Religious morality (and secular humanism) in Western civilization as precursors to medical ethics: A historic perspective

Abstract

In discussing bioethics and the formulation of neuroethics, the question has arisen as to whether secular humanism should be the sole philosophical guiding light, to the exclusion of any discussion (or even mention) of religious morality, in professional medical ethics. In addition, the question has arisen as to whether freedom or censorship should be part of medical (and neuroscience) journalism. Should independent medical journals abstain from discussing certain issues, or should only the major medical journals — i.e., the New England Journal of Medicine (NEJM), the Journal of the American Medical Association (JAMA) or Lancet — be heard, speaking with one “consensual,” authoritative voice? This issue is particularly important in controversial topics impacting medical politics — e.g., public health policy, socio-economics, bioethics, and the so-called redistributive justice in health care. Should all sides be heard when those controversial topics are discussed or only a consensual (monolithic) side? This historical review article discusses those issues and opts for freedom in medical and surgical practice as well as freedom in medical journalism, particularly in opinion pieces such as editorials, commentaries, or letters to the editor, as long as they relate to medicine and, in our special case, to neuroscience and neurosurgery. After answering those questions, and in response to a critical letter to the editor, this review article then expounds comprehensively on the historical and philosophical origins of ethics and religious morality. Necessarily, we discuss the Graeco-Roman legacy and the Judeo-Christian inheritance in the development of ethics and religious morality in Western civilization and their impact on moral conduct in general and on medical and neuroscience ethics in particular.

Recently, an important letter to the editor[48] was published in Surgical Neurology International (SNI) in response to my editorial, “The road being paved to neuroethics: A path leading to bioethics or to neuroscience medical ethics?”[22] In that article, I made several statements regarding ethics, morality, and religion, that to the letter writer seemed either inappropriate or outright incorrect. I took the attempted academic reprove with cordiality and in good cheer because it induced me to write about a contentious topic of interest to me, a topic in which no less than philosophy and history become judges of important moral assertions. Dr. Ludvic Zrinzo's critical letter, which so encapsulates the new paradigm and zeitgeist of our time, has inspired me to write this historical review that I hope will clarify the issue and correct real misconceptions. I write this, then, with affability, not to offend but to elucidate; not to condemn, but to instruct; not to stifle, but to facilitate the free exchange of ideas and foster intellectual discussion on a topic related to neuroethics, neuroscience ethics, and thus to SNI. This discussion is important because it may help clarify the speed and direction neurosurgery and neuroscience should take down the ethics road being paved, a road that leads either to the new secular humanism of bioethics or to continuing the traditional paradigm of medical ethics.[22] Besides, we still live in a free society where the free exchange of ideas is still possible and hopefully conducive to the maintenance of freedom in society at large as well as in medical academia in particular.

Now in the interest of facilitating this multidisciplinary discussion,[22,25] I quote below and in full one of the offending paragraphs in my editorial that prompted the letter writer to launch his missive. It also defines the topic and sets the tone for the discussion. It reads:

New York Times columnist William Safire chaired a seminal conference on neuroethics in 2002 and cited Cicero for coining the Latin term moralis derived from the Greek ethicos, but opined that there was an overlapping distinction between the terms. I agree with Safire in that there is still a fine distinction between the two terms. “Morality,” stemming from conformity with religious standards, has to do with the (moral) absolutes of right and wrong. “Ethics,” on the other hand, implies “subtle,” more complex “questions of equity” and refers to good and bad. Since what is good is usually right and what is bad is usually wrong, the terms overlap and have thus become interchangeable in modern times. Nevertheless, in the liberal zeitgeist of our time, and with our modern emphasis on egalitarianism, the word “ethics” predominates; thus, we have the terms “bioethics” and “neuroethics” in vogue and the nuances of meaning those terms entail.[22]

PROPOSITION OF SECULAR HUMANISM AND THE COUNTER ARGUMENT

The editors welcomed the critical letter as bringing forth a controversial subject of importance in medical ethics related to the neurosciences. The letter-writer's criticism begins with a quotation of Albert Einstein providing the gist of the disagreement:

A man's ethical behavior should be based effectually on sympathy, education, and social ties and needs; no religious basis is necessary. Man would indeed be in a poor way if he had to be restrained by fear of punishment and hope of reward after death.[17,48]

An opinion rendered by such an exalted figure in the history of science should certainly be taken into consideration. Nevertheless, I must reply reluctantly that although Einstein was an undisputed genius in physics, and is in fact a hero of mine in the scientific pantheon, it should be noted Einstein, not a deity but a man of flesh and blood, has been wrong more than once, even in theoretical physics. For example, Einstein posited a “cosmological factor” explaining the supposed forces holding a static universe in place. He was wrong; the universe is not static, but expanding. He made a variety of other mistakes in physics: Errors in the formulation of his never completed unified field theory; in light refraction; and in quantum mechanics. More apropos, Einstein's participation in his own family life was not a stellar performance. He was at times a cruel husband and a poor and neglectful father.[12] Furthermore, it should also be added that a man may be very knowledgeable in one or more areas of science, but this is no guarantee he may truly be a wise man or knowledgeable in all fields of knowledge.

