End-of-life decisions remain a complicated problem in the relationships between physicians and the patient’s family, with social and legal consequences which today face all civilised societies.
The attitude of doctors to euthanasia in particular seems to have occupied and troubled societies from antiquity, as the Hippocratic Oath and the concepts of the earlier Pythagorians indicate.
Although the Hippocratic Oath, perhaps following the school of Pythagoras, is categorically against every idea of euthanasia, it was thought unethical for a doctor in ancient times to treat a patient with a deadly disease, for this challenged nature and constituted hubris against the gods, so the doctor would risk paying the penalty of divine nemesis.
This concept is found even in some Hippocratic texts but cannot be justified in societies deeply influenced by the Christian religion where the physician ought to give love to his fellowman (anthropos) rather than to his art (techne) and to treat all his patients irrespective of class, status or wealth and ability to pay. In these societies the doctors’ altruistic duty apparently involves the compassionate care and consolation of the terminally ill.
For these reasons one can nowadays be surprised to find, on studying the Byzantine historians and chroniclers, some cases of abandonment of dying emperors by their physicians who realised that they could not offer any further medical treatment. The meaning of abandonment in these texts seems to have been exclusively restricted to medical treatment when no further scientific help was possible and only philanthropic and Christian compassion remained to be offered. As is self evident, Byzantine medicine – basically philanthropic because it was a product of Christian philosophy – could not permit this custom of abandonment.
For this reason, these cases referred to by reliable Byzantine writers appear at first sight unusual and inexplicable because they cannot be understood on the basis of the Christian thinking on and attitudes towards the relationship between patients and physicians. On the contrary, in accordance with the way of thinking of Byzantine medicine, it would seem most rational for physicians to be in attendance on the patient and offer medical assistance until the latter’s death.
The information provided by the Byzantine texts
1) A near fatal illness of Justinian the Great (527-565)
During the great epidemic which struck the empire in the age of Justinian, the well-known “Justinianic Plague”, the emperor himself became seriously ill. As evidenced by the historian Procopius: “The bubonic area of his body swelled up“. The same contemporary historian notes in another of his works that:
“This epidemic struck the population of Byzantium and it then happened that Justinian was seriously afflicted to the extent that a rumour was spread that he was dead“.
According to the historian, this rumour had political implications because some were thinking of the succession to the throne and this provoked the rage and immediate reaction of his wife, Theodora, who after the unexpected recovery of the emperor punished harshly the would-be pretenders to the throne. More information is provided by Procopius in his third work, in which he writes:
“When Justinian fell seriously ill and gave the impression that he was about to die he had been abandoned by his physicians because he was considered to be already among the dead. Then the saints Cosmas and Damien appeared before him and, paradoxically, saved him and his health was restored. The emperor, to express his gratitude, established a great and magnificent church in their honour at the end of the Golden Horn in Constantinople. Those who had lost all hope, as a result of unsuccessful medical treatment by physicians, took to the boats in the gulf and came to this church, the only hope remaining for them.”
The abandonment of the emperor by his physicians when they realised the hopelessness of his case is clearly evident from this extract.
2) The fatal disease of Alexius I Comnenus (1081-1118)
On the question of the aetiology of the fatal disease of Alexius I Comnenus many opinions and interpretations have been expressed.
During the last stages of the emperor’s disease, physicians made superhuman attempts to save him. At repeated medical councils his daughter, the well-known historian Anna Comnena, who had also studied medicine, presided. Comnena provides us with the most valuable details of her father’s disease. In her text it is apparent that the dietetic therapy, the drugs, the phlebotomy, the transfer of Alexius to the Maggana (another palace) for the change of air and finally the cauterisation of the stomach did not help the emperor but that, on the contrary, he remained on the verge of death. On the morning of 15 August 1118:
“some physicians rubbed the head of the Emperor with myrrh and left for their homes, not because they had an urgent reason but because they knew that fatal danger was approaching the Emperor“.
Comnena names three leading physicians among those who had left, Nicholas Callicles, Michael Pantechnes and Michael the Eunuch. Comnena also says that several hours later some physicians returned to the emperor’s bedside and checked his pulse, trying to encourage the empress, who was in a dreadful psychological state.
Another contemporary chronicler, John Zonaras, also refers to the last hours of the emperor, writing that:
“All day he was in death throes and in the afternoon he died at about seventy years of age and his end was in complete contrast to his happy reign, because he was abandoned by almost all his physicians and there were not even some to give him a final bath and to adorn his body in a way suitable for a king or even to provide him with the appropriate royal funeral.”
3) The disease of Andronicus III Palaeologus the Younger (1328-1341)
In the last twenty years of his life Andronicus III presented crises of the enlargement of the spleen and febrile attacks. His disease, probably malaria, caused the emperor to go into a coma and to die.
