I. The Birth of Medical Art in the Greek Culture. 1. The Medicine of Hippocrates. 2. The Studies of Aristotle and the Medicine of Galen. - II. Medicine and Christianity. 1. A New Vision of the Human Being. 2. The Study of Medicine in the Universities of the Middle Ages. - III. The Birth of Hospitals within Christian Culture - IV. The Beginning of Scientific Medicine - V. Is Medicine a Science of Nature or a Human Science? VI. Medicine as a Science, an Art and an Ethical Activity. 1. The Characteristic of Medicine and of the Medical Profession. 2. The Doctor-Patient Relationship. - VII. Some Teachings of the Magisterium of the Catholic Church on Medicine. 1. The Concern for Human Life and the Care for It. 2. Documents of Major Relevance. 3. Concluding Observations.
Among the various fields of knowledge medicine certainly occupies a very relevant place. It is a discipline with academic origins uniting aspects of theoretical and experimental science with those of a practical art. Above all it has a very special object: the human being with his experience of health and illness, of well-being and of suffering, an object for which any attempt to provide an exhaustive definition would result in being reductive. Essentially open to interdisciplinarity, medicine meets within its horizons the very emerging of life, but also its ending: medicine can help the human being to prevent and heal his or her illnesses, thus to regain health, but cannot avoid death in a definitive manner. Medicine is inherent to the human condition itself: although our sensitivity to pain is something we share with higher forms of animal life, we alone have the power to help ourselves and other human beings with specific acts that constitute a praxis and a universal tradition founded upon compassion (Lat. cum pati, "to suffer together"), which is a root of morality. Medical cures represent an exercise of compassion amongst human beings: the human being who suffers a disease is, in such sense, a "patient." To cure means to take care of the patient. The relationship between vulnerability (illness) and compassion (cure) constitutes the ethical-anthropological structure of medicine in each age, even when we emphasize the objective it has to look after health and to serve life. There is no illness without health and there is no health without illness. The concepts of health and illness cannot be fixed in objective terms once and forever. It is necessary to insert the universal experiences of suffering and of illness into a vision of the world, of humankind and of the scientific development of medicine. It should be done in such a way to enable a comprehension of the nature and causes of suffering, and of all the possible ways to prevent and to cure it. As illness manifests itself, while the wonder of health hides itself (cf. Gadamer, 1993), the attempts to define illness are more numerous with respect to the attempts to define health, synonymous with well-being and, in the fullest sense, of salvation.
The most ancient medical practices were a mixture of empirical interventions, whose real causes of efficacy and inefficacy were unknown, and of magic, that attributed to external mysterious forces the reason for the pain and illness. These forces were controllable by enigmatic procedures applied by certain tribesmen who, rightly initiated, enjoyed special curative powers. For many centuries, and in many cultures still today, the world of medicine remained profoundly linked to the mythical-religious world. The empirical therapeutic knowledge accumulated through time were enriched and transmitted along the ages, giving rise to a set of curative techniques preserved by the diverse cultures of the Earth. It was in the 6th-5th centuries B.C. that a true medical rationality, the source of the future medicine, took form in Ancient Greece. It is important to note that such a development did not represent a rejection of religion. The medical rationalism would attempt to explain diseases in natural terms, without necessarily endorsing an atheistic view. According to Amundsen (1987), there could be incompatibility between medicine and religion only in those relatively rare cases in which the religious concept of well-being did not include the well-being of the body; or in which religion considered permissible for the maintenance or the restoration of physical health only methods of a religious nature. Alongside medicine (scientific and alternative), even today methods of healing coexist as different attempts to respond to illness and to develop healthcare. Magic continues to live on, as a practice not exclusive of primitive populations. Within the religious sphere we also encounter prayer, which is a request full of hope for a miraculous intervention by God, that does not represent an incompatible praxis either with the recourse to medical cures nor with the progress of the conditions of life (cf. Kee, 1986).
I. The Birth of Medical Art in the Greek Culture
Greek medical rationalism constituted the transition of medical practices and knowledge from a mythical-religious phase to another phase that can be called "scientific." Scientific medicine is characterized by an attempt to understand the causes of illnesses, which can now be defined as a kind of natural phenomena that influence human behavior in such a way that they make the human being unable to carry out his or her physical and social functions, lessening his or her vitality up to the point of causing death. The achievement of a scientific level in medical knowledge coincides with the development of the arts (Gr. téchnai) and has a specific cultural root. The medical téchne is to be found at the threshold of what we define as science and implies a universal knowledge. In general terms, a téchne is a knowledge about the nature of something that should be used to help humankind, and that for this reason is carried out only in its practical application, that is, as a kind of practical knowledge. According to Gadamer (1993), the medical art constitutes a specific form of practical knowledge and not just the simple application of a theoretical one. The téchne model is the medicine that, based on the knowledge of the healthy human nature, also knows its opposite, i.e. ill nature, and can therefore find the way of healing to take nature back to the normal state.
1. The Medicine of Hippocrates. The initial medical knowledge pursued with a scientific method derive from the experiences and investigations made by the doctors of Ancient Greece (in Crete, Rhodes, Cnido, Kos). Its origins are linked to the philosophical view which searched for causal explanations of natural phenomena, as it was actualized by the Ionian philosophers. It was towards the middle of the 5th century B.C., when medical science made its first steps. Through his fame and prestige, Hippocrates, leader of the Kos school, gives his name to an ensemble of medical works entitled Corpus Hippocraticum. The Corpus constitutes the most ancient and important foundation of a medical science, endowed with its own epistemological statute.
Medicine becomes a science also thanks to a certain, fruitful conflict with philosophy, which helped medicine to be aware of its own method and develop its own concept of science. It was medicine and not philosophy, for instance, which elaborated the concept of "human nature," as something which remains constant and whose essential elements last unchanged in every time (cf. Jaeger, 1986). The Hippocratic concept of human nature is inserted within the concept of nature as a cosmic totality. Illness is not an isolated phenomenon: the ill person is part of the totality of nature and subject to the universal laws that govern it. Hippocratic medicine is the science of the human body subject to such cosmic laws and conceived as a microcosm. The basis of this medicine is the knowledge of the laws with which the human organism reacts to the effects of the forces that rule the universe, in its normal as in its pathological states.
We are dealing with an authentic knowledge of the human being, acquired through confrontation with illness and death. By means of this study we acquire the awareness that the finite structure of our being is not a sign of opposition exercized upon us by occult forces. Medical knowledge, supported by the possibilities of reason, shall have the possibility to extend ever farther than the still insuperable limit death. As Sophocles wrote in the tragedy Antigon , "only against death he cannot find a way to escape, yet he has found remedies for invincible illnesses." The art of medicine, according to what another dramatist, Aeschylus, wrote in the Prometheus , "is however not capable of moving away all types of illness."
From a religious point of view, the theoretical structure of Hippocratic medicine is neutral. It allows for explanations of a divine nature at the level of an ultimate causality, that is, attributing their own causality to the natural processes, but recognizing that the cosmos is ordered by the divinity, to whom humankind is closely joined. The Hippocratic refusal of divine intervention in the process of illness, and consequently the refusal of any magical therapeutic approach aiming at calming the divine anger, co-exists with the declared respect of divinity. The Hippocratic doctor substitutes a more or less obscure divine justice with the idea of an order of the universe, divine and natural, that accounts for all the illnesses. These also include the sickness referred to as "holy" (epilepsy), considered at that time to be more divine than the others. In the Hippocratic age we observe an adaptation of the divine to the natural, in the sense that the divine manifests itself with the same regularity as that of the natural laws (cf. Jouanna, The Birth of Medical Western Art in Grmek, 1998).
The Greek word ánthropos, human being, is frequently used within the Hippocratic writings. The doctor has before him, first of all, a human being. The aim of medicine is very well expressed in one of Hippocrates' aphorisms: "concerning the illnesses, have two objectives in mind: to be useful or, at least, not to be harmful" (Epidemies, I, 5). If it is not possible to be useful, the doctor must not aggravate the state of the illness with an inappropriate intervention, motivated by the excessive research of success. The reflections of the Hippocratic doctor on his own art gave rise to the Hippocratic Oath, a fundamental text on medical ethics that received from Christianity a universal appraisal and has remained in force through the course of the centuries (cf. Gracia Guillen, 1988).
In its raising, medical art must also struggle against the prevalence of philosophical theories proposed by practical doctors, such as Empedocles. The Hippocratic doctor, proud of his achievements obtained through a careful observation of the details and completely immersed in the cure of the sick, works far from the speculations of the naturalistic philosophers and defines once and for all the medical science as an independent art (cf. Jaeger, 1986). In his treatise, The Medical Art , Hippocrates responds to the adversaries of the medical art, demonstrating that this indeed exists and has the power to heal and to lessen the illnesses, within the limits that are given to it: it is the birth of medical epistemology (cf. Jouanna, The Birth of Western Medical Art, in Grmek, 1998). Hippocrates' argument comprises, in its introductory part, the defense of all arts, as now performed by a scientist and not by a philosopher, as it was usual at that time. When the Hippocratic scientist restricts his arguments to demonstrate the scientific criteria of the medical téchne, understood as a combination of art and science, he underlines at the same time how medicine does neither trust case nor fortune. Medicine, then, acquires a new statute: it is no longer philosophical anthropology, but rather the "science" of the human being.