In this regard, Socrates (469–399 B.C.) dealt exactly with this issue in Plato's Apology. During his trial by the Athenians in 399 B.C., Socrates explained why the Oracle of Delphi ruled him the wisest man of his time. And to make sure the Oracle was not in error, Socrates searched in vain for wiser men. He found all the notable politicians, poets, and the greatest men in Athens were deficient of wisdom. Searching further, Socrates went to the lower ranks of artisans and found them, as he expected, knowledgeable in their trades. But he told his judges:

However, Athenian men, it seemed to me that the workers also have the same fault as the poets; on account of performing the skill well each claimed also to be wise in other important matters, and this false note of theirs obscured that wisdom, so that I asked myself on behalf of the oracle, whether I should choose to be just as I am, neither wise in their wisdom nor ignorant in their ignorance, or to have both of what they have. Thus I replied to myself and the oracle that it is better for me to be as I was.[38]

Socrates was the wisest of men because, unlike other men, he was aware of his own limitations and deficiencies in the possession of knowledge. Knowledge in one field then does not make one an expert in all fields of knowledge or wise.

FREEDOM OR CENSORSHIP IN MEDICAL JOURNALISM?

In the critical letter's concluding second paragraph, Dr. Zrinzo sums up his objections in the manner of secular humanism[7,18] as follows:

The editorial in question repeatedly suggests that morals are derived from religious principles. This is a common misconception.... Personal religious bias has no role in scientific discourse, including the neurosurgical literature.[48]

First, as to “Personal religious bias has no role in scientific discourse, including the neurosurgical literature,” let's remind Dr. Zrinzo that the piece in question was an editorial, and what is an editorial? By definition it is an opinion piece usually written by a member of the editorial board of a newspaper, magazine, or medical journal. Second, what I stated is historically accurate and factually correct. “Misconception” implies error or opinion unsupported by factual information. In the paragraph cited above and in another paragraph I asserted moral precepts have their origin in, or are intertwined with religious morality, and that religion is beneficial, supporting the moral code of a society. As to the last of these statements, I admit, it is an opinion, but it is an informed opinion formulated from years of study.[18,19,20,21,22,23,24,25]

The giants of medical ethics did not write their treatises without “personal religious bias,” nor without the influence of both the Oath of Hippocrates and Judeo-Christian ethics. The Oath of Hippocrates itself begins by invoking the Olympian gods, which, as I have related elsewhere, reminds the physicians themselves that they are not gods, that they are subservient to a power greater than themselves, and that they should invoke that power, whatever they personally hold sacred, in the service of their profession.[19,20]

The English physician and medical ethicist Dr. Thomas Percival (1749–1804), who wrote and anticipated the modern codes of medical ethics followed in the next two centuries, not only in Great Britain but in the rest of Europe and the United States, was a devout Christian, a fact which is reflected in his emphasis on humanity and charity in his Medical Ethics (1803).[37] A father of neurosurgery, Harvey Cushing (1869–1939), wrote in his Consecratio Medici (1928), “From vain regrets good Lord deliver us,” and called medicine a “divine vocation” ministered by those inspired by “heaven.”[15] And another English physician, Sir Thomas Browne (1605–1682), who wrote during the secular 17^th Century of Genius, could not have written his meditations (Religio Medici, 1635) without the inspiration of religious morality in almost every page of his book. It has been said, Browne's “faith exuded tolerance and goodwill towards humanity in an often intolerant era.”[13,23] He was cited in the writings of Thomas Percival, William Osler, and Harvey Cushing.[15,37] It would seem, then, that the misconception about the separation of religious morality from medical ethics is itself the misconception, at least when the main figures of medical ethics are consulted.[13,15,19,20,22,37]

I believe medicine (and neurosurgery) should follow the compassionate medical ethics of these illustrious predecessors rather than the new bioethics. Traditional patient-oriented, medical ethics are based on the precepts of Hippocrates, placing the interest of the patient ahead of other considerations. Bioethics is population-based ethics, guided by utilitarianism, and/or monetary or budgetary considerations. There is a place for bioethics in laboratory research and veterinary medicine, but bioethics should not be the guiding light for what should remain the sacrosanct patient–doctor relationship. Bioethics and the veterinary ethic are applicable to humane animal research and when treating sick and injured animals – in which the veterinarian acts according to the wishes of the animal's owner, the person responsible for paying the bill – but not sick human patients.[20,22,45]

Third, still pertaining to the statement, “personal religious bias has no role in scientific discourse, including the neurosurgical literature,” let me reply that we have no such blanket censorship in SNI, which is an independent medical publication, nor am I aware such dogmatic prohibition exists in medical journalism at large in free societies. The discussion, in fact, falls within the scope of SNI, as it regards controversial social issues and ethics in neuroscience. Lastly, let me state this type of blanket statement is frequently used to stifle the free exchange of ideas, which is anathema to academic intercourse, as well as a threat to liberty in a free society.[8,10,11,21,27]

I would not be fully addressing the importance of freedom in contradistinction to censorship in medical journalism if I did not mention there is a persistent double standard in the presentation of socioeconomic and political issues in the major medical journals. It seems that physicians with “progressive” political leanings, often the editors themselves, do not really want to limit religious or political discourse per se in the medical literature, but only limit those with whom they disagree (e.g., conservatives) and have the temerity to express a contrarian view to that deemed politically correct.[8,11,16,21,27]

