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Appendix I Medical Ethics in the Life and Works of the Great Iranian Scholars Hassan Tajbakhsh Great Iranian physicians and scholars paid attention to ethics in their life, especially in their professional works. As a general rule, renowned physicians treated the rich while the poor and needy had no access to first-class physicians. Rare were such physicians as Rhazes or Mahmoud ibn Elias who treated the needy free of charge in their own houses, sup- plied drugs to their patients whenever needed, and even gave patients money to live. If there was a hospital in a city, the needy, the travelers, and the homeless received medical services free of charge. Iranian hospi- tals offered similar services to Christians, Jews, and followers of other religions. Haly Abbas, who died in 994, strongly recommended the constant pres- ence of medical students in the hospital, that they might follow their supervisor’s instructions, visit patients, and show them kindness. The medical recommendations of Haly Abbas to the contemporary physicians were taken from Hippocrates and other previous physicians. However, he reproduces them in a pleasing manner, highlighting the ethics of medicine. Nadjm al Din Mahmoud ibn Elias, who died 1325 A.D., was a great scientist and belonged to the noble physicians’ family of Shiraz. He was skilled in jurisprudence and in other sciences, but especially excelled in medicine. Mo’in al Din Djoneyd ibn Mahmoud (d. 1397), the author of Shad al-Ezar, records the following: “He treated patients in his office and helped the old patients, generous people, and the needy. Not only did he not accept honorarium from the poor, but also sent someone with them to purchase their drugs. Therefore, it is crystal clear that he spoke wisely and treated the patients with knowledge.”1 86

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87 APPENDIX I Excerpts from Methods by the philosopher Rhazes, who died in 925 are as follows: In summary, to date; I have written over 200 books and articles on vari- ous branches of philosophy, ranging from Divine sciences to wisdom…I have never joined an army nor have I been a government agent. Rather, if I have been in one’s company, it was merely for medical purposes, and my companion did not go beyond friendship while performing my medi- cal duties…Those who have observed my eating, drinking, and bad hab- its know well that I have never tended to extremes…However, with re- gard to my interest in science, those who know me from my youth are well aware that I have devoted all my life to this subject. My patience and exertion in studying science was so great that I have written over 20,000 pages in small letters on a certain branch of science. I have worked hard during day and night for 15 years of my life to write Al Havi, and I have lost my eyesight in this endeavor. My hand muscles have grown weak, and all this has deprived me of reading and writing. However, I have not stopped my research and studies. I read and write with the assistance of my companions. I forgive my enemies and I confess to my faults, but I do not know what they will say in the scientific fields. If they see faults, why do not they come to me to make sure they are right, be- cause I will make them understand that they are wrong. However, if they are critical of my way of life and my practical methods, I wish they would enjoy my knowledge and overlook my way of life.2 BASIS OF MEDICAL ETHICS Hippocrates first introduced medical ethics to the world of science. Since then, these ethics have influenced the way of life of all physicians in the history of humanity. Hippocrates was born in 460 B.C. on the island of Kos, Greece, and passed away in 375 B.C. He is regarded as the father of medicine. Ac- cording to W. Durant, Hippocrates’s masterwork was saving medicine from the boundaries of philosophy and metaphysics although he himself in his “Food Legislation” says chanting spells is sometimes useful. Hippocrates insisted that diseases had a natural cause, and he rooted his work in medical records and observations. 3 Hippocrates wrote an oath, (know as the Hippocratic Oath) and the physicians took the oath after graduation. He also wrote the “Medical 1 Djoneyd Issa ibn, N. Vessal, ed. Shad al-Ezar: Moin al-Din Djoneyd Shirazi (Arabic Lan- guage)/Persian Translation titled Hezar Mazar (A Thousand Tombs). Ahmadi Press, Shiraz: 1985. 2 Al-razi, K. al-Hawi fi ‘l-tibb. 3 The Story of Civilization, Vol. 2: p. 383; Tarikh-e-Dampezeshki va Pezeshki, Vol. 1: p. 259.

