|AIDS:The Burdens of History|
source ref: ebook.html
Current disputes about physicians' ethical responsibility to treat persons with AIDS or HIV infection have stimulated interest in how they behaved during previous epidemics. Most historical accounts have emphasized what individual physicians did or neglected to do. I ask a related, but different, set of questions about the past: How did the medical profession, collectively, behave toward patients with contagious diseases and how did public policy affect that behavior? Despite enormous changes in the practice of medicine and the social position of doctors over the past five hundred years, there has been remarkable continuity in how the profession has responded to the threat of contagion.
Recent papers by physicians ably summarize the literature about how members of the medical profession behaved in past epidemics. According to this literature, during most epidemics for which records survive, most physicians seem to have treated most of the patients who sought their help, though they frequently charged higher fees. Nevertheless, many physicians fled from cities in time of plague, including Galen from Rome in the second century A.D., Sydenham from London in the seventeenth, and some leaders of the profession in Philadelphia and New York during outbreaks of yellow fever in the eighteenth and cholera in the nineteenth centuries. In addition, many physicians who did not flee reportedly refused to visit patients who were acutely ill. On balance, however, most accounts describe members of the medical profession as dutiful despite personal risk. One historian assigned physicians in late medieval Europe a "high degree of ethical and professional responsibil-
ity." Another concluded that, after discounting exaggeration, American general practitioners in the nineteenth century responded to epidemics with hard work and at "great risk and sacrifice." Others have concluded that patients were at more risk of overtreatment than of abandonment.
The historical record is not, however, a straightforward source of ethical guidance for the present. Much of the evidence about physicians abandoning patients during epidemics, when read in context, furnishes no proof that such conduct violated prevailing ethical norms. During some epidemics, for instance, physicians followed their patients into temporary exile. Moreover, physicians have often justified abandoning individual patients. Their justifications have included powerlessness to help, threats of physical violence by distraught family members and neighbors, or, more recently, the scarcity of such resources as their time and hospital beds. Physicians have also justified not treating particular patients in order not to transmit disease themselves.
Similarly, physicians who treated patients during epidemics were not necessarily acting solely or even primarily on the basis of ethical principles, secular or religious, written or implicit. Two themes stand out in accounts of the mobilization of the medical profession during epidemics between the fourteenth and the nineteenth centuries. First, civic leaders and physicians negotiated about who would treat those who were stricken, especially patients in the lowest classes. Second, these epidemics offered physicians opportunities as well as risks.
These themes are closely linked. In instance upon instance the lay and medical leadership of a city jointly chose particular physicians to carry out the most onerous duties during an epidemic. The physicians who were chosen for these duties invariably knew from the beginning of their service that they were balancing personal risks against potential benefits in status and income.
The modern history of health policy begins with the response of the leaders of Italian city-states to the epidemics of Black Death that occurred periodically for three centuries after 1348. Policies devised in Italian cities became the model for the rest of Europe and, later, the Western Hemisphere. The merchants who dominated these cities during most of this period had prospered through international trade and had devised effective mechanisms to govern large populations. These mecha-
nisms included what one historian calls a "large and complex set of institutions which cooperated in looking after the health of [the cities'] inhabitants." With each outbreak of plague, the major issue of public policy for civic leaders was how to contain its spread. Because the prevailing etiological theory connected the spread of the plague to the movement of people and goodsâthe basis of the cities' economiesâcivic leaders quickly adapted existing public policy mechanisms. In most cities, health boards, composed mainly of merchants but often including physicians as members or consultants, organized quarantines, isolated victims in homes and plague hospitals, and disposed of the dead.
Medical treatment was an important but subordinate issue for organizers of the cities' responses to plague. They used a variety of policies, often in concert or in sequence, to ensure minimum levels of palliative treatment. Physicians were forbidden to leave some cities and their hinterlands. They were offered high fees and prizes to visit patients in the lazzarettos, or, as I will call them, plague hospitals. In many cities civic officials offered contracts to physicians to care for patients with plague. Most often, civic leaders tactfully delegated to local colleges of physicians the task of selecting members to serve in the hospitals.
