II. IRAN

Iran, a vast country in Southwest Asia, was long called Persia by Europeans until, in 1935, its government requested that the common indigenous name, Iran, identifying the nation as the "land of the Aryan people," be used internationally. The extensive Iranian Plateau and surrounding lands have been the site of many powerful political regimes during its long history, beginning with the empire of Cyrus the Great, the first Achaemenid emperor, in 549 b.c.e.. Located along a highway for the movement of people and ideas from the prehistoric period on, its indigenous Aryan culture has been an important link between Hellenic, Indic, and Semitic intellectual and religious traditions. Within the limits of this article, the history of Persian medicine cannot be traced; only the ethics characteristic of that history will be treated.

Prehistoric Period

Little is known about the healing practices or beliefs of the earliest inhabitants of Iran. An epic poem, Shāhnāmah (Book of Kings), written in the tenth century c.e., relates ancient myths, legends, and stories that may reveal something of the ancient past. Surgery is mentioned in the tales of the superhuman exploits of the heros Rustam and Isfandyar. Rustam himself is said to have been delivered by an operation much like that now known as a cesarean section, while his mother was anesthetized with wine. Abortifacients were known. The Elamite civilization, centered around Susa in southern Iran from the third to the first millennium, had cultural contact (and often political enmity) with Babylon, and it is likely that the medicine of the Mesopotamian world was known by the Elamites (Sigerist). The Code of Hammurabi, ruler of Babylon (ca. 1750 b.c.e..), which contains strict injunctions and penalties regarding surgical practice and malpractice, is known primarily from a stela found at Susa in 1902.

The Aryan Period (Ninth–fourth Century B.C.E.)

The nomadic Aryan peoples migrated from Central Asia, north and east of the Caspian Sea, to the Iranian Plateau around the seventeenth century b.c.e. By the ninth century, they dominated the region, and in 549 b.c.e., Cyrus consolidated rule over its inhabitants and established the Achaemenid dynasty, the first Persian empire. He and his successors, Cambyses, Darius, and Xerxes, extended the boundaries of Persian rule from the Ionian Sea in the west to the Indus River in the south. During this period, Persian medicine was undoubtedly in contact with Greek medicine. A story related in ancient texts tells of an invitation from Persian King Artaxerxes to Hippocrates, on the advice of a Persian physician, to become physician to the Persian army during a plague; Hippocrates refused, saying, "I have no right to share the wealth of the Persians or to liberate from disease barbarians who are enemies of the Greeks" (Pseudepigrapha 3; see Temkin).

In the seventh century, the mysterious religious figure Zoroaster appeared in eastern Persia. Very little is known of his life, and the writings attributed to him are brief. However, by the first century b.c.e., a defined cosmogony and theology attributed to his influence had been collected in the vast literature called Avesta, of which his own Gathas, or hymns, are a small part. The doctrine is basically constructed around a cosmic duel between good and evil, of which light and darkness, life and death are the material symbols. The powerful spirit of good and light, Ahura Mazda, the wise and greatest god, battles Ahriman (or Angra Mainyu), spirit of evil and darkness, and the world is the battlefield. Humans participate in the battle through their free choices. As individuals, humans are to maintain purity of life through moral goodness, pursuit of truth and physical cleanliness, and avoidance of pollution by the dead and unclean substances. As members of society, humans are to assure justice between social classes.

The Avesta also contains the elements of a theory of health and disease. Diseases, created by Ahriman, come from dirt, stench, cold, heat, hunger, thirst, and anxiety, although magical causes are also recognized. Medicinal plants are the creation of Ahura Mazda. Rules of healthful living are prescribed; cupping and bleeding are recommended to reduce hot blood. The destruction of life is prohibited for theological reasons; it would contribute to the victory of Ahriman over Ahura Mazda. Thus, abortion is forbidden, and both men and women are punished as willful murderers. Special rules are laid down for the care of pregnant females (both human and animal). Surgery is recognized and strictly regulated; one ancient law requires that a surgeon have three successful cases before being licensed to practice.

