THE DOCTOR-PATIENT RELATIONSHIP AND

ITS HISTORICAL CONTEXT1

THOMAS S. SZASZ, M. D., WILLIAM F. KNOFF, M. D.,

MARC H. HOLLENDER, M. D.2

The doctor-patient relationship in its correlations between social conditions and

historical context depends on the medical medical practice models, we shall comment
(or psychiatric) situation and the social only on a few historical periods. These will
scene. By medical situation is meant the be offered as vignettes to illustrate our
technical task at hand and the available thesis. The following epochs and their
means to cope with it. The physicians and concomitant doctor-patient patterns will
patients capacity for self-reflection and be considered: 1. Ancient Egypt (approx.
communication, as well as their special 4000 to 1000 B.C.). 2. Greek Enlighten-
technical skills, are included in the category ment (approx. 600 to 100 B.C.). 3. Medieval
of medical situation. The social scene Europe and the Inquisition (approx. 1200
refers to the socio-political and the in- to 1600 A.D.). 4. The French Revolution
tellectual-scientific climate of the time. (late 18th century). 5. Central Europe
In a previous article Szasz and Hollender (late 19th century). 6. The contemporary
(12) delineated 3 basic models of the doc- American scene (post World-War II).
tor-patient relationship. These are (a) ac-
ANCIENT ECYPT
tivity-passivity, (b) guidance-cooperation
and (c) mutual participation. Activity-pas- From earliest times, man feared helpless-
ivity refers to those instances in which the ness in an unknown universe. In his own
physician does something to a patient who defense he invented methods of coping with
is completely inactive (or passive). This is anxiety. Implicit in these methods has been
necessary whenever the patient is un- mans belief in an ability to manipulate
conscious (e.g., comatose, anesthetized). events, to control and direct nature in his
Guidance-cooperation presupposes that the own behalf.
physician will tell the patient what to do The doctor-patient relationship, which
and the latter will comply or obey. Both evolved from the priest-supplicant rela-
parties are active and contribute to the tionship(2), retained the belief in an
relationship. The main difference between ability of a parent-figure to manipulate
them pertains to status and power. Mutual events on behalf of the patient. Fearing
participation designates a relationship in helplessness, sickness and death, man has
which ihe doctor-patient contract is es- attempted to master nature by means of
sentially that of a parthership. The physi- 1. Magic and mysticism, 2. Theology and
cian helps the patient to help himself. This 3. Rationality (or science). Each of these
model is particularly applicable to the evolving belief systems, with its particular
management of chronic illnesses, to psy- technology, has served the healing art.
choanalysis and to some modifications of Healers have been in the past (and con-
psychoanalytic therapy. The models are tinue to be in the present) magicians,
illustrated in Table I. priests and doctors. With the development
Employing these conceptual models, we of social organization, or civilization, the
propose in this essay to present an histori- healing role became institutionalized as
cal overview of certain changes in the sorcerer, shaman, priest and physician.
doctor-patient relationship. Since our in- Each was imbued with the metaphor of
terest is primarily in calling attention to magic. At various times, these diverse heal-
ing roles have existed side by side in the
1 Read at the 114th annual meeting of The Ameri- same society; they may also co-exist in
can Psychiatric Association, San Francisco, Calif.,
the role-functions of a single individual
May 12-16, 1958.
2 From the Department of Psychiatry, State Uni.
(e.g., the shaman). As the functions of
versity of New York, Upstate Medical Center, instinctive self-help and mutual aid were
Syracuse, N. Y. gradually institutionalized into specialized

522
1958 1 THOMAS 5. SZASZ, WILLIAM F. KNOFF AND MARC H. HOLLENDER 523

TABLE 1 *

Three Basic Models of the Physician-Patient Relationship

CUNICAL
PHYSICIANS PATIENTS APPLICATION PROTOTYPE
MODEL ROLE ROLE OF MODEL OF MODEL

1. ACTIVITY- DOES SOME- RECIPIENT (UN- ANESTHESIA, E.C.T., PARENT-iNFANT

PASSIVITY THING TO ABLE TO RESPOND ACUTE TRAUMA,
PATIENT OR INERT) COMA, DELIRIUM,
ETC.

