Following up on Formula Comitis Archiatrorum – still not convinced

My previous blog post on Formula Comitis Archiatrorum has been by far the most popular on my site. It gets frequent visitors from all over the globe –  a fact that I was very surprised about but also very grateful for all the people who have shown interest in my little research. This is still a side project, one that I haven’t had too much time to return to, as it turns out its not even a footnote after all, but I’m very much intrigued by it. I have done some more research on it and I’d like to update some of the claims I made previously.

Most importantly, I’d like to return to the issue of what exactly is it? Is it a code and is it the first?

I still stand behind my main claims:

  1. There is no direct link or linearity between the Formula and our contemporary medical ethics codes.
  2. It is far more likely that other historical work in medical ethics has been more influential, such as Percival’s Medical Ethics or Hippocratic or Galenic medicine.
  3. Formula comitis archiatrorum is one example from the beginnings of Christianity but it doesn’t deserve any archetypal position as the first medical ethics code

In my previous post I wrote:

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.

I think there is some unnecessary ambiguity here, one that arises from my own limited understanding the etymology of the word Formula back then. I’d like to clarify, after examining the issue further, that what the document Formula comitis archiatrorum is, is a letter of investiture – in Latin formula – a letter to appoint the Comes archiatrotrum, the count of the chief physicians, to the royal court to serve as the royal physician. So in this sense, by taking the position as the Comes archiatrorum, the one who is appointed would have committed to the norms in the document, so it can be considered as a written oath. But there is no evidence of any practices of swearing an oath that carries the name Formula comitis archiatrorum. Why? The evidence is quite simple: Formula does not mean ‘an oath’. This is not to say that there wasn’t an oath and it is not to say that it didn’t, if indeed there was one, contain the same normative claims but the possible sworn oath is certainly not the same thing as this document that is called Formula comitis archiatrorum. I explain this idea in more detail below.

When was it written? What is it not?

Formula comitis arhciatrorum is credited to Flavius Magnus Aurelius Cassiodorus, a statesman and writer. Like the dates of his birth and death, much of Cassiodorus’ personal life is unknown. One estimate is that he was born somewhere between 484 and 490, and died between 576 and 590.[1] Some knowledge about his life as a statesman, however, is preserved through his writings.

Cassiodorus served in the administration of king Theodoric the Great, one of the greatest barbarian kings, who ruled the Ostrogoths from 471 to 526 and an independent Gothic kingdom in Italy from 493 to 526. It can be deduced from Cassiodorus’ writings that he served as a quaestor from 507 to 511 and magister officiorum from 523 to 527.[1] After Theodoric’s reign Cassiodorus served most likely only briefly his successor, the ten-year-old king Athalaric and Theodoric’s only child Amalasuintha who was the queen regent. He returned to office around 533 when Athalaric appointed him praetorian prefect for Italy and then served during both Theodahad’s and Witiges’ brief and stormy reigns until late 530s.

After this brief glimpse into Cassiodorus’ public and personal life we can easily put to rest the misunderstanding that Formula comitis arhciatrorum was written or published in the 5th century.[2-11] It may have been in use during the early reign of Theodoric in the 5th century but without any other documentation other than Cassiodorus’ texts, it is difficult to know for sure in which century Formula was first in use (if ever, as it is a model letter). In addition to the fact that Cassiodorus was born towards the end of the 5th century, we know that he composed Formula comitis arhciatrorum along with numerous other letters and model letters for appointments (Lat. formulae) during his time as a quaestor but no later than the year 534.[1] What we do know is that in the late 530s, towards the end of his service as the praetorian prefect of Italy, he selected and edited 468 letters, proclamations, edicts, and formulae which he had written during his service and compiled them into 12 books called Variae. The most comprehensive English translation of the works is still Hodkin’s 1886 abridged edition[12] in which Formula comitis arhciatrorum is only translated partly.

