Bioethics and the Human Body

Abstract

We discuss the concept of a ‘body’, the individual body as the lived experience of the body, the social body, shaped by the tensions between the demands of a social/moral order and the egocentric drives, and the body politic, as an institutionalized and disciplined body. We describe the body as it was perceived in Classical Greek Antiquity at the time when the Hippocratic Oath was first conceived, and any changes that may have occurred by Late Antiquity, using the concept of a body-world as represented by everyday life, the arts, politics, philosophy, and religion. This ‘recreated’ body-world elucidates how a person of Classical or Late Antiquity perceived her/his body via their ‘lived-in’ world and relates it to medical and philosophical thinking about the body as well as to concepts of health and disease. We demonstrate how the institutional structures of the Roman Empire and the Church influenced the way a body was understood, how the administrative and governmental needs led to the first developments of Public Health, and how the Christian understanding of the body as the body and spirit of Christ changed the attitude towards suicide, euthanasia, and abortion. These changes are reflected in the understanding of bioethical thinking and affected the interpretation of the Hippocratic Oath.

1. Introduction

Modern medicine is an essential part of our daily lives. Ultrasound inspections and medical monitoring are routine procedures even before we are of this world. Childbirth predominantly takes place in hospitals and each child’s maturation process is medically observed, checked, and documented starting at birth and at regular intervals during childhood until adolescence in a mandatory process. Affordable medical care is widely accessible for many people in the West1. There, medical bioethics2, referring to the ethical conduct in the relationship between physician or medical researcher and the patient or subject, is regulated via the respective professional organizations. Violations of bioethical rules are juridically relevant, rendering a legal status to bioethical considerations. Bioethics is a part of applied ethics. It encompasses both a policy-orientated approach to clinical decision making, i.e., morality as the informal systems people use for making moral decisions, and a moral theory providing the justification for morality. Here, a moral theory is supposed to deliver moral standards, consistency, and a systematic perspective in moral decision-making (Flynn 2021)3.

This is a rather late development. For most of Western medical history, the Hippocratic Oath4 was the only bioethical concept. This changed fundamentally after World War II.

This paper will investigate the history of bioethical thinking by exploring the crucial role of the human body as an important reference point for bioethical considerations. It posits that the perception of the human body is intricately linked to fundamental concepts of health, disease, and thus bioethical thinking. Furthermore, we argue that changes in the understanding of medical ethics can be attributed, at least in substantial parts, to a changing perception of the human body. If this interdependence can be validated, what factors influence the perception of the human body and the resulting bioethical modifications?

If the above emerges as a valid claim, further issues will have to be discussed. Why was a medical ethical text, as represented by the Hippocratic Oath, essentially unchanged during a period of almost two thousand years despite enormous cultural, religious, and scientific transformations? Alternatively, did cultural changes, especially newly emerging bodily concepts, affect the interpretation of the Hippocratic Oath while its text remained unaltered? Finally, can we disentangle the intertwined roles of body concepts, medical progress, and ethical discourse?

In search of answers, we will present the Hippocratic Oath, the first fundamental concept of medical ethics. We will then discuss the concept of a ‘body’: the notion of the (i) individual body as the lived experience of the body, (ii) the social body, shaped by the tensions between the demands of a social/moral order and the egocentric drives, impulses, wishes, and needs, and (iii) the body politic, as an institutionalized and disciplined body (Scheper-Hughes and Lock 1987).

We will describe our current understanding of disease to clearly distinguish it from cultural or historical definitions. Furthermore, it is important to note that concepts of disease vary depending on the perspective taken, such as a popular definition, a medical definition, or a philosophical definition. Thus, part two, the ‘Starting Points’, will provide the background for discussing Classical Greek and Late Antiquity’s concepts of disease, including the physician’s role in its various historical and cultural versions.

Having thus established the basis for subsequent considerations, we will proceed to describe the body as it was perceived in Classical Greek Antiquity and any changes that may have occurred by Late Antiquity. In doing so, we will cover a period of a thousand years. This clearly requires a selection process focusing on certain aspects of the representation of the body—in everyday life and the arts, religion and philosophy, disease and medicine—while other aspects cannot be comprehensively presented, not least due to the limitations imposed by this brief overview. Yet still, the narrative presented draws on an abundance of data to pinpoint a change that occurred not in one big leap, but rather gradually, without clear boundaries indicating any change. Those who lived through these transformative periods may not have noticed the changes that are so obvious to the historian’s gaze in retrospect. What is described here is not the one, big step, but the gradual, subliminal changes, where each minor modification is accepted as the prevailing normality, and not questioned in itself.

But still, how was a body perceived two thousand years ago? How do we describe the perception, feeling, acting, thinking, and living of everyday life in times that we have not experienced personally? We will use the concept of a body-world (Robb and Harris 2013) as represented by everyday life, the arts, politics, philosophy, and religion. A ‘body-world’ embeds the existence of every person. Each human mind is embodied. The phenomenological mind understands and experiences its body in relation to others and the world it lives in (Gallagher and Zahavi 2021; Merleau-Ponty 1966). Thus, the ‘body-world’ we try to recreate should allow us to elucidate how a person of Classical or Late Antiquity perceived her/his body via their ‘lived-in’ world. The overarching idea of these body-worlds thus created will then be related to medical and philosophical thinking about the body as well as to concepts of health and disease. Hereby medicine is defined as both a science and a clinical interaction concerned with the maintenance of health and the prevention, mitigation, or cure of disease.

Finally, these deliberations should allow us to identify the strands of ideas and considerations that interconnect the conceptualization of the body with bioethical thought, as well as the dialectic interactions that result.

2. Starting Points

2.1. Bioethics—The Long ‘Early Years’ of Medical Ethics

The earliest known deliberation about the physician–patient relationship is the Code of Hammurabi (Carrick 2001), presented by the sun god Shamash to the Babylonian ruler Hammurabi (1728–1686). As the first reference to bioethics, it points out the physician’s responsibility for the outcome of surgical interventions, prescribes the expected conduct of physicians, and outlines the penalties for negligence (Carrick 2001; Majumdar Sisir 2003). But it was the Hippocratic Oath5, part of the Hippocratic Corpus from the fifth century BC, that became the starting point of Western medical ethics. Six hundred years later, Galen of Pergamon (129–199/216 AC) revived these ideas, emphasizing the importance of a profound understanding of the human body and the significance of a virtuous physician (Jouanna and Neil 2012). For centuries, medical ethics had been guided by the Hippocratic Oath, which underlines above all the physicians’ social obligations, a ‘medical etiquette’ to their teachers, surgical colleagues, and the people in the patient’s household. In contrast, ‘proper bioethical considerations’ refer to the physician’s dealings with patients. They were to adhere to the principles of non-maleficence, refrain from assisting in suicide, euthanasia, or abortion, and maintain patient confidentiality (for details, please refer to the Appendix A). Any moral theory justifying the medical recommendations is not stated by the Oath and will have to be deduced from the prevailing philosophical background.

It was not until after the Second World War, about two millennia (Carrick 2001) after the conception of the Hippocratic Oath, that the Declaration of Geneva (World Medical Association 1948) modified the Hippocratic Oath, thus establishing a new, secular physicians’ oath for their dealing with patients (The Hastings Center Bioethics Timeline Committee 2023).

The Hippocratic Oath pertains to clinical ethics, i.e., “the day-to-day moral decision-making one faces while caring for particular patients suffering from particular ailments in particular (and often desperate) situations” (Carrick 2001, p. 4). In the period discussed in this paper, medical knowledge and the understanding of health and disease was diverse, as were the treatments offered. The physician–patient interaction was shaped by the physician’s collective, traditional knowledge, which was based on observing signs and symptoms, i.e., a kind of ‘external’ view of the patient, rather than an understanding of the underlying physiological or pathophysiological processes (Foucault 1975). Medicine was primarily supportive rather than curative. In this setting, the Hippocratic Oath served both the physicians and the patients. Medical research, as a scientific investigation of anatomy, physiology, and pathophysiology, did not exist. Medical understanding was grounded in a more philosophical than naturalistic concept of the human body. Thus, research ethics in a clinical setting had practically no role to play (Foucault 1975).

To conclude, from the very beginning of medical ethics, at a time when health and disease were seen as at least in part influenced by human acts instead of having a divine origin, the right or wrong of these acts, the proper behavior of the physician, became a point of consideration.

2.2. What Is a Body?

The question may seem irrelevant. Do we not all know about the body, our body as we experience it, or rather not consciously experience it at every moment, but simply live as the person we are? And yet the question of the body and its relationship to the person, soul, and mind is constantly asked anew. Both the Classical Greek and the Judeo-Christian heritage advance a “dualistic vision of man” (Porter 1992, p. 206), i.e., mind and body, psyche and soma.” Both concepts “have elevated the mind or soul and disparaged the body” (Porter 1992, p. 206), culminating in the Cartesian tradition of dualism or mind–body distinction, depicting the body as the matter that houses the mind. Body and mind as two distinct entities: ‘res extensa’ the material body and ‘res cogitans’ the mind, an immaterial thinking substance. It was the mind that mattered, with the material body a more or less neglected entity (Porter 1992, p. 207)6.

As Roy Porter demonstrates in his ‘History of the Body’ (Porter 1992), it is clearly too simplistic to “assume, that the human body has timelessly existed as an unproblematic natural object with universal needs and wants, variously affected by culture and society…. it would be misconceived to give the old mind/body dualism a new lease of life by attempting to study the (‘biological’) history of the body independently of (‘cultural’) considerations of experience and expression in language and ideology” (Porter 1992, p. 208). And further, “if bodies are present to us only through perceiving them, then the history of bodies must incorporate the history of their perception” (Porter 1992, p. 208).

Still, as Roy Porter points out, “we remain remarkably ignorant about how individuals and social groups have experienced and controlled and projected their embodied selves. How have people made sense of the mysterious link between the ‘self’ and its extensions? How have they managed the body as an intermediary between self and society?” (Porter 1992, p. 211).

In the late 19th and early 20th century, phenomenology brought attention to the embodied mind, bridging the mind–body dichotomy (Behnke 2023; Gallagher and Zahavi 2021; Merleau-Ponty 1966). It is in this tradition that Scheper-Hughes suggests that we can “understand the individual body, in this phenomenological sense as the lived experience of the body-self” (Scheper-Hughes and Lock 1987, p. 7), with perceptions and experiences of the body varying greatly in health and disease.

In addition to this individual body there is the social body, i.e., the understanding of the body as resulting from reciprocal interaction of social and symbolic representations with the ‘natural’ body (Scheper-Hughes and Lock 1987). It is there that the tension arises between ‘being a body’, i.e., the embodied, subjective experience, and ‘having a body’ i.e., an objective body, subjected to the constraints of the social world. These interactions have been explored by sociologists, with Max Weber [The Protestant Ethic and the Spirit of Capitalism (Weber [1930] 2005)] being a classic example, and more recently Bryan S. Turner [The Body and Society: Explorations in Social Theory (Turner 2012)]. It is at this crossroad of culture and physiology that the sociology of religion and sociology of medicine interact. Both are concerned with the complex interface between cultural and physiological structures (Turner 2012). In addition, religious thought interweaves spirituality, salvation, and healing.

Human physiology and the social world interact, with the socially constructed world setting limitations to unrestricted desires, as can be seen most clearly with sexuality (Turner 2012). Right now, we observe this interaction at work in the ongoing debate on sexual/gender ‘identity’, a discourse that blurs the boundaries between the concept of a ‘natural’ i.e., biological, unambiguous sexual attribution and the ‘engendered body’ (Meredith 1990), something that may be fluid, full of transitions, where attributions of sex, i.e., female vs. male, may change even within one individual over time, emphasizing the variable, socially dependent representation of the body. Thus, it is the “social discourse which specifies eligible sexuality not the dictates of human physiology” (Turner 2012, I, 5).

And finally there is a third body, the ‘body politic’, “referring to the regulation, surveillance, and control of bodies (individual or collective) in reproduction and sexuality, in work and leisure, in sickness and other forms of deviance and human difference” (Scheper-Hughes and Lock 1987, pp. 7–8). Self-control becomes institutionalized: monogamy and celibacy in Christianity, labor’s discipline and asceticism in capitalism (Turner 2012). The regulation and control of the body serve as a basis for the stability of the political system (Foucault 1973, 1975, 1979, 1980) by regulating population and individual bodies. A detailed control of female sexuality served to uphold the status of the landowning class in feudalism. In contrast, asceticism and the existence of a nuclear family are no longer pertinent to late capitalism. It operates through political, economic, and legal regulation of the population according to its requirement for the security of production, technology of consumption, and consumerism, as the commercial legitimation of desire (Turner 2012).

To summarize, there is no such thing as a body. There is the lived-in individual body experiencing the world and performatively expressing individual experiences as the social body in a culturally assigned way while at the same time influencing and forming these cultural concepts. Further, the body politic refers to how a body is objectively evaluated and normatively controlled by the governmentalization of the body.

2.3. The Body-World or How to Describe a ‘Historical’ Perception of the Body

Depicting historical concepts of the body is challenging, due to the scarcity of data and representations referring to the body proper. Theories of the body as delineated by philosophers, the clergy, scientists, or artists correspond to the ideas of an educated elite and must be interpreted within the framework of the prevailing historical cultural ideas. We know less about the way the peasant, the workers, the slaves experienced and thought about their own body. To get an idea of how people in Classical and Late Antiquity perceived the body, the conceptualization of a body-world may be helpful. “A body-world…encompasses the totality of bodily experiences, practices and representations in a specific place and time” (Robb and Harris 2013, I, 3).

