Fall 2008

Unspeakable Subjects

Shame and the Hippocratic Oath

George Makari

Public health poster designed by Foster Humfreville and Alex Kallenberg for the WPA Federal Art Project, 1937.

While researching my history of psychoanalysis,[1] I stumbled onto this: the FBI was spying on an European émigré, a socialist, who had resettled in this country. As the Cold War built to a crescendo, the word went out to the local mailman and the neighborhood informants to report any suspicious activity at the foreigner’s residence. They did. Every fifty minutes of so, the undercover agents noted, a car would pull up and a stranger would enter the house. Often these visitors looked nervous, as if they did not want to be seen. With bizarre, machine-like regularity, fifty minutes later, the first person would exit from a side door, while another would enter from the front. If the two guests ever crossed paths, they ignored each other and acted like there was something to hide. Again and again, all day long, this dance repeated itself. What furtive messages were being passed on in that home?

Like that exile, I traffic in secrets. We are both doctors, in our cases psychiatrists, who have sworn ourselves to a code laid down in the fourth century BCE. While forgoing any allegiance to “Apollo the Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses” as was initially demanded, my graduating medical school class agreed to abide by a central tenet laid down in the Hippocratic oath. “What I may see or hear in the course of treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken of.”[2] While this oath changed over time, its ethic of discretion persisted. In 1100, Constantine the African wrote that a doctor should “keep to himself confidential information containing the ailment, for at times the patient makes known to the physician things that he would blush to tell his parents.”[3] Others went so far as to suggest that physicians should not employ assistants, for fear these helpers might break this sacred vow.

And so, for over two millennia, doctors have been receptacles for matters of body and soul that their own society found obscene.[4] Doctors hear of silent plagues, strange growths, acts of self-destruction and abjection, terrifying family legacies, sex of all sorts, crushing poverty and neglect, betrayals and violence, addictions, madness, bodily decay, and news of impending death itself. They are our everyday concerns.

The moment of revelation is familiar to me: a sudden pause or a faint blush, and a patient’s face closes in thought. After some effort, he forces his way outward to disclose perhaps no more than the existence of some unspeakable subject, a private matter that might bring humiliation or a hail of stones if told in the village square. All doctors confront these critical junctures where public shame and medical necessity collide. And as Hippocrates understood, in these moments, propriety can be deadly. Old, mysterious Hippocrates, whose works are mostly a collated mish-mash of murky origin, this mythic father of medicine, established an ethic that overrode gossip, law, religious belief, and social morality, so that a physician might more fully enter into the lives of his patients. Physicians were obliged to keep their mouths shut, so their patients might not die of shame.

But what happens to the medical journeymen as they pass back and forth between the private and the public, and absorb so much their own community deems disgusting or reprehensible? What did old Hippocrates’ simple commandment do to his own people?

Poster designed for the WPA Federal Art Project, artist unknown, 1937.
Poster designed by Erik Hans Krause for the WPA Federal Art Project, 1938.

Some can not bear the brute contradictions they have been forced to witness and reach the conclusion that it is not their patients but their society that is sick. Consider the French physician, novelist, and Fascist sympathizer, Louis-Ferdinand Céline, whose jaundiced eye focused on one brutal social sham after another, or the German doctor and writer, Alfred Döblin, whose brilliant Berlin Alexanderplatz exposes his society’s rituals as insane, perverse, and hateful. Over the last century, revolutionary movements have often attracted disillusioned medical students and doctors, from Che Guevara to Ayman al-Zawahiri.

Of course, the overwhelming majority of Hippocrates’ heirs simply become masters of forgetting. A kind of double-consciousness emerges during medical training, a mental lockbox for the working day in which social codes are replaced by the ideals of cool objectivity and scientific knowledge. This other room begins to be built in the first semester of medical school, when students undergo their shocking initiation in anatomy lab—cutting open faces, penises, and breasts. By the time young doctors treat their first patients, they have developed a different frequency on which to hear “symptoms.”

In this register, the secrets themselves no longer even surprise. As patients step gingerly into my office, they are often convinced that they have a hidden mark that if discovered would make them outcasts. What they can’t quite imagine is that in offices around the world, at the very same moment, similar confessions are being heard. When I was a novice, a psychiatry professor once stunned me by saying there really were only a dozen or so “secrets.” When a patient told him there was something he had never told a soul, it wasn’t too hard to guess its nature.

However, even if people in the same culture hide the same things, I am interested in the fate of those untold stories, which involves not just their content, but the way these pieces of intense interiority crystallize so much else. In its earliest incarnation, psychoanalysis sought to liberate pathogenic secrets, but it soon became clear that confession alone was not enough. Secrets were not just sick-making; they were woven into the fabric of our being and helped color and construct our subjective worlds. Our interiority itself was a parade of concealed thoughts. I vividly recall my first recognition of this simple fact. I was perhaps five, and kidding around with my parents in their bedroom, when to avoid some perceived reproach, I blurted out a lie. I was confident my mother would, as always, gaze into my glass head and see that these words were untrue. She said nothing. Stunned, I locked myself in the bathroom and stared at the cold porcelain tiles on the walls. Ashamed and confused, I now faced a totally unforeseen dilemma. And for the first time in my life, I felt the loneliness, the weight, and the power of having a mind that was constantly humming and hidden.

In our era of massive health databases and managed care, patient confidentiality is at risk. What, we have been forced to ask, is this ethic worth? As our societies shift toward a global interconnectedness, perhaps we will have no need to remain so hidden. A friend who was going through a divorce dreamed of such a utopia. As she worried that her doctor’s notes would be requisitioned by the court and made available to the press, she wondered what it would be like if everyone gave up this game, and loosed their private lives into the public arena. Perhaps we would all be more charitable, and no longer act so dismayed by the clandestine things humans think and experience. Or maybe we would need to create new secrets to symbolize all that remains unspeakable in our subjective worlds, that private inner realm that must be antisocial by its very nature, and yet thanks to Hippocrates, can be safely shared with a select few, so that our shame does not kill us.

  1. George Makari, Revolution in Mind: The Creation of Psychoanalysis (New York: HarperCollins, 2008).
  2. I have cited the 1943 translation of the Hippocratic Oath by Ludwig Edelstein, as reprinted in Loren C. MacKinney, “Medical Ethics and Etiquette in the Early Middle Ages: The Persistence of Hippocratic Ideals,” in Bulletin of the History of Medicine, vol. 26, no. 1 (1952), p. 31.
  3. Ibid., p. 27.
  4. See Steven H. Miles, The Hippocratic Oath and the Ethics of Medicine (Oxford: Oxford University Press, 2004).

George Makari is the director of the Institute for the History of Psychiatry and associate professor of Psychiatry at Weill Medical College of Cornell University. He is the author of Revolution in Mind: The Creation of Psychoanalysis, which was published by HarperCollins in 2008.

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