Introduction

Life is short, and the Art long; the occasion fleeting; experience fallacious, and judgement difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals co-operate. (Adams 1985, 697)

The significance that this Hippocratic first aphorism has had for medical practice, and for medical education, rests on an understanding of its purpose, and on its positioning as the first among the 412 aphorisms that reflect the cumulative clinical experiences and knowledge gained by physicians in the periods that preceded and followed the life and work of Hippocrates. This aphorism’s importance has rested primarily on the evident wisdom within each of its first sentence’s five epigrams, whereas the second sentence’s directives that centre on the physician’s duties to his profession and its codes of conduct and to the responsibility he has to ensure his patient’s compliance with his treatment have received little meaningful analysis.

The aphorism’s second sentence contains two quite clear imperatives, must and make, directives that over two millennia have guided the professional conduct of physicians in the care of their patients. While such paternalistic injunctions are no longer accepted in contemporary clinical practice, in question is the degree to which these directives have been understood and the extent to which they may have been applied. Through an examination of the various renderings of this aphorism, the level of appreciation of the moral implications within these imperatives will be examined.

This essay undertakes a historiographic survey of the available extant English translations and interpretations of this aphorism from Greek, Latin, Syriac, Arabic, and Hebrew sources, in order to develop an understanding of the Hippocratic intent of this aphorism and the merit of its associated professional codes. It is hoped that some insights into the nature of the enduring Hippocratic model will thereby become evident, as expressed by Jouanna:

The Hippocratic model … ideally feeds the doctor’s conversation with the patient, reminding him and making him understand his duty of obedience. The Hippocratic model serves as a guide not only for the behaviour of the patient, but also for that of the doctor. (Jouanna 2012, 268)

Our physician forefathers’ acceptance of the evident paternalism within this aphorism, and their failure to comprehend its moral imperatives, reflects the veneration that was given to Hippocrates and the reliance that was placed on four of his Corpus books for ethical guidance. Those books were The Aphorisms, The Oath, The Law, and Epidemics 1, which with the art of medicine, were deemed to provide sufficient moral direction.Footnote 1 Each book was accepted as an authentic Hippocratic work and each was to contribute to the understanding of the physician’s professional obligations. Of these, Francis Adams suggested that The Aphorisms had been written in Hippocrates’ old age with the intent to, “give in a general view all the grand results of his preceding inquiries” (Adams 1985, 687).

These books, and others within the Hippocratic Corpus, were sufficient to establish a lasting devotion to Hippocrates, his teaching, and his practice methods and to generate a literature which has continued throughout the ensuing centuries. Such fidelity has persisted as an enduring Hippocratism and the acceptance of the professional standards that were expressed in Epidemics 1:

The physician must be able to tell the antecedents, know the present, and foretell the future—must mediate these things, and have two special objects in view with regard to diseases, namely, to do good or to do no harm. The art consists in three things—the disease, the patient, and the physician. The physician is the servant of the art, and the patient must combat the disease along with the physician. (Adams 1985, 360)

The Nexus Between Hippocrates and Hippocratism

Hippocrates’ fame as the ideal physician and as the first to treat the body as one whole was established by Plato in Phaedrus (270a), and his renown as a well-known physician was confirmed in Protagoras. Aristotle furthered his high regard by referring to him as “The Great Physician,” and Meno, Aristotle’s student, wrote of Hippocrates’ disease causation theories (Smith 2019). These important works, with Herophilus’ commentaries on Hippocrates’ Prognostics and Aphorisms (Mansfield 1980), Erotian’s lexicon of the Hippocratic writings, and that by other ancient authors as discussed by Elizabeth Craik, facilitated Galen’s detailed study of Hippocrates and the Hippocratic Corpus, which he recorded in his Commentaries on Hippocrates (Craik 2018).

However, Galen had made no mention of The Oath, The Law, or other Hippocratic deontic books; rather he relied on the professional standards that were expected of a physician in his society (Drizis 2008), and his Commentaries were to become, “the best guide on the subject” (Mattern 2013, 57).Footnote 2 Galen’s writings became the basis for an ensuing veneration of Hippocrates and his works, the preservation of the Hippocratic Model, and the acceptance of Hippocrates’ physician-based ethics:

Galen’s enthusiasm for certain texts in the Hippocratic Corpus was crucial to the continuing interest later physicians took in Hippocrates and his writings, and Hippocratic texts were copied in sufficient numbers to survive into Byzantine times and be reimported into the West during the Renaissance. (Hanson 2015)

Such Hippocratism was perpetuated through a pervasive philosophy-based teaching and practice of medicine that was characterized by four tenets: an adherence to the essential principles of Hippocratic medicine that entailed an art centred around the idealism of The Oath and The Law; on the meticulous observation of the patient that is evident in The Aphorisms; on the application of an empirical and inductive reasoning process in establishing the patient’s diagnosis, management, and prognosis that is inherent in The Prognostics; and on a reliance on the wisdom that is gained through practical experience (Fabre 1998; Ni 2017).

Hippocrates’ teaching and his practices became the standard that physicians would follow, and the trust that was placed in his writings was furthered by an unquestioning acceptance of the rightness of the first aphorism and its inherent paternalism, its innate heteronomy, and its doubtful moral standards.

That faith has persisted despite Galen’s doubt about the authenticity of the authorship of many of the sixty Hippocratic Corpus books, a doubt that had been expressed by others before Galen, and by many after him. Among those were the fifth-century monastic John the Solitary, the sixteenth-century Lois de Lemos who followed Galen’s opinions, and in 1595, Anunce Foës in his book Economia Hippocratica. Hieronymus Mercurialis, another sixteenth-century physician and philologist, translated the Hippocratic Corpus and determined the authenticity of each book, “[by] deciding what are the peculiarities of the style of Hippocrates, and in applying them as a test of the genuineness of the other works which had been attributed to the same author” (Adams 1985, 29).

Two others who questioned the Hippocratic Corpus were Daniel Le Clerc in The History of Physick, published in English in 1699 (Le Clerk 1699) and J.R. Coxe in The Writings of Hippocrates and Galen, published in 1846 (Coxe 1846).

