AMA Journal of Ethics^®

“Race” has been a four-letter word in the United States for almost four centuries. It earned that status in 1619 when Dutch traders sold the first African slaves in Jamestown, Virginia, and continued to have that status after the passage of the Thirteenth Amendment in 1865, which officially ended slavery throughout the United States. By the mid-nineteenth century, the “peculiar institution” as slavery was called—the term “peculiar,” according to the Merriam-Webster Dictionary, derives from the Latin “pecus,” for cattle [1]—was largely based in the South and border states. When the Civil War ended with a Northern victory, the formerly enslaved people who had been treated like cattle—“freedmen,” as they were called at the time—came knocking on the door of American civil institutions requesting admission as equals, as fellow citizens. This essay narrates what transpired when an integrated group of Americans of African and European descent from Howard University, a newly founded institution for freedmen, and the associated Freedman’s Hospital (founded during the Civil War), knocked on the door of the American Medical Association (AMA)—and were repeatedly rejected. It then sketches the history of the AMA and African Americans from 1868, when the issue of race was first raised, until 2008—when the AMA publicly apologized for its century-and-a-half-long record of mistreating African American physicians.

The issue of admitting Negro physicians to the AMA first arose in 1868, in the aftermath of the Civil War, at the very moment when America was debating the Fourteenth Amendment, which forbids denying “to any person…the equal protection of the law” or depriving anyone of “life, liberty or property without due process of law” [2]. As it happened, the controversy at the AMA’s May 1868 national meeting was not initially about admitting Negro physicians but rather about admitting female physicians. In the spirit of the Fourteenth Amendment, the AMA’s Committee on Ethics ruled that since female physicians were qualified practitioners “according to the rules of reason unbiased by prejudice…[the AMA] has no right to refuse them [admission] simply on the ground of sex” [3]. Nathan Smith Davis, self-styled “father” of the AMA, objected to the committee’s recommendation. Injecting race into a discussion initially about gender, Davis argued that admission standards with respect to “sex or color” should be left to local societies and those denied membership “should not claim the legislative power of this Association to pass ex post facto laws for their especial benefit” [4]. Having stipulated that local medical societies should have a right to enact segregationist or sexist admission standards without interference from the national society, Davis moved that the matter be indefinitely postponed [5]. His motion carried, quashing the ethics committee’s proposal that had upheld the right of qualified female physicians to be admitted to American medical societies and the AMA.

Nathan Smith Davis truly believed that he was the “father” of the AMA and had convinced the organization of that, even though, as the historical record attests, he did not actually propose or preside over the founding of the national medical society that became the AMA [6-9]. Nonetheless, Davis saw himself as a unifying force, responsible in the post-Civil-War era for reuniting the Northern half of the AMA with its alienated Southern brethren. From his perspective, controversies over who qualified for admission were an unnecessarily divisive matter, best decided at the local rather than the national level. In a series of debates over the admission of female and Negro physicians Davis urged “his” AMA to adopt a policy of deferring such issues to the local level. This would become the AMA’s policy until race- and gender-based discrimination was outlawed by the civil rights legislation of the 1960s.

Davis’s strategy of promoting national unity by leaving admission standards to local societies was directly challenged in 1870 at the AMA’s national meeting [8, 9]. The National Medical Society of Washington, DC, (NMS) and an integrated delegation of physicians from Howard University and the Freedman’s Hospital sought admission to the meeting. Leading the delegation was Robert Reyburn, a white former Union army officer, military surgeon, and the first dean of the Howard Medical College. His three Negro colleagues were Alexander Thomas Augusta, who was a Union army military surgeon, Charles Burleigh Purvis, and Alpheus W. Tucker. All four of these physicians were experienced and licensed to practice medicine who had received their medical training from allopathic medical schools, not from homeopathic or other alternative schools. Their integrated medical society, the NMS, had been founded in 1868-1869 because the established all-white Medical Society of the District of Columbia (MSDC) refused to admit Negro physicians. The NMS physicians had protested to Congress the MSDC’s practice of racial discrimination, and a congressional investigating committee confirmed that the all-white MSDC had indeed refused to admit Negro physicians “solely on account of color” [9]. This finding prompted an unsuccessful attempt by Republican Senator Charles Sumner to seek revocation of the MSDC’s charter.

