart of the concerns of medicine today. It is necessary, therefore, to identify them and analyze them carefully.

It has already been said that today ideological medicine affects mainly those grey areas of the medical profession which leave a margin for its action... Historical analysis shows that the harmful influences of ideology on the development of medical science were derived not so much from its absolute and exclusive causal efficacy as rather from the intrinsic weakness of knowledge and above all of technical instruments which encouraged conditioning by ideologies. In other words the first cause of the conceptual and practical errors of medicine lay, perhaps, in the very difficulty of the subject of medicine and the general backwardness of scientific knowledge on those matters which were not, as on the contrary mathematics was, mainly the product of the human intellect.

Therefore it can and must be recognized that the recourse to ideological "solutions" was sometimes the effect and not the first cause of the backwardness of medicine. For ideological medicine represented a convenient refuge for the disappointments of the doctor-scientists of the past who so frequently saw the brilliant precursory intuitions of the best of them, such as Hippocrates, shattered by the objective difficulties of the general problems of science and the particular problems of individual clinical cases.

In this sense, it is certainly possible to speak of the escape of medicine into philosophy and ideology as a remedy for frustration. This mechanism is only apparently set aside in the positivist enthusiasm aroused by the scientific and technical progress of the nineteenth century and even more by the breakthroughs in the latter part of this century. It is apparently set aside, because the temptation reappears before the inevitable failures that accompany successes, even today. This is, it seems to us, one of the explanations, certainly not the only one, of the destructive fury of modern psychiatry, the fruit, on the one hand, of the prevailing sociology, and, on the other hand, of the too many disappointments suffered by a discipline which has often looked on helplessly at far greater successes in the field for example of internal medicine, surgery, biochemisty, physiology and immunology. Society is held up then as the only cause of mental illness and there follows the inevitable dogmatic conclusion that to eliminate mental illness it will be enough to treat the whole of society with ready-made political prescriptions, declared to be infallible, even if their failure is before everyone's eyes.

A similar ideological influence was manifested in the vast and multiform field of psychology as has recently been stressed by Jean Bernard (Jean Bernard [1975]; Grandeur et tentations de la medecine. Buquet Chastel, Ed. Paris). Bernard recalls very shrewdly the radicalization of trends that has come about in this field. There is the distinction on the one hand of the medicine of organic diseases, limited to a few extremely serious cases; this medicine "very simple on the intellectual plane, can be entrusted to capable technicians who operate in a well-equipped hospital". There is on the other hand a medicine of functional disorders, extended to nearly all the ailments that give rise to consultation. This has been touched but little by the recent progress of science and needs the determinant aid of psychologists and physicians formed in their school. It is possible to arrive, Bernard points out, at a final stage, which he defines "imperialistic". In this the existence of organic disorders is questioned and it is suggested that the whole of medicine should be subordinated to psychology. There follows a terroristic action, so to speak, which takes on the form of ousting all those who are unable to accept the absolute priority of psychology. The latter are considered disparagingly "organicists" who exercise a hospital medicine that is "material, reactionary, limited to a few exceptional cases, the property of robots hardly able to think", and who reject, on the contrary, an extra-hospital medicine, modern, spiritualized, which has recourse to the very new techniques of the psychological approach. The "terrorists" are trained in dialectics and succeed in putting doctors in the wrong, often obtaining the opposite effect of causing people not to recognize the importance and usefulness of psychology when used correctly.

A further, perhaps clearer, example is represented by the interferences of sociology in the sphere of science and of the medical profession.

That the study of the relations between a man who is sick, or a subject for sickness, and his environment is indispensable, is unquestionable. Therefore the birth of medical sociology, in the sphere of which physicians, demographers, economists, teachers and sociologists cooperate, is to be considered positive. But this has led, with the usual mechanism, to abuses, always inspired by ideological predilections, as a result of which the attempt is made, on the one hand, to attribute to the environment an exclusive role in the genesis of diseases, and on the other hand even to change radically the concept of disease, asserting, for example, as Foucault does (quoted by J. Bernard) that "a disease takes on the reality and value of a disease only within a culture that recognizes it as such". These apodictic and dogmatic positions, often assumed with intolerant arrogance, aim at intimidating the tree researcher, who pursue the Hippocratic method of the search for non-preconceived truth and utilizes the most varied sources of information, including sociology. A study of pathology, in actual fart, shows that it involves the collectivity and the individual at the same time: "Every human action starts from the individual and goes beyond him towards the collective; then it returns to the individual since the diagnosis and therapy depend to a great extent on the specific molecular structure of every human being (J. Bernard, loc. cit.).

