50 Anos Do Tuskegee Syphilis Study BJournal 2022
50 Anos Do Tuskegee Syphilis Study BJournal 2022
The history of medicine is presented as a medical experiments are more ignominious the experiment was uncovered in 1972, it was
cavalcade of triumphal breakthroughs than that conducted by physicians who for difficult to imagine that the PHS could
leading to marked increases in life 40 years (1932–1972) intentionally withheld contain a worse chapter in its history (2). Yet
expectancy. Advances arise from the effective therapy from hundreds of African in 2010, we learned that the same group of
ingenuity and industry of innumerable American men known to have a life- researchers had deliberately infected
investigators but also depend on millions of threatening illness (1). hundreds of Guatemalans with syphilis and
patients who selflessly make their bodies One of the most disturbing features of gonorrhea in the 1940s in the hope of
available for experimentation. The this experiment is the realization that it was developing a better means of preventing
interaction between investigators and conducted by the major health arm of the these infections.
patients is a source of pride but on occasion federal government: the Public Health The PHS study has its origin with
has also been a reason for shame. Few Service (PHS; precursor of the CDC). When researchers who wanted to study the natural
(Received in original form January 19, 2022; accepted in final form March 8, 2022)
This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0.
For commercial usage and reprints, please e-mail Diane Gern ([email protected]).
Supported by National Institute of Nursing Research grant R01-NR016055 and Veterans Administration Research Merit Review Award 1 I01
RX002803-01A1.
Correspondence and requests for reprints should be addressed to Martin J. Tobin, M.D., Division of Pulmonary and Critical Care Medicine,
Hines Veterans Affairs Hospital, Hines, IL 60141. E-mail: [email protected].
This article has an online supplement, which is accessible from this issue’s table of contents at www.atsjournals.org.
Am J Respir Crit Care Med Vol 205, IIss 10, pp 1145–1158, May 15, 2022
Copyright © 2022 by the American Thoracic Society
Originally Published in Press as DOI: 10.1164/rccm.202201-0136SO on May 2, 2022
Internet address: www:atsjournals:org
history of untreated syphilis. The site chosen, opportunity for the study of the effects of path-breaking discoveries that revolutionized
Macon County, Alabama, had a population untreated syphilis” (1). In time, this thought the ability of physicians to manage the
of 27,000 in 1932, of whom 82% were became the Tuskegee Study of Untreated disease (15). Therapy was transformed in
African American (1). The PHS sought the Syphilis in the Negro Male. 1908 when Sahachir o Hata (1873–1938) and
cooperation of the nearby Tuskegee Institute, The men remained untreated only Nobelist Paul Ehrlich (1854–1915)
the Black university founded by Booker because the government doctors deliberately discovered an arsenical compound,
T. Washington (1856–1915), and made use withheld therapy over a 40-year period and arsphenamine, which was highly toxic to
of the facilities of Andrew Memorial misled the men into believing that the spirochetes and much less so to humans (15).
Hospital, located on the campus (3). The medications they received (vitamin tonics Arsphenamine was marketed as Salvarsan in
study population consisted of 600 Black men: and aspirin as placebo) were effective against 1910; Boeck became quickly convinced of its
399 with syphilis and 201 free of the disease their disease (6) (Figures 2 and 3). When efficacy and immediately terminated the
who served as control subjects (4). By 1969, seeking assistance from the principal of the Oslo study (16).
