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Ancient euthanasia: ‘good death’ and the doctor in the graeco-Roman world

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Abstract

This article maps the concept of 'good death' (euthanasia) in the ancient world and explores the marginal role of the doctor at a 'good dying'. His assistance was not needed when the Homeric warrior died as a hero and was expected to accept death with resignation. Later the city-state regarded as heroes the men fallen for the cause of the community, honouring these model citizens as those who died well. In the more individualistic age of Hellenism and the Roman Empire, a death in luxury or without suffering could be styled euthanasia. The doctor had neither a place in those acts of dying nor in cases of natural death. He shunned death as a failure of his art. Sometimes a doctor was called in to assist in voluntary death, a role that was not forbidden by the Hippocratic oath. An appeal to this oath by opponents of euthanasia in the modern sense of the word therefore is mistaken.
GOOD DEATH AND THE DOCTOR IN THE GRAECO-ROMAN
WORLD
ANTON J. L. VAN HOOFF
Dr. Anton J.L. van Hooff was senior lecturer in ancient history at Nijmegen University. His
address is: Van Oldenbarneveltstraat 16B, 6512AW Nijmegen, The Netherlands, tel.
+31243240730, e-mail: anton.van.hooff@online.nl
Abstract
This article maps the concept of ‘good death’ (euthanasia) in the ancient world and explores
the – marginal - role of the doctor at a ‘good dying’. His assistance was not needed when the
Homeric warrior died as a hero was expected to accept death with resignation. Later the city-
state regarded as heroes the men fallen for the cause of the community, honouring these
model citizens as those who died well. In the more individualistic age of Hellenism and the
Roman Empire, a death in luxury or without suffering could be styled euthanasia. The doctor
had neither a place in those acts of dying nor in cases of natural death. He shunned death as a
failure of his art. Sometimes a doctor was called in to assist in voluntary death, a role that
was not forbidden by the Hippocratic oath. An appeal to this oath by opponents of euthanasia
in the modern sense of the word therefore is mistaken.
Key words
Good death, Euthanasia, Voluntary death, Hippocratic oath, Medically assisted suicide,
Graeco-Roman times
The ancient word euthanasia
From 1 April 2002, a new law regulates euthanasia in the Netherlands. After calling in a
second opinion a doctor is permitted to end the life of a patient whose suffering he/she regards
as intolerable as well as incurable, provided the patient has explicitly expressed the wish to
die. The new law constitutes a major victory for the Dutch Association for Voluntary
Euthanasia (Nederlandse Vereniging voor Vrijwillige Euthanasie) that for decades has
pleaded for adequate legal rulings. It is to be noticed that in the modern concept of euthanasia
the presence of a doctor is taken for granted. In the ancient idea of euthanasia, good dying,
there was no place for the doctor.
The noun euthanasia, the adjective euthanatos, the adverb euthanatôs and the verb
(ap)euthanat(iz)ein made their appearance in the fourth and third century BCE. It seems that
they were first used by Greek comedy writers, such as Menander, Posidippus and Cratinus, in
scenes in which a glutton enjoys the good things of life so much that he wishes to die on the
spot. Thus, Menander has the tyrant Dionysius say:
One thing for my own self I desire – and this seems to me the only death (monos
thanatos) that is a one ‘well died’ (euthanatos) – to lie on my back with its many rolls
of fat, scarce uttering a word, gasping for breath, while I eat and say: ‘I am rotting
away in pleasure.’1
An astrologer from the second century CE, Vettius Valens, describes a (physically) good
death: those who are born under a certain constellation ‘die well (euthanatousin) falling
asleep from food, satiety, wine, intercourse or apoplexy’.2 It is this kind of sudden, gentle
death that the emperor Augustus wished for himself, according to his biographer Suetonius:
‘For always when he heard that somebody had died fast and without pain he bade for himself
and his family a similar euthanasia, for this is the word he used.’ Interestingly the Roman
emperor used the Greek term that obviously by his time had acquired a specific meaning.
The idea of good dying was not limited to a painless exit. The word euthanasia and its
derivatives were also used to indicate a happy end that crowned a good life. In his instructions
on how to praise somebody in a speech the orator Aelius Theon sums up the various personal
conditions that deserve acclamation: education, friendship, respect, political position,
1 Menander frg. 23 in J. M. Edmonds, The Fragments of Attic Comedy, Vol. III B, Leiden 1961.
2 Anthologiarum libri ix 126.
richness, being blessed with children (euteknia) and last but not least euthanasia.3 ‘Who does
not know that a good old age (eugêria) and euthanasia are the highest of human goods?’ so
the Jewish writer Philo of Alexandria says - only to mark the difference with God whose “old-
age-less” and immortal (athanatos) nature has nothing to do with these human goods.4 The
Christian Clemens (c. 150 – 211/212 CE) echoes this idea of a God who is in no way to be
compared with humans. The early Christian theologian revels in the paradoxes of faith. God
has given us humans innumerable blessings in which He Himself does not participate: ‘He by
birth unborn, as to food in want of naught, in growth remaining the same, as to good old age
and euthanasia immortal and undecaying.’5
In this argument, Clemens still holds to a rather concrete meaning of euthanasia. However, to
ancient philosophers dying a good death was more than having a painless or happy end. It
meant dying in moral perfection. One fragment of the Stoic Chrysippus (281-208 BCE) says
euthanatein is ending life by whatever death in perfection.’6 This idea is developed by the
Stoic emperor Marcus Aurelius (121–180), who recently became familiar to a world audience
through the film Gladiator, in which he appeared as the wise emperor. This reputation is
based on the philosophical diary he composed during his reign, Exhortations to Myself. In this
unique piece of writing, he admonishes himself to be nice to common people. Of course, the
wise man shall not be dragged away unwillingly from such people when the end is near, but
rather ‘as the soul shall easily slip from the body of a person that dies well (euthanatountos),
the departure from such persons has to be of such easy nature in order for one to die well
(euthanatêsontes).’7
Finally and most importantly, euthanatein could mean dying nobly. Thus the historian
Polybius (c. 200 – c. 120 BCE) describes the death of Cleomenes, a former king of Sparta
who, being imprisoned by king Ptolemy Philopator of Egypt, in the winter of 220/219 made a
dash for freedom, ‘not that he really believed that he could recover it […] but rather because
he was resolved to die nobly (euthanêsai).’ When the attempt was thwarted he and his
companions ‘turned their weapons upon themselves, and died like brave men and Spartans.’8
Such an end befitted this king ‘who was, in one word, formed by nature both to lead and to
rule’, but even a despicable person like Lykiskos who had caused much misery for his fellow-
