Hippocratic tradition and ethical foundations applicable to the life terminality

Occidental medicine has its origins in ancient Greece, when mythical thoughts and supernatural and empirical medical practice gave place to ideas which favored the development of the pre-technical era of medicine – tékhnē iatrikē – based on observations of nature. Tékhnē iatrikē understands the illness and the sick as constitutive parts of nature, driven by universal laws and preconceived rules, and, as a consequence, no irrational means should be used to surpass them. The technical rationality dominant in current medicine has departed contemporary medical practice from the Hippocratic art, and advances in science and technology allow conditions of maintenance of life that bring ethical dilemmas in terminal patients, not considering human dignity. Hippocratic ethics, based on the respect for natural laws and the human being is an important instrument that, allied to culture, to technique and to art allow doctors to practice medicine in conformity with the precepts of its traditions.


The empirical and mythical medicine
The archaic Greek culture originated the Western thought and science.In the Greek polis ways of life were developed, based on the reflection about the natural phenomena that changed man view about cosmos and himself.This has conditioned the thought of our predecessors, producing significant change in the interpretation of reality, which in turn has led to a peculiar way of looking at the surroundings.
As Laín Entralgo 1 , the thought, hitherto characterized by a cosmogony of religious and supernatural guidance, gives way to a cosmology in which the logos -the word, the reason -appears in the representation oh the universe by man.Thus, a change towards new epistemological concepts arises, that departs from the thinking of the mythical man towards the Western medicine as we know it today.
In the ancient Greece two concepts coexisted: a magical view, religious and mythical -as the Homeric epic, the theogony of Hesiod and the myth of Asclepius -and the prevalence of reason, that underlies science and will feature the first lines of Western philosophical thought.In the mythical understanding, the disease would emerge from divine or supernatural actions, which led to an empirical medical practice, based by the activity of healers, rudimentary, acting on symptoms alone.The pre-Socratic thinkers will determine, later, a detachment of these mythical representations, formulating ideas that will influence Hippocrates and will facilitate the displacement of the pre-technique Era of medicine to the tékhnē-iatrikē 2 .
The most representative of that mythical period in ancient Greece is Asclepius, whose existence dates back to 1500 BC.Asclepius, the god of medicine, was the son of Apollo and was educated by the Centaur Chiron, who taught him the art of medicine, the surgery and the use of medicinal herbs.Greek culture reports that his followers devoted him temples, surrendered tribute to the gods and practiced healing rituals to alleviate the ills.To the temples flocked the sick who sought, through the practice of the priests -spells, songs, diet, swimming, gymnastics, sleep and dream interpretation -the attenuation of suffering and healing.From these priests, called Asclepiades, descends Hippocrates, who will begin the technical period of medicine 3 .

Pre-Socratic philosophy and medicine
For Reale and Antiseri 4 , the need to philosophize is structurally rooted in human nature, as men tend to know the reason why they feel admired or marveled.Thus, at its root, philosophy is the wonder of the man who faces totality, inquiring himself its foundation and origin, besides the role and place he plays and takes in the universe.Therefore, philosophy is indelible and essential, precisely because it is not possible to extinguish the admiration at the presence of being and, likewise, one can not waive the need to satisfy it.
Developing a peculiar concept of nature and keeping it within the range of its thought, the pre-Socratic philosophers perceived the nature as something, before and above all, capable of a rational structure.From the reflections of the first philosophers, two basic concepts were established for that the magic-empirical medicine should become a rationality: the tékhnē (art) -the theoretical consideration of nature through reason -and the phýsis (nature) ⁵.
The term phýsis -noun derived from the verb phýein (born, sprout, grow), so that what is born, grows or springs -appears in the literature for the first time in the "Odyssey" when Hermes announced to Ulysses the existence of a plant that has the virtue to neutralize the harmful charms of Circe: a plant, says Ulysses, whose nature (phýsis) showed me: has black roots, its flower is white as milk, it is called moly by gods and is very difficult to be torn by a mortal 6 .Thus, the word phýsis designates a reality characterized by three evidences: borns and grows, has a susceptible constant aspect of precise description and carries the operational property of impeding the action of Circe's magic drugs -in short, phýsis is the regularity with which a visible appearance (eidos) expresses latent existence of a property (dynamis) 7 .
Naturalism is how the Greeks see the world, seeing reality as nature.For them, nature is, always and from the beginning, order, justice, legality and therefore necessity as well; nature completes its ministries with a purpose, its essential character.The phýsis is the genetic principle and the very foundation of the whole universe, your arkhē.As the universe never perishes, and considering that