2. The Studies of Aristotle and the Medicine of Galen. The works of Aristotle (384- 322 B.C.) constitute a clarification of the problem concerning the relationship between medicine and philosophy, with undoubted advantages for both. The Stagirite started off the methodical practice of animal vivisection, in this way increasing biological and zoological knowledge, to construct on a new basis a philosophy of nature, and to indicate a new feature of medical knowledge: "it is a tendency characteristic of the scholar of nature to consider the fundamental principles of health and illness, as neither health nor illness concern things devoid of life. Therefore almost all scholars of nature encounter medicine, and those doctors who pursue their art with a greater theoretical awareness, in order to practice medicine they turn their attention to the science of nature" (On the Sense and the Sensible, 1). The Aristotelian anatomical knowledge pushed medicine beyond the observational limits that were proper to the Corpus Hippocraticum. The medical téchne develops within the Aristotelian epistéme.
Hippocratic medicine, theoretical and practical, was centered on the concept of illness and upon the figure of the doctor as a professional entirely dedicated to the clinical demands (diagnosis and therapies). The Hippocratic clinic, not knowing the inside of the human body, attempted to reconstruct the internal invisible phenomena through analogy with the external visible ones. The body was not explored by anatomical inspection. Starting from the 3rd century B.C. Hellenistic doctors active in the school of Alexandria, above all Erophilus and Erasistratus, structurally modified medical science. They put in the first place, as the central matter of the whole discipline, the problem of health, that is the comprehension of the natural and normal state of human bodies, instead of favoring the study of illness (cf. Vegetti, Between Knowledge and Practice: Hellenistic Medicine, in Grmek, 1998). This new dimension of medical science was accompanied by the constitution of a new anatomical-physiological knowledge offered by the Aristotelian tradition, but above all, by that obtained through the dissection of human and animal bodies. Alongside the Hippocratic practitioners, most of whom were itinerant, who anonymously would perform their professional work by curing illnesses, the character of the medical scientists emerged. These wrote treatises recording the results and observations of their research.
The synthesis of ancient medicine is to be found in the work of Galen of Pergamum (129- 210 B .C.), called to Rome by the emperor Marcus Aurelius. The author of a great encyclopedia of medical knowledge, of which we now possess only a part, Galen is presented as the restorer of the doctor's dignity, also ethical, as it had already been attributed to him by Hippocrates. His affirmation that the true doctor is also a philosopher signifies a methodological choice that reconciles, like in the Corpus Hippocraticum, the logical moment (knowledge by intellect) and the experimental moment of observation (knowledge through sight, touch and other senses). It is the senses that inform the intellect on the nature of illness. Galen intended to work within the sphere of reason, in such a way that the therapeutic process could have predictable results.
Galen derived from the Aristotelian tradition the idea of teleology as the supporting structure of his system. His epistemological effort is to be found in his attempt to allow different sources to co-exist: the Aristotelian philosophy of nature, the anatomical-physiological studies of the doctors of the Museum of Alexandria, and the clinic of Hippocratic inspiration (cf. Vegetti, Between Knowledge and Practice: Hellenistic Medicine, in Grmek, 1998). The teleological conception of Galen was inspired by Platonic finalism and by the Aristotelian principle that "nature does nothing in vain" (Aristotle, Politics, I, 1253a 7), thus assuming the existence of a providential relationship between the structure of the organs and their relative functions: in other words, there are no useless organs. Finalism describes nature as a providential artificer of the living being: "nothing, of that which serves life, that contributes to a better quality of life, could be better provided than how it actually is" (On the Usefulness of the Parts of the Body, XIII, 1). In the human being all of this is revealed in a remarkable way. According to Galen, ideal health does not belong to this world, but it stands as something which we can refer to in order to evaluate the real state of health of an individual person. It is within this space between absolute good health and true illnesses that we can place the actions of the doctor (cf. D. Gourevitch, The Paths of Knowledge: Medicine in the Roman World, in Grmek, 1998). Like Hippocratic experimental methodology, also Galenic methodology recurs simultaneously to experience and reason, but with a strong innovation in both paths of knowledge. Experience is not limited to sensible observation, but is enriched by all the information drawn from the dissections of the human body, already started in the 3rd century B.C. by the Alexandrian doctors. On the basis of clinical observation and anatomical-physiological experience, Galen structures the diagnostic reasoning assigning to Aristotle's natural philosophy a quite important role. Though Galen's and Aristotle's medical knowledge had many limitations, the epistemological program of unification of medicine within a theoretical Platonic-Aristotelian framework permeated by religiosity, as it was carried out by Galen, represented the higher point in the constitution of medical knowledge and medical art as a true science. All of this developed into a synthesis of ancient medicine that survived until the 16th century.
II. Medicine and Christianity
1. A New Vision of the Human Being. The influence Christianity had on the earlier stages of medical science is just a part of its fertile relationship with the classical pagan world. It is rather significant that Luke, the redactor of the first Christian events, the author of the third Gospel and of the Acts of the Apostles, was a doctor from Antioch, a city in which a Hellenistic school of medicine had flourished.
Opposing the Gnostic sects which despised the human body and the doctors who dedicated themselves to the care of it, the Fathers of the Church traced the lines of Christian personalist anthropology in which both the body and the soul are essential. St. Gregory of Nyssa (335-394) is the most qualified witness of the new Christian vision of humankind that corrects the Greek cosmocentrism. In his work De hominis opificio, commenting on the biblical account of the creation of the human being, he affirms: "without any doubt, in terms of greatness the human reality goes beyond everything we know because only the human being, among all other beings, is similar to God" (Proemium: PG 44, 125D-128A). The human being is much more than a pure microcosm, because has been created at the image and likeness of God Creator (cf. ibidem, XVI: PG 44, 177D-180A).
In his work De medicina, the pagan writer Celsus (who was refuted by Origen because he considered Christ as a vulgar deceiver) reported in the 2nd century the news of the vivisection that Erophilus and Erasistratus, anatomists operating in Alexandria in the 3th century B.C., operated upon people having been condemned to death, in order to study their bodies. A century later, Tertullian (160-215 ca.) took up the information reported by Celsus to condemn the experimentation on living human beings, also before birth (cf. De anima X, 4: PL 2, 662). Moral, philosophical and theological problems of ancient Christian literature seem to be interwoven with medical knowledge. A new anthropocentric vision thus emerges: the universe can be explained only through its relationship with the human being, made in the image of God and whose existence has its reason in God's wisdom ( LIFE, IV). This new vision has many consequences on the study of illness and health. Illness is neither a divine punishment nor a misfortune or cosmic destiny, but rather an existential test that regards the human being in his or her entirety and somatic-spiritual wholeness (cf. Lain Entralgo, 1978, p. 141). Illness touches the essence of the human condition in the world. Therefore, the objective of a cure is not just the physical well-being, but rather the whole person, because it is the whole person who suffers illness, and not just the body alone. The human being is not only his or her body: a cure must reach the person in his or her tangible, but also spiritual and religious, reality.
2. The Study of Medicine in the Universities of the Middle Ages. It is worthwhile considering that the seed of the first Medieval university in Europe corresponds to a medical institution: the School of Salerno (cf. Kristeller, 1945). Historians of medicine have emphasized the contribution that this School gave to the medical culture and literature during the 11th-13th centuries. Historians interested in the origin of early universities have sought to shed light upon its institutional developments and its teaching methods. Whether the School of Salerno was clerical or lay in origin is still an unresolved question. However, its connection is certain with the Archbishop of Salerno, Alfano (poet and author of medical writings), and with the abbot of Montecassino, Desiderio. Concerning its origin, it is documented that during the second half of the 10th century the School was principally renowned for its practical capacity, while in the 11th century the first traces of medical literature appeared indicating the beginning of a theoretical teaching.
The medical treatises of Hippocrates and of Galen and the works of Arabian writers (Haly Abbas, Isaac Iudaeus and others) were at the basis of the medical teaching in Salerno and in all the Medieval universities. These Arabian texts were translated by the monk Constantine the African (d. 1087), who, although guided by interests of practical medicine, considered medicine a science connected with philosophy, as we read in the introductions he wrote to these works. The ancient qualification of "second philosophy" or "philosophy of the bodies" corresponded closely to its epistemological statute. Using the title Pantegni (The Whole Art), and writing under his own name, Constantine published the work of Haly Abbas, The Complete Book of the Medical Art. To the European doctors, this highly systematic work seemed the best text at the time for study and consultation.