3 Progymnasmata 110
4 On the sacrifices of Abel and Cain 100.
5 Stromata 5,68,2-3.
6 Moral Fragments 601.
7 Ta eis heauton 10,36.
8 Histories 5, 38-39.
Aetolians, died so nobly (160/59 BCE) that he was an example how Fortune grants to the
worst men the fine death, euthanasi, which is the guerdon due to the good and brave.9
The heroic connotation of euthanasia is still used with respect to Jewish and Christian
martyrs. In Book 2 of Maccabees, the aged Eleazar declares that by his death he will leave a
noble example to the young of how to die well (apeuthanatizein) in accordance with the
revered and holy laws of the Jews.10 This Bible passage is quoted by Origenes (184/5-254/5)
in his Exhortation to Martyrdom.11 He expects Christians when they have to give proof of
their faith to die nobly (euthanatizein) as Eleazar did.
Although the Greek euthanasia as a euphemism for gentle death was not unknown to the
Romans as we have seen with regard to Augustus, a prominent Roman like Cicero who was
more versed in Greek literature used it in the more common sense of a noble death. In the
chaotic situation after the murder of Caesar on March 15th 44 BCE he had left Rome on the
advice of Atticus. Now this same close friend urged him only a few months later to come
back. Cicero is surprised about this change of mind and shows some irritation about Atticus’
arguments: ‘What did astonish me beyond measure was that you should use the words: “A
fine thing for you, who talk of a noble death (euthanasia), a fine thing, í’faith. Go desert your
country.12
Our linguistic exploration has shown that euthanasia and its derivatives conveyed the idea of
a comfortable, happy and noble end. Medically assisted gentle death, which is the primary
connotation of modern euthanasia, was not covered by the Greek terms. Presumably,
euthanasia became a popular euphemism in modernt times because of its technical
undertones. For the Greek root of the word makes it look like the verbal constructs of which
medical terminology is full. At the end of this paper we shall see that ancient doctors did
sometimes assisted in self-killing, however not to ensure a gentle, but rather a noble death.
So already the exploration of the word suggests that the ancient paradigm of euthanasia was
quite different from the modern concept. The difference can only be fully understood against
the background of the ancients’ view of life and death. It may seem daring to cover many
centuries in sketching this attitude in a few pages. However, there is a great deal of continuity
9 Histories 32,4,3.
10 Macc.2:6,28
11 Ch. 22.
12 Letters to Atticus 16,7,3.
where these ‘essential’ questions are concerned. A traditional society like the Graeco-Roman
world did not easily change its views.
Therefore, in this paper the stress is on the concept of a good death in the context of classical
culture. Given the audience of this magazine we shall pay special attention to the role of the
doctor during our historical tour d’horizon.
Heroic resignation
It is not just the chronological order that makes us begin with Homer. Classical civilisation
did not only start with the Iliad and Odyssey, but these epics also continued to act as a point of
reference, for they represented basic ancient values. Among these, shame was a major
concern for Greeks and Romans. The Homeric hero is only concerned with his own glory.
This egotist attitude is the theme of Homer’s Iliad as he announces in the first lines of the
epic:
The wrath sing, goddess, of Peleus' son, Achilles, that destructive wrath which brought
countless woes upon the Achaeans, and sent forth to Hades many valiant souls of
heroes, and made them themselves spoil for dogs and every bird; thus the plan of Zeus
came to fulfilment, from the time when first they parted in strife, Atreus' son, king of
men, and brilliant Achilles.
Achilles is unable to swallow his degradation by Atreus’ son, Agamemnon, who has taken
away his concubine Briseis. The common well-being of the Greeks is no concern at all for the
hero. With grim satisfaction, Achilles watches the Greek failures against the Trojans during
the time in which he abstains from battle. Only when his closest friend Patroclus has been
killed by the Trojan Hector does grief overcome Achilles’ resentment. Then he returns to the
battlefield to perform miracles of heroism. He does so being quite aware that his death is near.
The fatal end will be brought about by an arrow that hits his only vulnerable spot, his heel.
This story is not told in the Iliad, but the reader – or rather the listener – is supposed to know
about Achilles’ tragic end. Only with this foreknowledge is he able to appreciate the perfect
heroism of Achilles, who goes into battle being aware that he is doomed to die soon. Achilles
accepts death as a fact of heroic life.
Similar resignation13 is demonstrated by the numerous heroes who actually fall in battle
during the episode of the Trojan War that the Iliad deals with. No hero will utter any protest
13 The qualification ‘résignation’ was coined by Ph. Ariès, L'homme devant la mort, Paris 1977.
when the moment of his end is at hand. A desperate ‘Why am I to die so young?’ would be a
perverse denial of heroic existence. The main concern of the dying hero is to meet his fate
with dignity. Sometimes he will bemoan his father who is going to be left behind without any
filial support. Another concern may be to get a proper burial that will guarantee his memory.