The Variae is an early example of formulary collections of legal and chancery documents.[13] Cassiodorus’ motives for compiling it was, as he himself proclaims in the preface for Variae, to supply models for official eloquence for future administrators, to ensure the immortality of those praised in them, strengthen respect for laws, and to provide a mirror of his own character.[13,14] It is likely that Cassiodorus had also propagandistic motives.[1] For the contemporary reader the letters are an important source of the history of the Gothic rule in Italy, its political appointments, judicial decisions, administrative orders, and military commands. Most of the letters are written in the name of the kings but there are some that are written in Cassiodorus’ own person, which is why we can’t be sure whether the Formula had been in use in the 5th century in some form or whether it was indeed composed in the 6th century, following earlier practices of appointing the Comes archiatrorum. Therefore, the compilation of the formulae function also as a document of one statesman’s public career. Formula comitis arhciatrorum is one of the letters that Cassiodorus did not author in his own person.

According to Amory, the Variae remain a reliable source of Theodoric’s policy.[15] Any alteration and editing Cassiodorus made concerned only the probable elimination of personal names, dates, of protocol and eschatocol, and the possible addition of excurses on natural phenomenon.[1,15] It is difficult to say, however, that how much of the words can be directly attributed to the kings and how much Cassiodorus polished the kings thoughts. Perhaps, as O’Connell suggests, they are something in between being a direct reflection of the thoughts of the monarchs and a complete production of Cassiodorus.[1]

So is Formula comitis arhciatrorum a code of medical ethics? Or is it, as Jaroslav Nemec claims, also an oath?[16] (I still need to get my hands on Nemec’s source, Castiglioni A. A History of medicine. New York: Aronson 1975.) It is a short model letter, a form of investiture, written for the purpose of appointing the count of the Comes archiatrorum, to office. Although it contains some normative clauses on how physicians and the Comes archiatrotum ought to behave, it is safe to assume that Formula comitis arhciatrorum is not, as it has been preserved for contemporary readers, a code of medical ethics. It is more likely that that is can be considered an oath in sense that the appointed comes archiatrorum, by accepting the appointment, committed to abide by the norms set in the letter. But there is nothing in the wording of the letter itself to indicate that it was a ceremonial oath that the comes architrorum would have sworn upon being appointed.

Is there any connection to contemporary medical ethics?

To support the argument that Formula comitis arhciatrorum is an archetype Timimi claims that “it required that physicians widen and deepen their knowledge and originated our current concept of physician-to-physician engagement and consultation.”[10] Is this true either?

The whole Formula reproduces Hippocratic medical etiquette. This is not surprising given that Hippocratic medicine was the accepted practice in Cassiodorus’ Italy. Formula comitis arhciatrorum begins with a description medicine as the foremost respectable art. Then it is established 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 six normative clauses follow: First, medicine should not be defined by case-based changing opinion but experience of the physician. Galen writes in a similar fashion in the 2nd century BCE where he argues for approaching signs of sickness logically, through science, and trough ethics. The second normative clause is the likely source for Timimi’s claim that Formula comitis archiatrorum required physicians to widen their knowledge. The Formula states that after their training physicians should have leisure for books, especially ancient ones, both within and outside medicine. Again, similar arguments can be found in Galen’s The best physician in also a philosopher.

The third clause is the likely source for Timimi’s second claim that our current concept of physician-to-physician engagement and consultation originated in Formula comitis archiatrorum. Physicians should, according to the Formula, 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. Hippocratic texts, De medico as well as the Oath, both discuss collegiality and seeking counsel.

The fourth normative clause asserts that physicians are consecrated by oaths. They should promise to their teachers to hate iniquity and love honesty. There is a similar pledge for loyalty to teachers, again, in the Oath.

The last two clauses concern the duty of healing and respecting human health and life. It sates that physicians are, fifthly, not allowed to fail in their duty and they must seek diligently what cures the sick and what strengthens the weak. Sixth and lastly, although mistakes may cause fault, a sin against the human health is the crime of homicide. The two last are clauses are similar to the Hippocratic idea of benevolence and the duties of physicians towards their art and their patients.

The formula ends with the honouring of the recipient 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.

So the argument about the archetype does not seem to hold true. There is nothing that really sets it apart that would earn it the special status it has been given in some articles. Rather than lifting one document among others, there is no one archetypal document from which our current medical ethics arises from. The way our conception of morality has evolved is rather attributable to religions, (medical) history and culture.