Update Articles
Hippocratic tradition and ethical foundations applicable to the life terminality http://dx.doi.org/10.1590/1983-80422014223027immortality is the privilege of divinity, phýsis will always be rationally considered the as "divine" 8 .
The fruitful collision between medicine and philosophy that medicine to become aware of itself, of its own method and the peculiarity of its knowledge; medicine instituted itself along with the philosophy and in proximity of the critique of the myth practiced by the pre-Socratics.Alcmaeon of Croton, Empedocles, Democritus, Philolaus of Croton, Hippon of Samos, and Diogenes of Apollonia were doctors and philosophers.The union of the two activities in the same person resulted in the conviction that man, part of nature, can not be understood isolated from it.
Medicine, in fact, inspired by the concept of phýsis toû hólou (nature of the whole) to establish the concept of phýsis toû ántrhrōpou (nature of man).The disease can not be understood separately, but only in communion with the nature that surrounds it, with its general laws and own individuality 8 .

The Hippocratic phýsis
The philosophy and medicine are two major Greek contributions to the creation of the Western mind.Ionians took an important step when starting a way of thinking which opposed the myth and the mythical world view.After the pre-Socratic generated a new concept of nature, of phýsis, medicine appropriated these new notions, applying them in the art of healing the sick man, thus favoring the development of civilization 9 .
The origin, in Greece, of a rational and scientific medicine (or pre-scientific) is traditionally linked to the name of Hippocrates.In a glorious time of Greece, when Pericles stimulated the arts, Herodotus and Thucydides wrote the immortal pages of their stories, Phidias carved marble the forms of the Hellenic ideal of beauty, Socrates centered thought in man, Sophocles and Euripides shook the souls of the crowd and the polis was developing with the ideals of freedom and greatness, it also arises Hippocrates, born in Kos Island in 460 BC Considered the greatest representative of Greek medicine, immortalized by his knowledge and practice, transformed the instinctive medicine, empirical, magical and sacerdotal, using observation and research, in a technical medicine, documented in medical treatises of varied styles and content known as Corpus Hippocraticum (CH) 10 .
The idea of human nature or the particular phýsis of human body grounds the Hippocratic medicine, which consists of individuals who as a whole are in accordance with the universal phýsis and has a generating (arkhē) and organizer principle.While organizing principle, phýsis determines in man qualities of order, beauty and harmony -maintaining the balance of the normal functions of the body -and also governs the disease, its symptoms and clinical manifestations 11 .
From the moment that stands, among the educated Greeks, the physiología of the pre-Socratic thinkers, the word phýsis acquires two main meanings, linked and complementary to each other: on the one hand, is the "universal nature", the divine principle and foundation of everything that exists and, secondly, it is the "particular nature" of each thing, that by which something is what it is and how it is.The universal phýsis takes place and realizes itself by giving each thing its own phýsis, its specific and individual constitution.The world parts have their own phýsis, the stars, the winds, the waters, the food, the organs of the human body, the soul 12 .
In CH in "Epidemics I", Hippocrates states that in the diseases we should consider human nature in general and the particular complexion of each one; the general constitution of the atmosphere, the particularities of the sky and of each country; the habits; the diet; the noticeable differences 13 .There is a phýsis of man -ánthrōpou phýsis -and one of several species of animals and plants; distinguishing in man several types in where phýsis diversifies itself: of man, woman, elder, child, Asian and European, for example 12 .
Thus, phýsis of a thing is its arkhē, its principle, since nature is in itself and for itself the principle of all that exists.Accordingly, we read "About food": Single confluence, single conspiracy, all in sympathy.All parts in harmony, all parts of each particular part, for the function 14 .And in "Places in man", affirms that the natural constitution is the starting point of the medical reasoning 15 .
Statically and dynamically, phýsis is harmony, has harmony and produces it; it is ordered in itself and ordering from within itself and, therefore, fair, expressing a well-adjusted: the rest was arranged