at least 28 and perhaps 100 men had died as Tuskegee Institute, the surgeon general, Once PHS investigators had enrolled
a direct result of syphilis; despite this Dr. Hugh Cumming (1869–1948), wrote to the Alabama men and obtained baseline
knowledge, the government scientists him in 1932 saying that the study “offers an measurements, they next decided to check
continued the experiment (1, 5). unparalleled opportunity for carrying on this for evidence of neurosyphilis. Dr. Raymond
“In 1932, Macon County was still very piece of scientific research which probably Vonderlehr realized that the men might
much tied to its plantation past,” Britt Rusert cannot be duplicated anywhere else in the refuse lumbar puncture if they realized it was
avows (Figure 1). “Most of the men selected world.” Presumably, Dr. Cumming did not solely for diagnostic purposes. “My idea,” he
for the syphilis experiments were poor intend any irony (12). wrote to his collaborators, is that “details of
sharecroppers with little or no formal The background knowledge that led to the puncture techniques should be kept from
education who worked under white farmers the PHS study came from the Oslo Study of them as far as possible” (1). To entice the
in a system of debt peonage” (6). The men Untreated Syphilis (9). Convinced that men to cooperate, he told them he would
agreed to participate because the available therapy, primarily mercury give them a special therapy: free “spinal
investigators offered them free medical care compounds that had been used since the shots,” deceiving them into believing that
and burial insurance (1). Informed consent 16th century, was harmful, Dr. Caesar Boeck lumbar punctures were therapeutic
was never sought. On the contrary, PHS withheld treatment from almost 2,000 (Figure 4) (9).
researchers deceived the men into believing syphilitic patients between 1890 and 1910 The final step in data collection was to
they were being treated for “bad blood,” a (13). Like tuberculosis, syphilis had been one obtain pathological specimens at autopsy.
colloquialism for several ailments (1). The of the most feared scourges of mankind, “As I see it,” another PHS investigator, Dr.
term is included in the title of a book by estimated to affect 1 in every 10 Americans Oliver Wenger, wrote to Dr. Vonderlehr,
James Jones, Bad Blood: The Tuskegee in the early 20th century (14). Around this “we have no further interest in these patients
Syphilis Experiment (1981), regarded as the time, German investigators made a series of until they die” (underlining in original) (17).
definitive history of the experiment (7) and
“the single most important book ever written
in bioethics” (8).
As an active physician who has spent
more than 45 years conducting research on
patients and a former journal editor-in-chief
who investigated various problems of
research ethics and imposed sanctions on
researchers for malfeasance, I reflect on how
physician-scientists who dedicate their lives
to a noble cause can persuade themselves
that it is morally acceptable to perform
disturbing experiments on unwitting
individuals to attain their goals. A more
detailed version of this article is available in
the online supplement.
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Figure 9. Left: A 25-year-old female patient in Asilo de Alienados (Psychiatric Hospital) in Guatemala was exposed to syphilis once with no
record of treatment. Right: A 16-year-old female patient in Asilo de Alienados was exposed to syphilis twice and was treated with penicillin.
Records indicate that the patient was “uncooperative.” Reproduced from the National Archives and Records Administration (in public domain).
from the country’s leading medical schools. publications in reputable journals read all Caplan avers that the PHS study is “the
The surgeon general was enthusiastic about over the world. The experiment is a story single most important event in the rise of
the studies and was kept informed of their that needs to stay forever on the moral bioethics” (8). Reforms arising from the
progress. horizons of medical scientists, yet many Kennedy congressional hearings led to
young investigators know little of its details fundamental changes in the infrastructure of
or lessons (85). research ethics. Yet it is doubtful that these
Lessons For the final 25 years of the Alabama provisions benefited significantly the
experiment, the message of the Nuremberg segments of society affected by the study:
Lessons from the PHS experiments are Code had been widely disseminated. impoverished Black persons.
manifold. The Alabama investigation was Investigators looked on it as “a good code for Some argue that revolutionary changes
conducted in an open society, it extended barbarians” (86), and it had little impact in in research ethics obviate claims by HEW
over 40 years, and it resulted in numerous the United States (87, 88). Bioethicist Arthur advisory panel members of a government
whitewash (5, 60, 89). History is the story of
roads taken, and counterfactual history
contemplates what might have happened had
a different road been ventured. The
dominant factor that undergirded the PHS
study was racism (90), which was played
down to near invisibility in the HEW final
report (5). Had society confronted the
flagrant evidence of structural racism in 1972
and instituted fundamental reform of social
contributors to health, the stark racial
disparities of health outcomes exposed by the
klieg light of COVID-19 could have been
prevented (58, 91); likewise, root reform of
law enforcement in 1972 could have
prevented the many deaths of Black persons
consequent to unlawful police actions (59).