Three kinds of healers are mentioned: healers with herbs, with knives, and with holy words (the latter, one text notes, being the most efficacious). There were also persons (durustpat, masters of health) trained to remove the causes of disease by purifying earth, air, water, and food. These physicians were often drawn from the noble and priestly classes. A modern Parsi (the contemporary Zoroastrians of India) scholar describes what he believes would have been the ideals of the Avestan physicians of ancient times:

The first indispensable qualification of a physician was that he should have studied well the science of medicine. He should hear the case of his patient with calmness. He should be sweet-tongued, gentle, friendly, zealous of honour of his profession, averse to protracting illness out of greed and God fearing. An ideal healer heals for the sake of healing.… He should carefully watch the effect of medicine that he prescribes … visit the invalid daily at a fixed hour, labour zealously to cure him, and combat the disease of the patient, as it were his own enemy (Elgood, 1951, p. 13).

Hellenistic Period (330 B.C.E.–224 C.E.)

In 330 b.c.e. Alexander of Macedon brought down the Achaemenid empire. For the next five centuries, the Greek culture that had long flourished on the Ionian frontier of the Persian empire dominated Persian ideas and institutions. Although the historical record is meager, it may be assumed that Greek medicine and Hippocratic ethics were included in this general influx of Hellenic culture. The Zoroastrian faith languished during that era, but it would not be unlikely that Avestan ideals that had permeated the culture survived.

Sassanid Period (224–632)

The Sassanid dynasty, after victories over Roman and Parthian armies in the mid-third century, ruled Persia for four centuries, restoring the traditions, law, and culture of ancient Iran and, above all, reforming and fostering the Zoroastrian faith. In the earliest years of the Sassanid era, an event of great importance for the history of medicine occurred. In the mid-250s, King Shāpūr I, son of the founder of the dynasty, defeated the Roman emperor Valerian and sacked the city of Antioch. The king invited many of the Antiochean scholars, including physicians, to a new city, Gondishapur, that he established in 260. His son enlarged the city and founded a university that in time became the center of scholarly work in Persia.

To Gondishapur in the late fifth century came a group of Persian Christians of a denomination called Nestorian. These Christians had originally dwelt in and around the Persian city of Nisibis, then moved to the Byzantine city of Edessa, where in 363 they established a school of theology. After certain of their theological beliefs were repudiated and their leader, the patriarch Nestorius, excommunicated by the Catholic church at the Council of Ephesus (431), the Persian Christians accepted an offer of asylum at Gondishapur from the Persian king Qubād. They brought with them not only works of theology but also an extraordinary library including Syriac translations of the Hippocratic corpus and of Galen.

Another scholarly migration entered Gondishapur in 529 when the Sassanid king Anūshīrvān the Just welcomed the Neoplatonists exiled from Athens, at the urging of his chief minister Buzurgmehr, who according to legend was himself a physician and philosopher. He is quoted as having said, "I read in medical books that the best physician is one who gives himself over to his profession.… I exerted myself in the treatment of patients, those whom I could not cure I tried to make their suffering more bearable.… From no one whom I treated did I demand any sort of fee or reward" (Elgood, 1951, p. 52).

The king also sent missions to India to procure the arts and sciences of Hindu culture, including the works of Ayurvedic medicine. By his order, a massive work on poisons was compiled, and many Greek and Indian books were translated into Pahlavi (ancient Persian). He convened what may have been the first medical convention, summoning the physicians of Gondishapur to debate the major medical questions of the day. During his long reign, Gondishapur became a leading center of scholarship; within its walls Greek, Jewish, Nestorian, Persian, and Hindu ideas were exchanged and enriched, and Islamic, Christian, and Zoroastrian ethical ideas mingled. The art of translation of the classic texts from Greek, Latin, and Syriac into Pahlavi and Arabic was fostered. The school of medicine existed for five centuries, creating from many sources the medical science generally known as Arabic or Islamic, and its great hospital, Bimaristan (House of the Sick), was the model for the Muslim hospitals of Baghdad, Damascus, and Cairo and the Christian hospitals of Jerusalem and Acre (Whipple).

