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Tuesday, April 16, 2013

1780 B.C.: The risk of being a physician

If you think doctors today have it bad, you should have been a doctor in Ancient Mesopotamia in 1780 B.C.  Back then malpractice was more narrowly defined, and the punishment would entail more than money; it was ius talionis -- 'eye for eye, tooth for tooth, hand for hand, foot for foot.'

Hammurabi was the greatest Babylonian king.  He fought a 30 year war with Elam, defeated Larsa, Eschunna, Mari and Ass(all city-ur , and ruled supreme in the center of Mesopotamia. While art declined somewhat during his reign, science and learning flourished, and the law was clearly defined and recorded 'literally' in stone.   

Hammurabi wanted to create a code of discipline for all the people to follow, and so he ordered his scribes to take all the best laws that were written before his time and inscribe them in stone. This became the first attempt by society to protect one man's rights over another.  And, likewise, the "first attempt by society to protect itself by way of legislation against misuse of the physician's power," notes Henry E. Sigerist in his book, "A History of Medicine."  (volume I, page 434)

The following are some of the laws regarding physicians in the Code:
  • Code 218:   If a physician make a large incision with the operating knife, and kill him, or open a tumor with the operating knife, and cut out the eye, his hands shall be cut off. 
  • Code 219:    If a physician make a large incision in the slave of a freed man, and kill him, he shall replace the slave with another slave. 
  • Code 220:  If he had opened a tumor with the operating knife, and put out his eye, he shall pay half his value
  • Code 221:  If a physician heal the broken bone or diseased soft part of a man, the patient shall pay the physician five shekels in money. 
Regarding these strict laws, Sigerist explains the following:
"These were draconian regulations and it is hard to understand how any physician had the courage to perform an operation when he constantly ran the risk of losing his hands at the first unsuccessful performance.  We know from other civilizations that laws frequently remained on paper and were never applied because they were not applicable.  They were formulated as a matter of policy and as a warning against abuse but would have defeated their own purpose had they been applied literally.  This is all probability the case here also." (Henry E. Sigerist, "A History of Medicine,"volume I, page 434)
However, Plinio Prioreschi, in his book "A History of Medicine," (vol. 1, page 464-5) explains that the Code only makes reference to physicians as it pertains to surgery, which may signify that "the physician was not held responsible for the outcomes of his therapy unless he used the knife, that is to say, that purely medical treatment was not subject to malpractice.  This seems to imply little esteem for the capacity of non-surgical therapy in influencing the course of the disease one way or another because, if medical treatments were recognized as powerful and effective, its misuse would have been deemed to cause as much damage as incompetent surgery."

Prioreschi continues, "The difference between medical and surgical treatments in terms of legal responsibility could also be the result of the belief that a disease was an act of got, whereas a surgical operation was an act of man and therefore subject to judgement and punishment.  This clear distinction between acts of man is well issustrated by the difference between two other laws (248 and 249) in the Hammurabii's Code.

Prioreschi then lists the two laws for comparison, as follows:
Code 248:  If a seignior hired an ox and has broken its horn, cut off its tail, or injured the flesh of its back, he shall give one quarter its value in silver 
Code 249:  If a seignior hired an ox and god struck it and it has died, the seignior who hired the ox shall (so) affirm by got and then he shall go free."
So the risk of being a physician may have been relegated to the type of medical treatment delivered by the physician.  Although when the risk of doing nothing was believed to be loss of a limb, or sight, or loss of life, the laws, however written, may have been disregarded as negligible so long as the physician was doing what was in the best interest of the patient.  

And he, or she (as there were female physicians as well) was paid well for his works, as noted by the following Codes:
  • Code 215:  If a physician performed a major operation on a seignior with a bronze lancet and has saved the seignior's life, or he opened up the eye-socket of a seignior with a bronze lancet and has saved the seignior's eye, he shall receive ten shekels of silver
  • Code 216:  If it was a member of the commonality, he shall receive five shekels.
  • Code 217:  If it was a seignior's slave, the owner of the slave shall give two shekels of silver to the physician
  • Code 218:  If a physician performed a major operation on a seignor with a bronze lancet and has caused the seignior's death, or he opened the eye socket of a seignior and has destroyed the seignior's eye, they shall cut off his hand.
  • Code 219:  If a physician performed a major operation on a commoner's slave with a bronze lancet and caused (his) death, he shall make good slave for slave.
  • Code 220:  If he opened up his eye-socket with a bronze lancet and has destroyed his eye, he shall pay one half of his value in silver
  • Code 221:  If a physician has set a seignior's broken bone, or has healed a sprained tendon, the patient (owner of the injury) shall give five shekels of silver to the physician
  • Code 222:    If he were a freed man he shall pay three shekels.
  • Code 223:  If he were a slave his owner shall pay the physician two shekels. 
Prioreschi explains (page 470) that most physicians received 2-10 shekels for successful surgeries.  He explains that "the silver shekel weighed 84 grams, this means that the surgeons received between 168 and 840 grams of a metal that, at that time, was more precious than gold.  Ten shekels of silver were enough, in fact, to pay the cost of labor for a substantial house or to pay a carpenter for 450 working days."

Non surgical feels, Prioreschi further notes, were paid much less for their services, and this may be proven by the fact that most physicians lived modestly, or were not rich at all.

"A substantial difference in the price of medical and surgical procedures would support the hypothesis that purely medical therapy was not held in very high esteem, which is suggested by the fact that the Code of Hammurabi did not hold the physician responsible for malpractice unless he used a surgical approach," Prioreschi notes (page 470).  "Perhaps if noninvasive procedures (which would include the setting of an ankle to prevent one from becoming shorter than the other) were to be used it was felt that a good incantation would have been equally effective and, therefore, command the same fee."


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