Medical Ethics and Spirochetes

[Guest guest]

1) Editorial from the ls of Internal Medicine on Nuremberg

In an editorial from 1997, the editors of the ls of Internal

Medicine acknowledge the conventional view that of Nazi medical

atrocities:

" Certainly we do not need to study such gross moral pathology that

could never happen again. "

The editors reject this view unequivocally:

" That is a dangerous conclusion. Moral lessons are quickly

forgotten. Medical ethics is more fragile than we think. Moral

reasoning based on defective premises tends to recur in new

settings. "

In explaining their position, the author of the editorial cites:

" ...the instances of unethical research behavior that have occurred

since the revelations of the Nuremberg Trials and wide acceptance of

the 10 principles they promulgated. Only a few such instances need

to be listed here: the Tuskegee Syphilis Study, the Willowbrook

Hepatitis Study, U.S. radiation experiments, the Jewish Chronic

Disease Hospital Study and the lysergic acid study supported by the

Central Intelligence Agency, and others that have not been brought

to light (7-10). "

2) The Tuskegee Syphilis Study

The Tuskegee Syphilis Study, in case members of this list are not

familiar with it, involved enlisting prison inmates infected with

syphilis in a study without informing them of their disease or the

fact that treatment would be withheld.

The study actually began before Penicillin treatment was known to

cure syphilis, all the way back in 1932. It continued,

uninterrupted, for 40 years - and when Penicillin's efficacy against

syphilis was widely established, (approximately 1943), the US Public

Health Service doctors involved in the Tuskegee study did not offer

treatment to a single infected patient.

Instead, for four decades the bodies and nervous systems of black

prison inmates were destroyed for the edification of medical science.

3) Acceptable Atrocities - How the " Medical Community " sanctioned

Nazi-style medical experiments in the US for over four decades

What is even more relevant is the attitude of the larger medical

community toward this experiment, which is nicely summarized in this

article:

http://onlineethics.org/edu/precol/classroom/cs3.html

" The nature of the Study was certainly not withheld from the

nation's medical community. Many venereal disease experts were

specifically contacted for advice and opinions. Most of them

expressed support for the project.

" In 1965, 33 years after the Study's initiation, Dr. Irwin Schatz

became the first medical professional to formally object to the

Study on moral grounds. The PHS simply ignored his complaint. The

following year, Buxtin, a venereal disease investigator for

the PHS began a prolonged questioning of the morality of the Study.

A panel of prominent physicians was convened by the PHS in 1969 to

review the Tuskegee study. The panel included neither African-

Americans nor medical ethicists. Ignoring the fact that it clearly

violated the human experimentation guidelines adopted by the PHS in

1966, the panel's recommendation that the Study continue without

significant modification was accepted.

" By 1972, Buxtin had resigned from the PHS and entered law school.

Still bothered by the failure of the agency to take his objections

seriously, he contacted the Associated Press, which assigned

reporter Heller to the story. On July 25, 1972 the results of

her journalist investigation of the Tuskegee Study of Untreated

Syphilis in the Negro Male were published. The response to Heller's

revelations was broad-based public outrage, which finally brought

the Study to an immediate end. "

4) The " Tuskegee Standard of Care " and Lyme Borreliosis

The US Public Health Service wanted to see what untreated,

dissemininated syphilis would do to human beings, found

a 'disposable' population of black prison inmates in Alabama, and

made minute observations from behind a wall of clinical detachment

as these patients were left untreated and endured the torments of

the damned. They did this for 40 years, from 1932 to 1972, with the

approval of the medical community.

So there is this clear precedent in Western Medicine for allowing

spirochetal infection to go untreated, fully aware of the horrendous

suffering that patients are then condemned to undergo.

We can call it " The Tuskegee Standard of Care. " It is morally

indistinguishable from the standard practiced by most infectious

disease doctors in the United States, Canada and the UK.

At one time, to practice this standard of care was possible only in

the shadows of a penal institution, and even there only really

sanctioned because the victims were African Americans.

Today, the Tuskegee Standard of Care is practiced in the open. It's

victims are no longer black prison inmates, but number in the

millions across the US, Europe and Asia.

5) Denial is Everywhere, But Perhaps History Can Help

In an age of Managed Care, The Tuskegee Standard of Care has been

given a new lease on life. Healthcare conglomerates and public

health bureaucracies delay or deny treatment all the time. Trying to

point out that there is a specific context, a specific category of

spirochetal disease, where the Tuskegee Standard is consistently

applied is a thankless task.

The outrage that ended Tuskagee I will not be generated by testimony

from victims like myself. We will instead be accused of fetishizing

our diagnosis, succumbing to paranoia, being " stoopid " or simply

wanting, out of infantile selfishness, to hog the " Lymelight " for

ourselves.

That we are trying to do the very opposite, to call attention to an

atrocity whose victims count in the millions, either does not occur

to anyone or is mistaken for hyperbole.

I was 11 years old in 1972, the last year of Tuskegee I. It was in

many respects a better, wiser and more hopeful era. People then used

to say " you are part of the problem, or part of the solution. "

Perhaps history, if we are willing to face it, can help us find our

way back now to the right side of that equation.

See below for full text of Nazi medicine editorial in ls of

Internal Medicine:

ls of Internal Medicine

EDITORIALS

The Nazi Doctors and Nuremberg: Some Moral Lessons Revisited

ls of Internal Medicine 15 August 1997. 127:307-308.

