I. ANCIENT AND MEDIEVAL. C. MEDIEVAL CHRISTIAN EUROPE

The Middle Ages are typically divided into early (500–1050) and high and late (1050–1545). This survey of the history of medical ethics in medieval Europe will first examine the sparse evidence from the early Middle Ages, and then deal thematically with significant developments during the high and late Middle Ages. The Middle Ages was a period of monumental changes. There was, however, one constant—the nearly complete identification of society with the Catholic church, which became the most thoroughly integrated involuntary religious system in human history. The Catholic church, of course, evolved throughout the Middle Ages. Nevertheless, the indirect influence of the church on most—perhaps all—aspects of life, as well as the effects of its efforts to define, direct, and regulate the details of secular and religious life, provide a backdrop for much of the discussion that follows.

The Early Middle Ages

We know of the existence of a variety of medical practitioners from the early Middle Ages. Here and there in the sources are physicians who had been trained in Alexandria or in Constantinople, Jewish or Islamic physicians, and public or civic physicians in some of the surviving Roman cities of Italy and southern France. But primarily there are those who seem to have been little more than craftsmen who had learned their techniques as apprentices. The sources, nevertheless, call all these varied types medici, and often contrast them with incantatores (enchanters, magicians, witch doctors). Medici, although sometimes depicted negatively in the predominantly religious literature of the early Middle Ages, are presented favorably as practitioners of an art not inherently inconsistent with the teachings of the church. The incantatores, however, are invariably condemned in the literature, including secular and canon law, as diabolical practitioners of illicit arts inherently opposed to the church (Flint, 1989, 1991). In this sense the physicians of the early Middle Ages—indeed, throughout the Middle Ages—were regarded by those who spoke for the church as providing a theologically neutral alternative to the spiritually pernicious ministrations of the nearly ubiquitous practitioners of those healing arts that the church condemned (Amundsen, 1986).

Not only are these physicians, of whose ethics we have little or no direct evidence, contrasted with the incantatores; they also are distinguished from monks or other clergy who practiced medicine as part of their religious calling. Surveys of medical history typically describe the early Middle Ages as a time when medicine was practiced predominantly by monks who treated the ills not only of their fellow monks but also of the laity of the surrounding community, as an act of Christian charity. The rule of Saint Benedict, founder of the Benedictine order (early sixth century), is often cited in this regard. Chapter 36 of the rule is addressed to those who tend ill monks. Since, however, this chapter says nothing about medical care of the laity, scholars have emphasized that the rule may not be used as evidence for a policy of monastic medical care of the ill by the Benedictines (e.g., Park). But the steward, who, according to chapter 36, is largely responsible for the logistics of the care of sick monks, is admonished elsewhere in the rule to "take the greatest care of the sick, of children, of guests, and of the poor, knowing without doubt that he will have to render an account for all these on the Day of Judgment" (chap. 31). The "children, guests, and poor" in this context certainly would not be monks, nor should the "sick" here be limited to them. Still, this is far from a concise articulation of a monastic obligation to succor the ill of the lay community at large.

In the mid-sixth century, Cassiodorus wrote a rule for the members of a monastery he had founded. The section governing monk-physicians begins with praise for their performing "the functions of blessed piety for those who flee to the shrines of holy men" (Institutiones 1.31), which suggests his expectation that the ill would come to the monastery for medical care. The availability and quality of medical care at monasteries varied enormously during those early centuries. Only from the ninth century on can we speak with any certainty about monasteries' playing a key role in providing medical care for the sick poor (Park). Various church councils during the early Middle Ages enjoined bishops to provide accommodations for the destitute. These, originally called xenodochia, but soon more commonly known as hospitia or hospitalia, were attached to cathedrals or other churches (Ullmann). These hospitalia were not hospitals in the modern sense of that term (Miller). Often they provided only food, shelter, and some amenities; only occasionally were they staffed with medical attendants, who would then not have been monks but other clergy who devoted part of their energies to practicing medicine.

Cassiodorus wrote two documents that describe the duties of physicians. One, already cited as evidence for monastic medical care of the laity, gives inspirational guidance to those of his monks who were also physicians (Institutiones). The other, which he wrote as an official in the service of King Theodoric, regulated the activities of the civic physicians of Ostrogothic Rome and of the royal household (Variae). While in both documents Cassiodorus lauds the medical art, there is little other similarity between them. He urges the secular physicians to place their confidence in their art, while the monk-physicians are to place their hope in the Lord and not in the medical art itself. Although Cassiodorus stresses that the secular physicians are to be dedicated to their learned art and mindful of the oath by which they were consecrated, swearing "to hate iniquity and to love purity," his major concern is nevertheless with correcting negative aspects of medical practice: professional jealousies, envy, an unwillingness to share techniques with colleagues, and bedside bickering. While this secular document places a minor emphasis on the calling, motivation, or qualities of the secular physicians, the monk-physicians are to be deeply compassionate, distressed with personal sorrow at the misfortunes of others, and grieved by their suffering and peril. Motivated by compassion, they will "perform the functions of blessed piety," and their reward will be received from the Lord. Similarly, Cassiodorus' contemporary, Benedict, had charged his monk-physicians, "Before all things and above all things care must be taken of the sick, so that they may be served in very deed as Christ himself" (Rule, chap. 36). Their reward would come from the Lord.

While Cassiodorus' guidance to the secular physicians has no distinctly Christian flavor, the peculiar qualities of the monk-physicians are those of the ideal physicians of earlier Christian thought and of a variety of clergy who were to devote their lives to the charitable care of the sick, especially the poor, during the high and late Middle Ages. The best-known example is the Knights Hospitallers of Saint John of Jerusalem (late eleventh to the mid-sixteenth century), an order founded to provide shelter and care for pilgrims. These Hospitallers vowed to "serve our lords, the sick" (Hume). This phrase not only is an inversion of the lord–vassal relationship but also conveys the same ideal as the injunction in the Rule of Saint Benedict that the monk-physicians should serve the sick as if the latter were "Christ himself." These highly spiritual ideals of monastic medicine merged with the secular tradition of medical ethics and etiquette in the medico-ethical literature of the seventh through the tenth century.

Numerous medical manuscripts survive from the early Middle Ages, including several that deal with medical ethics and etiquette (MacKinney). Unfortunately the authorship, intended audience, and purpose of these medico-ethical treatises remain uncertain. They may have been composed by monks or other clergy as purely literary efforts. They may have been used as part of clerical education in the liberal arts, of which medicine was typically a subdivision (Amundsen, 1979). It is most unlikely that they were intended for, or used in, the training of physicians. These treatises present a fusion of the classical tradition of medical etiquette with Christian principles of compassion and charity. The bulk of each treatise was apparently drawn from, and sometimes directly attributed to, Hippocratic writings on etiquette: The physician's aptitude and ideal character, conscientiousness and diligence in practice, bedside manner, confidentiality, sexual propriety, proper relations with colleagues, and the preservation of one's reputation, that is, decorum in the broadest sense of the word. There is nothing distinctly Christian about any of this. But intermingled with such commonsensical precepts are distinctly Christian emphases: The physician should serve the rich and the poor alike, looking for eternal rather than material rewards, making "the cases of others his own sorrow." MacKinney correctly observes that "the monastic spirit dominated … medical handbooks of the period." They were "classical as well as pious, and secular as well as ascetic" (p. 5).