That doubt was referred to as the “Hippocratic Question,” which, seemingly, was resolved by Emile Littré in his ten volume Oeuvres Completes D’Hippocrates and by Francis Adams in his 1849 The Genuine Works of Hippocrates, each author having referred to Mercurialis in making their determinations. Francis Adams rejected forty-six of the Corpus books and agreed with Littré that The Oath, The Law, The Aphorisms, Epidemics I and III, Prognostics, On Ancient Medicine, and seven others were the authentic Hippocratic works (Adams 1985, 28).

Adams also concluded that Galen’s commentaries, with Erotian’s lexicon, formed the basis of “a correct judgement respecting the authenticity of the Hippocratic treatises” (ibid.).

Galen’s Commentaries on Hippocrates was to have a profound influence on the continuity of the medical knowledge contained within the Corpus: “[he] saw his principal duty to be to explain Hippocrates by pointing out the reasons and learning that must underlie the medical wisdom of Hippocrates: Hippocrates needs interpretation said Galen” (French 2003, 48).

The understanding of the influence that Hippocrates had was considered by Henry Sigerist:

For more than 2000 years the great figure of Hippocrates, the “Father of Medicine,” had inspired the healing art. The works transmitted under his name had been copied and printed over and over again, for more than 2000 years. Medicine had progressed that long period of time. Vesalius, Harvey, Morgagni and so many others had laid the foundations of a new system of medicine. The Hippocratic books were no longer textbooks. And yet the medical world still venerated them as you venerate your ancestors. The physicians still admired the keen sense of observation of the Hippocratic doctors, their sound judgment in evaluating symptoms of disease, their carefully balanced therapy. One felt a sentimental attachment to Hippocrates. He was still fully alive. (Sigerist 1934, 190)

Such Hippocratism has persisted with little change throughout the medieval and modern periods, during which the discussions of Hippocrates’ first aphorism have been characterized by a consistent series of philological interpretations of the five important epigrams within the first sentence. By concentrating on the significance of these epigrams and the difficulties that confront physicians in their practice of medicine, many commentators have given little consideration to the unavoidable moral issues that are inherent in the care of each patient, issues that invariably involve the determination of what should be “the right thing to do.” That determination represents a decision-making process that reflects on the physician’s character and on his virtue, which, together with the innate moral dimensions of the second sentence, have received little meaningful consideration.

Instead, discussions that have concerned the ethical practice of Hippocratic medicine have centred on the Hippocratic Oath, The Law, and Epidemics 1. Of these, it is The Oath that has been thought to epitomize the moral principles of Hippocratism, which, in guiding the professional behaviour of physicians, was said to have become “the nucleus of all medical ethics” (Edelstein 1943, 64).

The reliance on and faith in Hippocrates and his Oath were questioned almost two centuries ago by John Coxe who in 1846 wrote:

I think it must be conceded, that … we cannot … admit that the title of Father of Medicine is justly his due. … Since it is incontestably proved that many of those treatises we admire as his, have really emanated from other sources. (Coxe 1846, 24)

Despite Coxe’s argument, it remained for Ludwig Edelstein, a century later, in 1943, to argue that the Oath had not been written by Hippocrates at all but by others some time after him, an argument that would seem to have been widely accepted. In 2005 Robert Veatch made this comment:

The Hippocratic ethic is dead. It should be allowed to die with a dignity worthy of a once honoured tradition. It is too paternalistic, and too consequentialist to be compatible with a plausible ethical stance for relations between health professional and lay people. ... It is rapidly being replaced by an ethic focussing on broad moral principles ... such as autonomy and justice as well as patient welfare. ... This is as it should be if we are to move beyond the era of Hippocrates. (Veatch 2005, 48)

Such Hippocratism was examined in 2001 in a collection of essays that considered the way in which Hippocrates and Hippocratism have been presented and used as tools for his promotion by his protagonists. Cunningham wrote that, “the image(s) and reputation(s) of Hippocrates created or current in any particular age meets the demands of that age, and may have little to do with the historical figure” (Cunningham 2001, 91), and John Warner in the same book went further and wrote:

In investigating the uses of Hippocrates, however, it is important to keep in mind that function is not meaning, or at least does not exhaust it. Hippocrates—who by the nineteenth century, was Western medicine’s most renowned mythical figure—was an obvious candidate for veneration, and it is hardly surprising that physicians laid claim to him not merely by drawing attention to how they resembled Hippocrates but also by representing him in ways that made “the father of medicine” resemble themselves as much as possible. Stories about Hippocrates were largely stories about identity—vehicles for displaying conceptions of self and for clarifying the social, moral and epistemological boundaries that distinguished self from the other. (Warner 2001, 221)

David Cantor, the editor of Reinventing Hippocrates, gave further reason to doubt the accounts of Hippocrates’ personal contributions:

There are various reasons why older accounts of Hippocrates created problems for understanding the various ways in which he has been portrayed … . Firstly, they tended to give Hippocrates or his ideas the primary role in influencing subsequent generations. Somehow Hippocrates reached out from death and the distant ancient world to shape the thoughts and actions of later peoples … . Secondly, Hippocratic values were often regarded as unproblematic and unchanging … . The Hippocratic tradition is, therefore, an “invented tradition,” constantly reinvented over time. (Cantor 2001, 2–3)

Then, in 2018, the authenticity of the entire Corpus was questioned by Craik, Pormann, and others, in the Cambridge Companion to Hippocrates (Pormann 2018).

Each of the arguments advanced by these scholars is sufficient to confirm, and put to rest, the doubts concerning Hippocrates’ authorship of the fourteen books that Littré and Adams had regarded as his. However, there has remained the persisting influence of physicians such as William Osler, perhaps the most famous physician of the nineteenth and early twentieth century, who epitomized that long tradition of Hippocratism:

The public of today makes it increasingly difficult for the physician to walk in the old paths, and yet, we cannot afford to abate one jot or tittle from the noble standards of the Hippocratic code, that most memorable of human documents. (Osler 1902, 158)

Osler’s Hippocratism, and his trust in the Oath, reflected that which Robert Veatch had chronicled in the development of the British Medical Association Code of Medical Ethics from 1849. Over a century later, in 1963, that code described the Hippocratic Oath as, “the most celebrated expression of the ethic of the profession, [and] the fundamental principles of professional behaviour have remained unaltered through the recorded history of medicine” (Veatch 2005, 77). Veatch also commented that while the initial nineteenth-century American discussions of a code of medical ethics had centred around that of the Scottish School, it was ultimately based on, “[t]he new-found interest in the Hippocratic literature, especially the Oath, [which] provided a one-page version of a medical ethic that sounded both profound and distinguished” (Veatch 2005, 7).

