Letters to the Editor

Editor’s note: The following letter was submitted regarding a recent “From the Archives” column published in the Bulletin. A response from the author of the column follows. Because the editors agree that this topic merits in-depth discussion, we are devoting the entire “Letters to the Editor” page to it.

Letters should be sent with the writer’s name, address, e-mail address, and daytime telephone number via e-mail to dschneidman@facs.org, or via mail to Diane Schneidman, Editor-in-Chief, Bulletin, American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611.

Letters may be edited for length or clarity. Permission to publish letters is assumed unless the author indicates otherwise.

J. Marion Sims, MD: A controversial legacy

In the January 2017 Bulletin of the American College of Surgeons, the surgeon J. Marion Sims was presented as a pioneering humanitarian for developing and popularizing novel procedures to treat vesicovaginal fistulas, whereas his controversial legacy was alluded to only briefly in concluding remarks.1 While we are not medical historians, we feel that readers ought to thoroughly consider the larger context of Dr. Sims’ innovations.

The manner in which Dr. Sims’ patients were selected for enrollment in his studies on vesicovaginal fistulas would clearly violate the ethical standards put forth by the Belmont Report, if repeated today.2 Black women slaves were the epitome of a vulnerable population. The very fact that it was poor black women, and not wealthy white women, who were subjected to Sims’ initial learning curve is a reflection of systematic oppression of African Americans in U.S. history. Not only is it unlikely these women truly understood the unforeseen risks of Sims’ novel fistula repair techniques, but it is also difficult to imagine that they chose to participate of their own free will, given that they were viewed as personal property in the eyes of the law. Thus, they were likely neither informed nor able to give consent.

Moreover, the failure to use anesthesia during these procedures goes against the principle of minimizing harm to human research subjects. While some historians argue that Sims may not have been comfortable using anesthesia since it had only recently been discovered, it is also likely that black women’s pain was not fully appreciated as some thought them to possess “a grim stoicism which may have been part of their racial endownment.”3,4

Let us pause for a moment to imagine the horrendous pain these women undoubtedly felt, naked and restrained, feeling the blade of the scalpel on their genitals, repeating this nightmare over and over again without knowing if a cure would come, and without a way to object.

We agree that one must acknowledge “the circumstances of that particular period of history.” Sims lived and worked in the antebellum South and experimented on black women slaves, obtaining his surgical discoveries in a way that would be considered morally reprehensible today. To summarily dismiss these violations is to suggest that the basic principles of research ethics that have been painstakingly developed over the last century are not fundamental and timeless, but rather wavering and easily abandoned.

We would argue that no matter how groundbreaking the discovery, the manner in which scientific discoveries are made must rigorously be held accountable to a consistent ethical standard—in the past, present, and future. The ends cannot be made to justify the means.

Finally, we do not feel that simply “celebrating” the forced contributions of vulnerable subjects alongside surgeons who volunteered their efforts toward scientific progress can negate the transgressions of the past. Rather, it is by critically examining both the successes and failures of the giants upon whose shoulders we stand that we ultimately honor our profession—by learning always from our mistakes, and committing to do no harm in our quest to find truth and better the lives of others.

Malini D. Sur, MD
New York, NY

David Muller, MD, FACP
New York, NY

Peter Angelos, MD, PhD, FACS
Chicago, IL

Selwyn O. Rogers, Jr., MD, MPH, FACS
Chicago, IL

References

  1. McGinnis LS. J. Marion Sims: Paving the way. Bull Am Coll Surg. 2017;102(1):64-65. Available at: bulletin.facs.org/2017/01/j-marion-sims-paving-the-way/. Accessed March 1, 2017.
  2. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research.Washington, DC: U.S. Government Printing Office; 1979.
  3. Harris S. Woman’s Surgeon: The Life Story of J. Marion Sims. New York: Macmillan; 1950.
  4. Spettel S, White MD. The portrayal of J. Marion Sims’ controversial surgical legacy. J Urol. 2011;185(6):2424-2427.

Response from the author

I appreciate the insightful and eloquent comments offered in the preceding letter and am grateful for the opportunity to respond here, especially because the 500-word limit for “From the Archives” columns may have inhibited my ability to fully articulate the context in which I believe we should view Dr. Sims’ work.

To begin, I agree that the manner in which Dr. Sims selected his patients for enrollment in his studies on vesicovaginal fistulas would be in violation of the Belmont Reports provisions pertaining to informed consent from participants in experimental procedures. Lest we forget, however, the concept of informed consent is relatively new. Until the 20th century, the physician was considered the best judge of what procedures and treatment options would restore the patient’s health, and therefore, the physician had final say on all medical decisions. Indeed, the Belmont Report was released as recently as 1979—more than 100 years after Dr. Sims was performing his operations.

So, what were the standards of the time? Although the original American Medical Association Code of Medical Ethics, published in 1847, did call for physicians to discuss with patients the risks and benefits of procedures, it made no mention of patient consent.* So, it is likely that Sims was acting in accordance with the accepted ethics of the time.

Furthermore, after told of the possible benefits of the procedure, it is conceivable that Dr. Sims’ patients acquiesced. These patients were experiencing the considerable physical and emotional anguish associated with vesicovaginal fistula and its source—prolonged obstructed labor. In addition to the fistula, which leads to urinary and often fecal incontinence, obstructed labor almost always resulted in the baby’s death, secondary infertility, loss of vaginal function, and damage to the pubic bones. Consequently, these patients often became social outcasts. Might not someone in this circumstance agree to undergo these procedures if she believed doing so would end her pain?

The authors note that Dr. Sims did not use anesthesia during these operations, thereby inflicting further pain on his patients. Again, Dr. Sims began these operations in 1845—more than one year before ether was introduced to the medical community and several years before it was commonly administered intraoperatively. Furthermore, he believed the risks outweighed the benefits of using anesthesia and continued to perform the operation without intraoperative anesthetics on the mostly white, middle-class patients at his Woman’s Hospital in New York, NY. In both situations, he did offer the common postoperative painkiller of the era—opium—derivatives of which are still prescribed today.

We may look back with disdain at some of the approaches 19th century surgeons used. Doing so is a reflection of our profession’s evolution, of our ongoing commitment to patient safety and better quality care, and to our dedication to upholding the highest ethical standards. I applaud the authors’ suggestion that we critically examine both the successes and failures of our forebears. At the time he was practicing surgery, Dr. Sims received worldwide acclaim and was considered an ethical practitioner. One can’t help but wonder how surgical ethicists will judge us 150 years from now.

LaMar S. McGinnis, Jr., MD, FACS
Atlanta, GA


*American Medical Association. Code of Medical Ethics of the American Medical Association. Available at: www.ama-assn.org/sites/default/files/media-browser/public/ethics/1847code_0.pdf. Accessed May 19, 2017.

Wall LL. The medical ethics of Dr J Marion Sims: A fresh look at the historical record. J Med Ethics. 2006;32:346-350.

Wall LL. Did J. Marion Sims deliberately addict his first fistula patients to opium? J Hist Med and Allied Sci. 2006;62(3):336-356.

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