(BEING CONTINUED FROM 28/07/2011)
4.3 Public physicians
Turning finally to the public interventions in secular health care, there was no quality regulation
as we invariably have today. The ancients themselves marvelled at (and sometimes deplored) the
degree of freedom they had granted to physicians; nothing prevented a person with only rudimentary training from acting as a physician.16 Instead, the market had to self-regulate, and the famous Oath may have been part of this as it took a strong stand against certain behaviours which certainly were practised, such as euthanasia and abortion (Edelstein 1987 , pp. 12-
13). It helped define just which school of medical thought the physician subscribed to and to
bolster his reputation, as noted above.17
An intervention that did take place, however, was that occasionally a physician was paid to reside
in a particular city (such as Demokedes above). Eventually, payment to a so-called public
physician (demosios iatros) became a widely spread practice in the Hellenistic period (Cohn- Haft,
1956, p. 7).
When this practice was first discovered by modern scholars, it was thought that it had
been part of an ancient “welfare state,” and that the public physicians had provided services free
of charge to everybody. However, it has since been recognized that there is no evidence that
they practiced free of charge, and in fact there is evidence to the contrary.18 Hiring a public
physician was rather like establishing a social health insurance with considerable co-payments.
So the purpose was most probably to persuade the physician to be present in the city, which
means that the objective must have been either to secure a supply of medical care or to ensure
that the supply came from a highly skilled physician.
Cohn-Haft (1956) argues that the most usual reason for hiring a public physician was simply to ensure the residence of a physician in the community. With physicians moving around there was no guarantee that you could get hold of
one when you needed him (just as lack of skilled sculptors, masons etc delayed the building of the
Asklepios temple in Epidauros for two generations (Burford, 1972)). However evidence also
shows that city-states occasionally strove to enlist a highly skilled physician.
In fact, it is likely that hiring a public physician both ensured his presence and served to increase
the quality of his services. As mentioned above, a good reputation is likely to have been of
considerably greater value for a physician who stayed in the same city for a longer period,
compared to one who moved around.
Thus a contract with a physician to stay in a city made it more profitable for him to invest in a good reputation. In other words, the quality of his services was likely improved by the contract, even if it only stipulated that he was to remain in the city.
At the same time, there is an important difference between availability and quantity supplied. It is
not to be taken for granted that paying a physician to stay in a city meant that the quantity he supplied to the citizens increased. He now only produced for his city of residence, which tended to increase the amount of services he provided in the city. Still, a fixed income that did not depend on the quantity of services supplied made the physician better off, and so more able to afford
leisure (an income effect). This effect unequivocally reduced his supply of services. Finally, the
overall demand for his services would have increased, because his reputation for being highly
skilled would have increased (as argued above), which suggests that he could charge higher fees (a
substitution and an income effect).
By now it should be obvious that using public revenue to hire a public physician was not
necessarily to the benefit of everybody in the community. He would have become more
expensive to consult and the quantity supplied may have decreased. This suggests that it would
primarily have been the more affluent in the population who would have benefited from his
presence, whereas everybody would have felt the opportunity cost of using public funds to pay
his salary.19 This was hardly seen as a problem by the ruling elite in poleis ruled by oligarchies (and
note that Demokedes moved to Athens when it was ruled by the sons of Peisistratos, i.e., by
tyranny). Phrases commending public physicians for treating all who came to him are common in
the inscriptions (Cohn-Haft, 1956, p. 37), suggesting that such a practice could not be taken for
In general, the ancient Greek avoided direct taxation of citizens as it was seen as socially
degrading. Hence it is noteworthy to find a special “doctors’ tax”, the iatrikon (Andreades
1979). It is usually surmised that this was a head-tax used to finance the services of a
5 The market for healing cults
Usually, the healing cult centres did not charge an entrance fee (Oropos being an exception).
However, sacrifices, dedications etc were expected, with the expenditure expected to reflect the
affluence of the suppliant. This, again, suggests either price discrimination or charity. In Oropos,the thankful patient was expected to throw silver and gold coins into the holy spring (Pausanias I,34).
Payment after treatment was the norm. This practice may have been facilitated by the fact that
organised religion may have been able to achieve a higher success rate than a physician could
because the placebo effect was probably stronger, cf. section 6.2 below. Ex post payment would
also have been facilitated to the extent that those who came to the sanctuary feared retributions
from an angry God if they defaulted on payment. I have assumed that the Gods in question did
not exist, but that does not mean that Asklepios did not exist in the patients’ view of the world.
Edelstein & Edelstein (1945, T. 423: 22) report the following testimony: “Hermon of Thasus. His
blindness was cured by Asclepius. But, since afterwards he did not bring the thank-offerings, the
god made him blind again.”21
A high success rate could also help explain that the healing cults achieved a considerable market
share despite the disadvantage – compared to the itinerant physician – of patients having to travel
to the sanctuary (whereas the doctor would appear on the patient’s doorstep). That travel costs
were important can be seen in a quote from Plato (Republic): “’A carpenter,’ said I. ‘when he is
sick he expects his physician to give him a drug which will operate as an emetic on the disease, or
to get rid of it by purging or the use of cautery or the knife. But if anyone prescribes for him a
long curse of treatment […] he hastily says that he has no leisure to be sick […] he bids farewell
to that kind of physician, enters upon his customary way of life, regains his health […] or […] he
dies and is freed from all his troubles.”
One should not forget that the sanctuaries were efficient at enhancing their reputations, by
votives, inscriptions from satisfied patients etc. A quote from Attic comedy shows that the
Greeks were aware that those who administered the organized religion might have had objectives
of their own:
”Then to the precincts of the God we went
There on the altar honey-cakes and bakemeats
Were offered …
There laid we Wealth as custom bids …
soon the Temple servitor
Put out the lights, and bade us fall asleep
… And I could catch no slumber …
Then, glancing upwards, I behold the priest
Whipping the cheese-cakes and the figs from off
The holy table; thence he coasted around
To every altar, spying what was left.
And everything he found he consecrated
Into a sort of sack”
(Aristophanes, Ploutos 659-683)
(TO BE CONTINUED )
Carl Hampus Lyttkens*
Department of Economics
Lund University, Sweden
* Corresponding author: Carl Hampus Lyttkens, Professor of Economics, Department of Economics, Lund
16 Edelstein (1966), Kudlien (1970). Cohn-Haft (1956) argues that the system was sufficiently self-regulating through
the apprentice system.
17 Horstmanshoff (1990). The famous Oath probably reflects the position of physicians associated with Pythagorean
ethics (Edelstein, 1987 , pp. 3ff; Phillips (1987) , pp. 114ff.)
18 Cohn-Haft (1956), Ch. 3, Hands (1968), pp. 134-138, Horstmanshoff (1990).
19 In the area of health one could for example point at alternatives such as the construction of water facilities.
20 Andreades (1979), pp. 249-250 n. 10, provides an analogous example: in Dubois in Wyoming, a poll tax was
used in the 1920s to pay the only physician to stay put. However, it seems that so little is known about the iatrikon
that it could even have been a tax on doctors instead, just as there were taxes on resident foreigners, freedmen, and
prostitutes. One of the few places where we have evidence of this tax is the island of Kos, well-known for its great
sanctuary to Asklepios and for being the birthplace of Hippocrates. So one wonders if it was designed to subsidise
the services of the physicians or to tax the competitors of the cult of Asklepios.
21 Asklepios seems to have understood moral hazard effects: ”Hush, he [Asklepios] gives to those who desire it, but
you do things that irritate and aggravate your disease, for you give yourself up to luxury” (Edelstein & Edelstein,
1945, T. 397).