However, that dependence on the Oath and other Hippocratic era deontologies by Hippocratists had overlooked the expression of the professional and ethical requirements that were expected of a physician that Galen had determined and recorded in his comprehensive treatise, The Best Physician is Also a Philosopher:

What grounds are then left for any doctor who wishes to be trained in the art in a way worthy of Hippocrates not to be a philosopher? He must be practiced in logical theory in order to discover the nature of the body, the differences between disease, and the indications for treatment; he must despise money and cultivate temperance in order to stay the course. He must, therefore, know all the parts of philosophy: the logical, the physical, the ethical …. And so he is bound to be in possession of the other virtues too, for they all go together. It is impossible to gain one without acquiring all the others as an immediate consequence; they are connected as if by one string. If, then, philosophy is necessary to doctors with regard both to preliminary learning and to subsequent training, clearly all true doctors must be philosophers. (Singer 1997, 30–34)

Galen’s exhortation demonstrates that the best physicians were expected to know those parts of philosophy that related to ethics and the virtues, and that such principles were to be expected of the physician in his practice of the art of medicine and in his decision-making. However, through the ensuing centuries of Hippocratism, physicians have carefully followed the aphoristic principles of Hippocratic medicine and have closely followed the specific directives within the first aphorism.

By doing so, they have in effect reversed the Epidemics 1 sequence that refers to the art of medicine and its trilogy, the disease, the patient, and the physician, and have placed the physician before the patient, one to whom he should be the servant (Jones 1931, 165).

The Significance of the First Aphorism

In addition to the duties that are expected of the doctor and the reciprocal responsibilities that should exist between doctor and patient are the aphorisms which “[were] probably meant to give an exposition in brief terms of all the principles of medicine, physiology, and practical philosophy” (Adams 1985, 686). They had been written by a person, “who had been long familiarly acquainted with the phenomena of disease, and had maturely reflected on all the various subjects to which the several books of the Aphorisms relate” (Adams 1985, 687). Among the many who have discussed these aphorisms is Roger French, who described them as:

Condensed pieces of wisdom … that seemed to be the product of long experience … [that] always seemed to need little explanation and every subsequent generation of doctors interpreted them in its own way, indicating what they surely had meant in antiquity in terms accessible to the contemporary world. (French 2003, 49)

French’s comment can be applied to the first of these aphorisms, one that has generated considerable discussion on its philology, its practical philosophies, and the accepted principles of medical practice that are inherent in its meanings and intentions.

William Osler, an acknowledged medical historian, illustrated French’s comment when he wrote in his Evolution of Modern Medicine: “But no single phrase in the writings can compare for directness with the famous aphorism which has gone into the literature of all lands: ‘Life is short and Art is long; the Occasion fleeting, Experience fallacious, and Judgement difficult’” (Osler 1921, 65). Osler, in avoiding any comment on the aphorism’s second sentence, demonstrated his acknowledged disinterest in philosophy (Veatch 2005, 130–135), in the professional mores of his time (Bliss 1999),Footnote 3 and in the importance that he had placed on the Oath (Osler 1902).

A century later, Albert Jonsen discussed the supposed bioethical insights inherent in the aphorism: “The famous first aphorism of Hippocrates, ‘Life is short, the art is long’ was long considered a perfect summary of medical ethics” (Jonsen 2006, 667). While Jonsen had analysed the contemporary technological and moral aspects of “the art is long,” and referred to the aphorism’s second sentence, he did not discuss its patient-relative professional mores; rather, he discussed it in relation to modern technology and referred to Maimonides’ perception of the “externals” (Jonsen 2006, 672).

A further viewpoint was advanced by Steven Miles:

Hippocrates and his followers created an empirical medicine grounded in ethical promises. Most physicians are familiar with the Hippocratic Oath …. Many modern medical ethicists, however, view the Greek physician-patient relationship as paternalistic in which the physician concealed diagnostic or prognostic information from the patient. (Miles 2009)

Such paternalism was indeed an evident part of the Hippocratic Art of Medicine, as was the acceptance of its implicit deontic and moral dimensions. Galen added to such dimensions by writing that both he and Hippocrates had “healed people for the love of mankind” (Mattern 2013, 289), a dictum which exemplifies the philosophical ideas that physicians have promulgated since Hippocrates, which ostensibly centre on a love of humanity and, presumably, encompass a similar love that is due to each patient.

However, within the many discussions of the aphorisms, it is the first that has received the most attention and given guidance to physicians in the conduct of their practices: “Men found in the aphorism, purged of its mysticism and obscurity, a most convenient means of expressing their thoughts. It served as an ideal vehicle of generalised fact” (Jones 1931, xxvii). Such facts refer to each of its five epigrams and to the quite explicit directives in the second sentence that have determined the conduct of the physician in his management of his patient.

Of the various renderings of the first aphorism, it is that of Francis Adams that has become the most widely-accepted interpretation, and warrants recall:

Life is short, and the Art long; the occasion fleeting; experience fallacious, and judgement difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals co-operate. (Adams 1985, 697)

The five famous principal epigrams within the first sentence were the work of an ancient physician-philosopher whose experiences and reflections led him to succinctly summarize the challenges that had confronted he and all physicians in their practice of the art of medicine. These epigrams have been the subject of persistent scrutiny and considerable analysis in the desire of each commentator to better determine Hippocrates’ meanings and his purpose and, to provide a truer interpretation of the original. However, it is the second sentence that has received little critical evaluation and even less examination of its moral significance, which positions the physician as the servant of a deontic art, who, as part of his professional duty, applies that art to the management of the disease, to the direction of the patient regarding her responsibilities, and to the attendants regarding theirs. His duty has required him to ensure the compliance of the patient and her attendants, and the control of the external factors.

Given such endless discussions of Hippocrates, his Oath and this aphorism, it is assumed that the second sentence’s expression of a deontic philosophy was accepted by the physicians in, and since, the Hippocratic era, despite being inconsistent with the professed love of humanity and of mankind. That love centred on a popular expression purportedly written by Hippocrates: “If love of humanity is present, love of craft is also present” (Hinohara and Niki 2001, 97),Footnote 4 which Jones had rendered as: “For where there is love of man there is also love of the art” (Jones 1931, 319). However, such a dual relationship should not have one dependent on the other and should be true as a generic love of man alone and not reflect a paternalism that has been evident in medical decision-making. Rather, the physician should be the servant of the patient who is the essence of the trilogy of the disease, the patient, and the physician.