2.4. The Concept of a Body-World

A body-world comprises its own cultural, social, political, and material frame of reference. It thus reflects its specific history, geographical space, order, class, and the body ideal. Our bodies reflect our history in the way we move, exercise, sleep, eat, and act in general. The body is not a universally shared physical object whose historical continuity comes from an unchanging biological structure, but rather something emergent through history. “The body is in history; indeed, the body is history” (Robb and Harris 2013, I, 4). Similarly, we live in a specific geographical and social space, both physical and psychological. As such, space is fundamental in defining public or private interactions among strangers, companions, family, or a couple. “These proximities not merely symbolize social relations, they create them” (Robb and Harris 2013, I, 7). Bourdieu’s concept of habitus, the dialectic relation of mostly unconscious bodily practices as productive and produced by different social orders, represents the understanding and relationship of bodies in society. An easy example to grasp is the ritualized, reserved, and controlled habitus of those listening to classical music in a concert hall: an expression of the classy, aesthetically informed listener (Bourdieu 1990; Robb and Harris 2013). And finally, each culture compares the body with implicit or explicit ideals, present via art, media, government, and public agencies. The body represents a symbolic capital, from the athletic nude male in Classical Antiquity to the disciplined ‘thin’ female images in the global West of today. Furthermore, medicine provides the guidelines that define a normatively healthy body. Lastly, images of the ideal body are associated with a moral norm or stigmatization for those failing to achieve these ideals. In this context, the body serves as a source of symbolic capital, or value, “less because of what the body is able to do than because of how it looks” (Robb and Harris 2013, I, 8).

The observation of these experiences and their social interconnectedness, the reflexes of personal autonomy and space underlying routines of bodily distancing and privacy, and the idea of bodily control as the balance of individual rights and collective authority draw a picture of the body-world we built and live in. We can understand the body as constructed from conventional discourses, “a core of practices and beliefs about the body which underlies a lot of social action, which we understand intuitively and rely upon every day to act and to understand each other’s actions, but which we rarely ever put into words. Thus, as we pass from one moment of living to another, we experience a coherency of meanings rooted in the body” (Robb and Harris 2013, I, 11).

To summarize, a body-world is represented as a bodily process; we live in body-worlds. A body-world captures all the elements of bodily life from unconscious practices through discursive knowledge. It is through body-worlds that we experience a feeling of coherence, as Robb and Harris describe it: “…when many apparently disparate events or practices nevertheless acquire a feeling of connectedness, of similarity born from the grounding in the reflexes and understandings the body uses to generate behavior”, and further: “the feeling of absolute reality which emerges from the imminent experience of the same presuppositions encountered everywhere one turns” (Robb and Harris 2013, I,11). These experiences may be contradictory, yet they dialectically reproduce the underlying traditions and norms. There, dissonance and coherence are inseparable (Robb and Harris 2013).

These experiences work as a set of ‘generative dispositions’, a learned ‘habitus’ (Bourdieu 1990).

The practices are embodied in bodily subjectivity like gender or age, in bodily qualities like masculinity or honor, in the way daily chores are performed. They are institutionalized and form a bodily governmentalization (Foucault 1979; Robb and Harris 2013). Describing the body-world may thus help to understand the way bodies are lived in, dealt with, valued, or abhorred, but foremost emerging, in reality and in imagination, via the body-world that surrounds and constructs them, and is constructed by bodies.

2.5. The Concept of Disease

Both, our common-sense expectations about the body and scientific theories of human biology refer to a naturalistic and/or constructivist understanding of disease7. From a naturalistic perspective, disease is scientifically understood as a deviation—an abnormal functioning of a bodily system—and a judgment that the resulting abnormality causes reduced well-being, with normative considerations influencing this judgment. Alternatively, constructivists argue that disease is a harm that we blame on a biological process because it causes harm, rather than because it is objectively dysfunctional. We experience something we devalue, we identify the causative biological process, and call whatever it is ‘abnormal’ (Murphy 2023).

Georges Canguilhem (Canguilhem 1974) describes an early ontological concept of disease as something either added to or missing in a human being. This understanding provided therapeutic hope, as additions can be removed and deficits can be substituted. There, health and disease are viewed as two distinct and separate qualities. Yet a qualitative view is difficult to sustain. Thomas Sydenham (1624–1689) emphasized the necessity of a diagnosis before therapy, thereby asking for demarcation and determination of the disease. Subsequently disease is defined as the pathological, i.e., the quantitative deviation of physical phenomena in a living organism, a hyper- or hypo- from the norm. From this discourse derived the laws of the ‘normal’ and the ‘pathological’. Disease was considered as a variation of the normal disposition of a phenomenon. This quantitative difference between the pathological and the normal state requires an objective and factual definition of the normal state. Furthermore, it is crucial that the definition of the pathological as a disruption of the normal state had to be understood in reference to the whole organism. Therefore, an isolated symptom or functional mechanism can only be considered pathologic by acknowledging that both are pathological only because they are integrated in the totality of an indivisible, individual comportment.

Clinical signs and symptoms refer to the whole individual, not only organs and their pathology. Thus, the clinic represents the concept of illness in contrast to disease, not as a quantitative deviation of a physiological state but something else in addition8. With the beginning of the 20th century, the dualism of health and disease as viewed within physiology and pathology was reflected in their diverging biological values. As far as physiology refers to invariable constants which define the reality of life, it is science. However, if physiology refers to the vital significance of these constants, classifying one as normal, the other as pathological, it is more than strict science. The physiological ‘gaze’, the objective, disinterested gaze of a scientist, becomes permeated by the lived experience of being. The clinical gaze reunites the body as an object and the lived body.

Michel Foucault, in The Birth of the Clinic: An Archeology of Medical Perception (Foucault 1975), describes the diseased body as the center of attention for the medical gaze. There “the human body is newly constituted as a medical body, quite distinct from the bodies with which we interact in everyday life. The intimacy with that body reflects a distinctive perspective, an organized set of perceptions and emotional responses that emerge with the emergence of the body as a site of medical knowledge” (Good 1994, p. 72). What takes place is a “reconstitution of the human body as it is brought under scientific medicine’s transforming gaze” (Evans 2001, p. 17). This medical body is an object of enquiry, a passive, uncharacteristically inert and yielding body on which the medical instruments are trained. The medical body is seen as a source of data, discoverable and convertible to information, i.e., facts, instead of the symbol of the everyday body, a biological organism, a complex of functions instead of the form of the everyday body. The medical gaze locates these facts and functions in the general nature of the medical body (Evans 2001).

The diseased body can be understood as a subcategory within each of these three concepts of the body: the individual body, the social body, and the body politic. The diseased individual body as the ‘lived-in-body’ experiencing the failure of functions, the added burden of fever and pain, nausea, and exhaustion. All experienced in a deeply subjective way but performatively expressed as the social body according to the culturally constructed role of the sick person. Taking up these overlapping, interacting perceptions of the body—the individual, the social body, and the body politic—facilitates the understanding of health and disease, as represented and lived by the body. Health and disease are invariably interlinked and refer to each other. Paraphrasing Judith Butler, health and disease are often invoked as material differences. However, health and disease are never simply a function of material differences which are not in some way marked and formed by discursive practices, and further, the categories of ‘health’ or ‘disease’ are, from the start, normative (Butler [1993] 2011, Introduction, 11). Taking this into consideration, there is no unique, timeless, natural human body, but both the healthy and the diseased body are (i) produced and elaborated by the performativity of the subject in each role, (ii) constructed by a cultural norm, a regulation of identificatory practices for each of these different perceptions of the body status, and (iii) formed by the effect of power, the regulation and control of the body by the political system9.

To these considerations we must add a further caveat for the comparison of historical concepts of the diseased body. ‘Body ecology’, a term referring to “culture-specific knowledge and experiences of ecological realities integrated into and elaborated in learned medical theories on the body, health and illness, in the course of complex historical processes” (Steinert 2021, p. 7), describes the culture-specific categories with possibly biologically distinctive manifestations (Steinert 2021). In this line, ancient yet preserved disease terms (like malaria, cancer) may only partly correspond to modern usage.

To understand the body with which medicine is concerned, we will have to refer to both the body in health and in disease. Today a scientific naturalistic understanding of disease prevails, with a preponderance of the constructionist’s viewpoint in the understanding of disease as an illness. Both categories contribute to and are interlaced with the objective, culturally constructed body and the ‘lived-in-body’. There is the body as an object, the ‘medical body’, scientifically and thus socially constructed as the diseased body, while the ‘lived-in-body’, i.e., the individual body, correlates with the concept of illness. It is this divide between the ‘medical body’ and the ‘lived-in-body’ that gives rise to “contrasting understandings of the source and significance of the imperatives of ethics in medicine” (Evans 2001, p. 28). And further, “the imperatives of ethics… cannot be read off the ‘medical body’, but must be “read-in’ from a discourse outside it, their application to the ‘medical body’ is circumstantial, contingent, as science itself is only circumstantially and contingently subject to the constraint of human values derived elsewhere” (Evans 2001, 28). What Evans states here is the dissociation of the body and bioethical considerations, bioethics only contingently related to the body, hovering over the body on which it yet has a major impact. It is exactly this void between the ethical thinking about the medical body and the body proper we are interested in. Is Evan’s description correct, and what consequences can we derive from a bioethical thinking understood as unrelated to both the ‘lived-in body’ and the ‘medical body’?

To summarize, a mostly qualitative view of disease gave way to additional quantitative interpretations necessary for the demarcation and determination of the disease, i.e., health vs. disease. Subsequently disease is understood as a quantitative deviation from the normal, i.e., the healthy body, with the laws of the ‘normal’ derived from the ‘pathological’, an ‘internalizing system’ where sickness is attributed to physiological mechanism. This mostly naturalistic concept of disease takes up part of the common-sense understanding of the diseased body and the scientific explanation of disease as abnormal functions of the ‘body system’, i.e., a quantitative deviation and a qualitative causal contribution, respectively, within a situation-specific context. The human body is newly constituted as a medical body, as a site of medical knowledge. The medical gaze locates the medical body as an object of enquiry, a source of data, facts, and functions, instead of symbols and forms of the everyday body.

In contrast, clinical signs and symptoms refer to the whole individual, representing the concept of illness in contrast to disease. The concept of illness is preferentially related to a constructionist’s viewpoint, where performativity and cultural norms not only define illness, but both categories “health” or “disease” are interpreted as normative (Butler [1993] 2011). They are performatively lived role-concepts of the individual body, constructed according to cultural identificatory practices, the social body, and controlled by the political system, the body politic. For the intersection between ‘body’ and further discursive, intersectional, performative categories (DIP) of knowledge production like ‘gender’, ‘race’, ‘nation’, and ‘class’, which also includes ‘religion’, see (Auga 2020, 2022).

The 20th century reflects this dualism. On the one hand, health and disease, based on a concept of physiology scientifically defining the facts of life, and on the other hand, the clinical view of illness as the lived experience. In parallel, a Christian ontological understanding persists far into modernity. There, health is related to salvation and disease to the original or individual sin.

2.6. Summary

The ‘starting points’ clarify the issues and the methodology used to explore the role of the human body as a reference point for bioethical considerations.

The first bioethical text, the Hippocratic Oath, primarily deals with a physician’s etiquette. It states that the patient–physician relationship should be based on non-maleficence, respect, and confidentiality. Support for suicide, euthanasia, or abortion was to be denied. The significance of these regulations will have to be discussed further in the respective historical contexts.

Bridging the mind–body dichotomy, a phenomenological approach is used to define the lived-in body-experience, the individual body, and the body as an object. The concept focuses on the social body, as an embodied experience reflected in a body-world. This body-world, the settings of everyday life, the arts, religion, moral life, and philosophy will explore an individual’s experience and understanding of its own body and a more general concept of the body along historical and cultural traditions. It is assumed that any significant changes in a body-world will be dialectically reflected in the way the body is perceived and dealt with as a body politic, i.e., the governmentalized body.

We finally introduce the medical body, by discussing modern concepts of health and disease. This will allow for a comparison with historical concepts and an understanding of the differences and variety of views on health, disease, and medicine across time and changing cultural landscapes.

These methodological approaches will help to derive the interactions of the concepts of the body with bioethical considerations and their respective reciprocal changes over time and across diverse cultural settings. Thus, the following chapters will describe the body-world of Classical and Late Antiquity and relate these concepts to the understanding of the body in health and disease and to the respective bioethical considerations.

3. The Body and Bioethics in Classical Greek and Late Antiquity

A caveat is needed when discussing the body in Antiquity. Going back over two millennia means bridging a gap in time that influences our understanding in a way we cannot probably take fully into account. For an overview, the work of Thomas Laqueur is seminal (Laqueur 1990).

All the testimonies we refer to are nothing but symbols, texts, artifacts we engage with and try to contextualize. However, our view is tainted with a 21st-century understanding of the body as indicated above, and all notions on how a body was lived in and reflected on will suffer from the incomprehensible experience of life in Antiquity. How does it feel to be a male citizen of Athens, a soldier, a peasant’s wife, a slave? What did it mean to be a child, an adolescent, or an elderly man, to be rich or poor or just sufficiently well off to live a ‘good life’? In particular, what did it mean to be ill, what was on offer as an understanding of health and disease, how did this relate to the body and shape the relationship between the diseased and the medical specialist?