In this regard, the major medical journals, such as the New England Journal of Medicine (NEJM), the Journal of the American Medical Association (JAMA), or The Lancet, can then speak unopposed with one collective voice in promoting leftist causes. We should counter: No, let both sides be heard! How many times have I seen correspondence sent by Dr. James I. Ausman, SNI editor-in-chief, asking dissenting readers to write and submit their own opinion pieces to SNI espousing their viewpoints? As the poetess Elizabeth Barrett Browning, in a different context, versified in a famous sonnet, “let me count the ways”! If politics and religion are supposedly out of the realm of medicine and neurosurgery, well then we should test that hypothesis.

The mission statement of World Neurosurgery, the official journal of the World Federation of Neurosurgical Societies, includes the wording, to “serve as a forum for scientific, clinical, educational, social, cultural, economic, and political ideas and issues for global neurosurgery... Topics to be addressed in World Neurosurgery include: Education, economics, research, politics, culture.”[47] Culture, a term derived from the word “cult,” refers to religious as well as secular morality and ethics.

Now let us consider JAMA; and among its editorial objectives listed in addition to its mission statement (1993), we find:

• Objective 5 – To foster responsible and balanced debate on controversial issues that affect medicine and health care

• Objective 7 – To inform readers about nonclinical aspects of medicine and public health, including the political, philosophic, ethical, legal, environmental, economic, historical, and cultural

• Objective 8 – To recognize that, in addition to these specific objectives, THE JOURNAL has a social responsibility to improve the total human condition and to promote the integrity of science.[21]

For several decades now JAMA, NEJM, and The Lancet have published politically charged articles fulfilling objectives such as those enunciated by JAMA. These objectives have been fulfilled largely with progressivist tendencies and with little or no opportunities for dissenting voices to express their views.[16]

Let us take a quick survey of the major medical journals and see if they follow the rule or fulfill their one-way missions. In the process we should wonder if irate readers were equally indignant when the JAMA, NEJM, and The Lancet published articles condemning the personal ownership of firearms, promoting socialized medicine, or discussing religion within a political context:

• “Would you say you ‘had sex’ if…?” This was a “peer-reviewed,” allegedly scientific article in JAMA answering the question of whether oral sex was real sex or not; and so conveniently, a poll of students was conducted at a mid-Western university to answer the question.[43] The article was even placed on “fast track” by JAMA's then editor Dr. George Lundberg in time to help President Bill Clinton when he was having political problems because of oral sex with Monica Lewinsky. You can guess the answer from the students: Oral sex is not sex!

• “Interpreting the Right to Bear Arms – Gun Regulation and Constitutional Law.” In this article, the NEJM provided a forum to a dissenting lawyer, Mark Tushnet, J.D., who opposed a U.S. Supreme Court decision affirming the constitutional right of individual Americans to keep and bear arms[44]

• “An open letter for the people in Gaza.” In this article, The Lancet gave a medical forum to Paola Manduca, Iain Chalmers, Derek Summerfield, Mads Gilbert, and Swee Ang, on behalf of 24 signatories and thereby endorsed one side of a highly charged political issue, blaming the Jews in Israel and exonerating the Moslems in Palestine for the escalating violence in Gaza during 2014[36]

• “Religion, spirituality, and medicine: Application to clinical practice.” And here is a rare article that must have escaped the detection of censors at JAMA about religion being helpful in medical practice. This article had the audacity to discuss how “seriously ill patients use religious beliefs to cope with their illnesses,” and considers whether “physicians should pray with their patients”[34] The article shows that religion is not banned from medical journals, although they are indeed rare birds.

I wonder if Dr. Zrinzo objected when The Lancet editorialized with the article above. I ponder whether he sent critical letters to any of the aforementioned influential medical journals when they took the progressive side of those issues? We certainly welcome him to voice his opinions in SNI and ask only that he keep an open mind about the alleged “biases” of others and to consider the implications of limiting academic debate. We published Dr. Zrinzo's letters and comments. Most of my letters to JAMA and NEJM have never been published.[16]

In short, it seems the moral indignation is only politically, ideologically and unidirectionally vented, expressed only when countering conservative points of view or detecting “religious bias” against Judeo-Christian medical ethics or the constitutional issues they consider unsavory, such as the individual rights of citizens to own firearms, the right to private medical care, the right of doctors to write about the influence of religion in easing the suffering of their patients, etc. No complaints are heard in meetings and publications about progressive ideas, such as utilitarian bioethics, more funding for socialized medicine, “redistributive justice,” and secular humanism. I’m aware Dr. Zrinzo claims that he is not promoting censorship and that I’m unfairly rewriting his letter,[48,49] but the fact remains that his concluding remark carried to its logical conclusion leads to censorship – i.e., the restriction of ideas deemed politically incorrect. In an academic setting and a free society, we should all be affirming: Let all sides be heard in the cause for academic freedom and the perpetuation of liberty.[6,8,10,11,21,27] Dr. Zrinzo further wrote, “...morality and ethics do not require a religious basis. This fact will stand, whatever the length of any forthcoming ‘extended commentary’.”[49] This reaffirmation suggests his mind is made up and closed, and that my attempt to inform, as well as exchange ideas, will be futile. Nevertheless, I hope the information will not be lost by all. He has also claimed I’m trying to teach morality to my neurosurgery colleagues.[49] I’m not. The vast majority of my colleagues are in no need of such instruction. What I am attempting is to restore the time-honored, individual-based, patient-oriented medical ethics of Hippocrates in the neurosciences, medical ethics that have been gradually replaced by utilitarian, collectivist bioethics. I am also attempting to reclaim the loss of morality that has been gradually lost in society at large leading to increasing violence and crime, injuries and death. I hope to encourage my colleagues to action in both the civic and professional arenas in these endeavors.

