III. TURKEY

The modern nation of Turkey is situated on the continents of Europe and Asia, with the majority of its landmass occupying the vast Anatolian peninsula of Asia Minor. Surrounded by three seas, the Mediterranean and the Aegean seas on the west and south, and the Black Sea on the north, its territory has been the home of many nations and civilizations. It was ruled by the Hittite and Phrygian kingdoms of the second and first millennia b.c.e., followed by the Persian, Hellenic, and Roman empires. In 330 c.e., the capital of the Roman Empire was moved to Byzantium, which was renamed Constantinople. In 1453, Mehmet II, the sultan of the Ottoman Turks, a people who during the previous century had invaded a great part of the deteriorating Byzantine Empire, captured Constantinople and established the Ottoman Empire over Asia Minor (and, in the course of time, over much of the Islamic world, from the Crimea to Morocco and the Balkan peninsula). The Ottoman Empire lasted from 1299 to 1922, and in 1923 it became a republic under the leadership of Mustafa Kemal. Turkey's medicine and its ethics bear the marks of this long history.

The Turkic peoples, dwelling from time immemorial in Central Asia, migrated into China, India, the Caucasus, and Persia. The earliest Turkic religion was a shamanistic animism marked by totems and magic. Contact with the spirit world was mediated by male and female shamans, called kam, who healed the sick with magic and charms and music. Other healers, called otaci, are mentioned in various sources, and archeological findings related to otaci exist as early as the eighth century c.e.Otaci were described as wise people informed of the causes of illness, advising about healthy living and treating mainly with herbs, as well as by bone-setting, massage, acupuncture, moxa, branding, etc. Otaci joined in a guild of healers called kutu. They were, according to the sources, in frequent debate with exorcists, who taught that illness was caused by evil spirits and driven out by charms. This conflict was especially emphasized following the conversion of many of the Turkic peoples to Islam in the tenth century.

In Turkistan, where Turkic peoples were in contact with Chinese Buddhism, monks functioned as healers (otaci bakshy in Old Turkish). Although supernatural healing powers were often attributed to them, they practiced medicine without remuneration as a way of achieving Buddhahood. Monasteries were places of hospitality and healing. A medical literature in Uighur Turkish began to appear in the eighth century. During this period there was considerable mingling of Chinese, Indian, and Persian medical concepts. Although healers were no longer believed to have supernatural powers, the attitude of holding them in high esteem was part of the Islamic culture.

From the sixth to the thirteenth century, Turkish tribes formed kingdoms throughout Central Asia and the Near East. In the tenth century, many Turkic tribesmen who were employed in the armies of the Abbasid caliphs were converted to Islam (some tribes adopted Buddhism; others, Manichaeanism; and some followed Nestorian Christianity or Judaism). Following the rise and fall of several significant pre-Islamic and Islamic Turkic kingdoms, one tribe, the Seljuks, became the most powerful force in Anatolia. They extended their rule into Iraq, Iran, and Syria, and during the eleventh and twelfth centuries they created the first major Turkish state, which fostered a rich literary, artistic, and scientific civilization. In 1066, Nizamul Mulk, vizier of the Seljuk ruler Alp Arslan, founded the Nazamiye University in Baghdad. The first state university known in history, it included a hospital. The Nureddin Hospital, founded by the Seljuk Atabeg Nurredin Zenagi in Damascus in 1154, educated many famous physicians, such as Ibn Abi Usaibia, Ibn al-Nafis, and Ibn al Qutt, and was the center of medicine at that period. The curriculum of the medical schools in the Seljuk period was demanding; after training and the presentation of their theses, the graduates were examined in the course of medical practice by the muhtasib, a high-ranking public official, and then swore an oath to practice medicine with competence and virtue.