Sometimes local physicians as a group declined to serve, in one case suggesting that treating patients meant "certain death." These doctors then suggested that the local surgeons should care for plague patients. (Surgeons were accorded lower status than physicians everywhere in Europe until the nineteenth century.) The physicians recommended that the surgeons shout the "quality, sex, and condition of the patient and stage of illness" from an open window to a physician at a safe distance, who would then shout back a course of treatment.
City officials could also coerce reluctant physicians. In 1656, for example, the cardinal who headed the health board in Rome ordered the arrest of a doctor who had denied that the outbreak was plague, and assigned him to serve in the hospital.
The civic leaders and physicians who offered these combinations of incentives and disincentives to treat patients with plague regarded them as business propositions. As such, they were regulated by contracts that differed in substance but not in form from the commercial instruments that merchants in Italian cities used to regulate what had become the most affluent economies since the end of the Roman Empire. Moreover, physicians routinely contracted to provide services during normal times to guilds, religious orders, hospitals, and the state.
Here is an example of how a contract expressed the mutual self-
interest of a physician and a city. In 1479 the city of Pavia contracted with a young physician, probably from the countryside, to treat plague patients at a monthly salary that was considerably more than that of a skilled laborer or university lecturer but less than the mayor or famous university professors. The doctor was also granted a salary advance, reimbursement for living expenses, and the promise of citizenshipâthat is, the right to practice permanently in Paviaâif he behaved acceptably. In return, he agreed to visit plague patients as frequently as necessary in the company of a man designated by the community who would make certain that the physician would not mingle with other people. As the historian who published the contract noted, "A plague doctor was regarded as a contact and all contacts had to live in isolation."
In sum, a plague doctor's obligation to treat patients was the result of a contract for personal services executed in response to public policy. The plague outbreaks between the fifteenth and seventeenth centuries seem to have raised the level of professional consciousness about ethics; treatises and codes proliferated. Still, ethical consciousness was less effective a motive for action than economic interest or, more broadly, fear of loss of status. Thus the author of a sixteenth-century treatise on professional ethics said that "to avoid infamy [I] dared not absent myself but with continual fear preserved myself as best I could."
By the seventeenth century, moreover, both civic and medical leaders in Italian cities could claim that by applying the best science of the time physicians could avoid getting or transmitting the plague and thus had less reason to avoid responsibility for treating patients. Physicians in France had invented a robe of fine linen coated with an aromatic paste that prevented the venomous atoms in the poisonous airâcalled miasmasâthat allegedly caused plague from adhering to the doctor and his clothing. This robe, which was widely used in Italy, apparently workedâwe would probably say because it repelled fleasâand helped confirm the theory that contagion was carried by miasmas. Science now reinforced civic authority, economic interest, and moral obligation as reasons for physicians to agree to treat patients during epidemics.
The history of physician conduct in epidemics in the United States from the 1790s to the 1850s illustrates the same themes that characterize the examples from Italian cities. Physicians' behavior in epidemics has been a result of their negotiations with civic authority, and as a re-
sult of such negotiations, plague doctorsâtemporary specialistsâoften balanced their opportunities against their risks. These themes transcend enormous changes in medicine and society.
Americans may not have known the details of how physicians behaved during epidemics in Italian cities, but they reacted similarly in similar situations. Some may have drawn analogies to events in London during the outbreaks of plague in the seventeenth century. More important, however, were the similarities in the conditions confronting medical and civic leaders in early modern Italy and the United States in the late eighteenth and early nineteenth centuries. In both situations, doctors were uncertain about the etiology and treatment of infectious disease. In both, city governments dominated by merchants developed policy to contain epidemics.
The most frequently described epidemic in American history before the twentieth century may be the outbreak of yellow fever in Philadelphia in 1793. Its fame derives partly from its severity but also from its occurrence in what was then the national capital, where it sharply curtailed the affairs of government, and mainly from the heroicâif in retrospect dogmatically wrongheadedâbehavior of Dr. Benjamin Rush. The slightest exposure to medical history is likely to include the story of Rush racing about Philadelphia trying to bleed patients back to health while many of his colleagues in the distinguished College of Physicians fled the city.
This is caricature, of course, but it links events in the young American republic with those in the Italian city-states. The conventional American accounts of epidemics, like those generated in late medieval and early modern Europe, portray both brave and cowardly doctors against a background of descriptions of contagion, suffering, and death. The American accounts, like the earlier European ones, are misleading in their emphases, not necessarily wrong in detail.
