The politics of physicians' responsibility in epidemics: a note on history.

The Politics of Physicians' Responsibility in Epidemics: A Note on History 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. [1] 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. 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 responsibility." [2] Another concluded that, excluding exaggeration, American general practitioners in the nineteenth century responded to epidemics with hard work and at "great risk and sacrifice." [3] Others have concluded that patients were at more risk of overtreatment than of abandonment. [4] The historical record is not, however, a straight-forward 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 retreating when medicine is powerless to help, threats of physical violence by distraught family members and neighbors or, more recently, the allocation of such scarce resources as their time and hospital beds. Physicians have also justified not treating particular patients in order not to transmit disease themselves. [5] Negotiation and Opportunity 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. …