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. Policies devised in Italian cities became the model for the rest of Europe and, later, the Western Hemisphere. The merchants who dominated these cities during most of this period had prospered through international trade and had devised effective mechanisms to govern large populations. These mecha-

nisms included what one historian calls a "large and complex set of institutions which cooperated in looking after the health of [the cities'] inhabitants."^[6] With each outbreak of plague, the major issue of public policy for civic leaders was how to contain its spread. Because the prevailing etiological theory connected the spread of the plague to the movement of people and goods—the basis of the cities' economies—civic leaders quickly adapted existing public policy mechanisms. In most cities, health boards, composed mainly of merchants but often including physicians as members or consultants, organized quarantines, isolated victims in homes and plague hospitals, and disposed of the dead.

Medical treatment was an important but subordinate issue for organizers of the cities' responses to plague. They used a variety of policies, often in concert or in sequence, to ensure minimum levels of palliative treatment. Physicians were forbidden to leave some cities and their hinterlands. They were offered high fees and prizes to visit patients in the lazzarettos, or, as I will call them, plague hospitals. In many cities civic officials offered contracts to physicians to care for patients with plague. Most often, civic leaders tactfully delegated to local colleges of physicians the task of selecting members to serve in the hospitals.

Sometimes local physicians as a group declined to serve, in one case suggesting that treating patients meant "certain death." These doctors then suggested that the local surgeons should care for plague patients. (Surgeons were accorded lower status than physicians everywhere in Europe until the nineteenth century.) The physicians recommended that the surgeons shout the "quality, sex, and condition of the patient and stage of illness" from an open window to a physician at a safe distance, who would then shout back a course of treatment.^[7]

City officials could also coerce reluctant physicians. In 1656, for example, the cardinal who headed the health board in Rome ordered the arrest of a doctor who had denied that the outbreak was plague, and assigned him to serve in the hospital.^[8]

The civic leaders and physicians who offered these combinations of incentives and disincentives to treat patients with plague regarded them as business propositions. As such, they were regulated by contracts that differed in substance but not in form from the commercial instruments that merchants in Italian cities used to regulate what had become the most affluent economies since the end of the Roman Empire. Moreover, physicians routinely contracted to provide services during normal times to guilds, religious orders, hospitals, and the state.

Here is an example of how a contract expressed the mutual self-

interest of a physician and a city. In 1479 the city of Pavia contracted with a young physician, probably from the countryside, to treat plague patients at a monthly salary that was considerably more than that of a skilled laborer or university lecturer but less than the mayor or famous university professors. The doctor was also granted a salary advance, reimbursement for living expenses, and the promise of citizenship—that is, the right to practice permanently in Pavia—if he behaved acceptably. In return, he agreed to visit plague patients as frequently as necessary in the company of a man designated by the community who would make certain that the physician would not mingle with other people. As the historian who published the contract noted, "A plague doctor was regarded as a contact and all contacts had to live in isolation."^[9]

In sum, a plague doctor's obligation to treat patients was the result of a contract for personal services executed in response to public policy. The plague outbreaks between the fifteenth and seventeenth centuries seem to have raised the level of professional consciousness about ethics; treatises and codes proliferated. Still, ethical consciousness was less effective a motive for action than economic interest or, more broadly, fear of loss of status. Thus the author of a sixteenth-century treatise on professional ethics said that "to avoid infamy [I] dared not absent myself but with continual fear preserved myself as best I could."^[10]

By the seventeenth century, moreover, both civic and medical leaders in Italian cities could claim that by applying the best science of the time physicians could avoid getting or transmitting the plague and thus had less reason to avoid responsibility for treating patients. Physicians in France had invented a robe of fine linen coated with an aromatic paste that prevented the venomous atoms in the poisonous air—called miasmas—that allegedly caused plague from adhering to the doctor and his clothing.^[11] This robe, which was widely used in Italy, apparently worked—we would probably say because it repelled fleas—and helped confirm the theory that contagion was carried by miasmas. Science now reinforced civic authority, economic interest, and moral obligation as reasons for physicians to agree to treat patients during epidemics.