We know little about the ethics of early medieval physicians except for some monks and other clergy who practiced medicine as an act of Christian charity, without thought of remuneration. We do not even know by whom, for whom, and for what purposes treatises devoted to medical ethics and etiquette were composed. Anyone could claim to be a physician and practice medicine. There were no licensure requirements and no professional organizations. Only rarely do we encounter evidence of legal efforts to regulate physicians' activities, for example, by the Visigoths (Amundsen, 1971). Nor did the church make any concerted effort, during these early centuries, to define the responsibilities and regulate the conduct of secular or monastic/clerical physicians, other than to wage vigorous warfare against the use of illicit means of healing that typically were employed not by medici but by incantatores. Much of the time, the lines blur between secular physicians and those practitioners of medicine who were monks or clergy but practiced medicine for financial gain; many physicians who appear to have been secular were in fact clergy. Nor do we have any evidence about the behavior of physicians during epidemics that affected the villages and countryside during the early Middle Ages. But all these matters were to change during the high and late Middle Ages.

The High and Late Middle Ages

MEDICAL AND SURGICAL PRACTICE BY THE CLERGY. At the beginning of the high Middle Ages most monasteries could provide medical care for their members without resorting to the services of secular physicians. Nunneries typically engaged secular physicians for serious illnesses, although nuns attended to the minor health needs of members of their communities. There were some nuns, however, who were as medically sophisticated as any monastic/clerical or secular physician. The outstanding example is Hildegard of Bingen (1098–1179). Well known to her contemporaries as a visionary and mystic, she was also famous for her scientific and medical writings. While the propriety of monks treating monks and nuns treating nuns appears not to have been questioned, the role of the clergy generally as physicians and surgeons was beginning to be subjected to close scrutiny.

In the early twelfth century, the Cistercian abbot Bernard of Clairvaux received a demand from another abbot to send back to his former monastery a monk who had fled to Clairvaux. This monk had left because his abbot "used him not as a monk but as a doctor," and compelled him "to serve not God but the world; that in order to curry favour with the princes of this world he was made to attend tyrants, robbers, and excommunicated persons" (Amundsen, 1986, p. 84), which had brought considerable financial reward to his monastery. The monk was troubled about the spiritual propriety of this. Bernard permitted him to remain. The Cistercians shortly thereafter forbade their monk-physicians to practice outside their monasteries or to treat the laity (Miller).

A general church council, Lateran II, in 1139 promulgated a regulation having the rubric "Monks and canons regular are not to study jurisprudence and medicine for the sake of temporal gain," which condemned the avarice that motivated some clergy to pursue such studies: "[T]he care of souls being neglected … they promise health in return for detestable money and thus make themselves physicians of human bodies" (Schroeder, pp. 201–202). This law also expresses concern that clergy who practiced medicine would see "inappropriate things." But the major focus was that if financial gain were the motive for the study and practice of medicine and secular law, such pursuits were not appropriate for those who had dedicated themselves to a religious life. We should note, first, that this stipulation did not apply to most clergy but only to monks and canons regular ("regular" means living under a "rule," which did not include most clergy) and, second—and worth noting—that it was never incorporated into canon law. A regional council at Tours in 1163 enacted a law much narrower than the one of LateranII. It simply prohibited monks and other regular clergy from leaving their religious institutions to study medicine or secular law (Amundsen, 1978). This regulation, which did not forbid the practice of medicine by clergy, became part of canon law.

In 1219 Pope Honorius III issued a rescript, also included in canon law, that extended the prohibition of the study of medicine and secular law to virtually all clergy whose major responsibility was the performance of spiritual duties. Many clergy, however, were not affected by this stipulation, whose prohibitions were significantly lessened by subsequent enactments (Amundsen, 1978). By the end of the Middle Ages, canon law still had not prohibited the clergy from practicing medicine. Surgery, however, was a somewhat different matter, since it involved much greater risk to the patient and increased the danger that a clerical practitioner might be held responsible for a patient's death and hence excluded from exercising his clerical office. In 1215, Lateran IV forbade clergy in major (holy) orders (subdeacons, deacons, and priests) to practice the part of surgery that involved cautery and cutting, in which clergy in minor orders (porters, acolytes, exorcists, and lectors) could still engage (Amundsen, 1978).

Although the practice of medicine by the clergy was permitted, the church was obviously uneasy about their motivation and the possible effects that it might have on their spiritual obligations. Many of the clergy who continued to practice medicine and surgery, at least with the tacit blessing of the church, did so predominantly for charity. For example, some clergy composed medical treatises so that their fellow clerics could treat the poor gratis. Many clergy also wrote medical handbooks to help the poor help themselves. The outstanding example is Petrus Hispanus, "who publicly taught, wrote on, and practised medicine during the early stages of a highly successful ecclesiastical career that culminated with his election as Pope John XXI in 1276" (Siraisi, p. 25). He is the probable author of the Treasury for the Poor, which describes herbs the poor could gather to treat themselves.

During the high Middle Ages rapid urbanization brought about widespread suffering and disease in the growing towns and cities. In the late eleventh century, Augustinian canons (who were regular clergy like monks, but unlike them in that they did not live apart from society) and various lay brotherhoods established charitable institutions that included facilities for the destitute ill (Miller). A variety of such institutions were founded by bishops, kings, feudal lords, wealthy merchants, guilds, and municipalities as endowed charitable institutions. Members of various orders, like the Knights Hospitallers of St. John of Jerusalem, sometimes staffed these hospitals. Nursing orders also arose, committed to caring for the destitute ill in such institutions. The Knights Hospitallers' phrase "to serve our lords, the sick," perfectly captures both the idealism and spiritual motivation of these orders and the very essence of their ethics. But such practitioners constituted only a small proportion of physicians and surgeons of the high and late Middle Ages. By the mid-fourteenth century, most monasteries were paying secular physicians to treat their ill monks (Park). The church's desire to decrease clerical involvement in medical practice, especially for financial gain, combined with rapidly changing social conditions that, beginning around 1050, significantly altered the practice of medicine and the nature of medical ethics.

LICENSURE, GUILDS, UNIVERSITIES, AND A RECIPROCITY OF OBLIGATIONS. Stimulated by a dynamic revival of a commercial economy, dormant since the collapse of Roman civilization, a gradual transformation of European society began around 1050, an urban revolution that created a starkly altered context for nearly all aspects of life. One of its most salient features was the corporate nature of late medieval urban society, as manifested in increasing institutional sophistication and formalized specialization of labor, regulated either internally by guilds or corporations or externally by secular or ecclesiastical authority. Both regulatory features changed the basis for the practice of most trades and professions, including medicine and surgery. No longer would the practice of medicine be a right that anyone could claim, a free enterprise constrained only by individual conscience and criminal law. The practice of medicine would now be a privilege granted, enforced, and protected by the state or the church, at the state's or church's initiative or at the request of guilds or corporations of physicians or surgeons.