About halfway through the 12th century the work of Constantine was substituted by the Canon of Avicenna, that appeared in Toledo in the Latin translation of Gherardo of Cremona. The two manuals, both divided into a theoretical and a practical section, had in common Galenic medical knowledge, Aristotelian philosophical inspiration, and the synthesis of the anatomical-physiological knowledge of the Alexandrian museum and of the Hippocratic clinic. With these scientific instances the field reached the necessary conditions for the admission of medicine within the rising universities, unlike other arts, such as architecture, economy or alchemy, which had precluded such admission at the time. The teaching of medicine in the Medieval universities coincides with its affirmation as a scientific discipline, one that irreversibly imposes itself onto society and the world, having its specific epistemological and intellectual statute (cf. D. Jacquart, Medical Scholasticism, in Grmek, 1998).
The 11th century signalled the moment of greatest splendour for the School of Salerno. The major part of its medical production belongs to this century: treatises about general therapy or about more specific arguments (fevers, urines, pulses, diets), the Treatise on Surgery by Ruggiero, and other treatises of anatomy. The progress of medical knowledge that transpires from these works is based upon the direct observation of the ill person and on the assimilation of the works translated by Constantine and other of his disciples. The greater part of this medical literature was written having didactic purposes; some of them contain clear references to the teaching of that time, that was becoming more and more methodical.
It should be noted that already at the beginning of the 12th century the writings of the School of Salerno passed from being mere compendiums and collections of casual notations to the form of Commentaries: this indicates the definitive passage from the practical teaching to a theoretical one. It is the first sign that this School suffered the influence of Scholasticism, or even, that it contributed in some way to the rise of the latter (cf. Kristeller, 1945). Used as textbooks in Salerno as elsewhere, the Commentaries, were the first known texts of this kind. They were based upon the same group of medical texts, Greek and Arab, that appeared around 1270 representing the core of the medical curriculum of studies in Paris, Naples, and Salerno. They were printed systematically during the 15th and 16th centuries under the title of Articella (The Little Art). Another method of teaching applied in Salerno was the Quaestio. In a manner similar to the theologians and the jurists, the doctors of Salerno turned to this procedure both to resolve controversial arguments, when the reading of a text raised difficulties of interpretation, and to formulate questions that were not linked to any specific text. The Quaestiones Salernitanae served to nourish discussions a great deal, which were in fact true scientific debates. The School of Salerno reached the climax of its scientific activity well before the time when Medieval academic institutions developed their definitive form, during the rebirth of the studies which happened in the second half of the 13th century. It was at that time when the three great universities of Bologna, Montpellier and Paris held a monopoly on almost all the medical formation in Europe (cf. D. Jacquart, Medical Scholasticism, in Grmek, 1998).
In the School of Salerono a subdivision was maintained between theory and practice, but both of them were considered scientific disciplines founded upon reflection and reasoning. The theory is the science of causes built upon an Aristotelian frame, whereas the practice is the science of signs; there cannot be practice without theory. Here came the proposal of the model of the practical and erudite doctor, who founded his therapeutic interventions upon the research of the causes. It was not simple, however, to insert the peculiarity of practical ability into this epistemological statute. In the Medieval universities a keen dilemma was raised: is medicine a science or an art? At the basis of such question, we once again find the different roles of reason (Gr. lógos and of experience (Gr. empeiría), that Galen described as the "two legs" of medicine, and that ultimately express the relationship between medicine and philosophy. However, in the 14th and 15th centuries medicine was heavily oriented towards practical activity. In 1335 the School of medicine in Paris imposed the obligation of an apprenticeship for its graduates, establishing some guide-lines. The training was simply about the verification of the principles of physiology and pathology, not yet collectively accepted, and not about their discussion or replacement by new principles. Danielle Jacquart has explained how the expression ingenium sanitatis, derived from the title De ingenio sanitatis that Gherardo of Cremona gave to the translation from the Arab of On the therapeutic Method of Galen, discussing the process through which the doctor passed from the reflection upon the general principles to their application in a particular situation. The Medieval therapeutic procedure was no longer limited to the prescription of a specific medical drug according to a defined type of illness, but also took into account the personality of the patient, his or her age and environment. The scientia ingeniorum reflected both the scientific character of medical practice and the capacity to resort to skilful and inventive solutions, depending on the diversity of the particular cases.
III. The Birth of Hospitals within Christian Culture
The impact of Christianity on the care and assistance of the sick is so obvious that it could be mistakenly interpreted within an exclusively religious perspective. Undoubtedly, the inspiration and the foundation of such work of assistance, materialized in the inventions of hospitals, is of evangelical origin. It is based on the example of the person of Jesus Christ, who, besides giving precise indications about looking after sick people (cf. Mt 25:31-34), was a "doctor" who healed the sickness of the body and assumed upon himself, through the Incarnation and his passion, the liability of the flesh (cf. Gv 1:14) and the weight of all human suffering. The healings operated by Jesus do not represent an alternative to medicine. It has been underlined that, in the Gospels, all traces of magic, but also true medical techniques, are absent (cf. Kee, 1986).
The corporal works of mercy, the compassion of Christ towards the sick and human infirmity, can only be fully understood within the new order of supernatural charity that constitutes an evident detachment from pagan philanthropy. Confirming the absolute supremacy of charity within Christian life —that put the human being close to God through affection up to becoming similar to Him—, Thomas Aquinas (1224-1274) analyzes the value of mercy, that renders those who live it similar to God (cf. Summa Theologiae, II-II, q. 30 a. 4 ad 3um). Union with God by means of charity must be translated into corporal works of mercy. The expressions or particular ways to intend these obligations throughout the centuries must neither deceive nor provoke perplexities. It is evident that the premises and the context of acting in a Christian way are supernatural, as the basic motivations for such acting is one's eternal salvation. However, this does not diminish the secular value of these Christian works, and hence the attention paid to each truly human need, which is characteristic of the sanitary acts of mercy. As long as the order of supernatural charity is followed, it gives rise to real acts of material assistance in favor of those who suffer in their bodies, according to the degree of medical knowledge reached at any given time. The attention to the spiritual life and to the eternal salvation of the sick, the nature of the illness itself, and its eventual moral connections, do not change the forms and times of assistance. In the medical practice of Christians, the health of the body and the health of the soul, although they are inseparable in each person, are to be held in a quite distinct way. The human condition of infirmity and frailty, that Christian Revelation attributed to original sin, and the natural causes of any single illness, needing to be analyzed and cured, must also be considered separately. Jesus reduced quite clearly the pathogenic import of sin. When answering to the question of whether illness should be attributed to the sin of the man born blind or to that of his parents, he declared that it did not depend upon sin (cf. Jn 9:1-41). He did not miss the opportunity to add that sickness is never devoid of religious significance because it allows God to manifest Himself through His works (cf. Jn 11:11-15).
This profoundly religious and innovative force has caused individual responses to spring up, which far from remaining alone have assumed a social and institutional dimension. The Council of Nicea (325) established that in every Christian city there should be a place for the reception and assistance of pilgrims, the poor and the sick. As we can see, the area of infirmitas often remains undifferentiated, in a way that the sick, as such, were not necessarily the object of a specific attention. The assistance was limited to the exercise of the virtue of charity through a pedagogy of suffering, useful for the healthy and the sick but medically insufficient; this has brought some historians to formulate partial or dubious interpretations of this chapter of medicine. Corporal works of mercy, due to the fact that they are works and corporal, are destined in the first place to promote the healing and well-being of the sick, within the limits of the historical context and of the achieved level of scientific knowledge. The spiritual dimension of these works operates at a higher level, something that sustains and reinforces both doctor and patient in their reciprocal relations facing the sickness.
The monastic rules, whether Eastern or Western, are very attentive to hospitality and the cure of the sick, first of all that of the monks themselves. It is in this way that the first monastic hospices were born. The monks regulated their austere discipline in order to prevent debilitating and haughty mortifications. Thus the monastic infirmary was created, with a room reserved for the doctor to receive infirm monks requiring specific cures. The conditions then rose to allow a therapeutic activity to develop, one that would constitute a unique and organized form of medical practice for a long period of time, at least until the 11th century (cf. J. Agrimi and C. Crisciani, Charity and Aid in Medieval Christian Civilization, in Grmek 1998). The monastic experience exercised an undeniable influence on the new hospital institutions that the rebirth of the 12th century would help to proliferate everywhere. It was mainly the monasteries that would ensure the conservation and transmission of ancient medical literature and of pharmacological knowledge. The superposition of the two roles, the one who heals the body and the one who looks after the soul, in the one and same person of the cleric or the monk, and the task of Church hierarchy in managing and governing the hospitals, both tended to disappear in the 12th century. Doctors acquired a scientific and professional character, obtaining corresponding university degrees at the various existing Schools of medicine, which authorized them to practise their profession and perceive rewards as a prize owed them for their preparation.