2. GUIDANCE- TELLS PATIENT COOPERATOR ACUTE INFEC- PARENT-CHILD

COOPERATION WHAT TO DO (OBEYS) TIOUS PROC- (ADOLESCENT)
ESSES, ETC.

3. MUTUAL PAR- HELPS PATIENT PARTICIPANT IN MOST CHRONIC ADULT-ADULT

TICIPATION TO HELP HIMSELF PARTNERSHIP ILLNESSES, PSYCHO-
(USES EXPERT ANALYSIS, ETC.
HELP) .

* A slightly altered version of a table which appeared originally in Szasz, T. S., and Hollender, M. H.:
A Contribution to the Philosophy of Medicine. The Basic Models of the Doctor-Patient Relationship.
A.M.A. Archives of Internal Medicine, 97: 585-592, 1956.

healer roles, status-role differences between tion on this subject-that in ancient Egyp-
healer and sufferer appeared for the first tian medicine the activity-passivity type of
time. relationship was ever altered. Neither the
Describing the treatment process, Siger- social circumstances nor the technical tasks
ist stated: and tools available were such as to require
a modification of this relationship.
The magician came or the patient was brought
to him. After some preparation, some purifica- CREEK ENLICHTENMENT
tions, the magic words were spoken, some rites
were performed, and all was over. In many As Zilboorg noted, Hippocrates lived in
cases this was probably enough for the pa- an age unique in history. . . It was the
tient who was under great nervous tension to age of Hellenic enlightenment( 13).
feel suddenly improved or even cured (6). In about the fifth century, B.C., the
Greeks developed a system of medicine
Even ancient Egyptian medicine, how-
based on an empirico-rational approach.
ever, was not devoid of empirico-rational By this it is meant that they relied in-
features. These were largely limited to the creasingly on naturalistic observation, sup-
treatment of externally visible disorders,
plemented by practical trial and error
such as fractures. Problems of internal
experience, abandoning, as much as they
medicine-like those of psychiatry-present
could(2) magical and religious explana-
certain observational difficulties in the face
tions of bodily disorders. Singer, for
of a naive (culturally unsophisticated or
example, described the Hippocratic writers
childish) approach. Thus an infusion of
as
magic in connection with these medical
endeavors has persisted much longer than clear-eyed
observers, unmoved in their
in relation to external and visible parts of pursuit of truth
by any preconceived view of
the body. Even today, children-and people its nature, uncorrupted by the jargon of the
generally-have many more fantasies (and schools, naked heroes of science facing the
world as it is and not as it may be thought
fantastic ideas) about the insides of
to be(7).
their bodies than they do, for instance,
about their hands or feet. Hippocrates rationalistic orientation can
It seems unlikely-and this is largely an be best illustrated by the famous statement
assumption, since we possess little informa- attributed to him concerning epilepsy:
524 THE DOCTOR-PATIENT RELATIONSHIP 1 December