The earliest datable law instituting medical licensure is from the Kingdom of Sicily. In 1140, Roger II issued a statute specifying that those who wished to practice medicine were to appear before his officers and judges and be examined by their court. Those who practiced in defiance of this statute were to be imprisoned and their property confiscated. "… this has been arranged so that subjects in our kingdom may not be experimented on by inexperienced physicians" (Powell, p. 130; Hartung). A considerable advance over this legislation was made by Roger's grandson, Emperor Frederick II, who in his capacity as king of Sicily, in 1231 promulgated the Liber Augustalis. Thereafter the examination for licensure was to be conducted by the masters of the medical school at Salerno, and the license to practice would be issued by the emperor or his representative. Before the examination, the aspirant was to study logic for three years and medicine (to include surgery) for five years, and to practice for one year under the direction of an experienced physician. These revisions are introduced by the following justification: "We see a special usefulness when we provide for the common safety of our [faithful subjects]. Therefore, since we are aware of the serious expense and irrecoverable loss that can occur because of the inexperience of physicians …" (Powell, p. 131). Physicians must visit their patients twice a day and, at the request of the patient, once during the night. Fees were to be determined in part by the distance involved. The physician was required to swear to abide by the regulations fixed by the government, treat the poor gratuitously, and inform the authorities of any apothecary who prepared drugs at less than the required strength. Physicians were forbidden to make any contracts with apothecaries or to own apothecary shops (Powell; Hartung).

On the Iberian Peninsula, the first medical licensure regulation, in 1289, imposed no requirement for a course of study in a medical school; forty years later a new law established a university medical degree as a prerequisite for practice (García-Ballester et al.). The law of 1329 and subsequent legislation provided very specific regulations governing physicians' conduct and responsibilities. These regulations, which benefited both the general public and the qualified and responsible physician, evince a reciprocity of obligations between the profession and the state. Elsewhere in Europe, by contrast, artisans, merchants, surgeons, physicians, and professors were organizing into guilds, gaining charters from municipal, royal, or ecclesiastical authorities, and guaranteeing standards of quality of goods or services in exchange for the privilege of holding a monopoly in their service or commodity.

One of the most striking features of late medieval urban life was its corporative aspect, particularly its guild organization. Perhaps originally formed simply as social organizations under the auspices of a patron saint, guilds had three major interests: (1) social, manifested in both internal and external charitable efforts, and social life within the guild (banquets, etc.); (2) political, especially guilds involved in the production of economically vital commodities; and (3) commercial, involving the protection of financial and vocational interests. In respect to the last, the guilds, by obtaining charters, secured the right to exercise a monopoly on their product or service in a particular geographical area. Such a monopoly entailed the right to make and enforce standards of quality in their products or services, to control hours and working conditions, to limit competition among members, to limit entry into the craft or profession, and to ensure the proper treatment of customers. Part of the monopoly was the right to train and license new members, thus eliminating competition from outside the guild. Although one of the major aims of such measures was economic, the guilds frequently claimed that such restrictions were necessary to maintain a high level of competence and ethics in the trade or profession. Distinct from the merchant and craft guilds, the medieval universities were essentially educational guilds. Beginning in the late twelfth century, some universities gained charters and thus became corporate bodies designed to further educational interests and to protect their members. The collegium of teachers who examined the candidates for a degree was, at some universities, vested with the authority to grant a license or, at others, to recommend to secular or ecclesiastical authorities that a license be awarded.

Conditions were so diverse that generalities are often misleading. But usually surgeons were organized in craft guilds; physicians, at least in cities having a university, were not members of a craft guild but were part of, affiliated with, or under the supervision of the medical faculty of the university. In university cities, medical licensure requirements were generally instituted earlier than in those without a university but, from the early fourteenth century on, many cities and towns required those who wished to practice medicine within their jurisdiction to have a degree and license from an acceptable university. Physicians practicing in such places often organized themselves into collegia or guilds, and in some instances obtained the authority to examine and license physicians who wanted to practice within the community, regardless of the degrees held by the applicants (Siraisi).

Practitioners brought to trial for practicing without a license often accused medical and surgical guilds and faculties of self-interest (Kibre; Cosman). However, restrictions on medical and surgical practice, whether imposed by authorities or requested by medical faculties or medical or surgical guilds, were justified in terms of the common good, especially the grave dangers to the people if charlatans and quacks were permitted to undertake medical or surgical care. For example, the medical faculty of the University of Paris initiated medical licensure provisions and, in seeking ecclesiastical and royal support to enforce these regulations, continually appealed to the "public interest." The same appeal was made in the medical faculty's attempts to establish a right to oversee the activities of surgeons, apothecaries, barbers, and herbalists, and to prosecute unlicensed practitioners in ecclesiastical or secular courts. The unlicensed practitioners often were women who were frequently "caught in the crossfire" (to use Green's phrase, 1989, p. 447) of the legal battles between licensed groups like physicians and surgeons (see also Park, for analysis; Kibre, for narrative examples). As in the early Middle Ages, there was also a concerted effort to exclude the illicit supernatural from healing procedures. Often suspected of being "witches and exorcisoresses of the devil," unlicensed women practitioners were in double jeopardy (Amundsen, 1986, pp. 93–94).

Although guilds were organized to serve their members' self-interest, guild ethics generally were beneficial to the public. In 1423, the physicians and surgeons of London petitioned the mayor and aldermen to authorize the creation of a joint collegium of the two crafts. George Unwin, a historian of English guilds, remarks that their petition illustrates "the best spirit of professionalism at this period of London history." He summarizes its contents as follows:

Their rules were meant to ensure that all practitioners in both branches should be duly qualified, if possible, by a university training, and they sought to provide a hall where reading and disputation in philosophy and medicine could be regularly carried on. No physician was to receive upon himself any cure [i.e., case], "desperate or deadly," without showing it within two or three days to the Rector or one of the Surveyors in order that a professional consultation might be held, and no surgeon was to make any cutting or cauterization which might result in death or maiming without similar notice. Any sick man in need of professional help but too poor to pay for it, might have it by applying to the Rector. In other cases the physician was not to charge excessive fees, but to fix them in accordance with the power of the sick man, and "measurably after the deserving of his labour." A body composed of two physicians, two surgeons, and two apothecaries, was to search all shops for "false or sophisticated medicines," and to pour all quack remedies into the gutter. (p. 173)

The foundational principles of medieval medico-surgical guild ethics were that each guild member must: (1) be ready to help the other; (2) protect the well-being and honor of the guild; and (3) help the sick. The order of these principles is very important. The guilds were functional, inherently selfish organizations designed to promote and protect members' special interests. They were brotherhoods, companies of people united more often than not by a common economic activity. The well-being and honor of the craft depended upon the mutual cooperation of its members. If these conditions were met, then the third—the service rendered or the commodity produced—could be effectively delivered. All these, in late medieval urban life, hinged upon the freedom of the artisans, merchants, professors, physicians, or surgeons to perform their functions unmolested by those who would illicitly meddle in their affairs. Hence they sought an exclusive right to fill a particular role; in exchange, a guild would guarantee a level of expertise in the production of its commodity or in the rendering of its service, and would assume the responsibility to police and to supervise its own members, both in respect to their qualifications, that is, training (leading to licensure), and to their performance. Regulations governing the minutiae of conduct, both within the guild and in relationships with customers or the community, varied considerably from guild to guild and from city to city. But the obligation to ensure competence and quality seems to have been a constant feature.