In Philadelphia in 1793 Rush's heroics were less significant than the decisiveness of the merchants who exerted civic authority. These highly political merchants "viewed the plague with a larger perspective" than did Dr. Rush. Indeed, the important medical story concerns the hospital created by these merchants during the height of the plague. The hospital, which was two miles outside the city, was initially staffed by four young physicians, who had found time to make only twelve visits, collectively, in two weeks to visit the sixty to two hundred patients in each day's census. The civic leaders, led by Steven Girard, then decided to employ a full-time physician. They found a recent refugee from Santo
Domingo, a French physician who preferred to treat yellow fever with stimulants and quinine rather than by venesection. After six days of conflict between some leading Philadelphia physicians and the merchants, the French physician's appointment was confirmed. He was soon joined by a full-time volunteer from the Philadelphia medical elite who, for whatever mixture of motives, was delighted to have allies in a dispute with his colleagues about medical policy. Again, civic authority and a negotiated contract with a physician who saw a personal opportunity in the epidemic determined the organization of medical care.
This pattern also appears in an anonymous contemporary account of a yellow fever outbreak in Natchez, Mississippi, in the summer of 1823. As usual, many affluent citizens and their physicians left the city. The author, using conventions for describing plagues that had become part of the Western literary heritage in the works of Boccaccio and Defoe, reported that the "practicing physicians of the city (one excepted) had prudently withdrawn themselves to the country with the citizens of better circumstances . . . leaving the dead to bury their dead." In contrast, civic leaders, the trustees of the Natchez hospital, "invited the sick poor to resort thither." The superintending trustee then "solicited an intelligent and well read physician to abide with the trustee's family and attend the hospital and sick poor . . . without fee or reward." More than likely, internal evidence suggests, the anonymous author was himself the plague physician and took his reward in local esteem.
Eyewitness accounts of cholera epidemics in New York City in 1832 and 1849 exemplify the linkage of civic and medical authority in somewhat different ways. In 1832, the resident physician of the portâthe highest-ranking public physicianâdenied that an epidemic of Asiatic cholera had begun. He angered the leadership of the New York Medical Society by refusing to make a night call to a patient who later died of the disease. In this instance, medical leaders, claiming that they were not "restrained" by "fear," successfully pressed the civic authorities to take action against the epidemic.
In the epidemic of 1849, much of the burden of communicating with the public in New York City was carried by three physicians serving as "medical counsel" to the Board of Health. In a public notice early in the epidemic, these physicians insisted that "in this city no difficulty in obtaining the speedy assistance of a physician can exist." Nevertheless, in a report three months later, the city Sanitary Committee regretted the death, as a "result of exhaustion in attendance on cholera cases of a physician who had been appointed to the Third Ward [Police] Station
House." Despite the claim of medical counsel about the availability of speedy assistance, New York was employing plague doctors.
The final example from the nineteenth century is the yellow fever epidemic in New Orleans in 1853, in which 10 percent of the population died. As in Philadelphia in 1793, overtreatment was more of a risk than abandonment for more affluent patients. Once again, the interests of the civic authorities and of individual physicians seeking opportunity converged. A group of young businessmen, calling themselves the Howard Association, raised funds and advised the city government on public health policy. According to a recent historian of the epidemic, "As the cases mounted with increasing rapidity the Howard Association eagerly hired all available medical men." He estimated that "dozens of young doctors seeking fame and fortune entered New Orleans."
The patterns of civic and medical response to epidemics established between the fourteenth and nineteenth centuries persisted, though in modified form, into the twentieth. These patterns were institutionalized as the nature of the threat changed. Civic authority was vested in permanent agencies of government rather than in temporary committees of influential businessmen and physicians. Since the late nineteenth century, state, county, and city public health departments have had responsibility for disease surveillance and prevention and, very often, for hiring physicians to work in public hospitals and clinics. During the twentieth century, the diseases of the sick poor became first a responsibility of graduate medical education and then an important source of income for medical faculty themselves. Foreign medical graduates remained the most conspicuous group explicitly seeking opportunities by caring for diseases among the poor.