Exactly 50 years ago, the world learned of the moral depravity of

the 20 Nazi physicians who were tried and convicted in Nuremberg for

the part they played in the brutal human experiments at Auschwitz (1-

4). Ethicists have since expounded on the moral lessons to be

learned from the Nuremberg Trials. So obvious these moral lessons

seem now, and so gross the malfeasance, that it seems redundant to

revisit them. Certainly we do not need to study such gross moral

pathology that could never happen again.

That is a dangerous conclusion. Moral lessons are quickly forgotten.

Medical ethics is more fragile than we think. Moral reasoning based

on defective premises tends to recur in new settings. Not all of the

Nazi physicians were mentally deranged—they believed they were doing

the right thing. If we are to avoid even attenuated errors of the

same kind, we are obliged to examine a few of their errors even now.

In light of the enormity of the crimes of the Nazi doctors, it seems

easy to acquiesce to the 10 basic principles promulgated by the

Tribunal to keep human experimentation within moral, legal, and

ethical boundaries (5). But acquiescence does not equate with

comprehension. The first principle of the Nuremberg Code is

this: " The voluntary consent of the human subject is absolutely

essential. "

However, this principle was compromised almost immediately after the

Nuremberg trials. The Helsinki Declaration, which superseded the

Nuremberg Trials, weakened the provision by placing too much

emphasis on the advancement of science and not enough on the

integrity of the subject. Katz faults the U.S. Department of Health

and Human Services Rules and Regulations for lack of a similar

failure fully to protect human research subjects (6).

Even more distressing are the instances of unethical research

behavior that have occurred since the revelations of the Nuremberg

Trials and wide acceptance of the 10 principles they promulgated.

Only a few such instances need to be listed here: the Tuskegee

Syphilis Study, the Willowbrook Hepatitis Study, U.S. radiation

experiments, the Jewish Chronic Disease Hospital Study and the

lysergic acid study supported by the Central Intelligence Agency,

and others that have not been brought to light (7-10).

Clearly, the major lesson of the Nuremberg Trials has not been

learned. Ethicists have the painful responsibility of reaffirming

that lesson even in the United States. Failure to respect the

absoluteness of the requirement for truly informed consent is a

major factor behind current moves to strengthen regulatory

mechanisms regarding research involving humans.

The integrity of medical ethics is important not because it protects

the physicians' prerogatives but because it is a bulwark against the

use of medical knowledge for purposes other than for the good of the

sick. The German physicians indicted at Nuremberg had been taught by

some of the world's best historians of medicine and ethics (11).

They could not plead ignorance of ethics and, in fact, made constant

allusions to medical ethics and the Hippocratic tradition in their

testimony (12). They even convinced themselves that their heinous

acts were consistent with those principles.

What the Nazi doctors illustrate is that ethical teaching has to be

sustained by the ethical values of the larger community. In Germany,

this support system was weakened well before the Holocaust and the

experiments at Auschwitz. German academics, especially

psychiatrists, were leaders in theories of racial superiority,

social Darwinism, and the genetic transmissibility of mental illness

before Hitler came to power (13). They even urged the Hitler regime

to adopt these nefarious ideals.

Clearly, protection of the integrity of medical ethics is important

for all of society. If medicine becomes, as Nazi medicine did, the

handmaiden of economics, politics, or any force other than one that

promotes the good of the patient, it loses its soul and becomes an

instrument that justifies oppression and the violation of human

rights.

Subversion becomes a greater danger whenever medicine comes too

close to the power of the state (14). The German medical profession

eagerly supported Hitler's Third Reich and made itself the Reich's

willing agent. Hitler, like his counterparts in Stalinist Russia and

Imperial Japan, recruited medicine at the very beginning of his

regime. Physicians should have refused. Even Hitler would probably

not have prevailed against a united profession exerting its

collective moral power. But the caduceus joined the swastika in a

lethal symbiosis that cost millions of lives and forever branded

German medicine as a traitor to every tradition that ever made

medicine a beneficent rather than a maleficent enterprise.

This lesson becomes even more important as medicine becomes

increasingly bureaucratized, institutionalized, and dependent on

government and politics for its support. Medical power is too great

to be left unregulated, but it is also too great to be enslaved by

government, however benign the government's intentions might be.

The Nazi doctors were rational beings. To be sure, they acted within

psychological and sociohistorical contexts (15-17). Ultimately, they

justified their actions by what they considered to be moral reasons

that have received insufficient attention (18). During the

testimony, the defendants and their lawyers repeatedly advanced a

few moral premises with a familiar ring: They were not killing by

their own authority but obeying the laws of the state, which can

determine the method of death (12). To resist would have been

treasonous; ethics must be subordinate to the demands of war.

Consent from those condemned to death was unnecessary. The death of

a few prisoners would save many German lives; medical ethics could

be set aside by law.

We see here the initial premise s that law takes precedence over

ethics, that the good of the many is more important than the good of

the few, that national emergencies supersede ethics, and that some

persons (prisoners in this case) can lose their claim to humanity.

The lesson here is that moral premises must be valid if morally

valid conclusions are to be drawn. A morally repulsive conclusion

stems from a morally inadmissible premise.

Perhaps, above all, we must learn that some things should never be

done. We will know when to say " no " if we extrapolate our moral

premises to their logical conclusions. This the Nazi doctors did not

do.

Clearly, there are moral lessons still to be learned from the

Nuremberg Trials and there always will be. These lessons must be

repeatedly relearned. They are pertinent to other contexts and other

issues in today's intensive bioethics debates. The Nuremberg Trials

and the Holocaust are metaphors for absolute moral evil, the lessons

of which are as old as ethics itself (19). This we must never forget

if we wish to be certain that the moral disasters revealed at

Nuremberg never occur again.

Edmund D. Pellegrino, MD

town University Medical Center

Washington, DC 20007