The highest guarantee of competence to practice medicine, recognized throughout Europe in the late Middle Ages, was a degree granted by a university medical faculty. A university curriculum in medicine, a set body of literature, and the presence of instructors qualified to teach and to test demonstrate that a standard of competence existed. The reality of such a standard has important ethical implications. Luis García-Ballester goes so far as to assert that "Everything connected with the conduct of the physician—from strictly technical matters … to the question of fees or the problems of etiquette …—was derived from this strictly technical organizational scheme … what later became known as medical ethics had this technical, intellectual origin. The specific morality of the practitioner derived, therefore, from his being a healer technically trained, and was essential for his status as an expert in medicine" (pp. 44–45).

An underlying and sometimes articulated principle of medical and surgical guilds was that the guild would ensure that the ill of the community, including the poor and the hopelessly ill, would not be abandoned at the whim of individual physicians or surgeons. This was based at least in part on the conviction, which was very strong in the late Middle Ages, that one had an officium, that is, an office or calling, that carried with it certain duties and obligations. In a work devoted to the responsibilities attached to kingship, Thomas Aquinas wrote, "Nor has [the king] the right to question whether or not he will so promote the peace of the community, any more than a physician has the right to question whether he will cure the sick committed to him. For no one ought to deliberate about the ends for which he must act, but only about the means to those ends" (De regimine principum 2). In late medieval urban (i.e., corporate) life, physicians and surgeons, by virtue of their privilege of engaging in a legitimate officium within the corporate structure of society, had responsibilities both to their officium itself, as represented by the guild, company, craft, or collegium, and to the community that granted them their privileges.

THE CHURCH'S EFFORTS TO DEFINE THE RESPONSIBILITIES OF PHYSICIANS. In 1215, a general church council, Lateran IV, promulgated a decree that required annual confession by all Catholics, on pain of excommunication. This decree was widely publicized and strictly enforced. In response, lengthy treatises on moral theology and numerous manuals to aid priests in interrogating penitents during confession were written by moral theologians in an effort to subject the broadest spectrum of human activities to Christian moral principles, including a wide variety of occupations. The discussion that follows is a very condensed summary of the sections of ten primary sources from the early fourteenth through the early sixteenth century that provided priests with a range of questions and moral guidance to be addressed to physicians and surgeons during their mandatory annual confession (Amundsen, 1981). Where the word physician appears, it should be understood to include "surgeon."

Competence and diligence. Physicians who are not competent according to accepted standards within the profession sin by practicing medicine. Simply possessing a degree in medicine does not in itself guarantee competence. Competent physicians sin if they do not conscientiously exercise diligence. Rashness, which may result from incompetence or negligence, is a sin in medical practice, especially if patients are harmed. Hence physicians should be cautious and not administer medicines about whose effects they are in doubt; patients should be left in God's hands rather than be exposed to additional danger. Generally, physicians sin if they engage in any experimentation at the patient's risk, especially if they experiment on the poor whom they treat without charge. Physicians also sin if they are so cautious that they fail to give the appropriate medicines, and especially if they do so in order to prolong the illness and thereby increase their fees.

Fees and charity. Beginning with the assumption that it is licit to receive remuneration for what one is not bound to do gratuitously, but bypassing consideration of how the scholastic principle of "just price" for services could be applied to medical practice, the moral theologians discuss a wide variety of moral aspects of medical fees. The most basic principle is that physicians should ensure that they accept only a "reasonable" fee, as determined by the quality of care; the physician's labor, diligence, and conscientiousness; the custom of the place; and the patient's means. A patient who is rich must not be exploited by exorbitant rates. More problematic is the sick pauper. Is the physician obligated to give free medical care to the poor? This, as we shall see when discussing the medico-ethical literature of the high and late Middle Ages, was a source of great frustration for physicians. Thomas Aquinas, beginning with the premise that "no man is sufficient to bestow a work of mercy on all those who need it," suggests that kindness ought first to be shown to those with whom one is united in any way. As for others, if one "stands in such a need that it is not easy to see how he can be succored otherwise, then one is bound to bestow the work of mercy on him." Hence a lawyer is not always obligated to defend the destitute, "or else he would have to put aside all other business and occupy himself entirely in defending the poor. The same holds with physicians in respect to attending the sick" (Summa theologiae 2–2, 71, 1). The authors of the confessional literature generally follow Aquinas and specify that physicians must treat the poor gratuitously if the patient would die without treatment.

An obligation to care (especially for hopeless cases). With the advent of medical licensure requirements and medico-surgical guild monopolies, the physicians' option of refusing to treat or of deserting hopelessly ill patients became more circumscribed. Social and religious pressures also changed. Typically the moral theologians maintain that "Desperate cases that, according to the judgments of men, are held to be fatal, sometimes the diligent physician is able to cure, but rarely … therefore, clear to the end the physician ought to do what he can to cure the patient" and should not entirely withdraw from the patient "as long as nature does not succumb." If a rich miser is unwilling to employ the services of a physician, the physician is obligated to treat him or her gratis, even to provide medicines without charge; otherwise the physician is killing such a person indirectly. If the rich miser recovers, the physician may sue for fees and expenses; if the miser dies, the heirs are obligated to pay (Amundsen, 1981).

Spiritual obligations of physicians to patients. While the theologians were quite concerned to protect the patient from physical harm and financial exploitation, they were even more determined to guard the well-being of the patient's soul. At Lateran IV in 1215, the following decree was enacted:

Since bodily infirmity is sometimes caused by sin, the Lord saying to the sick man whom he had healed: "Go and sin no more, lest some worse thing happen to thee" [John 5: 14], we declare in the present decree and strictly command that when physicians of the body are called to the bedside of the sick, before all else they admonish them to call for the physician of souls, so that after spiritual health has been restored to them, the application of bodily medicine may be of greater benefit, for the cause being removed the effect will pass away. We publish this decree for the reason that some, when they are sick and are advised by the physician in the course of the sickness to attend to the salvation of their soul, give up all hope and yield more easily to the danger of death. If any physician shall transgress this decree after it has been published by the bishops, let him be cut off from the church till he has made suitable satisfaction for his transgression. And since the soul is far more precious than the body, we forbid under penalty of anathema that a physician advise a patient to have recourse to sinful means for the recovery of bodily health. (Schroeder, p. 236)

The stipulation that physicians must advise and persuade patients, before all else, to call a priest concerns the curative effect of confession rather than the opportunity to confess before dying. The moral theologians' discussions of this stipulation vary enormously in length, detail, and sensitivity to the problems that it posed. Several maintain that this requirement applied only to cases of extremely dangerous or mortal illnesses. Some go so far as to provide lists of applicable diseases, symptoms, or injuries, especially those demanding immediate attention. This interpretation of the decree is surprising, since it flies in the face of the specific intent that patients be made aware that the requirement to call a confessor is not to be taken as an indication that their condition is hopeless. And some of the authors of the confessional literature interpret it strictly along such lines, making no exceptions. They wrestle with the question of whether a physician is obliged to withdraw from a case if the patient refuses to call a confessor, and reach a variety of answers ranging from a strict "yes" to an unequivocal "no," some of the latter maintaining that if the physician were required to abandon the stubborn patient, "the precept of the church [would] seem against the precept of God." At the end of the Middle Ages, there was no uniformity either of practice or of interpretation of this piece of canonical legislation.

