THE STRANGE CASE OF EVA PERON
Here is a tale for students of medical ethics as applied to the rich and famous.
Eva Perón, wife of Juan Perón when he was president of Argentina in the 1950s, arose from humble circumstances. She was born in 1919 to the mistress of a land manager in a small village in the Argentine “pampa” (flat, extensive plains). Her father departed to rejoin his wife about a year later, leaving the family of mother and five children in poverty. Eva left home at age 15 and headed for Buenos Aires where she worked as an actress and singer. Gradually attaining some reputation, she formed her own company. In 1944, she met Col. Juan Perón, Secretary of Labor at the time. They married in a small, semi-secret ceremony in 1945 when Peron became president. Eva, often called Evita, champion of the “descaminados” (the shirtless ones) and popular with the poor, organized the Eva Perón Foundation, a huge institution dispensing charity, and she was important in helping women obtain the right to vote.
Eva and Juan Perón (Wikipedia)
In 1950, the fourth year of the Perón presidency, Eva had a fainting spell, after which she had an appendectomy. One of her physicians later wrote that he had diagnosed uterine cancer and had advised a hysterectomy, but this story was not confirmed. Apparently recovered, she threw herself into her work, doling out charitable gifts in all directions. In time, she grew thinner, pale, and tired. Unknown to the public, she suffered vaginal bleeding and abdominal pain. Her doctors now made a diagnosis of cervical cancer and gave her radium implants preparatory to resectional surgery, but never told her she had cancer. Her brother and other relatives asked that Eva not be informed. Dr. Ricardo Finochietto, director of the Presidente Perón Hospital (built by Eva’s Foundation), was to do the abdominal surgery.
Juan Perón, however, asked a local oncologist, Abel Canónico, about an outside expert, and was advised of George Pack, a renowned cancer surgeon at New York’s Memorial Hospital Sloan-Kettering Center. Pack was contacted secretly by the Argentine embassy in Washington and agreed to operate on Eva. Because of possible political ramifications, he worked in cooperation with the State Department and the ambassador to Argentina, Ellsworth Bunker, who also approved the contemplated surgery. Pack flew with Dr. Canónico to Buenos Aires, examined Eva under anesthesia without her knowledge, confirmed the diagnosis, and flew back to New York, all in complete secrecy. He returned to Argentina and performed a radical hysterectomy and lymph node dissection on November 6, 1951, again seeing Eva only under anesthesia. He left the operating room before Eva awakened and stayed in a hotel room until she had stabilized. Eva, and the public, never saw him or knew of his involvement in either encounter, believing that Finochietto had done the surgery. Dr. Pack suspected the tumor would recur, which it did. He declined to do further surgery and never sent a bill.
The surgery and the concomitant maneuverings took place against the background of a violent campaign for a presidential election. Juan Perón felt that the survival of Eva was important to his reelection and her popularity was cetainly evident when a crowd of 20,000 gathered outside the hospital on the day of her surgery. Five days later, Eva cast her presidential vote from a hospital bed, helping her husband win the election. Then, fortified by large doses of pain medicine and a plaster frame, she stood next to him in an open automobile during the victory parade. She finally passed away on July 26, 1952, weighing less than 80 pounds.
A number of features of this case would not pass muster today. Regarding the diagnosis, Pap smears were uncommon in Argentina at the time and relatively new in the U.S. Though available in the late 1940s, the first time an Argentinian cancer organization advised Pap smears was in 1950. It received little public response and remained under-utilized. The dangers of vaginal bleeding were also not publicized. Furthermore, doctors were still wary of telling patients they had cancer, both in the U.S. and even more so in Argentina. In a survey of the staff of the Michael Reese Hospital in Chicago, published in 1961, fewer that 5% never told a patient of cancer but many couched the diagnosis in ambiguous terms, often leaving the patients confused. Even if Eva knew the diagnosis, she might have resisted further diagnostic measures, given her tendency to brush off illness. According to the priest who gave her last rites, she was never told the diagnosis.
More bizarre, the surgery was carried out secretly by a surgeon not known to the patient and without the patient’s knowledge or permission. In addition, the State Department and the U.S. ambassador to Argentina encouraged the plan, almost certainly to accommodate political considerations. The Assistant Secretary of State, Edward Miller, Jr., praised Pack for his skills “in such an important and critical situation.” Pack himself felt that he could render a service by performing an operation not well known in Argentina and he was flattered to be asked. He wanted to tell the story publicly one day but respected the privacy of the matter and died before the facts came out.
Medical care of the rich and famous, especially of political figures, can lead to compromises and unusual medical practices that would not meet today’s ethical standards. In addition to Eva’s surgery, the secret operation on President Cleveland and the care of the Shah of Iran raise similar questions.
SOURCES:
Lerner, Barron H, “The Illness and Death of Eva Perón: Cancer, Politics, and Secrecy,” Lancet 2000; 355: 1988-91. (Dr. Lerner is a bioethicist and Professor of Medicine at New York University)
Fraser, N and Navarro, M, Eva Perón. W.W. Norton, 1980.
Oken, Donald, “What to Tell Cancer Patients: A Study of Mental Attitudes.” JAMA 1961; 175(13): 1120-28.
Grant, Ronald M, “Never Say Die: A Personal tribute to George T. Pack, MD (1898-1969).” CA: A Cancer Journal for Clinicians, 2008; 19(3): 198-200.
De Gonzales, V, et al, “Argentina: Telling the Truth to Cancer Patients.” Bull NY Acad Science 1997; 809: 152-62.
Altman, Lawrence, “From the Life of Evita, a New Chapter on Medical Secrecy.” NY Times, June 6, 2000.