During the reign of the Anatolian Seljuks, the nobility founded charity hospitals: In Kayseri, the Gevher Nesibe Hospital was established by Princess Gevher Nesibe in 1206, and the Divriği Hospital in 1228 by Princess Turan Melik; both are still standing. The hospital and medical school founded at Sivas in 1217 also remains; and the original charter, still extant, shows that the staff consisted of physicians, surgeons, ophthalmologists, nurses, and pharmacists. All persons in need, Muslim and non-Muslim, were accepted for treatment in these institutions. Although a rich medical terminology had existed in the Turkish languages in the eleventh century, medical literature in Arabic and Persian flourished during the Seljuk era and hundreds of Arabic and Persian works were written by Turks. Turkish cities—Ferghana, Tashkent, Samargand, Bokhara, Khwarizm, Balkh, Maraghah, Kashgar, Farab, and others—were the birthplace of many famous Islamic scientists, including Ibn Sina, Ibn Turk, Biruni, Farabi, and Harezm, and were also the important centers of Islamic culture.

Medical literature in the Turkish language began to flourish again in the fourteenth century. After the conquest of Constantinople, the Ottoman Empire continued to promote care for the needy sick and to further medical science and education. It was common for the large complexes built around mosques throughout the land to have a hospital attached for the sick poor, whether Muslim or not. Sultan Mehmet II opened a hospital in his new capital in 1470. A great hospital and a medical school were established within the complex of the Süleymaniye Mosque (1536). According to the founding documents, the professor of medicine was expected to be a faithful Muslim, virtuous, charitable, self-confident, courageous, gifted with intuition and keen senses, and educated in the subtleties of logic and medicine. He was required to teach students both medicine and the virtues and duties of the physician. Those who sought admission to medical school were to have graduated from the medresse, or university. (The Ottoman medresse not only provided necessary services of religion, science, and instruction; it also trained administrative and judicial personnel to meet the needs of the bureaucracy.) Medical school applicants were required to be persons of high moral character, and to be faithful Muslims. All received scholarships from charitable endowments. The professor as well as the students were supervised by a dean.

A chief court physician was the minister of health; he was responsible for public health, for the proper training of physicians and the administration of examinations, as well as for the safety of drug preparations. Physicians employed in the palace and hospitals outside were paid by the state, and their income increased in relation to their skill and rank. Still, there were more physicians practicing medicine in their special offices than employed by the state. Pharmacists, trained in an apprentice system, worked in hospitals and palace pharmacies. A school for surgeons and ophthalmologists existed in the sultan's palace.

Women were admitted to the practice of medicine during the Ottoman period, particularly for the care of women. The Topkapi Palace in Istanbul had a well-appointed infirmary for women in the harem, as well as an infirmary for royal pages. Renowned female physicians were summoned to care for women of the harem when necessary. Nurses were employed in the palace infirmaries as well as in hospitals outside the palace and were expected to be gentle, dedicated, and devoted to their patients. Midwives were respected and given official recognition after an apprenticeship. Women prepared and sold herbal extracts, and women inoculated against smallpox. Women were also influential in the founding of hospitals and the support of charitable works.

The ethics of Turkish medicine were formed by Islamic morality, Turkish mores, and the Hippocratic ideas inherited from Greek medicine. Many medical manuscripts from the thirteenth to the nineteenth centuries state these values in chapters generally titled "Advice for the Physician." Chief among the qualifications required of the Ottoman physician was good character, which included mercy, generosity, honesty, modesty, and an even temper. Physicians were expected to be clean and properly attired, and never to exaggerate. Such virtues were said to have a positive effect upon the sick person. Advice was also given about preserving confidentiality, charging fair prices, and serving the poor without charge. Physicians were warned not to make definitive statements about prognosis, since the course of disease is not predictable with certainty. Medicine made from un-known herbs, folk remedies, and experimental treatments were not to be used. Administering poisons and abortion, except for a therapeutic purpose, were strictly forbidden. In general, as the eminent fifteenth-century Ottoman surgeon Sabuncuoğlu noted, the conscience of the physician should prevail over his desires and passions.

Physicians and surgeons were held responsible for injuries that resulted from their ignorance, incompetence, or use of unorthodox methods. Islamic law required that patients give personal permission, in the presence of a judge and witnesses, before undergoing surgery. Many records of the religious courts bear testimony to this practice. Edicts were often issued to bar quacks from practice, and, in order to ensure that only qualified practitioners served the sick, examinations for medical licensure were frequently repeated and only the licenses of the successful renewed.

