The Tuskegee Syphilis Study: A Comprehensive Ethical and Historical Analysis
The Tuskegee Syphilis Study: Racism and Research
Overview of the Tuskegee Syphilis Study
Initiation: In 1932, the U.S. Public Health Service (USPHS) began an experiment in Macon County, Alabama.
Purpose: To observe the natural course of untreated, latent syphilis in black males.
Subjects:
400 syphilitic black men.
200 uninfected men served as controls.
Duration & Publications:
The first report was published in 1936.
Subsequent papers were issued every 4 to 6 years through the 1960s.
The study lasted for 40 years.
Treatment Denial:
When penicillin became widely available in the early 1950s as the preferred treatment for syphilis, the men were not provided therapy.
The USPHS actively sought to prevent subjects from receiving treatment on several occasions.
A committee at the Center for Disease Control (CDC) decided in 1969 that the study should continue.
Termination: The experiment was only halted in 1972, after accounts appeared in the national press.
Outcomes for Subjects:
At the time of termination, 74 test subjects were still alive.
At least 28, and potentially over 100, had died directly from advanced syphilitic lesions.
HEW Panel Findings (1973): An investigatory panel appointed by the Department of Health, Education and Welfare (HEW) found the study "ethically unjustified" and argued that penicillin should have been provided.
The Experiment and HEW's Ethical Review
Author's Goal: This article by Allan M. Brandt aims to contextualize the Tuskegee Study historically and assess its ethical implications, arguing that it has been largely misunderstood.
Critique of HEW Investigation:
The HEW investigation failed to address fundamental questions: how the study began and why it continued for 40 years.
The panel misconstrued the experiment's nature and did not consult crucial documents in the National Archives.
Understanding the study requires examining how values influenced scientific research.
Racism and Medical Opinion (Early 20th Century)
Impact of Darwinism: By the turn of the century, Darwinism provided a new rationale for American racism.
Argument: "Primitive peoples" (referring to black individuals) could not be assimilated into complex "white civilization."
Speculation: Black people were "doomed" in the struggle for survival, prone to disease, vice, and crime, and beyond help from education or philanthropy.
Social Darwinists used census data to predict the "virtual extinction of the Negro" due to a "degenerative evolutionary process."
Medical Profession's Support: Physicians widely supported these findings from anthropologists, ethnologists, and biologists.
Effect of Emancipation: Doctors almost universally concluded that freedom led to the "mental, moral, and physical deterioration of the black population."
Comparative Anatomy:
Dr. W. T. English: "A careful inspection reveals the body of the negro a mass of minor defects and imperfections from the crown of the head to the soles of the feet…"
Cranial structures, wide nasal apertures, receding chins, and projecting jaws were cited as traits typing black people as the "lowest species in the Darwinian hierarchy."
Sexual Nature of Blacks:
Excessive Sexual Desire: Doctors believed black individuals possessed excessive sexual desire, threatening white society.
Quoted physician in Journal of the American Medical Association: "The negro springs from a southern race, and as such his sexual appetite is strong; all of his environments stimulate this appetite, and as a general rule his emotional type of religion certainly does not decrease it."
Lack of Morality: Doctors reported a complete lack of morality, with one physician stating, "Virtue in the negro race is like angels' visits-few and far between. In a practice of sixteen years I have never examined a virgin negro over fourteen years of age."
Desire for White Women: This "overzealous sexuality" was seen as particularly ominous, described as a "perversion from which most races are exempt."
Physical Peculiarities: English estimated the "gray matter of the negro brain" to be a thousand years behind white races, but genital organs were "overdeveloped." Dr. William Lee Howard linked "attacks on defenseless white women" to "racial instincts" not amenable to "ethical culture."
Proposed "Treatment": One southern medical journal proposed "Castration Instead of Lynching" for black sexual crimes, suggesting a "ghost-like kuklux klan [sic] and a 'ghost' physician or surgeon" for the operation.
Blacks and Venereal Disease:
High Prevalence: Attributed to "lust and immorality, unstable families, and reversion to barbaric tendencies."
One doctor estimated over 50 percent of all black individuals over 25 were syphilitic.
Inability to Treat: Doctors believed treatment was impossible, especially in the latent stage. Dr. Thomas W. Murrell noted that black individuals would not continue treatment once symptoms disappeared.
Threat to the Race: Venereal disease (along with tuberculosis) was seen as a threat to the future of the black race, contributing to low birth rates (stillbirths, miscarriages), increased insanity (a thirteen-fold increase since the Civil War), and crime.
Murrell's conclusion: "So the scourge sweeps among them. Those that are treated are only half cured, and the effort to assimilate a complex civilization driving their diseased minds until the results are criminal records. Perhaps here, in conjunction with tuberculosis, will be the end of the negro problem. Disease will accomplish what man cannot do."