THE TWIN PILLARS OF WESTERN CIVILIZATION

I now propose to show that my first assertion is correct and factual – namely, that moral precepts have their origin in and are inextricably entwined with both philosophy and religion. I beg my readers in advance to excuse my indulgence in taking so much time in expatiating on these fields of history, ethics, moral philosophy, and in tracing development, at least in part, from religion. But how is one to counter such a loaded assertion as, “morals derived from religious principles is a common misconception,” with a cursory denial without delving fully into the subject at hand? It is easy and quick to throw in such a blanket statement, even a cordial and academic objection; it takes much more time, effort, and persuasive evidence to refute such affirmation – even if it is the real misconception, particularly one so accepted and now taken for granted by the prevailing secular popular culture!

Western culture and civilization stand on twin pillars that have withstood the test of time: The Judeo-Christian inheritance and the Greco-Roman legacy. Of these pillars, the Judeo-Christian tradition, we must remember, predates Socratic philosophy by at least half a millennium. Moreover, “let us remember,” wrote Aristotle (384–322 B.C.) [Figure 1], “that we should not disregard the experience of ages.”[5] Indeed, traditional institutions that have benefited mankind are preserved, and those that have proven iniquitous or unworkable are discarded by the societies that have tried them and found them wanting. In the heroic age of the Near East that ended 3000 years ago, man propitiated gods for his well being in this life on earth. The heavens dictated man's existence (i.e., astrology and divination). The tenets of this heroic age collapsed as man's moral vacuity led to pessimism. There was, it seems, no purpose for man's existence. But then came the Hebrew experience, the Ten Commandments, the Old Testament, and man was seen as having free will and having the capacity to do good or evil – i.e., develop moral conduct, for which he would be rewarded or punished in the afterlife. Christianity and the New Testament came almost a millennium later. Judeo-Christian morality formulated a code of moral conduct to establish and preserve order in society and cement the fellowship of men. This religious tradition was assimilated by the West with the advent of Christianity after Constantine the Great (reigned A.D. 306–337) and his successors made it the state religion of the Roman Empire. We must remember Judeo-Christian morality then originated not with Greek philosophic ruminations but from the Biblical prophets of the Old Testament in the Near East. Joined in the Roman Empire, the two legacies became the twin pillars of Western culture and civilization. Let us then not forget that the Judeo-Christian religious teachings of piety, hope, and charity were added later to the precepts of Hippocrates and become central and fundamental tenets of medical ethics.[19,20]

Figure 1.

Bust of the moral philosopher and scientist Aristotle (384-322 B.C.)

The Greco-Roman pillar was erected in the West, stemming from the natural philosophers of ancient Greece in the 6^th century B.C. But it was not cemented, as far as moral conduct and ethics, until the advent of Socrates (469–399 B.C.), Plato (427–347 B.C.), and Aristotle (384–322 B.C.). The ancient Greek philosophers did two things. Beginning in the 6^th century B.C., the earliest ones, such as Thales of Miletus, Democritus and Empedocles, speculated on and attributed what was previously thought to be supernatural events to natural phenomena that followed physical (natural) laws. This major step laid the foundation for early science and philosophy. The successors to these natural (later denoted materialistic) philosophers in the following centuries, Socrates, Plato, and Aristotle, connected moral conduct, eternal truths, and goodness to God. Aristotle wrote in his Nicomachean Ethics that moral virtue develops as a result of habit (i.e., ethos that also gives us the word “ethics”; Greek, ethike) and practice, and that the moral virtues ultimately define character.[3,4]

In the course and development of Western civilization, the two legacies became inextricably entwined. This happened first, as previously mentioned, when the pagan Greco-Roman world of the Roman Empire adopted the Judeo-Christian religion and ethics in the form of Christianity in the 4^th century A.D. Moreover, the two legacies were reinforced when St. Augustine of Hippo (AD 354–430) reconciled Plato's philosophy to Christian theology via Neoplatonism. They were further cemented and placed in an even more solid foundation when St. Thomas Aquinas (1225–1274) reconciled Aristotle, “The Philosopher,” to Christian thought in the 13^th century. Those of us who were brought up in the West (and attended churches and synagogues) are familiar with the Judeo-Christian religious teachings and the accepted precepts of moral conduct. We are less familiar with the intellectual reincorporation of Greco-Roman philosophy into Christian thought by Aquinas in the 13^th century.