In the context of discussions of the requirement that physicians have their patients summon a confessor, some moral theologians raise the question of whether physicians are obliged to inform terminally ill patients of their condition. There is some disagreement among the moral theologians who address this issue, particularly since physicians (and here Galen is cited) typically tell patients that they will recover, even if there is little hope, since predicting a fatal outcome will likely remove all hope of recovery and hasten death. Generally the authors of the confessional literature insist, however, that unless physicians are certain that their terminally ill patients have set both their spiritual and their temporal affairs in order, they must inform them of their imminent demise, since otherwise harm may ensue to patients' souls and estates.

The second requirement of the legislation in question is for physicians to refrain from advising sinful means for the recovery of health. Several of the moral theologians simply quote that stipulation without elaboration. Others condemn specific matters, such as advising fornication, masturbation, incantations, consumption of intoxicating beverages, breaking the church's fasts, and eating meat on forbidden days.

Abortion and euthanasia. The authors of the confessional literature almost entirely ignore the subject of abortion when discussing the responsibilities and sins of physicians. While all include thorough discussions of abortion under the rubric "homicide" or "abortion" or both, only two include it in their extensive considerations of medical ethics. Apparently the rest did not think that physicians or surgeons were confronted with requests for abortions. Women who sought abortions would probably not have turned to physicians or surgeons, the overwhelming majority of whom were men during the high and late Middle Ages, but to another woman, such as a midwife or an unlicensed female practitioner.

Abortion, regarded both as a sexual sin and, under some circumstances, as homicide, was an issue fraught with interpretive problems during the Middle Ages (Noonan; Connery). The opinion of Jerome and Augustine (fourth century) that abortion is not homicide unless the fetus is "formed," that is, vivified or ensouled, was incorporated into medieval canon law, which also included a conflicting decree that applied the penalty for homicide to the induced abortion of a fetus at any stage of development. Theologians, canon lawyers, and the authors of the confessional literature were split between these two positions. The stricter interpretation generally forbade abortion at all times and under all circumstances. The more liberal interpretation, which was influenced by Aristotelian embryology, did not classify induced abortion as a mortal sin within the first forty days of pregnancy in the case of a male fetus, and eighty (or, according to some, ninety) days in the case of a female, and permitted abortion during these periods under a variety of extenuating circumstances. The conflict between the interpretations of these two camps was not resolved until long after the Middle Ages. Both, however, clearly condemned abortion as reprehensible if performed simply to destroy the unwanted consequence of sexual intercourse.

What we call active euthanasia is a subject that the moral theologians thus far surveyed never raised when discussing the sins of physicians; it was probably regarded throughout the Middle Ages simply as homicide on the physician's part and suicide on the patient's, assuming willing involvement by the latter. Martin Azpilcueta, better known as Navarrus, a leading canon lawyer and moral theologian of the sixteenth century, wrote in 1568 that the physician sins who gives any medicine that he knows is harmful, "even if he administers it out of pity or in order to please the patient." Navarrus's statement seems clear and unambiguous: active euthanasia, whether motivated by pity or by the wish of the patient, is sinful. This must be one of the earliest articulations regarding active euthanasia in such precise terms. Navarrus gives as his authority the canon lawyer Panormitanus (early fifteenth century), who had simply given the opinion that those having custody or serving a sick person sin greatly if, motivated by "a sort of pity," they obey or indulge the "corrupted desire" of the ill. Before active euthanasia was seen as a separate moral category, the closest the authors of the confessional literature could have come to including relevant comments in their sections on physicians' sins would have been to have stated that it was a sin for physicians to kill or poison their patients intentionally.

The effects of the moral theologians' efforts. Medieval European society was, with the exception of a small number of Jews and heretics (e.g., Albigensians and Waldensians), exclusively Catholic. Guaranteed the allegiance of virtually the entire population of western Europe and the prestige of ecclesiastical institutions, the church could exercise jurisdiction over areas of life that now would be the concern of either secular authority or the individual conscience. The church promulgated laws and expected obedience. Ecclesiastical courts imposed penalties ranging from penance to imprisonment to excommunication. The extent to which the confessional influenced ethics and conduct cannot be gauged with certainty. The authors of the confessional literature strove both to educate the laity so that they might be able to identify previously unknown sins, both of commission and of omission, and to correct sinful practices. The best confession was one that led to a changed life, and a changed life should be one in as close conformity to the expectations and standards of the church as possible. The priest's authority "to loose and to bind," although ultimately of eternal consequence, applied also to this life in that it included the authority—indeed, the responsibility—to grant forgiveness and restoration only to those who satisfied the requirements of the confessional, and to impose sanctions upon those who refused. The ultimate sanction, excommunication, when imposed upon those who exercised their vocation by license, would deprive them of their livelihood. Whether such steps were ever taken against physicians during the high and late Middle Ages remains unclear. Nevertheless, the morally educating (or possibly alienating) effects of this annual interrogation, which employed the detailed scrutiny available to every priest in his confessional manual, must have been profound.

PHYSICIANS' AND SURGEONS' ADVICE ON ETHICS AND ETIQUETTE. In the extensive medical and surgical literature that has survived from the high and late Middle Ages, one occasionally encounters comments made directly on matters of medical ethics or etiquette. Surgical manuals, for example, often begin with a discussion of the moral and educational qualifications of a practitioner, bedside manner, fees, and a variety of related matters. Medical and surgical literature also contains comments that indirectly reveal aspects of the ethical standards of the author, especially in the tractates written by physicians who attempted to understand and deal with the outbreaks of plague that struck Europe during the late Middle Ages.

Loren MacKinney perceived that, by the twelfth century, a change in spirit had occurred in medical literature from monastic to secular, a "shift of emphasis from ideals to practical considerations," a "despiritualization of the medical physician," particularly in the introduction of various "tricks of the trade" and a predominant concern with fees (pp. 23ff.). He credits this change to such factors as rapid urbanization, and he is probably right to a degree. But it is important to note the different walks of life from which the authors of the sources came. While the literature from the early Middle Ages was likely composed by monks, that of the high and late Middle Ages was written mainly by secular physicians. So it is not surprising that its tone is less otherworldly than that of the earlier treatises. The later literature was written with the clear intention of providing practitioners with two types of information: (1) the ideal physician's character, preparation, and practice; and (2) very practical and sometimes questionable advice on how best to survive in the profession. Both were at least moderately informed by the teachings of the medieval Catholic church.

The first category consists of the same range of commonsensical advice as appears in Hippocratic treatises and in the medico-ethical literature of the early Middle Ages. The second appeared especially in discussions of fees. As early as the tenth century, the physician is advised: "At the outset, accept at least half of the remuneration without hesitation, for he who wishes to buy [your services] is disposed to pay and to beg [for treatment]. Get it while he is suffering, for when the pain ceases, your services also cease" MacKinney, p. 24). Somewhat more enlightened is the suggestion by William of Saliceto (thirteenth century) that "a high salary, if demanded, imparts to the physician an air of authority, which strengthens the confidence of the patient in him … so that the sick man imagines from this that he is more skillful than others and ought therefore to be successful in curing him" (Mirfeld, p. 132).