Figure 10. The injection site of a female psychiatric patient who was exposed to syphilis three As with many instances of scientific
times and received some treatment. Reproduced from the National Archives and Records misconduct, senior scientists were fully
Administration (in public domain). aware of the nature and magnitude of the
PHS irregularities and took no action. Yet the Tuskegee study is mentioned, the captured the distinction in a letter to his
when the information was communicated in university and townspeople are touched by a nephew: “An honest heart being the first
the lay press, the problem was immediately legacy of shame. Rather than besmirching blessing, a knowing head is the second”
obvious to the general public. How can it be the victims and their descendants, it would (100). Intelligence and education are not
that problems reported on the front page of be more accurate to label the experiment enough in human affairs: character and
the New York Times become clear in after the perpetrators: the Public Health conscience come first. It is tempting to
retrospect, yet, in the preceding years, Service Study of Partially Treated Syphilis compartmentalize the lessons of the PHS
extremely accomplished physician-scientists (93). study into those that apply to our actions as
saw no problem? Lack of imagination, None of the study scientists wrote researchers and those that apply to our
rationalization, and institutional constraints articles reflecting on its moral lessons. “No behavior as lay citizens. That would be a
are formidable obstacles in such situations. apologies were tendered. No one admitted mistake because the two blend into each
In Humanity: a Moral History of the any wrongdoing,” inveighs James Jones (1). other.
Twentieth Century, philosopher Jonathan In 1993, Dr. Cutler appeared on the PBS When we look back at the Alabama and
Glover (92) analyzes several genocides, Nova documentary “Deadly Deception” (94). Guatemala stories, we fall into the trap of
bringing together ethics and history, and When asked about the Tuskegee men, he placing ourselves on the side of the angels, of
concludes that only moral imagination (the declaimed, “It was important that they were grouping ourselves with the Buxtuns of this
ability to imagine ourselves in the shoes of supposedly untreated, and it would be world. Hindsight is comforting, but it is also
endangered individuals) can enable us to alter undesirable to go ahead and use large misleading (101). Coping with challenges as
our outlook and take steps to remedy a amounts of penicillin to treat the disease, they unfold in real time is very different.
threatening situation. Many factors deaden because you’d interfere with the study.” He Only one Peter Buxtun stood up over
moral imagination—groupthink, tribalism, remonstrated, “I was bitterly opposed to 40 years. It is more likely that most
obedience—and prevent us from taking action. killing off the Study for obvious reasons” researchers would have followed in the
Cultivation of moral imagination, Glover (95). Regarding the enrollees, he attested, footprints of Drs. Vonderlehr, Wenger, and
contends, holds the best hope of battling “They served their race very well.” Heller and the many other investigators
against comforting conventional attitudes and Dr. Parran served as surgeon general involved.
official policy, making vivid the destiny of (1936–1948) during the time that penicillin There is a natural tendency to believe
dehumanized individuals, and becoming was advocated to treat every American with that group effort and cooperation are more
determined to take action. A succession of syphilis—except men in Macon County. He effective than the actions of an individual.
