the perception of medical ethics within the case study and

The Perception of Medical Ethics Within the Case Study and Campaign of Jennerian Vaccination

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The Perception of Medical Ethics within the Case Study

and Campaign of Jennerian Vaccination

Blake Edward De Leon

A Thesis in the Field of History

for the Degree of Master of Liberal Arts in Extension Studies

Harvard University

November 2018

ii

Copyright 2018 Blake Edward De Leon

iii

Abstract

Smallpoxiscreditedasthedeadliestinfectiousdiseaseinhistory.Fromthe

beginningoftheeighteenthcenturysmallpoxwastreatedbyinsertingsmallpox

matterintothearmofanindividual.Itwasnottheidealmethodoftreatment.

PhysicianEdwardJennerfromayoungageasanapprentice,wasinterestedinthe

folkloreofcowpox.Cowpoxwhencontractedbyahumanwasrumoredtomakethe

individualunsusceptibletosmallpox.Jennersoughttobringthisfolkloretothe

massesifinfactcowpoxdidprotectagainstsmallpox.Hedeterminedthrough

experimentation,thatcowpoxprotectedagainstsmallpox.Asaresultheentereda

decades-longcampaigninordertoseethismethodsavelivesfromthehellthatwas

smallpox.TheethicsofJennerwerequestionedthroughouthiswork.Thisresearch

findsthatJennerconductedhisexperimentsethically.Tounderstandtheethicsof

Jenneritisnecessarytoplacehimwithinthemedicalethicsestablishedpriorand

duringhisera.

iv

Dedications

Dedicatedtomywifeandfamily,Iloveeachofyoudearly!

Thankyouforalwaysbeingthere,IthankGodforeachofyoueverysingleday.

Iamtrulyablessedindividual

v

Acknowledgements

IwouldliketoacknowledgeandthankProfessorsDavidShumwayJonesandDonald

Ostrowski.Thankyoubothforassistanceduringthisprocess.

vi

TableofContents

Dedications.................................................................................................................................................. ivAcknowledgements................................................................................................................................... vI.Introduction ............................................................................................................................................. 1II.DefinitionofTerms.............................................................................................................................. 5III.Background ........................................................................................................................................... 7IV.HistoryofMedicalEthicsandtheFigureswhoCreatedthem ..................................... 14V.Jenner’sCaseStudyandPublication ......................................................................................... 35VI.Jenner’sVaccinationCampaign.................................................................................................. 42VII.Bibliography ..................................................................................................................................... 59

1

ChapterI

Introduction

Smallpoxiscreditedasbeingthedeadliestinfectiousdiseaseinhistory.Itis

responsibleforkillingoverthreehundredmillionpeople.Smallpoxdidnotknow

classorrace;anyonecouldpotentiallydiefromthisdisease.Therearenolonger

fearsofsmallpoxoutbreaksduetotheresearchandexperimentationthatmadethe

eradicationofsmallpoxpossible.Theseeffortsbeganwitheighteenthcentury

researcherandphysicianEdwardJennerwhotookwhatcouldbeconsidered

folkloretothescientificmassesandcreatedavaccinationcampaigntoridtheworld

ofsmallpox.PresidentThomasJeffersoninalettertoJennerthankedhimand

recognizedtheimpacthewouldhaveontheworld.PresidentJeffersonwrote,

“Medicinehasneverbeforeproducedanysingleimprovementofsuchutility…You

haveerasedfromthecalendarofhumanafflictionsoneofitsgreatest…Mankindcan

neverforgetthatyouhavelived.”1PhysiciansandscholarsgenerallycreditJenner

forhisworkonvaccination,butsomequestiontheethicsastohowJennercameto

hisfindings.ThisworkwillfocusonhowJennercametohisvaccination,the

resultingvaccinationcampaignandtheethicsheobservedalongtheway.

EdwardJennercompletedhiscasestudyonsmallpoxinthelateeighteenth

century;heperformedaseriesoftestonindividualsincludingchildren,toseethe

1ThomasJefferson,“LettertoEdwardJenneronhisDiscoveryoftheSmall

PoxVaccine,”May14,1806,http://www.let.rug.nl/usa/presidents/thomas-jefferson/letters-of-thomas-jefferson/jefl172.php14February2018.

2

effectsofcowpoxonhumansandifthecowpoxmattertransmittedviavaccination

toanotherindividualpreventedthemfromcontractingsmallpox.Hepublishedhis

findingsinapublicationhetitledAnInquiryintotheCausesandEffectsofthe

VariolaeVaccinae:ADiseaseDiscoveredinsomeoftheWesternCountiesofEngland,

ParticularlyGloucestershireandknownbythenameoftheCowPox.Thispublication

wasdirectlyresponsiblefortheobservationofJennerianvaccination,whichledto

savingmillionsoflives.Jennerstartedavaccinationcampaignthattravelledthe

worldwellafterhisdeathin1823.Hiseffortscontinuedforoveracenturyanda

half,in1977theWorldHealthOrganizationhadfinallysucceededintheeradication

ofsmallpox.Itspeaksvolumestothehellishdiseasesmallpoxwas,havingtowork

thatlongtoridtheworldofoneofitsworstadversaries.OnMay8,1990,theWorld

HealthAssemblyannouncedthattheworldwasfreeofsmallpoxandrecommended

thatallcountriesceasevaccination:“Theworldanditspeoplehavewonfreedom

fromsmallpox,whichwasthemostdevastatingdiseasesweepinginepidemicform

throughmanycountriessinceearliesttime,leavingdeath,blindnessand

disfigurementinitswake.”2

Theethicsofmedicalresearchandpracticelikeallethicalmattershas

evolvedovertime,amodernmedicalethicscholarwhoobservedJennersolelyin

thestandardsoftoday,wouldalmostcertainlyviewJennerasunethical.Fromhis

useofhumantestsubjects,topurposefullyintroducingindividualstoharmful

bacterialmatter,Jennerissurroundedbyethicalquestions.Butthosequestionsdo

2StefanRiedel,“EdwardJennerandtheHistoryofSmallpoxandVaccination,”January2005,https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1200696/(6March2018).

3

notresidesolelyinthepresent;theethicsofJennerwerehighlightedandarguedat

thetimeofhiscampaigntoo.WhileonecanplaceJennerwithintheethicsoftoday,

totrulyviewtheethicsofJenner,itwouldbenecessarytoplacehimwithinthe

ethicalstandardscreatedpriorandaroundthetimeofhissmallpoxcasestudy.The

term“medicalethics”wasnotcoineduntil1803whenphysicianThomasPercival

introduceditinhiseponymousbookMedicalethics.3Jennerhadalreadyperformed

hisexperimentsandpublishedhisfindingsby1803.(MedicalEthicswillstillbea

criticalpiecetothisworkasitissuchanimportantresourceinthehistoryof

medicalethics)Thuswhatweretheethicalguidelinesandproceduresforamedical

researcherorpractitionertoperformpropermedicinebeforeandduringthelate

eighteenthcentury?WhatelementsofJenner’scasestudyandcampaignwereseen

asbeingcontroversialethically?HowdidJenner’speersviewhimself,hisdiscovery,

andtheoverallethicsofhiscampaign?ItwillalsobeinterestingtoplaceJenner

withinthescopeofmodernmedicalethicstoseewhysomemodernethicscholars

canviewJennerunethically.However,withaproperunderstandingofthehistoryof

medicalethicspriorandduringthelifeofJenner,itmaybecomeevidentthatJenner

practicedhiscasestudyandcampaignethically.

ThisworkwillarguetheethicalnatureofJennerbasedoffhispersonal

publication,AnInquiry,aswellasotherpublicationsaboutsmallpoxandcowpox.

WhileJennerandhisworkarecritical,theworksofothersareofanevengreater

importancebecauseJenneralwayswroteinaverysimplemanner,hedidnotgointo

muchdetail.Hislackofdetailisamajorpointofargumentforthosewhostood

3RobertB.BakerandLaurenceB.McCullough,TheCambridgeWorldHistoryofMedicalEthics(NewYork:CambridgeUniversityPress,2009),3.

4

againstJenner.LuckilyscholarshavewrittenaboutJennerandhiscampaign,

providingambleinsight.

5

ChapterII.

DefinitionofTerms

Jennerianvaccination:theactoftakingcowpoxmatterandinsertingthe

matterintosmallincisionsonthearmofthetestsubject.Performingthevaccination

isbelievedtomakeoneimmunetotheillnessesassociatedwithsmallpox;though

morethanonevaccinationwassometimesrequired.

Variolation:themethodusedtoimmunizeanindividualagainstsmallpox

priortoJenner’svaccination.Smallpoxmatterwastakenfromanindividualwith

smallpoxandimplantedintothearmofanindividualwhohasyettobecome

infected.Variolationcausedanindividualtobecomeinfectedwithsmallpox;a

majorityofthetimesymptomswerefarlessseverethanifcontractednormally.It

wasnotideal,asvariolationoftenleftthepatientverysick,themethodwasdeemed

unsafeandoutlawedafterJenner’smethodwaswidelyaccepted.4

MedicalEthics:Moralprinciplesestablishedbyvariousphysicians,theystate

whatisdeemedproperbehaviorforaphysician.Coveringmatterssuchasthe

necessitytohealpatients,propertreatments,andtherelationshipestablished

betweenthephysicianandpatient.

4Riedel,“EdwardJennerandtheHistoryofSmallpoxandVaccination.”

6

Cowpox:Aninfectiousdiseasethatisthepartoftheorthopoxvirusfamily,

meaningitisinthesamefamilyofdiseaseassmallpoxbutreferstothetypethat

infectscows.Soreswouldappearontheudderofthecattle.5

5EdwardJenner,AnInquiryintotheCausesandEffectsoftheVariolaeVaccinae:aDiseaseDiscoveredinsomeoftheWesternCountiesofEngland,ParticularlyGloucestershireandknownbythenameoftheCowPox,London:SampsonLow,1798,3.AccessedFebruary20,2018,https://books.google.com/books?id=QDXShHV2z0MC&printsec=frontcover&dq=Jenner,+Edward.+An+Inquiry+into+the+Causes+and+Effects+of+the+Variolae+Vaccinae:+a+Disease+Discovered+in+some+of+the+Western+Counties+of+England,+Particularly+Gloucestershire+and+known.

7

ChapterIII.

Background

Smallpoxwasahellishdisease,oftenkillingitsvictimsorleavingthemwith

permanentdisfiguration.Theexactoriginofsmallpoxisstilldebatable,thelatest

researchsuggestssmallpoxbeganinEastAsiathenspreadtotheMiddleEastand

India.6Variolamajorwasthemoresevereformofsmallpox;itwasalsothemost

common.Variolaminorwastheotherlesscommonstrand;itencompassed

symptomsfarlesssevere.Bytheeighteenthcenturyaccordingtooneestimate,

smallpoxclaimedfourhundredthousandlivesannually.Athirdofallsurvivors

sufferedfromsomeblindnessfromthedisease.7Variolation,thepracticeoftaking

smallpoxmatterandinsertingitinasubjecttoprovideprotectionagainstsmallpox

wasintroducedtoEuropebyLadyMaryWortleyMontagu.8Afterherreturnto

Englandintheearly1720sshebegantocampaignforthetechnique.Whilenotideal,

theindividualwasstillsusceptibletoundesirablesymptomsassociatedwith

smallpoxsuchasblistersandfatigue,variolationlimitedthespreadofsmallpox.

Inoculationwasthestandardmethodusedinthepreventionagainstsmallpoxuntil

EdwardJennerbroughtforthJennerianvaccination.