Update Articles
Hippocratic tradition and ethical foundations applicable to the life terminality http://dx.doi.org/10.1590/1983-80422014223027 in order by nature, says in "On the Anatomy" 16 .In "On the diet," states that the body and the soul are in harmonious arrangement and that the gods themselves arranged in a good order the nature of things 17 .Thus, the Greek naturalism is in that radical equivalence between the cosmic and physical order and the ethical and political order.
To the physician Hippocrates, the principle of phýsis being ordered and ordenator of itself would enable it, by a spontaneous tendency, to remedy illnesses which sometimes individuals suffer, as taught in "Epidemics VI" 18 : Nature meets herself the ways and means; well instructed by itself, it does what it should.In CH, the kat à phýsin expression (as phýsis, according to phýsis) is used to refer to the morphological and functional state of the body or any of its parts, the natural state of moods, organic movements and mental activities, the good order of excretion, the genesis of diseases, the symptoms and the course of illness, the exploitation and the doctor's opinions, the therapeutic interventions of the surgeon or the properties of food and drugs 12 .
In turn, par à phýsin (against nature) may be the spontaneous or forced changes in the body and its parts or the individual constitutions and the state of the organs.Deviating from the concept that the kat à phýsin is the "normal" or "healthy", and the par à phýsin, the "abnormal" or "pathological", emerges the statement that a morbid symptom or symptomatic picture may be the kat à phýsin, and a person by the power of his natural constitution, can be very thin par à phýsin.Thus, the sovereign order of phýsis may belong to what we call sometimes "disorder" and, others, "illness" 12 .
For the Hippocratic, the phýsis is principle and foundation, fertility, harmonic order and rational structure; thus, it is divine -not that it has "something divine" (ti theion), but it is "the divine" (to theion).The diseases are also theia, divine, because all diseases produce themselves kat à phýsin, because they have in their true reality in phýsis (in her disorder).Thus, all diseases are divine and human at the same time, because they have their real foundation in phýsis.In "Prognosis", CH chapter, Hippocrates states: It is important to recognize the nature of the diseases and know how much they exceed the strength of the body constitution and, at the same time, to discern whether if there is in them something divine 19 .Then the doctor should know if in the diseases there is something insurmountable by the nature of that suffering, in its course operates perceptible and lethal the invincible necessity, the inexorable (anánkē) of the divine phýsis.
The need or obligation, what inexorably happens in the world and how it must occur, was named by the ancient Greeks as moira and anánkē.Moira is the destination that prevents all beings, divine or not, from never overcoming the insurmountable imperative of his own limit.Anánkē is the relentless necessity of movements and laws of the cosmos, it is the divine and supreme anánkē physeos, or "necessity of nature."However, spontaneously and independently of the will of man, phýsis can move or change "by chance", or kat à thýkhēn, in a contingent necessity; thus, for an absolute or forcible need, the resulting change can be favorable or harmful.Hence, there are spontaneous diseases and healing, determined by the anánkē or by the týkhē, convenient or adverse events for human health 12 .