As for this disease called divine, surely it too by implication, nation. This supranational
has its nature and causes whence it orginates, concept of health as an ethical value per-
Just like other diseases, and is curable by sists to this day, but it has undergone
means comparable to their cure (7). important reverses during practically every
In carrying empirical medicine to new major war and social upheaval.
heights, the Greeks were among the first MEDIEVAL EUROPE AND THE INQUISITION
to emphasize and develop what has be-
come an historically important schism, The revival of religious and mystical
namely, the separation of medicine (and world views following the fall of the
science) from religion (and ethics). Po- Roman Empire, and culminating in the
litically, too, they were among the first Crusades and witch-hunts of the middle
nations to evolve toward a democratic ages, brought with it a regression in both
form of social organization. They recog- political and medical relationships. A ma-
nized the desirability of equality, at least jor historical event worthy of special men-
among the elect (i.e., among the nobility tion occurred in 1484, when Pope Innocent
or non-slaves). Guidance-cooperation, VIII issued a papal bull in support of the
and to a lesser extent, mutual participa- popular medieval belief in witches.
tion, were the characteristic patterns of The Inquisition now shifted into high
the doctor-patient relationship. The Hip- gear. Two inquisitional theologians, Spreng-
pocratic oath, while overfly a code of er and Kraemer, authored that medieval
ethics for the physician, is, in a less obvious textbook of clinical psychiatry entitled
sense, also a Bill of Rights for the pa- Malleus Male/icarum-The Witches Ham-
tient. The rules of the game (as it were), mer-which fanned a smouldering demon-
codifying the physicians prescribed atti- ology into a flame which engulfed Europe
tude toward his patient, were defined, in and eventually spread to the shores of
part, as follows: the New World.8 In regard to this period,
Zilboorg observed:
The regimen I adopt shall be for the benefit
of my patients according to my ability and Galens humoral theory is pushed into the
judgment, and not for their hurt or for any background and the devil is elevated [again]
wrong . Whatsoever
. . house I enter, there to the role of causative agent of melancholy.
will I go for the benefit of the sick, refraining Sin and mental disease have become equated
from all wrongdoing or corruption, and es- in the mind of man; the major sin of man and
pecially from any act of seduction, of male or woman and the major preoccupation of the
female, of bond or free. Whatsoever things I devil is sex(13).
see or hear concerning the life of men, in my Thus the primitive, magico-religious be-
attendanae on the sick or even apart there- liefs embodied in the Old and New Testa-
from, which ought not to be noised abroad, I
ments were revitalized and charged with
will keep silence thereon, counting such things
to be as sacred secrets(8). (italics added). power. Social relations, too, drifted towards
ever-increasing depths of inequality and
This oath is of considerable interest from exploitation. While feudal monarchies
the point of view of the doctor-patient dominated the political scene, medieval
relationship and its connections with the Catholicism rose to achieve a level of
prevalent socio-political pattern of its time. secular power unmatched in its history.
Not only does the Oath reflect the con- The political dominance of feudal royalty
temporary ethical ideal of democracy for was paralleled by the moral dominance of
-and equality among-the free citizens of contemporary religion. The divine right
the state, but it rises above it and com- of kings had as its corollary the subjugation
mands a higher level of humanism. We of the masses. Magic, mysticism and super-
base this inference on the Hippocratic stition were rampart. Good and evil were
injunction to accord the same human
3 Although Massachusetts reversed most of its
privileges to the bonded patient, for
witchcraft convictions in 1711, it was as recently
slave, as accorded to free citizens of the as August, 1957 that the names of 6 women, ex-
state. Hippocratic tradition raised medical ecuted in Salem, and branded as witches for 265
ethics above the self-interests of class and, years, were cleared by legislative resolve.
1958 1 THOMAS 5. SZASZ, WILLIAM F. KNOFF AND MARC H. HOLLENDER 52

God-given and sharply and indelibly momentous social upheaval, the French
etched. This was the tenor of the time. As Revolution.
would be expected, medicine and religion There are striking illustrations of the
were inextricably entwined. The physician, effects of the dominant socio-political
imbued with magical powers shared by events on medical behavior during this
the priests, was in an exalted position. His period. As we noted, the pre-revolutionary
patient, unless of the nobility, was re- dungeon which served as a mental hospital
garded as a helpless infant. The model of was the appropriate place of confinement
the doctor-patient relationship, like that for socially undesirable elements in a
of lord-serf, was activity-passivity. society which viewed life and the deviant
Mental disorders, too, it should be noted, people in it only in two colors: black and
were regarded in the religious frame of white-witch and saint. The French Revolu-
reference. People were, so to speak, either tion-and the events which led to it-
possessed by God, and therefore saints, or brought this period to a socio-political
possessed by the Devil, and hence witches. end. Pinels effort to free mental patients
Neither fell within a category which could was equally dramatic, but it would seem,
be called medical or psychiatric. much less effective. Today, we look upon
It is interesting to note, in this connec- the open hospital and so-called milieu-
tion, that while in our time there has been therapy as if they constituted modern
a widespread desire to exonerate, as it dynamic-psychiatric innovations. Yet, their
were, the witches either as innocent victims relevance seems to lie mainly in that
of their time, or as mentally ill rather mental patients were until recently-and
than bewitched, there has been no simi- are today still-locked up (committed)
lar clamor for revising the diagnostic (11). Relieving them from this social and
category of saint (e.g., Joan of Arc). Yet iatrogenic trauma may then seem like a
it would seem that if logic rather than form of therapy. How different is this
sentimentality governs the up-grading of phenomenon from the well-known witticism
witches to patients, an analogous down- about the man beating his head against