Dismissal of Socioeconomic Factors: Doctors generally discounted socioeconomic explanations for black health, believing medical care could not alter the "evolutionary scheme."
Origins of the Experiment
Rosenwald Fund Study (1929): The USPHS, with a grant from the Julius Rosenwald Fund, studied syphilis prevalence and mass treatment possibilities in the rural South.
Macon County, Alabama, had the highest syphilis rate among 6 counties surveyed.
Conclusion: Mass treatment among rural blacks was feasible.
Despite this, findings were ignored due to the 1929 economic collapse.
Irony: The Tuskegee Study, which became a study of untreated syphilis, was based on findings that demonstrated the possibilities of mass treatment.
Inception of Tuskegee Study (1932):
Dr. Taliaferro Clark, Chief of USPHS Venereal Disease Division, saw Macon County's high syphilis prevalence as an "unusual opportunity" for observation.
"Study in Nature" Concept: The USPHS initially regarded it as a "study in nature" rather than an experiment, implying passive observation.
Clarification: Claude Bernard (1865) distinguished "study in nature" (simple observation) from "experimentation" (intervention). The Tuskegee Study, involving diagnosis, was clearly not a passive "study in nature" ( extit{a posteriori}).
"Ready-made situation": Clark believed that since syphilis was prevalent and most blacks untreated, observing the consequences was valuable.
Surgeon General H. S. Cumming's justification: Wrote to R. R. Moton of Tuskegee Institute, highlighting the "unusually high rate" and 90 percent untreated, offering an "unparalleled opportunity."
Study Objectives (Implicit Protocol):
No formal protocol, but letters suggest USPHS hoped to observe how disease affected daily lives.
Crucially, they believed the experiment might demonstrate that antisyphilitic treatment was "unnecessary" for latent syphilis.
Influence of the Oslo Study:
Background: From 1890 to 1910, Professor C. Boeck withheld treatment from nearly 2,000 syphilitic patients, believing available therapies (mercurial ointment) were useless.
Follow-up (1925-1927): E. Bruusgaard found that 27.9 percent had a "spontaneous cure," and up to 70 percent lived without inconvenience from the disease. However, he acknowledged dangers for the remaining 30 percent.
Contradiction with Standard Medical Opinion: At the time of Tuskegee's inception, major textbooks advocated treating latent syphilis. Dr. J. E. Moore, a leading venereologist, explicitly stated Bruusgaard's study should "by no means intended to suggest that syphilis be allowed to pass untreated."
Known Dangers: Untreated syphilis led to cardiovascular disease, insanity, and premature death.
Benefits of Treatment: Moore (1933 textbook) stated treatment reduced progression/relapse/death risk from 25-30 percent to about 5 percent and diminished relapse gravity. He also noted infectiousness of latent syphilis patients.
USPHS Contradiction: In 1932, the USPHS itself sponsored and published a paper by Moore and 6 other experts advocating treating latent syphilis.
The Actual Rationale for Tuskegee:
The study's justification derived from assumptions that conditions in Tuskegee were "natural" (high prevalence, untreated) and that the men would not seek treatment anyway.
These assumptions were rooted in prevailing racist medical attitudes towards blacks, sex, and disease.
Clark explained prevalence by emphasizing "promiscuity among blacks," "low intelligence," "depressed economic conditions," and "indifference with regard to treatment."
Dr. Moore, despite his prior advocacy for treatment, served as a consultant, suggesting that existing knowledge "did not apply to Negroes" because "Syphilis in the negro is in many respects almost a different disease from syphilis in the white."
Dr. O. C. Wenger, clinic chief, praised Moore's judgment and added, "We must remember we are dealing with a group of people who are illiterate, have no conception of time, and whose personal history is always indefinite."
Self-fulfilling Prophecy: The study's premise that black men were promiscuous and wouldn't seek treatment made an "untreated syphilis" test seem "natural," and the study itself ensured they remained untreated.
Selecting the Subjects and Deception
Recruitment Challenges:
Dr. Raymond Vonderlehr (sent in September 1932) found it difficult to assemble a sample of 25-60 year old black males with latent syphilis.
Initially, circulars for men over 25 were ineffective as men suspected draft physicals.
Vonderlehr had to test many women and men outside specifications, incurring expense for treating non-study participants, which Clark resisted.
Contradictory Findings:
Syphilis rates were lower than expected (actual 20 percent vs. USPHS projection of 35 percent).
More individuals had sought and received previous treatment than expected, contradicting the assumption that black individuals wouldn't seek therapy.