In this respect Achilles risks showing disrespect for the rules of heroic values. His wrath and
grief make him drag behind his chariot the corpse of Hector whose remains he has promised
to leave to the dogs and birds. Finally Hector’s father Priam succeeds in softening Achilles’
rage, appealing to the common fate of fathers and their heroic sons. Thus the epic of wrath,
which the Iliad is, ends in a serene spirit: the hero constitutes the perfect man, but in the last
resort he is mortal too. Only the gods, who are anthropomorphic both in (imaginary)
appearance and in their passions are the immortal ones, athanatoi, or the ‘always being’, aien
eontes, as the Homeric epithets have it.14 It was only in a sophisticated era that some
philosophers came to revel in the paradox that at least in one respect humans are superior to
the gods: only man has the power to put an end to his life.15
However, in the early stage of Greek civilisation that Homer’s epic represents, the hero
accepts death as an unavoidable evil from which even the supreme god cannot save his mortal
child. Only for a moment does Zeus hesitate, considering interference when he realises that
Sarpedon, the son he had with Europa, is about to die. Then his wife Hera warns him not to
put the normal order in disarray. Instead, she advises her divine husband to make sure that
Sarpedon’s corpse will be brought to his homeland of Lycia.16 In this way his brothers and
other relatives will be able to pay their respect to the dead and to keep his memory, seeing the
tumulus under which his ashes rest. To mark the tomb a standing stone suffices as a token, for
in Homeric times no inscription or representation is made. As long as people passing by
remember, the dead Sarpedon will live on in memory.
In order to remove Sarpedon’s body from the battlefield Zeus sends the gods Death,
Thanatos, and his twin brother Sleep, Hypnos.17 These are, according to Hesiod, the sons of
the goddess Night, Nyx.18 Elsewhere in Hesiod’s genealogy of the gods, they are denoted as
the ‘terrible gods’, deinoi theoi.19 A Greek vase by Euphronios in the New York Metropolitan
14 Iliad 1. 290, 494; 21. 518; 24. 99; Odyssey 5. 7; 8. 306; 12. 371, 377.
15 Pliny Historia Naturalis 2, 27.
16 Iliad 16, 433-457.
17 Iliad 16, 666-675.
18 Theogonia 212.
19 Theogonia 759.
Museum shows how Sarpedon’s corpse is lifted by Death and Sleep, who here as well as on
other Greek pottery are depicted as winged gods.20
In Homeric epic, it is only a violent end on the battlefield that is described. Of course, in the
scenes of heroic death, there is no place for a medical man to assist the dying in their last
moments, let alone to confirm death. Such a technical expert would detract from the respect
the poet wants to instil in his listener. That is not to say that doctors are unknown in the
Homeric world. However, such a ‘healer of evil’, iêtêr kakôn (Odyssey 17,384) is only called
in when somebody is wounded, as Menelaus is in Iliad 4,108. Then his brother Agamemnon
sends for Machaon who is highly regarded for his medical expertise. This iêtêr matches many
men, Homer says, but Machaon’s skill is not that of the professional specialist.21 He leads his
troops just like the other Greek princes. He just happens to distinguish himself by some
specialist knowledge.
The world of the Odyssey, that in many ways represents a later stage of Greek civilisation, is
already familiar with professional doctors. Together with the seer, the ship builder and the
singer – Homer’s own profession! – they are counted as ‘people’s workers’, dêmiourgoi, i.e.
experts whose skills are of great importance to the community.22 These professionals travel
around to offer their services. Obviously one could not reckon with their presence when
somebody was dying. Besides, in a world with a high mortality one did not need a doctor to
confirm death. Thus, their absence at the deathbed in Homeric epic is not only to be explained
by the codes of the genre, which depicts mainly violent death. There was simply no place for
a doctor when somebody was about to die. In the case of the hero, who had to exemplify good
death, a doctor’s presence would damage the effect. For a hero dies his own good death.
That is not to say that death was welcome. Just a shadow, called psyche or eidolon (figure) of
the dead remained to go to Hades’ place. This underworld was anything but a paradise, as
Odysseus finds out when he descends into it. Among other prominent ghosts he meets
Achilles, whom he praises exuberantly: ‘Say not a word,’ the great hero answers, ‘in death’s
favour; I would rather be a paid servant in a poor man’s house and be above the ground than
king of kings among the dead.’23 So being dead is no fun at all. The way the hero as a model
meets his fate is essential for his fame. A good death crowns a good life.
The continuing appeal of these Homeric values is demonstrated more than fice centuries later
by the historian Polybius when he speaks about the determination of Cleomenes III to
20 Metropolitan Nr.1972.11.10. Three lecuthi showing the winged pair made by the so-called Thanatos painter
are London D. 58, Munich 2777 and Berlin F3160.
21 Iliad 11,514-5
22 Odyssey 17,383-385.
23 Odyssey 11, 488-491.
euthanatein (see above on the historical context): ‘I suppose that there dwelt in his mind and
inspired him those words of the hero which are wont to commend themselves to men of
dauntless spirit:
but now again is my doom come upon me.
Nay, but not without a struggle let me die, neither ingloriously,
but in the working of some great deed for the hearing of men that are yet to be.’24
Good death in the city-state
The Graeco-Roman world never turned its back on the old heroic ideal. It modified this ideal
to make it fit into the value system of the new community state, the polis. The polis stressed
the collective element of death by citizens who sacrificed their life for the common cause, for
the virtues the polis wanted were co-operative rather than competitive as they had been in
Homeric society.25 The noblest end was to die together with compatriots, holding the line until
the last moment. In this way, the polis domesticated or rather channelled the agonistic spirit,
which in olden times had proved to be a destructive power. The ancient city-state glorified the
men who had given their lives for the commonwealth. They were venerated as the heroes of
the polis. Their collective tomb, sometimes a cenotaph, became the focus of a cult in which
the whole community took part. At Marathon in Attica, visitors still can see the tumulus
covering the bodies of the 192 Athenians who died there in the battle in which the Persian
invaders were defeated in 490 BCE.
The shift towards the social significance of death is exemplified in Herodotus’ story about the
meeting between the Athenian statesman Solon and king Croesus of Lydia, whose richness is
still proverbial. Solon was on a tour having reformed his polis into a community in which
both rich and poor had a place. To prevent the personal respect he had won among the
Athenians becoming an obstacle to the free functioning of the new constitution, Solon went
into a kind of voluntary exile. Having been received with great distinction by the wealthy
Lydian king, he is shown around. When the king thinks his guest sufficiently impressed, he
asks him who in his view is the happiest of men. Solon answers without hesitation: ‘Tellos of
Athens.’ Surprised the king asks for an explanation, which is duly given by the man who was
regarded as one of the seven sages of Greece:
24 Iliad 22,303-305.
25 A.W.H. Adkins, Moral values and political behaviour in ancient Greece: from Homer to the end of the fifth
century, London 1972.