The religious and cultural rebirth of many urban areas moved Christianity towards what has been called "the urgency for charity." A new image of the city hospital arose. The tendency to use more modern medical methods is in line with the more qualified forms of medical practice and the secular approach of the administrative management, often taken care of by the municipal authorities, so reducing the subsidiary work that the Church had operated for centuries. The urban hospitals assumed a social function that was ever more relevant and provided themselves with permanent structures. In these new hospitals it was easier to recognize the differences between illness and simple invalidity, between time of illness and that of convalescence, as well as the difference between curable and incurable sickness.
A negative note of this history of the assistance of the infirm, certainly connected to the epistemological statute of Medieval medical knowledge and to the historical development of the universities, was the absence of stable relationships between the university schools of medicine and the hospital institutions. In 1300 Peter of Abano recommended to the future doctors in Padua, according to the model of the Arabian medical schools, to assiduously visit hospitals to study also the rarer cases of illness. It is almost at this same time when the obligation of apprenticeship began for the graduates of the Paris school of medicine. There are also several Italian witnesses, both before and at the same time of the Paris' mandate, that underlined the necessity to attend to the lecta infirmorum in order to become doctus et espertus (cf. J. Agrimi and C. Crisciani, Charity and Aid in Medieval Christian Civilization, in Grmek 1998).
In conclusion, the institution of the Medieval hospitals reveals that these places would be an important pillar for medicine, as a science aimed at assisting the sick, but also a scientific knowledge that enriches itself at the bedside of those who are sick.
IV. The Beginning of Scientific Medicine
In the same year, 1543, in which De Revolutionibus orbium caelestium was published by Copernicus, Andreas Vesalius (1514-1564) also operated a sort of revolution within the medical sphere. He published De humani corporis fabrica so giving origin to a new era that interrupted the long and widely accepted hegemony of the Hippocratic-Galenic model. The Vesalian revolution brought to completion the preceding anatomical research in Italy, made possible by the didactic dissections and the judicial autopsies, that up until the initial decades of the 16th century had remained confined to university territory. The dissections enabled the study of the relationships between the clinical manifestations of those who were ill during life and the morphological changes of the internal structures observed in a post mortem analysis. The autopsies also led to the identification of the pathological states unknown up until that time. The Galenic-Medieval anatomical models appeared straightaway to be incomplete and full of errors.
M.D. Grmek and R. Bernabeo have stated that "contrary to a widespread opinion, the Catholic Church has not obstructed but rather favored the development of the anatomical research" (Bernabeo, 1996, p. 5). The interest for the natural phenomena that characterizes the Modern Age links up with the trust in the cognitive capacities of the human being and in the intelligibility of reality, as underlined by Christian philosophy. Novelties are now introduced in the method, in the questions being asked, in the innovative ways to obtain answers, and in the instruments used to ascertain the truth.
The rationalist and scientist drifts of the new scientific method also began to show up for medicine. This became a strictly naturalistic-positivist science, while life became progressively "devitalized" and reduced to a physical-chemical structure. Descartes (1596-1650) would begin to study the human body with mechanistic criteria (res extensa) separating it clearly from the soul ( res cogitans ), while the latter, abandoned to itself, drifts away almost in a complete manner from the horizon of the doctor, who has become a materialist scientist, and therefore a monist. Mechanism extends from nature to the spirit, from the animal machine of Descartes to the homme machine of La Mettrie , one who is made of pieces all of the same value which can be decomposed and put together again according to strictly utilitarian criteria (cf. Morra, 1988).
The scientific revolution operated by Copernicus, Galileo and Newton does not only modify the image of the universe, but also that of the human body. The episteme that had guided up until that moment the constitution of the medical knowledge, as an art and as a science, and supported the exercise of the medical profession, becomes profoundly renovated. A scientific medicine arises, having as its most characteristic aspect the introduction of the experimental method. According to Grmek (1998) in the history of the biomedical sciences born from the scientific revolution of the 17th century, three epistemological turning points can be distinguished. They indicate a clear line of distinction with respect to the medical and biological schools of thought of the preceding eras.
The first one, brought to maturation during the 18th century, caused a rupture of the Galenic-Aristotelian-Hippocratic paradigm, which had dominated for almost fifteen centuries. In addition to the scientific innovations of Vesalius, the great discovery of this first revolution is that of W. Harvey (1578-1657), who describes the blood circulation and the propellant impulse of the cardiac pump. Along to its scientific value, Harvey's discovery constituted one of the experimental basis of the philosophical mechanistic view postulated by Descartes. The synthesis between the new anatomical knowledge and the more refined clinical and symptomatological observations obtained at the bedside of the sick patients was operated by Giovanni Battista Morgagni (1682-1771), with his most important work De sedibus et causis morborum per anatomen indagatis. This first turning point of scientific medicine was enriched with the physiopathology of the tissues operated by the French doctor Xavier Bichat. The words through which Bichat summarizes his scientific approach clearly explain the point reached by medicine at that time: "to section in anatomy, to experiment in physiology, to follow the course of the illness and to operate an autopsy in medicine; this is the triple way, apart from which there can neither be an anatomist, nor a physiologist, nor a doctor" (quoted by Risse, 1996, p. 325).
The second turning point occurred in the 19th century and was characterised by new discoveries, such as cellular pathology by R. Virchow in 1858, who identified illness as the result of alterations within the cells. These are now recognized as the elementary biological structure and the site where molecular exchanges occur within the organism, now understood as the result of the association of structurally and functionally diversified cells. The development of the cellular theory are linked to the progresses of embryology and of genetics, whose implications are still important nowadays. The progress of experimental physiology, particularly that of the German school, constitutes the basis of Claude Bernard's (1813-1878) experimental medicine. The main principles of his reasoning as a physiologist and as a clinician are scientific determinism and the concept of milieu intérieure. In spite of the apparent spontaneity of the living organisms, Bernard extends the determinism characteristic of the inorganic world also to the organic world. He maintains that so much in the living organisms, as in the non-living bodies, we must admit as an axiom for our experimental work that the conditions of existence of each phenomenon are determined in an absolute manner. The denial of this proposition would be equal to denial of the science itself. The life of the elements within the internal environment of the human body is, according to Bernard, essential to modern scientific medicine. The defect of a sick organism does not necessarily lie in one of its parts, but it could regard the capability of harmonious integration among the parts, and of the adaptation of the living body to the changes of the external environment. These were intuitions that would have a profound impact on the subsequent development of studies, especially in the fields of endocrinology and immunology.
After having observed the patients in the most complete possible way, the experimental doctor must analyze all the symptoms and attempt to reconduct them to explanations and processes that should comprehend the relationship between the pathological state and the normal or physiological state. Bernard's experimental medicine adds to the "clinical qualification" of the illness at the bedside of the sick person, also the "technical-instrumental qualification" of the physiopathological phenomena in the laboratory. This type of quantification was to grow and later acquire an important role in the field of diagnostics and of therapy, on the individual as well as on the social scale (biostatistics, epidemiology, social medicine).
The third turning point of modern revolution medicine is one that must be still considered in progress. The old concept of organic predisposition was newly formulated by P. Ehrlich (1854-1915) and J. Mechnikov (1845-1916) as an immune reaction, a principle that is to be found at the basis of the science of immunology. The pharmacology and the chemistry of synthesis represent the origin of the chemiotherapeutic revolution. However, it was above all through the discoveries of molecular biology that medicine would change once again its scientific structure. Thanks to the work of L. Pauling, in 1949 molecular alterations were discovered as being the causes of the hereditary "molecular diseases." In 1953 Watson and Crick explained the model of the "double helix" of DNA, which is the chromosomic material vector of the genetic information. The field of genetic engineering arose, and the corresponding possibility to obtain new pharmacological compounds and to practise genetic therapies. The unexpected AIDS epidemic and the appearance of the spongiform encephalopathy ("mad cow" disease) require virological approaches that, though renovated, again propose ideas and paradigms that were considered out-of-date.
As pointed out by Grmek, the successes of scientific reductionism and of specialist medicine have not fully substituted the globalizing approaches and interpretations of the vital phenomena. In the field of medicine we should recognize the success of the word "holism", coined by the South African statesman J.Ch. Smuts and made popular by the biologist Haldane. According to the holistic principle, an integrated whole is not just the sum of its parts. As a consequence, if the organism is not the sum of its parts, then it must follow that neither the illness is the sum of the local pathological states and processes. In relation to the most complete meaning of this word, illness should thus regard the organism as a whole. These holistic visions of medicine are often limited to underline the perturbations of the processes of biological integration (nervous, chemical, etc.) of the organism, without taking into account a spiritual principle of integration and of unity of the human being. Holism can therefore regard both a materialistic-monist vision of the human being and a unitary personalist vision (Aristotelian, Kantian, Tomist).