These examples prove that the temptations and influences of ideological medicine are still operating and that they are actually exercised in those grey areas of Hippocratic medicine in which knowledge is still limited, and do not fear even to face Hippocratic medicine in its most valid and indisputable bulwarks, expressed in so many diagnostic and therapeutic successes.

Medicine and political ideology

It is not this, however, that is particularly worrying: the major danger is represented by the relationship that has been established between medicine and political ideology. The latter, with or without the mask of philosophical ideology, most often with the ancient mask of dogmatic pseudo-science, has discovered in medicine, in fact, one of the most powerful instruments for the exercise of power.

There is nothing new under the sun, since everyone knows how much the medical art, through its individual practitioners, was used in the distant past to perpetrate abuses or crimes. It was usually a question, however, of individual cases and clearly localized matters, not because the men and structures of power were better, but only because the power of the physician and of medicine was limited, with a modest radius of action.

Today medical science, with the support and help of the chemical industry, can decide to a large extent the destiny of the human population of the globe and also that of animal species: their increase, which can be controlled or turbulent, their state of well-being or illness, the average length of life.

This immense power arouses the interest of politicians and administrators and the greed of industrialists and financiers. And so we get the political and economic power including among its ideological and practical instruments medicine as a science and as a profession, claiming to interpret its content and purposes and to turn them to suit its purposes, working upon the medical category by means of enticements or blackmail, and on the rightful hopes and expectations of the populations.

The physician and medicine are therefore at the centre of an operation of instrumentalization which is wrapped, and wishes to be wrapped in the eyes of the collectivity, in humanitarian and protective tones. Anyone who opposes it, and it may often be the physician himself, is a heretic held up to public condemnation. In this action it may happen that the political authority does not limit itself to carrying out that organizational and promotional action—of care and prevention—which makes it the natural and obligatory ally of medicine. On the contrary, it trespasses on the very domain of medicine as a science, trying to change its principles and transform its aims, touching the most crucial areas of the physician's personal freedom and, in any case, proposing once more the. repressing domination of ideological medicine.

It is no mere chance that those very areas of medical science that we have just mentioned as examples of new ideological medicine, are the ones on which the interest of the political authority is focused. The latter encourages the new dogmatic positions and uses them as a means of ideological indoctrination exercised upon physicians, patients, and on the healthy collectivity, often with terroristic tones the effectiveness of which is assured by an orchestrated use of the mass media.

It is a question of a real battle, with its strategy, its tactics and arms wisely chosen, capable of striking the imagination and the sensibility of the masses, who have previously been "sensitized". In the front row among these arms there figure those chapters of medicine which concern most closely the ethical sphere of the physician and the populations, since they regard central points of the existence of the individual and of collectivities.

Legalized medical abortion, indiscriminate birth control, politicization of psychiatric problems, criminal use of Pavlovian conditioning and so on are, therefore, only aspects of manoeuvres of a vast strategy of domination. It is not desired to deny in the latter, a priori and always, illuministic good faith which sees in progress at any cost the good of humanity; but substantially it forces its way into the flank of modern medicine, transforms its purposes, injects into it toxic doses of ideological poison, and prepares a new period of decadence for it. For, contributing to exalt its functions beyond the limit of the reasonable and the materially possible and partly distorting its purposes, it opens the way to new disappointments with subsequent reactions of destruction or escapism. In short, it prepares new medieval temptations, and that in the best of hypotheses.

