ARTICLE IN PRESS

Social Science & Medicine 58 (2004) 975–985

Ancient euthanasia: ‘good death’ and the doctor in the

graeco-Roman world
Anton J.L. Van Hooff
Department of Ancient History, Nijmegen University, Erasmusplein 1, room 10.05, NL-6525HT Nijmegen, The Netherlands

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.
r 2003 Published by Elsevier Ltd.

Keywords: 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 euthanatos# 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.

1
Menander frg. 23 Edmonds (1961).
2
E-mail address: a.v.hooff@let.kun.nl (A.J.L. Van Hooff). Anthologiarum libri ix 126.

0277-9536/$ - see front matter r 2003 Published by Elsevier Ltd.

doi:10.1016/j.socscimed.2003.10.036
 ARTICLE IN PRESS
976 A.J.L. Van Hooff / Social Science & Medicine 58 (2004) 975–985
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, friend-
ship, respect, political position, richness, being blessed
with children (euteknia) and last but not least euthana-
sia.3 ‘Who does not know that a good old age (eug#eria)
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 (euthanatoun-
tos), the departure from such persons has to be of such
easy nature in order to die well (euthanat#esontes).’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 Philo-
pator of Egypt, in the winter of 220/219 made a dash for
freedom, ‘not that he really believed that he could
recover it [y] but rather because he was resolved to die
nobly (euthan#esai).’ When the attempt was thwarted he
and his companions ‘turned their weapons upon
3 8
Progymnasmata 110.
4 9
On the sacrifices of Abel and Cain 100.
5 10
Stromata 5,68,2–3.
6 11
Moral Fragments 601.
7 12
Ta eis heauton 10,36.
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-Aetolians, died so nobly (160/59
BCE) that he was an example how Fortune grants to the
worst men the fine death, euthanasia, 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 Martyr-
dom.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, !ı’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 modern
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
Histories 5, 38–39.
Histories 32,4,3.
Macc.2:6,28.
Chapter 22.
Letters to Atticus 16,7,3.
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A.J.L. Van Hooff / Social Science & Medicine 58 (2004) 975–985
this attitude in a few pages. However, there is a great
deal of continuity 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 numer-
ous heroes who actually fall in battle during the episode
of the Trojan War that the Iliad deals with. No hero will
utter any protest when the moment of his end is at hand.
13
The qualification ‘r!esignation’ was coined by Ph. Ari"es
(Ari"es, 1978), L0 homme devant la mort, Paris, 1977.
977
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 for the rest 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
Museum shows how Sarpedon’s corpse is lifted by
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.
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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
# (Odyssey 17,384) is only
‘healer of evil’, i#et#er kakon
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 i#et#er 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, which 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’,
d#emiourgoi, 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.
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 11,514–515.
22
Odyssey 17,383–385.
23
Odyssey 11, 488–491.
The continuing appeal of these Homeric values is
demonstrated more than five centuries later by the
historian Polybius when he speaks about the determina-
tion of Cleomenes III to 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 (Adkins, 1972). 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 that
his guest is sufficiently impressed, he asks him who
in his view is the happiest of men. Solon answers
without hesitation: ‘Tellos of Athens.’ Surprised the
24
Iliad 22,303–305.
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A.J.L. Van Hooff / Social Science & Medicine 58 (2004) 975–985
king asks for an explanation, which is duly given by the
man who was regarded as one of the seven sages of
Greece:
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.25
The answer begins and ends with the common-
wealth, 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
tim#e prevailed. The Greek word time# 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.’26
So in the heydays of the polis, good death
was understood as a socially meaningful end, in
which the co-operative values of the city-state were
demonstrated.
25
Herodotos Histories 1,30.
26
Thucydides Histories 2,42,3.
979
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 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.27
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.28
In this list of achievements that are proof of man’s
formidability, deinot#es, 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 non-
sense 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
27
Sophocles Antigone 332–337.
28
Sophocles Antigone 354–362.
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980 A.J.L. Van Hooff / Social Science & Medicine 58 (2004) 975–985
