Ethical Questions Raised by Sims' Experiments
J. Marion Sims has become an icon of medicine because of his accomplishments, which are truly too numerous to mention in a short paper. His keen intellect was always open to innovation. He overcame an unpromising background and the opprobrium arising from his Southern origin to make a name for himself not just in the quintessential American city of culture and knowledge, New York, but also in London and Paris. Monuments bear his likeness in New York City and the capitals of Alabama and South Carolina.
He reflected the heroic ideal in medicine, which became prominent in the 19th century. Famous practitioners such as Jean-Martin Charcot and Francois Broussais (a strong advocate of bloodletting) in Paris; Robert Liston, James Syme and James Young Simpson in Britain; Theodor Billroth in Vienna; and William Halstead at Johns Hopkins in the United States, tried ever more radical cures for challenging conditions. They refused to let Nature merely take its course, but boldly went against the grain of received medical wisdom.
So, Sims fit in with these iconoclasts in his search for new therapies. And yet, the ethical dilemma remains: was it proper for Sims to carry out his experimental surgeries as he did?
The question is bound up in issues of race and class. Sims' neglect of anesthesia illustrates this point. He considered his vaginal surgeries to be minor procedures and did not use anesthesia with either his African-American or Irish-American patients, for the most part. However, he found that upper-class white women could not tolerate surgery without ether. As McGregor states, Throughout his medical career Sims maintained a classbound prescription for the use of anesthesia with an unspoken premise that those women in the wealthy tier were by far the most vulnerable to pain. To be fair, this was not untypical of practitioners in the latter 1800s. Use of ether during surgery and childbirth had been reported in 1846 and 1847, respectively, but only after the Civil War did the surgical use of anesthesia become widespread, and even then cultural values intervened in its acceptance.
Sims was also of his time with regards to race relations. He owned slaves in Alabama, and in fact actually purchased one or more of the slave women he experimented on. After the end of the Civil War he defended the system of slavery in his letters. His writings are littered with uses of pejorative terms for African-Americans. However, he was not a virulent racist, and by all accounts treated black patients politely, if in a patriarchal fashion. In the early postwar period he urged the South to accept the 15th Amendment freeing the slaves, and move on.
While Sims did not disguise the facts of his cases, he did not trumpet them, either. It is implied that he was particularly keen to avoid the details of the women and their situation when he was trying to get established in New York. His 1852 paper on the successful vesicovaginal repair and his 1857 Silver Sutures lecture referred to his patients as healthy young negro women, failing to mention that they were slaves. Early illustrations from his writings show the women as white.
Some critics have suggested that the reason Sims left his native South had more to do with gossip about his immoral slave experiments than with his physical health. In fact, he found himself in a similar situation in New York, as his Woman's Hospital catered to destitute Irish immigrant women, whose inferior social status did not allow them to decline questionable treatments. He was criticized directly for unethical experimentation by his colleagues and the hospital administration during the acrimonious debates of the 1870s: The Lady Managers began to be convinced that the lives of all the patients in the institution were being threatened by these mysterious experiments.
In the end, the critical questions are not whether Sims was biased regarding race and class, or whether he was embarrassed by how others would perceive his past actions. They revolve around standard ethical principles of beneficence and autonomy, judged both by the standards of his times, as well as through the filter of history.
Regarding beneficence, ample evidence exists that Sims wished the best for his patients and for the broader community of female patients. He undertook the experimental treatments on his patients with the understanding that no operation would endanger life, or render their condition any worse. As he wrote mellifluously 12 years after he saw his first case of vesicovaginal fistula, I thought only of relieving the loveliest of God's creation of one of the most loathsome maladies that can possibly befall poor human nature.
However, one inescapable conclusion is that Sims' optimism, tinged with messianic fervor, blinded him to the suffering of his patients and any associated ethical implications. His brother-in-law Dr. B.R. Jones implored him to give up his surgeries, but Sims avowed, I felt that I had a mission . . . of divine origin . . . I could not have ceased my labors if I had tried. With the hindsight of history and a more mature ethical framework, we may ask if Sims' ends justified his means, or, more accurately, if the subjects were merely means to Sims' ends. It is quite clear that Sims falls short of modern Kantian ethical principles: To treat persons merely as means, strictly speaking, is to disregard their personhood by exploiting them . . . without regard to their own thoughts, interests, and needs. In that vein he sketches only the briefest of details of the effect of his surgeries on the health of his patients, and never records the ultimate outcomes. (In fact, arch-nemesis Bozeman scathingly questioned Sims' results after his death.)
The concept of autonomy is a similar ethical morass where Sims is concerned. Obviously, slaves had no autonomy, by definition. The Irish patients of Woman's Hospital had little autonomy. Can we judge Sims not by the standards of our times, but by those of his? Critics point out that many contemporaries made medical advances without the use of uninformed captive patients. Kentucky's Ephraim McDowell in 1809 performed perhaps the first successful abdominal operation, and in 1842 Georgia's Crawford Long used ether as an anesthetic for the first time, in both cases on informed, free, white patients. James Simpson of Edinburgh, a fierce rival of Sims, was critical of Sims' early work and made the following barbed observation in 1863: I took occasion to make an extensive series of experiments . . . upon the relative qualities of different metallic threads . . . [on] a number of unfortunate pigs, which were always, of course, first indulged with a good dose of chloroform.
South Med J. 2004;97(5) © 2004 Lippincott Williams & Wilkins