Cantacuzenus describes an episode of the disease during the first years of its appearance (c. 1329). This was obviously a cerebral form of the disease, beginning as an acute stroke, which in the evening of the third day intensified, when signs of approaching death appeared. From the text of Cantacuzenus, it appears that the emperor remained without any physician all night but unexpectedly recovered and asked for water from the spring of the Monastery of the Holy Mother. In the morning the physicians came and the leader of this group took his pulse and, amazed, discerned that there was a light pulse, which he attributed to a miracle.
From the three cases described above, and especially from the second, which is described by the reliable and well-educated historian Anna Comnena, it is clear that in Byzantium the abandonment by physicians of a patient at the stage just prior to death was a common custom when no medical means were believed available to save the patient. From Anna Comnena’s text this desertion appears to have been ceremonial. This derives from the fact that only some physicians withdrew from the emperor after they had applied myrrh to his head, returning after a few hours. Such events and the natural way Anna Comnena narrates them, stressing that the physicians left because they had no more scientific services to offer, lead us to the conclusion that this abandonment was the usual ceremony – normal behaviour – in such desperate cases.
The origins of this withdrawal must be sought in pre-Christian times. Plato, in The Republic says that Asclepius makes no attempt to prolong an unhappy life in the case of those who are seriously ill and furthermore states that Pindar and the tragedians maintain that “the son of Apollo, Asclepius“, once “was bribed by a large fee to cure a rich man who was at death’s door, and blasted by a thunderbolt in consequence“.
In the treatises of the Corpus Hippocraticum the belief is supported that physicians must be prudent in the application of their treatments and it is stressed that “where there is love for man there is also love for the art of medicine“.
Furthermore, an aphorism of Hippocrates refers to the fact that “for extreme diseases, extreme methods of cure, as to restriction, are most suitable“. The significance of this is that in difficult cases of disease an aggressive form of treatment must be applied. On the other hand, from some other ideas springs the whole treatise of the Corpus Hippocraticum, The Art, which is not one of Hippocrates’s works of genius. The author of the work writes:
“First I will define what I conceive medicine to be. In general terms, it is to do away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their diseases, realizing that in such cases medicine is powerless“.
In the same work the idea is presented that the art of medicine cannot treat every illness because there are limits which cannot be overcome. In all arts when the instruments are lacking the work stops, as the unknown Hippocratic author says characteristically. Thus, continues the writer, medicine must offer its assistance in treatment but must equally prudently avoid care of patients when their diseases are untreatable. Consequently it was thought to be in some way egoistic for the ancient physician to believe that he could treat the patients who were already condemned to die and any such endeavour was supposed to be hubris against the gods.
In Byzantium, physicians would not have been able to refuse their scientific help to patients even if they had reached the conclusion that a case was untreatable. This is because they believed that in many instances patients could be treated with the help of God, as, for example, in the above-mentioned case of Andronicus, where the physician, without hesitation, attributed the emperor’s recovery to divine intervention. Further, in the case of Justinian’s illness, which had occurred several centuries before, the recovery of the emperor was attributed by Justinian himself and his entourage to a miracle.
These two instances, but also a whole series of similar cases, indicate that during the times of the Byzantine Empire it was a common belief that the possibility of divine intervention existed until the last stages of a disease. On the basis of these principles, the Christian physicians would never have been able to confront any case as hopeless because they would always have retained the hope that God could assist their work until the last moment.
Some ideas, influenced both by the ideas of the Hippocratic treatise, The Art, and the Byzantine mentality, can be found in the work, Epitome, by the Byzantine physician Paul of Aegina (7th century). In his sixth book, when he refers to the cases of perforation by an arrow of vital organs of the body, such as heart, lungs, brain and so on and where already the signs of death have appeared, he advises the surgeons not to operate, because apart from the fact that they will not offer any benefit, they will give the ignorant the pretext to ridicule them, an idea deriving from the above-mentioned Hippocratic treatise. On the other hand, if the result of the operation seems unpredictable, the surgeon must make the patient aware of the possible danger and then proceed to the operation because, as Paul of Aegina concludes, in many patients, despite the fact that in these operations a part of the liver or peritoneum or all of the womb was removed the patient was finally saved.
Consequently, we can provide the explanation for abandonment, curious in the light of Byzantine ethics, that it followed a tradition from pre-Christian times which survived even in some texts of the Corpus Hippocraticum, and reached Byzantine times, as did many other beliefs of the Hippocratic ethos.
(Source: “Abandonment of terminally ill patients in the Byzantine era. An ancient tradition?”, by John Lascaratos et al.)
Research-Selection for NovoScriptorium: Anastasius Philoponus
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