The end of medical confidentiality? Patients, physicians and the state in history.

Medical confidentiality has come under attack in the public sphere. In recent disasters both journalists and politicians have questioned medical confidentiality and claimed that in specific contexts physicians should be compelled to communicate data on their patients' health. The murders of innocent individuals by a suicidal pilot and a Swiss convicted criminal have generated polemical debates on the topic. In this article, historical data on medical confidentiality is used to show that medical practices of secrecy were regularly attacked in the past, and that the nature of medical confidentiality evolved through time depending on physicians' values and judgements. Our demonstration is based on three moments in history. First, at the end of the 16th century, lay authorities put pressure on physicians to disclose the names of patients suffering from syphilis. Second, in the 18th century, physicians faced constant demands for information about patients' health from relatives and friends. Third, employers and insurance companies in the 20th century requested medical data on sick employees. In these three different situations, history reveals that the concept of medical confidentiality was plastic, modelled in the first instance to defend well-to-do patients, in the second instance it was adapted to accommodate the physician's social role and, finally, to defend universal values and public health. Medical secrecy was, and is today, a medical and societal norm that is shaped collectively. Any change in its definition and enforcement was and should be the result of negotiations with all social actors concerned.

[Ethical aspirations and the reality of medical practice at the end of the Ancien Regime]. / Aspirations ethiques et réalité de la pratique médicale a la fin de l'Ancien Régime.

At the end of the 18th century, economic survival was difficult for physicians. The medical market was crowded and to build (and seduce) a clientele, they had to pay particular attention to their appearance. Being well dressed and travelling by horse or in a carriage was necessary to demonstrate that they had a good reputation and were a "good" doctor. However, this still did not guarantee financial security for the doctor and his family. In an era when medical fees were only just beginning to be discussed, it was difficult to know how to bill patients and how to get paid. At the same time, the first texts on medical ethics appeared, insisting on modesty, authenticity, delicacy, and sincerity. In this article, by exploring personal archives and printed moral prescriptions, I will suggest that there were tensions between the everyday difficulties of medical practice and the recommendations on medical ethics, tensions that had consequences for the patient-doctor relationship.

Enlightened physicians: setting out on an elite academic career in the second half of the eighteenth century.

In the second half of the eighteenth century, medical doctors faced heavy competition. They competed for patients and for institutional positions and sought a variety of means to enhance their reputations. Among rank-and-file physicians, some strove to respond to the high expectations and rational discourse fueled by Enlightenment philosophy. They aimed to build a new medicine on rational and empirical principals. Concentrating on the rich correspondence left by young physicians born in Geneva, this article maps out the social and moral dilemmas encountered by ambitious young physicians in the second half of the eighteenth century, who, like many thousands of others, flocked to Edinburgh, "the first medical school" in Europe. Conscious that they formed but one group among a series of possible practitioners, they pondered over cultural codes, civilities and economic realities as they strove to promote the figure of a knowledgeable, experienced, gentlemanlike physician.

Medical humanities: a new undergraduate teaching program at the University of Geneva School of Medicine, Switzerland.

In 2001, a new program of medical humanities was initiated at the University of Geneva School of Medicine in Switzerland. Four mandatory seminars and one optional 2-week internship are offered to second-through fifth-year medical students. The program has four interdependent goals: contextualizing, developing personal reflection and judgment, encouraging imagination, and offering specific ways to improve the quality of the therapeutic relationship. The program is based on an integrated vision of the humanities and stimulates the students' imagination and reflection in a way that medical students should find useful. Three steps help teachers to build an integrated vision: familiarization, confrontation, and adjustment to the medical culture. The mandatory seminars are taught by a team consisting of a physician and a humanities teacher. All the physicians, department heads, and clinicians involved in each seminar actively collaborated. The medical humanities program is in the Bioethics Unit, which is housed in the Department of Community Health and Medicine with medical history and legal medicine. This intellectual, institutional, and physical proximity encourages informal dialogue and ensures a more coherent and unified vision of the different disciplines. In their assessments of the program, students stated that the seminars gave them food for thought and met their expectations. However, it is premature to draw conclusions from these assessments because the program is still in its infancy. The program strives to provide students with tools specific to the humanities so that they can strengthen their own judgment, listening skills, open-mindedness, creativity, and curiosity, attributes that are needed to ensure that the therapeutic relationship will be satisfying for both physicians and patients.