physicians worked on the Tuskegee project. If did more than any other person to control Correction of the great ills of society has
the consciences of new recruits were troubled sexually transmitted infections (68, 96, 97). always started in the heart of one individual
on being first exposed to the study design, they He was founding dean of the University of and thereafter spread to a small group who
acted as if they did not notice the peril of the Pittsburgh Graduate School of Public Health recognized the same injustice. An especially
enrollees, looking away and keeping silent. The (1948–1958), and the school’s main building astute commentator on social affairs, Adam
consciences of these physicians were protected was named Parran Hall in 1969. In 1972, the Smith, wrote in 1763, “Slavery has hardly any
by moral inertia—finding it easier to fall in American Sexually Transmitted Diseases possibility of it being abolished. . . . [It] has
with the momentum of established routine Association named its highest award in his been universall [sic] in the beginnings of
and policy (92). honor (98). The Pittsburgh school society, and the love of dominion and
When officials are confronted with introduced the John C. Cutler Memorial authority over others will probably make it
major sociopolitical problems, they spin Lecture in Global Health in 2003 to honor perpetual” (102). A few years later, a 25-year-
themselves. They convince themselves that another former faculty member. A new dean old deacon, Thomas Clarkson (1760–1846),
raising the concern will be futile and may canceled the lecture series in 2008 because of started a movement that forced British
even backfire with worse consequences. The community sensitivities regarding Dr. Parliament to pass an act in 1807 abolishing
CDC used this argument when trying to Cutler’s role in the Tuskegee research (69). In the slave trade (102).
persuade Peter Buxtun that the PHS study 2013, American Sexually Transmitted Individuals such as Buxtun and
should not be stopped. The blue-ribbon Diseases Association members voted to Clarkson who set out to make a difference
panel argued that penicillin would be remove Dr. Parran’s name from its annual are usually branded as irrational, soft, or
dangerous (28). When the men were award (76); in 2018, his name was stripped naive. In official and administrative circles,
eventually treated with penicillin, not a single from the Pittsburgh Graduate School of where discussion is performed in the cold
complication was observed (1). Public Health building (99). language of interests, people who urge
When morals collide with actions, a There is a common perception that intervention on the basis of moral arguments
common response is to blame the victim— moral judgment is linked to education. Yet are considered “emotional.”
Dr. Kampmeier blamed study participants the person who stopped the PHS study, Peter The reason people fail to take steps to
for failing to request penicillin for aortitis Buxtun, had no training in research; he was a halt behavior that in retrospect everyone
(33). The prefix attached to the study by PHS social worker and had far less conventional judges reprehensible is complex. Scholars
investigators is a variant of the blame-the- education than the future director of the have long pondered the question. One of the
victim tactic. Tuskegee University, founded National Cancer Institute who led the study first to wonder what light the second World
by former slave Booker T. Washington in for years and many surgeons general who War shed on this question was Hannah
1881, should be celebrated as a milestone in had intimate knowledge of it. With Arendt (1906–1975). She deconstructed the
African American history. Instead, each time characteristic concision, Thomas Jefferson psychological and moral implications of evil
1154 American Journal of Respiratory and Critical Care Medicine Volume 205 Number 10 | May 15 2022
STATE OF THE ART
(103). In 1961, she attended the trial of war and, at bottom, worthy people have, in our information and decide not to intervene as
criminal Adolf Eichmann. Arendt published time, the most extraordinary fear about events unfold in real time.
a controversial book, Eichmann in Jerusalem: making judgments. This confusion about We must be careful not to use the
A Report on the Banality of Evil (1963). The judgment can go hand in hand with fine and Alabama and Guatemala research as an
expression “banality of evil” gave rise to strong intelligence, just as good judgment opportunity for letting off moralistic steam.
much criticism and misunderstanding. Some can be found in those not remarkable for Denouncing an injustice, observes Tzvetan
saw Arendt as exonerating Eichmann and their intelligence” (103). For Buxtun, Todorov, “constitutes a moral act only at
blaming the victims. When writing early exercising judgment was a matter of moral those times when such denunciation is not
drafts, Arendt was inclined to describe the courage. simply a matter of course and thus involves
evil quality of totalitarianism as something When faced with serious injustice in some personal risk. There is nothing moral
utterly “radical” (104). One of her mentors, their midst, the real reason people fail to in speaking out against slavery today” (105).