6RobBoddice,EdwardJenner:PocketGiants(Stroud:HistoryPress,2015),22.

7Boddice,PocketGiants,22.


8

Jenner’sentryintothestudyofcowpoxwasoutofcuriosityandanevolving

intrigueastohowcowpoxmayimpactanindividual’sabilitytocontractsmallpox.

EdwardJennermayhavedesiredtostudycowpoxduetohishellishvariolationasa

child.9In1754bothofJenner’sparentsperished,hismotherfromcomplications

duringthebirthhersixthson(thesonalsopassed)soonafterhisfatherpassed

awayaswell.10WhileorphanedEdward’ssisterstookcareofhimforthenexttwo

yearspriortosendinghimawayin1757toattendtheWotton-under-Edge

GrammarSchoolforboysattheageofeight.Whileattheschooltherewaslikelya

smallpoxoutbreakanditwasdecidedtheboyswouldundergovariolationbylocal

surgeonMr.Holbrow.11Variolationinvolveddeeppurgingandastrictdiet.12

AccordingtooneofJenner’sfriends,Fosbroke,thevariolationprocesstooksix

weeks,hestated“Hewasbledtoascertainwhetherhisbloodwasfine;waspurged

repeatedly,tillhebecameemaciatedandfeeble;waskeptonverylowdiet,smallin

quantity,anddosedwithadietdrinktosweetentheblood.Afterthisbarbarismof

human-veterinarypracticehewasremovedtooneoftheinoculationstables,and

halteredupwithothersinaterriblestateofdisease,althoughnonedied.”13‘This

9PaulSaunders,EdwardJenner:TheCheltenhamYears1795-1823(London:UniversityPressofNewEngland,1982),2.

10RichardFisher,EdwardJenner1749-1823(St.Edmunds:StEdmundsburyPress,1991),14.

11Fisher,EdwardJenner1749-1823,14.



9

barbarismofhuman-veterinarypractice’hadreducehimtoaskeleton.14The

variolationhadaphysiologicalimpactonyoungFosbroke,hecouldneversleep,was

hauntedbyimaginarynoises.15Thehellishvariolationlikelyhadasimilarimpact

uponJennerasheandhisfamilydecidedtoleavetheschoolandcontinuehis

educationelsewhere.16

Yearslaterattheageofthirteen,Jennerbecameanapprenticeforsurgeon

JohnLudlow,themedicalabilitiesandknowledgeofJennergrewimmensely.Under

Ludlow,Jennerlearnedofcowpox,about1768Jennerlearnedofareportfromthose

indairiesofadistempernamedthecowpox.17Thereportstatescowpoxoccursfrom

theinfestedteatsofmilkcows,theinfectionisthenspreadtothehandsofthe

milkers,theresultbeingsometimesapreventiveofsmallpox.18Manyoverlooked

thisreport,likealotofearlycowpoxresearch,butitresonatedwithJennerand

startedhimdownapathtowardsgreatercowpoxresearch.

AfterLudlow,EdwardcontinuedhiseducationinLondonwithJohnHunter,

thegreatestsurgeonofhistimeandoneofahandfulofeighteenth-century

scientistswhobelievedthatknowledgegrewonlyoutofexperimentand

14GeorgeMilbryGould,AnomaliesandCuriositiesofMedicine(Philadelphia:W.B.Saunders,1900),906.





10

observation.19JennergrewfromthehabitsofHunter,JohnBaronfriendofJenner,

whoauthoredthefirstbibliographyofJennerafterhisdeathtitledLifeofEdward

Jenner,M.D.PhysicianExtraordinarytotheKingwithIllustrationsofhisDoctrinesand

SelectionsfromhisCorrespondencespokeofwhatJennersawinHunter.Heremarks

“Hesawakind,free,andmanlynaturedevotedtotheacquisitionofscience,and

puttingawayfromhimentirelytheselfishandpersonalconsiderations,whichare

tooapttoencumbertheresearches,andtocircumscribetheobjects,ofless

enlightenedminds.”20

JennerwasfortunatetolearnunderJohnHunteraswellashisbrother

WilliamwhowasPhysicianExtraordinarytotheQueen,hiseducationunderthe

brotherswasbetterthanthatobtainedatOxfordatthetime.21JohnHunterwasa

worldlysurgeonandmanofscience,hewasaFellowoftheRoyalSociety,asociety

ofscholarswhostudythescientificartsanddesiredtodetermineworldly

discoveriesintheworldofscience.Hunterwasinterestedinallofthesciences,

howeverasamanofmedicinehefocusedmainlyonthestudyofthehumanbody.

Hunter’sworksincludethestudyofvenerealdiseases,thedevelopmentofthechild,

andthestudyofthelymphaticsystem.22Havingmentorswhobelievedthereisno

absolutetruthbutonlyanapproximation,whichmustbetestedandrevisedby


20JohnBaron,LifeofEdwardJenner,M.D.PhysicianExtraordinarytotheKingwithIllustrationsofhisDoctrinesandSelectionsfromhisCorrespondence(London:HenryColburn,1827),5.


22“JohnHunter,”IllustratedMagazineofArt4,no.22(1854):210.

11

experimentandobservation,wascriticalinthedevelopmentofJennerandhis

cowpoxexperimentation.

Jennerstoodbythisprincipallaterinlifeduringhiscowpoxresearch,

opposingtheonewhooriginalstoodbythosewords,JohnHunter.Hunterwroteto

Jennerstatinghiscowpoxresearchwasnotthatpromisingandlikelytohurthis

standingwithinthescientificcommunity,thatheshouldenteranotherendeavor.

Jennerdidnotlistentohismentorandbegantoseekgreaterknowledgeand

experimentationoncowpox.SadlyHunterpassedin1793anddidnotgetthe

chancetoseethesuccesshisstudentbecame.

In1780whiletravelingwithhisfriendEdwardGardner,Jennerbeganto

explainhisopiniononcowpoxandhowthediseaseattackedthehandsofmilkers,

thusprovidingprotectionagainstsmallpox.AfterhisexplanationJennerbeganto

feeldeepemotionashefeltthepracticeofcowpoxcouldleadtowardstheextinction

ofsmallpox.Jennerconcludedhisdiscussiononcowpoxwiththesewordsdirected

towardshisfriend:“Gardner,Ihaveentrustedamostimportantmattertoyou,

whichIfirmlybelievewillprovebenefittothehumanrace.Iknowyou,andshould

notwishwhatIhavestatedtobebroughtintoconversation;forshouldanything

untowardturnupinmyexperimentsIshouldbemade,particularlybymymedical

brethren,thesubjectofridicule-forIamthemarktheyallshootat.”23Jennerknew

hisresearchneededtobethoroughlyconductedandstudiedpriortopresentingor

publishinganyfindsforthescientificcommunitywasveryopinionatedand

dismissive.

23Baron,LifeofEdwardJenner,128-129.

12

TheRoyalSocietywasnotasupporterofJennerandhiscowpoxresearch

priortohisexperimentoruponthereleaseofhispublication.However,Jennerwas

electedtothebodyfromhisworkonthecuckoo,Jennerbegantoresearchthe

cuckooundertheadviceofHunterasJennerwasseekingawaytoentertheRoyal

Society.24Thecuckoowasseenasasubjectworthstudyingduetoitsirregularegg

nestinghabits.25Cuckoobirdsdonotbuildtheirownnesttolayandhatchtheir

eggs;insteadtheylayeggsinthenestofothervariousbirds.Jennerprovedthe

youngcuckooandnottheparentbirdremovestheeggandtheyoungfromthenest

towhichitisdeposited.26JennerbecomingamemberoftheRoyalSocietyandother

societiesthatcenteredmoretowardsmedicinewerecritical;theyexposedJennerto

feedbackandrelationshipsthatassistedhimintheformationofhiscampaign.

WhenJennercametoLondonin1788or1789toeitherreadhiscuckoo

paperbeforetheRoyalSocietyortobeelectedintothesociety,hebroughta

drawingofadairymaid’shandthathebelievedhadpossiblycontractedcowpox.27

Jennerbroughtthedrawingtoshowhiscolleaguesandheartheiropinionsuponthe

drawing.ThelikesofJohnFewster,JosephBanks,andHunterwereshownthe

drawing,theyallmentionedhearingofcowpoxmilkersbeingunabletotake

smallpox.However,thesamescholars,includingFewsterwhoknewthemostabout

24StefanRiedel,“EdwardJennerandtheHistoryofSmallpoxandVaccination.”



27CharlesCreighton,JennerandVaccination:AStrangeChapterofMedicalHistory(London:Sonnenschein,1889),24.

13

cowpox,refusedtoaccepttheidea,astheyallmentionedinstanceswerecowpox

milkershadbeenattackedbysmallpox.28RememberingthewordsofHunter,Jenner

knewfromthebeginningofhisresearchthatexperimentandobservationwouldbe

requiredtodeterminetheeffectivenessofcowpox.Jennerdidnotdiscovertheuse

ofcowpoxasapreventiveagainstsmallpoxbuthetookwhatwasoncearusticlore

andmadeintoascientificmatter.

28Creighton,AStrangeChapter,24.

14

ChapterIV

HistoryofMedicalEthicsandtheFiguresWhoCreatedThem

Thischapterobservesnumerouspractitionerswhocreatedethicalcodesto

bettertheconductdeemedproperofaphysicianinclusiveofdiagnosis,healing,the

relationshipbetweenaphysicianandhispatientamongothers.Itisdifficulttosayif

Jennerhadaccesstoeveryethicalguidecreatedbythefiguresbelow,butobserving

Jenneragainsttheseworksholdsmerit.Theindividualstobediscussedcreated

codesandguidesthatrepresentthefoundationoftoday’smedicalethics.

InthelateeighteenthcenturywhenJennerperformedhissmallpoxcase

studytherewasnosetmedicalethicsestablishedthat“had”tobefollowedby

physicians.Medicinewasforthemostpartwasuncontrolled;professorofmedical

ethicsatBostonUniversityMichaelGrodininhisbookTheNaziDoctorsandthe

NuremburgCodediscussesthismanner.Hewrites“Itshouldbenotedthatuptothe

nineteenthcentury,almostallmedicalpracticemaybeconsidereduncontrolled,

unstandardizedandinnovativetherapeutics,orquitesimply,humanexperimentof

apurelyempiricalnature.”29However,thatdoesthatmeanethicsdidnotexistat

thetimeofJenner’scasestudy;physicianshadcreatedandpracticedtheirownset

ofethicsforcenturies.

Noconceptionofmedicalethicsandthepracticeofmedicinetracesbackto

thebeginningofmedicine.ScholarsRobertB.BakerandLaurenceB.McCullough

29MichaelGrodin,TheNaziDoctorsandtheNuremburgCode(NewYork:OxfordUniversityPress,1992),124.

15

authorsofWhatIstheHistoryofMedicalEthics?makeaveryinfluentialargument

whentheystateuntilthetwentiethcenturythehistoryofmedicalethicsis

cementedintheworksoftraditionalism.30Traditionalismarisesfromthe

legitimizationofancientauthorities,suchasJesus,Muhammad,Hippocrates,

Confucius,Galen,amongothers,themoreancientandnobleaheritagethestronger

theclaim.31

AsidefromGod,Hippocratesmaybethemosttraditionalistsourcefoundin

thehistoryofmedicalethics,Hoffmann,Gregory,andPercival(allmedicalethic

scholarswhomwillbecriticaltowardstheethicalargumentofJenner)reliedon

Hippocratesastheycreatedtheirownethicalguides.TheHippocraticwritingswere

thefirsttodiscusstheethicalprincipleswithinmedicine.ManyviewHippocratesas

thefatherofmodernmedicine;hebelievedmedicinewasbasedontheobservation

ofclinicalsignsandrationalconclusions.32Hisethicsdidnotrelyonreligious

conceptions;thisseparatedhimfrommanymedicalethicsscholars.Hippocratic

medicinewasbasedonthePythagoreantheorythatNaturewasmadeoffour

elements,water,earth,wind,andfire.33Hippocratesinturnanalogouslyviewedthe

bodyasconsistingoffourfluidsor‘humors’(blackbile,yellowbile,phlegm,and

30BakerandMcCullough,WhatIstheHistoryofMedicalEthics,5.