Islamic Period (636–)

The victory of Arabian Muslim armies at al-Qādisiyah in 636 inaugurated the era of Islamic rule and culture in Iran. The distinctive ethic of Islam entered and eventually predominated in the rich mix of Persian life. Gondishapur continued to flourish under Arab rule and became more influential as its scholars, teachings, and books spread through rapidly expanding Islam, carrying Greek and Arabic medicine across Africa and, through Sicily and Spain, into Western Europe. The new Muslim rulers summoned scholars from Gondishapur to their capital at Baghdad, where they established a new center of medical science. Studies in biology, human anatomy, and pathology were encouraged. The caliphs in Baghdad, Damascus, and Cairo organized public-health administrations, staffs of public-health doctors, public hospitals, and a public examiner of physicians, responsible for their skills and their ethical standards.

Some of the greatest names of medical history were Persian: Ţabarī, Rhazes (known as the Galen of Islam), Haly Abbas, Avicenna (Ibn Sīnā), all of whom flourished in the tenth and eleventh centuries. Their scientific work was renowned. (Avicenna's Canon of Medicine was used as a text in many European schools as late as the seventeenth century.) All of these distinguished physicians wrote treatises on the ethical qualities of physicians. The text of one of these, Advice to a Physician, by Haly Abbas, reflecting Hippocratic and Islamic sentiments, can be found in the Appendix of this encyclopedia. A book by the eleventh-century Iranian philosopher-physician Ibn-Hindū praises the nobility and criticizes physicians who use medicine only to win wealth and reputation, recalling the story that Hippocrates, when summoned by the Persian ruler, disdained to give his service only for gain (Mohaghegh). Another scholar of the next century, Niz̧āmī 'Arūḑī, summarized the moral principles that should guide a physician:

A physician should be of tender disposition and wise nature, excelling in acumen, this being a nimbleness of mind in forming correct views, that is, a rapid transition to the unknown from the known, and no physician can be of tender disposition if he fails to recognize the nobility of the human soul; nor of wise nature unless he is acquainted with logic, nor can he excel in acumen unless he be strengthened by God's aid, and he who is not acute in conjecture will not arrive at a correct understanding of any ailment (Elgood, 1951, p. 234).

Modern Period

For many centuries medicine in Iran was more or less as has been described. The foundation of Dār-ul-Funūn (the Polytechnic School) in Tehran in 1852 changed the situation. At first it was a military academy, but it soon began to develop into a university. The foundation of the Faculty of Medicine was laid by a number of excellent European and Iranian teachers. The school curriculum at first was a combination of Iranian and Western medicine, and the ethical point of view was influenced by Iranian tradition.

Iranian students had been sent to Europe for medical studies for several decades before the founding of the medical school at Dār-ul-Funūn. With the return of these physicians and scientists and the establishment of a modern hospital in Tehran in 1868, the curriculum of Dār-ul-Funūn and the practice of medicine were gradually westernized. Also, during the nineteenth century, a number of Western physicians resided in Iran, the most famous being a Frenchman, Charles Fourier, physician to Shah Nāşir al-Dīn.

Since the period of Reza Shah (1923–1941), the program of the medical school of the modern University of Tehran has been based completely on modern medicine; medical ethics and the history of the medical tradition are both taught. Graduates of the Tehran medical school are asked to take an oath, an excerpt from which follows:

Now that I … have been found eligible to practice medicine, in the presence of you, the board of judgment of my thesis and others here present, I swear by God and the Holy Book of Koran and call to witness my conscience that in my profession I will always be abstemious, chaste, and honest and, as compared with the glory of the art of medicine, I will hold in contempt all else—silver, gold, status, and dignity. I promise to help the afflicted and needy patient and never divulge patients' secrets. I will never undertake dishonest work such as producing abortion and recommending a fatal drug. What I do, I will try always to be approved by God and be known for my uprightness.