Having rejected Negro physicians as members of their own society, the MSDC sought to block their admission to the AMA’s national meeting by charging them with “contempt of the organized Medical Society” by “attempt[ing], through legislative influence, to break down” the MSDC, because bringing charges of racial discrimination to the attention of the US Congress threatened the MSDC’s charter [10]. The NMS filed countercharges, accusing the MSDC of racial discrimination. The entire matter was then referred to the AMA’s Committee on Ethics, led by AMA President-elect Alfred Stillé of Philadelphia. Other members were Nathan Smith Davis, a delegate from the US Army (i.e., the Union army), and delegates from Delaware and Kentucky—both slave-holding border states during the Civil War. Kentucky had recently enacted a segregationist “Black Code” legalizing racial discrimination [11].

The outcome of the dispute was predetermined by the members’ backgrounds: with the singular exception of Davis, the Northerners voted to admit both the integrated NMS delegation and the all-white MSDC delegation. The border state physicians, joined by Davis, voted to admit only the all-white MSDC society members. On its face, the issue was black and white: the whites-only society was in; the black-and-white society was out.

So Davis and his border state colleagues wrote a report justifying their acceptance of the segregationist all-white medical society and their rejection of the integrationist society. The Northerners answered by writing a minority report. The majority report stated that the Congressional determination that the MSDC had discriminated against admitting qualified physicians solely on account of color or race was “not of a nature to require the action of the American Medical Association,” because the alleged conduct “does not come into conflict with any part of the [AMA’s] code of ethics” [12]. The minority report held that since both the Negro and white “representatives of the National Medical Society, [and] the Howard Medical College…are qualified practitioners of medicine who have complied with all the conditions of membership…no sufficient ground exists for the exclusion of such institutions and physicians” on the basis of the AMA’s Code of Medical Ethics [13].

A vote was called to decide the question of which report to accept. By an overwhelming majority of 114 to 82, AMA members voted to deny admission to the integrated NMS delegation and to admit the delegates from the segregated MSDC [14]. A second vote was then called on a motion “that no distinction of race or color shall exclude from the Association persons claiming admission and duly accredited thereto” [15]. This motion was defeated 106 to 60 [14]. The AMA had put itself on record as rejecting racial integration. And then, by a feat of parliamentary legerdemain, the AMA voted to expunge the vote from the official record on the grounds

that inasmuch as it has been distinctly stated and proved that the consideration of race and color has had nothing whatsoever to do with the decision of the question of the reception of the Washington delegates…the report of the majority of the Committee on Ethics be declared, as to all intents and purposes, unanimously adopted by the Association [15].

This motion passed 112 to 34.

This whitewash could not cover up the evident racial issues. An 1870 New York Times headline on the AMA’s vote read, “The Doctors: The Question of Color” [16]; the Boston Medical and Surgical Journal (now known as the New England Journal of Medicine) that same year characterized it as “a muss over the question of giving the Negro doctor his rights” [17]. In his 1871 address Alfred Stillé, the AMA’s next president, deplored the fact that “the colored physician, and even his white representative, [was] refused admission upon the ground that the proposal is an outrage to the Association and a personal insult to many of its members” [18], i.e., because Southern whites found the admission of Negroes an insult to their organization. In 1871 a white commentator observed in the National Medical Journal that the real question facing the authors of the majority report was “how were these colored men who claimed admission to be excluded, and yet make it to appear that they were not excluded on ground of color? Nothing less would please or satisfy the southern brethren and their sympathizers, and yet the thing was somehow monstrous, and would need a plausible excuse before others” [19]. This white commentator continues.