Moreover, as a result of medical advances, general economic conditions, and changes in the natural history of infectious disease, devastating epidemics seemed to many people to be a matter only of historical interest, except in non-Western countries. In the twentieth century, epidemics in the United States have generally been perceived as manageable and likely to be resolved in short course by the application of modern scientific methods. I have seen no evidence that access to physicians was considered a problem during the influenza and polio epidemics earlier in the century. Most physicians seem to have regarded risks to themselves from treating patients with communicable diseases as manage-
able, often as negligible, if proper procedures were used. An exception to this generalization, until the late 1940s, was the risk to every medical student and house officer of contracting tuberculosis.
The common law, medical practice acts, and codes of ethics seemed adequate to regulate physicians' behavior in choosing patients. This body of precedent and exhortation permitted physicians to select their patients, except in emergencies. Once having chosen a patient, in the AMA's formulation earlier in this decade, "a physician has a duty to do all he can for the benefit of his individual patient" without concern for the "allocation of scarce resources."
AIDS does not raise new issues about physicians' responsibility to treat patients. Even before the AIDS epidemic caused some physicians to reexamine their obligations, a few critics were uneasy about the subtle and less than subtle ways in which physicians sometimes denied their services to patients. Such issues have a long history that is perceived more clearly against the background of previous centuries than in the context of twentieth-century optimism about the progress of medicine. It is a history of professional accommodation to civic obligation rather than simply of adherence to ethical precepts. Accommodation has been based on a sense of collective professional responsibility: Most medical communities have been intolerant of assertions that each physician could make his or her own decision about how to behave in an epidemic. Instead, civic and professional leaders have jointly chosen or recruited plague doctors. Moreover, a similar pattern has been followed for identifying physicians to treat such endemic infectious diseases as leprosy, syphilis, and tuberculosis.
The question of what should be done when contemporary physicians hesitate or refuse to treat patients whose conditions may harm them may not be resolved much differently than in the past. If the resolution is similar, however, it will result from political circumstances, not historical inevitability. A considerable number of physicians are refusing to treat persons with AIDS or HIV infection, or threatening to refuse. Leaders of the medical profession have recently joined with civic authority, both formally and informally, in setting policy. In New York, for example, where medical school faculty members treat most persons with AIDS in public and voluntary hospitals, the members of the Asso-
ciated Medical Schools threatened to censure faculty members who withhold treatment. However, the civic and medical authorities who negotiate with physicians to treat persons with AIDS are more likely to offer them incentives than disincentives. In the past, many physicians' incomes improved during epidemics. Plague doctors performed the most dangerous tasks, but they were amply rewarded in cash and, if they survived, in the more important coin of social and professional status. A new cadre of plague doctors now serve in dedicated AIDS units or treat most of the persons with AIDS in particular hospitals. Their rewards are often access to research funds or academic status rather than income alone.
The new problem of our time is the potential risk to physicians who perform invasive procedures on patients potentially infected with HIV. In the past, most physicians who were uneasy about treating patients with infectious diseases did not run the risk of working inside their bodies. Moreover, physicians cannot identify HIV infections in asymptomatic patients and therefore cannot refuse to treat them without first testing. A negotiated solution to these problems may involve more widespread testing of patients upon admission to hospitals or more rigorous adherence of physicians to universal infection-control procedures.
There isâand no professional historian would say this judgmentallyâcontinuity between the physician in Chaucer's Canterbury Tales who delighted in the "gold he kept from pestilence" and the well-known academic physician who said in my presence two years ago that "AIDS has been good to me." This continuity may be the result of a broader truth about civic behavior in Western society, at least since the late Middle Ages: It is not that every person has a price, but that, within any group, enough people's prices can be paid to achieve most goals of policy.
Reprinted with permission, Hastings Center Report 18 (1988): 5-10.
1. Erich H. Loewy, "Duties, Fears and Physicians," Social Science and Medicine 12 (1986): 1363-1366; Abigail Zuger and Steven H. Miles, "Physicians, AIDS and Occupational Risk: Historic Traditions and Ethical Obligations," Journal of the American Medical Association 258 (1987): 1924-1928.