Although Turkish medicine had been in contact with European medicine since the sixteenth century (inoculation against smallpox was originally introduced into Europe from Turkey at the beginning of the eighteenth century) (Ünver), European medicine became influential with the founding, by Sultan Mahmud II, of a school of medicine in 1827 and a school of surgery in 1832; these schools were combined in 1836 and moved, three years later, to Galatasari, then a suburb of Constantinople. Although it was primarily a military school, civil students were admitted, too; all students were given scholarships by the state. European physicians joined the Ottoman instructors on the faculty, and from 1839 to 1870 the language of instruction was French. A vigorous flow into Turkey of faculty members from the European medical centers and a flow of students and specialists from Turkey to Europe marked nineteenth-century medical education. An Ottoman professor, Nahabed Roussignan, lectured on ethics in 1876–1877 at the University of Constantinople School of Medicine. The course was continued for many years by Professor Hovsep Nouridjan, who published his lectures as Précis de déontologie medicale, one of the earliest books on this subject printed in Europe. In 1933, the first department of medical history and ethics was founded by Süheyl Ünver in Istanbul University. Doctorates in medical ethics are now awarded, and as of 1994, ten of the twenty-eight Turkish medical schools had departments of ethics and such courses were given in all schools of medicine.

After establishment of the Turkish Republic in 1923, new laws and regulations were passed regarding healthcare, public health, and the duties of physicians. A successful fight was waged against epidemic diseases, and many municipal and state hospitals were founded all over Turkey. The Turkish Medical Association was founded in 1929, and the current version of the medical ethics code appeared in 1960; it comprises rules dealing with patient–physician and physician-physician relationships, confidentiality, advertising, human research, termination of pregnancy, malpractice, truth-telling, consultation, fees, and organization of practice. This code has juridical standing. Provincial medical associations have disciplinary authority over physicians who violate the code. Dentists and pharmacists have formed associations in recent years and also have codes of ethics. A National Congress on Medical Ethics was organized by the Medical Faculty of the University of Istanbul in 1977. It opened discussion of many topics, such as organ transplantation, determination of death, reproductive technologies, and military medicine. A second such congress was held in 1994.

A law on organ transplantation was passed in 1979. It specifies procedures for consent, donation, and determination of death, and prohibits advertising and commercialization of organs. Regulations dealing with the education and duties of those who provide family-planning services, including abortion and sterilization, appeared in 1983. Abortion, available on demand for any reason if there is no medical contraindication for the mother, is permitted up to the tenth week of gestation, and therapeutic abortion after that time; married women must have permission of their husband, and minors, of their parents. Married persons seeking sterilization must have consent of their spouse. Centers providing assisted reproduction must be licensed by the Ministry of Health. Embryos are not to be used for purposes other than reproduction and cannot be sold. A professional committee has been established for the over-sight of assisted reproduction.

The Turkish Medical Association endorses the Nuremburg and Helsinki declarations. In 1993, a state regulation governing research with human subjects required review committees in research hospitals, and a Central Ethics Committee was established in the Ministry of Health. Local review committees sometimes function as ethics committees as well. In 1992, the Turkish Human Rights Association, the Turkish Medical Association, and the Torture Victims International Rehabilitation Council sponsored the Fifth International Conference on Torture and the Medical Profession in Istanbul. This conference issued a declaration against torture and specifically against any physician's involvement.

nil sari (1995)

BIBLIOGRAPHY

Esin, Emel. 1981. "'Otaci': Notes on Archaeology and Iconography Related to the Early History of Turkish Medical Science." In Uluslararasi Türk-islam Bilim ve Teknoloji Tarihi Kongresi 14–18 Eylül 1981, 5: 11–22. Istanbul: Istanbul Teknik Üniversitesi.

Kiyak, Yahya. 1987. Lectures on Medical Ethics. Istanbul: Marmara University.

Sari, Nil. 1988. "Educating the Ottoman Physician." Tip Tarihi Araştirmalari. History of Medicine Studies 2: 40–64.

Sari, Nil. 1989. "A View on the Dealers with Health in the Turkish Medical History." Tip Tarihi Araştirmalari. History of Medicine Studies 3: 11–33.

Ünver, A. Süheyl. 1958. Turki nizam-i-tib ki tarikh. Lahore: Avicanna Society.