In all the [Civil] war I did not see a more acute attack of judicial hardening. I can conceive of how men may dispute the political status of the Negro…[yet] when a man of certified competence and character knocks at the door of a great national association, claiming to represent legitimate practice, and because of his color a body like ours goes manipulating about for some excuse to keep the man out, it is too trivial and sad to record. Why, that question was decided long ago. The equalities of science are older than that of politics…I doubt whether in the last fifty years, a national scientific society has convened anywhere that would have excluded a competent scientist on the ground of color, and least of all should a medical man take such a stand…We degrade not him but ourselves by such breaches of the law of ethics which indwells in science [20].

Any lingering doubts about whether race was an issue in the 1870s vote were removed in 1872, when Robert Reyburn again presented his credentials to the AMA as a delegate representing the integrated institutions of Howard University and the Freedman’s Hospital. A committee on ethics again refused to recognize his credentials, contending that Howard had been deemed in violation of the AMA’s code of ethics in 1870 and that, furthermore, Howard violated the AMA Code of Medical Ethics by allowing women to serve on its faculty [21].

Reyburn replied in a short speech.

Howard University…received all who applied for medical education, without distinction of color or of sex…. If the [American Medical] Association sees fit that institutions of that class shall not be represented, of course they have the power so to act, but, at the same time, they should consider well what they were doing before taking such a step [since] every human being should be allowed the right to the very highest development that God has made him capable of [22].

After the debate the AMA voted yet again to refuse to recognize the integrated DC medical institutions.

In 1873 and 1874, Davis fully implemented a stringent version of his “local” strategy, according local societies the prerogative of determining criteria governing membership in their organizations. State societies in the North would be free to integrate, Southern societies would similarly be free to segregate, and the national union of medical societies known as the AMA could pursue its business untroubled by issues of race or gender. This meant that segregationist state societies could freely discriminate against Negro physicians without violating the rules of the national society.

As a direct consequence of the AMA’s decision to preserve institutional tranquility by trading away the civil rights of Negro physicians, Negro physicians were denied membership in state, county, and municipal medical societies throughout the American South and in many of the border states. Exclusion from these medical societies meant more than just professional isolation; it also restricted access to training and limited professional and business contacts. Worse yet, since membership in a state medical society was required by most Southern hospitals, it resulted in the denial of admitting privileges, which, in turn, erected barriers to board certification and advancement in the profession [23]. To secure reunion with the well-established (white male) medical societies of the South, the AMA dashed Negro dreams of equality and the integrationist ideals of returning Union Army soldiers like Reyburn, shamefully wrapping discrimination in sophistry as it did so.

The AMA’s policy of tolerating racial exclusion was pivotal in creating a two-tier system of medicine in the American South and border states—racially divided, separate, and unequal. Within a decade African American medical societies were founded as an alternative [24, 25]. In 1895 these societies banded together to form an African American alternative to the AMA, the National Medical Association (NMA). In the words of one of its founders, the NMA,

conceived in no spirit of racial exclusiveness, fostering no ethnic antagonism, but born of the exigencies of the [segregated] American environment…has for its object the banding together for mutual cooperation and helpfulness, the men and women of African descent who are legally and honorably engaged in the practice of the cognate professions of medicine, surgery, pharmacy and dentistry [26].

The AMA’s whitewash of its actions became more effective with the passage of time. Abetted by the characteristic American indifference to history, by the twentieth century the AMA had blinded itself to its own complicity in racial discrimination. Thus in 1933 the AMA unblushingly protested “persecution in Germany” [27], voicing its opposition to Nazi discrimination against Jewish physicians and “condemn[ing] the persecution of any individual on account of his race or religion by any state or under any flag” [28]. Nonetheless the AMA tolerated institutional racism in its affiliated societies. On more than a dozen separate occasions, starting in 1939 and repeated in 1944, 1948, 1949, 1950, 1951,1952, 1963, 1964, 1965, 1966, and 1968, the AMA reiterated its condemnation of racial discrimination and yet, in very same year, invoked Davis’s “local autonomy” principle to vote against motions prohibiting racial discrimination by member medical societies [25].