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88 THE EXPERIENCES AND CHALLENGES OF SCIENCE AND ETHICS Principle” or “Medical Law” for students of medicine and compiled “Medical Manner” or the recommendation for the physicians mentioned by Ibn Abi Osaybia in his Oyoun al-Anba.4 Ibn Ekvah writes: “Physicians must swear using the Hippocratic Oath with the Mohtasseb (Censor).”5 THE HIPPOCRATIC OATH “I swear by Apollo the Physician, Asclepius, Hygieia, Panaceia, and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant: “To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money, to give him a share of mine, and to regard his offspring as equal to my broth- ers in male lineage and to teach them this art— if they desire to learn it— without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else. “I will apply dietetic measures for the benefit of the sick according to my ability and judgment. I will keep them from harm and injustice. “I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art. “I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work. “Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves. “What I may see or hear in the course of the treatment or even outside treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about. 4 Osaybia, Ibn Abi (Arabic Language), Emr-ul-Qays ibn al-Tahan, ed. Oyun al-Anba fi Tabaqat al- Atebba (The Sources of News on the Classification of the Physicians), Vol. 2. Al Vahabia Press, 1881. Vol. 1, Persian Translation by S. J. Ghazban and M. Najmabadi; Tehran Univer- sity Press, Tehran: 1971. 5 Qarshi, Ibn (Ibn Ekhvah), and Zia al-Din Muhammad (Arabic Language)/ Persian Trans- lation by J. Shoar. Maalem al-Qorba fi Ahkam al-Hasseba (The Manner of Municipality on the Supervisional Judgment) p. 171. The Foundation for Iranian Culture, Tehran: 1969.

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89 APPENDIX I “If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come. If I transgress it and swear falsely, may the opposite of all this be my lot.”6 HIPPOCRATES’S MEDICAL PRINCIPLE “Medicine is the holiest of all professions. It may not be understood well by those whose deeds may cause public distrust. There is no fault with medicine in any cities except the ignorance of those living because of it but not understanding it. These people are like puppets played by ac- tors for public amusement and as such puppets are only faces and not real. He who wants to learn medicine must have good deed and creed and must have the greed to learn and the inborn interest in what is needed for this profession. A student of medicine must yield good fruits as the re- sults of the seeds sown on earth. Medicine is like soil and teaching is planting. Education is like the seeds sown on cultivable earth. Upon graduation the students must settle in a city to be practical and profes- sional physicians, not physicians in words only. The science of medicine is an exquisite treasure for those who want to learn it. A learned physi- cian is always pleased internally and externally. Ignorance of this science for him who has made it his job leads to a cursed profession that brings no happiness, no satisfaction to him. Such a person is suffering all the time and is impatient and rash. Impatience is a sign of weakness and his rash- ness comes out of misinformation and shallow experience.”7 HIPPOCRATES’S MEDICAL MANNER “It serves him who is in the position of learning medicine to be tem- peramentally of good nature and mold. He must be young, of average height, and well bodied. He must be quick to understand, conversable, and of good judgment in consultation. He must be chaste and brave but not a lover of material gain. He must be able to calm down in anger and prevent rage. He must not be slow to learn or lazy. A physician must show sympathy to the afflicted and sick and be kind to them. He must keep all secrets about diseases and patients to himself because the major- ity of the patients reveal everything about their disease to the physician, but do not want physicians to speak about it elsewhere. The physician 6 Edelstein, Ludwig, trans. From The Hippocratic Oath: Text, Translation, and Interpretation. Johns Hopkins Press, Baltimore: 1943. 7 Ibid.