We have spoken of political ideologies without giving any specification of identity. There would be a great deal to be said about what ideologies. But the task is a difficult one and the analysis would be long and complex. Scientific objectivity requires at least that among the guilty there should be pointed out not only those who plead guilty—Marxist ideology and its derivations—but also, though in a different form, the more composite pragmatic and liberal ideologies of the West. In these latter the distressing and inexorable logic of profit often makes medicine slip into the consumer ideology, exercising in this way another form of instrumentalizing power, which must also be picked out, analyzed and condemned. The question of the contraceptive "pill" on which Marxist ideology, on the one hand, and industrial capitalism cloaked in illuminism, on the other hand, agree, is the most obvious example. It is a question of a form of association which, with official motivations that are not medical but almost exclusively social, subjects a good part of the female population of the globe to massive "experimentation", brazenly passing over individual risks in silence, in the name of political ideology and of the consumer ideology.

Necessity of a choice

So far, therefore, we have seen that there actually exist two trends in the history of medicine, which can be distinguished from each other and which can be called Hippocratic medicine and ideological medicine. We have been able to ascertain, though briefly, that they face each other with alternate vicissitudes in the whole span of the history of medical thought; that certainly in the last century, and in particular in the last half century, Hippocratic medicine has met with enormous success, but that in the meantime ideological medicine is still flourishing... In drawing this picture, a judgment of positive value has explicitly been given to Hippocratic medicine and a negative one to ideological medicine. It is necessary to come back briefly to this point to ask ourselves if there are ethical reasons, in addition to rational ones, for the physician to make a choice, and if this choice is legitimate in the present political and social context.

There is nothing to be added about the rational motives for the choice, since it is sufficient to have ascertained that the enormous development of medicine and biology was the fruit of the abandonment of every preconceived ideological bond, eliminating the possibility of an alternative choice.

But in this choice ethical motivations, too, can and must intervene, with regard to which agreement will not perhaps be easy within the medical category, where there exist divisions and alignments which go back to different ideological inspirations. The attempt must be made, however, not by means of a priori choices, but on the basis of an analysis of the actual situation and of the legitimacy of some principles of medicine.

It is necessary to refer once more to Hippocrates to ask ourselves if the oath attributed to him, possibly in the updated forms of present-day national deontological codes, can still be a univocal point of reference for physicians today. And in the case of an affirmative answer, if there are motivations other than the sentimental and emotional ones that refer "to the good old times", to the "physician of the past" and so on.

The oath of Hippocrates, as is known, consists of a few essential points which concern: the "one aim" of the physician which is "to treat and cure the sick without abusing them", prescribing for them "the regimen" that he "will judge" suitable for their situation according to his "science and conscience" and avoiding everything that could harm them. In this aim is included the physician's ban upon himself to provide deadly poison and procure abortion; professional self-limitation by means of a. precise determination of one's own limits of competence ("I will not operate those suffering from stones but will leave this operation to the persons charged with it); professional secrecy; integrity of life and honour of the art; relationship with colleagues and their family, and the relationship with disciples; the relationship with the religious origins of medical art.

The official oath of the physicians of many nations is still modelled today on this ancient oath. But it is important to point out that in some of the present-day deontological oaths there are waivers or omissions which, on the basis of clearly ideological inspirations, are in deep conflict with the general Hippocratic principles. The oath of the Soviet physician is a clear example. Not only is there no mention in it of the ban on the procuring of abortion, but, though following a series of declarations that coincide completely with the Hippocratic ones, there appears another one that challenges the very heart of the Hippocratic oath. In the latter, the relationship between physician and patient is based exclusively on this dual concept without any substantial external interference, according to the "science and conscience" of the physician, obviously brought into line and updated to the particular historical moment, with the one aim of the individual interest of the patient.

In the oath of the Soviet physician there appears, therefore, the commitment to develop "the noble traditions of national medicine" and particularly that of basing all medical acts "on the principles of Communist morality", always keeping in mind "the high title of the Soviet physician" and being aware of "responsibilities towards the Soviet people and State". In other words, the following is a fundamental principle of Soviet medical deontology: "if the interests of the patient are in conflict with those of the State, the physician must give preference to those of the collectivity because health care is not addressed only to treatment of the sick person but also to prevention of diseases in the interest both of the individual and of the collectivity" (cf. Gromov A.P. (1975): Deontologia e responsabilita professionale del medico Sovietico. Coop. Libr. Ed, degli Studenti, Padua).