First, because his country was flourishing in his days, and he himself had sons
beautiful and good, and he lived to see children born to each of them, and these
children grew up; and further because, after a life spent in what our people look upon
as comfort, his end was surpassingly glorious. In a battle between the Athenians and
their neighbours near Eleusis, he came to the assistance of his countrymen, routed the
enemy, and died upon the field most gallantly. The Athenians gave him a public
funeral on the spot where he fell, and paid him the highest honours.26
The answer begins and ends with the commonwealth, for in the new code of the city-state it is
not enough to have enjoyed a blessed private life. Of course Tellos was most lucky to have
seen his family flourish into the second generation. This circumstance ensured that his tomb
would be visited by his male offspring who would pay respect to him. However, what most
contributed to his happiness according to Solon was that he, living in a flourishing state,
contributed to its well-being by sacrificing his life.
The Athenians later regarded Solon as the founding father of Athenian democracy, mistakenly
from an historical point of view, for in 594 BCE Solon reformed the constitution only from an
aristocracy into a timocracy (a kind of meritocracy), a system in which timê prevailed. The
Greek word timê denotes ‘value’ both in an abstract and in a concrete sense, for those who
had the financial means to afford heavy armour had a higher value and thus were accorded a
higher status in the polis.
When Herodotus (c. 484-424 BCE) composed or remodelled the Tellos story, he saw Athens
in its climax as a democracy. To sacrifice one’s life for the benefit of this perfect polis made
good all individual defects, as Pericles argues in his famous funeral speech on the fallen of the
first season of the Peloponnesian War. ‘For there is justice in the claim that steadfastness in
his country's battles should be as a cloak to cover a man's other imperfections; since the good
action has blotted out the bad, and his merit as a citizen has more than outweighed his
demerits as an individual.’27
So in the heyday of the polis good death was understood as a socially meaningful end, in
which the co-operative values of the city-state were demonstrated.
Doctors and death
The fifth century BCE saw not only the climax of democracy, ‘people’s power’ as a political
system, but also the cultural climax of Athens. On the Acropolis, the Parthenon was erected as
26 Herodotos Histories 1,30
27 Thucydides Histories 2,42,3.
the focus of the city’s cult. At two great annual festivals, tragedies and comedies were
performed that have become part of world literature. These plays by Aeschylus, Sophocles,
Euripides and Aristophanes addressed the sentiments of the audience and thus give an insight
into contemporary public opinion. In Sophocles’ Antigone the praise of man’s achievements is
sung:
Wonders are many, and none is more wonderful than man. His power spans the sea,
even when it surges white before the gales of the south-wind, and makes a path under
swells that threaten to engulf him.28
Thus, the greatness of man shows itself in shipping, in agriculture, in the domestication of
animals, in hunting and fishing. Man has wrought miracles in intellectual and social fields as
well as in house building:
Speech and thought fast as the wind and the moods that give order to a city he has
taught himself, and how to flee the arrows of the inhospitable frost under clear skies
and the arrows of the storming rain. He has resource for everything. Lacking resource
in nothing, he strides towards what must come. From Death alone he shall procure no
escape, but from baffling diseases he has devised flights.29
In this list of achievements that are proof of man’s formidability, deinotês, medicine has a
prominent place. Here we see the impact of the school of Hippocrates of Kos (460- c. 370
BCE), whose rationality is expounded in the first lines of the On the Sacred Disease: ‘As to
the so-called sacred disease it is like this: it seems to me no more sacred than other diseases,
but it has a natural cause.’ The explanation that follows is complete nonsense in modern eyes
– an overflow of phlegm in the brains – but at least it is rational nonsense. For here a serious
attempt was made to establish a physical cause. Looking for causes, aitiai, is the common
concern of historians and medical men in Greece’s Golden Age. Herodotus the historian says
in the opening lines of his Histories that the aim of his studies is to find the cause, aitia, of the
Persian Wars. Similarly the Hippocratic doctor does not content himself with the observation
that diseases vanish spontaneously: ‘Indeed, under close examination spontaneity disappears;
for everything that occurs will be found to do so through something, and this “through
something” shows that spontaneity is a mere name and has no reality. Medicine, however,
because it acts “through something” and because its results may be forecasted, has reality.’30
Such is the glorious language of the scientist who believes that only on a rational basis can
28 Sophocles Antigone 332-337.
29 Sophocles Antigone 354-362.
30 On the Art 6
medicine develop: ‘Medicine […] has discovered both a principle and a method, through
which the discoveries made during a long period are many and excellent, while full discovery
will be made, if the inquirer be competent, conduct his researches with knowledge of
discoveries already made, and make them his starting-point.’31
In Hippocratic medicine death is there when the balance between fire and water, the two basic
elements of all animal life, is lost.32 Only rarely, however, do medical authors discuss the
nature of death. Hippocratic doctors are primarily concerned with prognostics.
Characteristically, an electronic search of all Hippocratic writings on the phrase ‘death is’
(thanatos esti) only produced places with ‘death is near when…’ Above all ancient doctors
were interested in the question whether an ailment was fatal or curable, so that they could
decide if they should take care of a case or not. For instance diseases of the brains, liver,
diaphragm, backbone, stomach, arteries and heart were regarded as deadly.33 They paid much
attention to the indications of death, in Greek the sêmeia thanatodea, in Latin the signa
letalia or indicia mortis. They discerned a specific face that announced death, the so-called
Hippocratic face, the facies hippocratica. This countenance is not like its usual self. ‘The latter
will be as follows. Nose sharp, eyes hollow, temples sunken, ears cold and contracted with
their lobes turned outwards, the skin about the face hard and tense and parched, the colour of
the face as a whole being yellow or black.’34 The ancient doctor was an observer rather than a
therapist. In the medical texts no mention is made of the doctor’s task to relieve the suffering
of those who are fatally ill. Palliative care to ensure a gentle death was not a major concern of
ancient medicine.