Some of the advice that follows, written by physicians or surgeons, may appear particularly crass. It is, however, important to realize that the medical literature of the time stressed, in Luis García-Ballester's words,

the mutual confidence that should exist between doctor and patient. Without such confidence the efficacy of the curative action would be greatly undermined …. the physician's or surgeon's confidence in his patient was demonstrated by two conditions of equal significance: the first was that the patient should carry out what had been prescribed by the healer; the second that the patient should pay the remuneration agreed upon. The fee would be for the doctor the objective and tangible expression of his relationship with the patient and that of the patient with the doctor, while, at the same time, it would be a guarantee of continuity in treatment. (p. 51)

Henry de Mondeville (fourteenth century) laments that "The chief object of the patient, and the one idea which dominates all his actions, is to get cured, and when once he is cured, he forgets his own obligations and omits to pay; the object of the surgeon, on the other hand, is to obtain his money, and he should never be satisfied with a promise or a pledge, but he should either have the money in advance or take a bond for it" (Hammond, p. 159; Welborn, p. 356). Mondeville's attitude was probably the fruit of bitter experience. Official documents from the late Middle Ages record many cases of physicians suing patients in order to collect their fees. In most cases in which the treatment had been unsuccessful, the suit went in favor of the patient. Quite unreasonable demands by patients for extensive credit, the necessity that physicians sometimes demand securities before undertaking treatment, and lucrative contractual arrangements all contribute to the complex and ethically ambiguous way in which late medieval medical and surgical practitioners made a living (Rawcliffe, for late medieval England).

One area in which physicians seemed to act against their more mercenary interests was in providing advice that would keep potential patients from needing their services.

Mondeville wrestled with the problem presented by surgeons' advising their patients how to stay healthy, "because the treatment which stops the onset of a new disease is more useful to a patient than all other treatments. But this is, as one can see, useless and harmful to the surgeon because he thus stops the appearance of a disease whose treatment would be advantageous to himself" (Hammond, p. 155; Welborn, p. 355).

Neither Mondeville nor his contemporary, John Arderne, seem to have felt any embarrassment over pressing for as high a fee as possible. The former recommends that "The surgeon should pretend that he has no living nor capital except his profession, and that everything is as dear as possible, especially drugs and ointments; that the fee is nothing as compared with his services; and the wages of all other artisans, masons, for example, have doubled of late" (Hammond, p. 156). He considered it essential that the fee not be reduced too much. It would be better, then, to charge nothing.

In determining how much to charge, Mondeville recommends that the surgeon consider three things: "First, his own standing in the profession, then the [financial] condition of the patient, and, third, the seriousness of the illness" (Hammond, p. 156; Welborn, p. 356). It was the second of these that was probably the most trying. Mondeville advises the doctor not "to have too much faith in appearances. Rich people have a bad habit of appearing before him in old clothes, or if they do happen to be well dressed, they make up all sorts of excuses for demanding lower fees" (Welborn, p.356). So strong, though, is the sense of obligation to succor the poor gratis, or at least to give the appearance of doing so, that physicians and surgeons probably were quite frequently faced with very difficult judgments.

The motivation of physicians and surgeons to extend charity to the poor was more than the advantages that might accrue to their reputation and to the honor of the profession; it was a product of enlightened self-interest, with eternal consequences, fully compatible with the theology of the time, as is succinctly expressed by Mondeville: "You, then, surgeons, if you operate conscientiously upon the rich for a sufficient fee and upon the poor for charity, you ought not to fear the ravages of fire, nor of rain nor of wind; you need not take holy orders or make pilgrimages nor undertake any work of that kind, because by your science you can save your souls alive, live without poverty, and die in your house" (Hammond, p. 156).

While some effect of the church's teaching is manifest in even Mondeville's fee policies, in other areas spiritual concerns are more evident. An anonymous twelfth-century Salernitan treatise advises: "When you reach [a patient's] house and before you see him, ask if he has seen his confessor. If he has not done so, have him either do it or promise to do it. For if he hears mention of this after you have examined him and have considered the signs of the disease, he will begin to despair of recovery, because he will think that you despair of it too" (De Renzi, vol. 2, p. 74). This work was composed some time before Lateran IV of 1215, and thus before physicians were required "before all else to advise and persuade" their patients to call a confessor. The anonymous author of this treatise does not appear unusually devout. Indeed, were one to attach an adjective to the work, "eminently practical" would describe it better than any other. The author, of course, was a member of a society in which the belief in the necessity of confession before death was deeply ingrained. While he may not have considered it especially his own spiritual duty to look after his patients' spiritual as well as physical health, he must have considered the alternative of advising patients to confess only when in dire straits to be potentially dangerous to them.

The advice on confession, as it appears in a treatise attributed to Arnald of Villanova (late thirteenth century), is significantly different in emphasis from that in the anonymous Salernitan piece: "[W]hen you come to a house, inquire before you go to the sick whether he has confessed, and if he has not, he should immediately or promise you that he will confess immediately, and this must not be neglected because many illnesses originate on account of sin and are cured by the Supreme Physician after having been purified from squalor by the tears of contrition, according to what is said in the Gospel: 'Go, and sin no more, lest something worse happens to you'" (Sigerist, p. 141). This version, written after Lateran IV, quoting the same Scripture as the canon law, demonstrates the direct influence of a constitution of canon law on a strictly secular piece of medical literature, as does even more strongly the following passage in an anonymous plague tractate composed in 1411: "If it is certain from the symptoms that it is actually pestilence that has afflicted the patient, the physician first must advise the patient to set himself right with God by making a will and by making a confession of his sins, as is set forth according to the Decretals; since a corporal illness comes not only from a fault of the body but also from a spiritual failing as the Lord declares in the gospel and the priests also tell us" (Amundsen, 1977, p. 416). About a century earlier, similar advice had been given by Mondeville: "Do not let the patient be concerned about any business except spiritual matters only, such as confession and his will and arranging similar affairs in accordance with the rules of the Catholic faith" (Amundsen, 1986, p. 90). Whether these writings composed after Lateran IV are simply examples of lip service to ecclesiastical author ity or reflect genuine approval of the underlying principle upon which the legislation was based must remain an open question.

An eleventh-century treatise advises that the physician should "never become involved knowingly with any who are about to die or who are incurable" (MacKinney, p. 23). Although from the earliest times such counsel was common, in the late Middle Ages it was becoming increasingly less so. The previously quoted anonymous Salernitan treatise from the twelfth century advises the physician, just before leaving, to "promise the patient that with the help of God you will cure him. As you go away, however, you should tell his servants that he is seriously ill, because if he recovers you will receive greater credit and praise, and if he dies, they will testify that even from the beginning you despaired of his health" (De Renzi, vol. 2, p. 75). Although this treatise may be described as eminently practical, it is not clear that this particular bit of advice is ethical.

A parallel passage in a treatise attributed to Arnald of Villanova (late thirteenth century) is nearly identical, with the significant difference that instead of promising the patient "that with the help of God you will cure him," which still leaves the matter in doubt and at least partially in God's hands, it advises more crassly that "you promise health to the patient who is hanging on your lips" (Sigerist, p. 142). This treatise appears to have been hastily thrown together from various sources, since elsewhere it flatly contradicts the advice that the physician should promise health to the patient. Later it suggests that the physician "must be … circumspect and cautious in answering questions, ambiguous in making a prognosis, just in making promises; and he should not promise health because in doing so he would assume a divine function and insult God. He should rather promise faithfulness and attentiveness …" (Sigerist, p. 141). For two such opposing pieces of advice to be found in the same treatise is unusual. Such conflicting opinions, however, are typical of medical ethics in the late Middle Ages. For example, Bernard de Gordon (thirteenth–fourteenth centuries) advised that if there was little likelihood of a patient's recovering, "One should try to escape from such cases, provided one can do so honorably" (Demaitre, p. 153). Nevertheless, he also expresses a concern to do everything possible to postpone the death of terminally ill patients.

