History Is a Tangled Mess: Medical Progress, But at What Cost?

This year’s events¹  have caused us to revisit and reevaluate our nation’s checkered history. Profoundly important and deeply fundamental issues such as the right to free speech while not inciting violence are front and center in contemporary headlines. The seminal events highlighting these issues took place in Charlottesville, Virginia, on August 11–12, 2017, and began as a protest of the removal of a statue of Robert E. Lee from its location in a park. Similar controversies regarding other statues honoring Confederate soldiers followed. This controversy reminded us all that the evil of slavery is one of the main reasons the United States fought the Civil War. It logically follows that the heroes of the Confederacy were, at least tacitly, proponents of slavery and should not be glorified in our current society. The controversial issue of removing statues celebrating Confederate Civil War heroes has spread throughout the nation and as far north as New York City. It now has touched medicine.

A large statue stands at 5th Avenue and 103rd Street in Manhattan, New York, dedicated to Dr. J. Marion Sims.²  Similar statues exist in Columbia, South Carolina, and Mobile, Alabama. Sims (1813–1883) is considered by many to be father of the field of modern gynecology, helping to give this field gravitas and create it as a separate specialty. But controversy exists regarding his history and legacy because it is clear that his many accomplishments came about as the result of experimental surgery performed on enslaved black women—without their consent and without anesthesia.^3–5  This information has given rise to protests in Manhattan to have his statue removed from its current neighborhood (but not destroyed), where some consider it offensive.⁶  In this editorial, we explore the challenging and provocative question of how we, in historical retrospect, judge the medical contributions of Sims.

Sims was originally from South Carolina, graduated from Jefferson Medical College in 1835, and moved with his family to Mobile, Alabama, where he started his practice of surgery and gynecology. His controversial period—and coincidentally, some of his most significant work—began in 1845 and lasted until 1849. During this time, he performed operations on slaves that he kept in a “hospital” (recorded by many as a shack) behind his house. According to multiple accounts, these operations were done without the women’s consent and without anesthesia.^7–11  These women were treated primarily for vesicovaginal fistulae, a physically and socially debilitating complication of childbirth, for which, at that time, there was no cure. Sims came up with innovative techniques to visualize the relevant anatomy and developed novel surgical procedures where none had been previously successful. He invented or created new equipment, techniques, and positions for patients for surgery; his name remains affixed to the Sims position and Sims speculum.

Sims then moved to New York City in 1853 (evidently in an attempt to improve some of his own chronic health issues). His career skyrocketed, and he became one of the founding physicians of the New York City “Woman’s Hospital,” described as the first hospital for women in America. He was in Europe from 1861 to 1871 (encompassing the Civil War period), where again he received great praise and accolades from the medical community. Returning to New York in 1871, he remained an important, though often highly contentious, figure in medicine. As an example, at his hospital’s holiday party, he threatened to resign because of operative restrictions that were being placed on him. The medical center took him up on his presumed bluff, separating him from the medical center he had helped found 20 years earlier. Undaunted, he went on to become president of the American Medical Association and was one of the originators of the New York Cancer Hospital (which eventually became Memorial Sloan Kettering Cancer Center). He remained busy and productive, despite having serious health issues with angina pectoris and typhoid, operating until a day before his death (presumably from a heart attack) at age 70.

The most vexing and thought-provoking parts of an exploration of Sims, his career, and his accolades are that the more one reads, the less clear the situation becomes. The facts surrounding his life and accomplishments are not controversial. It is the analysis of these events or, rather, determining the best manner in which to interpret his legacy, that remains of great debate. There also exists a confusing and somewhat disconcerting disconnect between the perspective of the medical literature and the nonmedical literature regarding the merits of Sims’ work, with the medical literature (in general) shining a more favorable light on the physician.¹⁴  Given the complex history and our current vantage point, should Sims continue to be extolled as a groundbreaking surgeon, or should his actions be placed in the same category as Nazi physician atrocities of World War II¹²  or the Tuskegee syphilis experiment?¹³ 

As we stated in the beginning of this editorial, the disagreement surrounding Sims does not question any of the eventual outcomes: he did in fact develop new lifesaving techniques with a zeal and passion verging on the messianic. But it becomes evident upon evaluating Sims’ actions over the course of his lifetime that he did not feel that it was necessary to obtain informed consent or use appropriate analgesia and anesthesia during experimental surgery on patients who were slaves. Although the 2 potential perspectives that fall out of an analysis of Sims’ life are fairly clear, they are somewhat difficult to reconcile:

Perspective 1: He performed experimental surgery on enslaved women without informed consent and without anesthesia. This behavior is reprehensible, and he should not be the lauded hero of medical history that he has become. There is simply nothing to discuss: his immoral deeds speak for themselves.

Perspective 2: Sims’ actions should be interpreted in the context of the history in which he lived. This is not to excuse him simply because the actions and behaviors occurred in an era with different values—a concept known as “moral relativism.” These women had vesicovaginal fistulae, and Sims was doing what he could to help them and relieve their suffering. There were just no other effective alternative therapies known at the time. In terms of general anesthesia, most medical historians state that Sims did not consider these procedures major surgery, and one must recall that general anesthesia was only first safely documented by Morton in 1846⁹ —nevertheless, his lack of use of anesthesia in these patients remains extraordinarily controversial. The issue of informed consent is an even more complex one to tackle: the ugly truth is that slaves at the time were considered property, and the idea behind consent simply did not exist or apply. Let us not forget that the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research did not release their important Belmont report (summarizing ethical principles and guidelines for research involving human subjects) until 1979, more than 130 years after Sims’ experimental surgery.

Evidence also shows that Sims did not hide his racial or social biases in the development of his innovations. As one author states, “Throughout his medical career, Sims maintained a class bound 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.”¹⁵  It is important to note that there were contemporary rivals of Sims who strongly disagreed with his approach at the time, such as Dr James Simpson, who performed his surgical experiments on animals with appropriate anesthesia, rather than on enslaved human beings without anesthesia.⁷ 

We have delved into history to carefully examine the controversy and gain more facts regarding the rationale behind the laudatory statues of Dr J. Marion Sims, considered one of the fathers of gynecology. A large statue in his honor stands in a predominantly African American and Latino community in New York City.⁶  His experimental operations on enslaved black women named Anarcha, Betsey, Lucy, and others allowed him to receive numerous accolades and honors, as well as have a long and prestigious medical career.

Although the exploration of the relevant literature did provide more facts regarding Sims and his career, we, as the editors of this journal, wish to make our stand on the issue quite clear: viewed through the lens and the laws of the 21st century, what Sims did was immoral and illegal, no matter how important the work turned out to be. He plainly performed experimental surgery on an extremely vulnerable patient population. We must use this case as an example in the medical community of where the ends cannot justify the means. Although Sims’ work was of great medical import, it came at a dreadful—many would say unforgivable— moral cost, a cost that we in the medical and nursing community should not make excuses for. The ends may have justified the means in Sims’ era, but they do not and cannot in ours.