Pleasant dying
In the fourth century BCE the city-state no longer constituted the complete world of an
individual. This development was due to the emergence of great powers like Macedonia that
reduced the significance of the polis. Now private life was more valued as well as a private
good death. Maybe that is the reason why the vocabulary of ‘euthanasia’ originated in this
period. In the Menander fragment quoted above Dionysios the glutton ends by saying: ‘I am
rotting away in pleasure.’
The Greek word for ‘pleasure’ in this comedy fragment is hêdonê, which was to become a
central concept of Epicureanism. Modern language uses ‘Epicurean’ and ‘hedonistic’ in a
31 On Ancient Medicine 2.
32 Peri diaitês 1, 3, 2; death as the effect of decreasing warmth and moisture in Galen De temperamentis (Kühn
1.523, line 3 and 1.582, line 4 and 17).
33 On Diseases 1,3,5.
34 Prognostics 2.
vulgarised sense for ‘pleasure seeking’. In fact, Epicureanism was a noble philosophy that
tried to meet the new conditions of Hellenism. Since Alexander the Great had opened up the
whole of the Middle East to the Greeks, the city-state was no longer the horizon of man’s
existence. The whole (civilised) world, kosmos, merged into one polis, the kosmopolis, in
which the individual could easily feel himself lost. The two major philosophical schools of
Hellenism, Stoicism and Epicureanism, both tried to redefine man’s place in the world. The
Stoics advocated a ‘cosmopolitical’ attitude, arguing that an individual had to regard himself
as a citizen of the whole world. A wise man just played the role that had been accorded to him
and subjected himself willingly to the great order of things. The Stoic sage accepted illness
and death as natural vicissitudes of life, which he had to meet with firmness and moral
perfection. We met this attitude above in the dictums of Chrysippus, who was the second head
of the Stoic school of philosophy, as well as in Marcus Aurelius. In modern usage ‘stoic’
denotes an attitude of the stiff upper lip, whereas in the world of the Hellenistic Greeks and
the Romans it was a highly elaborated philosophy that defined the individual’s place in a
divinely ruled world. In many ways Stoicism prepared the ground for Christianity.
Epicureanism on the other hand was loathed by the Christians. They rightly sensed that it was
the ultimate elaboration of pagan values. For Epicurus (341-270 BCE) there was no existence
beyond the grave. So death was nothing to man. ‘When we live death is not, when death is
there, we are no more.’35 In phrases such as this Epicurus and his followers argued for the
doctrine that the sense of life was life itself, i.e. a life of good quality, for that is what hêdonê
stands for. In Herculaneum the charred papyrus rolls of a monograph On Death (Peri
thanatou) have come to light. In this work Philodemos (first century BCE) elaborates the
Epicurean doctrine of a good end. In his view it is nonsense to assume that death is always
painful because the soul is separated from the body. As the soul consists of material particles
of the body death is just one of the changes, metabolai, that a person undergoes. Moreover
there are instances in which death comes without any suffering, e.g. during intercourse, in
drunkenness or in a coma. It does not make sense to postpone enjoying life. This Epicurean
view was popularised in Horace’s famous dictum ‘carpe diem’ (grasp the moment). To long
for death was unnatural. Why bother about one’s reputation after death, the disfiguration of
the decaying body, the absence of children or dying in a foreign country? Only if one frees
oneself from these common, but irrational anxieties can one live and die without perturbation,
ataraxia.
35 Epicurus, Letter to Menoeceus 125.
The Epicurean view of death is a development of a generally shared pagan view, as is shown
by epitaphs. In some of these the dead exhort the passer-by to enjoy life, seeing what fate has
in store for every mortal.
Nothing I was, nothing I am. You who are alive, eat, drink, play, come (namely to
the sad underworld that is inescapable)36
Do not fear the river of the underworld. For it is always stupid, by fearing death, to
forfeit the joys of life.37
Titus Flavius Martialis who died at the age of eighty had this text inscribed on his tomb:
What I ate and drank, I have; what I left behind, I lost.38
It would be far fetched to see Epicurean philosophers behind these epitaphs. Actually, these
texts testify to the popularity of the ‘Epicurean’ attitude. Their message, sometimes backed by
pictures of macabre skeletons, are the opposites of the Christian ‘memento mori’, remember
you have to die. They do not admonish people to see their temporary existence in the
perspective of eternal life. On the contrary they say ‘memento vivere’, remember to live.
Good emperors die well
For the Roman component of the ancient world we use the emperors as a test group. No
ancient biography of an emperor will skip the way he died as death is the final proof of his
(un)worthiness. Out of 80 emperors whose death cause is more or less certain only 29 died a
natural death. 38 were murdered or executed, 7 fell on the battle field, out of whom five in
civil war and two (Decius and Julian the Apostate) against foreign enemies. Five emperors
committed suicide. Finally one, Theodosius II (401-450) had a fatal accident: he fell from his
horse and broke his neck.39
The emperor, in particular the good emperor constituted an example, a paradigm. He was well
aware that he had to play the show to the end as Augustus did:
36 Found in Cordoba, Corpus Inscriptionum Latinarum II2262. A collection of ‘Epicurean’ epitaphs in H. Geist
and G. Pfohl, Römische Grabinschriften, Munich 19762, p.167-172.
37 Rome first century CE, F. Bücheler, Carmina Latina Epigraphica, Leipzig 1895-1926, nr.1567.
38 Hermann Dessau, Inscriptiones Latinae Selectae, Berlin 1892-1916. nr. 8155a = Carmina Latina Epigraphica
(previous note) nr. 244.
39 This count is based on a recent Dutch monograph: Fik Meijer, Keizers sterven niet in bed. (Emperors do no die
in bed), Amsterdam 2001, in which the author summarises the lives of 86 emperors from Caesar to Romulus
Augustulus 44 BCE - 476 CE, highlighting the end of these ‘legitimate’ rules. If one was to include all the
pretenders one reaches the number increases considerably A young German scholar, Tobias Arand from
Münster who has has processed all these cases too in his dissertation Das Schmähliche Ende (The Shameful
End), Frankfurt a/M 2002 deals with 171 persons.
