The elusive Formula Comitis Archiatrorum – The first medical ethics code?

Check out also my follow-up on September 8 2016, where I re-examine some of the claims I made here on the Formula Comitis Archiatrorum. My original post is below.


While looking into the history of medicomoral principles and codes for my PhD thesis, or rather for one footnote in my thesis, I came across with reference to the Formula Comitis Archiatrorum (another link including other works here) which is said to be the first known code of medical ethics (Aboujaoude et al. 2014, 5; Battacharya et al. 2015Cantú-Quintanilla et al. 2013; De 2015; Freed 2015, 144; Leigh 2015, 134; Long et al. 2014; Motamedi 2014; Ramana et al. 2013Timimi 2012). Incidentally, or perhaps not, Wikipedia tells the same story as do numerous non-academic Internet sources.

The Formula is credited to Magnus Aurelius Cassiodorus, born c. 484-90 and died c. 577-90 CE. He was a statesman and writer serving in the administration of Theodoric the Great, the king of Ostrogoths. The Formula is referred to as the historical archetype of contemporary medical codes of conduct. As Timimi (2012) writes:

When we discuss medical morality and medical ethics, what we are really referring to is our core belief of what is the right medical action and what is the wrong medical action; in essence, the code by which we practice.The first historic archetype of this from which our current ethics have evolved was likely the Formula Comitis Archiatrorum […]

The claim that this text was the first known medical ethics code seems odd to me as there is little mention of it in any credible source on the history of medical ethics. I did a search about the Formula in couple of databases. There is very little research done on it at all apart from couple of articles (see Amundsen 1971; Kibre 1953) that show up in an article search, and no research on it as the so called first code of medical ethics. In fact, it took me some time to even find an English translation (reprinted in Plinio Prioreschi’s remarkably comprehensive book series, pp. 121 – 122). Could it be that such an important text – the first code of medical ethics – has been paid so little attention and that the research on it, as the first code of medical ethics, is non-existent? If the Formula is the first ever known code of medical ethics, what sets it apart from Hippocratic or Galenic texts, or al Ruhawi’s, ibn Sina’s, or ben Maimon’s texts which also describe/prescribe suitable conduct for physicians? To answer these questions I need to see whether the Formula truly is the first medical ethics code as has been claimed or whether these claims are merely based on an unfortunate case of limited source checking and repetition of false information.

Is it the ‘first’ and is it ‘a code’?

There is more to show that the claim made of the Formula as the first code of medical ethics is false than that it is true. Firstly, the Formula is simply not the first code of medical ethics (“firstly” because there’s more to come in case I fail to convince). By a closer inspection on the use of sources in the articles that hold that the Formula is the first known medical ethics code, either there are none or the reference is one and the same: Jaroslav Nemec’s Highlights in Medicolegal Relations. Nemec writes (pages 10-11, with my italics):

Theodoric (454-526), King of the Ostrogoths and conqueror of Italy, renewed the ancient Roman institution of comes archiatrorum [the count of the chief physicians] and prescribed the wording of the oath which persons appointed to that position were supposed to take. The oath, called then Formula comitis archiatrorum, was inspired apparently by Theodoric’s “magister officiorum,” Flavius Magnus Aurelius Cassiodorus, and it is considered the earliest known code of medical ethics from the beginnings of Christianity.

It is clear here that Nemec does not claim that the Formula is the first medical ethics code. It is rather the earliest known code for physicians from the beginnings of Christianity which is a very different matter. This claim makes much more sense and places the Formula in a more credible relation to Hellenic, Hellenistic, Roman, and Medieval medical writings.

Secondly, one argument to support the claim that Formula was the first known code of medical ethics would be that it has a distinctive formulation, values, or principles which resemble contemporary ethical codes more than any other medical ethics text in antiquity or medieval period. This argument does not seem to hold true. There is nothing that really sets it apart from other similar texts that would earn it the special status it has been given in some articles. Moreover, there is nothing in it that proves it as an archetype of contemporary codes of conduct.