We will try to capture at least part of the understanding of a body via recreating a body-world based on the testimony of everyday life, art and beauty, religious and philosophical thinking, asceticism, and discipline. Lastly, we will discuss the body in medical terms—the tension between health and disease, the help sought in case of illness, the role of healers and physicians, and the bioethical guidance humans sought, kept, neglected, affirmed, or changed over time.

3.1. Classical Greek Antiquity10

3.1.1. Everyday Life

Ancient Greeks understood the human world through conceptual dichotomy, with the opposition between male and female most important, as fundamentally different natures, reflected visibly but also in their characters and capacities. Men were strong and rational, engaging in public interaction, warfare, and athletic competition. Women were weaker and emotional, principally related to domestic tasks and reproduction. Male sexuality was free. In contrast, females were restricted to modesty and fidelity. Yet, these definitions derived from legal and philosophical texts may not represent the full reality of life. Women worked in fields and held other jobs supporting the family economically; extramarital liaisons were well known and the plot of comedies. Furthermore, it is worth keeping in mind that the concept of female seclusion in Classical Athens originated with 19th century male perceptions of women’s ideal roles set by Victorian sensibilities, with more than a hint of Orientalism11. Gender roles in the Athenian family probably were more fluid, and seclusion may well have been a literary construct more than a working reality (Robb and Harris 2013).

Slavery was prevalent. In Athens, one quarter to one third of the population were slaves. Slavery was a bodily condition; slaves could be sexually used, beaten, and tortured to give evidence in court. Most slaves were ethnically distinct from the Greek population. They came from Persia, Scythia, the Levant, or Egypt. Yet, the slave status was not made visible on the body with specific costumes, badges, or gestures. The important legal and institutional differences between people were differences of class, wealth, and status, i.e., citizen or foreigner, free persons or slaves. Yet streets and marketplaces were free spaces. There important, fluid discussions between diverse kinds of people took place. Hence the difference between bodies, the citizen, the merchant, the farmer, the foreigner or the slave, “were invoked flexibly and situationally [,] not rigidly categorized across contexts” (Robb and Harris 2013, Chap. 5, p. 109).

The major points of the Classical Greek lifespan—birth, becoming human nine days after birth, marriage, old age, and death, when the soul undertook a journey to the underworld—were highlighted through rituals. These rituals shared a common structure, i.e., washing, clothing, and decorating the body and publicly affirming, by relatives and friends, its new status. Here, the public dimension of these rituals is important as not only the body but also others’ relations to it could be witnessed, as in marriage or funeral rites (Robb and Harris 2013).

The border between humans and animals is culturally defined, and Greeks drew a clear but mobile border between them. In contrast, the border between human and the divine was more open. “The bodies of deities were marked only by their perfection. Gods simply had super-bodies and were super-humans” (Robb and Harris 2013, Chap. 5, p. 110).

Festivals allowed for transgressions in a carnivalesque atmosphere. Religious practice took shape in formulized interactions with gods and demigods. Religious ritual practice made no distinction between the image of the deity and the deity him/herself: the statue receiving sacrificial prayers “was not a representation of the god, the statue was the god” (Robb and Harris 2013, Chap. 5, p. 112).

In summary, everyday life in Classical Greek Antiquity is characterized by the dichotomy of male/female, citizens/others, and the diverse social status available. People were visible in public or working spaces, at public activities or religious rituals. Bodily ‘differences’ like gender, ethnicity, and social status were clearly acknowledged, but not on the forefront of everyday activities, and were not essentialized. That is the reason why Ulrike Ernst-Auga describes this time, including the first Christian centuries, as pre-essentialist (Auga 2020).

3.1.2. The Arts

What we visually know of the Classical Greek period is represented mostly by statues and vases. From the fifth century on, Greek statues showed the body naturalistically, in anatomical detail and human postures, yet without individual traits. This was a new development beginning around 400 BC. The stiff kuroi, male nude sculptures in rigid postures, changed into a lively posture decorating graves, public monuments, temples, religious dedications, and commemorations, though never for private use. Kore, the female statue, was clothed, and depicted significantly less than its male counterparts (Robb and Harris 2013, Chap. 5, p. 104). The reproduction of an idealized human body within an image-system representation is a political act (Robb and Harris 2013, Chap. 5, p. 99). By making an idealized, ‘naturalistic’ human the aesthetic measure of all things (including the gods themselves), Classical Greeks placed humans at the center of the cosmos (Robb and Harris 2013, Chap. 5, p. 100). These idealized bodies represented and affected the way the Classical Greek world saw itself. Most statues depicted idealized male citizens in their athletic body and posture. Yet those exhibited represented only about ten percent of the Greek population. Obviously, the cultivation of a masculine body was important. Male nakedness and nudity in sculpture were cultural costume rather than the mere absence of clothes. In everyday life, nudity was rare outside of warfare or athletics. Thus, nude male statues expressed a range of meanings from godlike beauty to vulnerability and abjection. The beautiful body was not identified by specific physical features, but by harmonious proportions and symmetry.

A statue of an older bearded male looking at a beautiful, young, male body may have not only referred to an age difference but also to a conceptual complementarity between a mature male and his homoerotic desire for a young male at the peak of his beauty. It represented the form of a highly conventionalized courtship between an older, bearded man and a young, beardless protégé. For the young men, homoeroticism was considered a transient phase, while it was shameful for the adult male to take a passive or ‘female’ part in a sexual relationship. In that sense, Greek male homosexuality ”seems inescapably part of a narcissistic meditation upon male beauty” (Robb and Harris 2013, Chap. 5, p. 107). ‘Foreigners’, despite being up to ten percent of the population, were not represented in statues by their physiognomy.

The “classical sculpture can be interpreted as a carefully blank, quasi universal human serving as an aspirational political object” (Robb and Harris 2013, Chap. 5, p. 120). The classical sculpture represents a life lived in measured, rational, truth-based discipline. It keeps up and reproduces the ontological order, the natural order of things, and thus refers to a ‘beautiful life’. Thus, beauty is to be found in control of the soul and the body (Foucault [1984] 2020a), demanding careful conduct of the individual. To keep up the normal functionality of the body, the healthy body—disciplined and ascetic within a range of bodily desires, be they hunger and thirst, exercise, or desire—was a moral virtue. Thus, beauty is related to the well-functioning, the healthy, the moderate and controlled, the capable and rationalized body. And this kind of beauty still can be relived today, when we look at the classical statues with their well-proportioned, trained bodies displayed in sparse, well-intended gesture of a still enviable beauty. It is worth noting what we do not see in these statues—there are no physical traces of hard work, occupational deformities, or disease. This clearly demonstrates that the self-care displayed in these statues was attainable only by a few. Yet the social distinction displayed was subtle and contingent, thereby underscoring its universal aspirational value.

To summarize, Classical Greek Antiquity depicted the human body as the aspirational political object, the entelechy of human development. Therein, the idealized, yet naturalistic body is male, healthy, athletic with harmonious proportions. These images allowed the self-identification with a specific type of Greek human being: disciplined, controlled, and capable, where neither status, traces of hard work, disabilities, or disease blemished a beautiful and harmonious body.

3.1.3. Religion

Religious practices, formalized interactions with gods and goddesses, ranged from elaborate public rituals (incantations, sacrifices, and prayers) to private prayers at sanctuaries or informal prayers in passing a statue or an altar. The relation between the believer and a god was built on reciprocity, i.e., a sacrifice or a donation in exchange for a favor. A pledge was asked for in front of the statue that not only represented the specific god, but within the context of the ritual was the god. The worshippers switched between contradictory modes of thought as they moved from one context to another, i.e., from their more rational dealing with everyday problems to mystical animation of statues while worshipping.

The interaction of religious thinking with the body is most obvious in the relationship of health and disease and supernatural powers. Healing cults associated with Asclepios or other deities were effective throughout Antiquity. Supernatural external causes—sorcery, attacks by ghosts, and abandonment by personal deities, the latter provoked by transgression of either the patient or family members—were to be appeased by healing cults (Steinert 2021, p. 31). The health problems associated with a diagnosis referring to a ‘supernatural’ cause were treated through a combination of drug-based therapies and rituals, prayers, or incantations, aiming at an alleviation of the symptoms and at mending or normalizing the underlying causes of the ailment, which resulted from ruptured social relations and social conflicts (Steinert 2021, pp. 30–31). Votive body parts, representations of ‘diseased’ body parts, demonstrating how illness was conceptualized, were deposited in sanctuaries, shrines, or cult sites as supplications for healing. Here, with disease understood as ill body parts, differed from medical writing, where the body was viewed as an integrated whole (Robb and Harris 2013, Chap. 5, p. 114), a disbalance of the humors with the fundamental criterion of disease an “impairment of natural function” (Steinert 2021, p. 32).

To summarize, both the concepts of the body of the average and the idealized citizen were based on a healthy body. Taking seriously one’s responsibility for one’s body was supposed to result in good health. Moral failure, either in lack of bodily control or social transgression, may induce divine punishment, i.e., reduced well-being and disease. Thus disease was interpreted as a divine punishment for individual misdeeds and cure achieved via religious cults and sacrifices.

3.1.4. Moral Life

There was no organized judicial moral code, no coercive authority or institution defining the ways to deal with, to act by, and to interact with a body. Bodily behavior was regulated via a moral conduct that asked for the individual to establish the ethical substance, the way to constitute one’s moral behavior. The individual had to define its own subjective way to deal with the prevailing moral ideas and develop “self-practices” to support its own attitudes (Foucault 1973, p. 36ff). The Antique person is first organized via self-practices, askesis, rather than via the codes of behavior asked for by the law, the nomoi. The body and its desires are interpreted as given by nature and as such are seen within a natural order. Men—and these arguments relate to the male, civilian viewpoint, not the female, the peasant, or the slave (Foucault 1973, p. 109)—will deal with the body via their rationality, their logos, analyzing and relating to the truth, in a structural, instrumental, and ontological condition of the institution of the individual as self-restraining and moderate-living, an ascetic existence where the natural body serves as the measure of a moral life. To deal sovereignly with one’s desires (hunger, thirst, sexuality) is seen as a constitutive element of happiness and the functioning of the polis (Foucault [1984] 2020a), and every exaggeration is deemed to destroy a beautiful, ordered way of life (Foucault 1973, p. 118). Thus, there is no institutionalized regulation on how to deal with the body, but a social moral code offering eudaimonia, fulfillment via an ethically well-lived life based on the relationship of the individual towards itself. Thus, dietary prescriptions and prescriptions for sleep, exercise, and sexuality indicate the striving for a way of living determined by care for the body.

In summary, a moral life, i.e., adhering to the prevailing moral code, resulted in eudaimonia, the ‘good life’. Responsibility was with the individual to act rationally with respect to its own body and its obligations towards the polis.

3.1.5. Philosophy

The nature of the body per se was not a major philosophical focus. The body was discussed principally in contrast to the soul. Socrates may have seen the body as a material liability which distracted attention from the soul, while Plato, in the cave allegory, interpreted humans’ perception of the material world as a reflection of an ideal truth. In Timaeus, he draws upon Hippocratic medicine, while in the Republic he makes an analogy of a city-state and the human body. Aristotle’s empirical viewpoint arranged all living things into a hierarchy, with humans at the top due to their vegetative capacity of reproduction, sensitive capacity of movement, and rational capacity of thought. Aristotle took up the idea of four elements as the primary material cause of health and disease. Disease became the disturbance, no longer of the four humors but of elements representing the four qualities, hot, cold, dry, and moist. Modifications of the course of disease were possible by adjustments in diet, exercise, and habits. In short, everybody had a responsibility of his own for one’s well-being and the probability of disease (Carrick 2001, p. 38ff).

Overall, Greek philosophers imagined a dichotomy between the body and the soul. The soul allowed for contact with the divine, persisted after death, escaped the body, and undertook a journey to Hades, a concept widely accepted. Similarly, gender difference was universally accepted, with the male body providing the basic bodily standard. Yet philosophers focused on abstract concepts and rarely on problems of daily life. Thus, it remains doubtful that classical philosophy provided a general spearhead of ‘truth’ rather than a fashionable cultural pastime amongst the minorities of educated, urban capital-classmates (Robb and Harris 2013, p. 113; Carrick 2001).

In summary, philosophy understood the body within a dichotomy of body and soul, the body nothing but matter, the soul a pre-existing concept of rationality, sensitivity, and vegetative reproductive capacity. Overall, these concepts were accepted, but in-depth discussion remained a privilege of the philosopher.