Deceitful Recruitment:
False Promise of Treatment: Cooperation was only secured by offering "treatment"; men were told they were ill and promised "free care."
"Bad Blood" Belief: Subjects believed they were being treated for "bad blood" (colloquialism for syphilis) and thought they participated in a public health demonstration, not an experiment.
Eagerness for Care: Men were so eager for medical care that defaulters were insignificant.
Ineffective "Treatment" to Maintain Interest:
Vonderlehr administered mercurial ointment (noneffective) and, for some younger men, inadequate dosages of neoarsphenamine.
He actively requested drugs to prevent the experiment from failing due to lack of perceived treatment. He desired "to keep the main purpose of the work from the negroes" and maintain their interest in "treatment."
This readiness to participate further contradicted the notion that black individuals would not seek therapy.
Spinal Tap Deception:
A painful, purely diagnostic spinal tap (to check for neuro-syphilis) was presented as a "special treatment."
Clark noted: "These negroes are very ignorant and easily influenced by things that would be of minor significance in a more intelligent group."
A letter to subjects announced a "last chance for special free treatment" after a "very special" second examination.
Crucial HEW Oversight: The HEW investigation failed to uncover that men participated under the guise of treatment, not informed consent or voluntary participation.
Continuation and Further Deceptions
Extension of Study (Summer 1933):
Despite proven incorrect assumptions about disease prevalence and attitudes towards treatment, USPHS continued the study.
Rationale: The sample existed, and treatment costs were deemed prohibitive (though never truly considered).
Vonderlehr suggested extending the follow-up for 5 to 10 years to learn about the course and complications of "untreated" syphilis.
Autopsy as the Main Goal:
Wenger's chilling response: "As I see it, we have no further interest in these patients until they die."
Physicians believed only autopsies could scientifically confirm findings.
Surgeon General Cumming requested continued cooperation from Tuskegee Institute Hospital for "pathological confirmation" through autopsies.
Deception for Autopsies:
Wenger warned against letting the black population know that "accepting free hospital care means a post-mortem," fearing they would leave.
Vonderlehr confirmed his intention not to publicize "the main object of the present activities is the bringing of the men to necropsy."
Exploiting Trust: Dr. Dibble, Director of Tuskegee Institute Hospital, was given an interim USPHS appointment to secure trust for autopsies, as "when these colored folks are told that Doctor Dibble is now a Government doctor too they will have more confidence."
Black Cooperation: The extent of black cooperation is unclear; some staff, like Moton and Dibble, seemed aware, while others, like intern Dr. Joshua Williams and nurse Eunice Rivers, might not have fully understood the deception or dangers. This involvement, however, doesn't mitigate the study's racial assumptions.
Control Group Protocol:
Vonderlehr selected a control group of healthy, uninfected men, who also received noneffective drugs, suggesting they believed they were undergoing treatment.
Gross Violation: Control subjects who became syphilitic were simply transferred to the test group, a highly inept violation of standard research procedure.
Inducements and Continuity:
Nurse Eunice Rivers: Hired to maintain contact with subjects over 40 years. She provided "noneffective medicines" (e.g., "spring tonic," aspirin), transportation, hot meals, and shopping trips.
"Miss Rivers' Lodge": The project was referred to as this, associating it with free medicines and burial assistance/insurance.
Continued Deceit: USPHS continued to deceive participants who believed they received government therapy. Letters to subjects promised an examination to see "whether the treatment has improved your health," despite no actual effective treatment after the first six months.
Burial Expenses: The Milbank Memorial Fund provided approx. 50 dollars per man starting in 1935 to cover burial costs, a strong inducement for rural black families.
Findings and Suppression of Treatment
Published Reports: Regular reports in the medical press consistently cited the ravages of untreated syphilis.
1936 paper: Untreated syphilis in its latent period "tends to greatly increase the frequency of manifestations of cardiovascular disease" (only 16 percent of subjects showed no morbidity vs. 61 percent of controls).
1946 report: "nearly twice as large a proportion of the syphilitic individuals as of the control group has died," reducing life expectancy by about 20 percent.
1955 article: Slightly over 30 percent of autopsied test group died directly from advanced syphilitic lesions.
1956 account: "appreciable number have late complications of syphilis which probably will result, for some at least, in contributing materially to the ultimate cause of death."
1950 (Dr. Wenger): "We now know, where we could only surmise before, that we have contributed to their ailments and shortened their lives."
Dr. Vernal Cave: "They proved a point, then proved a point, then proved a point."
Active Prevention of Treatment:
Local Doctors (1934): Vonderlehr met with black doctors to ask their cooperation in not treating the subjects, providing lists of names.
