Abandonment of terminally ill patients in the Byzantine era. An ancient tradition?

Detail of a historiated initial of a physician, and a patient in bed.

Detail of a historiated initial of a physician, and a patient in bed.

Abandonment of terminally ill patients in the Byzantine era. An ancient tradition?

By John Lascaratos, Effie Poulakou-Rebelakou and Spyros Marketos

Journal of Medical Ethics, Vol. 25 (1999)

Abstract: Our research on the texts of the Byzantine historians and chroniclers revealed an apparently curious phenomenon, namely, the abandonment of terminally ill emperors by their physicians when the latter realised that they could not offer any further treatment. This attitude tallies with the mentality of the ancient Greek physicians, who even in Hippocratic times thought the treatment and care of the terminally ill to be a challenge to nature and hubris to the gods. Nevertheless, it is a very curious attitude in the light of the concepts of the Christian Byzantine physicians who, according to the doctrines of the Christian religion, should have been imbued with the spirit ofphilanthropy and love for their fellowmen. The meticulous analysis of three examples of abandonment of Byzantine emperors, and especially that of Alexius I Comnenus, by their physicians reveals that this custom, following ancient pagan ethics, in those times took on a ritualisedform without any significant or real content.

Introduction: End-of-life decisions remain a complicated problem in the relationships between physicians and the patient’s family, with social and legal consequences which today face all civilised societies.  The attitude of doctors to euthanasia in particular seems to have occupied and troubled societies from antiquity, as the Hippocratic Oath and the concepts of the earlier Pythagorians indicate. Although the Hippocratic Oath, perhaps following the school of Pythagoras, is categorically against every idea of euthanasia, it was thought unethical for a doctor in ancient times to treat a patient with a deadly disease, for this challenged nature and constituted hubris against the gods, so the doctor would risk paying the penalty of divine nemesis. This concept is found even in some Hippocratic texts but cannot be justified in societies deeply influenced by the Christian religion where the physician ought to give love to his fellowman (anthropos) rather than to his art (techne) and to treat all his patients irrespective of class, status or wealth and ability to pay. In these societies the doctors’ altruistic duty apparently involves the compassionate care and consolation of the terminally ill.

For these reasons one can nowadays be surprised to find, on studying the Byzantine historians and chroniclers, some cases of abandonment of dying emperors by their physicians who realised that they could not offer any further medical treatment. The meaning of abandonment in these texts seems to have been exclusively restricted to medical treatment when no further scientific help was possible and only philanthropic and Christian compassion remained to be offered. As is self evident, Byzantine medicine – basically philanthropic because it was a product of Christian philosophy – could not permit this custom of abandonment. For this reason, these cases referred to by reliable Byzantine writers appear at first sight unusual and inexplicable because they cannot be understood on the basis of the Christian thinking on and attitudes towards the relationship between patients and physicians. On the contrary, in accordance with the way of thinking of Byzantine medicine, it would seem most rational for physicians to be in attendance on the patient and offer medical assistance until the latter’s death. Before, however, interpreting this curious custom, we should examine the cases which are referred to and described by Byzantine writers.

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