Doctor-patient relationships, laws, clinical guidelines, best practices, evidence-based medicine, medical errors and patient safety

Patient safety has now become a mantra of modern medical practice. Rules, laws, guidelines, evidence and best practices are frequently invoked to improve patient safety. These are not new; they have governed the practice of medicine since antiquity. A set of laws, known as the Code of Hammurabi (circa 1740 B.C.E.) have come down to us from the Babylonians after its namesake, the founder of the Babylonian empire.1 These 282 statues or common laws governed nearly all aspects of social, political, economic and professional life including those pertaining to physicians, surgeons, veterinarians, midwifes and wet nurses. Carefully conscribed details were devoted to specifying the relationship between patients and practitioners, including fees and penalties. Problems of “internal medicine” were dealt with physicians of the priestly class who saw to internal disorders caused by supernatural factors. The surgeon who dealt with physical problems, however, was accountable for both remuneration and liability to earthly courts. If a doctor performed surgery, generally with a bronze knife, and saved the life or eyesight of an upper class citizen, he was to be paid 10 shekels of silver. A similar outcome for a commoner was worth 5 shekels and only 2 shekels for a slave. If the outcome for the upper class citizen was bad (blindness or death), the doctor’s hand was amputated. If a slave died because of the surgery, the doctor had to provide a replacement but had to pay only half the value in silver if the slave was blinded. The Code provided further detail for many procedures including those of veterinarians (“doctor of an ox or ass”). Probably the most famous physician of all time and the founder of clinical medicine is Hippocrates (circa 460-360 B.C.E.) of Greek antiquity, the putative author of the Corpus Hippocraticum.2 Upon graduation from medical school, many modern physicians continue to take the Hippocratic Oath, the model of the ideal physician. Many historians question whether Hippocrates actually wrote this Oath or even the essays attributed to him. Some even question whether Hippocrates was a real person or was a composite created later by Greek and Roman scholars. Even in antiquity there were rules, policies, and regulations on how to behave as a physician. Next to Hippocrates, Galen is probably the next most famous physician in history. His works and texts continued to be studied by medical students and scholars for hundreds of years after his death. When Galen ventured to Rome in 161 A.D. he was met with hostility by the medical establishment. For five years he was able to remain to practice medicine, lecture and conduct public discussions under the protection of the powerful Emperor Marcus Aurelius who named him the “first of physicians and philosophers”.2 Eventually, Galen left to return to Greece complaining that he had been driven out of Rome by the medical establishment who saw him as an interloper. Galen did subsequently return to Rome honoring a request from Marcus Aurelius. He remained for the rest of his life.

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