Highly Valued Virtues of Classical Ottoman Turkish Medical Ethics: A View From Past to Future

Virtues such as modesty, contentedness, fidelity and hopefulness expected from a physician must be perceived as general criteria of ethical standards, since principles are also the criteria for the preference of values, in a sense. Virtues are based on and directed by moral values, too. Ottoman medical ethics was based on the trust of people to physicians believed to be virtuous. Moral behaviour expected to be observed by physicians depended on virtues turned into regulations as guides for action. Several examples dealing with the subject are quoted from Ottoman medical manuscripts, and are discussed with respect to contemporary medical ethics in this article.

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Nil Sari*

Table of contents

1. Introduction

2. Virtues Ignored as a Result of Changing Values
     a. Modesty
     b. Contentedness
     c. Fidelity
    d. Hopefulness

3. Discussion on Contemporary Medical Ethics
    a. Modesty
    b. Contentedness
    c. Fidelity
    d. Hopefulness

4. Discussion

5. Bibliography
    a. Turkish Medical Manuscripts
    b. Other Sources


1. Introduction

Ottoman medical ethics was based on the trust of people to medical practitioner believed to be virtuous. Moral behavior expected to be observed by medical practitioner depended on virtues turned into rules as guides for action [1]. What kind of virtues might be highly effective for training one to be a virtuous physician? The four virtues, modesty, contendedness, hopefulness and fidelity were specifically noted by Ottoman physician writers as inevitable for being qualified as a virtuous physician. Several examples dealing with the subject are quoted from Ottoman medical manuscripts, and discussed with respect to contemporary medical ethics in this essay.

2. Virtues Ignored as a Result of Changing Values

Experience is as important as experimentation in gaining knowledge. Social sciences specially owe much to historical experience, both individual and social. Ignoring past experience means failure in utilizing valuable knowledge accumulated by man in history. Utilizing past experience is also important for studies on medical ethics. Patient-medical practitioner interrelation and its mutual moral elements in medical history have developed as a result of interaction in the course of time. Today great change has taken place in the field of medical ethics due to the fast development of medical knowledge and technology. Some values lost importance, while others came to be favored and new values have developed, which regressed some virtues, while fostered others [2].

Ottoman Turkish physician compilers described and suggested "what ought to be done or not", that is, proper and improper behavior in medical practice. When ethical advices (vasiyyet) in Ottoman medical manuscripts are studied, one can find a principle included in these advises guiding health practitioners to virtuous behavior. Ottoman Turkish expectations for medical morality were concentrated on the virtuous behavior of a practitioner [3]. In this study, the virtues modesty, contentedness, fidelity and hopefulness, considered to be a necessity in Ottoman Turkish patient-practitioner relationship, are quoted as ignored today.

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Figure 1: An illustration of a medical practitioner and a patient. (Source: Millet Kutuphanesi, Ali Emiri, nr. 79.).

During the last quarter of the 20th century great progress has been achieved in the field of medical ethics studies, and great effort has been paid in developing ethical principles and rules to lead decision making in the medical field. Contemporary medical ethics concentrated on solving moral dilemmas in accordance with ethical principles and rules [4]. Actions came to be prescribed for certain cases, described within the frame of specific groups of ethical conflicts. The practitioner having justified his/her action on the basis of principles and rules, a probable risk of omitting "virtuous behavior" needed for ethical patient-practitioner relationship, arose. Prefering principles and rules for guidance in developing ethical behavior for medical practitioner, the quality of practice that is "how to act" has come to be ignored. Yet, physician's behavior is perceived as a physical and literal language of the practitioner by the patient, not as ethical principles suitable for the case. Ethical principles and rules isolated from virtuous behavior patterns will speed up the regress of the values that virtues are derived from. There are some declined moral values which led to virtuous behavior in the past that played highly important role in patient-practitioner relationship. However, they are no less important today, as it may harm the patient when they are ignored. Some of the ignored virtues fostered by some values are indispensable in acting within the frame of ethical principles properly.

a. Modesty

A Physician has always been authorized and effective, having means and tools which might be useful or harmful, such as drugs and surgical instruments. It is the belief in the role of Godly power on the acts of man, though, that drove Ottoman Turkish physicians away from considering himself esteemed. Modesty was a highly valued virtue, because the duty of physician was conceived as being a caliph of the Creator, whose will was believed to realize the treatment. The Ottoman Turkish physician was expected to perceive himself as a caliph of God in the act of healing and not conceive himself as the real healer. Although the cause of disease was considered to be the imbalance in humours and it was the nature/temperament of the patient regarded as important in treatment, the belief that both illness and healing are God's will, sublimated the value of modesty. The belief that a physician was only a means and the real healer is God, the Creator, and without his generosity no cure could be achieved, fostered modesty as a valuable virtue. Many Ottoman Turkish medical writers adviced physicians not to be proud and not to over trust themselves. Physicians were perceived to be impotent like everybody, as physicians, whether able or unable, all passed away. While a physician was sublimated as a caliph of the Creator, being reminded that the real healer is Allah - God the Creator himself, pride was disapproved. Authorative behavior was not suitable for medical practitioners [5].