Given also that the “love of humanity” quotation had come from the apocryphal Precepts and that Edelstein had regarded the Oath as apocryphal, the Hippocratic moral imperative that is central to the first aphorism and to Hippocratism may also be questioned, as may Jonsen’s renditions of the aphorism and his comment that it was a “perfect summary of medical ethics” (Jonsen 2006, 667).

Jonsen, in his Short History of Medical Ethics, rendered the aphorism from the 1959 edition of the Loeb Classical Library book, Hippocrates IV:

Life is short, the art is long, opportunity fleeting, experiment treacherous, judgement difficult. The physician must be ready, not only to do his duty himself, but also to secure the co-operation of the patient, of the attendants and of externals. (Jonsen 2000, 25)

However, in a subsequent article, “Reflections on a Bioethical Insight,” Jonsen transcribed a different version of the first aphorism from a source he cited as the “1962” Loeb edition of Jones’s Hippocrates IV.Footnote 5

Life is short; the medical art is long. Opportunity is fleeting, experience perilous and decision difficult. The physician must be ready, not only to do his own duty, but also to secure the co-operation of the patient, of the attendants and of externals. (Jonsen 2006, 669)

In considering the first sentence epigrams, Jones had, in 1931, differed from Adams’ 1849 translation in using opportunity instead of occasion, experiment in place of experience, and treacherous for fallacious. This—and Jonsen’s 2006 use of perilous and decision—were further variations that made little difference to the meanings or intent of the sentence. However, each rendition perpetuated the deontic imperatives of the second sentence and affirmed the principles that Hippocratic physicians would have employed in their practices.

Notwithstanding that Adams’ second sentence directive to make was rendered by Jones as to secure, the moral significance of the imperatives was made quite clear by Jonsen: “An imperative is a strong moral word; it is a command, imposing an obligation without exception” (Jonsen 2006, 671).

That obligation became a centrepiece of Hippocratism, and the moral significance of the first aphorism’s second sentence has remained “hidden in plain sight.” Despite Miles’ determination of its paternalism and Jonsen’s acknowledgment of its deontology, there has been little examination of the ethical significance of the imperative nature of the second sentence.

Galenic and Medieval Interpretations of the Aphorism

Galen’s rendition of the second sentence of Hippocrates’ first aphorism, as presented by Jacques Jouanna, read: “It is not only the doctor who should behave in conformity to his obligations, but also the patient and the people present,” and wrote of the discourse that is required between the doctor and the patient. The doctor should explain his responsibilities to the patient and, as well, make her understand her duty of obedience (Jouanna 2012, 266–267). However, Galen did not employ the imperatives that later interpreters would.

Among those who followed Galen, the earliest to interpret the first aphorism was John the Solitary, who in the late fourth century translated the aphorisms from Greek into Syriac. His interpretation of the first sentence of the first aphorism was presented by George Kessel:

The followers of Hippocrates, who were admirable in the art of healing, said, concerning all knowledge of the body, life-time is short and the art is long. Which is to say that all a person’s life, as long as it might be, is too short [for him] to comprehend in his mind the teaching of the richness of the branches of medicine. (Kessel 2015)

While discussing neither the fourth and fifth epigrams, nor the second sentence, John the Solitary had suggested that the aphorism had been written after Hippocrates; his interpretations formed the basis of Isaac of Nineveh’s comments in the seventh century. Thereafter, among the pre-Renaissance translations, “more than twenty authors between the tenth and sixteenth centuries” were in Arabic (Pormann 2019), which were to preserve Galen’s Commentaries on Hippocrates for the scholastics in the early Renaissance universities.

Among the Islamic scholars was Hunayn ibn Is-haq al-Ibadî (Johannitius), a ninth-century pre-eminent physician and philosopher, author, and translator, whose translations of Hippocrates, Plato, Aristotle, Galen, Dioscorides, Ptolemy, and other Greek authors became the cornerstone of Arabic science and determined the evolution of Arabic medicine. Next in importance was Constantinus Africanus, who, during the eleventh century, translated into Latin the Arabic renditions of Galen’s Aphorisms and his commentaries but seems not to have interpreted them.

Then, during the twelfth century, Moses Maimonides’ based his Arabic Commentary on the Aphorisms of Hippocrates on the earlier translations of Johannitius. His works were of considerable importance in both Arabic, and, when further translated, in Hebrew. In 1963, Bar-Sela and Hoff examined both the Arabic and Hebrew texts of Maimonides Commentary and translated his first aphorism into English:

Life is short, the Art is long, the time limited, experiment dangerous and judgement difficult; you should not be content with resolving upon whatever action is appropriate unless the patient and his attendants do the same, and the external matters also. (Bar-Sela and Hoff 1963, 349)

Following a detailed discussion of the interpretation of each of the five epigrams, they quoted Maimonides’ comment on the second sentence:

Because of the moral virtues of Hippocrates, he commands in this aphorism with which he begins, that the physician should not be content with doing what is proper only, and stop there, because this is not sufficient for the recovery of the patient. For, the end will be accomplished and he will recover, if the patient, also, and all those about him, will do with the patient that which is proper to be done, and remove all the external impediments that prevent the healing of the sick. (Bar-Sela and Hoff 1963, 354)

While Maimonides had explained the ethical responsibilities that are inherent in this aphorism, and the responsibilities that are shared by the physician, the patient, and the attendants to best provide for her care, he continued:

He [the physician] should address the patient and those about him, warn them against making mistakes, and make those about him undertake his care as is proper in the absence of the physician. … Only to say what should be done and then depart, he should not do. (Bar-Sela and Hoff 1963, 354)

Despite recognizing the moral significance of the aphorism, Maimonides’ directives, commands and make, are alike in meaning to Adams’ must and make. Notwithstanding that the Hippocratic physician explained his treatment to the patient and ensured the removal of any deleterious environmental or other factors and exercised his social responsibilities and his moral virtue, Maimonides became the first to employ the imperatives.