physician-philosopher Karl Jaspers intervene is a lack of willpower. Consider the One can legitimately make moral
(1883–1969), argued that such a Rwandan genocide—the most efficient demands only on oneself. To imagine
characterization made Nazism seem killing spree of the 20th century (107). oneself floating above the fields of Macon
somehow unique and thus, in an awful way, Across 100 days (April 6 to July 18, 1994), County and Guatemala City and wagging
“great” (103). As Arendt reflected on the 800,000 Tutsi and politically moderate Hutu an indignant finger at the shades of Dr.
matter, she arrived at the conclusion that evil were murdered—the equivalent of more than Vonderlehr and Dr. Cutler constitutes
arises from a simple failure to think. two World Trade Center attacks every day “moralism.” People who hold themselves
What struck Arendt when listening to for 100 days. In contrast to the broad support up as examples to others are in fact acting
Eichmann was his banality: “his penchant for for the United States after September 11, immorally, irrespective of how
‘officialese,’ for stock phrases, for shallow every country turned away when the Tutsi commendable their conduct may otherwise
elations, his ‘empty talk,’ his being ‘genuinely cried out. During the 3 months of the be (105). Hannah Arendt again: “Goodness
incapable of uttering a single sentence that genocide, the U.S. president never once can exist only when it is not perceived, not
was not a cliche’” (104). She continued, “The assembled his top policy advisers to discuss even by its author; whoever sees himself
longer one listened to him, the more obvious the killings (108). After being personally performing a good work is no longer good,
it became that his inability to speak was lobbied by Human Rights Watch, Anthony but at best a useful member of society” (104).
closely connected with an inability to think, Lake (born 1939), the president’s national Reflection on the PHS experiments
namely to think from the standpoint of security adviser, issued a statement calling on highlights that out of the crooked timber of
somebody else” (104). As Arendt inferred, Rwandan military leaders to “do everything humanity, nothing entirely straight can be
“The trouble with Eichmann was precisely in their power to end the violence fashioned. Everything we know about the
that so many were like him, and that the immediately.” PHS researchers informs us that they were
many were neither perverted nor sadistic, When Lake was informed 6 years after perceived as being decent people who did
that they were, and still are, terribly and the genocide that this statement constituted
much good in other parts of their
terrifyingly normal . . . this normality was the sum total of official public attempts to
professional lives. Given the actions of Drs.
much more terrifying than all the atrocities shame the Rwandan government, he was
Parran, Mahoney, and Cutler and other
put together” (104). In this sense, the evil of stunned: “You’re kidding,” he replied.
esteemed researchers, we need to approach
the PHS experiments is banal and not “That’s truly pathetic” (108). Here is a leader
today’s ethical challenges with “fear and
radical. Banality does not trivialize evil: it is who had acquired a reputation as a person of
trembling” (Kierkegaard’s phrase)—and
precisely what makes the behavior so conscience, who was in a position of
remember to pause and think, reflect and
dangerous (105). enormous power, and yet he failed to act;
examine our conscience, and have the
Allied to a lack of thinking is a lack of indeed, he appeared to be unaware that he
courage to speak and, above all, the
reflection, an examination of conscience— had not acted. So it is not only medical
willpower to act. 䊏
the courage to form a judgment. Peter researchers who fail to act on concerns that
Buxtun was not afraid to judge and be seem repellant in retrospect. In all walks of
counted. Today, we are constantly cautioned life, people who have reputations for good Author disclosures are available with the
text of this article at www.atsjournals.org.
against being judgmental—not to form a conscience, who are trained at the highest
moral opinion about the actions of others level, who possess all the facts and know the
Acknowledgment: The author thanks Sidney
(106). Ahead of her time, Arendt saw the harmful consequences, and who have the Wolfe, M.D., and Charles Natanson, M.D.,
dangers of ethical relativism. Writing to power to act, still fail to act. Instead, they find for comments on an earlier version of the
Jaspers in 1963, she reflected that “even good sound logical reasons to dismiss all the manuscript.
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