This collection of nine of Darrel W. Amundsen's previously published articles and two new ones is a cause for celebration for all students of ancient and medieval medicine and for those interested in the interaction between medicine and the Christian faith, institutions and ethics. For the first time our students will have access to Amundsen's articles, some of which have been published for a highly specialized audience. They will learn that "modern" questions can receive ancient and medieval answers and that these answers give fresh and illuminating insights to past as well as contemporary societies. Abortion, euthanasia, physicians' complicity in suicide, artificially prolonging the life of terminally ill patients, medical attitudes to deformed newborns, and moralizing about sexually transmitted diseases are but a few of such "modern" issues discussed in this book.
Amundsen wages war against dilettante historians who anachronistically read into ancient sources ambiguities quite alien to their original concerns. Diatribes against ignorance, rash generalizations, lack of circumspection all responsible for gross historical misconceptions open many of his articles. Whilst one may wonder whether all this is really necessary, one can only warmly endorse Amundsen's lesson: refrain from broad generalizations based on secondary literature and go directly to the primary sources (which must be read in the original language) if you wish to reach historically valid conclusions. The result is a scholarly set of articles which are of interest for experts and general readers alike.
Amundsen has taught us that phrases like "open conflict," "hostility," "deep suspicion" are not helpful in describing the relationship between Christianity and medicine. All the Patristic sources that discuss medical issues share the assumption that recourse to human medicine and its suppliers is not intrinsically inappropriate for Christians. But they place significant limitations on Christians' use of corporeal medicine, stress that one must not rely exclusively on it, and preach absolute trust in God as the source of medical cure. At the same time they hold that healing comes also through spiritually pernicious channels (demonic healing cults and magic) and that the art of medicine can be used for evil purposes. The result of this was tension and ambivalence between clerical and non-clerical suppliers of medicine. This tension persisted well into the late Middle Ages when there emerged an uneasy alliance of the church with orthodox medicine as practiced by a licensed profession. The story of this uneasy alliance between Christianity and medicine from late antiquity to the late Middle Ages is one focus of Amundsen's research. The other focus investigates the contribution of Christianity to changes in the concept of human life, and the principle of sanctity of human life. The Christian obligation to care (not to cure) and to extend compassion in word and deed to the poor, the destitute, the widow, the orphan and the sick, was a revolutionary change in attitude toward the sick. At first this obligation did not include the duty to minister in any way to the dying. This gradually changed throughout the Middle Ages, and growing tendency to take on dangerous or even hopeless cases is detected. In the late Middle Ages there is increasing theological emphasis that physicians should do all they could to cure until the end, and that they had the right to a fee under such circumstances. The Judeo-Christian principle of the sanctity of life was wedded to the ethics of the supplier of medicine.
The main focus of the volume is Christianity, but it contains two essays which specifically deal with classical antiquity. The first, shows that the physician's duty to prolong life does not have its roots in classical medicine. In a society which lacked professional standards enforceable by law or by a system of medical licensure, the medical art (perceived as a right not a duty) had two functions: preserving and restoring health (not prolonging life as such). Bound by no duty to a licensing authority or professional organization, the physicians held the right to refuse to treat those who were overpowered by their disease. Consequently, it was up to the physician, if asked, to assist his patient to commit suicide. Literary evidence suggests that this was common practice for Greco-Roman physicians.
The second essay, which focuses on Classical civilization, reconstructs the common notion that those who are born physically defective, or are chronically ill, should not be kept alive by diet, drugs and regimen. Where the only legitimate claim to medical care was the social usefulness of the patient, where the notion of an inherent human value was absent since human value was primarily social value, defective children who were likely to produce wretched offspring had to be removed. There were nuances even in Classical society such as the critique of abortion and active euthanasia in the early centuries of the empire, but even then this pagan "humanitarianism" was not grounded on an inherent value of life, and passive euthanasia was not rejected. There were no laws in the Greco-Roman world that prohibited the killing, by exposure or otherwise, of defective newborns. Furthermore, in Aristotle's state there would be a law that no deformed child should be reared. In Roman culture the killing of defective newborns was common and was even required in the case of monstrous births. The morality of such attitudes appears not to have been questioned. That the care of defective newborns was not a medical concern is manifest from the basic lack of interest in the topic shown by medical writers and from the works of physicians like Soranus, who devoted a passage in his gynecological treatise to "How to recognize the newborn that is worth rearing." According to Amundsen we owe the conception of an inherent human value and of the sanctity of human life, even of the defective newborn, to the early Christians who condemned abortion and infanticide, including exposure. The basis for this condemnation was the concept of God's image (imago Dei) which is common to all human creatures and which provided the structure for the idea of inalienable rights and intrinsic and universal human value. This essay appeared before John Boswell's The Kindness of Strangers which drew a somewhat less idealized description of early Christian society where reservations about abandonment coexisted with equanimity and compassion for parents driven byrnecessity to expose or sell their children.