The psychical-spiritual factors, absent in most of the medical-naturalistic models of illness, are taken more and more into consideration by some medical schools that acknowledge ideas of psychological-dynamic and analytical features, from Freud to Jung, from Adler to Frankl. Psychosomatic medicine elaborated by Victor von Weizsäcker (1990) exalted the role of the constitution of personality and of biography, attracting attention to the fact that, in the Hippocratic triangle (disease-patient-doctor), the doctor takes part in the determination of the way of expression of the illness. There is a certain analogy with the principles of quantum mechanics, according to which it is not possible to separate the observer's role from the observed reality. The scientific determinism of Bernard's experimental medicine is brought into question. The doctor is no longer a cold and extraneous observer of a deterministic regularity.
Although psychosomatic medicine is actually linked, as other medical specializations, to a defined group of illnesses, it offers an anthropologic vision that goes beyond the naturalistic and mechanistic models because it takes into consideration the patient as a whole, with his or her psychical structure, environment and social position. That has paved the way to a new anthropologic medicine, no longer tied to the concept of "psychosomatic symptom," that somehow maintained the inappropriate dualism between body and mind and, hence, between diseases of the body and mental diseases, as they were rigidly classified by the mechanistic medicine of the 17-20th centuries. It is too early to state whether or not a change of paradigm has taken place regarding the concept of illness, due to the biomedical revolution of the 20th century. However, it is clear that a unitary vision of the human being now prevails, substituting the mechanistic vision.
The encounter of medicine with the experimental sciences opens numerous and important problems due to the impossibility to wholly compare medicine with them. The object of medicine is neither a passive nor neutral subject; it is not simply an hypercomplex physical-chemical object: the nature of the human being is intrinsically ethical. The new medicine of the millennium that has just started is still searching for a paradigm that we could call "clinical neo-humanism," "where health and illness, birth and death, ageing and survival, require that the doctor should have resources no longer only scientific and technical, but also anthropologic and human" (Cosmacini and Rugarli, 2000, p. 21); and let us add, above all ethical.
V. Is Medicine a Science of Nature or a Human Science?
In his posthumous work Crisis of European Sciences and Transcendental Phenomenology (1954), Edmund Husserl (1859-1938) emphasized how scientistic objectivism and pragmatic technicism are consequences of the loss of the philosophical foundations of science. The natural sciences, no longer anchored to any reference to philosophy of nature, have become victims of positivism. They are no longer natural but "naturalistic," and each reality they study becomes entirely reduced to a mere object. The pure sciences of facts have nothing to say regarding the question of sense or non-sense of human existence. Medicine has also suffered from the repercussions of this crisis of the natural sciences, mostly when scientific, reductive categories, come to substitute the Husserlian "world of life", the world of feelings, of needs, of finalities and of intuitions. Medicine is not a science endowed with an epistemological statute comparable to that of the natural and experimental sciences. It is the most humanistic of the natural sciences and the most "exact" of the human sciences. Although it uses the knowledge of many branches of science, such as physics, chemistry, biology, genetics, anatomy, physiology, and from these it adopts a methodological rigour; at the same time medicine differs from these because its object is not totally measurable nor entirely subject to experiments. Nor can we automatically apply to it the forms of knowledge usually considered as "neutral" or "exact." No science is today considered as neutral, and this is even more true for medicine, that develops into an anthropological reality which is intrinsically ethical and refractory to any form of reductionism. Medicine is interested in the human being as an individual and personal subject, in the constitutive dimension of his or her being, in a real or possible way, characteristic of an ill man or woman.
There is no doubt that the progress made in the field of the biomedical sciences, from which medicine has certainly benefited greatly, is due to the use of the analytical, reductive, experimental method. However, we must acknowledge that the human being to whom this knowledge must be applied, represents a unity: all within him or her, the material and spiritual reality, the biological aspects and psychical functions, is relevant and consistent (cf. Polo, 1991). The reductionist approaches of analytical type limit themselves to the observation of fragments, pieces of humanity, and are not able to interpret the unrepeteable interiority of each human being. These approaches lead to an unavoidable division between the dynamism of the ill subject and the passive-naturalistic dimension of the object of study, that is the illness as such (cf. Peláez, 1997, p. 56). The ill subject, devoid of his or her individual notes, becomes objectivated into a clinical entity which is more like a numerical table rather than a personal history.
Post-Galilean scientific medicine has been strongly influenced by the materialist mechanism and by the positivist organicism, derived from an anthropology that was firstly dualist and then monist. This was the cause not only of the division between the object-illness and the ill-subject, but also of a more radical and insidious division the human being suffers when he or she is deprived from his or her own illness, once that everything that resists to a strictly quantitative approach is considered as irrelevant. In reality, medical knowledge is truly scientific only when it takes into account that the ways to understand the sick body (soma and psyche) must necessarily coincide with an approach to the human person understood in his or her totality and unity. The human being, unlike the animal, which can represent an important object of experimentation and thus a source of biomedical knowledge, is a natural and cultural subject, who is historically placed in a relational context of customs, values and rules, that medicine cannot simply ignore. Medicine today is "interpreted in a twofold manner as a humanistic undertaking: as an interhuman relationship that is full of 'lived' episodes having existential meaning, and thus also demanding on a personal level; and as scientific-practical knowledge oriented essentially to the well-being of the one who suffers in his complex totality, thus respectful of his moral values and of the meaning of his individual history" (Cattorini and Mordacci, 1993, p. 8).
The doctor's decisions, although based on the results obtained by the more recent biomedical investigations and by the more advanced diagnostic and therapeutic technologies, are assumed within an area of "persistent inaccuracy" (cf. Cattorini, 1986, p. 136), that includes the unavoidable heuristic evaluations subjectively matured through the relationship with individual patients. All of this means that the action of a doctor is not simply interchangeable with the action of another doctor. The doctor is not just a passive carrier of a neutral knowledge, and neither is the patient a simple prefixed sick entity. Cultural-humanistic and scientific factors are mixed together with the existential factors proper to the sick person, who subjectively perceives his or her pathological situation and then helps the doctor to modify the medical intervention according to the indications received by the patient. Regarding all that we have said, the difficulties faced nowadays by medical science when formulating a plausible concept of illness are quite understandable. Neither can we consider illness as a defined alternative to the status of health, but rather as an aspect of a continuum that connects the two states to each other, emphasizing the importance of the predictive, preventive and rehabilitative moments (cf. Coltorti, 1998, pp. 162-175). Diseases are not natural, morbid entities, but rather scientific abstractions that describe classes of patients and form groups according to criteria that continuously change when new knowledge is acquired (cf. Cosmacini and Rugarli, 2000, p. 144). The description of each disease reported by medicine books always differs from the clinical picture observed in reality. Each sick person is unrepeatable, even when within his or her illness there are elements present that are in common with other sick persons. Character, family, professional and environmental conditions — not just the patient's genome —are at the origin of the very different manifestations of the same illness.
The history of medicine indicates many ways through which the human sciences nourish medical knowledge. Contemporary attempts are the first didactic realizations of the Medical Humanities (cf. Peláez, 1999, pp. 6-63), enabling the future doctor to comprehend the complexity of the human condition. It is not just about giving humanistic cultural information to the medical specialist, but rather considering the studia humanitatis, mostly in their ethical-anthropological dimensions, as an essential contribution so as to establish a correct relationship with the patient and to take an adequate medical decision. After a diminishing trust towards technological progress, that needs to be controlled and guided, we must turn now to the ethical-anthropological sciences and to bioethics in order to identify the fundaments of the decisions to be taken. A number of elements need to be re-evaluated: among them, the concept of person, the inseparability between the illness and the person who is sick, ways overcoming anonymity in diagnosis and therapy.
VI. Medicine as a Science, an Art and an Ethical Activity
1. The Characteristic of Medicine and of the Medical Profession. Medicine is a practical science whose original concept has been partly lost in the context of modern scientific thinking. The limits of a science that approaches its object in an impersonal way, as an object of measurement only, so tending to lose that "world of life" mentioned by Husserl, are more and more evident today. The doctor must unify highly specialized competence with being part of the world of life (cf. Gadamer, 1993). The practical capacity of the doctor includes components, such as flexibility and attention, that do not strictly belong to science, but rather to one's own experience of life.
A greater separation between the pure and the applied sciences, is today more evident because of the influx of social and institutional factors in each practical moment of scientific knowledge, making the situation of medicine even more uncertain. If on the one hand the weaving of medicine with the new forms of social organization of sanitary assistance, and thus with the juridical dispositions, is greater, on the other hand the development of the biomedical sciences in close connection with scientific research makes the reality of a pure scientific medicine quite explicit. Along with the professional doctor, the figure of the doctor-scientist emerges, one dealing very specific problems and decisional logic. None of them can operate without the help of the other.
In spite of the increasing role of biomedical knowledge and of technological instrumentation, and consequently the multiplying of doctors dedicated to scientific-technological research often lacking any direct contact with the sick, we are not authorized to oppose scientific medicine to the medical art. Their distinction does not mean their antagonistic separation. As a matter of fact, biomedical knowledge cannot be considered medicine until it is used in a particular clinical context, to promote health and well-being in favor of an individual human life. It is the human being, through appropriate diagnosis and therapies, who is the site of the creative application of scientific medicine.