The divine necessity -anánkē physeos
The concept of disease as punishment, very clear in Homeric Greek thought, suffered progressive change with the evolution of philosophical ideas in the post-Homeric Greece.Since ancient times it is questioned: why humans get sick?The reflections of the pre-Socratic philosophy and the establishment of Hippocratic medicine as tékhnē iatrikē understand that the disease does not happen because of you or by imposition of a capricious and angry deity, but for a necessity of nature -anánkē physeos.Thus, it is a facts that human nature let the man always vulnerable to diseases, produced by anánkē (necessity) -kat'anánkēn -in obedience to what is forcible in nature or týkhē (misfortune, accident) -katà thýkhēn -according to luck or fortune of human nature 20 .
For the Hippocratic physician, certain diseases and ways of becoming ill necessarily and inexorably belong to an order of nature, and, in such cases, nothing can make the art of a physician, because facing the needs of phýsis all is vain.Hippocrates says, in "About the art", as for medicine (because it is about it), I'll do the demonstration; and firstly defining it such as I conceive it; I say that its goal is, in general, to separate the suffering of patients and to reduce the violence of diseases, refraining from touching those whose evil is stronger; as stated, as you may know, over the resources of art 21 .
However, in cases where the disease is casual or because of a misfortune, the medical science -whose first fundament is an empirical and rational knowledge about the order and regularity of nature -can prevent it or cure it, as taught in "I Diseases":

Update Articles
Hippocratic tradition and ethical foundations applicable to the life terminality http://dx.doi.org/10.1590/1983-80422014223027Such phenomena occur not through ignorance or skill of doctors, but spontaneously and by chance; and, by occurring, they may be helpful or harmful; and, if they do not occur, benefit or harm for the same reason 22 .So, if man is affected by a morbid state, harmful by necessity, and consequently may die because the disease from which he suffers is fatal by necessity, he should accept without protest this invincible and only apparent disorder of nature, which is not less divine when it kills than when it heals.Among the objectives of the Hippocratic and his tékhnē iatrikē is the intellectual and moral duty of the physician, in addition to judgment of noticing in sickness what is anãnkē physeos, "divine necessity of nature," and what is susceptible disorder of intervention and technical correction 20 .

Ethics and moral at the end of life
From the naturalistic mentality of Greek thinkers derive the concepts of arkhē (generator principle and organizer) and télos (end).Nature holds an order that is the beginning, the dynamics of things, and that inevitably makes them to lead to an end.What amends the order of nature or prevents its natural evolution and the tendency to the end is unnatural and bad.
The morality of principle in the naturalistic ethics is based on the order of nature.Tending to an intrinsic end, nature is teleological and therefore must be considered imoral any interruption of the natural process of reaching the end.The diseases alter the natural order and prevent men from a natural end, the eudamony -happiness, fulfillment -that is the goal of the moral life.The disease, by altering the ordering principle, is unnatural and evil, and every ill has something immoral; being the disease a perversion of nature, it hampers the obtention of his moral end, which is happiness.Hence the need for the doctor to be a moralistas well 23 .
The eudamony manifests itself in two different ways: eu zen (live well) and eu práttein (doing well).These are moral obligations, and therefore when these goals are lost and can not be reached, the moral duty to the terminal illness of human life is to die well, eu-thanasía, seeking a honorable and free of oppressions death, but this search however should not be carried out in order to avoid evils and sufferings.The natural law requires that the virtuous potential of human beings become action and that life is not extinguished before it spontaneous term 24 .
Therefore, suicide is reprehensible and euthanasia is prohibited, as the "Oath": [... ] I will not give to anyone, even being asked, no lethal drug, nor will I make similar suggestion 25 .
In addition to preventing diseases and trying to restore health, medicine should help the well dying, for a moral reason.Medicine can not abandon a person who is in the process of end of life.The role of medicine is to promote the welfare, promoting health and good living, however, when this is not possible, it is the doctor's duty to help in getting a good death.It is not intended to prevent death when it is a necessity of nature, nor to take care of the patient in order to cure him at this stage 23 .