The Christian part of the book starts with a study of early Patristic attitudes to suicide. Through a careful reading of Tertulian, Cyprian, Clement of Alexandria, Basil of Caesarea, John Chrysostom, Lactantius, Jerome and Augustine, Amundsen conclusively shows that the absence of a debate over suicide in early Christian literature is an indication not that Christians were indifferent to suicide as an ethical issue but rather that its condemnation as a sinful act was generally assumed throughout the period. Augustine did not formulate the Christian position on suicide, and except for his unequivocal condemnation of suicide to preserve chastity, hardly contributed anything new to it. But he is the first Christian to discuss it thoroughly.
In the fourth and fifth essays Amundsen examines the range of attitudes of Patristic sources towards medicine. With exception of marginal figures like Arnobius (early fourth century) and the heretic Marcion (d. ca. 160), all the sources he discusses display various degrees of sympathy toward human medical care. But since for all, God is the source of health and all medical knowledge, He can cure with or without human medical agents and patients must rely upon God when ill. Consequently, miraculous healing when physicians have failed, or simply instead of human medical care, is always a possible channel for cure. In the fifth essay, Amundsen shows that Tatian's (fl. 160-80) condemnation of pharmacology (and not of medicine in general) can only be understood in light of the fact that early Christians did not see God as the source of all healing, believing that evil forces healed as well.
One of Amundsen's important contributions to contemporary history of medicine is his use of non-medical sources for drawing facts and information which are pertinent to historians of medicine. This clearly appears in the next three essays. In the seventh essay Amundsen gives a general survey of ecclesiastical attitudes to medicine throughout the Middle Ages. For the early Middle Ages, he describes the delicate balance between the condemnation of pagan healing practices and their accommodation into daily Christian practice. He concentrates on practices of miraculous Christain healing (the cult of saints and the anointing of the sick for physical healing) and on the intertwining of spiritual and secular healing, whici created sporadic tension between the Church and folk medicine. His main sources here come from the penitential literature of the period. For the later period his main sources are canon law and practical confessional manuals. In the eighth essay a careful study of all the official Church documentation concerning the vexing question of whether the medieval clergy were ever forbidden to practice medicine or surgery leads Amundsen to correct broad statements to the effect that such a prohibition indeed existed. Medieval canon law never prohibited the practice of medicine by clerics, while surgery was forbidden in 1215 only to clerics in major orders. The ninth essay is an examination of medical issues in the literature designed to help confessors in all aspects of their confessional responsibilities ( summae confessorum or summae de casibus conscientiae). These sources portray the growing concern of the Church, particularly in the fourteenth and fifteenth centuries, with medical ethics and the concentrated effort to regulate various aspects of medical practice (competency, treatments, relations with patients and colleagues, fees, abortion, moral and religious obligations).
In the last two essays, the author deals with some aspects of medical ethics vis-a-vis pestilential diseases in the fourteenth and fifteenth centuries. This is the time when clearly defined medical deontology and professional ethics gradually developed in the Latin West. In the tenth essay Amundsen assumes that though some physicians fled or refused to treat those stricken by the plague, probably most others remained and faithfully treated the sick. On the basis of a study of plague tractates, he shows that the treatment of plague victims was motivated by compassion, charity and a sense of professional duty. The large number of plague tractates suggests that physicians felt professionally responsible to explain the plague and to educate the people in prevention and treatment.
The eleventh essay, published here for the first time, should be read in light of the AIDS epidemic and the mixed (occasionally hostile) response of physicians and surgeons to the need to treat seropositive patients. Because of its venereal mode of transmission, Amundsen regards syphilis rather than the plague as the historical antecedent of AIDS. Studying the writings of the earliest syphilographers between 1495 and 1505 he reconstructs their moral response to the disease and its victims. He is anxious to know whether the syphilographers felt a moral and/or religious duty to treat those whose actions (immoral in the eyes of some people) had brought the disease upon themselves. Though f{nal (divine) causality was widely accepted, it was entirely irrelevant to the physicians' understanding of immediate causality, prevention and cure. They did not see the disease as punishment specifically for sexual sin. Nor did they imply that those afflicted were specifically sinful. Until 1500, the venereal path was one of several ways to contract the disease. Only after 1500 we see recognition that the morbus Gallicshwas primarily a sexually transmitted disease, but even then there was still no suggestion in the medical literature that one refrain from curing those who suffered from what, by the turn of the century, had become generally recognized as a sexually transmitted disease. Between 1495 and 1505 there is no evidence that physicians refused to treat syphilis patients because of the disease's venereal nature. Some of the syphilographers evince theological and moral judgments by stressing that the disease was spread primarily by sexual promiscuity. But even they regarded such considerations irrelevant to their role as physicians. The only ethical debate in the syphilis literature of the studied period was not whether to treat but how to treat.
Amundsen's articles show the scope of the contribution by the cultural history of medicine to ancient and medieval history in general. Nobody working on late antiquity, early Christianity, and the Middle Ages, or interested in religion, healing and medical ethics, can afford to overlook it.