3.1.6. Disease and the Physician

Most information on Antique medicine is related to the Hippocratic Corpus (440–340 BC)12. Hippocratic medicine grounded the understanding of health, disease, and the body on natural philosophy and rejected the idea of the supernatural, divine origin for disease. The Hippocratic text ‘On the Sacred Disease’ “plucked disease from the heavens and brought it down to earth” (Porter 1999, p. 53). Medicine was seen as an art and closely related to philosophy, where metaphysical speculations interpreted the human body as a microcosm of the grand order of nature. Thus, diverse interpretations were discussed: Parmenides (c. 515—459 BC) denied a material essence to the body and viewed cosmic processes governing change and stability as relevant. Pythagoras (c. 530 BC) argued for numbers and harmony, the dynamic balance of contraries, the opposition of odd and even, while Heraclitus (c. 540–475 BC) saw the true constant in change itself, in a macrocosm composed of fire and water. Empedocles (mid-fifth-century BC) saw nature as a composition of basic elements (earth, air, fire, and water) building only temporarily stable mixtures. He described the concept of innate heat as the source of living processes, the cooling function of breath, and the idea that the liver produces the blood to nourish the tissue. He advanced key physiological doctrines in Greek medicine. Overall, philosophical and medical thoughts were in a dialectic relationship that partially inspired the writings in the Hippocratic Corpus (Porter 1999). The body in health was viewed as stable, in a state of equilibrium, an appropriate mixture of body fluids (humors) which were set in relation to natural properties until illness disturbed this harmonious balance, an undue concentration of fluid in a particular body zone. Thus, disease was defined as a disturbance of a finely tuned balance of four fluids: phlegm from the head, blood from the heart, bile from the gall bladder, and black bile from the spleen (Robb and Harris 2013). Within this line of thought, a flow of humors to the feet resulted in gout, the flow of phlegm from the head to the lungs caused cough. The four humors were correlated to the four elements (air, fire, water, and earth), the four primary qualities (dry, hot, wet, and cold), the four seasons (spring, summer, autumn, and winter), and the four ages of mankind (infancy, youth, adulthood, and old age) and thus to the constituents of the universe.

Together these concepts gave a high explanatory power for disease (Robb and Harris 2013, 50ff). Disequilibrium may stem from a quantitative, most often dietary-induced change in the four humors, from external causes (violence, accidents etc.) or seasonal changes. With disequilibrium among the humors, pain due to inflammation at the site of the ‘leaving humor’ and swelling at the site of the ‘arriving humor’ may arise. The theory allowed people to classify diseases and ascribe physiological causal explanations. The four seasons’ characteristics (hot, cold, dry, and wet) were related to the four elements (fire, earth, air, and water), and via their relation to the body, the body was a constituent of the universe.

Health and disease were seen as an individual constitution. Its interaction with the environment allowed people to systemize the idea of seasonal illnesses (Steinert 2021, pp. 24–25). Due to these multiple and varied interactions, each person harbors a unique infliction and a unique pathological process (Carrick 2001, p. 35)13. People from different places had different physiognomies because of environmental influences such as heat, cold, moisture, and dryness. Carrick (Carrick 2001) indicates seven principles that together describe the medical understanding: the principle of equilibrium, seasonal influence, contraries, innate heat, natural healing, pepsis14, and critical days. In this conception, health is the proper balance of the interacting principles, an equilibrium of humors within the body, with imbalance resulting in disease.

This scheme of a cosmologic symmetry of qualitative humoral and elementary pairings allowed for reestablishing the equilibrium by qualitative contraries, i.e., treating a disturbance described as cold and dry with hot baths and fluid intake, respectively. Treatment was therefore basically non-invasive and aimed at maintaining or restoring this balance and ameliorating the patient’s symptoms. The permeability and fluidity of the body meant that external treatments of diet and exercise could modify it. This view was passed down to Galen and up to mediaeval medical thought (Robb and Harris 2013, Chap. 5, p. 113).

Medicine was almost gender-neutral, apart from specific problems related to menstruation, pregnancy, and childbirth, with the underlying concept covering both men and women. Overall, the body in health and disease was understood as being fluid rather than fixed and stable (Robb and Harris 2013, Chap. 5, p. 113). The notion of mental illness comes from the Cartesian dichotomy, and thus categories like psychiatry or psychology are problematic when referring to Antique understanding. Singer describes the absence of a mental disease category in the Hippocratic Corpus (Singer 2020).

Therapy was mostly dietetic, and advice for a healthy lifestyle included exercise, bathing, sleep, and sexual activity. Responsible control of bodily desires and athletic training were seen as those activities that kept up health and kept disease at bay. It was an individual responsibility towards one’s own body, and failure to act accordingly may have resulted in disease. Physicians prided themselves on their art of diagnosis—by profiling a patient’s way of life, habitations, work, and dietary habits—and their prognostic capabilities.

In summary, from a modern viewpoint, the Hippocratic physicians were unaware of the true causes of a disease. Still, they were aware of the effects of a disease on the body, which were recorded and classified to draw conclusions (Carrick 2001, p. 27ff). A balanced dietary regimen, responsible control of bodily desires, and athletic training were seen as the activities that kept up health and kept disease at bay. It was an individual responsibility towards one’s own body, and failure to act accordingly may have resulted in disease. Bodily functions were interpreted in a naturalistic, physiological concept of health and disease. While none of it was based on a strict physiological and scientific insight, the underlying assumptions and interpretation of bodily functions were based on a system that allowed for rational interpretation of dysfunction and disease, and subsequently therapeutic concepts, and bound humankind to the constituents of the universe.

The Antique physician was seen as a secular craftsperson in possession of a specific knowledge, but of varying skills, like the practitioner with only little basic, theoretical understanding of their craft in contrast to a master. Physicians still were generalists; specialization into medicine versus surgery was inexistent (Carrick 2001, p. 14ff). Physicians were either residents or itinerants, members of a free, uncertified craft15—this lack of oversight allowed for experimentation and improvements—and as such belonged to a lower social order. Yet their social status and their economic success were dependent on the reputation as a successful healer (Carrick 2001, p. 20), which was clearly distinct from that of a magician, a priest, or spiritual healer related to the god Asclepius.

Still, physicians may have been only affordable for the wealthy. Medicine, within the framework of the Hippocratic Corpus, was only one way of referring to health and disease, and perhaps offered primarily to the educated patient. Other concepts referred to the divine order of things, with health and disease related to a supernatural power and promises of cures being sought at places of worship of Asclepius or other spiritual healers.

Most of the population were cared for by practitioners like bonesetters, midwives, family members, or practitioners of herbal lore. Their traditions of understanding disease and a more diffuse, less formalized healing practice differed from the detailed observations and distinct knowledge provided by Hippocratic writings (Robb and Harris 2013, Chap. 5, p. 114). The understanding that illness was caused by spiritual factors rather than physical cause was common. Subsequently, exorcists, religious healers, shamans, and priests, with the cult of Asclepius the most common, tended to the sick. There shrines and temples were visited and votives offered as a plea for healing (Porter 1999; Robb and Harris 2013). Others, like Jewish medicine at this time, saw rational medicine and mystical healing as complementary. Greek medical thinking was accepted, yet the sick depended on God who ultimately delivered cures or took lives (Carrick 2001, p. 18).

Taken together, there was a huge marketplace for those seeking a cure for their disease, with the physician probably playing only a minor role, due to a varied and diverse understanding of health and disease. Health was seen as the highest external good, the basic prerequisite for having a good life. It was the physician who advised a regimen for the preservation of health. Yet the definition of the ‘good life’, along with the ultimate aims and values with which to achieve this goal, was posited by the philosopher (Carrick 2001, p. 22).

3.1.7. Medical Ethics in Classical Antiquity

In thinking about Antique medical ethics, there are some caveats with Antique medical concepts in comparison to modern medicine: methodological problems, as in disease concepts, nomenclature, etc. (see above), and incommensurabilities like the ideas of (i) ‘women’s health’, other than gynecology and obstetrics, as it is thought about today, (ii) ‘just distribution’ of medical resources, or (iii) ‘state-organized health care’, all inexistent concepts in Antiquity (Carrick 2001).

Following Carrick, the Hippocratic oath, a document with unspecified authorship, dated between the sixth and third century BC (Carrick 2001), is the first voluntary ethic commitment of Greek physicians who acted in an unregulated profession. As the only medical ethical Greek document, it demonstrates influence from religious Greek cults, homicide laws, popular ethics, and Pythagorean thought. It was probably sworn by only a minority of ancient physicians, who may have been part of a medical fraternity or guild. It was not legally binding and thus only related to an individual’s understanding of professional ethics and conduct. The ethical code claims the duty to others, i.e., to protect the patient from harm and provide cure. This was specified by opposing euthanasia. As at these times suicide was not considered unethical or illegal, the obligation to not provide a deadly drug may however refer to abstain from practicing medical knowledge with a murderous intent, as Carrier argues. Similarly, the prohibition of abortion, at these times a stepwise process to end a pregnancy, may only refer to the last option of providing a poisonous pessary, which required a physician’s skills. The prohibition of providing surgery may be related to a Pythagorean influence, as in the Hippocratic Code, surgery is recommended if deemed necessary. Besides these medical considerations, the Oath refers to medical etiquette. The physician should not have a sexual relationship with the patient or the members of the patient’s household and commits to patient confidentiality. These regulations of etiquette can be interpreted as recommendations for the physician to keep a good reputation, necessary for financial survival in an unregulated medical marketplace, which depended entirely on “the patient’s perception of the physician (regardless of what medical skills the physician in fact possessed)” (Carrick 2001, p. 101).

3.1.8. Summary

By bringing together these different strands of life, we may be able to provide an idea of the way the body was perceived. The fundamental dichotomy expressed in life in the polis was clearly related to the way a body was interpreted: the ‘natural’ dichotomy of female/male bodies, the differences of social status enclosed and enclothed in the bodily habitus, were accepted as part of a social role in an interlocked societal net, expressed by but not exaggerated along bodily differences. The idealized, naturalistic statues of Classical Greek art, representing the male, athletic body with harmonious proportions, formed by asceticism, exercise, and restraint, reflected the prevailing moral code of living ‘the good life.’ These idealized body-images were in a dialectic interaction with the politics of the polis, its male/female dichotomy, and strict class status forming a habitus of the political, responsible, and active individual. These statues depicted the human body as the aspirational political object, the “entelechy” of human development, a specific type of Greek human body: disciplined, controlled, and capable, where neither status, traces of hard work, disabilities, or disease blemished a beautiful and harmonious body. A body clearly distinct from animal life, but close to the divine, with each of the gods displayed not as the definite other, but a ‘super-human’, a comparable but even more beautiful and perfect body. The religious interactions with the gods were on a quid pro quo basis, offering sacrifices, incantations, and prayers for divine support. The healthy body was an individual’s responsibility via adherence to a moderate regimen in daily life, and this extended from the privileged citizens to all other participants of Greek life in the polis, i.e., merchants, farmers, warriors, foreigners, and ultimately slaves. The idealized body of the free adult member of the polis became an aspirational self-understanding of the body, even for those members of the society it did not represent. It related to women only as the fundamental ‘other’. Disease was interpreted either as the disturbance or disbalance of the humors, according to the concepts of the Hippocratic corpus, a consequence of divine interference or alternatively as insufficient self-care. Cure for disease was probably primarily sought within the household, via healers, sorcerers, or divine interference. Medical thinking as described by the Hippocratic Corpus and delivered by physicians was probably available for educated and wealthy citizens only. Thus, a physician’s results were important for the physician’s economic survival. Therapy was non-invasive; therapy-related harm may have been rare and this is reflected in the professional code. The Hippocratic Oath deals mostly with the physician’s etiquette with colleagues and in reference to the patients and their families. Medical ethics as understood today, with concepts of patient’s autonomy, non-maleficence, beneficence, and health care justice (Beauchamp and Childress 2019), were mostly irrelevant according to the prevailing understanding of health and disease, the available type of cure, and the lack of institutionalized health care. The prohibition of euthanasia and abortion, with suicide and abortion morally accepted acts, was probably influenced by Pythagorean thinking and may not have expressed a prevailing view in the population. Furthermore, without an institutionalized health care system, adherence to a bioethical code depended on the physician’s individual knowledge and acceptance of the Hippocratic Oath. Thus, at the time of its origin/emergence, the practical significance of the Hippocratic Oath may well have been of minor relevance for most of the population in Classical Antiquity, as it did not represent the understanding of the individual’s body and health, was insufficiently spread even in the subgroup of healers that were represented by physicians, and may have in addition given a moral code that referred to a specific group, i.e., the Pythagorean school of thought only. Yet from this humble origin, its effect and influence would grow, and the interpretation would undergo some changes over the almost two thousand years during which it remained the only ethical binding for physicians.

3.2. The Understanding of the Body during Late Antiquity

Late Antiquity or Early Christianity refers, with minor exceptions, to the time interval from 200 to 60016 and will be used according to context (Brown 1971; Sessa 2018). Applying a similar schematic approach to that used for Classical Antiquity, we will focus on those differences, new aspects, and developments of a body-world that emerged during Late Antiquity and may have affected the perception of the human body.

3.2.1. Everyday Life

Late Antiquity was a Greek-Roman world characterized by military and autocratic rule. The Roman Empire was divided into ‘West ’ and ‘East Rome’. In the fourth century, Constantine had Christianized the apparatus of the state, making the world of the Eastern empire a more Christian empire than the western parts. Yet paganism survived in the cultural life of the elites, the ‘Hellenes’17 of East Rome, against the ’barbarian theosophy’ Christianity (Brown 1971, Chap. 1, p. 72). West Rome, with Romulus Augustulus the last West Roman Emperor, was falling apart (476 AD) into many smaller domains (Sessa 2018), while East Rome, “the cultural power-house of Late Antiquity” (Brown 1971, Chap. 1, p. 19) was left unscathed.