Lest we forget, we should digress briefly to mention that as to the actual practice of the art and science of medicine, Aristotle, whose father was a court physician to King Philip II of Macedonia (father of Alexander the Great), often cites Hippocrates of Cos (460–370 B.C.) as his authority in medical knowledge. Hippocrates is the father of medicine and his celebrated Oath remains a high watermark in medical practice [Figure 2]. Hippocrates’ dicta of non-maleficence and beneficence – i.e., Primum non nocere, (“First Do No Harm”) – remain central tenets in medical ethics, in accordance with Judeo-Christian ethics and morality, which as we shall see, also stress non-maleficence, beneficence, and the Golden Rule.[1]

Figure 2.

The Oath of Hippocrates, a high watermark in medical ethics. Photo: Public domain

In his Ethics, Aristotle stressed that human action and ethics seek moral goodness – i.e., justice, temperance, courage, moderation, self-control, etc. – and the source of these moral virtues was God.[3] For Plato [Figure 3], God was transcendent, the highest intelligence, who can punish those who performed wicked actions in this life. Death in the good man unites him with God and the universe.[39] For Aristotle, God was also eternal and immutable, the Prime Mover, who gave order to all things and was the Final Cause (i.e., the reason and purpose for existence) of all things.[2]

Figure 3.

Bust of Plato (427-347 B.C.), philosopher and founder of the Academy in ancient Athens

RECONCILING ARISTOTELIAN ETHICS WITH JUDEO-CHRISTIAN TEACHINGS

It was because of this connection of philosophy and moral conduct to religion in part that St. Augustine was able to reconcile Plato with Christian dogma and even credit Neoplatonism with facilitating his spiritual journey toward Christianity. St. Thomas Aquinas [Figure 4], for his part, reconciled Aristotle to Christianity in a momentous step in Western philosophy and Christian morality and ethics.

Figure 4.

Painting of St. Thomas Aquinas (1225-1274), who reconciled Aristotelian philosophy to Christian theology and the father of scholasticism

It should not be left unsaid the Jewish physician, Moses Maimonides (1135–1204), and the Spanish Moslem physician, Averroës (1126–1198), attempted to reconcile Aristotelian rationalism and theology in Judaism and Islam, respectively, in a similar fashion as St. Thomas Aquinas accomplished more thoroughly in Christian theology. Maimonides went on to even compose an Oath of medical ethics (that begins with “Exalted God...”) still in use today.[23] Ironically, Averroës has been called “a father of secular thought,” not in the Islamic East, where his followers were persecuted as heretics,[23] but in Western Europe.

St. Thomas’ Christian moral philosophy came to a significant extent from Aristotle and remains dogma in the Catholic Church. St. Thomas Aquinas’ cardinal virtues – prudence, temperance, justice, and fortitude (courage) – are not too different from the moral virtues of Aristotle. Aristotle's Ethics also included intellectual virtues such as intelligence, prudence, and wisdom. St. Thomas Aquinas instead listed the theological virtues – faith, hope, and charity. Any virtues with charity added becomes a “complete virtue” and “an object of God,” who is the cause and end of all things (Final Cause).[1] The Judeo-Christian tradition had been incorporated into the Greco-Roman world by the assimilation of Christianity into the empire in the 4^th century A.D. It was subsequently spread throughout Europe after the collapse of the Graeco-Roman world in the West less than two centuries later [Figure 5]. With the advent of St. Thomas Aquinas and the 13^th century, nearly a millennium later, Graeco-Roman ethics would in turn be inserted anew into the teachings of Christianity.[19]

Figure 5.

Graeco-Roman legacy: The Forum Romanum — the ruins of the forum and monuments of ancient Rome. Courtesy Wikipedia

In this context, we should also mention there were further contributions from Roman scholars, contributions to morality and ethics that are frequently neglected because of the earlier Greek philosophers. The Roman statesman and philosopher Cicero (106–43 B.C.) [Figure 6], influenced by Aristotle and the Stoic philosophers (including Panaetius [c. 185–110 B.C.] and Cicero's own teacher, Posidonius of Rhodes [c. 135–51 B.C.]), discussed the tenets of Natural Law – universal, just and eternal laws – derived from Nature's God.[14] The concept of Natural Laws would also be woven centuries later into the tapestry of Christian moral philosophy by St. Thomas Aquinas. The concept of Natural Rights, incidentally, rights derived from God or Nature and not from governments, would likewise be added to political theory during the Enlightenment in the 17^th century. And more apropos in professional ethics, we must also recollect that in the 1^st century A.D., the physician (medicus), scholar and medical ethicist, Scribonius Largus, wrote about the need for compassion, humanitatis, on the part of the physicians: Medicis, in quibus nisi plenum misericordiae et humanitatis animus est secundum ipsius professionis voluntatem, omnibus diis et hominibus invisi esse debent. Here humanitatis refers to humanity (humanitarianism or compassion) rather than humanism that refers to the study of man. In a letter to me, published in the Medical Sentinel, the late scholar Plinio Prioreschi M.D., Ph.D. (1924–2014) specifically translated the passage in his monumental History of Medicine as follows: “All men and Gods, in fact, should despise any physician whose heart is not full of humanity and mercy according to the purpose of his profession.”[40,41]

Figure 6.