2. Darrel W. Amundsen, "Medical Deontology and Pestilential Disease in the Late Middle Ages," Journal of the History of Medicine and Allied Sciences 32 (1977): 403-421.
3. Donald E. Konold, A History of American Medical Ethics , 1847-1912 (Madison: Madison State Historical Society of Wisconsin, 1962). Unfortunately, how people perceived risks in different historical periods cannot be compared, except in dangerous speculation. The reasons for this difficulty are beyond the scope of this paper. In simplest terms, we do not know much about the history of terror and angerâor even pleasure.
4. For example, John Duffy, Sword of Pestilence : The New Orleans Yellow Fever Epidemic of 1853 (Baton Rouge: Louisiana State University Press, 1966).
5. Mary Catherine Welborn, "The Long Tradition: A Study in Fourteenth-Century Medical Deontology," in Legacies in Ethics and Medicine , ed. C. R. Burns (New York: Science History Publications, 1977), 204-217. Carlo M. Cipolla, Faith , Reason and the Plague in Seventeenth-Century Tuscany (Ithaca, N.Y.: Cornell University Press, 1979), 13. Carlo M. Cipolla, "A Plague Doctor," in The Medieval City , ed. H. Miskimin, D. Herlihy, and A. L. Udovitch (New Haven: Yale University Press, 1977), 65-72.
6. Katherine Park, Doctors and Medicine in Early Renaissance Florence (Princeton: Princeton University Press, 1985). Cf. Richard Palmer, "Physicians and the State in Post-Medieval Italy," in The Town and State Physician in Europe from the Middle Ages to the Enlightenment , ed. A. W. Russell (WolfenbÃ¼ttel: Herzog August Bibliothek, 1981).
7. Carlo M. Cipolla, Cristoforo and the Plague : A Study of Galileo (Berkeley and Los Angeles: University of California Press, 1973), 25-26.
8. Carlo M. Cipolla, Public Health and the Medical Profession in the Renaissance (Cambridge: Cambridge University Press, 1976), 9.
9. Cipolla, "A Plague Doctor"; cf. Robert S. Gottfried, The Black Death : Natural and Human Disaster in Medieval Europe (New York: Free Press, 1983), 125-126; cf. Walter George Bell, The Great Plague in London in 1665 (1924; London: Bodley Head, 1951), 85-86, 162, 286. Dr. Benjamin Freedman called to my attention an account of plague doctors in the seventeenth-century records of the Portuguese Congregation in Hamburg in I. Jakobovits, Jewish Medical Ethics (New York: Bloch, 1967), 108-109.
10. Amundsen, "Medical Deontology," 411.
11. Carlo M. Cipolla, Fighting the Plague in Seventeenth-Century Italy (Madison: University of Wisconsin Press, 1981), 9-12.
12. Walter George Bell, The Great Plague in London in 1665 ; for references to plague doctors see pp. 86, 162, 286.
13. John Harvey Powell, Bring Out Your Dead : The Great Plague of Yellow Fever in Philadelphia in 1793 , 2d ed. (New York: Arno Press, 1970), 148.
14. Henry Tooley, History of the Yellow Fever as it Appeared in the City of Natchez in the Months of August , September and October , 1823 (Washington, Miss.: Andrew Marchall, 1823).
15. John Stearns, "Concerning the Cholera Epidemic, 1832." New York Academy of Medicine, MS 169-171. For a full account of the epidemic, see Charles E. Rosenberg, The Cholera Years : The United States in 1832 , 1849 , and 1866 (Chicago: University of Chicago Press, 1962).
16. Samuel Smith Purple, "Manuscript Notes on Cholera in the United
States, 1849." New York Academy of Medicine. Dr. Purple saw no reason to note that the American Medical Association had recently adopted a code of ethics that obligated physicians to treat in time of pestilence.
17. Duffy, Sword , 164-166.
18. During the influenza epidemic of 1918-1919, most countries already had a cadre of plague doctors in military service; see Alfred W. Crosby, Epidemic and Peace , 1918 (Westport, Conn.: Greenwood Press, 1976).
19. Current Opinions of the Judicial Council of the American Medical Association (Chicago: AMA, 1981), IX.
20. Geoffrey Chaucer, The Canterbury Tales (London: Penguin Books, 1972), 31.
21. Privileged communication with the author.