Still, most everyday experiences may not have changed substantially compared to Classical Greek Antiquity. At about 200 AD, life expectancy was twenty-five years; only four percent of men and fewer women lived beyond the age of fifty (Brown 1988). There was farming, most of the population living from subsistence farming (Brown 1971), household chores to be taken care of, and the ever-present threat and reality of war. The society was characterized by a hierarchical class system with a small elite of citizens, alongside wealthy landowners, merchants, craftsmen, farmers, and slaves. Culturally, the East and West were still close. The dichotomies of Greek Antiquity, such as male and female, free citizens and slaves, the rich and the poor, were maintained within the Roman Empire. One significant difference was the language: Latin in the West, and Greek as well as Coptic (Egypt), Aramaic, and Syriac in the East (Sessa 2018).

Governors were responsible for overseeing fifty, and eventually—after Diocletian’s administrative reforms in the late third century AD—one hundred provinces (Sessa 2018). The administration of the Roman Empire was more ‘institutionalized’ compared to the diverse rulings of the many—relatively small—classical Greek polis. The government constructed and maintained various infrastructural developments. A network of roads for wartime usage improved access, the transportation of merchandise, the flow of information, and everyday life. Roman innovations, like high-arched bridges, stopcocks, storage reservoirs, and settling tanks optimized aqueducts, which provided a wide-ranging water supply (Cartwright 2012). The construction of huge, vaulted public baths served the entire population. Luxuries such as underfloor heating (hypocausts), originally used for hot baths and public buildings, eventually became available in private, probably only the more affluent, homes. Yet it was the ‘military revolution’ that most importantly influenced Roman society. The Senatorial aristocracy was excluded from military command and had to make room for a meritocracy of professional soldiers. The frontier detachments became a strong striking force of cavalry, the emperor’s companions, the comitatus18. These changes came with a cost, and by 300 AD, civilians complained: “there were more tax-collectors than tax-payers” (Brown 1971, Chap. 1, p. 24). It was this pressure of taxation that greatly influenced the structure of the Roman society in the fourth and fifth century (Brown 1971). During the reign of Constantine (324–337 AD), a new ‘aristocracy of service’, educated as administrators and paid with the new stable gold coinage, the solidus, emerged19 beside the classically educated, conservative elite of landowners (Brown 1971).

In Classical Antiquity, foreigners were an accepted minority. In Late Antiquity, the increasing migration and later dominance of people with non-Roman background—‘barbarians’—posed a challenge. These individuals served as mercenaries for the Roman army, assimilated into Roman culture, and adopted Roman customs, languages, and political frameworks. Conversely, Romans also adopted some ‘barbarian’ customs, such as wearing woolen shirts from the Danube, a cloak from Northern Gaul, and ‘Saxon’ trousers (Brown 1971; Sessa 2018). During the final period of the Roman state, the rulers of these ‘barbarian’ kingdoms in the West cooperated with East Rome. Their administrations comprised both Romans and non-Romans. They adopted Roman government practices, relied on Latin for official use, and were Christians of Nicene or Arian creed. From these close interactions with and influence of non-Romans, cultural changes emerged in this final period of the Roman state (Sessa 2018).

3.2.2. The Arts

As we have pointed out, Classical Greek Antique sculpture emphasized the naturalistic yet idealized human body, offering an aspirational self-understanding and identification with a way of life reflected in these bodies. In contrast, the Roman art of Late Antiquity individualized the body, showing its characteristics, flaws, and quirks. Roman bodies were clothed, indicating function and status, unlike the idealized male Greek nudes. Although Greek style was influential, inspiration was drawn from Etruscan art as well. There, the deceased were realistically depicted reclining on top of sarcophagi to preserve the individual who would receive the sacrifices from their descendants (Meyer 1986). Later, during Imperial Rome, portraiture was used, reviving idealistic representations to create a political image. There the emperor is closer to God than ordinary mortals, expressed in his artistically idealized portrait. Roman art, from the first century AD onwards, developed a certain formal and ceremonial expression. This is evident in reliefs that depict a bureaucratic reporting on war, with the individual soldier overshadowed by the fighting itself (Gombrich [1989] 1995; Meyer 1986).

Painting may have been valued during the Hellenistic period. Unfortunately, we have no surviving examples beyond reports in classical art books. In the first century AD, the ubiquity of wall paintings in Pompeii demonstrates their importance. Still-lives, human and animal figures, scenes of everyday life, even landscapes were depicted as a focus per se, not as a background for a story to be told. Charming countryside scenes featuring shepherds, shrines, and distant villas were created to please the eye (Gombrich [1989] 1995). These paintings were an enchantment of life, allowing viewers to dream about, to visualize oneself as part of a graceful and peaceful surrounding. It was a life very much oriented towards this-worldly pleasures.

Neoplatonism and Early Christianity both influenced the depiction of the human body. For both, the role of matter in the hierarchy of reality, the role of the human body in the world, was a central focus of aspects of self-perception20. For Early Christianity, the discussion ranging from denying human images at all to the acceptance of their representation as a means of a Christian narrative divided Eastern byzantine and Western art, respectively. For West Rome this led to the problem of how to display the divine, the beyond, in the forms of this world. Initially, Christ was portrayed like an Antique God, a young Apollo, or a venerable teacher after the example of Antique philosophers. Later, this was conceived as inadequate. During Early Christianity, in an atmosphere of awaiting redemption, religious art was characterized by features of world-negation, no longer praising earthly reality. This orientation towards the beyond reduced any display of earthly pleasures, erotic associations, heroic fighting, or human relations. Painting and mosaics became the preferred medium, taking over from statues. Thereby, naturalism gave way to a more representative display, with dignitaries or important persons shown frontally as symbols of the state or divine power—the ‘pantocreator’ or the ‘autocrat’. Religious mosaics were stylized and systematized to be recognized and remembered (Brown 1971). They no longer represented the living human to be recognized in the representation, but a divine narrative imbuing the figures with meaning and distance. “This art is not ‘otherworldly’, it is ‘innerworldly’” (Brown 1971, Chap. 2, p. 74), emphasizing the eyes as “revealing an inner life hidden in a charged cloud of flesh” (Brown 1971, Chap. 2, p. 74).

In summary, the major effects on the artistic representation of the human body in Late Antiquity were due to an increasing governmentalization as well as multiple and diverse ethnic and religious influences. Obviously, these changes occurred slowly, over time accepted as the new normality, the traditional and the new possible existing side by side until the older tradition slowly faded away. Greek and Etruscan influence, the idealized emperor Augustus, the Sol Invictus, merging the state and Roman religion, the diverse religions such as the Mithras cult, Manichaeism, Gnosis, Judaism, and Christianity, and philosophical schools like the Stoa and Neoplatonism, all existing side by side and tolerated until Constantine made Christianity the state religion. This rich tapestry of tradition and new developments, of diverse ethnic and religious practices, is reflected in the diverse expressions of Roman art. The naturalistic influence of Greek art merged with Etruscan style and morphed into a more individualized representation of humans. However, as the Empire struggled to maintain its borders and bring together its various ethnic groups, the portrayal of an idealized human being may have served as a means of self-identification with the Empire and thus the cohesion of the Empire. Statues depict a divinized and idealized emperor; reliefs were homages to wars fought and fallen heroes. Christian religious art strove to show Christ and the holy men in their divine glory without referring to earthly or worldly attributes. It was only in private pictures or mosaics that naturalistic, graceful humans led enchanting lives full of beauty and pleasure.

3.2.3. Religion

Hellenistic polytheism influenced the Roman faith, and subsequently the Greek gods were ‘Romanized’. Pagan polytheism was both a means of identifying with Rome through public religious rituals at temples and shrines and a private practice of having a small shrine dedicated to a favored deity in the household, for the daily ‘quid pro quo’ of prayers and sacrifices for divine support. At the turn of the millenium, the human’s status in the world and in relation to the divine was based on Platonic thinking, a dichotomy of matter and soul. The soul was a pre-existing principle comprising both the intellect (nous) and the emotions. During the second and third centuries, both Judaism and Early Christianity were subject to pagan imperial authority and shared the same urban spaces (Shama 2014). Judaism, with its monistic view of the body, was a tolerated religion, a religio licita (Brown 1988). After the destruction of the Temple in Jerusalem (70 AD) by the Romans, Jewish tradition underwent a restructuring, seeing the rise to dominance of the rabbis within Judaism (Brown 1988, I, 142) and the establishment of the codification of Jewish rules, with the Mishna as the second normative text alongside the Tora. At the end of the fifth century, the Talmud unified Mishna and Gemara (Shama 2014). In parallel, the Christian Church saw the strict division between the clergy and the laity (Brown 1988).

Early Christianity presupposed the neo-platonic understanding of the body, with the Enneads of Plotin (205–270 AD) highly influential on the thinking of Augustine (354–430 AD). There we find a clear hierarchy: the One—completely simple, undivided, and unique—as the basis of all being, the measure of all values, but beyond all being and therefore also beyond all knowledge, unknowable and therefore also inexpressible. From the One emanates the intellect (nous), as the mentally ascertainable universe, from which arises the soul as the Creator of Time and Space. The soul sees below itself nature, the material world. At the basis of this hierarchy, we find the body which is ‘in the soul’ rather than ‘the soul in body’ (Brachtendorf 2014; Emilsson 2017; Möbuß 2005). These ideas are reflected in Christian thought as the distinct difference between the body and the mind, with the latter superior over matter. It is the mind that governs the body. In Christianity, the humanity of Christ—the Incarnation, wherein God took on a body to save humanity—instituted the sacrality of the human body (Boureau and Semple 1994).

The coming of Christ to earth and Christ’s victory over death were thought of as bringing an end to ‘the present age’, seen as “the product of an overriding demonic tyranny, to which human beings and, indeed, the universe as a whole, had come to be subjected” (Brown 1988, I, 84). This change was to be manifested in the life of the believers. One possibility was via overcoming a bodily drive, i.e., sexuality. The renouncing of intercourse was supported by varying arguments: sexuality, via procreation, was no longer a remedy for death, but a possible first cause of death, representing Adam and Eve’s loss of immortality, a separation from the Spirit of God and thus a kinship with the animal world that the serpent had forced upon Adam and Eve. The Encratites (from enkrateia, continence) asked for complete sexual renunciation (Brown 1988). Others, like the Valentinians, offered a solution to the problem of sexuality by a hierarchy of believers, the ‘spiritual’ and the ‘psychic’, where the spiritual men and women renounced sexuality. Jewish rules of purity were extended, especially so in the early Church of Alexandria and Palestine, to renounce bodily desires as a precondition for the ‘reborn’ believer, or instant redemption as claimed by the Gnostics (Brown 1988). Gnostics denied salvation for the body and denigrated the material creation. They posited distinct kinds of human nature: ‘good’, ‘intermediate’, and ‘evil’, i.e., ‘spiritual’, ‘psychic’, and ‘earthly’, respectively, which correlated to different post-mortem destinies. In this view, evil natures are earthly and corporeal. This anthropological-cum-moral dualism suggests that the creator is responsible for evil (Cartwright 2018). For Clement of Alexandria, the physical drives of the body could not be eliminated. Yet, meticulous and continuous investigations into a body’s needs enabled a person to achieve a ‘passionless state’, apatheia, according to the Stoic idea of a life freed of passions (Brown 1988). Thus, in the early centuries of Christianity, bodily desires, sexuality, these sensual or vegetative drives controlled and contained by askesis and according to social rules in Classical Antiquity, were now on the forefront in defining the body and its role in redemption.

Manichaeism, a religious synthesis of all previous religions, was at its height in the Roman Empire of the fourth century only to disappear by the end of the fifth century. It was a dualistic gnostic religion with salvation through knowledge of special truth. The body is of the evil darkness, and purity can only be achieved by cognizing the need of the separation of light from darkness, and death from life. The ‘electi’ had to live an ascetic life as itinerant preachers (Markschies 2018).

At a time when a Christian doctrine was still in the making, it was mandatory to differentiate Christian thinking from ‘Gnostic heresy’. Ireneus of Lugdunum (d. c. 202) in his ‘Against Heresies’ stated that the perfect anthropos is “a mingling and the union of the soul receiving the Spirit of the Father, and a mixture of the fleshly nature that was moulded after God’s image” (Cartwright 2018, p. 175). The body is the matter from which it is composed while personal subjectivity is related to the ensouled matter, with the soul being the seat of mens, ratio, and intentio. The human being is body and soul and spirit, seen in a holistic rather than monistic anthropology, to counter the dualism of Gnosticism (Cartwright 2018). The coherent union of body and soul reflects the coherence and order of the cosmos. The body, as the locus of the human experience, is more corrupt than the immortal soul, and it is the body that needs salvation. God did not create evil, thus in principle, nature and the body are good, and evil is related to human self-determination (Cartwright 2018).