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90 THE EXPERIENCES AND CHALLENGES OF SCIENCE AND ETHICS must be tolerant of curses because some persons suffering from pleurisy, obsession, and melancholia talk harshly, but we know that those curses do not come from them, rather they come from the diseases. A physician must keep his hair tidy. He must not shave his head nor grow it bushy. He must trim his nails, but not deeply nor should he grow long nails. His garments should be white and clean, and he must not hurry when walk- ing because walking hastily is a sign of rashness and walking too slowly is sign of indifference and laziness. He must sit cross-legged if he has been asked about a disease, slowly and patiently. There should be no hurriedness or embarrassment in his words. In my view, this form of life and behavior is better than the other forms.”8,9 HALY ABBAS’S LETTER OF EXHORTATION TO PHYSICIANS Ali ibn Abbas Majussi, know as Haly Abbas to the Europeans, in his Kamel al-Sanaat al-Tibbia has included exhortations based on testaments of Hippocrates, other physicians, and some of his own views for physicians and students of medicine. The text is as follows: “I should say that he who wants to be a highly learned physician must act upon the testaments Hippocrates wrote in his time for the future phy- sicians. Then the first testament is this: Be pious and fear and obey God. Respect and serve and appreciate those who have taught you. Regard them as you regard your father and share with them what you possess. As your fathers were the cause of your coming to this world, your teach- ers are the cause of your reputation, good deeds, and creed. Yes, man should regard his teachers as his father. Give a share of precepts, oral instruction, and all the other learning to his children without any fee, condition, or reward and teach them like your children. Beware not to impart medical education to inappropriate, incapable, or wicked persons. “Also, the physician must try to cure the patient with food and medica- tion with no intention of accumulating wealth, but meaning spiritual re- wards and charity. He must not give deadly medicine to anyone and must not talk about these drugs. He must not give to a woman an abor- tive drug, nor explain about it with others. The physician must keep everything on the disease and patient to himself, not talking about it 8 Osaybia, Ibn Abi (Arabic Language), Emr-ul-Qays ibn al-Tahan, ed. Oyun al-Anba fi Tabaqat al-Atebba (The Sources of News on the Classification of the Physicians), Vol. 2. Al Vahabia Press, 1881. pp. 58-61. Vol. 1, Persian Translation by S. J. Ghazban and M. Najmabadi; Tehran University Press, Tehran: 1971. 9 Bimarestanhay, Tarikh-e. Iran: The History of the Iranian Hospitals from Ancient Times to the Present Era. pp. 331-334. Persian Translation by Hassan Tadjbakhsh. Institute of Human Culture, Tehran: 2000.

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91 APPENDIX I with relatives, because many patients hide their disease from their fami- lies and relatives but tell it to the physician, such as metrodynia and hemorrhoids. Thus the physician must try to keep the secrets of the pa- tients confidential even more than the patients themselves. “The physician must conform his deed and creed to what Hippocrates has said. He must be popular, doing his best to cure needy patients. He must not seek material gain from his medical practice, and pay for the drugs himself if the patient does not have money to pay. He is requested to prescribe and explain about drugs. If the patient has an acute disease, the doctor must visit him day and night to help him recover health, be- cause acute diseases change conditions quickly. “A physician must keep himself from lust and material gain, and from being involved in menial and useless jobs. He must not drink excessive wine because it is harmful to brain, adds excretion, and destroys the mind. The daily amusement of a physician should be studying books, and pondering them, specifically upon medical texts. He must not be- come tired of reading. He must memorize whatever he has learned and review material even when walking in order to learn whatever aspect of science and deed he needs. He must learn and grow scientifically so that he does not need to refer to the books, because his books may be lost, then his mind will help him. He ought to memorize materials when he is young, because learning when one is young is better than learning when one is old. “A student of medicine should be always at the service of skilled masters of medicine in the hospitals and clinics to serve patients, to be compas- sionate to them, and to compare what clinical signs and complications of sickness he sees with those he has read in books, and to come to know about benign and malignant diseases. “Then, it is that he who acts upon the above will make best use of the medical profession and he who wants to be an able physician should act upon this recommendation and enrich his learning with whatever ethi- cal materials we wrote about and not understate this recommendation. If he does so he will treat people well, and they will trust and gather around him, and he will enjoy all goodness and friendship, and benefit from these people. And God is the wisest.”10 10 Ali ibn Abbas Majussi (Haly Abbas). Kamel al-Sanaat al-Tibbia (The Perfect Art of Medi- cine); Vol. I pp. 8-9, (Arabic Language). Al-Dassuqi, Ed. Saadat Press, Cairo: 1877.