William of Saliceto (thirteenth century) recommends that the physician should "comfort his patient, and on every occasion should promise him restoration to health, even if the physician himself shall regard the case as desperate." He justifies this on the grounds that this will greatly encourage the patient, increasing his chances of recovering. He further suggests that the physician "acquaint the friends of his patient with the truth, and discuss the case fully with them as he shall deem best, lest he incur scandal or loss of reputation from inability to offer a satisfactory statement of the case, and lest the friends of the patient regard him with distrust: nor will he then be held responsible for having caused the death of a patient who shall die; but he will be given credit for having cured the man who lives and is restored to health" (Mirfeld, p. 122). William's reason for giving a favorable prognosis to the critically ill patient is strictly for the latter's benefit. He recommends that the physician tell the patient's friends the truth for the physician's own protection, a far different piece of advice from that in the two treatises previously discussed, which recommend that the physician, regardless of the patient's actual condition, advise those close to him or her that the case is dangerous and that the patient is not faring well.

Mondeville wrote that the surgeon "ought to promise a cure to every sick person, but he should refuse as far as possible all dangerous cases, and he should never accept desperately sick ones" (Welborn, p. 350). Physicians and surgeons were sometimes charged with the deaths of patients in the late Middle Ages, and the fear of facing blame for a patient's death still motivated some to recommend, as Mondeville did, that dangerous cases not be taken on. Mondeville, incidentally, writes at some length about how to ensure that a patient's friends or relatives can be compelled to exonerate the surgeon if a case should end in the patient's death (Welborn). Nevertheless, advice not to take on dangerous cases occurs much less often in late medieval sources than in the medical literature of ancient Greece and Rome. Instead, physicians are advised to protect themselves either by telling the relatives or friends of the patient that the situation is critical, regardless of the patient's condition, or to tell the truth in cases that actually are critical.

PLAGUE AND MEDICAL ETHICS IN THE LATE MIDDLE AGES. The devastating plague epidemics that periodically swept through Europe, beginning in 1348 and continuing well beyond the Middle Ages, tried and tested the ethics of medieval physicians far beyond conditions encountered in ordinary practice. Contemporary sources almost uniformly express the conviction that plague was extremely contagious. Merely being in the vicinity of the sick, many supposed, doomed one to become infected and die. Numerous sources describe parents deserting their dying children, children their parents, wives fleeing from their sick husbands, and husbands from their wives. All who could, fled the cities and towns to take refuge in the countryside. Not only were the sick deserted by their families; physicians would not come near them, and even priests would not meet the final spiritual needs of the dying. Such accounts are plentiful. But they must be set against abundant accounts of responsible actions by family members, magistrates, physicians, and clergy.

Some physicians undoubtedly did flee. In 1382 Venice stipulated that physicians who fled during epidemics would lose their citizenship. Barcelona and Cologne took similar action during the sixteenth century. While it is impossible to determine the extent to which physicians actually did flee from plague-ridden communities, the percentage was probably relatively small. A study of nearly three hundred plague tractates written by physicians between 1348 and the early sixteenth century found not even one allusion to physicians who fled from areas afflicted with plague (Amundsen, 1977). Medieval physicians were not at all timid in castigating their colleagues in writing. Vitriolic criticism, particularly of fellow physicians' theories and medical techniques, is found throughout the medical literature. If the flight of physicians had been extensive, then one should encounter among the plague tractates such statements as "Although many other physicians fled, I remained."

Many physicians did advise people to flee from plagueinfected areas as the best form of prevention. This advice, however, was typically followed by the concession that since flight "rarely is possible for most people, I advise that, while remaining, you. …" Prevention is the primary concern of most of the plague tractates. Even if they are unanimous in urging flight, it does not follow that the physicians who wrote them intended by doing so to justify flight for themselves and their colleagues. The authors of the tractates appear simply to have assumed that their readers would be able to avail themselves of the services of physicians during plague epidemics.

Did physicians who fled, or who refused to visit and diagnose those perhaps afflicted with pestilence, or who abandoned patients actually suffering from plague, violate their responsibilities as conceived at that time? Contemporary sources make it abundantly clear that both the public at large and physicians themselves viewed those physicians who fled from plague as having acted disgracefully. In the mid-fourteenth century, Guy de Chauliac, at one time personal physician to the pope, wrote concerning his own activities during the Black Death, the earliest and most devastating of a long series of plague epidemics: "It was so contagious … that even by looking at one another people caught it …. And I, to avoid infamy, dared not absent myself but with continual fear preserved myself as best I could" (Campbell, p. 3). Faced with both extreme peril to themselves and with the knowledge of the extremely high mortality rate of plague victims, physicians found themselves in an ethical quandary. Chauliac wrote, "It was useless and shameful for the doctors, the more so as they dared not visit the sick, for fear of being infected. And when they did visit them, they did hardly anything for them, and were paid nothing" (Campbell, p. 3).

One tractate maintains that physicians "must treat the ill," and another that "they must treat or visit the ill" (Amundsen, 1977, p. 414). The difference between these two is very important. While the first holds that physicians must treat plague victims, the second asserts that physicians must treat or visit the afflicted. Physicians who fled from a plague-infected area or hid in fear obviously failed even to attempt to diagnose the condition. But if the sick were indeed afflicted with the plague (since not all who became ill during a time of plague were necessarily afflicted with the plague), did physicians have an ethical obligation to attempt treatment?

A basic feature of medieval medical and surgical guild ethics was an obligation to be available to treat the ill or injured of the community and not to abandon hopeless cases. To the moral theologians who wrote the confessional literature, the duty to treat and to stay with the patient was unequivocal, although they were considering normal conditions rather than the exigencies of plague epidemics. Physicians were ambivalent about whether to take on hopeless cases; so were authors of the plague tractates. During outbreaks of plague, some physicians viewed the disease as treatable and others as at least potentially curable. Many physicians felt compelled to investigate the various strains of plague and to seek ways both to prevent and to treat them. Many of the plague tractates discuss treatment, distinguishing among different varieties of plague and stressing their faith in the efficacy of their curative methods. Some physicians, however, considered all forms of plague to be incurable. Of course physicians had to visit the ill to determine whether they were suffering from pestilence. If the condition was diagnosed as plague, some physicians then sought to determine whether the patient was possibly curable.

A plague tractate composed in 1411 advises: "If the patient is curable, the physician will undertake treatment in God's name. If he is incurable, the physician should leave him to die, in accord with the commentary on the second of the aphorisms [probably a medieval commentary on Aphorisms II in the Hippocratic Corpus]. Those who are going to die must be distinguished by prognostic signs and then you should flee from them. He labors in vain who attempts to treat such as these" (Amundsen, 1977, pp. 416–417). A plague tractate written in 1406 suggests that physicians not immediately inform patients if their condition is diagnosed as hopeless. Nevertheless, the physician "should refrain from administering anything to the patient that will cause him to die quickly, for then he would be a murderer" (Amundsen, 1977, p. 417, n. 64).