The essential core of medicine is the clinic, structured upon the doctor-patient relationship and aimed at the greatest well-being of the latter. Illness for the doctor represents the principle of an action that assumes theoretical-specialist biomedical cognitions, technical ability and a careful study of the actual case within an ethical perspective. Medical act reaches its objective, the best well-being of the sick person, when it results from a technical-scientific reasoning ethically operated, which in the end arrives at a diagnosis and a therapy, usually followed by a prognosis; this is of particular importance for the sick person, who has the right to know the expected course of his or her illness. A purely technical approach towards the problems of the patient is considered unbearable: there are no separate moments within the medical decision, one which is technical-scientific, totally anonymous, and another one which is personalized and ethical. The therapeutic perspective is placed within the logic of welcoming the other as a person. When they endorse this perspective, the doctors do not add something to their profession; they live the totally human (ethical) meaning of medicine, trying to avoid alienating themselves through the abstract practice of their professional competence. Welcoming the patient is an expression of an "ethics of compassion," which is at the basis of any medical practice (cf. Botturi, 1993, p. 110).
Medicine has been defined by Pellegrino and Thomasma as a "scientific site wherein science, art and praxis are particularly discernible characteristics." Medicine is téchne, art, the application of science through a clinical and surgical capacity linked to a praxis understood in an Aristotelian way, that is not simply a technical "making," but rather a moral "acting" aimed at the well-being of the patient. The professional competence of the doctor is based upon three pillars: the scientific-natural knowledge, the technical ability, and the knowing of persons through a quality that Karl Jaspers (1883-1969) defined, with a clever though ambiguous expression, éthos humanitario (passion for what is human), and that we can now define more exactly as "anthropological ethics founded upon the notion of person" (cf. Sgreccia, 1999, pp. 60f).
Neither a simple application of a scientific law or of a technological method, the doctor's action must emerge, like every other moral action, as the result of an "artistic" composition that must assure its aim: to preserve or acquire again the health of an individual person. The scientific laws and technology ensure method and efficacy to the medical act. The personal dimension of the action of the medical operator guarantees the ethical dimension of such an act, as it is evident from the associated responsibility and from the target: the well-being of the sick. As the concept of illness does not exhaust itself within the terms of a naturalistic vision, so health cannot be defined resorting to quantitative criteria only, since it comprehends the fulfillment of the person up to the point of approaching the original concept of integral health or of salvation. Not so much in the sense that medicine must provide salvation as such, but rather in the sense that the health which is contributed by the medical act, takes part objectively in the totality of the person (cf. Botturi, 1993, p. 108). Biological health belongs to the total health-salvation of the person, whose universal desire joins the sick to the healthy person and to the doctor.
2. The Doctor-Patient Relationship. Nowadays medicine highlights old and new problems that require particular ethical commitment. A central problem of medical practice is the doctor-patient relationship, that today acquires totally new characteristics, due to scientific and technological progress, the actual forms of exercising the medical profession, and the complexity of the institutional contexts wherein health and sanitary assistance are today safeguarded. In this particular situation, the necessity to reconsider the relational questions also in the medical field strongly emerges. The lack of clear communication, attentive to the social and individual needs, has prompted some to say that today medicine is "mute" (cf. Valdrè, 1995). Between doctor and patient, between medicine and society, there are a series of technological, scientific, and bureaucratic barriers, that have impoverished their relationships, from both an ethical and an anthropological point of view. The doctor looks at the patient as a sum of finely measured and quantified organs and functions; the patient looks at the doctor as a "sorting center" pointing to various specialized experts. Medicine that neglects the ethical implications of the doctor-patient relationship soon becomes disappointing, expensive, and ineffective.
The fact that today diseases are better understood and that we have an increasing availability of pharmacological, clinical, and surgical means, must be necessarily matched to a careful evaluation of the way in which all of this is perceived by the sick person. The doctor's work cannot at any time ignore either the site where the sick person is receiving treatment, or the cure of the ill person: the medical inspection, anamnesis, diagnosis, prognosis, therapy and its course through time. Also in contemporary medicine, then, the doctor-patient relationship preserves all of its centrality. It is true, of course, that it presents new modalities due to the characteristics of the assistance to the sick person and for the many specializations that empower scientific medicine. This relationship must not be intended (with the exception of special cases), as one between two physical persons, but rather as a relationship that a team of sanitary operators, responsible for a particular set of cures, has with a sick person, placed within a vital environment made up of individual subjectivities as well as of familiar, social and institutional relationships (cf. Cattorini e Mordacci, 1993, pp. 13f ).
The doctor-patient relationship still preserves all of its ethical-deontological structure characteristic of a "therapeutic alliance" whose guiding principles are still goodness, liberty and justice (cf. Sgreccia, 1999, pp. 20f). By alliance we mean a common effort that emerges from acknowledging that doctor and patient belong to the same humanity (co-humanity), and thus to an ethical community. The encounter of a doctor with a sick person is part of a radical inclination to be welcoming towards the other, a tendency that is constitutive of the human being as a person. Without a personal, reciprocal acknowledgement, doctor and patient are destined to exhaust themselves in merely performing a certain role (cf. Mordacci, 1993, p. 231).
The well-being of the patient (goodness) that the doctor must pursue is the biomedical one (health, life); it includes various other elements having a bearing upon the social-cultural and religious spheres. Pellegrino and Thomasma (1992) distinguish the biomedical good, the good intended as such by the individual patient, the good of the patient as a human person, and finally the supreme good (salvation), indicating the procedures to compose the conflicts that could arise among these different kinds of good. In fact, what sometimes is considered by the patient as his or her own good does not compel the doctor to favor him or her. Not all aspects of the doctor's decision are negotiable. The good intended as dedication of the doctor for the best interest of the patient must not destroy the first aim of such dedication, the binding value of the therapeutic alliance: the healing cure of the sick person. As the patient and the doctor cooperate together in the cure, it would be unreasonable to ask the doctor for professional services, such as euthanasia, that go against his or her professional ethics and deontology.
The free self-determination of the patient does not always coincide with what is called the principle of autonomy, once this is understood individualistically and without any link with the anthropological truth. There are different levels of liberty. One of them is that of connecting one's own liberty (which in the sick person is always limited and thus needs help), with the liberty of providing treatment, belonging to the doctor. For the patient to make a free choice two conditions are needed: a) to have enough information; b) to be able to make this type of free choice. The doctor must provide all the essential information so that the sick person may take decisions in full conscience and liberty (in the case of physical or psychical incapacity, the family or some legal representatives). In the therapeutic context as well as in the experimental research field, all of this information today is juridically safeguarded and formalized in what is called "informed consent." Since the doctor must join together the scientific information regarding diagnosis and therapy, and the human, ethical and anthropological, purposes of his or her professional activity, the consent must not be understood as a "compromise" between the doctor and the patient negotiating the way of curing some specific illness. It is not about negotiating over anything, but rather to consciously agree to the cures proposed for the patient's good globally intended. The health and the biomedical good, because of their inner connection with the whole good of the person, are only exceptionally negotiable. The free self-determination, unlike the libertarian autonomy, is first ethically founded, and then protected juridically.
In conclusion, the doctor-patient relationship is ethically and juridically only properly established when it becomes a virtuous practice, capable of overcoming any conflict of interests, whether they are individual, corporate or social. The only guarantee that the well-being of the patient will be respected is given by the public and private virtues of the doctor. Virtue enables ethics to escape the shallows of legalism and introduces it to the more ample sphere of morality (cf. Peláez, 1989). Although acknowledging that it «is better to be good rather than bad», some authors state that: «a doctor that knows his work can easily hold a very useful relationship with his patients, independently from his moral qualities» (Cosmacini and Rugarli, 2000, p. 70). On the contrary, Pellegrino and Thomasma (1996) consider the doctor's virtue a very important element, obviously including that of possessing a qualified scientific knowledge. The patient's trust in the doctor's person can be inspired only by his or her virtuous behavior: without trust, no good can be done. Within a complex sanitary system which allows personal responsibilities to be uncertain, patient's trust is called to rely on unknown persons. The only barrier to the tendency to exploit the vulnerability of the patient is represented by the moral virtues of the persons to whom the patient is entrusted. Gracia Guillen (1993), following here Lain Entralgo (1969), proposes Aristotelian friendship as a virtue par excellence: the virtuous doctor must always be a friendly doctor.
VII. Some Teachings of the Magisterium of the Catholic Church on Medicine
Religion, here intended in the larger sense, cannot be ignored as a source of medical theory and practice, not even in a pluralistic society like ours: disregarding religion would mean to neglect the most universal ethical source that guides human behavior. Pellegrino and Thomasma have emphasized the limits of the various contemporary bioethical schools, proposing a recovery of the "religious roots" of medical ethics. Religion deals with the very meaning of disease and recovery, and thus it influences the aims of medicine, the treatment of sick people, and the corresponding ethical choices. Christian anthropology of medicine offers, as we have already seen, a precise vision of nature and human life, of the eternal destiny of humankind, of the value of suffering and of the meaning of health. Within the contemporary medical-sanitary situation, the rediscovery of the religious dimension of medicine becomes an important factor of development for an adequate assistance, above all for the most vulnerable and weakest sick persons, so as to avoid that medicine be governed by the rules of the market. This is particularly urgent since medicine suffers today the fragmentation of specialist knowledge, the bureaucratisation of most of the welfare sphere, and the thrifty reduction of expenses.