Dying nowadays
In today's society, death is no longer a natural process.With advances in medical science and technology, the patient no longer shares his last days in the family, being given to the doctor and his staff in hospitals, where the artificial maintainance of his weakened body's vital functions keeps him alive.In this context, the process of dying can be controled, enabling both therapeutic obstinacy, for interventions that prevent the person to die, and euthanasia, anticipating the moment of death 24 .
This evidences confront the Hippocratic statement contained in "Epidemics I": One must inform himself on the disease history, to know the present status, predict future events; to work on it; and to aim at two objectives: to be useful or not to damage 26 , as well as the principles of beneficence and non-maleficence described by Beauchamp and Childress 27 .
The change in the assimilation of the final stage of life and idea of death is not solely dependent on technological and scientific developments in medicine; it is a cultural process that began in the industrialized countries in the nineteenth century, throughout our days 28 .The medicine, which has transformed itself from art into technique and science, is constantly more concerned with the cure of a disease, leaving behind the attention to the patient.Health, within this context, is defined as absence of disease, and the great enemy to be defeated is death.The target of the physician is health, and the criterion for evaluating his procedures is whether these are beneficial to the patient or not 29 .
The technical questioning, in this respect, is how to prolong the life of a person in an advanced stage of his disease, which is considered terminally ill patients and without therapeutic recovery possi-

Update Articles
Hippocratic tradition and ethical foundations applicable to the life terminality http://dx.doi.org/10.1590/1983-80422014223027bilities?The ethical question is: until when to invest in this procedure?What is the point of keeping the person artificially alive?The chronically ill and terminal patient has the right to know and decide, to not to be abandoned by relatives in large hospitals that artificially keep his life, and to not receive a dehumanizing care in its final stage of existence, of a palliative treatment to alleviate the suffering and pain, and also not to be treated as a mere object, whose life will be prolonged or shortened according to what suits the family or the medical staff 29 .
For the consumist and welfare society, life must be lived as there is a possibility of satisfaction and pleasure.When there are diseases, pain, suffering, there is no internal capacity to deal with them as before, in civilizations that preceded us, in which death was part of existence.There is an unwillingness to accept these difficulties in our society today.Hence the reluctance in solidarity monitoring those who are suffering 30 .
Dying is a consequence of living.The physical fatigue of a body is inexorable and confronts the human being with death.Humanity has assimilated understanding for centuries about the meaning of death; philosophy understood the human being as a being for death.However, at the prospect of dying in the solitude of a bed in an intensive care unit (ICU), under the use of diehard therapeutic means that prolong suffering and postpone the day of death, many would rather die in another way and in another environment .
Because of this, there were clinics, named hospices (in the UK and rest of the Anglo-Saxon world), that escort people in the terminal phase of illness.The hospice movement, and the palliative medical care resulted from it, becomes each time a more important reality and presents itself as a specialty in development.The caring and benevolent presence of personnel trained for this purpose, apart from family, may provide intense human experience to the terminal patient, making the end of life an existential moment less painful in the lived relations, ceasing to be an experience of which to escape from 31 .
The medical knowledge not only requires the application of a series of scientific knowledge relevant to the understanding and treatment of diseases.The human being must be addressed, his subjectivity, his suffering and his surroundings.It is necessary for the physician to act beyond the disease.Thus, this knowledge becomes consolidated, and the physician recognizes it at the time that characterizes it.Applying his scientific knowledge in association with a humanitarian and social vision, the physician may perform his skills for the well-being of society 32 .
When encountering human finitude and the comprehension of the being in the world, the medical practice requires that the old unity originary of life is rediscovered, comprehending therefore the patient that, as a human being, is full of possibilities 33 .