grading of saints to patients would the wall, because-as he said-it felt so

follow( 10). good when he stopped it?
The effect of Pinels efforts, however,
It is consistent with the human atmos-
should not be minimized. Certainly the
phere sketched above that it was during
status of the patient and the attitude of the
this period that the insane asylums, which
physician were altered. The model of this
were nothing but dungeons in which mental
relationship, accordingly, changed (al-
patients were chained until they died, came
though not completely) from act1rity-pas-
into being. Such were the historical-and
sivity to guidance-cooperation. It should be
from the point of view of the evolution of
recalled that more than 200 years earlier,
mans struggle for freedom, logical-ante-
Weyer had advocated reforms in the treat-
cedents of the French Revolution.
ment of the insane. His pleas, how-
THE FRENCH REVOLUTION
ever, fell on deaf ears. He was, so to
speak, ahead of his time. By this it is
The spirit of liberalism initiated by the meant that he advocated an altered doctor-
Renaissance, fostered by nascent Pro- patient relationship which was premature
testantism and brought to a high pitch by in terms of the social scene.
the French Revolution re-animated mans
LATE NINETEENTH CENTURY CENTRAL EUROPE
search for equality, dignity and empirical
science as opposed to dogma. The suc- The rapid growth of science during the
cessful Protestant protest-the original 18th and 19th centuries led to the develop-
meaning of this word is probably rarely ment of the physician as the expert engi-
remembered now-against the unopposed neer of the body as a machine. This state
might of the Roman Catholic Church was of affairs favored, as we know, develop-
followed by Americas successful overthrow ments principally in microbiology and
of English dominance, and then by that surgery. Concurrently, patterns of the doc-
526 THE DOCTOR-PATIENT RELATIONSHIP [December

tor-patient relationship stressed the latters From the standpoint of our present
dependency and inferiority. In medicine interest, one of the most significant fea-
proper, the development of anesthesia tures of Breuers psychological discoveries
stimulated progress in surgery. The main lies in the great attention which he was
non-surgical illnesses of the time were, of able to pay to his patient as a human being.
course, syphilis, tuberculosis and typhoid In terms of the doctor-patient relationship,
fever. In treatment, the activity-passivity, the cathartic method meant that it was
or at most the guidance-cooperation, type worth while to listen to the patient at great
of doctor-patient relationship prevailed. length. While this may seem like a minor
In the late 19th century two major point today, it should be remembered that
psychiatric trends developed. One was the the listening role, extended over a period
Kraepelinian, or organic approach; the of time, was a radical departure in the
other, originated by Breuer and Freud, medical and psychiatric practice of the
was the psychoanalytic-and in a broad, 19th century.
contemporary sense, the psycho-social- Breuers personal qualities and interests
approach. Both, as we well know, are still made it possible for him to develop what
very much with us and constitute, in fact, must be judged as the first genuinely
the principal conceptual and methodologi- communicative relationship (in a medical
cal viewpoints of present-day psychiatrists. setting) between doctor and patient. As a
Commenting on this phase of psychiatric result of it, as Breuer reported, the pa-
history, Szasz stated: tients . . . life became known to me to
an extent to which one persons life is
Xraepelins chief objects of observation were
inmates of mental hospitals[4]. He studied seldom known to another. . .( 1).
them by direct common-sense observation. The Breuers relationship with his patients
underlying assumption was first that they must, for proper emphasis, be contrasted
suffered from diseases much the same as other with that of Charcot. Charcot, no doubt,
diseases with which physicians were familiar, may have divined some of his patients
and second that society and the physicians secrets such as unfulfilled (sexual) longings.
who studied them were normal and consti- We submit, however, that he never knew
tuted the standards with which their be- his patients in the sense in which Breuer
havior was compared. Accordingly, patients
and Freud came to know theirs. According-
were subsumed under categories (diagnoses)
based on the behavioral phenomena (symp-
ly, Breuer and Freuds historical role lies
toms) that were judged to be dominant. The (among others) in having reintroduced, as
spirit of the inquiry precluded emphasis on it were, the patient into the medical arena
specifically individualistic features and deter- as an active, cooperative-and indeed, col-
minants; Kraepelins approach, as Zilboorg laborative-participant in illness and in
[13] noted, was therefore at once humane and health. The early cathartic method opened
inhuman. He was interested in man, but was the way not only to the psychoanalytic
not interested in the patient as an individual method but-from the point of view of the
(9). doctor-patient relationship-also to the de-
The Kraepelinian or organic approach velopment and broad implementation of
to psychiatry thus rests on the premise the model of mutual participation.
that the patient has-in the sense that It is apparent that while in the Krae-
he possesses something-a disease. The pelinian viewpoint mental diseases are
eradication of the disease is thus pictured regarded as entities located in the patients
on the model of ridding the body of patho- body, and usually in his brain, according to
genic bacteria. In a way this is a scientifical- the psychoanalytic approach-as it is
ly updated analogue of exorcising the generally understood today-the same
devil(5). Adherence to this orientation phenomena are considered as problems or
predisposes to continued espousal of the conflicts in human relationships. The full
activity-passivity or the guidance-coopera- effect of these divergent views on the nature
tion models as the appropriate types of of the doctor-patient relationship has been
doctor-patient relationships in psychiatric appreciated only recently.
treatment. There is the danger of over-psychologiz-
1958 1 THOMAS S.. SZASZ, WILLIAM F. KNOFF AND MARC H. HOLLENDER 527