1. The Concern for Human Life and the Care for It. Care of the sick has been a part of the diffusion and the spiritual activities of the Church throughout history. This service of mercy has been carried out thanks to the many Christian institutions founded with an aim to bring healing and provide assistance, although the circumstances through which this service has taken place have changed over time. Concerning the contemporary magisterium of the Catholic Church, many teachings of Pope John Paul II have urged Christians to deeply reconsider the hospital organization so that it would reflect the evangelical values proposed by the social and moral doctrine of the Church. Christian medical Institutions have been asked to avoid being ruled by the logic of many modern sanitary systems, which seem to be interested only in the economical-financial component and in carrying out scientific research.
Analogously to the diffusion of hospitals, the Church has also historically promoted all around the world the studies of medicine through centers of medical and paramedical formation as far as the university level. During the pontificate of Pope John Paul II two organizations of the Holy See were founded, through which the Catholic Church calls for the attention of both Catholic and non-Catholic people to the problems regarding health and sickness, within an anthropological and ethical vision of Christian inspiration: the Pontifical Academy for Life, founded on October, 22, 1996, and the Pontifical Council for Pastoral Assistance to Health Care Workers, founded on February, 11, 1985 (cf. motu proprio Dolentium hominum). This Pontifical Council, besides coordinating the Catholic Institutions engaged in the field of health assistance, periodically promotes international conferences. In October 1994 the Council published, and since then it periodically updates, the Charter for Health Care Workers. A kind of deontological code, this document is structured in three parts, defined as "generation," "living" and "dying," and gathers many teachings from the magisterium of Pius XII to John Paul II, particularly regarding the establishment and the defense, in the health field, of the value of human life.
A new scientific and cultural context raises questions and problems today which the Magisterium of the Church tries to answer by offering its guidance and its service. The progress of science in all that concerns the sphere of health has in fact extended the traditional boundaries of medicine, no longer aimed at satisfying elementary human needs, but rather more interested in satisfying the needs of individual well-being (cf. Cottier, 1994, pp. 271f). The growing mass of medical, surgical, and pharmaceutical consumptions does no longer correspond to the question of healing and avoiding death, but rather to the limitless desire of physical and psychical well-being. Church teaching is faced with a prevailing utopian concept of health, that goes beyond the simple absence of disease, and is strongly influenced by the hedonist culture dominating today's society. Such a concept is accompanied by the political obligation of assuring everyone the best conditions of life, almost to the point of satisfying all desire of well-being and happiness. These ideas gave rise to the definition of health given in 1948 by the World Health Organization (WHO), instituted by the UN, that in the first part of its Constitution states: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition." Lain Entralgo (1978) asks in a controversial manner if these words constitute not so much a definition but rather the formulation of a false expectation or the declaration of a utopia (cf. p. 118). The desires of well-being and happiness presented by this concept of health, can actually be placed at the borders of medicine. They seem rather to include horizons of responsibility which are mostly of an extramedical type (ecological, demographic, socio-economical) and run the risk of confusing the professional character of the doctor with that, less defined, of the social engineer. If we do not want to lose the professional profile, the moral credibility, and the dignity of the doctor, we cannot consider the latter as being responsible for all forms of human suffering and for any event threatening the well-being of humankind (cf. Jonas, 1985).
The most recent biomedical researches allow manipulations regarding the origin, the genetic determination, and the end of individual life. The various procedures of artificial insemination, the possibility of knowing certain genetic anomalies in the embryonic phase, so allowing to intervene directly on the genome of an individual human being, have metaphysical and ethical implications of great importance for the life of the individuals and of humanity as a whole. There are also many instruments to artificially maintain in life a human organism. Medicine is no longer therapeutic and preventive, but it is also predictive, and proceeds along with genetic and medical engineering, the latter engaged in the design of artificial organs, prosthesis and more and more sophisticated medical institutions.
2. Documents of Major Relevance. There are many documents of the Church's Magisterium that look at these problems in the light of both reason and faith. In a speech addressed to the participants of the international conference on Women's Health Issues, after recalling the definition of the WHO centered upon the idea of "complete well-being," Pope John Paul II affirmed: "Whenever well-being is conceived in an hedonistic sense without referring to moral, spiritual and religious values, we encounter "negative consequences for health itself" (OR, February 21, 1998, p. 5). Speaking to the World Medical Association on October, 29, 1983, he wanted to warn the doctor of the danger of subordinating the worries for the sick to the interests of the healthy people (cf. ORWE December 5, 1983, pp. 10-11). Other Church documents have reproached the way of distributing the public sanitary expenditure that provides medical economical resources to services not directly aimed at curing illness, such as direct sterilizations, not strictly therapeutical interventions of artificial procreation and of cosmetic surgery, abortions, with the consequent rationing of the resources destined to the elderly, to chronically handicapped persons, and to terminally ill patients. The Congregation for the Doctrine of Faith published on March, 13, 1975, the guide-lines to follow in the Hospitals run by Catholic Institutions as regards to the practice of sterilization (cf. Sterilization in Catholic Hospitals, EV 5, 1199-1202).
The magisterium of Pope John Paul II has encouraged contemporary medicine to evaluate its nature and its function, that must have as a main objective «not just the well-being and the health of the body, but also the person as such who, within the body, is affected by the illness» (Dolentium hominum, 2): the identity of medicine is the service to the suffering human being, "corpore et anima unus —made of body and soul, the human person is one" (Gaudium et spes, n. 14). The respect of personal dignity as an ethical criterion in every medical act must coincide with the promotion of human rights. In fact, the dignity of the person is that which provides the grounds to the rights that belong to the human being as a man or a woman: the right to live from the moment of conception until death, as a foundation of any other right, right of true information, right of psychical integrity, of medical privacy, of the freedom to be cured by choosing one's own doctor. Specific interventions aimed at safeguarding these rights that are part of the doctor-patient relationship can be found in the collection of documents of the magisterium of the Catholic Church edited by Angelini (1960), Tettamanzi (1988), Verspieren (1987), and in the previously mentioned Charter for Health Care Workers. Of particular relevance is the encyclical Evangelium vitae issued on March 25, 1995, that re-affirms the intrinsic value of every human life (cf. nn. 57-67). In a speech addressed to the participants of the International Conference of Catholic Physicians, held on July 7, 2000 on the theme "Medicine and Human Rights," John Paul II encouraged the use of the objection of conscience when facing laws favouring euthanasia or abortion (cf. ORWE July 19, 2000, p. 2). On the specific theme of transplants there are also many interventions of this same Pontiff, through which he clearly states the human and Christian value of the donation of organs, emphasizing that the modes of explantation must take place according to the respect for the liberty of the donor and never provoking danger or shortening in an artificial way his or her physical life (cf. Discourse to the XVIII International Congress of the Transplantation Society, Rome, August 29, 2000, OR August 30, 2000, pp. 4-5); this theme is also dealt with the encyclical Evangelium vitae (cf. n. 86).
A very special attention has always been given by the Church to the thorough analysis of the Christian meaning of suffering. A proof of this is, for instance, Pope John Paul II's apostolic letter Salvifici doloris (February 11, 1984) and his various messages delivered on the occasion of the yearly "Day of the sick." The situation of an incurable illness represents for the Christian faithful the opportunity to experience union with Christ, patient in the humiliation of the Cross. The use of analgesics is considered without any doubts by the Church's Magisterium as being permitted (cf. The Charter for Health Care Workers, n. 122), but in the case of ill patients it raises specific questions whenever it runs the risk of provoking in advance the death or the suppression of conscience (cf. ibidem, nn. 123-124; cf. Peláez, 1997, pp. 106-108).
The Congregation for the Doctrine of Faith issued in 1987 its Instruction on Respect for Human Life in its Origin and on the Dignity of Procreation (Donum vitae, February 22, 1987), this may be considered the most ample and organic document on bioethics. It mainly concerns respect for the human genetic make-up, for the human embryo and the fetus, while condemning unnecessary genetic and biological manipulations. This document provides specific answers to the main questions regarding the interventions upon the initial phases of life of the human being and on the processes of human procreation. The Instruction also offers some orientations on the relationships occurring between the moral law and the civil law regarding the legitimacy of the techniques of artificial procreation. The guiding principle of the Instruction is the establishment that science and technology must serve the human person, at the same time corporal and spiritual. The human body is a constitutive part of the person and cannot be considered just as a complex of tissues, organs and functions. Any intervention upon the human body involves the person itself. The need to respect the human being as a person from the first instant of his or her existence must provide the conditions for the lawfulness of prenatal diagnosis and of therapeutical and experimental interventions on the human embryo. The fundamental values connected with the techniques of artificial procreation are: a) the life of the human being called to existence and the originality of human life transmission through marriage; b) the reciprocal respect of the rights of the married couple to become either father or mother only the one through the other. For this reason the document condemns all practices of fecundation that entail the destruction of human embryos or which are not the result of the specific conjugal act of love of the married couple. After the announcement, in the first few months of 1997, of the cloning of Dolly the sheep, the Pontifical Academy for Life published on June, 24, 1997, the document Reflections on Human Cloning (cf. ORWE July 9, 1997, pp. 10-11). There the ethical problems connected to human cloning are discussed, once again stating the principles already present in the Instruction Donum vitae.