Final considerations
Among the great merits of Hippocratic medicine is the separation between the art of healing and the superstitions and the divine punishment fears that characterized the previous medicine.Exorcised of terrible problems out of the reach and human understanding, medicine has become more philanthropic and close to the understanding of our own pain and peculiar nature.
The speculation of the pre-Socratic philosophers turned to the outside world -ideas that are thought to reside the unitary principle of all things and the intention of explaining the nature through reason, without resorting to supernatural powersis a key contribution of the archaic Greek civilization to the Western culture.
With the advent of tékhnē iatrikē, the art of healing, the Hippocratic physician roots in nature the cause of the disease and the healing virtue.The patient, a constituent part of nature, is governed by specific, accurate, preconceived standards.The disease is chaired by laws and, therefore, irrational means should not be used to try to cure it.
The hegemony of technical rationality that dominates the medicine from the twentieth century brought a sense of oblivion born in its art, practiced by Hippocrates, being transformed into an artificial technique that does not match the tékhnē iatrikē.It is necessary to recover that sense by their tradition and to recognize the medicine in relation with its bond with the origin and unity of human existence.Scientific advances and new technologies provide better sustaining conditions of life, but carries ethical questions and inversion of values when science and technology overlap man, relegating human dignity to a second place.
In Brazil, in curriculum terms, it is precarious the medical training to deal with death.The medical student is not prepared to deal with this parameter, and there has been a dehumanization of patient care at this stage of their diseases.The withdrawal of death from the medical education hinders and

Update Articles
Hippocratic tradition and ethical foundations applicable to the life terminality http://dx.doi.org/10.1590/1983-80422014223027disables the physician who will take care of the terminally ill patients.
In the health professional curriculum, subjects as "Paliative care" and "Thanatology" could be included; and in hospitals there should be the presence of thanatologists, which could favor the meeting of special needs of irrecoverable patients.Medical schools, medical associations, class councils and committees of ethics, for their power to organize, have an important role to review and change the university curriculum in this regard.It should be noted that the Federal Council of Medicine of Brazil has dedicated efforts to promote an ethically correct medical behavior on this issue, with the enactment of Resolutions 1.931/2009 34 (which puts into effect the new Code of Medical Ethics), 1.805/2006 35 (which allows the physician to limit or withdraw procedures that prolong the life of a terminal patient) and 1995/2012 36 (which provides for the directive will or living will) but an approach from university training is still needed.
In Western medicine, the tradition is still Hippocratic, and of it what is alive is precisely the ethical aspects; despite the guidelines of contemporary medical ethics are not exactly as the Hippocratic ones, there was no break with that tradition.When analyzing the old precept "primum non nocere" for example, we glimpse the tradition and innovation that represent the most archaic essence of Hippocratic ethics and at the same time, is one of today's conflicts of bioethics.
The general rules and ethical doctrines, nosologic and prognostic from the CH exerted strong influence on medical schools posterior to its disclo-sure; a current re-reading, the interpretation and the consequent assimilation of this traditional content would be valuable tools to aggregate values of the past to contemporary medicine, to the clinical practice and to the training of medical professionals, aiming for humanization and ethics in medical practice.
According to Werner Jaegern, the structure of the whole society is based on written and unwritten laws and rules that unite itself and its members.All education is therefore the result of living consciousness of a rule governing a human community, whether family, a class or a profession.Further on, he adds: For the stability of current regulations correspond the strength of the education foundations.From the dissolution and destruction of standards come debility, the lack of security and even the absolute impossibility of any educational activity.This is what happens when tradition is violently destroyed or suffers internal decay.And finishes: When our whole culture, shaken by a monstrous historical experience, is forced to re-examine of its own grounds, it is once again proposed to the examination of antiquity the problem, last and decisive for our own destiny, of the form and the value of classical education 37 .
With these considerations, we conclude by pointing out that the doctor, by helping the patient at his terminaity and acting on the border between life and death, must have as tools -beyond technique -culture and art, assuming then a moral attitude and ethical posture to the suffering and pain of his resembling, as pointed the precepts of the Hippocratic tradition.