These ideas reflect Pauline (Paul, c. 10 BC—c. 60 AD) understanding of the body. The body is the whole individual, where the Lord and humankind are intertwined. Resurrection is the transformation of the earthly body into the spiritual body, not a transformation into something different but an entelechy. The body means the individual and the relationship between individuals, whereas the flesh and the spirit have a negative and a positive connotation, respectively. The flesh is the body affected by sinfulness; the spirit is the body as a communion with Christ. Thus, radical asceticism, regarding the body as distinct from the soul, a dualistic attitude to body and soul, is not justified. Paul adopted from Stoic thinking a metonymical use of the term ‘body’ as the unity of individuals: Christians, so far as they participate in the body of Christ, access the whole individuality of Christ through the Eucharist, and can be seen as one body, i.e., they are the body of Christ via the eucharistic participation in Christ. The Christian community is thus interpreted as the body of Christ, as the personal unity of individuals. The notion of the body of Christ as the unity of Christians has two aspects: (i) each member of this unity has its own place and belongs to it, and subsequently (ii) each member has to take care of each other (Limone 2018). This radical sense of community was one appeal of Christianity: “it absorbed people because the individual could drop from a wide impersonal world into a miniature community, whose demands and relations were explicit” (Brown 1971, II, 68).

Origen of Alexandria (c. 184–253 AD), in a more neo-platonic view, argues that the soul is part of the nous and fell from this pre-cosmic origin into the earthly body through sin. In a similar vein as Ireneus, he argues that sin comes from self-determination rather than from the soul’s inherent evil. It is the function of the body to bring the soul to perfection in earnest pursuit of the imitation of God. Evagrius Ponticus (345–399 AD) takes both the soul and the body as a fallen mind. The mind falls first to the status of soul and further to become a body. This is in line with neo-platonic ideas, the body as the fallen mind, the mind’s fall an act of self-alienation. The necessity to achieve unity in God asks for liberation from our bodies and thus from the world. Further, this ascent into unity asks for self-knowledge, i.e., knowledge of one’s soul through one’s body as an ascetic practice and self-contemplation (Cartwright 2018).

The fourth Ecumenical Council in Chalcedon (452 AD), fending off Arianism and dualist heresies, stated that the hypostatic union, i.e., two natures, divine and human, co-exist in the unique person of Jesus Christ God, which up to today, as the Chalcedonian Creed, is upheld by most Christian Churches. In the sixth century, Boethius defined the person as “the individual substance of a rational nature”, aligning the human body with the dignity of the model of Christ, thereby conferring divine legality on the humble union of the body and the soul. This created a bond that bound the individual body to the perfection of the soul. It unified the body with the soul and with rational intellect (Boureau and Semple 1994). However, the body is understood as divided, the body and the flesh. “In the night before the violent destruction of the flesh Christ designates the ontological permanence of his body in its manifestation as the Eucharist: ‘this is my body’, ……. underwriting the ontological alliance between body and soul and the exclusion of the flesh” (Boureau and Semple 1994, p. 7). In this line of thinking, the body can still be perceived as sacralized, while anything considered ‘out of control’, negative, or sinful is attributed to the flesh. This sacralization of the human body in concordance with the exclusion of the flesh fended off the problems arising from a failing body as observed in sinful appetites, desires, in imperfection or disabilities, or diseases. Yet, with the concept of the incarnate God still questioned by heretic dualism, both versions may have been operative: the idea of glorifying man as microcosm and the contempt for the body, respectively.

Beyond these theoretical religious considerations, religion was based for most of the believers in everyday religious acts and ritual. Households and their small shrines were viewed as space of divine presence and ritual practice. Amulets and apotropaic symbols protected from evil spirits, prayers and blessings were daily activities to protect the household members and provide prosperity and good health. Pagans, Jews, Mithras worshippers, and early Christians worshiped in the home, as did those attending to Manichaeism, a religion without temples or altars yet a highly institutionalized domestic cult. Diverse manifestations of belief, i.e., pagan deities decorating the walls, coexisted with Christian shrines and apotropaic symbols (Brown 1995; Sessa 2018, Chap. 6, p. 198ff).

It was not before the late Empire that churches and synagogues as centers of public prayer expanded public space for Christians and Jews, while on the other hand pagans and Manichaeans experienced a gradual contraction of their options, until pagan sacrifices in temples finally ceased during Late Antiquity. Still, participation in pagan festivities continued, interpreted by Christian elites as a legitimate expression of their dedication to civic traditions (Brown 1995; Sessa 2018, Chap. 6, p. 212ff).

To summarize, in Late Antiquity, Romans could profess one of various religious beliefs, with Roman paganism the basic option in parallel to Judaism, Mithras cult, and diverse gnostic beliefs. This changed in the fourth century, when Christianity took over as the state religion under the rule of Constantine. Each of these beliefs envisioned a specific role for the body: the platonic dichotomy of body and soul, the monistic view of Judaism, the extreme dichotomy of gnostic beliefs, and the spectrum of understanding of the body that emerged in Early Christianity. The incarnation of Christ, which placed the body in the realm of the divine, had to be reconciled with the idea of evil or sin associated with the body. Thus, the flesh offered the possibility to be consistent with both the ‘divine’ and the ‘sinful’ manifested in body and flesh, respectively. Nevertheless, religious practice in Late Antiquity may have been largely a pragmatic approach to the divine in daily devotion to individually preferred and socially accepted paths. The shift towards Christian rituals and liturgies, a slow process intertwined with traditional rites and beliefs, would have structured a normative understanding of the human body according to religious belief. At last, we see a new idea emerging of a unified mind/spirit and body. But a body divided into body and flesh, where the body is seen to re-unite with Christ, while the flesh is demarcated by evil desires.

3.2.4. Moral Life

There was no organized governmental, judicial moral code, no coercive authority or institution defining the ways of dealing with, acting through, or interacting with a body. However, the increasing governmental organization of Late Antiquity expanded the interactions between the government and the citizen: an intensified ‘institutionalization’, a bureaucracy based on the administration of population data, i.e., data on bodies living in the Roman Empire. Data that had to be collected, stored, and kept accessible to serve the interests of the imperial government. Access to and distribution of these data was improved by the administrative reforms of Diocletian (r. 284–305 AD). Provincial boundaries were redrawn, resulting in smaller provinces, grouped into larger units called dioceses. This structure also served as the framework for ecclesiastical organization (Sessa 2018). Bureaucracy was grounded and depended on knowledge about the population gained through repeated censuses. Taxes had to be assessed and revenues collected. Men were called to arms and had to undergo a prior physical assessment. To qualify, men had to be at least 18 years old, meet a minimum height (165 cm), and be able-bodied. Slaves and women were excluded from recruitment.

The Empire depended on the collaboration of local elites and on administrative structures based on the individual city for the collection and redistribution of taxes. The relentless yearly taxation was fundamental to the organization of the state. Authority was exerted not via violence but by a ‘politics of the art of the possible’, by instilling ‘devotio’, i.e., loyalty and prompt obedience expected of the upper-class subjects of the Empire. Loyalty could not be imposed by force alone but was mobilized by appeals to a shared code of behavior. As a result, the exercise of power in a hard-driving and potentially abrasive system was not controlled, in the sense of being subject to legal restraints. But it had to be rendered dignified, and needed to be naturalized, by acquiring an aura of ceremonious majesty. “[T]he serenity associated with the vast notional omnipotence of the emperor was mediated, throughout the imperial system, by a succession of representatives and collaborators, by means of innumerable interchanges in which courtesy, self-control and quiet confidence—the mark of innate superiority—were believed to have prevailed” (Brown 1995, Chap. 2, p. 40).

The law offered a functional legal system even at village level. Access depended on the payment of fees, with assistance available for those without income. The ecclesiastical courts, with the bishop as judge, offered a lower cost for judicial ruling. Criminal cases were only pursued if brought to court. There, interrogation could involve torture21. Torture—as power in its most direct, physical effects—was intended to elicit truthful testimony, an attempt to make subjects responsive to authority. Torture was to reveal the truth through human means, rather than through reference to divine judgement (Asad 1993, Chap. 3, p. 83ff). Torture thus demonstrates power in relation to the body (Foucault 1979).

Within the Christian communities, religious discipline and the dangers of transgression had to be kept at bay. The community of the faithful, i.e., the body of Christ, excluded and readmitted those who had transgressed, ”imposing on them a range of physical discomforts and deprivations and requiring from them a confession of the truth about themselves for fear of pain in the life after death” (Asad 1993, Chap. 3, p. 97). Confession of guilt, penance, and reconciliation were required to be publicly performed as part of a single sequence of rites known as exomologesis. There, bodily pain and discomfort required by penance preceded reconciliation, i.e., the restoration of truth and justice. The notion of bodily pain for achieving truth is comparable to the concept of purgatory, where physical pain is a measure of transgression, and a means to restore the sinner to divine justice. In addition, in a medical metaphor, interpreting transgression as sickness, pain is conceived as a purging, the salutary effect of therapy to restore the sinner to spiritual health (Asad 1993). For these arguments, the body is both the means of transgression and reconciliation.

The ‘Pauline body’, the understanding of the body as a social body, i.e., the Christian community, acknowledged communicatively via religious ritual and liturgies, led the way to a new understanding of the other as a brother or sister in faith in need of mutual support beyond an individual’s interest (Limone 2018).

Sexuality and desires were to be kept under control. The body must not be permitted to force its need upon the tranquil mind. It was overall a Roman elite culture, where indulging bodily desires was a ‘mark of lack of refinement’. Yet an “ostentatious ascetic was equally distasteful” (Brown 1988, Chap.1, p. 27). Procreation was to be expected, with the emperor Augustus rewarding families for producing children. For the population to remain even stationary, each woman had to have at least five children. Thus, in the Roman Empire, chastity was ‘antisocial’ and accepted in virgin priestesses only. But Christians offered alternative ideas. Clement of Alexandria added to the austere classical image of the person, “our idea is not to experience desire at all”. Related to the idea of the end of the present world, a universe shattered by Christ’s rising from the grave, by renouncing all sexual activity the body could join in Christ’s victory, release itself from the grip of the animal world. Christians, refusing desire, could bring marriage and childbirth to an end, as an alternative to the prevailing moral and social order (Brown 1988).

To summarize, the increasing governmentalization of Late Antiquity by both the state and by the emerging ecclesiastical Christian structures, modelled on the institutions of the state and justified by religious beliefs, created a framework of moral rules that went beyond individual ethical thinking. We witness a transformation in which the individual’s responsibility extends beyond its own private life and the polis is embedded in the necessity of the organization of the state and the church. Official power extends to the individual bodies that are counted, taxed, measured, defined, and subjected to governmental or ecclesiastical needs or religious arguments, creating the governmentalized body, the body politic.

3.2.5. Philosophy

Greek philosophy, i.e., Platonian and Aristotelian thought, had a standing as the classical philosophy, a canon still revered in Late Antiquity. There the Platonian view posed the immaterial soul outside the body, in contrast to Aristotle, who saw the body as ensouled, a particular kind of informed matter. In a similar vein, Epicureans and Stoics thought of the body as a material unity, body and soul as one. Thus, there existed both a Platonian pre-existence dualistic concept (body and pre-existing soul) and an Aristotelian, Epicurean, and Stoic monistic anthropology, with the soul an offshoot of its father’s, a traducianistic22 anthropological concept (Blosser 2018). The Epicurean’s materialistic understanding is based on Democritus’s interpretation of atoms as the fundamental building blocks of the world, including the body and the soul (Kenny 2012).

During the second century of Early Christianity, the social stratum of believers broadened to take up all members of society, from the poor and uneducated to the wealthy and educated elite. Christian thinking strived to integrate religious Christian, i.e., Pauline, thought with Platonic and, less so, Aristotelean thinking (Kenny 2012). The discussion focused on the possible relation of body and soul along the Christian narratives of the body as an image of God, original sin, the Incarnation, and Salvation. Clement of Alexandria (c. 150–215 AD), Hippolyte of Rome (c. 170–235 AD), Tertullian (c. 155–240 AD), and Origen of Alexandria (c. 185–254 AD) consent to the idea that the soul is created, rather than of divine origin. The soul and the body are seen as one, undivided, consistent with the plan of a benevolent creator. Arguments that the soul is from one’s father, and has its nature from Adam (original sin) until it is born again in Christ (Salvation), fitted the biblical narrative. Thus both Stoic/Aristotelean traducianism and Platonic pre-existence23 were possible explanatory frameworks as long as any concepts supporting strict dualistic Gnosticism were avoided (Blosser 2018). In the fourth century, with Christianity the state religion under the reign of Constantine, new and promising careers within the ecclesiastical leadership became available for the educated Greek and Roman aristocracy. Among them, the foremost intellectual discourse centered on Neoplatonism. Neoplatonism (see page 23) saw the divine associated with the spiritual, the intelligible, the immaterial. Traducianism was interpreted as reducing the soul to biological creation on par with animals. In contrast, Neoplatonism emphasized the spiritual origin of the soul. Both Athanasius of Alexandria (296–373 AD) and Gregory of Nyssa (335–394 AD) argued for the immateriality of the soul, and Leo I (400–461 AD) finally anathematized both traducianism and pre-existence, establishing creationism24, the belief that each soul is created by God in the womb, as the only acceptable doctrine. “Men’s souls did not exist until they were breathed into their bodies, and….they were not there implanted by any other than God, who is the creator both of the souls and of the bodies” (Blosser 2018, p. 216). Thus, creationism was the formula (i) replacing traducianism with the Neoplatonic idea of the soul’s immateriality, as an immaterial soul could have no material origin and (ii) discrediting Gnostic dualism and pre-existence, as an immaterial soul could not pre-exist its insertion into the body. Augustine (354–430 AD) strove for a synthesis of these intellectual currents, i.e., Neoplatonism, Gnosis—especially in its form of Manichaeism—and Christian thought. He persisted on the Neoplatonic idea of the immortality and immateriality of the soul, denying traducianism, yet insisted on the transmission of the original sin by sexual reproduction, confirming Origen’s view. These deliberations resulted in the Western Church’s doctrine of creationism, that every immaterial soul is created by God with no prehistory, and in parallel with the traducianist idea of the hereditary of the original sin (Blosser 2018).