Several examples of the perspective, "physician assuming to have cured patient must not boast", are found in Ottoman medical literature. Within the same perspective, Nidâî, a physician of the 16th century, advices his colleagues as described in the following couplet:

"Consider what awarded to you by God
Always keep (your) inefficiency in mind."

Nidâî describes in verse the failure of the physician assuming to have cured a patient:

"Don't say I have cured a patient
This assumption is a real lie
Both suffering and remedy is emerged by the Creator
He does whatever he wishes; it is his, the Creator's will"

According to Emir Çelebi, another physician of the 16th century, "Physician conceiving himself to be humble, should not relate the effects of treatment with his knowledge and skill. He should not conceive himself to be able; should not be proud of his art and practice; whatever may take place he must believe that God's favor will always be helpful. He must not behave proudly at the side of patient; he must even try to please and console patient." Emir Çelebi believes that a physician should also be dignified [7].

The meaning of modesty reflected other aspects of a physician's behavior, as well. Modesty was noted useful with respect to the development of medicine, as an attitude of a physician questioning himself/herself, too. For example, Abbas Vesim, a physician of the 18th century, deals with modesty with respect to a physician's consultation to his colleagues, valued as a favorable attitude in medical practice:

"Physician should travel from one country to another and should get in touch with those who were informed enough to discuss and present information about drugs and medical compositions; and should inquire and learn how drugs effect the body; should not pride with his ability; should not miss even a single word to be learned. For, facts and real knowledge are ideas and affirmations spoken by virtuous man" [8].

b. Contentedness

Justice and the right of equality in medical treatment was an important ethical norm and the value of justice fostered contentedness as a preeminent virtue expected from medical practitioners [9]. The assumption that "an ambitious physician eager to make money and own goods may drive him/her away from observing justice and truthfulness, consequently patients would not only be harmed, but trust in physician and medicine would be lost", is recorded in Ottoman Turkish medical manuscripts [10].

The developing function of the virtue of compassion by observing the virtue of contentedness can be noted in medical manuscripts, too. Perceiving a physician as compassionate meant that people trusted him as well. Şerafeddin Sabuncuoǧlu, a surgeon of the 15th century, advices not to treat illnesses difficult to operate, in aiming to gain money:

"Do not try to operate a patient hopeless to be healed. While you are regarded as virtuous, beware being perceived as vulgar, being fond of gaining money. Act so that your mercifulness will overweigh your respectability and ambition" [11].

Nidaî describes his evaluation of the expectation from a physician to "contend with the reward paid to him" in verse:

"Don't be fond of money, be satisfied with what you have a right to
Do not be fond of this temporary existence
Be careful to observe your destiny
Behave truthfully, so that you will not be distressed"

Abbas Vesim relates that a physician must be contended with what he/she has a right to get, that is, the sum of what is spent in treatment, the drugs used and the fee mentioned. Abbas Vesim advices physicians to be "contented, not to be ambitious and zealous for making money." The following words of Abbas Vesim describe clearly the real aim and function of medical practice [13].

"The meaning of physicians being unambitious means the ambition for obtaining estates and gaining money, not willingness to cure the patient and the poor. Because, ambition for property and money lowers respect for the physician and trust for his treatment" [14].

c. Fidelity

Fidelity also being a highly valued virtue, a physician who started treating a patient was expected to continue his treatment so long as he can. A physician was expected to continue his treatment in spite of patient's improper behaviour disturbing him. It was an ethical rule for physician not to seize treatment, abandoning a patient untimely [15]. This rule was imposed as a responsibility to the physician. Abbas Vesim describes the rules of fidelity as:

"Physician must bare the misbehaviour of his patients. Physician should not retaliate his patient, even if patient behaved impolitely. Physician should ignore patient's rude acts. Physician should not react to patient's improper behaviour, on the contrary he should act within the framework of medicine and his skill, that is he should not incline to stop treatment, not feel offended, but try to continue treatment.
Patience of an efficient physician is a way of treatment
Patient's function is always to cause pain"

In return, the patient was expected to be responsible for experiencing the prescribed medicine and way of treatment. The patient was expected to act in accordance with the physician's advices for treatment, both for the patient's and physician's beneficence. Disregarding the physician's advices might be harmful both for physician and patient. This mutual responsibility is described by Siyahi, a physician of the 16th century:

"Some patients partly practice physician's suggestions, consequently may not be cured, for which physician is blamed. Do not commit a sin by meddling with physician's work" [17].

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Figure 2: An illustration of a medical practitioner during treatment of a patient. (Source: Millet Kutuphanesi, Ali Emiri, nr. 79.).