Cicero (106-43 B.C.), Roman philosopher, orator, and statesman

The merging of Greco-Roman thought with Judeo-Christian morality began in the Roman world even before Christianization of the empire. And we find paradoxically more (Judeo-Christian) compassion, humility, charity, sense of duty, and fellowship of man in the Stoicism of the philosopher-emperor Marcus Aurelius than the imperial hubris, atheism, and secular humanism expected in a pagan Roman Emperor.[35] Ethics then in Western civilization evolved directly from the concept of the moral virtues of secular Greco-Roman philosophy as well as Judeo-Christian morality. In addition to the Oath and precepts of Hippocrates, traditional medical ethics inherited this dual inextricably entwined intellectual and devotional legacy.

We must also keep in mind that moral behavior is nurtured by habit (ethos), which forms character and appears in the common man, not from reading the exulted writings of Plato's Republic and Aristotle's Nicomachean Ethics, but from home instruction, practice and habit, ultimately derived from the religious teachings of Christian churches and Jewish synagogues. The same is true in the East, where the devotees commonly exert their devotions and learn moral principles from the priests in the Buddhist temples, and other religious institutions. All good religions and moral philosophies teach variations of the Golden Rule: “Do unto others as you would have them do unto you” (Luke 6:31). In fact, close study of supposedly secular moral philosophies, derived from the teachings of ancient “pagan” Greek philosophers and even from their disciples in the Age of the Enlightenment, reveal them to be permeated with religious morality. Ethics and moral conduct are entwined with religious teachings in most cultures, with the notable exception of totalitarian tyrannies, particularly openly atheistic, communists dictatorships.[22,28]

ANGST, MELANCHOLY, AND MODERN MAN

The next assertion in the critical letter:

Amoral and unethical behaviour is often supported by religion; historical and contemporary examples are support for slavery and oppression of women and homosexuals.[48]

Historically, religion has made its share of mistakes. But by and large, the Judeo-Christian religion has been beneficial to those who have been nestled in Western civilization, and religious morality has been a partial bulwark against anarchy on the one hand, and the rise of totalitarian tyranny on the other. I have also expounded on this topic previously elsewhere.[30] This benefit is true also for other religions, particularly Buddhism [Figure 7] and Hinduism, which have provided peace, moral guidance, and solace to an otherwise trying existence for countless millions in Asia and elsewhere over the centuries.

Figure 7.

Statue of Gautama Buddha, “the enlightened one” (c. 5^th century B.C.)

The length of this already quite extended historical review article precludes expounding on the possible effects of skepticism, angst, irreligion, and the stress and fast pace of modern life on the state of mind and mental health of contemporary society. Let me just remind the reader that mental illness, random violence and senseless crime have been on the rise concomitant with modern technological advances.[25,29,31] And as early as the 19^th century through the mid-20^th century, eminent psychoanalysts, Sigmund Freud (1856–1939) and Carl Jung (1875–1961); existentialist philosophers and thinkers, Søren Kierkegaard (1813–1855) and Albert Camus (1913–1960); not to mention numerous illustrious Catholic and Anglican theologians, such as G.K. Chesterton (1874–1936) and C.S. Lewis (1898–1963), discussed the toll that misunderstood science and learning, in association with moral vacuity, were exacting on the human spirit and in precipitating anxiety and other mental disorders of the modern age. Even poets and novelists were concerned. In the philosophic treatise, The Garden of Epicurus (1908), the French novelist, Nobel Prize winner in Literature (1921) and liberal social critic, Anatole France (1844–1924) discoursed on this topic. He noted: “Religions are strong and beneficent because they teach man his raison d’être, the final causes of his existence.” And not exempting himself, France expounded, “those who have rejected the dogmas of theological morality, as almost all of us have done in this age of science and intellectual freedom, have no means left of knowing why they are in the world and what they are come there to do.” For the French novelist, rational thinking without spirituality reveals “cruelly the tragic absurdity of living.” And it is to this cruel realization that France traced the roots of the “melancholy” of modern man and the preponderance of “physical evil, moral evil, the miseries of the soul and the senses, the prosperity of the wicked, the humiliation of the just man.” Nevertheless, “all this would still be endurable…if we could divine a providence directing the chaos.”[32]

Modern angst and anxiety aside, faith and religion provide an invisible support to the moral code, encourage discipline, and promote civility. Their influence on moral conduct and overt behavior is certain.[7,22,25,30] Without the support of religion and our churches and synagogues, crime in Western society would certainly increase, forcing and giving the State the pretext to step in to combat the increased lawlessness and crime – steps that frequently end up restricting the freedom of lawful citizens and even establishing tyranny. This is no empty accusation; agent provocateurs have elicited violence and terror countless times from ancient Greece and Rome to the present age, instigating government reprisals that have resulted in the curtailment of freedom and the imposition of the brutal dictatorships of the 20^th century.[8,26,27,28]

SLAVERY AND THE TYRANNY OF FALSE RELIGIONS

Slavery was also mentioned in the critical letter, and it is true that the system was supported by most religions and many thinkers and philosophers, right up until the era of the Enlightenment. Nevertheless, slavery was commonplace since ancient times supported by conquests and wars and again needing no religious support. The Catholic Church, in fact, ended slavery of Christian and Jews in most of Europe during the Middle Ages. And it was the Christian tenets of universal brotherhood, charity and compassion that gradually abolished the institution in most of the Western world.