Did these intellectual discussions affect the everyday believer? The persistence of traducianism is obvious with infant baptism and its concomitant ritual of exorcism, both based on the assumption that newborns, according to Origen, were afflicted by a spiritual sickness “contaminated [with Adam’s sin] in his father and in his mother” (Blosser 2018, p. 218). In contrast, the ecclesiastical elite kept to Greek ethics, relating sin to personal and individual responsibility, and thus rejecting the necessity of infant baptism. The Pelagian controversy25 of the fifth century developed along this divide. While Pelagius understood the newly created soul as free of any sin, Augustine had to deal with the problem that a soul bearing Adam’s sin must have had a prior existence in Adam. Thus, due to the problems of original sin, in this line of thinking creationism and traducianism persisted in parallel, with consequences in liturgical and ritual acts of the believers.

During most of Late Antiquity, philosophy was practiced within philosophical schools in a vein similar to the Platonic academy, the Aristotelean Lyceum, the Epicurean Gardens, and the Stoics, privately organized schools of philosophy where the aspiring philosophers joined the head of the school as paying pupils. The bureaucratic reforms of Diocletian and Constantine changed the intent of a philosophical education. It no longer aimed at the moral education of a small number of provincial and imperial elites for their leading role in government, but set the goal of specifically educated bureaucrats to increase provincial participation in the Empire. Valencian, by 370 AD, systematized access to imperial positions by creating a registry of students, “permitting emperors to learn the merits and education of the various students, so that they may be judged whether they may ever be necessary to Us” (Watts 2018, Chap. 1, p. 15). Education thus changed its goal from making a person ‘better’ to making them ‘marketable’. At this time, philosophical education represented only a small part of the publicly funded faculties, and philosophers mostly worked in private institutions competing for private funding, with all the problems of patronage to be dealt with in addition to philosophical work. In short, philosophers, like everybody else, needed to make ends meet, attend to social and professional demands of their disciples, and manage their household. This was understood by some as the irreconcilability of life and contemplation. A possible solution to this tension between the life of the mind and the bodily existence was offered by the withdrawal from worldly responsibilities and devotion to a life of asceticism or monasticism. As Watts suggests, these deliberations may explain in part the emphatical discussions of the relationship between body and mind by both pagan and Christian thinkers (Watts 2018).

For religious specialists, i.e., the individual eremite or monastic communities, asceticism is seen as the way to the truth. From Origen through the early Church Fathers to the monastic discipline of the Middle Ages, the body is to be chastised, as it is an obstacle to the attainment of perfect truth. “The marks of sin are made on the soul and on the body” (Asad 1993, Chap. 3, p. 106). Thus, pain becomes necessary because of the involuntary connection of the self with sensations, feelings, and desires. These require a constant labor of inspection and of assessing the body lest the soul be betrayed. Inflicting pain becomes part of the discipline, confronting the body’s desires with the desire for truth on the part of a suspicious will. In this line of thought, the body became “a medium by which the truth about the self’s essential potentiality for transgression could be brought into the light, so that it could be illuminated by a metaphysical truth, a process in which pain and discomfort were inescapable elements” (Asad 1993, Chap. 3, p. 110). The ascetic specialist served as the paragon of piety, living an exemplary pious life on behalf of all those too weak or too involved in everyday life to dedicate their lives to God alone. The ascetic body thus can be interpreted as a sign of true piety to be emulated. The idea survives in the pre-Eastern forty days of fasting, where denying food serves as a spiritual exercise (Asad 1993).

Briefly summarized, the theological concepts of the body aimed to unite the idea of the body with the concepts of Incarnation and Salvation, to explain the unity of body and soul/spirit and to solve the problem of original sin. The solution offered was to relate evil to the flesh and accept both creationism and traducianism, side by side. Salvation was in part relegated to the religious specialist, who transcended the body by asceticism, rejecting the desires of the flesh in representation of the community, i.e., the ‘body of Christ’. In this line of thinking, disease can be interpreted as resulting from sin. In addition to the religious specialist who acted in lieu of the individual of his community, the Church itself offered hope via confession, repentance, and punishment.

3.2.6. Disease and the Physician

Different medical schools, Dogmatists, Empiricists, Methodists26, and Pneumatics27, arose until the times of Galen (129–199 AD) without reaching overarching significance [for details see (Carrick 2001, p. 40ff)]. Galen, basically a follower of Hippocrates, added Aristotelean thoughts and the emphasis on breath from the Pneumatics, and his own anatomical and physiological empirical data, to integrate all parts of the body into a functional whole. Galen saw the body and soul as an inseparable system, a psychosomatic unit28. He linked the brain with the center of thought and claimed that a person’s perceptions were communicated via the spinal cord and the nervous system. In accordance with the Pneumatics, a patient’s pneuma originated in the blood and circulated through the body. The condition and the natural function of the pneuma were in part responsible for a patient’s health or disease, as were the structural arrangement of the body’s constituents. In this view, a proper arrangement of the four elements is a necessary but not sufficient condition for health. The proper blending of the opposite qualities and the proper arrangements of the body parts are individually necessary and jointly sufficient for a healthy constitution. As no person is exactly alike, the physician must know the individual characteristics to prescribe a helpful therapy. Interestingly, Galen describes health in a relative sense. The Hellenic notion of health as an absolute ideal is replaced by the idea of health according to a person’s individual needs and self-knowledge (Carrick 2001, p. 41ff).

Roman authors such as Celsus and Aretaeus define a group of conditions such as mania, melancholia, and epilepsy together in a thematic arrangement as mental diseases, although attributing different underlying physical causes to them. Galen utilized the category of mental disorder, relating these conditions to a key symptom, and further linked them with different bodily locations and impaired functions. As a shift from earlier Greek cardio-centric traditions, Galen located all cognitive and mental functions in the brain.

In summary, while the Hippocratic concept still prevailed, Galen’s interest in anatomy and physiology focused the understanding of human physiology on the natural working of the body. Still, health and disease were understood as a fine-tuned balance of humors, individual characteristics, and the environment. The principal ideas did not change so much, yet became more fine-grained and tuned, not so much a gaze from the outside on the body but a medical gaze trying to understand the inner working of the body beyond a concept of free-flowing humors.

The physician’s task was to understand the way of the working of nature and support it with his prescribed therapies. Knowledge of the disease and its prognosis were essential for the physician to support these natural processes in the right ways and at the right time (Carrick 2001). The medical profession emphasized organic causes as explanations for bodily deviations observed in disease (Porter 1992).

Asceticism, i.e., the control of bodily desires and the development of a healthy body (via exercise), was emphasized by Galen as a healthy way of living. Dietary prescriptions, exercise, and bathing were used to treat disease (Sessa 2018, Chap. 3, p. 161ff), confirming ideas from Classical Antiquity and Hippocratic medicine and supported by the newly developed religious understanding of the body.

Overall, medical thought had diversified, with different schools offering various and diverse interpretations of physiology and disease. Yet Hippocratic medicine elaborated by Galen’s increasingly ‘scientific’ view of health and disease dominated medical thinking. Still, the overall situation for the physician may have been close to that of the itinerant physicians of Classical Antiquity. Galenic medicine was for the elite, the educated and wealthy class who could afford a physician. Most Roman citizens, apart from the military who were provided with medical advice, had to rely on traditional concepts of disease and cure. Greek medicine was seen with a xenophobic prejudice, and traditional healing by the paterfamilias with herbs and charms preferred to the ‘effete’ Greek medicine. “Beware of doctors, they would bring death by medicine” (Porter 1999, p. 69). Disease, in accordance with Jewish healing traditions, signified the ‘wrath of God’ and certain maladies (for instance leprosy) a punishment for sins, with Yahweh the only healer, and thus rejection of professional physicians. Early Christianity may have increased the portion of Romans who understood disease as related to an ethically failing body or flesh, and disease a punishment for the failure of the flesh to adhere to a purity necessary for the unification with Christ, for Redemption and Salvation. When sin and sickness were similar states, spiritual healing might be requisite. The leading healing saints, Cosmos and Damian, to refer to in case of illness, were ‘reviving’ the heathen Castor and Pollux.

3.2.7. Medical Ethics in Late Antiquity

There is a rare reference to bioethics in Roman medicine. In the preface to his Compositiones, a book on drug recipes, Scribonus (c. 1–50 AD) quoted the Hippocratic Oath. Without other references available, information about the dissemination and endorsement of professional bioethics is lacking (Porter 1999, p. 70), a fact that hints at the little importance that may have been attached to bioethics in medical circles.

Christian understanding of the body upheld the individual’s responsibility for disease. The pursuit of the ultimate goal, i.e., redemption and reunion with Christ, requires an awareness and responsibility for the failure of the flesh. Clearly the responsibility for one’s own body took on a new significance compared to Classical Antiquity. There the individual strove to live the ‘good life’ in search for eudaimonia, which included an individual’s responsibility towards the polis. Still, bodily control was an individual decision depending on circumstances of living and social status. Responsibility ended with death. By contrast, in Late Antiquity failing to control evil desires, i.e., the flesh, condemned the believer for all eternity and denied him any chance of salvation. Here disease bears witness to an individual’s inability to control the flesh. Consequently, any cure of disease depended on remorse, proper repentance, and acceptance of the corresponding punishments. The physician played only a minor role in providing a cure. It was the Church with its liturgical rituals of initially public confession that offered redemption for individual failure and cure.

Apart from the great plague in Athens (430 BC), no epidemic diseases are reported from the Greek world. In contrast, the Roman empire saw a changing pattern; smallpox, brought back by the legions from Mesopotamia, ravaged the Mediterranean world. The Antonine plague (165–180 AD) proved highly lethal throughout the Roman empire. During the Antonine plague processions, sacrifices to city-protecting deities were organized asking for divine help. Epidemic diseases were interpreted as the punishment for communal lives lived in ‘sin’.

The idea of a Christian community, the body of Christ, the siblings to be taken care of, i.e., responsibility and help for those who were poor, ill, or dying, signified a remarkable change in Late Antiquity. The care for the sick and poor was institutionalized. Deacons were charged with distributing alms. The first hospitals were built by Leontius, Bishop of Antioch, Bishop Eustathius of Sebasteia in 360 AD, and St. Basil in Caesarea as houses for the sick, poor, and leprous. In West Rome, Fabiola, a wealthy female Christian, founded a hospital in 390 AD. Hospitals became large institutions with more than two hundred beds in Jerusalem and Constantinople, with specialist departments for surgery, eye disease, and gynecology, resident physicians, and teaching facilities. Exposing oneself to infection to care for the lepers was a mark of holiness, and supporting hospitals financially became a common religious ethos of charity. This was new, as charity duties had not been acknowledged in the Greek and Roman pagan world (Porter 1999, p. 83ff). At the end of Late Antiquity, monasteries and hospices cared for the poor, the ill, and the dying who had no one else to look after them. The basic idea was not medical cure, but pity, empathy, caretaking. This care extended to everybody in need of caring, independent of faith or ethnic origin.

Thus, health care became institutionalized. Primarily this was in the army, where buildings were set aside for the wounded and the sick. Standardized military hospitals evolved with individual rooms or cells, latrines, and baths. The cities took care (i) to provide clean water by building aqueducts, (ii) of waste removal, (iii) to build public lavatories, and (iv) to provide dwellings with plumbed sanitation. Civic officials oversaw the water and sewage system. Quarantine was used in case of epidemics. All these activities expressed the state’s care for Public Health, a state taking care of its citizens, not because of empathy but necessity to keep up a functioning, healthy society. Thus, the setting of the scene on health and disease had changed. Responsibilities were no longer only with the individual but with the community, the state.

Both the government and the religious organization increasingly organized and structured the field of Public Health. Governmental and ecclesiastical power set new rules, and influenced and enforced rules on dealing with health and disease, taking over parts of individual decision-making and the way to live one’s life in exchange for health and health care. Here we find the early realization of bioethics as related to Public Health.

Did this institutionalization include the training of physicians, the supervision of individual physicians? The wide range of interpretations of disease, from a divine scourge to a purely physical problem, the small number of physicians who cared mainly for wealthy citizens, and the many different medical schools despite the overarching ideas of Galen, provided no incentive for ethical regulations. Healing success may have been the most important regulator for physicians and their economic needs.

The changes in the perception of the body by Christian thought—the body an image of God, shared with Christ in the Eucharist—made suicide or euthanasia no longer an available option as it had been in Classical Antiquity. Similarly, abortion was no longer a final option to prevent childbirth. The rejection of both suicide or euthanasia and surgical abortion had already been stated in the Hippocratic Oath. It was, however, a change in public awareness, not the enforcement of a professional bioethics, that grounded these views on life (Carrick 2001).

