Patrick Fiddes
Australia

The art consists in three things—the disease, the patient, and the physician. The physician is the servant of the art.¹

Among the 412 aphorisms in Francis Adam’s Genuine Works Of Hippocrates² are three that employ the term “Art.” Two have achieved popular acclaim while the third, the “Art of Medicine,” has received fewer plaudits and has been neglected in the appreciation of its philosophy and potential to teach the moral and professional responsibilities common to the practice of all physicians and health professionals.

Of the three, “Life is Short and the Art Long” is the first of the Hippocratic Corpus book Aphorisms and states: “Life is short and the Art long, the occasion fleeting, experience fallacious and judgement difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals co-operate.”³ While its first phrase has been widely quoted,⁴ the second reflects its heteronomy, paternalism, and ethically disturbing directives that remained unquestioned until 2021, when its lack of ethical merit and insufficient professional standards were made evident.⁵

Despite its popularity, the aphorism is antithetical to the intrinsic concept of the physician as “the servant of the art,” and, having no moral or ethical principle, is incompatible with the intent of the epigraph from the “Art of Medicine” aphorism.

The second aphorism, “Where there is love of man, there is also love of the art,” is part of a discussion of beneficence from the apocryphal Hippocratic Corpus book Precepts V1. While both Francis Adams and W.H.S. Jones considered the Preceptiones to be apocryphal, Adams excluded them from his 1923 book, and Jones in his multi-volumed Hippocrates, Medicine, Greek and Roman,⁶ included this translation of Precepts V1⁷:

I urge you not to be too unkind, but to carefully consider your patient’s superabundance or means. Sometimes give your services for nothing, calling to mind a previous benefaction or present satisfaction. And if there be an opportunity of serving one who is a stranger in financial straits, give full assistance to all such. For where there is love of man, there is also love of the art. For some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician. And it is well to superintend the sick to make them well, to care for the healthy to keep them well, but also to care for one’s own self, so as to observe what is seemly.⁸

However, Émile Littré had previously included the Preceptiones in his 1831–1861 ten-volume Oeuvres complètes d’Hippocrat,⁹ in which the aphorism’s essential sentence is rendered as “…the love of humanity associated with the love of his craft,”¹⁰ which William Osler employed in his final speech, “The Old Humanities and the New Science.” Consequently, Littré’s version has been popularly accepted and widely employed.   

The disparity between Littré’s and Jones’ first “love” predicate depends on its subject, for  Plato, in his discussion of love, identified three different loves: eros, philia, and agape.¹¹ Of them, Jones’ “love of man” would accord with philia as “a fondness and appreciation of the other…that incorporated not just friendship, but also loyalties to family and one’s community, job, or discipline.” And, Littré’s “love of humanity” accords with agape as “the paternal love of God for man and of man for God but is extended to include a brotherly love for all humanity.”¹²

In their second use of “love,” the two subject terms “Art” and “Craft” are are again dissimilar. Jones’ “love of the art” reflects a humanist application of ethical principles, whereas Littré’s “love of craft” reflects the more tangible skills and material matters as part of the practice of medicine. While each invokes the principles of compassion and an expectation of both personal and professional standards and judgments, each also denotes a professionalism that is distinct from the obligations that are inherent in the Art of Medicine epigraph.

The previous aphorisms demonstrate a Hippocratism that has centered around the physician and avoided consideration of the beneficent ethical intentions evident in the third and most important aphorism from the authentic Hippocratic Corpus book Epidemics 1, “The Art of Medicine”¹³:  

The physician must be able to tell the antecedents, know the present, and foretell the future—must mediate these things, and have two special objects in view regarding diseases, namely, to do good or to do no harm. The art consists in three things—the disease, the patient, and the physician. The physician is the servant of the art, and the patient must combat the disease along with the physician.¹⁴

The tenets within this aphorism invoke the essence of a professionalism that entails a knowledge of disease, the exhibition of semiotic skills,¹⁵ and an accordance with the professional obligations, ethical principles, and moral responsibilities expected of physicians. The Art of Medicine epitomizes the humanist principles and fiduciary obligations that are expected of physicians in their compliance with societal mores, a professionalism that has been a continuum throughout the history of the teaching, professional development, and practice of all physicians.   

While giving direction for the conduct of both physician and patient, it also requires the physician-servant to “mediate these things” encompassing the nature of disease, the science concerning it, the social dimensions of the practice of medicine, and the manner in which physicians conduct their semiotic skills. Such matters led Galen to describe the Hippocratic Art of Medicine as “an art that teaches how to preserve and to restore health, or cure disease…a science that teaches the knowledge of what is healthy, unhealthy, or intermediate between both.”¹⁶ In doing so, Galen identified the responsibilities the physician-servant has to the patient, the community, and to their students in implementing and transmitting knowledge of the nature of disease and the practices that are required to maintain health.