Paracelsus, in the sixteenth century, translated the aphorisms into Latin with his own idiosyncratic interpretations, which were discussed by Wesley Smith (Smith 1979). Paracelsus was very critical of the works of both Aristotle and Galen and of the scholastic’s interpretations of the ancient’s writings. But while he had accepted the authority of Hippocrates, his interpretations of the Hippocratic first aphorism were conditioned by his own astrological convictions and his argument that physicians must have a knowledge of all nature and the cosmos. When commenting on the third epigram, “the occasion fleeting,” Paracelsus revealed his predilections by arguing that as man is influenced by both time and season, and, as Hippocrates was an astronomer, the epigram was saying: “the physician should be an astronomer” (Schlueter 1936, 457). Paracelsus moved on to discuss the second sentence and wrote: “Hippocrates wants the patient to be obedient and to do all that is offered him and applied by the physician” (Schlueter 1936, 460) Again, there are imperative requirements in wants and obedient.

Next, was Rabelais, also in the sixteenth century, who edited a volume of Hippocrates’ aphorisms, with the vulgate on one page and on the opposite, the Greek. However, he neither translated nor interpreted them.

The first English medical textbook was written by Peter Lowe, The Whole Coverse of Chigurgerie, in 1597, in which he wrote a dedication; “Whereunto is annexed the presages of divine Hippocrates” (Lowe 1597); however, he did not discuss the Hippocratic aphorisms. The first Englishman to do so was Richard Redmer, who in 1610 translated the Aphorisms into English as The Aphorismes of Hippocrates, Prince of Physitians. His translation of the Galenic rendition of Hippocrates’ first aphorism read:

The life of man is short, the Arte of Physicke long, occasion suddaine, experiēce vncertain, iudgement difficult. Neither is it sufficient that the Physicion do his office, vnlesse also the Patient, and those which are attēdants about him doe their dutie, and that outward things bee as well ordered as those that are giuen inwardly. (Redmer 1610)

While this 1610 translation is without either of the Adams’ imperatives must or make or Jones’s must be ready and to secure, the inherent deontic imperatives that Galen had rendered as Hippocrates’ remain.

Following Redmer, in 1675 Lucas Verhoofd translated Galen’s aphorisms into Latin, which in 1817 Elias Marks translated into English as The Aphorisms of Hippocrates, from the Latin Version of Verhoofd. Verhoofd’s interpretation of Galen’s first aphorism read: “Life is short, art long, occasion brief, experience fallacious, judgement difficult. It is requisite that the physician exhibit what is essential, and that the patient, attendants, and all that surround him, concur therein” (Marks 1817, 29). While the Verhoofd/Marks imperative, requisite, had applied to the physician’s duty, the paternalistic expectation that both the patient and the attendants would concur remained.

In 1696, twenty-one years after Verhoofd, Daniel Le Clerc translated the first aphorism in his Histoire de la Médecine:

Physic, like other Arts, has its good and bad Workmen. The Art is of great extent, life short, opportunity slippery, experience fallacious, and judgement difficult. It is not enough that the Physician does his duty, the Patient and those about him must do theirs, and things about him must be in convenient order. (Le Clerc 1699, 338)

While Le Clerc had expected the physician to perform his deontic responsibilities, he made clear to the patient and those around him that their responsibility was to comply with the physician’s recommendations, while employing no directive to either the patient or the attendants.

Of these English renderings of Galenic and Medieval interpretations, only Maimonides had required the physician to explain his treatment to the patient; however, he was the first to portray the aphorism’s two second sentence imperatives. He was followed by Paracelsus, Redmer, and Le Clerc, whose renditions also expected the patient to be obedient to the doctor’s directives and perpetuated the aphorism’s inherent paternalistic deontology.

Within these twelve renditions of the first aphorism, there is a sufficient degree of consistency to warrant that the deontic imperatives were the intent of its original author and that his intentions were accepted and applied by successive generations of physicians.

Modern Interpretations of the Aphorism

Thirty-two years after Elias Marks’s translation of Verhoofd, Francis Adams’s translation from the Greek rendered the physician’s directive as must, and rather than requiring or expecting the patient to concur, he gave the physician the responsibility to make the patient cooperate. His complete translation is restated: “Life is short, and the Art long; the occasion fleeting; experience fallacious, and judgement difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate” (Adams 1985, 697).

Below this aphorism, Adams wrote the following commentary:

His work bespeaks at once the reflective philosopher and the practiced physician ... [and] evinces how well he had apprehended the difficulties which beset the practitioner of Medicine, who must not only be well acquainted with the part which he himself has to act, but ought also to possess the talent of making the patient, the assistants, and all around cooperate with him.

Adams made it quite clear that the physician must be able to make the patient and the attendants cooperate; he advised that experience may be interpreted as experiment and that secure had little meaningful difference to make. He also wrote of the aphorisms: “Every previous attempt to confer upon this great work its proper position in the English literature has proved a complete failure” (Adams 1985, 685) That failure in regard to the first aphorism was seemingly righted by William Osler in 1913, who wrote: “But no single phrase in the writings can compare with the famous aphorism …. Everywhere one finds a strong, clear common sense, which refuses to be entangled in either theological or philosophical speculation” (Osler 1921, 65). Given that the first sentence expresses no ethical philosophy, as does the second, and that Osler, a determined Hippocratist, had made no reference to its second sentence, and had little interest in philosophy (Veatch 2005, 130–135), it could be presumed that he had accepted its imperative nature and not considered its moral significance.

During the same period, Émile Littré was writing his monumental ten volume Oeuvres Completes D’Hippocrates; however, as there is no extant English translation, his important work has not been included in this survey.

The next, and perhaps the most important, English translations of the works of Hippocrates were published between 1923 and 1931 by W.H.S. Jones, whose first aphorism read: “Life is short, the Art long, opportunity fleeting, experiment treacherous, judgement difficult. The physician must be ready, not only to do his duty himself, but also to secure the co-operation of the patient, of the attendants and of externals” (Jones 1931, 99). Jones’s translation of the second sentence included the words must, duty, and secure; each of which confirms the physician’s responsibility to ensure that his management is accepted and acted upon by the patient and those about her. He had also written:

Declare the past, diagnose the present, foretell the future; practise these acts. As to diseases, make a habit of two things—to help, or at least to do no harm. The art has three factors, the disease, the patient, the physician. The physician is the servant of the art. The patient must co-operate with the physician in combating the disease. (Jones 1931,165)

Jones confirmed that the patient must accept her responsibility to apply the recommended treatment and ensure her recovery, for if she does not, she must accept an adverse outcome. Physicians from Hippocrates to the modern era, and their patients, have without question accepted these imperative responsibilities as just duties that entail a seemingly unapparent, yet quite evident, deontic and paternalistic authority.