31BakerandMcCullough,WhatIstheHistoryofMedicalEthics,5.

32ChristosYapijakis,“HippocratesofKos,theFatherofClinicalMedicine,andAsclepiadesofBithynia,theFatherofMolecularMedicine,”Review,InVivo(Athens,Greece)23,no.4(2009).

33Yapijakis,“HippocratesofKos.”

16

blood)andfourelementalconditions(cold,hot,dry,andmoist).34Accordingto

Hippocratesaproperstateofhealthwasachievedwhenthesewhereinbalance,and

incaseofsickness,aphysicianhadtofigureouthowtorestorethebalance.35To

achievethatbalancethephysicianhadtoexamineapatient,observesymptoms

carefully,makeadiagnosis,andthentreatthepatient.36Hippocratescreatedthe

basicsofclinicalmedicinethatarestillusedintheprocessoftreatmenttoday.

Hippocratesandhisfollowerswrotemanyworkswithinthefieldofmedicaltheory

andpractice,oversixtywereproducedandarenowknownastheHippocratic

Corpus.”37ScholarsHelenAskitopoulouandAntoniosN.Vgontzasremarkon

HippocraticCorpustheystate“Thiscollectionofmanuscriptscreatedover200

years,transformedmedicalconceptsfromanoraltheocraticandhieratictradition

toawrittenrationalmedicalscienceandeducation.”38WilliamHenrySamuelJones

authorofHippocratesandthecorpusHippocraticumstates“thegreatestmessageof

theHippocraticCorpusisthatmedicineisanimportantbut“difficultart,




37BakerandMcCullough,WhatistheHistoryofMedicalEthics,355.

38Askitopoulou,Helen,andAntoniοsNVgontzas,"TheRelevanceoftheHippocraticOathtotheEthicalandMoralValuesofContemporaryMedicine.PartI:TheHippocraticOathfromAntiquitytoModernTimes,"EuropeanSpineJournal:OfficialPublicationoftheEuropeanSpineSociety,theEuropeanSpinalDeformitySociety,andtheEuropeanSectionoftheCervicalSpineResearchSociety,2017,EuropeanSpineJournal:OfficialPublicationoftheEuropeanSpineSociety,theEuropeanSpinalDeformitySociety,andtheEuropeanSectionoftheCervicalSpineResearchSociety,2,https://link-springer-com.ezp-prod1.hul.harvard.edu/content/pdf/10.1007%2Fs00586-017-5348-4.pdf.2March2018.

17

inseparablefromthehighestmoralityandtheloveofhumanity”withemphasison

theindividualpatientandhisillness.”39WithinHippocraticCorpus,oneofthemost

influentialworksinthehistoryofmedicalethicswaspublished,theHippocratic

Oath.

TheHippocraticOathdefinedmoralcodeanddistinguishedprofessional

expertisefrompersonmoralitywithinthepracticeofmedicine.40Beforethe

HippocraticOath,HippocratesinhistreatiseLawcriticizedthedisciplineof

medicinehewrote“ofalltheartsbyfartheleastesteemed”becausenoruleswere

establishedagainstphysicianmisconduct.41TheOathisnotasacredscriptorlegal

document,itcanbeobservedasa“short“elegantlycomplete”documentthat

appearstohavebeendesignedfortheswearinginofapersonatthebeginningofa

medicalapprenticeship.”42TheOathestablishesthegeneralmoralconductofthe

physician-patientrelationship,includingtheideasofbeneficence,non-maleficence,

confidentiality,andaccountabilitywithinthemedicalcommunity.43Themoralcode

sectionoftheOathhasthephysicianfirstgivingprioritytodietetics,thephysician

pledges“Iwillapplydieteticmeasuresforthebenefitofthesickaccordingtomy

39W.H.S.Jones,HippocratesandtheCorpusHippocraticum(London:G.Cumberlege,1945).

40AskitopoulouandVgontzas,“TheRelevanceoftheHippocraticOath,”3.


42StevenH.Miles,TheHippocraticOathandtheEthicsofMedicine(NewYork:OxfordUniversityPress,2004),3.


18

abilityandjudgment;Iwillkeepthemfromharmandinjustice.”44Asidefrom

dietetics,theethicalnormsofpharmacologyandtheuseofdrugsinthetreatmentof

patientsarediscussed.Itbeginswiththephysicianpledgestating“Iwillneither

giveadeadlydrugtoanybodyifaskedforit,norwillImakeasuggestiontothis

effect.”45PhysicianswhoswearundertheHippocraticOathareforbiddenfrom

performingorrecommendingeuthanasia.ThepharmacologyportionoftheOath

concludeswiththequote“InpurityandholinessIwillguardmylifeandmyart.”46A

physicianhasadutytoberituallyclean,tonotfallfromthestandardsoftheOath,to

alwaysrememberandpracticemedicineinaproperfashion.

TheHippocraticOathdiscussesthephysicianandpatientrelationshipbeing

onebasedonhealing.Thephysicianmustadheretoconfidentialityandavoid

speakingofpatient’sdiagnosisandtreatmenttoothers.TheOathconcludesby

stating“IfIfulfillthisoathanddonotviolateit,mayitbegrantedtometoenjoylife

andart,beinghonoredwithfameamongallmenforalltimetocome;ifItransgress

itandswearfalsely,maytheoppositeofallthisbemylot.”47Aphysicianwillearn

salvationifhefollowstheoathhepledgedto,hemusttreatandobservepatientsin

amoralfashionorelsefailandbeunabletoenjoylife.TheHippocraticOathhashad

44RobertM.Veatch,Hippocratic,Religious,andSecularMedicalEthics:ThePointsofConflict(Washington,DC:GeorgetownUniversityPress,2012),13.

45Veatch,Hippocratic,Religious,15.

46LudwigEdelstein,“TheHippocraticOath,”PhilosophicalReview53(1944):609.

47Edelstein,“TheHippocraticOath,”609.

19

numerousversionsthroughoutitshistory;itcontinuestobethestandardforthe

properconductforaphysician.

In1347,theBlackDeath,apandemicofbubonicplague,arrivedinEurope

evokingadeontologicalthemeabouttheobligationaphysicianhadtoservethesick

andstrengthentheroleofthephysicianinthecommunity.48However,many

physiciansdidnotbelieveintheirethicalobligationinsteadfollowingadvicethey

gavetheirpatientsknownastheHippocraticPrescription:cito,longe,tarde:“leave

fast,gofarandreturnslowly.”49MedicalEthicsprofessorAlbertJonsenstatesa

relevantquestionaboutphysiciansduringtimesofdiseaseandplagueheremarks

“thequestionofservicetothesickevenatthecostofdangertooneselfmight

troubletheconscienceofavirtuouspersonwhopracticedmedicine,butshoulditbe

themarkoftheprofessionasawhole?”50ApothecaryWilliamBoghurst,statedan

ethicalidealforphysiciansandeveryoneelsewhofoughtdiseaseoutbreaks,he

states“everymanthatundertakestobeofaprofessionortakesonhimselfanoffice

musttakeallpartsofit,thegoodandtheevil,thepleasureandthepain,theprofit

andtheinconveniencesalltogetherandnotpickandchoose;forMinistersmust

preach,CaptainsmustfightandPhysiciansattenduponthesick.”51Amorallyright

48AlbertR,Jonsen,AShortHistoryofMedicalEthics(NewYork:OxfordUniversityPress,2000),45.

49Jonsen,AShortHistory,45.



20

physicianhadtheconsciencetoputhimselfindangerforthetreatmentofothers

duringplagueanddiseaseoutbreaks.

DuringthelateMiddleAgesphysicianswereemerginginanewworldof

medicine.In1495GabrieledeZerbireleasedAdvicetoPhysicians(DeCautelis

Medicorum),historianL.R.Lindbelievesthistobethe“firstsystematicaccountof

medicalethics.”52Zerbidescribes“thephysicianasaneducatedpersonofthe

middleoruppersocialclasswhoseprimaryethicalobligationistoearnthetrustof

patients.”53Thatthecentralvirtueofbeingagoodphysicianwas“fidelity”whichis

describedaswide-rangingadviceaboutintercoursewithpatients,fees,and

consultations.54Physiciansmustavoidfalsedoctrinesbecausetheirapplication

leadstopublicdisgrace,themostdespisedmemberoftheprofessionis“the

physicianonlyinname.”55Zerbithoughtthatitisimpossibletogainasatisfactory

knowledgeofmedicinejustfromstudyingdoctrinesandtheories.56Physiciansmust

befaithfultothelearnedtraditionsofmedicineandtothechurch,therulesof

medicalmoralityandethicsrestonthewrittenwordsofthegospel.Zerbistates,

“Thephysicianislikeapriest,towhomGodhasrevealedthedivinepowersof

healingandtowhommenrevealtheirsoulsforthecureoftheirbodies.Aphysician




55DavidE.J.Linden,"GabrieleZerbi'sDecautelismedicorumandtheTraditionofMedicalPrudence,"BulletinoftheHistoryofMedicine73,no.1(1999):22.https://muse.jhu.edu/(accessedFebruary22,2018).

56Linden,“GabrieleZerbi.”

21

mustcultivatealifeworthyofthepriesthood.”57Theologybeginstoplayalarger

roleinthedeterminationofwhatisethicalinthefieldofmedicine.

Inthesixteenthandseventeenthcentury,therewasanincreaseinmoral

theologybasedmedicalethics,duringthefifteenthcenturyCatholictheologians

developedaspecialbranchoftheologyconcentratingonthemoraldutiesof

Christians.58ItalianPhysicianGiovanniCodronchusappliedmoraltheologytothe

workofphysicians.In1591hepublishedabooktitledDeChristianaactutamedendi

ratione(ChristianandCarefulMethodofMedicine).Inhisbookhewarnsofsins

physiciansmuststrayawayfrom,suchasconcealingillness,wishingsicknessupon

othersforincreasedbusiness,orgivingmedicinetoahealthypersonsotheymay

fallill.59Hesummarizes:“Thephysicianmayhavemanyvirtues,but“ifhelack

justice,allothervirtueswillfailhim,forjusticeisthesumandsourceofall

virtues.””60AhasveriusFritschpublishedaProtestantversionofmoraltheologyin

medicinein1684entitledMedicusPeccans(TheSinningPhysician)thebooklist

twenty-threesinscommonlycommittedbyphysicians.61Thelistincludedpracticing

medicinewithoutsufficienteducation,fleeingthecityincontagion,anddamaging

thereputationofotherphysicians.62






22

FriedrichHoffmann,thefirstprofessorofmedicineattheUniversityofHalle

inGermany,wasatraditionalistwhoselecturesplayedacriticalroleinthe

developmentofmedicalethics.Theselectureswerepublishedin1738byhis

studentsandtitledMedicusPoliticus(ThePoliticPhysician),afteritsreleasethe

worksawwidesuccessaroundEuropeasaguidetowardsethicsandthe

relationshipsbetweenaphysicianandhispatient.63MedicusPoliticuswasoriginally

writteninLatinthentranslatedtoFrenchbutwasnevertranslatedtoEnglish.64

SinceitwasnottranslatedtoEnglishmanyEnglish-readingthinkersinthe

generationsthatfollowedwerenotfamiliarwiththiswork.ThoughJennerandhis

peerswereeducatedinLatinthushemayhavereadorstudiedtheworkof

Hoffmanninhislifetime.MedicusPoliticuswasdividedintothreeparts:thepersonal

characteristicsrequiredbythenewpoliticphysician,secondthephysicians

relationshipwithothermembersofthemedicalcommunity,andlastlythe

relationshipbetweenpatientandphysician.65

Hoffmannbelievedproperscientificinvestigationinmedicinerequiredboth

observationandreasoning.66Sciencerequiredlogicalinferenceandarejectionof


63ThomasEttingerBaril,"PhilosophicalAnalysisoftheConceptofthePolitic

PhysicianinFriedrichHoffmann's‘MedicusPoliticus’,"OrderNo.3589880,UniversityofTexasatAustin,2008,accessedFeb13,2018,viii,http://search.proquest.com.ezp-prod1.hul.harvard.edu/docview/1430963607?accountid=11311 (13February2018).