ing Breuer and Freuds early ideas con- pressure on medical relations to conform to
cerning the nature of their own work. It a similar pattern, whenever possible.
seems to us that while they were well In (non-psychiatric) medicine, all these
aware of the human problems, so to factors tend to favor the increasing utiliza-
speak, with which they dealt, they never- tion of mutual participation in the doctor-
theless continued to formulate their work patient relationship. At the same time, the
in the traditional theoretical framework doctor is involved, probably more often
of their time (i.e., disease-and-health). than ever before, in the task of educating
The alleged diseases simply were regarded his patient in matters of health, illness
as belonging to a special group, namely or treatment.
those due to the damming up of libido. In psychoanalysis and psycho-socially
Moreover, according to Strachey, oriented psychiatry, the same factors have
led to two major developments. One is the
To the end of his life, Freud continued to
adhere to the chemical aetiology of the actual relatively widespread acceptance of, indeed
neuroses and to believe that a physical basis demand for, psychotherapy. Thus, the
for all mental phenomena might ultimately social and economic success of psycho-
be found(1). analysis, which has been greater in the
United States than in any other country,
THE CONTEMPORARY AMERICAN SCENE
probably has resulted-as has been sug-
The development of our current ideas gested by others too-from the political and
and practices, both in medicine and in socio-economic climate of this country. The
psychiatry, reflect the influences of 3 main second development, in which psycho-
factors: 1. From psychoanalysis specifical- analysis again has pointed the way, is the
ly, and more generally from modern Ameri- need in many situations for both doctor
can psychiatry (Meyer, Sullivan), stems and patient to scrutinize the very relation-
an increasing appreciation of the impor- ship in which they are engaged. Freuds
tance of the patients role as that of a self- fundamental concept of transference was
determinate partner in the therapeutic the first step in this direction. Inquiry
relationship. 2. Increasing medical and along this line received great impetus,
social emphasis on chronic illnesses (e.g., however, also from the work and findings
diabetes, arthritis, cardio-renal diseases, of sociologists and cultural anthropologists.
etc.) during the first half of this century All this is not to say that the psycho-
made it necessary for physicians to enlist analytic method of treatment rests wholly
their patients collaboration as medical on, or employs only, the model of mutual
assistants, as it were, in the management participation. There is controversy over
of their own health problems.4 Since com- certain important variables in this regard,
plete cure is not a meaningful concept for example concerning how much regres-
in most of these medical situations, it is sion is fostered by the analyst in the
for technical reasons usually impossible analytic situation. Since we are not con-
for the physician to rely on active-passive cerned now with a discussion of the precise
techniques. The guidance-cooperation mod- details of a particular mode of psychiatric
el is therefore feasible but falls short of or medical treatment, it should suffice to
being desirable. 3. The steady drift in note that the scrutiny of diverse therapeutic
social relations (in America as well as in interactions in terms of their characteristic
most parts of the world) toward increasing doctor-patient relationships would consti-
acceptance of, and often insistence on, tute an important means of clarifying
democratic or socialistic (equalitarian) dissimilar operations, now subsumed by a
patterns of behavior exerts-we assume-a single name (e.g., psychotherapy).
4 In this connection it is interesting to recall the
Hippocratic aphorism, Life is short, art is long, SUMMARY
opportunity fugitive, experimenting dangerous, reason
The doctor-patient relationship which
ing difficult: it is necessary not only to do oneself
what is right, but also to be seconded by the patient, characterizes a given situation depends on
by those who attend him, by external circumstances two principal categories of variables: the
(3, p. 96; italics added). medical situation and the social scene.
528 THE DOCTOR-PATIENT RELATIONSHiP [December