Alabama Health Department (early 1940s): USPHS warned them not to treat subjects when a mobile VD unit visited Tuskegee.
US Army (1941): USPHS supplied the draft board with a list of 256 names to exclude from antisyphilitic treatment, and the board complied.
Limited Outside Treatment: By the early 1950s, almost 30 percent of subjects received some penicillin, but only 7.5 percent received adequate doses.
Vonderlehr hoped antibiotics hadn't "interfered too much."
A 1955 report rationalized the low exposure to penicillin by suggesting "the stoicism of these men as a group; they still regard hospitals and medicines with suspicion…"
The authors failed to note subjects believed they were already under government care.
Continued Justification (1960s):
CDC meeting (1965): "Racial issue was mentioned briefly. Will not affect the study. Any questions can be handled by saying these people were at the point that therapy would no longer help them. They are getting better medical care than they would under any other circumstances."
CDC meeting (1969): Despite one doctor's dissent, consensus was to continue. Dr. J. Lawton Smith: "You will never have another study like this; take advantage of it."
Dr. James B. Lucas's memo (1970): Acknowledged "Nothing learned will prevent, find, or cure a single case of infectious syphilis" but still concluded the study should continue "along its present lines."
Data collection and autopsies continued until national press accounts in July 1972.
The HEW Final Report (1973) and its Limitations
Panel Formation: Created August 28, 1972, in response to press criticism; composed of nine members, five black.
Panel's Focus:
Was the study justified in 1932 and was informed consent obtained?
Should penicillin have been provided in the early 1950s?
Should the study be terminated, and assess current human experimentation policies?
Brandt's Critique of the Report:
Misunderstanding of Purpose: The report focused on penicillin and informed consent, betraying a misunderstanding. The study's entire premise was non-treatment.
Understated Ethical Breach: Declaring the experiment "ethically unjustified" due to lack of informed consent was an understatement. The men believed they were receiving treatment, not volunteering for research; they were lied to.
Failure to Address Racism: The report treated the study as an "aberration," failing to place it in historical context and address its "essentially racist nature."
Limited Scope: Concern about critiquing human experimentation generally limited the inquiry, assuring readers it wasn't a "general repudiation of scientific research with human subjects."
Questionable Justification: The report suggested a "properly conceived" study of untreated syphilis in the pre-penicillin era might have been justified, a questionable position given the known dangers of untreated syphilis in 1932.
Contemporary Defenses of the Tuskegee Study and Brandt's Counter-Arguments
Arguments for Defense:
Dr. R. H. Kampmeier: Centered on limited knowledge of effective therapy for latent syphilis at the outset and claimed penicillin would have been useless by 1950.
Goldwater/Lasagna: Suggested men were fortunate to avoid toxic early treatments.
Assumption: The men would never have been treated anyway. Dr. Charles Barnett (Stanford, 1974): "The lack of treatment was not contrived by the USPHS but was an established fact of which they proposed to take advantage."
Dr. J. R. Heller (participating physician, 1972): Claimed "no racial side," a "perfectly straightforward study, perfectly ethical, with controls" because it was part of a mission "to find out what happens to individuals with disease and without disease."
Brandt's Counter-Arguments:
These apologies, including the HEW report, ignore essential ethical issues.
The study exposed the "persistence of beliefs within the medical profession about the nature of blacks, sex, and disease-beliefs that had tragic repercussions."
The entire health of a community was jeopardized by leaving a communicable disease untreated (latent syphilis was considered communicable at the time).
Researchers regarded subjects as "less than human," completely disregarding ethical canons for human experimentation.
Broader Implications
Professional Self-Regulation & Scientific Bureaucracy:
The study highlights a failure in professional self-regulation; once extended in 1933, it was unlikely to stop before the men's deaths.
For 40 years, reports were published without significant protest from the medical community.
No bureaucratic mechanism within government existed for periodic reassessment of the study's ethics or scientific value.
The press accounts in 1972 were the only factor that ended the study.
The HEW investigation itself was compromised by fears of being a threat to future human experimentation.
Rejection of "Value-Free Science":
The Tuskegee Study reveals more about the "pathology of racism" and the "nature of scientific inquiry" (i.e., its susceptibility to social values/attitudes) than about syphilis itself.
The "degree of deception and damages have been seriously underestimated."
The notion that science is a "value-free discipline" must be rejected.
Need for Vigilance: Greater vigilance is required in assessing how social values and attitudes affect professional behavior.
Ethical Considerations in Subject Selection (Hans Jonas): When subjects are drawn from minority groups with whom the researcher cannot identify, basic human rights may be compromised. Jonas argued that for human experimentation, subjects should be chosen from "the most highly motivated, the most highly educated, and the least 'captive' members of the community."