64Baril,“PhilosophicalAnalysis,”viii.

65Baril,“PhilosophicalAnalysis,”65.

23

anythingnotexperiencedinobservation,atruemedicalscientistmustobserve

naturetorestoreandmaintainhealthofothers.67DiscussingnatureHoffmann

discusesHippocrates,hestates“Hippocrates,theancientfatherofmedicine,writes

reverentlyandwisely,Trytoacquireaknowledgeofnature.Itisunfortunateand

disgracefulthatuptothepresenttimethewarningofthedivineelderisneglected

bythosewhopracticetheritesofmedicine.”68Hoffmanncommentsonnatural

philosophy,heremarks“Withoutnaturalphilosophythewholescienceofhealingis

maimedandweak,andisnotsuitabletoexplainanydiseaseorwiselydirectany

cure.Thenaturalphilosopherpeersintotherecessesofnature,examinesthehidden

structures,proportionsandmixtures,andfromthesehedrawsconclusionsmost

fruitfulformedicine.”69

MedicusPoliticusPartOne’stitle“TheRulesofPrudenceconcerningthe

PersonalQualitiesofthePhysicianhimself”representsfullywhatisdiscussedtothe

reader.PartOnecontainsfivechaptersandeighteenrules,thethreelongestrules

are:rule5whichstatesletthephysicianbeaphilosopher(106lineslong),rule6let

thephysicianbeerudite(79lines),andrule7letthephysicianlearnclinicaland

individualpractice(66lines).70Hoffmann’sfirstlecturesareonthemoralcharacter

ofthephysician;Hoffmann’sideaofmoralityisbasedonthedevelopmentofvirtues






24

andtheavoidanceofvices.71Studentsandphysiciansbecamevirtuousbyapplying

religious,rational,andpracticalconsiderationsintheirdailylivesandwork,alsoby

learningtheChristianvirtuesofcompassion,humility,andmoderation.72Thefirst

rulegiveninMedicusPoliticusstates“LetthePhysicianbeaChristian”speakingto

Hoffmann’sdevotiontotheChristianfaithandhowadamanthewasthathavinga

relationshipwithChristwasnecessarytobeamoralphysician.73Hoffmannstates:

“Godisthemodelofbenevolence:…themostbenevolentGodmadetheartofmedicinegracious.GoodChristiansingeneralmustimitatethismodel:…theChristianexerciseskindness.GoodChristianPhysicians,ontheotherhand,mustgoevenfurtherbecauseGodhasdeterminedthat(theartofMedicine)istobepracticedoutofpurebenevolence.Foritisinmedicinethatwehavethegreatestopportunitytoimitatethemodel:…norwillanoccasionbelacking,indeed,thedailymiseryofmanwillremindhimtogivehelptotheneedy.JustascompassionistheappropriateformGod’slovewhendealingwithourfallennaturesoiscompassiontheappropriateformofthephysician’sloveforhisfellowmaninthestateofdailymisery.Thus,thecompassionofGodmustbemirroredinthelifeofthephysicianwhofreelygiveshismedicalskilltothepoor-i.e.,abenevolentreflectionofthebenevolenceofGod.”74

Virtuespreservethenatureofathingwhilevicesdestroythatnature.Theviceof

prideisthemostapparent,withtwoversionsmentioned,thefirstpridedwellsin

themindwhenhedeniesconversationanddoesnotvaluetheopinionsofthosehe

believestobeinferiortohim.75Theotherpridedwellsincarriage,whenaphysician





25

carestoomuchabouttheirappearanceandhowwellofftheyare,havingtoomuch

self-interest.76

Hoffmannispresentinghisethicsbasedontheprincipleshedeemedas

NaturalLaw.Hoffmann’sNaturalLawTheoryopenedstudentsandreadersof

MedicusPoliticustohiswidergoalofharmonizingfaithandreason.77Moving

physician’sbehaviorfromfocusingonreligionordecorumtoatheorythatwas

inclusiveofthosebutalsomadeaconnectionbetweendemeanorandmorality.78

Hoffmann’sNaturalLawstateditwasman’ssocialobligationtoensuresocietywas

preservedbymutualorreciprocallovebetweenallmen.79Hoffmannstates,“The

naturalorderistobepreserved”thatmanhasthemoralprincipletoensurenature

(inclusiveofman)continuestobebeneficent.

Hoffmannarguesphysiciansmustbecompassionate,modest,andhumane,

theequalitythatHoffmanspeaksofinNaturalLawmustbepresentinaphysician

andpatientrelationship.Thatthefirstemotionfeltbythepatientistrust,ifthey

believetheycantrusttheirphysician,butitmustbeareciprocalrelationship.80The

moralideathatphysicianandpatienthavethesharethegoalofrestoringthe

patient’shealth,thatthephysicianmustgivehisalltothisprinciple.Hoffmann

75Baril,“PhilosophicalAnalysis”,103.






26

states“hesurrendershimselfcompletelytosickpersons,itisasifallillnessisthrust

ontothephysicianandinservingthelifeandthehealthofothersmuchisremoved

fromhisconvenience.”81Physicianshavethemoralobligationtolookoutfor

everyone,hestates,”Thephysician…oughttowatchovereveryone…Heshould

understandthatitisshamefulforthephysiciantoleavethedoorclosedtothose

whoareknocking.”82Theprimarypurposeofaphysicianshouldbethehealthand

wellbeingofhispatients,notthemoneyreceived.

Hoffmann’sethicsarethefirsttoincluderulesinclusiveofthepatient;he

treatspatientsandphysiciansequally.Boththephysicianandpatienthavethe

responsibilitytobemoraltowardseachother.Whilethephysicianhasthe

responsibilitytotreateveryone,Hoffmannarguesifthepatientisnotmoralby

usingdeception,withdeceptionthephysicianhastherighttorefusetreatment

and/orendthecontractbetweenthetwo.83

JohnGregorywasaproductoftheScottishEnlightenment;the

Enlightenmentiscategorizedbythemanyintellectualandscientific

accomplishmentsfoundedduringtheperiod.TheEnlightenmentproducedScottish

philosophy;philosophyrepresentedthecorevaluesofGregory’smedicalethics.

DavidHume’smoralphilosophyanditscoreconceptofsympathyhadadeepimpact




27

onGregoryasthevirtuesofsympathyappearthroughouthis1772publication

LecturesontheDutiesandQualificationsofaPhysician.84Gregoryremarks:

“Medicinepresentsanolessextensivefieldfortheexerciseofhumanity.Aphysicianhasnumberlessopportunitiesofgivingthatrelieftodistress,nottobepurchasedbythewealthofIndia.Thistobeabenevolentmind,mustbeoneofthegreatestpleasures.Butbesidesthegood,whichaphysicianhasitofteninhispowertodo,inconsequenceofskillinhisprofession,therearemanyoccasionsthatcallforhisassistanceasaman,asamanwhofeelsforthemisfortunesofhisfellow-creatures.Inthisrespecthehasmanyopportunitiesofdisplayingpatience,goodnature,generosity,compassion,andallthegentlervirtuesthatdohonortohumannature.”85

DavidHumebelievedtheentiremorallifeisfoundedonanaturalandintuitive

sympathywithmoralsentimentsofothers.86Besidessympathythechiefmoral

qualitythataphysicianmustpossessishumanity,beingabletofeelwhatdistresses

yourpatientandthedesiretohelpthem.Beingabletofeelsympathyforthem

offersyouwaystorelievethemmorethansomethingthatcouldbepurchased.87

Gregoryargueshowcriticalitisforaphysiciantohavearelationshipwith

hispatients.Thatexperiencedphysicianshavetomaintaintheattitudetheyhad

whentheybegantopracticemedicine,anattitudethatwaspolite,humane,and

attentivetohispatients.Donotfailinyourwaysandendupbeinghaughty,careless

84LaurenceB.McCullough,"BioethicsintheTwenty-FirstCentury:WhyWeShouldPayAttentiontoEighteenth-CenturyMedicalEthics,"KennedyInstituteofEthicsJournal6,no.4(1996):329-333.

85JohnGregory,LecturesontheDutiesandQualificationsofaPhysician(London:W.Strahan,1772),8.


87Gregory,LecturesontheDuties,19.

28

andbrutalinyourmanners.88Physiciansgainarelationshipthatoftengoesbeyond

basiccarewiththeirpatients,suchasprivateconcernsoffamiliesandseeingpeople

whentheyareattheirgreatestdisadvantage.

TheEnlightenmentwasresponsibleforthecreationofthemedicalfacultyat

theUniversityofEdinburgh,atwhichGregorytaughtasprofessorofmedicineand

recordedhislecturestobeusedashispublication.89Gregorydescribeshis

occupation,hestates:“ThedesignoftheprofessionwhichIhavehonortoholdin

thisuniversityistoexplainthepracticeofmedicine,bywhichIunderstandtheart

ofpreservinghealth,ofprolonginglife,andofcuringdiseases.”90Inthefirst

publishedlectureGregorystates:

“Physiciansconsideredasabodyofmen,wholivebymedicineasaprofession,haveaninterestseparateanddistinctfromthehonorofthescience.Inpursuitofthisinterest,somehaveactedwithcandor,withhonor,withingenuousandliberalmannersofgentleman.Consciousoftheirownworth,theydisdainedeveryartificeanddependforsuccessontheirrealmerit.Butsuchmenarenotthemostnumerousinanyprofession.Someimpelledbynecessity,somestimulatedbyvanity,andothersanxioustoconcealignorance,havehadrecoursetovariousmeanandunworthyartstoraisetheirimportanceamongtheignorant,whoarealwaysthemostnumerouspartofmankind.”91


89RobertM.Veatch,DisruptedDialogue:MedicalEthicsandtheCollapseofPhysicianHumanistCommunication(1770-1980)(NewYork:OxfordUniversityPress,2005),6.