Various contemporary lay accounts from the time of the Black Death accuse some physicians of hiding in their houses and refusing to visit the sick for fear of infection. The authors of many plague tractates, while advising the general public to avoid contact with those afflicted with plague, do not direct such advice to their colleagues. They recommend varied and imaginative prophylactic techniques for use when visiting plague victims. The variety and abundance of such recommended precautions show the extent to which many physicians thought they were effective; moreover, there are numerous artistic representations of physicians who employed prophylactic measures while visiting plague victims. Many tractates deal exclusively with prophylaxis because their authors feel that treatment must be left to the discretion of the physician handling the case. Those that do include a discussion of treatment generally express great confidence in the curative methods prescribed. Many introduce new methods claimed effective by physicians who say they have employed them.

Some people did recover from the plague, from some strains of the disease more than from others; and although such cases of recovery were often in spite of the treatments to which the patients had been subjected, the attending physicians would have thought that their techniques had indeed been effective. The success rate in medieval medicine was, of course, much lower than in modern medicine; hence the expectations of both physicians and the public were not nearly as high as those of the present. The efforts of physicians to combat and cure various strains of plague, as well as their attempts to educate people in prevention and treatment by writing plague tractates, graphically demonstrate a high level of ethical and professional responsibility.

Summary and Conclusions

The medico-ethical treatises of the early Middle Ages blend Hippocratic etiquette with Christian morality, particularly emphasizing compassion and charity. The high and late medieval treatises, while loyal to the traditional concerns of the genre, suggest a new pragmatism born of the realities of medical practice by secular Catholic practitioners in a society starkly different from that of the monastic ethos of the early medieval medical literature. Although no mention of guilds or universities appears in this later literature, its tone and emphasis demonstrate that its authors regarded the practice of the art of medicine as a privilege that required training and skill, and carried consequent responsibilities. While there is no direct articulation of physicians' obligations to their immediate community in this literature, the obligation to the Christian community at large—an obligation to extend medical charity to the poor and destitute—is implicit and sometimes explicit.

Treating dangerous and even desperate cases is not discouraged in the later literature nearly as often as it had been before. Warnings against it are so infrequent, compared with advice on what to tell critically ill patients and their relatives or friends, that one may conclude there was a growing tendency to take on dangerous or even hopeless cases. But were physicians who in the late Middle Ages declined to treat patients for whom they foresaw little or no hope of recovery, still acting within the strictures of accepted ethics? This was a time during which popular attitudes toward physicians' responsibilities to the terminally ill were changing. Physicians who refused to treat patients were accused of deserting them because they thought they would not be paid for their services, while physicians who continued to treat such patients were suspected of greed for ministering to patients they know would not recover.

We see these two extremes illustrated by two sermons preached in fourteenth-century England. Lanfranc of Milan exclaimed, "O wretched physician, who for the money that you may not hope to get, desert the human body travailing in peril of death; and allow him, whom, according to the law of God, you should love and have most concern for, of all creatures under heaven, to be in jeopardy of life and limb, when you can and know how to apply a suitable remedy" (Owst, p. 351). John Bromyard, by contrast, asserted, "All craftsmen would at once refuse a job for which unsuitable materials were provided. If a carpenter were offered wages for the building of a house with planks that were too short or otherwise unsuitable, he would at once say: 'I will not take the wage or have anything to do with it, because the timber is of no use.' Similarly the physician who can see no hope of saving his patient" (Owst, p. 351).

Bromyard's sentiments were deeply rooted in tradition, but attitudes were changing. This change is very significant for the history of medical ethics. It seems to have been the product of two complementary and possibly related catalysts. The first is that the practice of medicine and surgery had been changed from a right to a privilege. A specific authority, whether royal, ecclesiastical, or municipal, granted to a select few the privilege of practicing in a specified, limited region. The authorities who granted what was essentially a monopoly also were ostensibly responsible for protecting that monopoly, and the privilege of holding a monopoly carried certain responsibilities, among them to service the sick of the community indiscriminately.

The second source of the growing tendency to take on dangerous or hopeless cases is the increasing theological insistence that physicians should do all they could to cure until the end, or nearly the end, and the church's support for their right to receive fees under such circumstances. One sees in the confessional literature the seeds of what was later to blossom into a medical duty to prolong life. The view is strongly articulated that physicians are religiously obligated to extend care to a rich miser even if he or she both resists treatment and refuses to pay. Some moral theologians also maintain that even if patients refuse to call a confessor, physicians must not desert them, since help must be given to those who are in danger, regardless of how stubborn they are. While this is still far from an imperative to prolong life, it is a significant change from earlier medical attitudes and practice.

This fundamental change in perceived responsibilities of physicians to their patients is illustrated by the acts of a late-twelfth-century and a mid-eighteenth-century pope, both of whom address the request of physicians to enter the priesthood. Clement III, in the late twelfth century, ruled that the physician in question should search his memory to ensure that he had never, even inadvertently, harmed a patient by any treatment that he had administered. In the mid-eighteenth century, Benedict XIV's ruling centered on the problem that physicians can never be entirely positive that they have consistently used every available means for patients who died under their care (Amundsen and Ferngren). The concern in the twelfth century was with harm perhaps inflicted actively on patients: "Did you ever harm patients by the treatment you gave them?" But by the eighteenth century, attention focused on harm that may have resulted from oversight: "Did you ever harm patients by failing to give them the treatment you should have given?" These two papal rulings highlight a fundamental change both in physicians' sense of responsibility to their patients and in social and religious expectations, a change that occurred primarily in the late Middle Ages.

We look nearly in vain in the medico-ethical literature of the late Middle Ages for statements on two topics of medical ethics: abortion and euthanasia. We cannot conclude from this that both theologians and physicians considered abortion and euthanasia ethical for physicians to perform. Indeed, the presumption is quite the opposite. Theologians and physicians alike took it for granted that both were sinful, so much so that their sinfulness need not be mentioned explicitly. Rather, it would seem that abortion was a procedure for which women would turn to someone other than a male physician or surgeon. Facilitating the death of a patient was undoubtedly so repugnant to medieval moral principles that to mention it as unethical for a physician to do would have been gratuitous, at least in a general treatise on medical ethics.

When the contents of the late medieval medico-ethical treatises are supplemented by guild ethics and the moral pronouncements of the theologians, as well as by the evidence of physicians' conscientious response to the outbreaks of plague, the picture that emerges is of relatively high ethical standards. Although "Hippocratic ideals" persisted throughout the Middle Ages and provided the basis for medical etiquette, the role and responsibilities of physicians and surgeons were variously affected by Christian morality. This is particularly evident in concern for the gratuitous treatment of the poor, both by individual physicians and by professional associations. The discipline of moral theology provided distinct criteria for medical ethics from a late-medieval Catholic perspective. Secular law and medico-surgical organizations, including university faculties, established regulations and standards of competence for medical licensure, and guilds and university faculties set precise codes of conduct. Essentially, the creation of medical licensure, medical faculties, and professional organizations helped to formulate medical professionalism and ethics in a sense that is still very much present today.

darrel w. amundsen (1995)

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