In 1932, George Dock published “The First Aphorism of Hippocrates,” in which he accepted Adams’s translations and discussed at some length the various interpretations that have been placed on the five original Greek epigrams within its first sentence. However, in his discussion of the second sentence he referred to Hippocrates as “a wise and experienced physician who knew well one of the most important parts of the practice of his art … [who] avoided all discussion and argument in one apodictic sentence” (Dock 1932). While Dock’s discussion was more that of a philologist and historian than that of an expositor of philosophy, he had determined that the imperatives within the second sentence were necessarily true and reflected the approach of “a wise and experienced physician.”

Then in 1941, Moses Scholtz altered the whole aphorism to read: “‘Life is short and Art is long,’ says wise Hippocrates; and proceed with care, in dealing with disease. Thy judgement and experience May fail you, as your skill; Seek from thy patient and his nurse Their help and goodwill” (Scholtz 1940). Scholtz’s paraphrasing of the first aphorism’s second sentence reflected a sensitivity to the patient’s concern that was alike to Maimonides initial rendition. In doing so, Scholtz was to become the first of many modern commentators to consider the patient as an autonomous person.

He was followed by Chadwick and Mann, who reinterpreted the Greek and determined that the first aphorism should read:

Life is short, science is long; opportunity is elusive, experiment is dangerous, judgement is difficult. It is not enough for the physician to do what is necessary, but the patient and the attendants must do their part as well, and circumstances must be favourable. (Chadwick and Mann 1950, 148)

Again, the imperatives are evident. They also translated the Oath, and as their translation had taken place one hundred years after Adams, the minor differences in phraseology between the two texts may simply reflect the time changes in English expression.

Next, in 1961, D.W. Richards presented the aphorism in Greek and discussed the different meanings that could be placed on each word and phrase; he suggested that by his rendition “some more coherent thought and stronger meaning may be found,” and argued:

The last three epigrams are sound doctrine also, but these are not as clear; partly, no doubt, because the translations of them differ considerably from one version to another, but partly because they seem disconnected, with no consistent or logical sequence from one to another. (Richards 1961, 61)

He altered three of the five epigrams and modified part of the second sentence to present a further interpretation:

Life is short, and the art long, and the right time but an instant, and the trial precarious, and the crisis most grievous. The physician himself must not only provide the needed treatment, but also hold the confidence of the patient and those beside him and manage the outside affairs. (Richards 1961, 61)

While Richards had succeeded in presenting his translation of the five epigrams as prose, the use of trial suggests a test, or perhaps an experiment—as was used by Maimonides, Jones, Chadwick and Mann, Antoniou, Loscalzo, and Jonsen in his 2006 article. As well, Richards became the first to alter judgement difficult, rendering it as crisis most grievous, in which he was in accord with Jones’s suggestion. His second sentence retained the physician deontology and the need to hold the confidence of both patient and others. Richards likened Hippocrates to a contemporary conscientious physician, but more problematic is his contention that a modern physician would see his patient management as a trial precarious and his judgement as grievous. Nor, in holding the patient’s confidence, did Richards’ doctor grant the patient her independent rights.

In 1963, Bar-Sela and Hoff published the Maimonides translations that were discussed above, and in 1966, Franz Rosenthal presented a further detailed analysis of various Arabic commentaries on the first Hippocratic aphorism, particularly those of a contemporary of Maimonides, Abd-al-Latif al-Baghdadi. Rosenthal discussed the ways in which the philosophy inherent in the first part of this aphorism had been applied to other crafts and suggested the first aphorism should be understood as a preface to The Aphorisms and that Hippocrates had been regarded as a philosophical dogmatist rather than an empiricist. He discussed Abd-al-Latif’s interpretation, “Life is Short, the art is long: the time is narrow, empiricism is a risk, the decision is difficult,” and gave his own explanation of each of the epigrams (Rosenthal 1966). However, Abd-al-Latif had seen the second sentence as an independent aphorism that described the physician–patient relationship:

First [he] gave a description of the agent, telling how he must behave in order to be able to produce the correct action (effect). This he followed by a description of the passive (element, that is, the patient), telling how he must behave in order to be receptive for the action of the agent and to benefit from it all the way through. (Rosenthal 1966)

Then followed an exhortation to the patient and those who attend him, telling them how they must behave: “The patient … must be receptive to all the physician orders him to do and obediently accepts all he prescribes” (Rosenthal 1966). Again, there is an injunctive, a command, that requires the patient to obey, one that was alike to Maimonides commands and make.

Lloyd, with Chadwick and Mann, in 1983 published Hippocratic Writings, and their translation was the same as that of Chadwick and Mann in 1950:

Life is short, science is long; opportunity is elusive, experiment is dangerous, judgement is difficult. It is not enough for the physician to do what is necessary, but the patient and the attendants must do their part as well, and circumstances must be favourable. (Lloyd, Chadwick, and Mann 1983, 206)

Next, in 2003, Roger French wrote:

Life is short, art long, opportunity fleeting, experience deceptive, judgement difficult. It is necessary for him to make appropriate himself, the patient, the assistants and the circumstances …. When we have supplied the verbs and guessed, as Galen guessed, that “him” is the doctor, it is still a rather obscure expression of wisdom. (French 2003, 50)

However, while the usual imperatives were not employed, there remained the expectation that the patient and those around her would comply with the doctor’s directions for her care.

In 2009, Diamandopoulos et al. examined the 412 Hippocratic aphorisms and found thirty-six of nephrologic interest (Diamandopoulos 2009). They referred to the first aphorism as that of Adams but had obtained their copy from the Internet Classics Archive, which had incorrectly referred to the quotation as being that of Francis Adams; rather, the aphorism was that of Charles Darwin Adams who had written it in 1868: Footnote 6

Life is short, and Art [of medicine] long; the crisis fleeting; experience perilous, and decision difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and the externals cooperate. (C.D. Adams 1868)

This same quotation was used by Quentin Shaw in 2009 in his article “On Aphorisms,” in which he cited Jones’s Hippocrates IV Loeb Classical Library edition as the source, which he had obtained through Google Scholar. That citation was also incorrect, for it was also that of Charles Darwin Adams (Shaw 2009).