It is a short text; a model letter (Lat. formula), a form of investiture, written for the Comes archiatrorum. Cassiodorus did not write it in his own person. It begins by a description of medicine as the foremost respectable art. Then it moves on to state that in such art there should be a foremost one, Comes archiatrorum, to whom all those who take care of human health should report. Then a few normative claims are made:

– Medicine should not be defined by case-based changing opinion but experience of the physician
– After their training physicians should have leisure for books, especially ancient ones, both within and outside medicine
– Physicians should desist from quarrels that injure patients; if agreement is not made they should seek advice from somebody who can be asked without envy for a prudent man is willing to seek counsel
– Physicians are consecrated by oaths: they should promise to their teachers to hate iniquity and love honesty
– Physicians are not allowed to fail in their duty and they must consider souls; they should therefore seek diligently what cures the sick and what strengthens the weak
– Although mistakes may cause fault, a sin against the human health is the crime of homicide

After this the recipient is honoured with the title of Comes archiatrorum to be a judge in the art of medicine, to cure the sick by eliminating conflicts among physicians. The visit of the Comes archiatrorum should mean “health for the sick, relief for the weak, hope for the tired.” They should observe signs of sickness through their science and, finally, they are allowed to enter the palace and attend to the royal family.

My third point to undermine the claimed status of the Formula as the first code is that there are other texts written roughly at the same period that resemble ethical codes more, e.g. De Medicis et Aegrotis (Concerning Physicians and Sick Persons) in Lex Wisigothorum, Book XI, Title I (see Appendix A), written perhaps even earlier than Formula, c. 504 CE. All of this is not to say that Formula Comitis Archiatrorum is not an important document. As Prioreschi argues (2003, 120), it is significant in the sense that it underlines the consideration in which medicine was held at Theodoric’s court, it contains important information about the way medicine was practiced and perceived, and it contains information about medical theory and therapy at that point of time and place. My point is, rather, that the reason why it deserves a special mention instead of some other text should be seriously questioned: despite its possible significance, its position as a distinctive medical ethics milestone seems now more and more arbitrary.

Nemec also mentions that the Formula was an oath. It is not clear, however, what the oath called Formula Comitis Archiatrorum really is. It is certainly not the same thing as the text documented by Cassiodorus. This document might however, as the normative claims in it show, contain something about the oath if it existed. Finding the answer to whether the oath existed and whether it is preserved in its entirety in Cassiodorus’ letter Formula Comitis Archiatrorum would require meticulous research through archives, whether any references are out there.

The value of finding ‘the first’

I can only conclude that the claim about Formula Comitis Archiatrorum as the first medical ethics code, the archetype for contemporary ones, is not backed by any research. It might be among the first Christian medical ethics codes but there is nothing to show that it is any more significant than others.

The claim is based on an unfortunate poor use of sources and limited source checking, i.e. a total lack of critical reading. The problem perhaps is the need to establish ‘the fathers of’ and ‘the first originals’ as if this would establish the validity of any introductory remark on the history of medical ethics. As if finding ‘the first’ had value in itself. And once ‘the first’ has been found, there is no longer need to question its validity: it is the original, this is where it started, end of story. And when ‘the first’ is safely mentioned, it shows that some research has happened. Moreover, I seriously question the value of such ‘information’ in the first place. Rather than seeking for ‘facts’, classifying and categorising them, ticking the box ‘history of ethics’ done, and attempting to construct a linear timeline of so called important milestones, wouldn’t it be more interesting to discuss the text itself and its implications for contemporary medical morality?

References

Amundsen, D. W. “Visigothic medical legislation.” Bulletin of the History of Medicine 45, issue 6 (1971): 553-569.

Kibre, P. “The faculty of medicine at Paris, charlatanism, and unlicensed medical practices in the later middle ages.” Bulletin of the History of Medicine 27, issue 1 (1953): 1-20.

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