Hospitals and Civil Rights, 1945-1963: the case of Simkins v Moses H. Cone Memorial Hospital

In the 1960s, the legacy of discrimination against black persons still existed in all areas of medicine. This historical analysis investigates the strategies that were used by lawyers alongside physicians, dentists, and patients in elevating health care for black persons. Primary resources include oral histories, government documents, hospital records, archival and personal manuscripts, and professional and hospital periodicals. After World War II, leaders in the black community were determined to improve health care for black persons by ending discrimination in hospital policies and practices. Leaders of professional organizations developed a collaborative strategy that involved the court system, federal legislation, and research and education of the public and health professionals to integrate the hospital system rather than to expand the existing separate-but-equal system. Efforts culminated in the case of Simkins v Moses H. Cone Memorial Hospital; this case became the landmark decision by the U.S. Supreme Court and led to the elimination of segregated health care. Three months after the case, President Johnson ratified the Civil Rights Act of 1964, which included Title VI, thus extending the policy of equality to all federal programs. Laying a foundation for universal access to health care in the United States depended on a victory in the courts, in national health legislation, and in public opinion. All were achieved through strategic efforts to amass widespread support for the elimination of discrimination in medicine.

A review of the use of radio-isotopes in medicine and medical research in Australia (1947-73)

Recent reports in the Australian media have claimed that after the Second World War 'hundreds of (Australians) were injected with radioactive materials in medical experiments that continued in Australian hospitals until the 1960s'. These claims prompted a review of archival records of the Australian Radiation Laboratory (ARL) that are held by the Australian Archives pertaining to the medical uses of radio-isotopes during the period 1947-73. The material examined indicates that the procurement, distribution, and therapeutic and diagnostic uses of radio-isotopes were stringently controlled by the Radio-isotopes Standing committee (RSC) until 1973, when the responsibility of regulation of medical uses of radio-isotopes passed to the Therapeutic Goods Administration. On the basis of available information it appears that the claims made by the media that many Australians were subjected to unconscionable medical experiments are unjustified. A full report has been released by the Commonwealth Minister for Human Services and Health. The following is an abridged version of that report, detailing some of the more contentious uses of radio-isotopes for medical purposes in Australia during the period 1947-73.

The doctor as businessman: the changing politics of a cultural icon

From just after the Civil War, when medicine began to professionalize, until the late 1970s, doctors and policy makers believed that clinical judgment should not be influenced by the financial interests of doctors. Physicians were highly entrepreneurial, and organized medicine fought to preserve their entrepreneurial interests, but the moral norm that justified their autonomy from state regulation was a strict separation of clinical judgment and pecuniary interests. Under managed care, the old norm is reversed. A good doctor takes financial considerations into account in making clinical decisions. Theoretically, doctors should consider measures of cost to society, but in practice, the payment systems of managed care plans induce doctors to consider the impact of each clinical decision on their own income. Because doctors share the risks of insuring patients with managed care plans, they have the same incentives as insurers to avoid patients who are expensively sick. The new cultural image of doctors as entrepreneurs masks their considerable loss of clinical autonomy under managed care. It also serves to persuade doctors to accept managed care arrangements and to persuade insurance consumers and patients to accept reduced benefits from employers and the government.

Changing priorities in residential medical and social services

During the past thirty years a high proportion of all long stay hospital beds have been closed. The responsibility for those who would have occupied those beds previously has to a large extent been transferred from health to social services departments, or to family, voluntary and private care. The overall effect has been to prioritize acute medical care, and to expose the public provision and funding of long term residential care, whether medical or social, to the direct determination of political and economic forces. These policy changes have been introduced under the banner of community care, but are dependent on complex concepts which are morally contentious and often obscure. The purpose of this paper is to analyse these processes as a prerequisite to devising better policies in future.

Retired registered nurses' stories about being in ethically difficult care situations

Twelve retired nurses were asked to narrate a care situation in which it had been difficult for them as nurses to know what was the right and good thing to do. The transcribed interviews were examined by content analyses. Physicians were the central coactors in the nurses' stories. Colleagues were seldom mentioned. Other ward staff were mainly called "the girls". The patient was central and referred to with respect. All the nurses focused on experiential learning. Guiding ethical principles are listed.