Conclusion

I have tried to make some clarifying points on this issue. I still hope to return to researching Formula Comitis Archiatrorum. I wish to clarify again that my intention is not undermine the document itself. The Variae, including Formula, are our most important documents for the history of Italy under Gothic rule.[13] Prioreschi argues that 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.[17] Max Neuburger argues that Formula proves the existence of cultivated and organised medical practitioners in the 6th century Italy.[18] Whatever its significance, it is a part a wider historical context.[19-20]

References

1 O’Connell JJ. Cassiodorus. Berkeley: University of California Press 1979.

2 Aboujaoude E, Weiss Roberts L, Reicherter D. Introduction to ethics in clinical medicine. In: Weiss Roberts L, Reicherter D, eds. Professionalism and ethics in medicine. New York: Springer 2015:3–26.

3 Battacharya S, Stubblefield BG, Banerjee SK, et al. Ethics and moral principles in the practice of medicine. In: Battacharya N, Stubblefield GS, eds. Regenerative medicine. 2015:281–285.

4 Cantú-Quintanilla G, Alberú-Gómes J, Reyes-Acevedo R, et al. Conveniencia de un código para mejorar los estándares éticos en la Sociedad Mexicana de Trasplantes. Revista Mexicana de Trasplantes 2013;2: 97–100.

5 Freed JS. Legal and ethical issues in global health: a trip through the vagaries of truth and culture. In: Roth R, Frost EAM, Gevirtz C, eds. The role of anesthesiology in global health: a comprehensive guide. New York: Springer 2015:14–158.

6 Leigh H. Systems and ethicsl issues in CL psychiatry: hospital as a social sytem, sicj role and doctor role, ethical and legal issues. In: Leigh H, Streltzer J, eds. Handbook of consultation-liaison psychiatry. New York: Springer 2015:129–138.

7 Long NP, Huy NT, Trang NTH, et al. Scientific productivity on research in ethical issues over the past half century: a JoinPoint regression analysis. Trop Med Health 2014; 42: 121–126.

8 Motamedi MHK. Breaching medical ethics in research. Trauma Mon 2014;19: e17112.

9 Ramana KV, Kandi S, Bionpally PR. Ethics in medical education, practice, and research: an insight. Annals of Tropical medicine and Public Health 2013;6: 599–602.

10 Timimi FK. Medicine, morality and health care social media. BMC Med Aug 2012;10(83). doi:10.1186/1741-7015-10-83 (accessed Oct 2015).

11 Schwartz M. Ethical Challenges for the Nurse Caring for Neurologically Impaired Patients: A Case-Based Discussion. Journal of Hospice and Palliative Nursing 2015;17: 90–95.

12 Hodgkin T. The letters of Cassiodorus: being a condensed translation of the Variae epistolae of Magnus Aurelius Cassiodorus Senator. London: Henry Frowde 1886

13 Mommsen T. Cassiodori Senatoris Variae. Berolini [Berlin]: Weidmann 1894.

14 Barnish SJB. Introduction. In: Cassiodorus. Variae. Liverpool: Liverpool University Press 1992.

15 Amory P. People and identity in the Ostrogothic Italy, 489–554. Cambridge: Cambridge University Press 1997.

16 Nemec J. Highlights in medicolegal relations. Bethesda: U.S. Dept. of Health, Education, and Welfare, Public Health Service, National Institutes of Health, National Library of Medicine 1976: 10–11.

17 Prioreschi P. A history of medicine. Vol. V – Medieval medicine. Omaha: Horatius Press 2003.

18 Neuburger M. Geschichte der Medizin: Erster teil. Stuttgart: Verlag von Ferdinand Enke 1911. Also in Hoops J. Reallexicon der Germanischen Altertumskunde. Berlin: Gruyter 1973: 443.

19 Amundsen DW. Visigothic medical legislation. Bulletin of the History of Medicine 45, issue 6 (1971): 553.

20 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.

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One thought on “Following up on Formula Comitis Archiatrorum – still not convinced

  1. Pingback: The elusive Formula Comitis Archiatrorum – The first medical ethics code? | Critical / Health / Philosophy

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