Abbas Vesim advices physicians not to approach a patient disregarding a physician's advices, as did Siyahi. In such a situation, observance of the fidelity rule by the physician can be disregarded. In case a patient neglects to observe the physician's advices, the rule of fidelity can be ignored by the physician. Physician's right to leave a patient who doesn't observe his/her advices is defended and justified by Abbas Vesim, because, in such a case the patient may be harmed, consequently trust in the physician may be lost. If a patient hesitates to take the medicine adviced by the physician, or refuses to observe the physician's advice or speaks with the physician so as to get physician misunderstand him, the physician must end his relation with the patient. For, this is sure to cause a mistake. This approach is commented by Abbas Vesim. He writes that, if a patient distorts the physician's advice of treatment, being effected by advices of those inefficient in medicine and changes the treatment prescribed by his/her physician by the words of people who come and go; or not trusting the physician's advices based on the rules of medicine and acting on his own will, this act being against the law of medicine, mistake is inevitable. This fault is sure to be imposed upon the physician who treated the patient. For this reason, avoiding the treatment of such a patient can be justified. Otherwise, a physician's practice and advice will be comprehended/conceived as if he had not performed what he really did, and as if he had performed what he really didn't; and what he says will be conceived in the same way. In short, the patient was expected to cooperate with his/her physician and in return physician was expected not to desert his/her patient. Fidelity to a patient is in a sense derived from the importance paid to the value of hopefulness in treating a patient [18].

d. Hopefulness

Physicians were expected to treat patients honestly, but not to express outrightly neither the patient's cure certainly, nor the hopelessness of curing or of nearing death. Cases in the past were used as analogies. As it was impossible to know of the patient's destiny certainly, the duty of the physician was to try to treat the patient until death. Ibn Shareef, a physician of the 15th century, utilizing his own experience, justifies the importance of being wary in disclosing the fatality of patient to relatives:

"If a physician is asked, ‘Is the patient going to die and when?', the physician must not inform the patient's relatives of his/her death; the physician must not say that the patient is going to die today or tomorrow. Not disclosing is beneficial, for we have come across many physicians who assumed that the patients treated and healed by us could not be cured and were going to die undoubtedly, they were not destined to die yet, so they recovered. We felt the pulses of many of them, it was a sign of death completely and prepared their shroud and dug their grave. However, they did not die, they recovered and got up. So, it is proper not to inform relatives and friends of a patient's death, even if the physician preconceives it. God alone knows the truth. Whatever the illness may be, the patient must be nicely treated. Perform whatever they are willing, and try to protect patients against disappointment. Patients must be kept away from sadness and anxiety whatever your way of treatment may be. Please some by motivating and by means of hopefulness and others by awarding presents. Rejoice others by having their close friends and kind hearted people visit them, so, patients will feel happy and their morale will be improved" [19].

The physician was advised not to speak to the patient with certainty about the prognosis of his/her illness. Haci Paşa, a physician of the 15th century, puts forth the rule: "It is not proper to express outrightly that the patient is certainly going to die or be healed" [20].

Abbas Vesim puts forth similar rules: "A physician should not say that a patient is sure to go on living. Beware noting a certain period about the duration of patient's illness" [21].

It was regarded an ethical rule for a physician to go on with treatment even with the hopeless patient, that is, never to give up treatment. Even if recorded in medical books that no medicine will cure an illness, it was believed that one should not seize hoping of God's mercy. A patient or a wounded could be cured miraculously, though not expected. Patients should be informed and warned of the harmful consequences of ending treatment. Some physician writers pushed this attitude even further, defending the idea that a patient must not be informed of the disappointing prognosis, thus hopefulness for treatment and the will of patient for going on to live should not be ceased. Not to grow hopeless of being cured, going on to be hopeful of the Creator's mercy and the body's potentiality of getting healed itself was highly valued [22]. Ahmed b. Bali reflects this attitude by advising physicians to "encourage patient raising his/her morale by telling him that he/she is going to recover soon"; "Do away with patient's troubles, supporting him/her willingly" [23].

The Ottoman Turkish physician practicing Hippocratic, Galenic and Islamic medicine regarded himself as an assistant of nature and its power to heal. This was the main approach to the different prognosis in observing patients treated in the same diagnosis and indication.

3. Discussion on Contemporary Medical Ethics

Contemporary medicine has developed fast along with the development in technology and physician utilizing technology shared its miraculous products. Today, the human body and its various functions are observed and noted by means of developed diagnostic methods, technological instruments and laboratory tests. As physicians got to know more and more about the secrets of human biology and depend highly on technology, he/she intervened increasingly to the human body.

Expectations from the scientific development of medicine influenced cultural and social views, too. Consequently, traditional ideas of health and life transformed, more or less, all over the world. However, as societies' moral values differ from one another, proper argument of ethical issues in the developing medical field necessitates complementary knowledge, such as patients' culture. Embodied in a particular society, each patient and family shapes and thus reflects the way he/she understands moral problems and what she/he takes to be feasible responses. Traditions and historical backgrounds of societies have to be valued to reach a better understanding of their contemporary morality.

Figure 3: View from the exhibition in Edirne History of Medicine Museum. (Source).

As quoted shortly above, Turkish medical ethics in history relied on a virtuous behaviour expected from a health practitioner. Health practitioners were required to have a virtuous character for employment in Ottoman hospitals [24]. This may be the reason why today "real informed consent from patient" is far from being practiced in Turkey, patients relying on a physician known to be virtuous and efficient. A virtuous physician is expected to protect the patient from being harmed from a medical intervention and act fairly [25]. However, paradoxically, written consent from patient before treatment has always been a requisite of law, both in Turkish history and today