And it is well known that the horrific conditions of black slavery in later centuries, including in the British territories and the United States, were ameliorated at least in part by those same Christians. It was also the Christian teachings of various denominations (e.g. Anglicans, Quakers, and other Congregationalists) that fueled the abolitionist movements which in Britain was led by the evangelical Christian convert William Wilberforce (1759–1833) and in the Northern United States by the black abolitionists and Underground Railroad leaders, Frederick Douglass, Sojourner Truth, and Harriet Tubman, who even attended the same African Methodist Episcopal Churches in New York and Washington, D.C.[46]

Horrible crimes were committed in war and peace in the name of religion, but much of this evil was committed by brutish individuals lacking self-control, acting on their own, presumably under the aegis of the Church or tyrannical governments. Aristotle admits there are wicked men who act and do evil for their own sake, although institutions or governments may be erroneously blamed.[4] The Church also erred as an institution, and religious inquisitions and wars conducted on her behalf are rightly condemned. Nevertheless, the institutions, including religious establishments that survive the test of time, survive because in the balance of human experience they are found to be of net benefit to mankind.[18,30] Such is the case with the Christian churches, the synagogues, mosques, temples of various other sects – and the Judeo-Christian ethics of the West.

If we consult the history of man, we find that those religions based on false or evil principles; that bring more mischief than benefits to their followers; that bring more desperation and disquietude than solace and peace to the soul – are rejected or discarded to the dustbin of history, or eventually overthrown from within or from without. And so it happens that the dustbin of discarded religions is half-full containing such remnants of antediluvian religions as Aztec cannibalism, Celtic sacrifices, the pantheon of gods at Mount Olympus, thuggery in the Cult of Kali, as well as the even worse cults of civil religion represented by the cult of occultism and Aryan superiority of the Third Reich and the cults of personality of Lenin and Stalin in the USSR (and of Mao Tse-tung in China, moribund but still ostensibly in the books).

RELIGIOUS MORALITY AND THE AMELIORATION OF THE HUMAN CONDITION

In the West, the Christian religion also built the first colleges and universities, as well as almshouses and later hospitals. The Saint days were and remain Catholic feast days, days of rest and hearty meals for the faithful in otherwise days full of sweat, toil, sickness and death. The legacy of learning, the preservation of the classics of ancient Greece and Rome, and the retention of the rudiments of the medical and surgical professions (e.g., practicing monks and barber-surgeons) were preserved in parchments and in actual service in the monasteries of Europe in the Middle Ages, until rediscovered by scholars in the late Medieval period and the Renaissance.[18] Knowledge was also preserved in Constantinople, capital of the Byzantine Empire, and in the Islamic East in translations of Aristotle and other Greek classical writers as well as in actual medical practices by Islamic physicians, such as Avicenna (A.D. 980–1037), Avenzoar (1094–1160), and others.[23]

Hinduism in India and Buddhism in Nepal, China, and the Far East provided the same service and guidance in the East. Mao Tse-tung attempted to eradicate philosophic tradition and religion, (e.g., Confucianism and Buddhism) in China. Despite exterminating 40–60 million Chinese, the Chairman failed to do so, and today tradition and religion are resurgent there. The former Soviet Union attempted to eradicate Islam from Chechnya and her southern Republics, such as the Uzbekistan, Kazakhstan, Tajikistan, etc. Despite exterminations and resettlements of Chechens and Tatars, the USSR was unable to eliminate Islam from its soft underbelly. The Soviet State collapsed but the people's religious faith did not. Religion, and the moral conduct it engenders, may be suppressed but not easily uprooted from the people. The greatest benefits of religion have been in ameliorating the hard life and trying existence for millions living in poverty, in providing solace to others in difficult times, and in soothing the soul of countless others living lives of quiet desperation in primitive as well as modern society.[29,30,31,32]

But there is even a more concrete evidence of the benefit of religion: What greater proof is needed than the fact that religious morality provided throughout the world the first civilian hospitals in the history of humanity? Ameliorating the suffering in the human condition of the times, the first civilian hospitals were all consecrated in the name of compassion and religious charity. In India, the great ruler Asoka (c. 273–232 B.C.) converted to Buddhism, created the first charity hospitals there, and sent missionaries to proselytize the world. Likewise in China, a country without a religious foundation, it was nevertheless the Buddhist devotion of a prince that created the first hospitals in A.D. 491.[42] Likewise, in Baghdad and Cairo in the Near East and Córdoba in southern Spain, Islamic public hospitals ministered with religious compassion to the sick, and provided shelter for the infirm during the Middle Ages.[23]