mere name and has no reality. Medicine, however,
because it acts ‘through something’ and because its
results may be forecasted, has reality.’29 Such is the
glorious language of the scientist who believes that only
on a rational basis can medicine develop: ‘Medicine [y]
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.’30
In Hippocratic medicine, death is there when the
balance between fire and water, the two basic elements
of all animal life, is lost.31 Only rarely, however, do
medical authors discuss the nature of death. Hippocratic
doctors are primarily concerned with prognostics.
Characteristically, an electronic search of all Hippo-
cratic writings on the phrase ‘death is’ (thanatos esti)
only produced places with ‘death is near wheny‘ 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.32 Doctors paid much attention to the indications
of death, in Greek the s#emeia 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.’33 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
29
On the Art 6.
30
On Ancient Medicine 2.
31
Peri diait#es 1, 3, 2; death as the effect of decreasing warmth
and moisture in Galen De temperamentis (Kuhn . 1.523, line 3
and 1.582, line 4 and 17).
32
On Diseases 1,3,5.
33
Prognostics 2.
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 hedon# e, which was to become a central
concept of Epicureanism. Modern language uses ‘Epi-
curean’ and ‘hedonistic’ in a 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.’34 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 h#edon#e 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
34
Epicurus, Letter to Menoeceus 125.
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A.J.L. Van Hooff / Social Science & Medicine 58 (2004) 975–985
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.
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) Geist and Pfohl (1976) 35
* Do not fear the river of the underworld. For it is
always stupid, by fearing death, to forfeit the joys of
life.36
Titus Flavius Martialis who died at the age of 80 had
this text inscribed on his tomb:
* What I ate and drank, I have; what I left behind, I
lost.37
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’, remem-
ber 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, seven 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
35
Found in Cordoba, Corpus Inscriptionum Latinarum
II2262. A collection of ‘Epicurean’ epitaphs in Geist and Pfohl
(1976).
36
.
Rome first century CE, F. Bucheler, Carmina Latina
Epigraphica, Leipzig 1895–1926, nr.1567.
37
Hermann Dessau, Inscriptiones Latinae Selectae, Berlin
1892–1916. nr. 8155a = Carmina Latina Epigraphica (previous
note) nr. 244.
981
one, Theodosius II (401–450) had a fatal accident: he
fell from his horse and broke his neck.38
The emperor, in particular the good emperor con-
stituted an example, a paradigm. He was well aware that
he had to play the show to the end as Augustus did:
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. (Suetonius, 1920,
chap. 99).
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. He
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
38
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, the number increases considerably A
young German scholar, Tobias Arand, from Munster . who has
processed all these cases too in his dissertation Das Schm-
a. hliche Ende (The Shameful End), Frankfurt a/M 2002 deals
with 171 persons.
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982 A.J.L. Van Hooff / Social Science & Medicine 58 (2004) 975–985
vomitted 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
(David, 1967a).
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: ‘equani-
mity’.
Other emperors of good fame died with similar
dignity: Vespasian, Nerva and most of all the philoso-
phical emperor Marcus Aurelius:
[y] 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 (David, 1976b).
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.39
The Homeric heroic resignation in the face of death
had developed into the philosophical ideal of equani-
mity.40
Roman death
‘Why should I play the Roman fool?’ Shakespeare has
Macbeth say, playing upon the concept of ‘Roman
death’, i.e. suicide.41
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 David (1967b).’42
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 euphe-
mism). Therefore, Cicero is unfair when he summarises
the Epicurean attitude as: ‘One should drink or die.’
(Aut bibat aut abeat).43 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
39
11,3, transl. George Long, The Meditations, 1891.
40
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.
41
Macbeth V, iii,1.
42
De Civitate Dei out.
43
Tusculan Disputations 5, 118.
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A.J.L. Van Hooff / Social Science & Medicine 58 (2004) 975–985
(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 Phaidon—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 (c. 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 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.44
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. It 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
44
15, 60–64.
983
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