On the last day of his life he asked every now and then whether there was any
disturbance without on his account; then calling for a mirror, he had his hair combed
and his falling jaws set straight. After that, calling in his friends and asking whether it
seemed to them that he had played the comedy of life fitly, he added the tag: "Since
well I've played my part, all clap your hands and from the stage dismiss me with
applause." Then he sent them all off, and while he was asking some newcomers from
the city about the daughter of Drusus, who was ill, he suddenly passed away as he was
kissing Livia, uttering these last words: "Live mindful of our wedlock, Livia, and
farewell," thus blessed with an easy death and such a one as he had always longed for.
For almost always on hearing that anyone had died swiftly and painlessly, he prayed
that he and his might have a like euthanasia, for that was the term he was wont to use.
He gave but one single sign of wandering before he breathed his last, calling out in
sudden terror that forty young men were carrying him off. And even this was rather a
premonition than a delusion, since it was that very number of soldiers of the pretorian
guard that carried him forth to lie in state.40
In this description some elements that mark the end of a good emperors are stressed. Augustus
preserves his bodily decorum. He is not left alone in his final moments, but friends and family
surround him. His does not loose the grasp of his mind, apart from a minor slip. Augustus’
end is without much suffering, the euthanasia he had longed for.
Similar circumstances are highlighted in the story about the end of another good emperor,
Antoninus Pius (86/7-161).
He died in the seventieth year of his age, but his loss was felt as though he had been
just a youth. They say his death was somewhat as follows: after he had eaten too freely
some Alpine cheese at dinner he vomited during the night, and was taken with a fever
next day. On the second day, as he saw that his condition was becoming worse, in the
presence of his prefects he committed the state and his daughter to Marcus Antoninus,
and gave order that the golden statue of Fortune, which was wont to stand in the bed-
chamber of the emperor, be given to him. Then he gave the watchword to the officer
of the day as “Equanimity,” and so, turning as if to sleep, gave up the ghost at Lorium.
To his daughter he left his private fortune, and in his will he remembered all his
household with suitable legacies.41
40 Suetonius Life of Augustus ch. 99, in the translation of J. C. Rolfe, Cambridge MA 1920
41 Life of Antoninus Pius 12 trans. David Magie, The Scriptores Historiae Augustae I, Cambridge MA/London
1967, p.131.
Until the last moment this model emperor remained true to himself. Before closing his eyes he
had taken care of his private affaris as well as those of the state. He accepted death with the
watchword he gave: ‘equanimity’.
Other emperors of good fame died with similar dignity: Vespasian, Nerva and most of all the
philosophical emperor Marcus Aurelius:
[…] being eager to die, he refrained from eating and drinking, and so aggravated the
disease. On the sixth day he summoned his friends, and with derision for all human
affairs and scorn for death, said to them: “Why do you weep for me, instead of
thinking about the pestilence and about death which is the common lot of us all?” And
when they were about to retire he groaned and said: “If you now grant me leave to go,
I bid you farewell and pass on before”. And when he was asked to whom he
commended his son he replied: “To you if he prove worthy, and to the immortal
gods”. The army, when they learned of his sickness, lamented loudly, for they loved
him singularly. In the seventh day he was weary and admitted only his son, and even
him he at once sent away in fear that he would catch the disease. And when his son
had gone, he covered his head as though he wished to sleep and during the night he
breathed his last.42
Apart from the familiar scenario it is stressed that the emperor showed a contempt of death
such as befitted a philosopher. In his Exhortations to Myself (see above) he had often dealt
with the topic of a dignified death stressing that one had to accept it as a natural phenomenon.
What a soul that is which is ready, if at any moment it must be separated from the
body, and ready either to be extinguished or dispersed or continue to exist; but so that
this readiness comes from a man’s own judgement, not from mere obstinacy, as with
the Christians, but considerately and with dignity and in a way to persuade another,
without tragic show.43
The Homeric heroic resignation in the face of death had developed into the philosophical
ideal of equanimity.44
42 Life of Marcus Antoninus philosopher 28 trans. David Magie, The Scriptores Historiae Augustae I, Cambridge
MA/London 1967, p.203.
43 11,3, transl. George Long, The Meditations 1891.
44 Of course one can wonder in what degree the pictures of a good emperor’s death was distorted. Arand p.229
(see note 39) argues that anyway they contain more veracity than the ghastly descriptions of the end of bad
rulers. Even if the pictures have been idealised they reflect the ancient model of good death.
Roman death
‘Why should I play the Roman fool?’ Shakespeare has Macbeth say, playing upon the concept
of ‘Roman death’, i.e. suicide.45 This phrase reflects the popular idea that self-killing was
permitted and even glorified in the ancient world, especially among the Romans. In general,
this view is correct, although there was always an undercurrent of doubt and even rejection of
suicide, especially among the Pythagoreans and Neo-Platonists who held to a dualistic view
of man’s nature. In their philosophy the soul as the divine element was not to be released from
the prison of the body by violence, but only by wisdom. It is not surprising that this view
prepared the ground for the Christian concept of self-killing as the mortal sin of self-murder,
which was formulated by St. Augustine: ‘Who kills himself is a homicide.’46
Epicureanism in particular, with its stress on the quality of life, recognised man’s fundamental
right to dispose of his own life. 'Let us go out of life unconcerned, when it does not please us,
as out of a theatre', so the Epicurean says. In About Death Philodemos qualifies the Epicurean
attitude: it is preferable not to seek death before the best of life has been enjoyed (and one
never is sure whether the best is not still ahead). Epicurus himself had explicitly stated in On
Life that a wise man even when he has lost his eyesight, will not ‘withdraw himself from life’,
as the Epicurean euphemism calls the final act of volition. So the philosophy of pleasure
warns against frivolous motivation for ‘leading oneself out’ (another euphemism). Therefore,
Cicero is unfair when he summarises the Epicurean attitude as: ‘One should drink or die.’
(Aut bibat aut abeat).47 Personally Cicero felt more attracted by Stoicism. This doctrine told
every (wise) man to do his duty and stay in the place given to him by fate. In principle,
therefore, suicide was not permitted. Only if one was sure that self-killing was in line with
fate (or divine providence) could one leave life. So the doctrine was ‘no, unless’ as opposed to
Epicurean ‘yes, provided that’.