Institutional racism insidiously cloaks racial discrimination in the innocence of the accidental. Thus the network of institutional rules created by Davis obscured the impact of the AMA’s policy of inaction so effectively that the association could at once condemn racism and yet fail to prohibit, or even acknowledge, the racial discrimination practiced by its own affiliates. One Negro physician likened this to

a man who is standing on the shoreline watching a fellow-man floundering in the sea and proclaiming to the world…that he does not believe in drowning. This alone does nothing for the man in the sea....Their conscience maybe eased so that they can sleep at night...but, it takes…positive action to rescue those caught in the sea of discrimination [29].

Rescue from the “sea of discrimination” for African American physicians came, not from the AMA, but from the African American community itself: from the NAACP (National Association of Colored People, founded 1909), the SCLC (Southern Christian Leadership Movement, founded 1957), and affiliated groups that organized the 1963 March on Washington, paving the way for the civil rights legislation of the 1960s that ultimately forced the AMA to cease tolerating racial discrimination.

It was not until a half-century later, however, that another physician named “Davis,” AMA President Ronald Davis, commissioned an independent panel, the Writing Group for the History of African Americans and Organized Medicine [30], to analyze the AMA’s history on issues of race. This group was convened in 2005 and delivered its report to AMA board in 2008. On July 30, 2008, Ronald Davis, by then the immediate past president of the AMA, met with the NMA members in Atlanta to offer an apology. “I humbly come to the physicians of today’s National Medical Association, to tell you that we are sorry…on behalf of the American Medical Association, I unequivocally apologize for our past behavior. We pledge to do everything in our power to right the wrongs that were done by our organization to African-American physicians and their families and their patients” [31]. A formal written apology had appeared earlier in the Journal of the American Medical Association [32].

Davis summarizes the Writing Group’s findings [33] as follows:

In an article published in this issue of JAMA, Baker and colleagues—review and analyze “the historical roots of the black-white divide in US medicine.” This panel of experts, convened and supported by the AMA, found that (1) in the early years following the Civil War, the AMA declined to embrace a policy of nondiscrimination and excluded an integrated local medical society through selective enforcement of membership standards; (2) from the 1870s through the late 1960s, the AMA failed to take action against AMA-affiliated state and local medical associations that openly practiced racial exclusion in their memberships—practices that functionally excluded most African American physicians from membership in the AMA; (3) in the early decades of the 20th century, the AMA listed African American physicians as “colored” in its national physician directory and was slow to remove the designation in response to protests from the National Medical Association (NMA); and (4) the AMA was silent in debates over the Civil Rights Act of 1964 and put off repeated NMA requests to support efforts to amend the Hill-Burton Act’s “separate but equal” provision, which allowed construction of segregated hospital facilities with federal funds.

These dishonorable acts of omission and commission reflected the social mores and racial segregation that existed during those times throughout much of the United States. But that context does not excuse them. The medical profession, which is based on a boundless respect for human life, had an obligation to lead society away from disrespect of so many lives. The AMA failed to do so and has apologized for that failure [34].

Apologies in themselves cannot right past wrongs, but they do indicate that those responsible acknowledge that a wrong was committed, that they feel ashamed of their role in committing it, that they resolve not to commit such wrongs in the future, and that they will attempt to rectify the wrong as best they can. Apologies offer an opportunity for progress—but only if one understands why an apology was needed. I end these reflections with a quotation from a fellow philosopher—George Santayana—who famously observed that “progress, far from consisting in change, depends on retentiveness…. Those who cannot remember the past are condemned to repeat it” [35].