29

Unfortunatelyinthefieldofmedicalpractitionersmanydidnotpracticewiththe

dignitynecessarytobeconsideredethical,theyarephysicianswhentheyshouldnot

be.Amajorityofphysiciansareundereducatedandinthefieldbecausetheywishto

appearrelevantandimportant.Physicianshavetounderstandtheeducational

principalswithinthefield,whichincludeknowledgeofphysiology,anatomy,and

medicine.92

Gregorydiscussesexperimentation;hebelievesexperimentationcannotbe

pursuedwithoutareasontoperformresearch.93Ifperforminganexperimentthere

mustbesomepointofview,someanticipationfortheprincipaltobeestablishedor

rejected,andthatthereasonwillbeusedtodiscoverthetruth.94WhenGregory

referstoexperimentationhelikelyisreferringtotrialsfornewmedicinesor

methodstotreatcertainillnessesorsituations.Whileitisadmirabletakingona

newtasktotrytobettermedicine,onehastohavereasonandanideaofwhatthey

wishtoachievefromtheexperiment.

Gregorystates“Withoutreasoning,orwithouttrustingtocertainprinciples,

eitherestablishedorrenderedprobable,wecouldneverbebenefitedbyexperience,

becausewecouldnevertransferitfromthecasewehaveseen,tothecase

immediatelybeforeus.”95Oftenexperimentsinvolvehavingnoconclusive

92Gregory,LecturesontheDuties,73-81.




30

knowledgeofwhatwillhappenbutwithreasoning,physiciansmustproceedintheir

experimentsuntilfutureobservationsshallassertresults.Gregoryremarks:

“Ifshouldseem,uponthewhole,thatallphysiciansmustreason;andthattheonlydifferenceamongtheconsistsinthis,thatsomereasonbetterthanothers.Some,forexample,searchintothecausesofdiseases,andtheeffectsofremedies.Deeplysensibleofthedifficultyoftheenquiry,andthevariouswaysinwhichtheymaybedeceived,theycollectandarrangeallthefactsrelatingtothesubject;whentheyhavegotaremoteviewofaleadingprinciple,theyattempt,byexperiment,tobringadirectandconclusiveproofofitsexistence.Iftheproofturnsoutagainstit,theysee,andcandidlyacknowledgetheirmistake,ifthecasedoesnotadmitofadirectproof,theyconsidertheirprincipleasmoreorlessprobable,butneverrelinquishthepursuit.These,Ithinkhaveajustclaimtothetitleofrationalphysicians.”

Rationalphysiciansemploytheiringenuitytostrainfactsintoacorrespondence;

theywillnotbendtheirresultstostopanexperimentfromresultinginfailureor

discoveringtheincredible.96

Gregorycreatedawell-versedcodeofethicsthatnewandestablished

physicianscouldstudy,learn,andabideby.BeingpartoftheScottishEnlightenment

GregorybecameeducatedinthephilosophyoftheEnlightenment,his

understandingofhumanityandthemoralqualityofsympathywerecriticalasthey

eachhelpeddevelophisethics.Hisinclusionoftherationalphysicianisverycritical

withinthisthesis;Jennerwillbeexaminedtodetermineifhehadreasonandthe

moralresponsibilitytoaccuratelyperformhisexperiment.


31

Theterm“medicalethics”wasdebutedbyDr.ThomasPercivalinhis1803

publicationMedicalEthics;or,aCodeofInstitutesandPrecepts,Adaptedtothe

ProfessionalConductofPhysiciansandSurgeons.97Percivalcreatedhisethicsguide

in1792attherequestofthegovernorsoftheManchesterInfirmary(theywere

havingissueswiththestaff),thegovernorsdesiredPercivaltocreatea“schemeof

professionalconductrelativetohospitals.”98Hesetout“toframeageneralsystem

ofmedicalethics;thattheofficialconduct,andmutualintercourseofthefaculty,

mightberegulatedbypreciseandacknowledgeprinciplesofurbanityand

rectitude.”99Whiletheworkwaswrittenin1792itwasnotpublisheduntil1803,

howeverhecirculatedcopiestofriendsinthedecadepriortopublicationfor

commentsandreview.ItispossiblethoughunlikelyJennerreadPercival’swork

priortopublication,JennersentPercivalacopyofAnInquiry(hisopinionwillbe

discussedlater)butcallingJenneraclosefriendofPercivalwouldbeincorrect.

WhilePercivalhadnotpublishedhiscodeofethicsuntilafterJennercompletedhis

casestudy,hehadwrittenitalreadythusobservingJenner’scasestudyfromthe

perspectiveofthoseethicsholdsmerit.Thisthesisgoesbeyondthecasestudyand

intoJenner’scampaign,whichextendedwellafter1803;Percivalwillbeusedtoin

theobservationofthecampaign.ThomasPercivalwhileaskedtocreateaguideto

easetensionsbetweenfigureswithintheManchesterInfirmaryinactualitycreated

97ThomasPercival,MedicalEthics;oraCodeofInstitutesandPrecepts,

adaptedtotheProfessionalConductofPhysiciansandSurgeons(Oxford:JohnHenryParker,1803).


99BakerandMcCullough,TheCambridgeWorldHistoryofMedicalEthics,7.

32

acodestillrecognizedinthemoderneraasthefoundationoftheobservationof

propermedicalethics.

Percival’sdeterminationofmedicalethicsissomewhatdifferentfromthe

priorexamplesthatdealmainlywithaphysicianandhispatientduetothe

developmentseenineighteenthcenturyhospitals.Insteadofaoneonone

relationship,patientsareoftencaredforbymultiplephysicianswhoneedtowork

togethertoridthepatientofillnesses.ScholarsBakerandMcCulloughstatePericval

tookthreeadherentlydifferentethicalnotionsandcompoundedthemintoanew

conceptionofethicswithinmedicine.Theystate“Thethreeconceptionsthat

Percivalcompoundedwereaconceptionoftheprofessionalassomeoneplayinga

rolegovernedbyitsowninternalmoralityofservicetoothers,theideaofthe

professionalasboundbyasocialcompactinwhichsocialprivilegesareconferred

onalearnedoccupationinexchangeforsocialobligationstoservesociety,andthe

notionoftheprofessionalasamemberofafraternalsociety,boundbyitsownself-

imposedrules.”100MedicalEthicsissplitintofourchapters:1)thepersonalconduct

relativetothehospital,2)thepersonalconductofprivatepractice,3)theconduct

betweenphysiciansandapothecaries,4)aphysiciansnecessaryunderstandingof

thelawincertaincases.Onceagaintheideaofhealingeveryoneispresent,hospitals

werenotjustforthewelloff,physicianshavetobepreparedtotreatallindividuals.

Percivalbelievedtheunderlyingthemeofhisworkwasthemoralnotionofa

physicianbeinga“gentleman”inalldealingswithcolleaguesandpatients.101

100BakerandMcCullough,TheCambridgeWorldHistoryofMedicalEthics,

247.

33

Percivalwrites“thestudyofprofessionalethics…willsoftenyourmanners,expand

youraffections,andformyoutothatpropertyanddignityofconduct,whichare

essentialtothecharacterofagentleman.”102Thegentlemanphysician“mustunite

tendernesswithsteadiness,andcondescensionwithauthority,astoinspirethe

mindsoftheirpatientswithgratitude,respect,andconfidence.”103Percivalcreated

hiscodeundertherecommendationofthehospitalgovernorsbutbelievedthe

patientistheonethephysicianshouldadheretonothegovernors.Thegovernors

wereinclinedtoovercrowdingandtheuseofcheapmedicinetoensurethe

monetarysuccessofthehospital,Percivalarguesprovidethesepatients(oftenthe

sickpoor)thesamecareasprivatepatients.104

WhilemanyscholarsarguePercivalstartedanewchapterinthehistoryof

medicalethics,itisarguablytheoppositeasPercivalwastheconclusioninthatera

ofmedicalethics.Whiletheterm“medicalethics”wastermedbyPercival,hisethics

codewasbuiltonthefoundationsetbythosementionedinthisworkandothers

whodesiredphysicianstohonorthepracticeandpracticemedicineinaproper

moralfashion.105ScholarEdmundPellegrinomadeaveryencompassingstatement

aboutthemoralsandethicsfoundwithinthestudyandpracticeofmedicine.He


102Percival,MedicalEthics,63.



105AndrewWear,JohannaGeyer-Kordesch,andRogerFrench,Doctorsand

Ethics,TheEarlierHistoricalSettingofProfessionalEthics(NewYork:EditionsRodopi,1993),10.

34

states“Medicineisamoralenterprise,andhasbeensoregardedsincethe

Hippocratictimes:thatistosay,ithasbeenconductedinaccordancewithadefinite

setofbeliefsaboutwhatisrightandwrongmedicalbehavior.”106Heremarksthat

ethicsdidnotbecomestricteruntilalaterdate,whichholdstruth,physicianscanbe

moralbylearningtheethicscreatedbythelikesofHippocratestoPercivalbutit

wasnotnecessary.Untilthenineteenthcenturythepracticeofmedicinewas

uncontrolled,itwasonthemoralbeingofthephysicianiftheywishedtobea

benevolentandfollowtheoathsandcodesbeforethem.

ObservingthecasestudyandcampaignofJennerwithageneralized

understandingofhowaphysicianwasethicalintheeraofJennerwilljustifyhim

beingseenasanethicalbeing.Jenneradheredtomanyofthethemesstatedbythe

scholarswhodeterminedwhatitmeanttobeethicalinatimewhenmedicinewas

uncontrolled.ThechancesJennertookinhisexperimenttohiseffortstospreadhis

vaccinationafteritsreleaseallimpacttheethicaloutlookofamanwhoispraised

forriddingtheworldofoneofitsgreatestdiseasesyetquestionedforhowhe

obtainedhisresults.

106EdmundD.Pellegrino,“TowardsaReconstructionofMoralMorality,”AmericanJournalofBioethics,6,no.2(2006,):65.

35

ChapterV

Jenner’sCaseStudiesandPublication

Jennerbeganhiscowpoxexperimentsin1796.Initsinfancytheexperiments

experienceddifficulties.Jennerfrompersonalobservationandothermedical

scholarsknewsmallpoxwasnotacertainpreventiveagainstsmallpox.Herealized

thatcowsweresubjecttoavarietyofsoresoftheirteats.Allwerecapableofbeing

transmittedtothehandsofamilkerbutonlysomeproducedcowpox.107However

withfurtherinvestigationJennerwasabletodeterminecowpoxhadtwoforms:

Truecowpoxandpseudocowpox,truecowpoxwascapableofprotectingagainst

smallpoxwhilethefalsewasnot.108Jenneralsohadtodealwithshortagesin

cowpoxmatterduringhisexperiment,withoutoutbreaksamonglocalcattle

Jenner’sresearchwasonhold,hewasunabletoperformanyvaccinationcasesfor

manymonthsleadingintothespringof1798.109Luckilyanoutbreakoccurredin

Mayof1796,Jennerwasabletoperformhisfirstpersontopersonvaccinationwith

cowpoxmatterasaresult.AdairymaidnamedSarahNelmesfellvictimtocowpox

byacownamedBlossom.110Thematterwastakenfromherhandandinsertedby

107Baron,LifeofEdwardJenner,131.


109Bazin,TheEradicationofSmallpox,38.


36

twosuperficialincisionsintothearmofJamesPhippsonMay14,1796.111Phipps

wasahealthyboyofabouteightyearsold,thecowpoxbroughtuponminor

symptomsincludinguneasinessintheaxillaontheseventhdayandontheninthhe

becamecoldwithalostofappetiteandslightheadache.112Thefollowingdayhe

wokeupandwasfeelingfine,afterthediseaseseemedinasatisfactorymanneron

July1stJennerperformedvariolationuponPhippstoseeifsmallpoxfollowed.No

diseasefollowed,Jennerhadsuccessfullyperformedhisfirstpersontoperson

vaccination.