No physician, of course, can affirm today that his diagnostic and therapeutic action must disregard the interests of the society in which he lives, but the Hippocratic principle of the primary and prevalent interest of the patient is irrevocable and the motivation can easily be given.

The medical profession, unlike all others, administrates the life and death of men. The healthy man who fears disease and the sick man entrust themselves to other men who possess a set of cognitive and operational instruments which, in order to pursue the aim of the cure, may often put the patient even in the condition of risking his life. A relationship of this type confers on the individual physician, and on the medical category as a whole, quite special duties and responsibilities.

The religious origins of medicine find here a logical explanation which is still valid. Those references of the Hippocratic oath which are clearly connected with the rules of the priestly caste, cannot have the mere meaning of a contingent compromise that Hippocrates tried to make with the Asclepiadae, but can and must be interpreted as a sign of the awareness of the sacredness of the medical act in relation to the sacredness of life.

There is therefore a real ethical justification for a deontological code that is independent of historical contingencies and of the influences and suggestions of the political authority as well as ideologies of all types. There remains, in fact, unchanged, even in the vicissitudes of history and in the expansion of scientific knowledge, the nature of the relationship which is strictly interpersonal (it does not matter whether it is a question of one or several physicians in a team) between the physician and his science, between the physician and his patient because the aim is one only, direct in professional practice, indirect in the sphere of scientific research: the aim of preserving the good of life.

This does not mean that the physician is not subject to the laws that the community has given itself. On the contrary, he is more strictly subject to them than others, just because the laws, and especially penal law, set themselves the same purpose, that is, maximum protection of the integrity of the individual human person. Nor does it mean that there cannot be, as in fact there are, branches of medicine that study the problems of the life and health of the masses and that suggest for this purpose actions of an organizational character with preventive, diagnostic and curative aims. But these actions in the operational phase are carried out by individual relationships. It is now necessary to raise the question whether the medical category really abides by these principles and, if not, if there is a motive for yet another battle under the banner of Hippocratic medicine.

In all ages, unfortunately, there is present the image of the uncultured physician, an exploiter, or the servant of power: the medical category inevitably repeats within itself the variety of human types. It is not surprising, therefore, if it also repeats the ideological and political divisions of a society such as the present-day one, composite, full of growing tensions, characterized all over the world by deep divergences of inspiration and concepts which do not necessarily coincide with the two great blocs of the Marxist world and the Western world, but pass through the two blocs themselves. The position assumed on the problem of abortion by many European and American physicians is a proof of this.

It is, therefore, in the first place within medicine, rather than outside it, that it is necessary to combat the great new attack of ideological medicine which casts shadows on the lights of medical progress in this last part of the century, announcing new medieval threats. This attack is made with the technique of all times. Once more, crime is carried out in the name of the sacred principles of short-lived philosophies, with pressure and infiltrations operated by the other disciplines that medicine utilizes, by the sciences it inspires, and even more by the political authority, often with up-to-date methods of ideological terrorism.

The essential duty of medicine today is to affirm its own unity and independence, recognizing indispensable alliances and rejecting temptations. If this unity is lacking, it is necessary courageously to recognize the fact, and the physicians inspired by Hippocratic medicine must take the field again by means of a common strategy, expressed in public, in group and individual stands.

Conscientious objection

Conscientious objection is one of the instruments that must be used whatever the personal cost may be. In the field of abortion it can be foreseen that physicians will be subjected to increasing operations of ideological terrorism to induce them to withdraw their objection. There will be objection to objectors. But anyone who has the deep conviction that the matter of the liberalization of abortion is only a passing phase, another of the eternal returns of human error in history, knows that nature always has its inevitable revenge. The abortion-euthanasia binomial is bound to lose in the long run. The medical category must, therefore, appeal to conscience and to the ideal charge that comes from it and take its place on the front line of resistance. It will be a long, difficult and painful way. But physicians are not new to these tasks, because their daily life is interwoven with obstacles of every kind. The question is just not to lose the way of Hippocratic medicine.

"L'Osservatore Romano", Via del Pellegrino, 00120, Vatican City, Europe, Telephone 39/6/698.99.390.

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