Fourteenth-century England, medical ethics, and the plague.

In the 20th and 21st centuries, human immunodeficiency virus (HIV), severe acute respiratory syndrome (SARS), and the threat of bioterror attacks have raised questions about the role of the physician in response to epidemics. Modern medical ethics, with its precepts of beneficence, nonmaleficence, and respect for patient autonomy, focuses almost exclusively on the relationship between the doctor and patient. As a result, this ethical framework is less well-equipped to deal with the relationship of the physician to society as a whole. Personal autonomy is often at odds with public health ethics, which stress the needs of the population over the needs of the individual. The emphasis on the personal over the public applies to physicians as well as to their patients. Indeed, in the face of modern epidemics, the concept of a " duty-to-treat " — although explicitly and forcefully stated in the professional codes of the 19th and early 20th centuries—has been in conflict with a physician's autonomy in determining whom he or she will treat [1]. While the ethical challenges of today may be new, the threat of epidemic is not. It was present when, in 1354, Henry, first Duke of Lancaster and grandfather of Henry IV, began writing a devotional treatise. Composed of daily entries, Le Livre de Seyntz Medicines (The Book of Holy Medicine) is unique among medieval devotional literature in that it contains the most extensive known use of medical metaphors and imagery to describe religious experience. The book is a catalogue of Henry's sins, expressed as various wounds and diseases, followed by a similar account of spiritual remedies in the form of common medieval medical treatments [2]. What ultimately moved Henry to write this work remains a mystery, but coming so soon after the first arrival of the Black Death in England in 1347, it is not hard to imagine that the swift and devastating mortality of the disease made an impact. Life in a Time of Sudden Death The first wave of the Black Death occurred between 1347 and 1351, arriving most likely from China, and killing approximately one quarter to one third of the European population within 2 years [3]. In some locations, historians estimate that as much as 60 percent of the population died. After this first onslaught, the plague remained endemic for the next 300 years, returning every so often to cull the population. While epidemics such as the Black …