Figure1:SarahNelmesHand113

JennerrecordedthecasesofSarahNelmesandJamesPhippstolaterbe

publishedinAnInquiry,ascasesXVI(Nelmes)andXVII(Phipps).114Representing


112Jenner,AnInquiry,34.


37

thetwomostimportantcaseswithinhisargumentthatvaccinationwaspossible

individualsandledtowardsprotectionagainstsmallpox.CasesXVIII-XXIIIcontinue

thepracticeofvaccinationandacttogreaterJenner’sargumentasallsubjectswere

thenvariolatedyetprotectedfromsmallpox.115CasesI-XVinvolvedindividualswho

hadalreadycontractedcowpox(orwhatwasbelievedtobecowpoxasJennerwas

nottheretoperformvaccination)withoutperformingthevaccinationhimself

Jennerhadtoperformvariolationandseeifsmallpoxappeared.116CasesXIII-XVare

particularlyinterestingasJennermakesnoteofpatientswhonevermilkedcows

andhadreceivedpustulesfromdressingthehoofsofhorses(grease).InCaseXIII

theindividualwasprotectedfromsmallpox,CaseXIVhehadminorsmallpoxrelated

symptomsthatmadeJennerbelievethediseasepartiallytook,andinCaseXVthe

individualcontractedsmallpox.117Jennermakestheargumentthattransmissionhas

tobemadetoacowfromthehorseviathehumanasthemediumbecauseotherwise

theindividualprotectionagainstsmallpoxisnotcertain.118Thematterofhorse

greasewillfollowJennerandbecomeanissueofcontributionforthoseagainst

Jennerandvaccination.

PriortopublishinghisfindingsJennerwrotehisfirstmanuscriptandsentit

tothePresidentoftheRoyalSociety,SirJosephBanks,forobservation.Banks

114Jenner,AnInquiry,31-36.





38

remarkedthenumberofcasesstudiedwastoosmallandthatifJennerwishedto

keephiscolleaguesesteeminrespecttotheRoyalSocietyheshouldwithdrawhis

manuscriptandforgetaboutitassoonaspossible.119Jennerwasnotinfluencedby

Banksopinion,onceagainJennerhadtobrushoffcriticalopinionsfroman

esteemedpeer,Jennerknewhisresearchheldmerit.In1798EdwardJenner

publishedAnInquiryintotheCausesandEffectsoftheVariolaeVaccinae:aDisease

DiscoveredinsomeoftheWesternCountiesofEngland,ParticularlyGloucestershire

andknownbythenameoftheCowPox.Thepublicationforeverchangedthehistory

andprogressionofmedicineandtreatment.

BeforeobservingtheimpactandreceptionofJenner’sreleaseontheworld

andthecorrespondingethicsobserved,thisworkwillobservetheethicsdisplayed

byJenneruntilthereleaseofAnInquiry.Theethicsofhumantestsubjectsisa

criticalissuewithinthecampaignandexperimentsofEdwardJenner.Jenner’sethics

areinquestionforperformingvaccinationonJamesPhippsandthesevencases

afterwardsinanefforttoprovidefurtherevidenceforhisvaccinationargument.

First,theuseofhumantestsubjectswascompletelyanacceptablepracticeduring

thetimeofJennerandwasexpected,howwasaresearchersupposedtoconducthis

researchwithoutobservation?Humansubjectsweretheonlyfiguresthatcouldbe

observed.Insertingmatterintothearmofanindividualwasnotunethical;

vaccinationinvolvedthesamemethodasvariolationexceptcowpoxmatterwas

usedinsteadofvariolamatter.ThemethodJennerused(smallincisioninthearm)

wasintroducedbysurgeonRobertSuttoninthelate1750s,thushadbeencommon


39

practiceforaroundfortyyears.120Likewisebothmethodsrequiredvariolationtobe

performedaftertheinitiallyvariolation/vaccinationtoseeiftheprocedure

protectedtheindividualagainstsmallpox.

Whiletestsubjectswereethicalpractice,Jenner’sethicsarejustifiably

questionedwhenweperformedvaccinationonJamesPhippsbyinsertedcowpox

matterfromonesubjectintoanother.Jennerdidnotknowhowthematterwas

goingtotakeanduponthecompletionofthevaccinationheperformedvariolation

toseeifthesubjectwasprotectedagainstsmallpox.Jenner’suneasinessisnotedby

Baronwhowrites“Hewentthroughthediseaseapparentlyinaregularand

satisfactorymanner;butthemostagitatingpartofthetrialstillremainedtobe

performed.Itwasneedfultoascertainwhetherhewassecurefromthecontagionof

smallpox.Thispoint,sofullofanxietytoDr.Jenner,wasfairlyputtoissueonthe

firstofthefollowingJuly.Variolousmatter,immediatelytakenfromapustule,was

carefullyinsertedbyseveralincisions,butnodiseasefollowed.”121Jenner’sanxiety

wasfornotasPhippsdidnotcontractsmallpoxafterhisvaccination.Gregory

mentionstheimportanceofexperimentsinhisethics,experimentsoftenhaveno

conclusiveness,butwithreasoningandfutureobservationresultsshallassert.

Jennerhadstudiedandpushedfurtherresearchontheinfluencesofcowpoxon

smallpoxfortwodecadespriortohispublication,hehadthenecessaryreasoning

andexperience.Thatexperienceledtosuccessfulvaccinationandwithsuccessthe

ideathatusinguntestedmatterbecomeslessunethical.



40

EthicsscholarThomasA.Kernsauthorof,JenneronTrial:AnEthical

ExaminationofVaccineResearchintheAgeofSmallpoxandtheAgeofAIDS,

discussesindetailtheethicsofJenner’sexperiment.Hedoessobycomparing

Jenner’sexperimentwiththeNazidoctorswhoperformedtyphusvaccination

experimentsonhumantestsubjectsatthecontainmentcampsinBuchenwaldand

Natzweiler.122ThevaccinationscompletedbytheNazidoctorsinsomeaspectswere

quitesimilartoJenner’sexperiments,butunlikeJenner’swerecondemned.Kerns

observeswhyandcontributestotheoverallethicalappealofJenner.Firsthe

discussespreliminaryevidence,itmentionedJennerdidambleworkleadingtohis

experimentsohehadastrongbasistobelievehisexperimentwouldprotecthis

patients.WhiletheNaziphysicianshadnoevidencepriortotheirexperiments,thus

theywereputtingtheirsubjectsatgreatrisk.123SecondlyKernsdiscussestheuseof

vulnerablesubjects,JennerusedchildrenwhiletheNazisusedprisoners,bothof

whichrepresentedgroupslikelytohaveissueswithfreeinformedconsent.But,

Jenner’sexperimenthadahighlikelihoodofbenefitingthesubject,assmallpoxwas

adiseaseapersonintheeighteenthcenturywouldbeexposedtonumeroustimes

throughouttheirlives.Unlikethetyphussubjectswhodidnotknowiftheywere

goingtoactuallybeprotectedfromthevaccination.Itisalsoimportanttorecognize

thesubjectsofthetyphustrialshadnosayintheirparticipation.

122Kerns,Thomas,JenneronTrial:AnEthicalExaminationofVaccineResearchintheAgeofSmallpoxandtheAgeofAIDS(Lanham:UniversityPressofAmerica,1997),59.

123Kerns,AnEthicalExamination,60.

41

Kernsdiscusseshowitisimportanttodiscussthecharacteroftheindividual

performingtheexperiment.Jennerdisplayedcompassiontowardshissubjects,

beingconcernedfortheirwellbeingasheattemptedtoridtheworldofsmallpox.

TheNazisontheotherhandtooksomeoftheirsubjectstothegaschamberstobe

killedaftertheirtrailwascompleted.KernsremarkshadJenner’sfailedhewould

notbeviewedasethical,butJennerpassedthetestsetbeforehimbyhumanity.124

Kernsstates:“Moreover,Ibelievethatthemannerinwhichweaspeopledealwith

largescaleepidemicdiseasesisindeedatestofourscience,ourpoliticsandour

economicstructures.Butevenmoresignificantlythanthese,themannerinwhich

wefacethesechallengeswillbeseenultimately,andmostimportantly,asatestof

ourhumanity.Itwillbeseenasatestofourworthinessasaspecies.Ifthisistrue,

thenDr.Jenneracquittedhimselfadmirablywellinthetest.”125Jennersucceededin

thefirstpartofthetestprovingcowpoxcouldprotectagainstsmallpoxvia

vaccinationfromsubjecttosubject.Hiseffortscouldnotstopthere,tocompletethe

testJennerhadtopushforvaccinationtobeobservedandpracticedifhewishedto

ridtheworldofsmallpox.

124Kerns,AnEthicalExamination.61.

125Kerns,AnEthicalExamination.77.

42

ChapterVI

Jenner’sVaccinationCampaign

EdwardJennerwasethicalthroughouthiscampaignhecontinuedtoputthe

publicfirstwithoutfallingtothewaveofcriticismbroughtuponhim.Hoffmannin

MedicusPoliticusremarked,“theartofMedicineistobepracticedoutofpure

benevolence.Foritisinmedicinethatwehavethegreatestopportunitytoimitate

themodel…thedailymiseryofmanwillremindhimtogivehelptotheneedy.”126

ThemiseryofsmallpoxandJenner’scontinuedeffortstowinsupportfor

vaccinationallowedJennerandthosewhoassistedinthecampaigntobeobserved

asbenevolent.

Jennerhadtodedicatehimselftohisvaccinationcampaign,astherewasa

strongmovementamongthoseagainstvaccination.WithinonemonthofAnInquiry

beingreleasedJennerreceivedhisfirstletterrefutinghisvaccination.Dr.

Ingenhousz,asupportofvariolationfromVienna,wrotealettertoJenner.Inthe

letterhetoldJenneritwaspublicknowledgethatpeoplewhohavehadanattackof

cowpoxcouldcontactsmallpox.127TheletterdidnotfazeJennerashehadalready

hadcountlessconversations,uponwhichtheexactsameargumentwasmade

againstvaccination.Hesaidtheanswerwasasimplematterofnotconfusingtrue



43

cowpoxwithspuriouscowpox.128JennerwasrightwhenhetoldhisfriendEdward

Gardner“thesubjectofridicule-forIamthemarktheyallshootat”hisvaccination

causedananti-vaccinationmovementtostartwithinthemedicalworld.129

WilliamWoodvilleplayedacriticalroleinthepromotionofvaccinationbut

inthestagesofinfancyhehadarockyrelationshipwithJenner.InJanuaryof1799,

WilliamWoodville,thedirectorofthesmallpoxhospitalinLondondiscovered

cowpoxwaspresentwithinsomecattleinLondon.130Cowpoxhadbeentransmitted

tohandsoffarmworkersaswell.Thisallowedphysicianswithinthecitytosee

cowpoxfirsthandonthecattleaswellthehumansubject.Significantfigureswithin

Londoncametoobserveincluding:SirJosephBanks,LordSommerville,andSir

WilliamWatson.131ThephysicianscomparedtheengravingdisplayedinAnInquiry

tothehandoftheworker,itwasthesamepustules,fromtheworkercowpoxmatter

wasextractedandthemenwentbacktothehospitalwhereWoodvilleperformed

vaccinationonsixpeople,bringingthetotalinoculationsperformedbyWoodvilleto

fourteen.132UnfortunatelyforJenner,thetrialstookplaceindeplorableconditions,

Woodville’shospitalwasasmallpoxhospital,exposingthesubjectstothat

environmentwasunfavorableespeciallysincethesubjectisnottobeexposedto


129Baron,LifeofEdwardJenner,128-129.