And in the Western world, the first hospital experiences were most instructive. The formidable Roman legions were served by physician surgeons (medici legionis). The Roman military tradition created well-provided infirmaries and military hospitals (valetudinaria), some were even attached to gymnasia for physical exercise and to spas (thermae) for the recuperation and enjoyment of the convalescing legionaries,[42] but there were no hospitals for civilians until Christian times. Actually, there was an institution that at first glance resembled a civilian “hospital” in the West, but it was, in fact, a pagan hospice dedicated to Asclepius, who was said to have come to Rome to combat an epidemic. It was built in 293 B.C. on the Insula Tiburina (an isolated island in the Tiber River) also known as “the Island of the Epidaurian Serpent,” where the indigent and “worn out” slaves were left to die.[18,36,44] The first true hospital, though, was a compassionate Christian shelter also built in Rome by the Christian charity of Ladies Fabiola and Marcella (fl. A.D. 4^th century).[18,33,42]

Subsequently, after the collapse of Rome in the West, Byzantine facilities were built with the impetus and treasure of Christian charity in the Eastern Roman Empire. I believe no greater and more convincing proof can be found of the benefit of religious morality in general and Christian charity in particular in ameliorating human suffering than the first hospital experience.[18,33,36,42,44]

In the Middle Ages, it was the Christian tradition that continued to build hospitals (e.g., Hôtel-Dieu hospital in Paris and St. Bartholomew's in London) as well as founded the first colleges and universities.[18,33]

As it regards the first medical schools, the evidence is that they were initiated by Benedictine monks – i.e., Monte Cassino, becoming a religious, and Salerno, a lay medical school. Constantine Africanus (A.D. 1010–1087), who translated ancient manuscripts from the Arabic into Latin (returning lost Greek knowledge to the West) and who made Salerno a great center of learning, had been a monk at Monte Cassino. Moreover, the order of barber-surgeons, who gave rise to the renowned Renaissance surgeon Ambroise Paré (c. 1510–1580), originated with monks and monastic medicine in the early Medieval period.[18,33,37]

HUMANITARIANISM OR SECULAR HUMANISM?

Finally, the letter writer, expressing another contemporary view of secular humanism pregnant with casuistry, states:

Numerous secular, non-religious individuals and organisations (such as Doctors Without Borders) display highly moral and ethical behaviour without belief in a god/gods or religion.[48]

This is true as far as the organizations are concerned [Figure 8], but not necessarily true of the individuals who actually do the work. The often-ignored reality is many of the individuals participating in many of these organizations are in fact quiet, religious people operating with compassion and guided by an engendered religious morality. These altruistic individuals keep their religion to themselves (as it should be), although they might be working under the umbrella of a secular organization. Others have been influenced by religious principles in earlier life, even if they no longer are practicing Christians, Jews, Moslems, or Buddhists. The fact is that in our present age openly espousing religion is not faddish or politically correct and can get you into trouble. And yes, there might be others, who are professed atheists or avowed secular humanists and who do humanitarian work under a moral and personal ethic. Aristotle also mentions people who are intelligent and wise and who live virtuously, guided by reason in the pursuit of goodness. But these “noble” individuals, who are intrinsically good, needing no education, training, or religion to exercise virtue, are the happy few. Most people need the guidance of religion or moral codes. Aristotle writes, “For each state of character has its own ideas of the noble and the pleasant, and perhaps the good man differs from others most by seeing the truth in each class of things, being as it were the norm and measure of them.”[3] Secular humanists refer to these few when they proclaim that man is the measure of all things. Some materialistic and Epicurean philosophers of ancient Greece believed this to be the case. Plato and Aristotle denied it, and in their writings, criticized many of the materialistic philosophers who preceded them and the sophists who followed them.

Figure 8.

Doctors Without Borders, international humanitarian medical organization. Courtesy Doctors Without Border

Lucky few perhaps, but for the rest of common humanity, we must cultivate the moral virtues, achieve them through discipline, moderation, education, habit, contemplation, and religious morality as discussed by both the ancient Greek sages, Plato and Aristotle; the theologians, St. Augustine and St. Thomas Aquinas; as well as the medical ethicists, Sir Thomas Browne and Dr. Thomas Percival. Happiness and “the good life” come from good conduct and from exercising the moral and intellectual virtues, and never doing evil. This is also what the Judeo-Christian ethic and all good religions espouse and fortify in the people because religious morality not only provides spiritual solace but also promotes moral guidance and ethical behavior. Not all people will act virtuously of their own initiative. Those “brutish persons lacking self-control,” the intemperate, and the wicked, posited Aristotle, must be made to behave properly and punished for their crimes by the force of law. Aristotle writes, “[The] legislators.... punish and take vengeance on those who do wicked acts.”[3]

Thus, like St. Thomas Aquinas, Aristotle, and other realistic and sagacious Greco-Roman statesmen and medical ethicists we have mentioned, I prefer individualism, freedom, and humanitarianism, even if stemming from religious precepts, and at last resort, the law of the State; rather than to depend on the secular humanist notions of collectivist utopias and the purportedly intrinsic goodness and capabilities of rational man.[7,9,11,27] These are misguided notions that failing in their dreams of creating paradises on earth, have been conducive, as history has shown, to the expansion of government, the use of force, curtailment of liberty, censorship, collectivist statism, and veritable hells on earth.[6,7,8,26,27,28]