The cultural matrix impinges on the in- tion of the doctor-patient relationship
dividual characteristics of both physician usually predisposes to change, while non-
and patient in the form of learned orienta- scrutiny of human social relations favors
tions to disease, treatment, cure and to the the status quo.
doctor-patient relationship itself.
BIBLIOGRAPHY
We have briefly reviewed and com-
mented on the probable connections be- 1. Breuer, J., and Freud, S.: Studies on
tween the socio-historical and intellectual- Hysteria (1893-95), in The Standard Edition
of the Complete Psychological Works of Sig-
scientific circumstances of 6 historical
mund Freud. London: Hogarth Press, Ltd.,
epochs and the prevalent type(s) of doctor- 1955, Vol. II.
patient relationship. 2. Edelstein, Ludwig: Bull. Hist. Med. 5:
It is our thesis that the value of a 201, 1937.
specific pattern of the doctor-patient rela- 3. Anon. Aphorism. Encyc. Britann. 2: 96.
tionship can be established only by evaluat- 4. Kraepelin, E.: Manic-Depressive Insani-
ing all the relevant and pertinent variables. ty and Paranoia. Edinburgh: E. and S. Living-
We would suggest, however, that awareness stone, 1921.
of the cultural relativity of the doctor- 5. Reider, N.: Am. J. Psychiat., 111: 851,
patient relationship should make us skepti- 1955.
6. Sigerist, H. E.: A History of Medicine,
cal of the assumption that our current
Vol. I, New York: Oxford University Press,
pirs are good or the best possible. 1951.
Probably more often than not, they are 7. Singer, C.: Hippocrates and the Hip-
neither, but simply reflect the congruence pocratic Collection. Encyc. Britann. 11 :583.
of social expectations and socially shared 8. Singer, C.: Medicine, History of. Encyc.
ethical orientations of physicians. In this Britann. 15: 196.
connection, physicians, and perhaps psy- 9. Szasz, T. S.: Am. J. Psychiat. 114:
chiatrists particularly, explicitly may con- 405, 1957.
sider which of the following 3 alternatives 10. Szasz, T; S.: A.M.A. Arch. Neurol.
they favor: 1. That they reflect the pre- and Psychiat., 76: 432, 1956.
11. Szasz, T. S.: J. Nerv. and Ment. Dis.,
valent social values and expectations of 125: 293, 1957.
their culture; 2. That they lag behind the
12. Szasz, T. S., and Hollender, M. H.:
social changes of the time and represent A.M.A. Archives of Internal Medicine, 97:
the values of the immediate past; or 3. 585, 1958.
That they join with those forces in society 13. Zilboorg, G.: A History of Medical
which lead to its modification (whether to Psychology, New York: W. W. Norton and
progress or regress). Critical examina- Co., Inc., 1941.