In 2012, the Jones translation was used correctly by Antoniou et al., who interpreted the aphorism in a more contemporary setting; they cited each epigram in Greek, followed by the English in parentheses, and discussed their meanings in some detail. However, in citing the fourth epigram as experiment treacherous, they instead discussed experience:

The word peira, or experience, originates from the word peiromae, which means to try, to attempt. Experience, along with knowledge, judgment, and astuteness are essential tools a practitioner of medicine needs to possess to successfully proceed into the diagnostic process and provide patients with appropriate treatments. (Antoniou et al. 2012, 867)

Their second sentence was: “The Physician must be ready, not only to do his duty himself, but also to secure the cooperation of the patient, of the attendant and externals.” In their discussion of this sentence, they wrote:

The physician must not only provide the needed treatment to the sick; solely making diagnoses, administering medications or performing medical interventions is a part only of the holistic care the patient should be provided with. The physician should show affection, kindness, patience, and understanding …. Furthermore, the physician must be able to hold the confidence of the patient and those beside him. (Antonio et al. 2012, 867)

However, this initial recognition of a laudable holism and an empathic appreciation of the patient’s needs was followed by a contradiction: “He [the physician] must not only be prepared to do what is right himself but also to make the patient, the attendants, and the externals cooperate” (Antonio et al. 2012, 867). This apparent volte-face gives reason to contend that the inherent imperative paternalism and heteronomy that rests in the Hippocratic first aphorism continues to have an influence in contemporary medicine.

In 2016, Joseph Loscalzo rendered the aphorism as: “Life is short, the art is long, opportunity fleeting, experiment perilous, judgement difficult” (Loscalzo 2016, 383). While his discussion centred on the fourth of these epigrams in which he employed experiment, he determined that the Greek epigram could be interpreted as experiment perilous, experience dangerous, or experience fallacious and noted the variations used by Bar-Sela, Richards, and Antoniou in their interpretations of experience fallacious and that experience may also be interpreted as trial (Loscalzo 2016, 388). However, Loscalzo discussed neither the second sentence nor the approach the physician should make to his patient to ensure her care and determine her recovery.

Most recently, Anthony Papagiannis suggested that experience fallacious should more correctly be translated as fallible experience (Papagiannis 2019) and Pormann suggested the epigrams be “Life is short, the art is long, the [right] time is fleeting, experience dangerous and decision difficult” (Pormann 2019).

Among these various renditions of the first sentence epigrams, life is short was consistently rendered as had Francis Adams, while the second, the art is long, had two variations— Chadwick and Mann’s science is long and Le Clerc’s is of great extent. The third, the occasion fleeting, had variations in both words; occasion was used four times, opportunity six, time four, and crisis once by Richards and twice in the use of Charles Darwin Adams’s interpretation; fleeting was used nine times, and suddaine, limited, slippery, brief, narrow, and elusive each once. The fourth, experience fallacious, was the most discussed epigram. It was translated as experience nine times, experiment six, and empiricism and trial once each. Its second word, fallacious, was used three times, perilous and dangerous four times, and treacherous three times, and risk, precarious, fallible, dangerous, and deceptive once each. The fifth, judgement difficult, was used as such ten times, and instead of judgement, decision was used five times, and both crisis and grievous once.

Within this survey of nineteenth, twentieth, and early twenty-first-century translations and interpretations of Hippocrates’ first aphorism, are seemingly significant differences in the philological interpretations that have been derived from different language sources; however, be the source Greek, Latin, Syriac, or Arabic, the essential purpose of the first sentence remains as Adams had stated: “His work bespeaks at once the reflective philosopher and the practiced physician … [and] evinces how well he had apprehended the difficulties which beset the practitioner of Medicine” (Adams 1985, 697).

The Second Sentence of the First Aphorism

These various interpretations of the Greek, Arabic, and Latin versions of the aphorism’s second sentence have together demonstrated the translational challenges that Adams and others had anticipated, the generational and cultural interpretational differences that had concerned Roger French, the way that David Cantor had seen Hippocratism being represented and employed, and the persisting Hippocratic veneration that was described by Henry Sigerist.

As well, it is evident that the sentence’s deontological phrases are meant to demonstrate the physician’s beneficent purpose that is reflected in his intent to do no harm. Concerningly, however, among these twenty-seven representative medieval and modern commentators, only Scholtz had sought to seek from the patient her help and to involve her in her care. Despite both Arabic translations by Maimonides and Abd-al-Latif al-Baghdadi giving recognition to the role the patient should play, each had concluded that the physician had the right to require the patient to comply with his recommendations.

Uwe Vagelpohl, in comparing the Galenic rendition of Hippocrates’ first aphorism’s second sentence to that from later Arabic translations, demonstrated that such deontology had been evident in the earlier Hippocratic writings. Vagelpohl translated the second sentence of the aphorism first in the Greek and then in the Arabic:

The physician must be ready, not only to do his duty himself, but also to secure the co-operation of the patient, of the attendants and of externals [Greek] …. You should not confine yourself to aspire to perform the necessary action without (ensuring) that what the patient and those who attend him do is the same and the things that are external [Arabic]. (Vagelpohl 2015)

Vagelpohl, in his Arabic translation, continued:

Not only should you know your duty, but you should also secure the co-operation of patients, their attendants, and external things … you should not confine your action to performing your duty, without the patients’ actions being (considered), also those of their attendants, and external things. (Vagelpohl 2015)

The commentaries on the imperatives within this aphorism are consistent in their requirement that the physician should undertake his duty in the expectation the patient, and her attendants, would do their duty and unreservedly accept and follow the physician’s recommendations. Within such imperative directives there exists an evident paternalism and heteronomy that has been accepted since Galen while its inherent and fundamental ethical challenges have remained essentially unseen and so unexamined.

Despite Jonsen’s determination that the first aphorism was a perfect summary of medical ethics, there has been little that has addressed the oversight of its moral dimensions since Galen.

His was the earliest English translation of this aphorism to be available for this survey, in which he had considered the obligations of each of the physician, the patient, and the attendants and had also required that the physician make the patient understand that it was her duty to comply (Jouanna 2012, 262). However, in addition to confirming the Hippocratic physician’s imperative directions, he had required that the physician explain his treatment to the patient.

