What does it cost to care? Contemporary debates about medicine and the health system often return to this question through the language of burnout, emotional labor, and clinical detachment. Yet the problem is far from modern. At the beginning of the Hippocratic treatise De flatibus, a speech intended to be delivered before an audience and datable to the last quarter of the fifth century BCE, medicine is described as one of those arts that benefit the many while burdening the person who practices them (Jouanna 1988). Some technai, the author says, bring hardship to those who possess them, but are useful to those who need them: they are a common good for the people, but painful for their practitioners. Medicine is one of these arts. The physician “sees terrible things,” “touches unpleasant things,” and from the misfortunes of others gathers private pains (Hp. Flat. 1.1–2).
This is a striking way to introduce medical expertise. The physician is first of all defined by the use of the senses. They see what is frightening; they touch what is repellent. As stated in Epid. 4.43, “[doctors observe] with the eyes, the ears, the nose, the hand … [on the one side, there is] the patient; [on the other side, there is] the practitioner, who, in each case, touches or smells or tastes and is informed about the rest.” (Kazantzidis 2016). The final movement is emotional. The physician, the author says, draws private pains from others’ misfortunes. This is not simply compassion in an abstract moral sense, nor is it a formal theory of empathy. Rather, the passage offers an early image of the affective dimension of medical professionalism: the physician’s work requires them not only to observe suffering, but to remain with it and be touched by it.
Medical work transforms another person’s suffering into something that affects them too. The patient may be relieved from disease, pain, distress, and death through the art of medicine; but practitioners must repeatedly encounter these very things. Medicine becomes a redistribution of suffering: the community benefits because physicians accept a share of what the community fears.
A similar idea can be found in a tragedy not far removed in time. In Euripides’ Hippolytus, produced in 428 BCE, Phaedra’s nurse emphasizes that the physician’s condition is more painful than that of the patient (Wilamowitz 1891 on verse 188). From a more practical perspective, Thucydides likewise recalls that, during the plague of Athens, physicians died in great numbers because they were the ones who came into closest contact with the sick (Thuc. 2.47). These parallels show that the Hippocratic passage is not an isolated rhetorical flourish. In late fifth-century Greek culture, physicians could be imagined as figures whose expertise required proximity to suffering and whose proximity entailed emotional and even bodily cost.
In this sense, the contemporary value of De flatibus does not lie in the fact that the text “anticipates” burnout. Such a reading would be both anachronistic and reductive. It makes visible a deeper structure: medicine protects the many precisely because it exposes the few.
Contemporary reflection on burnout has rightly drawn attention to the institutional factors that make this exposure heavier and more difficult to sustain: workload overload, lack of control, insufficient remuneration, collapse of the sense of community belonging are just few examples (Maslach and Leiter 1997). These factors are not secondary. On the contrary, they often determine the point at which this burden becomes unsustainable, turning into exhaustion, depersonalisation, and detachment (Maslach and Jackson 1978; Grassi, Biondi and Costantini 2003). Yet De flatibus helps us to see that the problem does not arise only when institutions fail. It already exists, in its primary form, in the very relationship between the one who provides care and the one who needs it, in the very essence of what has been defined the “Hippocratic triangle” between physician, patient, and disease.
This asymmetry is such an intrinsic feature of medical care that it cannot be entirely eliminated. However, this does not mean that this weight should be left to the individual resilience alone. Nor should distress be explained simply as the consequence of any sort of personal predisposition, fragility, or excess of altruism (Kobasa, Maddi and Kahn 1982; Pines et al. 1981). If medicine is a common good, as the Hippocratic text suggests, then its costs too must be recognised as a common responsibility. The healthcare worker’s “private pain” cannot remain entirely private.
Contemporary reflection should begin from this image, from this passage, from this same idea of the “art that hurts the healer” in order to ask not only how burnout may be prevented, but also how collective forms of support might be built around a vulnerability that belongs structurally to care. Training, supervision, spaces for discussion, recognition, and institutional responsibility are not external additions to medicine. They are necessary conditions for medicine to remain sustainable for those who practise it (Fujimori, Oba and Koike 2003; Ripamonti and Clerici 2008).
De flatibus thus reminds us that care has never been without cost. Yet precisely because this cost is ancient and structural, it should not be naturalised. It must be named, shared, and addressed. The question that the Hippocratic text hands down to the present is not simply what physicians must endure, but what a community owes to those who, every day, bear the burden of care for the benefit of all.
Works cited:
Euripides, Hippolytos, ed. by U. von Wilamowitz-Moellendorff, Berlin, 1891.
Fujimori M., Oba A., Koike M. et al., “Communication Skills Training for Japanese Oncologists on How to Break Bad News”, in Journal of Cancer Education, 18, 4, 2003, pp. 194-201.
Grassi L., Biondi M., Costantini A., Manuale pratico per l’intervento psicologico in oncologia, Roma, 2003.
Hippocrates, De flatibus, in Hippocrate. Tome V, 1re partie: Des vents – De l’art, texte établi et traduit par J. Jouanna, Paris, 1988.
Kazantzidis G., “Empathy and the Limits of Disgust in the Hippocratic Corpus”, in D. Lateiner, D. Spatharas (eds.), The Ancient Emotion of Disgust, Oxford, 2016, pp. 45-68.
Kobasa S.C., Maddi S.R., Kahn S., “Hardiness and Health: A Prospective Study”, in Journal of Personality and Social Psychology, 42, 1, 1982, pp. 168-177.
Maslach C., Jackson S., A Scale Measure to Assess Experienced Burnout: The Maslach Burnout Inventory, San Francisco, 1978.
Maslach C., Leiter M.P., The Truth about Burnout. How Organizations Cause Personal Stress and What to Do about It, San Francisco, 1997.
Pines A.M., Aronson E., Kafry D., Burnout: From Tedium to Personal Growth, New York, 1981.
Ripamonti C., Clerici C., Psicologia e salute. Introduzione alla psicologia clinica in ambito sanitario, Bologna, 2008.
Image: Thetis and the Nereids mourning Achilles. Corinthian black-figure hydria, c. 560–550 BC.