3. Concluding Observations. Medicine is not a closed science, confined within the limits of its specific competency. Faithful to its original epistemological statute, medicine must become once again the incarnation of a professional éthos, exemplary as regards to the relationship between knowledge and a practical-ethical objective: we must always turn to such an éthos when promoting confidence into the fecundity of the theoretical knowledge, for the edification of the human life (cf. Jaeger, 1986). The role of medicine within the culture of our time cannot be reduced to scientistic models, abandoning the idea of becoming an essential guide for the humanization of science and the promotion of human relationships founded upon trust. It is not just illness that limits the freedom of human beings, asking them to trust other human beings. The dissolution of the person through its "becoming a thing" within a kind of sanitary machine can represent the symbol of the dissolution of the individual being within the great mechanism of technological civilization. Gadamer (1993) considers the medical profession as emblematic, since its aim is not that of "producing," but rather that of helping the human being to once again acquire health, to lead him or her back into life. Medical science is probably the only one that does not produce anything substantially, but must resolutely face the prodigious capacity of life to restore itself.
Pius XII: Discourse to the participants at the VIII World Medical Assembly, September 30, 1954, Discorsi e Radiomessaggi XVI, pp. 167-179; Moral and right in medicine, September 11.1956, Discorsi e Radiomessaggi XVIII, pp. 423-435; Cooperation and work in équipe in medical activities, July 27, 1958, Discorsi e Radiomessaggi XX, pp. 271-278. John Paul II: “Catholic doctor requires a superior witness,” October 3, 1982, ORWE October 25, 1982, pp. 9-10; Address to the World Medical Association: The Dangers of Genetic Manipulation, October 29, 1983, ORWE December 5,1983, pp. 10-11; Salvifici doloris, February 11, 1984; Dolentium hominum, February 11, 1985, EV 9, 1410-1418. John Paul II, Evangelium vitae, 57-67, 88-89. Pontifical Council “Cor Unum,” Health Care and Promotion of Human Dignity, April 1, 1976, EV 5, 1929-1950; Pontifical Council “Cor Unum,” Some ethical questions concerning dying, June 27, 1981, EV 7, 1234-1281. CDF, Donum vitae, EV 10, 1150-1172 and 1232-1235.
History of Medicine: W. AMUNDSEN, “Medicine and Religion in Western Traditions,” The Encyclopedia of Religion, M. Eliade, ed. in chief, Macmillan Co. (New York: 1987), vol. 9, pp. 319-324; R. BERNABEO, “La macchina del corpo,” Storia del pensiero medico occidentale, edited by M.D. Grmek, vol. II: Dal Rinascimento all’inizio dell’Ottocento (Roma-Bari: Laterza, 1996), pp. 3-50; GALEN, On the Natural Faculties (Cambridge, MA: Harvard University Press, 1979); D. GRACIA GUILLEN, “La medicina nella storia della civiltà,” Dolentium Hominum 3 (1988), pp. 67-75; M.D. GRMEK, “La rivoluzione biomedica del XX secolo,” Storia del pensiero medico occidentale, edited by M.D. Grmek, vol. III: Dall’età romantica alla medicina moderna, “Roma-Bari: Laterza, 1998), pp. 492-520; M.D. GRMEK (ed.), Western Medical Thought from Antiquity to the Middle Ages (Cambridge: Harvard University Press, 1998); HIPPOCRATES, Works, eng. transl. by W.H.S Jones et al. (Cambridge, MA: Harvard University Press, 1948); W. JAEGER, Paideia. The Ideals of Greek Culture (New York – Oxford: Oxford University Press, 1986); J. JOUANNA, Hippocrates (Baltimore, MD: Johns Hopkins Univ. Press, 1999); H.C. KEE, Medicine, Miracle, and Magic in New Testament Times (Cambridge - New York: Cambridge University Press, 1986); P.O. KRISTELLER, “The school of Salerno. Its Development and its Contribution to the History of Learning,” Bulletin of the History of Medicine (Baltimore), 17 (1945), pp. 138-194; P. LAIN ENTRALGO, Historia de la Medicina (Barcelona: Salvat, 1978); G. MORRA, “Meccanicismo e natura umana,” Studi Cattolici 30 (1986), pp. 483-490; G.B. RISSE, La sintesi fra anatomia e clinica, in Storia del pensiero medico occidentale, edited by M.D. Grmek, vol. II: Dal Rinascimento all’inizio dell’Ottocento (Roma-Bari: Laterza, 1996), pp. 291-335.
Scientific, and ethical aspects: F. ANGELINI (ed.), Pio XII: Discorsi ai medici (Roma: Orizzonte Medico, 1960); F. BOTTURI, “La medicina come prassi della cultura dell’accoglienza,” P. Cattorini, R. Mordacci (eds.), Modelli di medicina. Crisi e attualità dell’idea di professione (Milano: Europa scienze umane, 1993), pp. 105-110; P. CATTORINI, R. MORDACCI (eds.), Modelli di medicina. Crisi e attualità dell’idea di professione (Milano: Europa scienze umane, 1993); G. COTTIER, Scritti di Etica (Casale Monferrato: Piemme, 1994); M. COLTORTI, “Riflessioni sul concetto di malattia e la sua evoluzione,” Medic 6 (1998), pp. 162-175; G. COSMACINI, C. RUGARLI, Introduzione alla medicina (Roma-Bari: Laterza, 2000); H.G. GADAMER, Uber die Verborgenheit der Gesundheit. Aufsatze und Vortrage (Frankfurt am Main: Suhrkamp, 1993); D. GRACIA GUILLEN, Fondamenti di Bioetica (Cinisello Balsamo: San Paolo, 1993); H. JONAS, Technik, Medizin und Ethik. Zur Praxis des Prinzips Verantwortung (Frankfurt am Main: Insel, 1985); P. LAIN ENTRALGO, Doctor and Patient (New York: McGraw-Hill, 1969); R. MORDACCI, “Fra etica della cura ed etica del contratto. Argomento per una sintesi,” P. Cattorini, R. Mordacci (eds.), Modelli di medicina. Crisi e attualità dell’idea di professione (Milano: Europa scienze umane, 1993); M. PELÁEZ, “La carta degli operatori sanitari,” Studi Cattolici 39 (1995), pp. 489-492; M. PELÁEZ, Etica, professioni e virtù (Milano: Ares, 1989); M. PELÁEZ, “Umanizzazione della medicina,” Medic 5 (1997), pp. 55-58; M. PELÁEZ, “L’assistenza medico-infermieristica al morente,” Studi cattolici 41 (1997), pp. 106-108; M. PELÁEZ, “L’antropologia nell’Università,” Medical Humanities. Le scienze umane in medicina, edited by G. Mottini (Roma: SEU, 1999), pp. 6-63; E.D. PELLEGRINO, D.C. THOMASMA, Per il bene del paziente. Tradizione e innovazione nell’etica medica (Cinisello Balsamo: Paoline, 1992); E.D. PELLEGRINO, D.C. THOMASMA, Medicina per vocazione. Impegno religioso in medicina (Roma: Dehoniane, 1994); E.D. PELLEGRINO, D.C. THOMASMA, The Christian Virtues in Medical Practices (Washington: 1996); E.D. PELLEGRINO, D.C. THOMASMA, Helping and healing. Religious Commitment in Health Care (Washington DC: Georgetown University Press, 1997); L. POLO, Quién es el hombre. Un espíritu en el mundo (Madrid: Rialp, 1991); PONTIFICAL COUNCIL FOR PASTORAL ASSISTANCE TO HEALTH CARE WORKERS, The Charter for Health Care Workers. A Synthesis of Hippocratic Ethics and Christian Morality (Vatican City: LEV, 1995); E. SGRECCIA, “Manuale di Bioetica,” vol. I: Fondamenti ed etica biomedica, (Milano: Vita e Pensiero, 1999); L. VALDRÈ, Medicina muta (Milano: Rusconi, 1995); P. VERSPIEREN, Biologie, medecine et ethique. Textes du magistere catholique reunis et presentes par Patrick Verspieren (Paris: Centurion, 1987); D. TETTAMANZI (ed.), Chiesa e Bioetica (Milano: Massimo, 1988).