By an irony of history, however, the cases of Stoics who committed suicide have become
emblematic of ‘Roman death’. First it was Cato Minor, who preferred death to appealing to
Caesar’s clemency. Cato, the last defender of the republican constitution, was besieged in the
North-African city of Utica in 46 BCE. There was no escape. Having read Plato’s Phaidôn
on the immortality of the soul – he plunged a sword into his breast. In the time of the early
emperors, in the first century CE, Cato became something of a Stoic saint, especially after the
praise Seneca (ca 4 BCE – 65 CE) gave him. In his writings Seneca shows himself fascinated
by the topic of suicide, a fact that attained a poignant significance when he was forced to kill
45 Macbeth V, iii,1.
46 De Civitate Dei out.
47 Tusculan Disputations 5,118.
himself by his former student Nero who had become emperor. By his time something of a
suicide ritual had developed in the circles of the Roman aristocracy. Seneca’s death show was
the climax of this staging of voluntary death. The historian Tacitus devotes several chapters of
his Annales to Seneca’s last act.48
First Seneca’s veins and those of his young wife Paulina were cut by one stroke. Since
Seneca’s aged body, emaciated moreover by frugal living, did not produce much blood, the
arteries in his legs and at the back of his knees were also opened. Even these measures did not
help. Next Seneca swallowed hemlock, a sacred method of death since Socrates the Athenians
had been executed by means of this poison. However, Seneca’s body did not respond in the
way expected. Finally he entered a warm bath, the idea being to make the blood thinner. He
sprinkled some water on the slaves who surrounded him, saying that the liquid was a drink
offering to Jupiter the Liberator. So slaves were present as well as friends, who took notes of
Seneca’s lengthy last words. Also a medical doctor was there, Statius Annaeus. Is was he who
produced the poison on Seneca’s request.
Medical assistance in a good death
Did this doctor breach his oath by furnishing Seneca with the means to die? It is a widespread
belief that Hippocrates’ Oath forbade doctors to assist in suicide. Some in the medical field
are still convinced of this, and think that their professional oath is based on the traditional
formula or at least implies the ancient pledge only to preserve life.
Firstly, we do not know whether Statius Annaeus belonged to the Hippocratici, who after all
were only one medical school. If their oath indeed did forbid them to give assistance to
suicide, it would be a mark of distinction, implying that other doctors had fewer scruples, but
we do not even know to what extent it was ever sworn. The evidence is very meagre indeed.49
Even if the Hippocratic Oath had some meaning as a professional ethical code, it should not
be understood as dealing with assisted suicide, but with surreptitious murder by a doctor. The
argument is mainly linguistic, so it is rather difficult to present it in English. However, we can
approach this by giving a literal translation of the key passage that - significantly - follows
after some sentences in which the doctor promises to refrain from ‘injustice’ (adikia): ‘And I
48 15, 60-64.
49 Vivian Nutton, Hippocratic Morality and Modern Medicine, in: Hellmut Flashar and Jacques Jouanna,
Médecine et morale dans l’antiquité, Vandoeuvres-Genève 1996, p.46: “Pious hopes from Scribonius Largus, a
sentence in Gregory of Nazianzus, Arabic reconstructions of Classical Antiquity, and the Constitutions of Melfi
do not inspire great faith in the universality of the Oath, when contrasted with the numerous occasions when one
can state that the Oath was not sworn.”
will not give a drug that is deadly to anyone if asked [for it].”50 In the Greek text the
‘anybody’ to whom the deadly medicine is not given is in the dative, whereas ‘requested’ is
nominative, going with the subject, the ‘I’ who swears. If the person who requests and to
whom the fatal drug is not given were to be one and the same person, the ancient Greek would
be something like ‘to anybody requesting’, both words in the same case, i.e. dative, especially
as the words follow each other. Now the different cases, dative and nominative, are indicative
that the two words are not be to be linked. The person who requests is not necessarily the
person to whom the poison is (not) given. The Hippocratic doctor only swears that under no
circumstance shall he lend himself to murder by poisoning on the request of a third person
since, being in close contact with a patient, he was in a position to kill secretly.51 We should
remember that the fear of being poisoned was common in antiquity. Many a sudden death that
was probably due to food poisoning was ascribed to a criminal act. However, a patient who
hired a Hippocratic physician could be sure that he did not run the risk of being murdered by a
criminal doctor. The argument that the oath formula was understood in antiquity to mean this
is supported by the hexametric, more elaborate version of the Oath: “Nor should somebody
by presents make me to commit a painful trespass and to administer to a man harmful drugs
that will bring about a fatal evil.”52 In using the words ‘fatal evil’ I render as neutrally as
possible the Greek thumophthoron kakotêta, which rather means ‘a deadly crime’. Also the
word ‘trespass’ (paraibasiên) points at a criminal context rather than one of professional
ethics. Most of all the pledge not to accept ‘presents’ shows that murder by proxy is meant.
Why should the patient wishing to die, or for that matter his relatives, offer presents to the
physician to induce him to administer deadly drugs?
In modern times Ludwich Edelstein, who was deeply shocked by the perverse ‘euthanasia’
practices of Nazi doctors, found in the Oath the magna carta of medical pro-life ethics, a
pledge valid for all times and all doctors.53 His translation expressed his moral interpretation:
“I will neither give a deadly drug to anybody if asked for it.”54 The Dutch historian of
50 Translation by Heinrich von Staden, Personal and Professional Conduct in the Hippocratic Oath, Journal of
Medecine and Allied Sciences 51(1996)404-437, p.407.
51 Even if one would argue that the passage refers to any assistance in bringing about death requested by the
patient or a third person, the stress certainly is not on assisted suicide. The refusal to commit adikia also points to
murder, for self-killing was not regarded as a criminal act by ancient law, as was proven by Andreas Wacke,
‘Der Selbstmord im römischen Rechts und inder Rechtsenwicklung’, Zeitschrift der Savigny-Stiftung für
Rechtsgeschichte 97(1980)26-77.