44

smallpoxuntilafterthevaccinationhassettled.133Sixtypercentofthoseinitially

vaccinatedbyWoodvilledisplayedidenticalsymptomstosmallpox,makingit

impossibletodistinguishbetweenvariolationandvaccination.134Theissues

continuedascowpoxmatterbeingsentaroundEuropehadbeenmixedwithvariola

virusunderthecareofWoodville.Jennerlearnedthatsomepatientsshowed

identicaleruptionstosmallpox,JennersuggesteditwasWoodville’sfaultashewas

constantlycoveredheadtofootinthesmallpoxvirus.135Woodvillereleaseda

publicationoncowpox.Heclaimedcowpoxcausedserioussymptomsinlessthan

onepercentofindividualswhoreceivedvaccination.However,hereportedone

persondiedfromcowpox.Jennerbecamefuriousasthenonlethalnatureofcowpox

wasoneofhismainarguments.136Heclaimedyouaremorelikelytodiefrom

cowpoxthansmallpoxanddeclaredJennerianvaccinationasanundesirable

practice.137

InanattempttodiscreditJennersomeargueagainsthimbeingtheindividual

whodiscoveredvaccination.BenjaminJesty,aDorsetshiredairyfarmer,performed

oneifnotthefirstroughformsofcowpoxvaccinationuponhisfamilyintheyear

1774.138Jesty,in1774learnedofsmallpoxbeinginthenearvicinity,hehadtwo






45

milkmaidswhoattendedtofamilymemberswithsmallpoxandneitheracquired

smallpox.139Bothofthedairymaidshadpreviouslybeenaffectedwithcowpox,Jesty

knewofaneighboringfarmerwhosecattlehadbeeninfectedwiththepox,hetook

hiswifeandtwochildrenagestwoandthreetotheneighboringfarmand

preformedtheprocedure.140Jestytookmatterfromoneoftheinfectedcattleand

usedoneofhiswife’sknittingneedlestoinoculatethem,bothboysreceivedthe

inoculationabovetheelbowontheirarmwhilehiswifehadhersperformedbelow

herelbow.141Hedidnotperformtheinoculationonhimselfashehadalreadybeen

infectedwithcowpoxpriorly.HistwosonshadlocalreactionswhilethearmofMrs.

Jestybecameveryinflamedandshefellveryill,thelocalsurgeonMr.Trowbridge

wascalledtoattendtoher,allthreesurvivedtheinoculation.142In1789Mr.

Trowbridgeduringanothersmallpoxepidemicperformedvariolationonmanyof

theneighboringchildren,includingbothofJesty’ssons,allofthechildrenacquired

smallpoxbesideshissons.143Hisboyslikethedairymaidswereexposedtoothers

withsmallpoxandnevercontractedthedisease.

JohnFewsterisanotherpersonbroughtforwardtodiscreditJenner’scowpox

research;theargumentbeingmadestatesFewsterwasthefirstpersontoperform

138Creighton,23.

139JamesHammarsten,“BackgroundandHistory,”TransAmClinClimatolAssoc.1979,46.

140JamesHammarsten,“BackgroundandHistory,”46.




46

vaccination.SinceJennerdidnotdiscovervaccinationthenhisresearchholdsno

merit.ThisargumentcanbeobservedbylookingatBaronwhoremarkson

numerousoccasionsthatJennerattemptedtodiscusscowpoxwithFewster,

FewstercontinualtoldJennercowpoxdidnotprovidecertainpreventionagainst

smallpox.NomentionofFewsterperformingvaccinationismade.Itisalso

discussedinanarticlepublishedbyThurstonandWilliams.Theyaddressaletter

writtenbyJohnPlayertoJohnCoakley,whicharguesFewstercompleted

vaccinationpriortoJenner.144ThisisfollowedwithaletterwrittenbyFewsterto

surgeonMr.Rolph,theoriginalcopynolongerexistanditisnowonlyanabstractin

GeorgePearson’sAnInquiryConcerningtheHistoryofCowpox.145Intheletter

Fewsterstatesheperformednearlytwothousandinoculationsbutfeltthe

symptomsassociatedwithvaccinationwereworsethanvariolationsohedecidedto

dropthemethod.146Thisargumentishighlycontroversialbecausetheonlycopyof

thisletterispresentedinaworkofGeorgePearson,PearsonwasenviousofJenner

andthefameheearnedfromhisvaccinationthusheattemptedtodiscredithim

numeroustimes.

GeorgeDockdiscussesJestyandtheclaimsmadeabouthimperformingthe

firstvaccination,hisremarksarealsorepresentativeofFewster.DockarguesJesty

andthosewhoargueonJesty’sbehalfwouldhaveremained“longinobscurity”had

144L.ThurstonandG.Williams,“AnExaminationofJohnFewster’sRoleintheDiscoveryofSmallpoxVaccination,”JournaloftheRoyalCollegeofPhysiciansofEdinburgh45,no.2(2015):174.

145ThurstonandWilliams,“JohnFewster,”176.

146ThurstonandWilliams,“JohnFewster,”176.

47

itnotbeenforJenner.147ThenhestatesJennerincontrasttoJestywasnot

overcomebyfearwhenperformingcowpox,hecontinuedthepracticeandbrought

forthvaccination.148SimilarsentimentscanbearguedagainstFewster;Jennerwas

theindividualwhombroughtforththegreatestinformationandsupportfor

vaccination,evenifhedidnotdiscoverhiscontributestothepracticecouldnotbe

surpassed.

AntiVaccinationleagueswereestablishedasindividualscontinuedtoprotest

thepracticeofJennerianvaccination.Itislikelymanywhojoinedtheseleaguesdid

sooutofjealousyorbecausetheyexperiencedfailurewhentheyattemptedto

performvaccination.Rarelydidtheypresentrationalarguments,MoseleyaLondon

physicianwholedananti-vaccinationgroupclaimedthatindividualswhohad

vaccinationwouldgo“bovinise”andturnintocattle.149

JohnBirchwrotealetterthatwasarationalargumentagainstvaccination.In

it,hediscussessuchmattersasconsentandbeingatestsubject.Hisfirstconcern

wasthefailedvaccinationexperimentattheSt.ThomasHospital.150Hethen

remarkshowhewastakenbackbytheideathatdependingonthestrainofcowpox

itcouldbegenuineorspuriousandthatthesuccessdependeduponwhenthe

147GeorgeDock,TheWorksofEdwardJennerandtheirValueintheModernStudyofSmallpox,NewYork:NewYorkMedicalJournal,1904,7.

148Dock,TheWorksofEdwardJenner,7.

149HerveBazin,TheEradicationofSmallpox:EdwardJennerandtheFirstandOnlyEradicationofaHumanInfectiousDisease(SanDiego:AcademicPress,2000),74.

150JohnBirch,“ALetterOccasionedbytheManyFailuresofCow-pox.”

48

matterwastaken.151Birchthenmakesmentionthatsomeindividualsperforming

vaccinationwereneverproperlytrainedtoadministervaccination.Hereferredto

cowpoxasanimalpoison,thatitwasnotusedunlesstestedonaninitialvictim.152

Birchmakesaverycriticalargumenttowardsconsentofachildorinfanthewrites

“Insultinghumanity,howcantheconstitutionofachildbeascertained,whenonly

onemonth,orsixmonthsold?Tovaccinateaninfantwhowasnotofaproper

constitutionmightbefatal.”153

ThosewhoquestionJennerandhisdiscoverymaybringintoquestionhis

beliefonhowcowpoxoriginated.Jennerbelievedcowpoxwasaproductofahorse

diseasehecalledgrease,whichoccurredfromtheinflammationandswellingofthe

horses’heels,hearguedgreasestronglyresembledhumansmallpox.154Jenner

thoughtmilkerswhoapplieddressingtotheheelsofthehorseshadgreasematter

stillontheirfingersandcarriedthediseasetothecowstheymilked.155This

argumentwasthefirstJennermadeinAnInquiry,Jennercitedsevencasesshowing

therelationshipaswellasimmunityfurnishedagainstsmallpoxafteraccidental

inoculationofgreasecowpox.156ManyinvestigatorsagreedwithJenner,strainsof

151Birch,“TheManyFailuresofCow-pox.”





156Dock,TheWorksofEdwardJenner,7.

49

“vaccine”virusoriginatedinthesoreheelsofhorses,butthefinalconclusionwas

thatgreasewasnotaspecificdisease,oratleastrelatedatalltocowpox.

Jennerliketheabovementionedinvestigatorswerelikelysomewhat

confusedasallpoxdiseases,includingcowpox,swinepoxandgrease,arecausedby

amemberoftheorthopoxvirusfamily.157(Excludingchicken-poxwhichiscaused

bytheherpesvirus)Allpoxdiseasescouldinfecthumans,werehardtodistinguish,

andhadsymptomssimilartothehumanstrandsmallpox.158InNovember1789,

Jennerinoculatedhiseldestsonofabouteighteenmonthswithswinepoxmatter.He

noticedtheprogressionofthediseaseseemedsimilartotruesmallpox.Then

performedvariolationuponhissonfiveorsixtimeswithouttheslightest

inflammationorsymptomofsmallpox.Jennerperformedvariolationagainin1791.

Thistimethesmallpoxcausedarasharoundthewoundandabrownishfluidsore

aboutthesizeofalargesplitpeaonhisarm.159Thechildneverbecameindisposed

duringthevariolation,displayingtheswinepoxstillprotectedtheboybutthe

protectivepropertieswereweakening.160Jenneradmittedhewasneverableto

showtherelationbetweencowpoxandgreasebutheldontothebeliefandnever

abandonedhistheorybutitsuncertaintyrelegatedtheclaimtoobscurity.161Having

157Fisher,57.

158Fisher,56.



161Dock,5.

50

acontroversialsubjectsuchasgreasehurtJenner’spublicationamongstsomewho

didnotwanttoobservehisfindingsaslegitimate.