(Nutton, 1996).45
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 will not give a drug that is
deadly to anyone if asked [for it], (von Staden, 1996). 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.46 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.’ (Heiberg, 1927). In using
the words ‘fatal evil’ I render as neutrally as possible the
Greek thumophthoron kakot#eta, which rather means ‘a
45
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.
46
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 Wacke (1980).
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984 A.J.L. Van Hooff / Social Science & Medicine 58 (2004) 975–985
deadly crime’. Also the word ‘trespass’ (paraibasi#en)
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.47 His translation expressed his moral inter-
pretation: ‘I will neither give a deadly drug to anybody if
asked for it.’ (Edelstein, 1967). The Dutch historian of
medicine Lindeboom was even more outspoken in his
translation: ‘I shall administer to nobody not even on his
request any deadly drug.’48 (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 that 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’49
47
Ancient Medicine, Baltimore 1967, p. 9–20.
48
In the Dutch original: ‘Ik zal aan niemand, ook niet op zijn
verzoek, enig dodelijk geneesmiddel toedienen.’ G. A. Linde-
boom, Hippocrates, Antwerpen/Amstersam 1949, 34. Linde-
boom has denoted the Oath as the magna carta of medicine.
49
Pliny Epistles 1,22,7–12.
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 like his ancient colleague?
Acknowledgements
Thanks are due to my colleague John Thorley of
Lancaster University who corrected the English and
induced me by his comments to revise some of my
arguments.
References
Adkins, A.W. H. (1972). Moral values and political behaviour in
ancient Greece: From Homer to the end of the fifth century.
London: Chatto and Windus.
!
Ari"es, Ph. (1978). L’homme devant la mort. Paris: Editions du
Seuil.
David, M. (transl.) (1967a). Life of Antoninus Pius 12. In The
scriptores historiae augustae I (p. 131). Cambridge, MA/
London: Heinemann.
David, M (transl.) (1967b). Life of Marcus Antoninus
philosopher 28. In The scriptores historiae augustae I (p.
203). Cambridge, MA/London.
Edelstein, L. (1967). The Hippocratic oath, In O. Temkin, &
C.L. Temkin (Eds.), Ancient medicine. Selected papers of
Ludwig Edelstein (pp. 3–67). Baltimore, reprint Baltimore/
London 1987.
Edmonds, J. M. (1961). The fragments of attic comedy, Vol. III
B. Leiden: Brill.
.
Geist, H., Pfohl, G. (1976). Romische Grabinschriften (p. 167–172).
Munich: Heimeran.
Heiberg, I.L. (Ed.) (1927). Corpus Medicorum Graecorum I.1.
(p. 5–6). Leipzig/Berlin. (in Greek)
Nutton, V. (1996). Hippocratic morality and modern medicine.
In H. Flashar, & J. Jouanna (Eds.), M!edecine et morale dans
l’antiquit!e (p. 46). Vandoeuvres-Gen"eve: Fondation Hardt.
von Staden, H (transl.) (1996). Personal and professional
conduct in the Hippocratic oath. Journal of Medicine and
Allied Sciences 51, 404–437, 407.
Suetonius (1920). Life of Augustus. Rolfe, J.C. (transl.) Cam-
bridge, MA: Heinemann, 1920.
.
Wacke, A. (1980). Der Selbstmord im romischen Rechts und
inder Rechtsenwicklung. Zeitschrift der Savigny-Stiftung fur .
Rechtsgeschichte, 97, 26–77.
Further reading
Bremmer, J. (1983). The early greek concept of the soul.
Princeton: Princeton University Press.
Grmek, M. D. (1987). Les indicia mortis dans la m!edecine
gr!eco-romaine. In F. Hinard (Ed.), La mort, les morts et la
 ARTICLE IN PRESS
A.J.L. Van Hooff / Social Science & Medicine 58 (2004) 975–985
!
au-dela" dans le monde romain (pp. 129–144). Caen: Editions
Gallimard.
van Hooff, A. J. L. (1990). From autothanasia to suicide. Self-
killing in classical antiquity. London/New York: Routledge.
van Hooff, A. J. L. (1998/99). De antieke dokter en de dood
(ancient doctor and death). Geschiedenis der Geneeskunde
(History of Medicine), 5.5, 313–321.
van Hooff, A. J. L. (2001). Thanatos und Asklepios. Wie antike
.
Arzte zum Tod standen. In T. Schlich, & C. Wiesemann
(Eds.), Hirntod. Zur Kulturgeschichte der Todesfeststellung
(pp. 85–101). suhrkamp taschenbucher . wissenschaft
1525, Suhrkamp, Frankfurt am Main 2001, ISBN 3-518-
29125-4.
Horstmanshoff, M. (1999). Ancient medicine between hope and
fear: Medicament, magic and poison in the Roman Empire.
European Review, 7.1, 7–51.
985
Jackson, R. (1995). Doctors and diseases in the Roman Empire.
London: British Museum Publications.
.
Pfannmuller, G. (1953). Tod, Jenseits und Unsterblichkeit in der
Religion, Literatur und Philosophie der Griechen und Romer, .
Munich, Basel: Reinhardt.
.
Rutten, T. (1997). Medizinethische Themen in den deontolo-
gischen Schriften des Corpus Hippocraticum. In M!ed!ecine
et morale dans l’antiquit!e. Entretiens sur l’antiquit!e classique
43 (pp. 65–120, especially pp. 68–98). Vandoeuvres-Gen"eve:
Fondation Hardt.
Sourvinou-Inwood, C. (1995). ‘Reading’ Greek death to the end
of the classical period, Oxford: Oxford University Press.
Toynbee, J. M. C. (1971). Death and burial in the Roman world.
London: Thames and Hudson.
Vermeule, E. (1979). Aspects of death in early Greek art and
poetry. Los Angeles: University of California Press.