52 Greek text in I.L. Heiberg (ed.), Corpus Medicorum Graecorum I.1, Leipzig/Berlin 1927, 5-6.
53 Ancient Medicine, Baltimore 1967, p.9-20.
54 Ludwig Edelstein, ‘The Hippocratic Oath’, in: O. Temkin/C.L. Temkin, Ancient Medicine. Selected Papers of
Ludwig Edelstein, Baltimore 1967, reprint Baltimore/London 1987, 3-63.
medicine Lindeboom was even more outspoken in his translation: “I shall administer to
nobody not even on his request any deadly drug.”55 (the italics of ‘his’ are mine)
There is ample positive proof that ancient doctors were ready to assist in suicide, Seneca’s
case being the most famous of a euthanasia in the ancient sense, i.e. a noble death. If
physicians had no scruples in providing professional help to a healthy person who wanted to
leave life, why should they refuse to secure for their patient a gentle death, a euthanasia in
modern usage? The fact that ancient sources are silent on that topic is to be explained by the
fact that the ancient physician had a position that radically differed from that of his modern
colleague.
Relevance of the ancient euthanasia paradigm
In November 2001, a few months before the new Dutch law on euthanasia came into force,
the Dutch Association for Voluntary Euthanasia organised an invitational conference on the
association’s future task now it had achieved one of its major aims. I felt much flattered to be
invited among doctors, lawyers, psychiatrists, pharmacologists and other experts. In my
contribution I stressed the element of volition in the ancient model of self-killing as an
alternative to the modern approach. In the mors voluntaria a medical doctor only acted as the
instrument of the will of a suicide, who was an agent rather than a patient. It was not up to the
doctor to decide whether life had lost its sense. He was only asked to present his expert view
when somebody considered ending his life because of serious ailments, as Titius Aristo did,
who opted for life ‘for the sake of his wife, daughters and friends’56
In our medicalised world the doctor is increasingly placed in the moral position that priests
used to have. The ancient paradigm invites us to redefine the doctor’s role. Why should he be
the arbiter of life and death, instead of limiting his role to that of an instrument of euthanasia?
55 In the Dutch original: “Ik zal aan niemand, ook niet op zijn verzoek, enig dodelijk geneesmiddel toedienen.”
G. A. Lindeboom, Hippocrates, Antwerpen/Amstersam 1949, 34. Lindeboom has denoted the Oath as the magna
carta of medicine.
56 Pliny Epistles 1,22,7-12.
Selective bibliography
Ariès, Philippe, L’homme devant la mort, Paris 1978
Bremmer, Jan, The Early Greek Concept of the Soul, Princeton 1983
Grmek, Mirko D., ‘Les indicia mortis dans la médecine gréco-romaine’, in: Hinard, F. (ed.),
La mort, les morts et la au-delà dans le monde romain, Caen 1987, pp.129-144
Horstmanshoff, Manfred, ‘Ancient medicine between hope and fear: medicament, magic
and poison in the Roman Empire’, European Review 7.1(1999) pp. 7-51.
Hooff, Anton J.L. van, From Autothanasia to Suicide. Self-Killing in Classical Antiquity,
London/New York 1990
Hooff, Anton J.L. van, ‘De antieke dokter en de dood’(Ancient doctor and Death),
Geschiedenis der Geneeskunde (History of Medicine) 5.5(1998/99)313-321
Hooff, Anton J.L. van, ‘Thanatos und Asklepios. Wie antike Ärzte zum Tod standen’, in:
Thomas Schlich und Claudia Wiesemann, Hirntod. Zur Kulturgeschichte der
Todesfeststellung, suhrkamp taschenbücher wissenschaft 1525, Suhrkamp, Frankfurt am
Main 2001, ISBN 3-518-29125-4, pp.85-101
Jackson, Ralph, Doctors and Diseases in the Roman Empire, London 1995
Pfannmüller, Gustav, Tod, Jenseits und Unsterblichkeit in der Religion, Literatur und
Philosophie der Griechen und Römer, Munich/Basel 1953
Rütten, Thomas, ‘Medizinethische Themen in den deontologischen Schriften des Corpus
Hippocraticum’, in: Médécine et morale dans l’antiquité. Entretiens sur l’antiquité
classique 43, Fondation Hardt, Vandoeuvres-Genève 1997, pp. 65-120, especially pp. 68-
98.
Sourvinou-Inwood, Christiane, 'Reading' Greek Death.To the End of the Classical Period,
Oxford 1995
Toynbee, J.M.C., Death and Burial in the Roman World, London 1971
Vermeule, E., Aspects of Death in Early Greek Art and Poetry, Los Angeles 1979.
Thanks are due to my colleague John Thorley of LancasterUniversity who corrected the
English and induced me by his comments to revise some of my arguments
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Introduction: Suicide, a multifaceted complex outcome that arises from numerous biopsychosocial factors, is a public health concern which is growing in numbers despite valiant prevention efforts. There is still a lot of stigma surrounding suicide that needs to be addressed. Social media is growing exponentially and there are many forums where suicidality is being discussed. As a result, we conducted a brief survey on the perception of suicide on social media platforms of Facebook and Reddit in order to gather more information. Results: Of the 152 respondents, 86% believed that suicide is preventable, and 72.85% believed that it is a person’s right to die by suicide. About a third (31.79%) had lost someone close to them to suicide. Respondents who did not think suicide was preventable also viewed suicide as either a sign of strength (42.86%) or a revenge act (33.3%). Those who responded that someone close to them died by suicide believed that the media glorified suicide (56.25%) while those who did not lose someone, did not believe that (66.99%). Women (61%) found social media to be a good platform for people to ask for help while men did not (60.61%). Conclusions: We utilized the social media platforms to gauge the perception of suicide and found among the sample of mostly young white respondents, suicide is not stigmatized, most believed it is preventable and it is a person’s right to die by suicide. While women found social media to be a good platform to ask for support, men did not, which is in keeping with the trend that women tend to be more willing to seek help. A third of the group had lost someone close to them to suicide which was the national average, who tended to believe that media glorified suicide. Limitations of this study include the fact that those who respond voluntarily to a survey likely have an interest in the topic, and this might not accurately reflect the public opinion and attitude.
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