Edmund D. Pellegrino's philosophy of family practice

Family medicine has grown as a specialty from its early days of general practice. It was established as a Board Certified specialty in 1969. This growth and maturation can be traced in the philosophy of family medicine as articulated by Edmund D. Pellegrino, M.D. Long before it was popular to do so, Pellegrino supported the development of family medicine. In this essay I examine the development of Pellegrino's philosophical thought about family practice, and contrast it to other thinkers like Ian McWhinney, Kerr White, Walter Spitzer, Donald Ransom, and Hebert Vandervoort. The arguments focus on whether the goals of family medicine and family practice (possibly two distinct entities) can be articulated, especially considering the definitional problems of "family" and "community." I conclude by echoing Pellegrino's hope that family medicine can contribute a fresh alternative to isolated, individualistic and technological thinking in medicine.

The significance and applications of informed consent

Bringing well-informed patients to the OR is a challenge for all who participate in surgical patients' care. Although the issue of informed consent has been around for a long time, it was not until the latter half of the twentieth century that health care professionals and patients began to focus on informed consent as a central concern in health care. This article explains the roots of informed consent, the path it has traveled, and the importance that health care professionals, especially perioperative nurses, play in ensuring that patients are fully informed about their impending procedures.

Overdramatization of the burdens on health and social services: a continuing debate in the history of German medicine

Departing from the latest academic research into Nazi medicine in Germany, the author looks at theoretical and ideological concepts in German history that left their mark on the formation of race hygiene. He argues that the overdramatization of the economic burden caused by the special requirements of the chronically ill and handicapped runs through all epochs of modern medical history and that this culturally pessimistic way of looking at a serious social problem in Germany reveals a frightening tradition which reached its cruelest climax in the so-called T4 operation of the Nazis. The author makes a plea for this dark chapter of German medical history to be carefully analyzed and for the results of this research to be used in the current discussion on the further development of the health system, particularly in regard to patients who require special care.

50 years ago: the Nuremberg Doctors' Tribunal. Part 3: The failure of coming to terms with the past

After the sentences at the Nuremberg Doctors' Tribunal, the German and Austrian medical profession tried to avoid the subject of medicine during the Third Reich at almost any cost. Only under persistent pressure did the subject gradually became a topic for more open discussion. many of the perpetrators within the ranks of the medical profession were not properly punished and were allowed to remain members of the profession. The German and Austrian medical profession may have forfeited the chance to learn an important lesson relating to its own past.

50 years ago: the Nuremberg Doctors' Tribunal. Part 4: Nazi medicine's relevance today

The final part of this series attempts to evaluate the relevance of Nazi medicine for doctors today. Euthanasia, informed consent, the conflict of interests of the individual versus those of society and racism were as prominent themes of Nazi medicine as they are today. It would be foolish not to learn from experiences of the past. Nazi medicine can therefore never be an irrelevant subject of the days gone by.

Informed consent in human experimentation before the Nuremberg code

The issue of ethics with respect to medical experimentation in Germany during the 1930s and 1940s was crucial at the Nuremberg trials and related trials of doctors and public health officials. Those involved in horrible crimes attempted to excuse themselves by arguing that there were no explicit rules governing medical research on human beings in Germany during the period and that research practices in Germany were not different from those in allied countries. In this context the Nuremberg code of 1947 is generally regarded as the first document to set out ethical regulations in human experimentation based on informed consent. New research, however, indicates that ethical issues of informed consent in guidelines for human experimentation were recognised as early as the nineteenth century. These guidelines shed light on the still contentious issue of when the concepts of autonomy, informed consent, and therapeutic and non-therapeutic research first emerged. This issue assumes renewed importance in the context of current attempts to assess liability and responsibility for the abuse of people in various experiments conducted since the second world war in the United States, Canada, Russia, and other nations.

Nuremberg lamentation: for the forgotten victims of medical science

Fifty years after the Nuremberg medical trial there remain many unanswered questions about the role of the German medical profession during the Third Reich. Other than the question of human experimentation, important ethical challenges arising from medicine in Nazi Germany which have continuing relevance were not addressed at Nuremberg. The underlying moral question is that of the exercise of professional power and its impact on vulnerable people seeking medical care. Sensitisation to the obligations of professional power may be achieved by an annual commemoration and lament to the memory of the victims of medical abuse which would serve as a recurring reminder of the physician's vulnerability and fallibility.