In the Islamic Republic of Iran, founded in 1979, the interest in vivifying Islamic tradition and law touches medical ethics as well. Issues related to bioethics are sometimes treated in works dealing with Islamic religious law, the shar'ia. However, the premodern shar'ia contains little that can directly guide conscience and conduct in morally troublesome cases, such as the permissibility or prohibition of medical treatments. Muslim jurists have undertaken to provide new rulings, the most prominent of which states the rights of the patient in determining which modes of treatment are compatible with his or her religious and moral beliefs. These scholars are also grappling with the medical technology developed in the Western secular culture, technology that has altered conventional understandings of life and death and has posed perplexing questions for a new, religiously aware generation of Iranian physicians and their "believing" patients.

Some recent works in medical ethics, such as Fiqh va ţibb (Islamic Jurisprudence and Medicine) and Qānūn dar ţibb (Law in Medicine), reflect a change in the attitude of Muslim physicians, who have become increasingly aware of the role religion plays in the lives of Iranian men and women. Whereas in the early days of modernization and secularization, Iranian physicians, not unlike their counterparts in other Third World countries, "played God" in attempting to save and restore human health, the 1980s and 1990s are characterized by a growing concern about the religious and cultural values of the society. Thus, for instance, an important issue in Islamic law is the recommended segregation of females and males, which has implications for medical ethics. The ethical issue is whether it is permissible for a physician to treat a member of the opposite sex. While responses have varied among the Muslim jurists, there is a consensus that since a physician should never sexually abuse his or her patients, it is strongly recommended that a physician examine patients of the opposite sex only in the presence of a third person, as a safeguard. This applies to both male and female doctors. However, under special circumstances, when no doctor of the same sex as the patient is available and there is an urgency in treating the condition, the law permits male doctors to treat female patients and female doctors to treat male patients.

Advances in biomedical technology raise issues that challenge Islam to provide concrete and relevant solutions. A group of Muslim jurists and philosophers has begun to develop guidelines for dealing with ethical issues that confront the medical profession. Leaders in both secular and religious education have begun to prepare textbooks on medical ethics. Two of these works are especially significant: Akhlāq-i pizishkī (Medical Ethics), prepared and published under the supervision of the Ministry of Health in 1991, and a book with the same title, written by Manşūr Ashrafī and published by the Medical Faculty of the Open University of Tabriz in 1988. The former includes chapters dealing with the juridical decisions by major Iranian religious leaders, including Ayatollah Khomeini, on issues related to what is known in the West as bioethics. The latter work is based more on the Western secular discussion of bioethical issues without any reference to Islamic or other religious views. Both are used as textbooks in the Iranian schools of medicine.

Major obstacles persist for those who work to solve the problems created when medical technology is brought into a culture steeped in religion. The most serious problem that confronts Muslims in general, and Iranians in particular, is denial of the ethical problems stemming from technicalization of the society and its adverse impact on interpersonal relationships. A striking example is acquired immunodeficiency syndrome (AIDS). To date, the Muslim ethical response to AIDS has characterized the disease as God's curse on those who engage in illicit sexual behavior. In this direct or indirect critique of the moral decadence of the West, important issues are overlooked, including the cause of the disease and its prevalence in the Muslim world, as well as guidelines for treatment of those affected.

Muslim jurists in Iran have not yet formulated relevant responses to some of the most complex ethical issues—those that arise because of human endeavors to improve health and extend life. The highly cherished religious value of compassion has been overshadowed by the language of condemnation for moral failure of humanity.

abdulaziz sachedina (1995)

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