After Galen, only three others were to consider the responsibilities that lay beyond the physicians’ duty; in the twelfth-century Maimonides recognized the moral requirement of the physician to do more than “what is proper,” which, some five centuries later was essentially restated by Redmer. The only subsequent exception to the Adams standard deontic interpretation was that by Scholtz in 1941, who had recognized the patient’s autonomy.

In each of the remaining translations and interpretations, the duties expected of both doctor and patient are explicitly stated, as is the requirement for the patient’s unquestioning acceptance of the doctor’s recommended management. To be expected, or perhaps required to accept such duties and directions entails the “rule of others,” a rule that reflects the heteronomy that is implicit in this first aphorism, which, with the associated paternalism, have not been appraised. Instead, the Hippocratic Oath has been seen to sufficiently address the ethical relationship inherent in the patient–physician engagement, despite Galen having excluded The Oath, and the other deontic treatises from his Commentaries (Jouanna 2012d).

Galen did, however, include in the Commentaries this rendition from Epidemics 1, which was somewhat different to that translated by Francis Adams. Adams had written, “The physician is the servant of the art, and the patient must combat the disease along with the physician,” whereas Galen had used the less imperative, “should oppose:”

I have always followed Hippocrates’ recommendation and tried very hard to exercise the art in such a way that the drug administered, according to what the great man wrote, is either useful or does no harm …. The art comes about by three elements: the disease, the patient and the doctor; the doctor is the servant of the art; the patient should oppose the disease with the help of the doctor. (Jouanna 2012, 266)

The more important determination of Galen’s ethical principles was evident in his essay, “The Best Doctor is also a Philosopher,” in which he placed great emphasis on the physician’s personal characteristics, on his knowledge of the philosophy of ethics, and on the virtues of those who wished to practice medicine. His tract warrants repetition:

What grounds are then left for any doctor who wishes to be trained in the art in a way worthy of Hippocrates not to be a philosopher? He must be practiced in logical theory in order to discover the nature of the body, the differences between disease, and the indications for treatment; he must despise money and cultivate temperance in order to stay the course. He must, therefore, know all the parts of philosophy: the logical, the physical, the ethical. In that case there will be no danger of his performing any evil action, since he practices temperance and despises money: all evil actions that men undertake are done either at the prompting of greed or under the spell of pleasure. And so he is bound to be in possession of the other virtues too, for they all go together. It is impossible to gain one without acquiring all the others as an immediate consequence; they are connected as if by one string. If, then, philosophy is necessary to doctors with regard both to preliminary learning and to subsequent training, clearly all true doctors must be philosophers. (Singer 1997, 30–34)

Beyond the almost invariable acceptance of the deontic nature of the physician’s duties and responsibilities to manage the disease that afflicts the patient, is the role of the physician as the healer, which also entails the humane obligations that the physician has to his patient. This trust goes beyond the ethical requirement that the physician does no harm, yet it has, despite being an integral part of the Hippocratists’ expressed love for humanity, received little, if any, discussion.

As the Hippocratic physician’s practice-related epigrams are more empirical than ethical, and reflect the cumulative experiences of physicians, it is appropriate that their consideration has centred on unremitting philological considerations, and as such, those epigrams can be removed from the substance of Jonsen’s “perfect summary of medical ethics.” Further, the various interpretations of the aphorism’s second sentence have accepted, with few exceptions, that its imperatives, or commands, have imposed an obligation without exception on the physician’s conduct of his professional patient responsibilities. These obligations have determined the professional behaviour of physicians over more than two millennia, and in consequence little consideration has been given to the moral responsibilities that, while evident, have lain “hidden” within a heteronomous authority that has been perpetuated by centuries of Hippocratism.

Conclusion

This most famous Hippocratic aphorism, the first, has too often been seen through the lens of its first sentence, which contains five famous epigrams that have been the subject of perennial philological interrogations while little cognisance has been taken of its accompanying second sentence. The latter, however, contains two quite clear imperatives, most commonly rendered as must and make, or their synonyms, which, as deontic directives, have guided physicians in their professional conduct and in the care of their patients.

This aphorism has come to be regarded as the “perfect summary” of medical ethics, which together with the Hippocratic Oath, The Law, and other works have purportedly epitomized medicine’s highest ethical standards. However, all of these documents were probably not authored by Hippocrates himself.

The examination of twenty-seven extant English translations of various scholastic and philological renderings of this aphorism has made evident the lack of any meaningful or consistent appreciation of the moral implications within the imperative commands of the second sentence. Of these twenty-seven examples, only one of the commentators has explicitly drawn attention to the fact that the Greek physician–patient relationship was paternalistic, and only one other has sufficiently considered the patient’s right to self-determination. That right, which today is considered to be inherent, has throughout history been denied patients through the consistent application of heteronomous imperatives requiring her to obey her physicians’ directions.

Notwithstanding that such deontic directed paternalism has characterized medicine for more than two millennia, little consideration has been given to the moral imperatives that rest in the aphorism’s second sentence, nor has any been given to the actual nature of its paternalism. Rather, the latter has been hidden in the physician’s intention to give benefit to the patient through a supposed acceptance of heteronomous directives.

Heteronomy, as the rule of others, has been the inevitable consequence of an acceptance of the guidances given by the author or authors of the Hippocratic first aphorism, guidances that had been widely accepted as those of Hippocrates himself. Furthermore, these guidances have significantly influenced the course of both medical thinking and its practice, and have persisted through debates that have perpetuated an outdated Hippocratism more concerned with the philologic nuances of the aphorism’s first sentence than with the moral implications of the second. By failing to question the paternalistic obligations the second sentence seeks to impose, physicians and commentators have effectively neglected the essence of humanism and love for mankind that should determine medicine’s overarching moral standard.

This historiographic survey of extant English translations of the first aphorism has revealed a legacy of paternalism, deontic imperatives, and heteronomy that have for too long remained hidden in plain sight. Such disregard has been assisted by a determined Hippocratism whose raison d'être has been removed by modern scholarship that allows us to conclude confidently that Hippocrates can no longer be credited with the authorship of those Corpus books previously attributed to him.

It is time that the Hippocratic first aphorism is relegated to history and its contribution to an enduring Hippocratism and neo-Hippocratism finally put aside.