The Art of Medicine’s inherent principles require the physician to respect the patient’s autonomy, abide by their professional standards and their communities’ social values, and make best use of all available medical sciences and health services. Such mediation involves an appreciation of the relationships between medicine, the humanities, and the societies in which medicine is practiced and taught, the teaching of which ensures that medicine’s history and the humanities are considered “alongside the natural sciences at the core of our understanding of medicine’s nature and [its] goals.”¹⁷ Further, as a “science that teaches,” the Art has an innate responsibility to include students in the process of clinical teaching as being integral to the patient, disease, and physician triad, a principle that Islamic physicians introduced into Western clinical teaching during their occupation of Sicily.¹⁸

However, such ethical obligations and responsibilities inherent in the concept of the physician-servant were abrogated by those “derived from the dominant religious and philosophical systems crafted by theologians,”¹⁹ which were perpetuated by the teachings of successive Christian scholars and philosophers through the Medieval, Renaissance, and Enlightenment periods. These were put aside by the determinations of physician bodies such as the American Medical Association, which in 1847 determined that, “Medical ethics, as a branch of general ethics, must rest on the basis of religion and morality. They comprise not only the duties, but also the rights of a physician.”²⁰

But such rights were not defined,²¹ for “The medical profession had long understood that its medical ethics were directed not just to the observance of generally endorsed societal norms, but to the protection of the economic interests of physicians.”²² Further, the right of physicians to independently determine their rectitude was made evident in 1885, when the newly formed Association of American Physicians resolved that at their meetings “there will be no  [discussion of] medical politics and no medical ethics,” a position which Michael Bliss suggested “meant that honorable men had no need to subscribe to anyone else’s formal codes.”²³

The Art of Medicine, in contrast to the first two aphorisms, represents a summation of the innate ethical principles and moral responsibilities that physicians have in their clinical teaching and their practice of medicine, where the principles that stem from the concept of the physician-servant should become “a core strategy in the development of professional values and behaviours [and] professional identity formation.”[xxiv] The inherent values of the Art of Medicine should assume their rightful place in the appreciation and teaching of medical professionalism. 

However, the Art of Medicine’s intrinsic values were discounted in 2005 when the Royal College of Physician’s Working Party published item 2.14 of its determinations:

The art of medicine has a long history, going back at least as far as Galen. In the sense of the application of knowledge or a technical skill, art is a useful idea. But the Working Party received much evidence arguing that a defining feature of medical professionalism was judgement—the application of critical reasoning to a problem presented by a patient in order to arrive at an opinion about how to solve or ameliorate that problem.²⁵

By dismissing the Art of Medicine’s ethical principles and innate values in favor of judgment and critical reasoning, the College overlooked the more fundamental mores and qualities that characterize the professional behavior of all health practitioners and denote the responsibilities that are inherent in the philosophical concepts of the physician-servant and medical professionalism.

The Art of Medicine warrants incorporation into the teaching of the principles of a professionalism that is the essence of every physician-patient clinical engagement.

References

1. Adams, F. 1849. The Genuine Works of Hippocrates. Epidemics Book 1, 360. (London: The Sydenham Society).
2. Adams, (n. 1), 697-774.
3. Adams, (n. 1), 697.
4. Often as the Latin, Ars longa, vita brevis.
5. Fiddes, P.J., Komesaroff, P.A. “Hidden in Plain Sight: The Moral Imperatives of Hippocrates’ First Aphorism.” Bioethical Inquiry. Jul 2021;18(2):205-220.
6. Jones, W.H.S. 1923. Hippocrates, Medicine, Greek and Roman. Precepts. (London, Heineman,). (trans. Potter, P.). Internet Archive. Jones did not accept that the Preceptiones was written by Hippocrates. The Preceptiones contained 14 Precepts. 313-333.
7. Jones, (n. 6), 313.
8. Jones, W.H.S. Hippocrates Collected Works. (Cambridge; Cambridge University Press). https://daedalus. umkc.edu/hippocrates/HippocratesLoeb1/page.235.a.php.
9. Littré, Émile. Oeuvres complètes d’Hippocrate. Ten Volumes (Paris, J.B. Baillière).
10. Littré. (n. 9), 258.
11. Moseley, A. “Philosophy of Love.” Internet Encyclopedia of Philosophy. iep.utm.edu. Plato determined them to be Eros, Philia and Agape.
12. ibid.
13. Accepted by Adams and other authorities as being written by Hippocrates. (Adams (n.1), 54.
14. Adams, (n.1), 360.
15. The study of symptoms, somatic signs, history taking, and physical examination.
16. Coxe, J.R. 1856. Hippocrates and Galen. (Philadelphia: Lindsay and Blakiston), 35.
17. Greaves, D. & Evans, M. “Conceptions of medical humanities.” Medical Humanities. 2000, 26; 65.
18. Chiarelli, L. “Muslim Sicily and the Beginnings of Medical Licensing in Europe.” Journal of Indian Medicine. 1999; 31, 79-82.
19. Veatch, R.M. 2005. Disrupted Dialogue. Medical Ethics and the Collapse of Physician-Humanist Communication (1770-1980). (New York, Oxford University Press), 3.
20. McCullough, L.B. 1998. John Gregory and the Invention of Professional Medical Ethics and the Medical Profession. (Boston, Kluwer Academic Publishers), 278.
21. The only Code of Doctor’s Rights found through an internet search was that published by the Association profesional medicos de ejercicio libre. www.aspromell.org. Madrid, October 26, 2014.
22. Peppin, J. 2014. “Introduction: Bioethics as a Global Phenomenon.” Annals of Bioethic: Regional Perspectives in Bioethics. (New York; Routledge) xvii.
23. Bliss, M. 1999. William Osler: A Life in Medicine. (Toronto. University of Toronto Press.), 151.
24. Petrou, L. et al. “The role of humanities in the medical curriculum: medical students’ perspectives.” BMC Medical Education 2021; 21, 179.
25. Doctors in society: medical professionalism in a changing world. Report of a Working Party of the Royal College of Physicians of London. London: RCP, 2005.