3.2.8. Summary

Comparing the ‘body-world’ of both Classical and Late Antiquity, changes in the perception of the body are obvious. The basic dichotomy of female/male bodies, the differences of social status, enclosed and enclothed in the bodily habitus, were accepted as social roles in an intertwined social net throughout. The concept of the idealized human body of Classical Antiquity gave way to an individualized representation of the body indicating rank and social status. With the transition of the Roman Republic into an imperial power, the representation of the individual slowly disappeared from perception. The focus shifted to the body politic, depicting the divinized and idealized emperor as a symbol of unity and power—the unifying figure that Romans aspired to. These official representations of the body politic were complemented by paintings and mosaics in private settings that created a pleasant environment, and later by public mosaics in religious buildings aimed to convey a religious narrative rather than depict individual bodies. The representations, i.e., the perception of the human body, shifted alongside changes in political structure and power. The displayed bodies testified not only to the human figure per se, but also to the way humans interacted, their social bonds, and the political power they organized or were subjected to.

State control and institutionalization gradually increased from the Classical period to Late Antiquity, potentially limiting individual choices. Adherence to rules was emphasized by state power or ecclesiastical institutions. These rules were enforced in everyday life or meant to affect the afterlife, respectively. The concept of the individual pursuing the ‘good life’ had been superseded by the notion of the individual adhering to governmental or ecclesiastical regulations regarding the appropriate way to live one’s life. In line with Foucault’s arguments (Foucault 1979), the governmentalization of one’s own body took over in many ways via public health regulations, censuses, and conscription. Educational goals shifted from moral education of a small number of provincial and imperial elites to training many capable bureaucrats. Thus, education no longer aimed to produce ‘better’ individuals but rather ‘marketable’ ones. The individual body became a commodity of the state to be dealt with efficiently.

In Classical Antiquity, the difference between humans and gods was gradual, with gods displayed with super-human bodies and capabilities, anthropomorphized and achievable (Markschies 2019; Robb and Harris 2013). The Platonic dichotomy of matter and soul was probably of little relevance for all but a small philosophically educated elite. Different religious beliefs offered various understandings of the body. The Platonic dichotomy of matter and soul, echoed and extended by Gnostic beliefs and Manicheism, expressed a deep suspicion, rejection, and disapproval of the body versus the soul. In contrast, Jewish monism interpreted body and soul as a unified whole. Furthermore, Early Christianity aimed to reconcile body and soul through the concept of a unified body and soul as expressed in Christ. The Church fathers explained sin as arising from bodily desires. Subsequently the human body was perceived to have a vulnerable and unregulated aspect, referred to as the flesh, the weak and uncontrolled evil in the human body. Ultimately the religious specialist, through ascetic practices, would endure suffering in lieu of the ordinary believer to subdue the flesh, embracing bodily pain as a means of penance and redemption.

The understanding of the body differed according to the various philosophical schools. Platonism and the thinking of Aristotle were prevalent in the early years. Later, Epicureans and Stoics shared a monistic anthropology. Yet it was with Neoplatonism that a strict hierarchical view on the topic of matter and soul was reintroduced, significantly influencing Christian thinking.

In this line of view, disease could be brought on by a lack of bodily control. In this view, the flesh succumbs to its desires and sinful actions due to a weakened control of the individual body. Disease thus could be interpreted as the outward sign of failing to adhere to religious rules. Sin and disease are interchangeable expressions of a failure to live a righteous life. Redemption is offered through confession and penance, often involving bodily pain. Epidemics were interpreted as punishment for the amoral life of the community and cure asked for by religious rituals.

The Christian notion of the individual body as part of the body of Christ, and thus part of the religious community, brought with it empathy and responsibility for one’s brethren in the religious community and later for all humanity. Charity, care for the poor, the sick, and the dying, became an expression of faith. The motivation to care for the weak and helpless was based on the promise that the good deed would positively affect the individual’s destiny after death. In parallel, the Empire established military hospitals to care for and motivate those who gave their lives in war in support of the Empire.

In conclusion, the most obvious changes are related to the body being subjected to ‘governmentalization’, as an object to be shaped according to the needs of the structures and deliberations of the Empire. Furthermore, the body became a battlefield for religious discourse on the role of body, soul, spirit, condemnation, confession, penance, and redemption by diverse religious communities. In Late Antiquity, Christian arguments prevailed, and the body and soul were unequivocally seen as a representation of the body and spirit of Christ. Consequently, euthanasia, suicide, and abortion were deemed unacceptable options. An individual’s moral attitude and one’s control of bodily desires were reflected in one’s physical well-being or disease.

4. Conclusions: The Concept of the Body from Classical to Late Antiquity and Its Interaction with Bioethics, i.e., the Interpretation of the Hippocratic Oath

Considering the above deliberations, can we deduce an answer to the problem posed? Does the perception of the human body interact with the basic ideas of health and disease, and possibly bioethical thinking? Can we therefore relate a transforming perception of the human body to a transformation in the interpretation of medical ethics? Did, despite an unchanged text of the Hippocratic Oath, a transformed perception of the human body, the understanding of disease and medicine as indicated in the events of everyday life, of arts and religion, philosophy, and the role of the physicians, affect the understanding of medical ethics in both the population and the physician?

In addressing these questions, we will have to decide whether the perception of the human body changed from Classical to Late Antiquity. Our arguments can only be indirect, using observable historical changes as indicators. As we exemplified in the preceding paragraphs, everyday life was based on similar assumptions, such as the basic dichotomy of the female/male body, the difference in social status in a largely agrarian society, a social status enclosed and enclothed in the bodily habitus. The main differences were related to a changed political reality. Classical Antiquity, with its rather small polis states, involving at least the citizen in political decision-making, stands in stark contrast to the imperial organization of Late Antiquity. There, ‘governmentalization’ (Foucault [1984] 2020a, [1984] 2020b) built, shaped, and controlled the individual body in contrast to the moral and bodily control to be realized by the individual in search of the ‘good, i.e., morally right, life’ in Classical Antiquity. Responsibility and control, while still to be exercised by the individual, were expected to be based on the needs and in support of the state, rather than the needs and understanding of the individual. Instead of an individual’s contribution to the polis, the body became part of the Empire, inscribed by rules and organizations dealing with Public Health, the needs of the army, bureaucracy, and agricultural production to feed the Empire.

In parallel with this governmentalization, Early Christianity brought about a fundamental change in the understanding of the body—a body united in the image of Christ, body and soul, separating the flesh as the source of evil and sin. Whereas in Classical Antiquity ascesis was intended to strengthen the body in health and athletic performance in keeping with the idealized body that corresponded to the ‘good life’, ascesis became a means of controlling the negative, the unrestrained desires, the sin, to provide a unified body and soul to achieve redemption and salvation in the eternal afterlife. This dichotomy of body and flesh is reflected in the dichotomy of health and disease.

Furthermore, the ‘body of Christ’ became a metonym for the community of the faithful, emphasizing a responsibility towards others, since ‘we are all one body in Christ’. A responsibility for the well-being and care for the bodies of others, for the relatives, the neighbors, the individuals in one’s own community and, later, for all humankind.

In short, the idea of the body broadened from one’s own individual body, to the social body and the body politic. While each society and historical phase creates, supports, and enhances its own type of social body, the increased power and extended control of government over its people, i.e., institutionalization and governmentalization, expanded the role of the body politic, as did religious institutions. For the first time, responsibility for the body no longer ended with one’s own body, but extended to and included the bodies of the members of one’s community.

It is at this crossroad, the interface of ‘culture’ and physiology, that the sociology of religion and sociology of medicine interact (Turner 2012). In addition, religious thought interweaves spirituality, salvation, and healing.

Was this new perception of the body—the individual body as part of a whole body, i.e., the body of Christ, understood as the members of one’s community—reflected in the understanding of health and disease? Can we discern, at this interface between cultural and physiological structures, the interaction of the sociology of religion and sociology of medicine (Turner 2012)? Are these new perceptions of the body reflected in Galen’s writings when compared to the Hippocratic Corpus?

Both the Hippocratic Corpus and Galen’s writings interpret disease from a ‘naturalistic’ point of view. They related close observations to a concept of physiology and pathophysiology, which despite being scientifically incorrect had enormous explanatory power. In essence, the concept of the four humors did not change. Galen broadened the basis of observation to include anatomy and physiology, as they could be gleaned from animal dissections, accidents, and injuries. The environment, the seasons, individual characteristics, and ‘temperament’ still played a vital role in diagnosis, prognosis, and therapy. One important change was Galen’s concept of relative health, i.e., health as defined by an individual body’s needs to succeed in its circumstances. This individualization of health is reflected in the representation of an individualized body in the statues of Galen’s time, contrasting with the idealized bodies of Classical Antiquity.

Compared to Classical Antiquity, public health efforts had increased. Infrastructural measures were taken to provide clean water, to deal with sewage and waste, to offer public baths and central heating, and to centralize the supply of food to the population, all with the aim of ensuring the well-being of the population. The almost constant wars made it necessary to provide medical care for soldiers in veterans’ hospitals and to train those physicians who treated them. In addition, Christians, understanding themselves as responsible for their siblings in faith, cared for the poor, the sick, and the dying in hospitals. Both the governmental and ecclesiastical organizations took care of individuals over and beyond their own responsibility. The individual, along with the individual’s healthy body, became a commodity necessary for the functioning of existing power. They were taken care of, offered support, and subjected to specific measures with authority.

Christian thought extended the responsibility for one’s body beyond everyday life to the afterlife, shaping the destiny of the faithful after death and in all eternity. This required a new moral attitude for the individual. Furthermore, the faithful, as part of the body of Christ, or in a less spiritual way, part of a governmental/ecclesiastical community, had a reciprocal relationship concerning the well-being of the body. Being part of the community involved caring for others and receiving care in return. The perception of the body had changed from a means to live the good life to a tool for achieving salvation through self-care and caring for others.

Lastly, how important was the theoretical medical comprehension of the body for the general population? Most would have had limited access to physicians. Medical care was mainly provided by household remedies, traditional healers, and religious practices. Health was protected by amulets, and cures were sought through votive gifts, sacrifices, and prayers. It was common to view disease as a spiritual or bodily failure due to the sinful nature of the flesh. The former attributes disease to the scorn of the gods, the latter—in a Christian understanding—to the failing flesh. Both traditions may have coexisted for the individual and in times of epidemic diseases may have expanded to include blaming a community’s misbehavior for the spread of disease and resulting deaths. Thus, it is unlikely that Galen’s writing had a significant impact on both the perception of the body and the help and assistance sought from a physician in case of disease for the majority of the Roman population.

The control exerted by the Empire and the Church influenced the moral attitude towards the body. Being a Roman or Christian determined the perspective on euthanasia, suicide, and abortion. Until late into Late Antiquity, it was generally accepted that it was a personal decision to end one’s life, as was the option to end physical suffering caused by incurable disease or the termination of an unwanted pregnancy. Preserving life as asked for by the Hippocratic Oath—rooted in Pythagorean thought yet with negligible effect on the actions of the few physicians who were aware of it—now gained widespread acceptance due to a broad religious consensus in society. Preserving life became mandatory.

In short, we observe a political and spiritual governmentalization by both the governmental and ecclesiastical institutions, a power that shaped the way a body was perceived and dealt with in health and disease.

The inclination given by the Hippocratic Oath, probably of no effect at the time it was conceived, became now a governmental and ecclesiastical demand, enforced by the Christian motive to save oneself for the afterlife. Thus, we may argue that an idea indicated as a mandatory behavior of the physician towards his patients, incepted in the Hippocratic Oath, but at that time without much effect, may have been awarded a new significance and wider adherence as a reflection of a change in the way a body was perceived. While the moral and economic rulings of a physician’s etiquette as elaborated in the Hippocratic Oath would not have changed much, the interpretation of those aspects of the Hippocratic Oath that dealt with decision-making in life-threatening situations underwent a change in importance and interpretation, that was now based on a broad Christian understanding of the body as a gift of God. Despite the changes in the perception of the body, as much as they may have affected the dealing with the body, in addition to the interpretation of the Hippocratic Oath, the Oath by itself would not have been acknowledged widely. This is foremost due to the role of Galen’s medicine pertaining mostly to the wealthy elite who could afford to deal with physicians in case of need. Secondly, we surely can interpret the rare acknowledgment of bioethics in only one available reference as an expression of its overall low importance in the everyday dealings of the physician. To conclude, the Pythagorean admonitions of the Hippocratic Oath to refuse support of suicide, euthanasia, and abortion, a marginalized view in Classical Antiquity, were now seen in line with a broad Christian consensus on the preservation of life. Bioethics, as related to the interaction between physician and the patient, was based on a broad social consensus, yet probably without much effect even for most of those wealthy citizens who were taken care of by a physician. In comparison to the understanding of the bioethics of today, many questions were irrelevant. Neither medical knowledge nor therapeutic efficacy were as effective as to be discussed as optional or involve asking for the patient’s decision. Medicine was still patriarchal, with the physician knowing best.

However, we can acknowledge the emergence of Public Health, which is an important part of today’s bioethics. The government, which had a keen interest in the health of the population, provided clean water supplies, sewage and solid waste disposal, public baths, and quarantine during times of epidemics, established hospitals for veterans, and used these hospitals as training grounds for doctors. Christians cared for sick members of the community, which was understood to be part of the body of Christ.

Overall, the changed perception of the body influenced bioethical thinking. It emphasized the Pythagorean ideas on suicide, euthanasia, and abortion in the Hippocratic Oath. However, this did not increase bioethical awareness in interactions between physicians and their patients. On the other hand, both the “governmentalization” of the body and the Christian interpretation of the body led to Public Health projects that can be interpreted as part of an impending bioethical commitment.