TheeffortsmadebyJennerandthosewithinthepro-vaccinationcampaign

continuethedisplayofJenner’sethicalappeal.Hoffmannstates“ThePhysician…

oughttowatchovereveryone…Heshouldunderstandthatitisshamefulforthe

physiciantoleavethedoorclosedtothosewhoareknocking”Jenneradheredto

Hoffmann’swords,hisdoorwasneverclosedhevaccinatedasmanypeopleashe

could.Asmanyas400peoplewouldcomevisitJennerdailyathishousein

Cheltenham,Jennerofferedvaccinationfreeofcharge.162Jennerrecruitedothersto

followhiminhismovement,evenministerslearnedvaccinationtoprotectpeople

forsmallpox.MinisterofSurreyChapel,theReverendRolandHill,advocated

vaccinationsoonafteritsintroductionandvaccinatedthosewhocametohim.From

thepulpitonSundayevenings,afterthesermon,heusedtosay:“Iamreadyto

vaccinatetomorrowmorningasmanychildrenasyouchoose;andifyouwishthem

toescapethathorribledisease,thesmallpox,youwillbringthem.”163

Inthestudyofmedicalethics,thephysicianandmoneyisdiscussedindepth,

itisunethicaltooverchargeandmakefakediagnosisinthehopeofcontinued

service.Aphysicianisprohibitedfromprescribingmedicationthatisnotneeded

andmostimportantlychoosingwhomtotreatandwhomtoignore.Jennerdidnot

practiceanyoftheseunethicalmethods.Infacthedidnotrequestany

compensationforhisvaccination,theamountofmoneyhecouldhavemadeifhe



51

chargedforvaccinationisunimaginable.Jennerevenwentandabandonedhis

practicetofullycommenthimselftohisvaccination,beingethicalandnot

requestingmoneyforvaccinationsleftJennerwithlittlefinancially.Howeverhe

soongainedimmensewealth,theBritishParliamentawardedhim£10,000,164which

equatestoaboutthirtymilliondollarsintoday’sstandards.In1806KingGeorgeIII

askedtheRoyalCollegeofSurgeonstheimpactvaccinationhadonGreatBritain,of

the164,381reportedvaccinationsonly56casesofsmallpoxoccurred.165The

Committeecompletedtheirinvestigationin1807andwithoutreservationcameout

insupportofJennerianvaccination.166

TheethicalqualitiesdiscussedbythelikesofGregoryandHoffmannwere

readilypresentwithintheworldwidecampaignthatEdwardJennerledtowards

massvaccinationpracticeandeducation.EarlierGregorywasquotedhestated:

“Medicinepresentsanolessextensivefieldfortheexerciseofhumanity.Aphysicianhasnumberlessopportunitiesofgivingthatrelieftodistress,nottobepurchasedbythewealthofIndia.Thistobeabenevolentmind,mustbeoneofthegreatestpleasures.Butbesidesthegood,whichaphysicianhasitofteninhispowertodo,inconsequenceofskillinhisprofession,therearemanyoccasionsthatcallforhisassistanceasaman,asamanwhofeelsforthemisfortunesofhisfellow-creatures.Inthisrespecthehasmanyopportunitiesofdisplayingpatience,goodnature,generosity,compassion,andallthegentlervirtuesthatdohonortohumannature.”167

164Riedel,“EdwardJennerandtheHistoryofSmallpoxandVaccination.”



167JohnGregory,LecturesontheDutiesandQualificationsofaPhysician(London:W.Strahan,1772),8.

52

ThisquotewasrepeatedinitsentiretybecauseJenneradherestotheethical

qualitiesmentionedinrelationtohiseffortstospreadhiscampaignacrossthe

world.Jennerdirectlyinfluencedtheintroductionofvaccinationfromneighboring

FrancetoasfarandbeyondNorthAmerica.FrenchscientistLouisPasteurinthe

1888inauguralspeechofthePasteurInstitute,anon-profitdedicatedtothestudyof

biology,diseases,andvaccinesremarked,“Sciencehasnocountry.”168These

remarksmadeninetyyearsafterJennerbeganhiscampaignexemplifywhyEdward

Jennerwasrevolutionaryinthefieldofpublichealth.Jenner’sviewoftheworldwas

notthatofakingorgeneral,hedidnotseepeoplefromothernationsasalliesor

foes,herecognizedmanindependentofaffiliationwithintheefforttoridtheworld

ofsmallpox.Hestated:“Ihopethatsomedaythepracticeofproducingcowpoxin

humanbeingswillspreadovertheworld−whenthatdaycomes,therewillbeno

moresmallpox.”169

EdwardJennerneverleftEnglandduringhiscampaignbutwasstillableto

createaworldwidevaccinationcampaign.Jennersharedhisworkandsentcowpox

lymphwithinstructionstonumerousforeignscholarsandleaders.Vaccinationwas

notaclassbasedpractice,Jennersentlymphandinstructionstoeverypersonhe

could,whichinturncontinuedthepromotionofvaccination.Jennerdidnotview

vaccinationasatechniquetobeperformedsolelybyaphysician,ifanarealackeda

physicianthelocalpopulationcouldstillperformvaccinationtofendoffsmallpoxas


169MichealC.Burge,Vaccines:PreventingDisease(FarmingtonHills:LucentBooks,1992),33.

53

longastheyfollowedhisinstructions.170Jennerpracticednumerouswaystosend

cowpoxlymphtootherlocationsincludingplacingitonivorypoints,theuseofglass

slides,andplacingitonstring.171Oncethecowpoxmatterreacheditsdestinationit

hadtobereanimatedbytheadditionofwaterandthencouldbeinjectedintoa

host.172Afterafewweekscowpoxlymphwouldbepresentandcouldbetransferred

toothersthroughvaccination,thisinturncreatedmorecowpoxlymphallowinga

largegroupofpeopletobevaccinatedfromonesample.173Jennerwiselyoften

providedmatterfrommorethanonesourceasaprecautionincasethesampletrial

failed.

EnglandandFrancehadavolatilerelationshipleadingintothenineteenth

centuryduetotheFrenchRevolution.TheRevolutionresultedinwar,territorial

conquest,andthesubversiveideasof“liberty,equality,andfraternity.”174Allof

whichwereconcerningtotheBritish,whohadsuspendedalmostallconversation

andinteractionwiththeneighboringnation.175Thesuspensionhadanimpacton

FrancelearningofJennerianvaccination,AnInquirywasnottranslatedtoFrench

until1800.176Franceranitsowntrialsonvaccinationbutquestionsandconcerns







54

arose,scientificallytheFrenchheldBritishscientificdiscoveryinhighregard,thus

theyknewJenner’svaccinationwaslikelypromisingbutagainthelackofa

conversationbetweenthetwonationshinderedFrance.Francewashavingissues

gainingaccesstolymphthatcouldbeusedforvaccinationandthetrialexperiments

onlyproducedbadreactions.177

FortunatelyforFrance,thetwonationswereinthebeginningdiscussionsfor

theTreatyofAmiens,thetreatydiscussionopenconversationandvisitation

betweenthetwonationsandallowedFrancetobebettereducatedon

vaccination.178AyoungFrenchphysicianDr.AuberttravelledtoEnglandtolearn

howtoproperlyperformvaccinationwithalistofquestionsfromthejoint

committeeformedfromtheFacultyofMedicineandtheFrenchAcademyof

Sciences.179WhileinEnglandDr.AubertlearnedofJennerianvaccinations

successfulnature,butmoreimportantlyhewasabletoconvinceDr.William

WoodvilletotravelwithhimtoFrancetoteachtheFrenchthecorrectmethodof

vaccination.180WoodvilletravelledtoFrancewithAubertandNowel,Nowelwasan

EnglishphysicianwhopracticedinBoulognepriortotheRevolutionthensought

refugeinLondon.OntheirwaytoParisthethreestoppedinBoulognewereNowel

stayedandcontinuedhispractice,heperformedvaccinationonthreeyounggirls






55

thenWoodvilleandAubertwereontheirway.ItwasquitefortunatethatNowel

returnedwiththembecausebythetimeWoodvillereachedParisthecowpoxmatter

wasinactivelikelyduetotheheat.WoodvillewroteNowelwhowasabletogather

activecowpoxfromthegirlshevaccinatedthensendfreshlymphtoParis.181

Woodvillewasabletoshowthecommitteesuccessfulvaccinationandtheproper

dosagethatwasdeemednecessarybyhimtodoso.Thecommitteebeganto

performvaccinationonorphanchildren;ethicallytheybelievedtheywereassisting

childrenwhohadbeenabandonedbyriddingthemofthepossibilityofsmallpox.At

thesametimeitcouldbearguedtheywerebeingusedassubjectstofurther

researchonJennerianvaccination.Resultsfromthevaccinationsweresuccessful

andParisestablishedavaccinationcentre,inordertohelpchildrenofpoorlocal

familiestheywerevaccinatedforfree.182

Vaccinationestablishmentsofferingfreevaccinationsbegantoappear

throughoutFrancewithnewsoftheestablishmentsbeingspreadbyciviliansand

themilitary.In1804TheGeneralCounciloftheDepartmentofIndreandLoire

thankedJennerandthosewhohelpedestablishvaccinationinFrance.Theywrote

“Gloryandrecognitiontotheinventorandpropagatorsoftheprocesswithwhose

assistancewearesavingthehumanracefromthescourgethatwasdecimatingit.

TheGeneralCouncilgivesasolemnvoteofthankstothosebenefactorsof

humanity.”183InParisacommitteewascreatedin1804tofocussolelyon



56

vaccination,itwastitledtheCommitteeonVaccination.184FromApril4,1804until

theendof1811,thecommitteevaccinated2,300,937people.Thisfiguredidnot

includevaccinationsperformedbyprivatepracticesortheGeneralCouncil

beforehand.185TheFrenchMinisterofInteriorinhisaddressonvaccinationmade

strikingdeclarationsthatdisplayedtheimpactofJennerianvaccinationuponthe

peopleofFrance.HeremarkedwithintheFrenchEmpirepriortotheintroduction

ofvaccination,onemillionpeoplecontractedsmallpoxannually,ofwhich150,000

perished.186Intheyear1811only75,000casesofsmallpoxwerereportedwith

8,500casesresultingindeath,likelyintheperiodofonedecadetheamountoflives

lostannuallytosmallpoxwasloweredbyover140,000.187

WhileJennerwasnotinFrance,hewasstillrecognizedasthemonumental

figurethatsavedsomanyliveswithinthenation.TheTreatyofAmiensendedone

yearafteritsenactmentin1803,asaresulthostilitiesbeganonceagainbetweenthe

twonations.LordYarmouth,thesonofJenner’sfriendMarquessofHertford,wasin

Francewhenthetreatyended.Hewasbeingheldasanoncombatantprisoner

whomwasunabletoreturntoBritain.188JennerpersonallywrotetotheNational

InstituteofFrancerequestinghisrelease,hewrote“Thesciencesareneveratwar”







57

andthenspokeofMarquessofHertford,hewrote“Hestandshighinmyestimation

forbeingamongtheforemostwhoencouragedmyschemeofVaccinationwhenin

itsinfancy,andcontendingwiththeprejudicesoftheworld.”189Jennermakestwo

veryvalidargumentstotheFrench;inhiscampaignJennerdidnottellhisfollowers

toavoidassistingoreducatingtheFrenchbecausetheywerecitizensofacountry

Britainwascurrentlyatoddswith.Jennerviewedsmallpoxasaworldlydiseasethat

neededtobetreatedanderadiatedinaworldlyfashionbyprovidingvaccinationto

asmanynationsaspossible.Secondly,Jennerpointsouttheimpactsupportershad

onthesuccessofJennerianvaccination,withoutmenlikeMarquessJennerian

vaccinationwouldhavebeenlikelybeenpassedoverandthesteadydecreasein

casesofsmallpoxwouldnotbepresent.Jennersharedaletterofsimilarsentiment

toNapoleon,Napoleonreplied“thatnothingcouldberefusedtothatman”andLord

Yarmouthwasreleased.JennerwasasaviorofenemyFrance,andaherointheeyes

oftheenemyleader.TheCentralCommitteewassothankfultheysentadelegation

totheBritishParliamenttopraiseJennerandtelloftheprideparliamentmustfeel

astheircountrymenwassavingnationsfromsmallpox.190

EdwardJennerwasarevolutionaryphysicianintheeighteenthand

nineteenthcenturyasJennerianvaccinationprotectedmillionsofpeoplefrom

smallpox.Intheobservationofmedicalethics,thecentralizedthemesofhealingand

relationshipareapparent.Jennerexemplifiedthosequalities,stickingtohisbeliefs

anddidnotfalterfromthenumerousindividualswhoquestionedtheeffectiveness

189Baron,LifeofEdwardJenner,603.190Bazin,TheEradicationofSmallpox,90.

58

ofcowpox.Hisambitionledtoacampaignwherehesavedmillionsoflives

throughouttheworld,sendinglymphandguidestodistantlandsinanefforttorid

theentireworldofsmallpox.WhileJennerdidnotgettoseetheeradicationof

smallpox,hestandsasthesinglemostimportantindividualinthateffort.

59

ChapterVII

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