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p;: The Unethical In Medical tr: in w FRANZ J. INGELFINGER, M.D., M.A.C.P., Boston, Massachusetts dt tJ­ aJ If An increasing societal recognition that the rights and dignity I shall discuss are not only some occasional well_ Ct of the individual must be protected has led to an appropriate intentioned, if unfortunate, of professionals in imposition of stricter ethical guidelines in medical research ethics, but also-and to a far greater extent-the activities e: v and practice. Occasionally, however, is of others who, for a variety of reasons, exploit medical exploited. Examples are irresponsible accusations of ethics. Thus some critics have that when Yo unethical conduct, sensationalism, undue concern for I mention the unethical in medical ethics I should use C s· prisoners as opposed to other ex~rimental subjects, a quotation marks, or that I should speak of "the unethical b bureaucratic proliferation of ethical regulations and review in what passes for medical ethics." Moreover, when I use mechanisms, and a trivialization of ethical objectives. Such the word "ethicist" I refer not only to the professional misuse of medical ethics compromises medical research, but to anyone who undertakes to trade in medical ethics. enhances public distrust of the physician, and devaluates medical ethics itself. The unethical in both medical practice " J' Accuse" and medical ethics can be contained by determined and Although the Pappworth book is an example of the greater effort to achieve understanding between physicians ''J'accuse'' phenomenon, Pappworths are nevertheless es­ and ethicists. sential if moral climates are to be changed. Someone has to have the courage to stand up and demand, "Halt! What we are doing is wrong." This is what Pappworth did in England, and of course, is what Henry Beecher did in his article, "Ethics and Clinical Research" (2). These A SENSATIONAL BOOK entitled Human Guinea Pigs: Ex­ two physicians sensed the antitechnologic, pro humanistic perimentation on Man was published in England in 1967 temper of the sixties, and the emphasis on the individual as (1). Written by M. H. Pappworth, M.D., this account opposed to societal priorities that was emerging. And it indicts some 200 human research projects as unethical. was indeed fortunate for medicine that the first to call At the end is an index chiefly the names of those certain research practices into question were physicians. responsible for the studies Pappworth found objectionable. As Pappworth himself wrote as early as 1963, "Unless Among the "I" 's you will find one "Inglefinger"-mis­ the medical profession itself stops the unethical practices spelled but nonetheless unmistakable-and the procedure of this minority, the public outcry will eventually be such to which this citation refers is indeed frowned upon today: as to cause opposition to all clinical research" (3'). the catheterization of hepatic veins without adequate ex­ At the end of his paper, Beecher calls for editorial re­ planation to the as to the purpose of the study, sponsibility and argues that data, even if valuable, should which was the development of a method to estimate not be published if they were improperly obtained. Most, ic blood flow. But I take some consolation in the fact that although not all, biomedical editors now appear ready to far better-known clinical investigators are cited more fre­ accept that responsibility, but the means that the editor quently-one of them 23 times! should use to discourage questionable human experimenta­ I use the Pappworth book for two reasons. Firstly, you tion is widely debated. The New England Journal of Medi-. may accept it, if you so wish, as an explanation for my cine has tried to follow Beecher's suggestion, but others bias. hold that all scientifically valid reports should be published., Secondly, it shall serve as a paradign. of a practice that, provided those based on ethically suspect methods are. so if out in an unrestrained and overly zealous fash­ identified in an accompanying editorial. It is this suggestlon ion, may in itself be questionably ethical-this is the cava­ that first made me realize the predicament that should be lier and often imitative disposition to cry, "J'accuse." I sensed by any person who undertakes to accuse a colleague. shall go on later to four other examples: sensationalism; publicly of unethical conduct. What special insight or prisoners as a class; bureaucracy of and superior moral sensitivity gives me license not only to aC-: ethics on the slippery I am using the term "medical cuse but to Occasionally, the impropriety of a ethics" in a comprehensive sense. Included in the five given protocol is but most of the time the editor ... From the New England Journal 01 Medicine, Boston. Massachusetts. who would be ethicist has to sort out the grays. For e1~

5 264 Annals of Internal Medicine 83:264-269. 191 " ample, what sort of ethical rating should be given to a raking by the press and teleVision are all to the , randomized clinical trial of medical gallstone dissolution particularly when the impropriety of the procedure is in which the placebo-receiving controls, as well as those egregious-for example, the threat ~ofphysical punishment receiving the drug, would be subjected to two liver bi­ to coerce prisoners to participate in::-a-·drug trial. But when opsies? the ethical pros and cons of al{',,'~:1Periment are not so Similar scruples do not appear to inhibit the Beecher­ easily segregated and measured, or' if the accusations are pappworth imitators, who commit, in my opinion, ethical in fact vastly exaggerated, it is the'!i;!::ct,J;l!i'ed who is at peril. transgressions in the name of medical ethics. It is these The investigator who is pilloried on page one, but later iJUitators who still find it profitable to discover and to label exonerated far to the rear among the ads, hardly gets a fair with sanctimonious confidence this or that research en­ deal. Indeed, it may be the researcher's rights, rather than deavor as unethical. Particularly disturbing to me are those of his alleged victims, that may be violated. those who, from the vantage point of our current social As an example of sensationalism, I shaH cite a BBC and ethical climate, point the accusatory finger at experi­ program shown both in England and here in the USA ments carried out at a different time and under different under the imprimatur of the excellent Nova series. The conditions. al well­ very title of the program is pejorative: "Are You Doing Even the overall reaction to the so-called Tuskeegee nals in This For Me, Doctor, Or Am I Doing It For You?" Al­ experiment concerns me, that is, the Public Health Ser­ ::tivities though personal satisfaction and gain must to a variable vice program in which heavy metals and then penicillin nedical degree motivate most researchers, the real and undistorted were not given to poor black men to determine the natural ,I when and hence the ethical question is, "Are you doing this for course of syphilis. According to today's standards, the lId use me, doctor, or are you doing it for others?" The issue study was wrong-dreadfully wrong. Yet who is sure that Jethical hinges on the old dilemma of individual versus societal be would have stood up and told the Pu15iic Health Service n I use rights. To frame the question in words suggesting that in 1933-or even in 1953-"You are committing an out­ essional individual rights are being weighed against the length rage"? Who is so sure? Many, it would seem. For after the thics. of the investigator's bibliography represents a bit of mis­ Tuskeegee experiments were brought to light in 1972 a chievous sensationalism. wave of indignant writers and speakers jumped on the The opening sequence of the film as shown in Britain of the bandWagon of propriety to denounce both experiment and was even more unfair than the title. The first shots show less es­ experimenters. But you will find little in the New England an appealing infant, but the infant is blind, as emphasized Jne has Journal of Medicine about it. Why? Because I find nothing by two black marks effacing his eyes. The accompanying t! What ethically noble in joining the mob to deliver another boot narrative runs as follows: did in to a dying beast-no matter how filthy the beast may be. "Although most experts were aware that a special her did Unfortunately, it is far too easy to be ethically obtuse; but likewise, it is far too easy to be ethically self-righteous. form of blindness in premature infants was due to , These excessive use of oxygen, it was decided to prove this nanistic It is quite another matter, of course, when a critic, conclusively on a scientific basis. At a New York ,dual as within the context of current criteria, challenges the ethi­ hospital, a group of premature babies were deliberate­ And it cality of a contemporary study. But even under such cir­ ly given large amounts of oxygen. This directly reo suIted in the permanent blindness of eight of them."* to call cumstances, the process becomes unethical to the extent that the critic is unaware of all the facts. In addition, the ·sicians. The implications are that the investigation was no more critic who bases his accusation on his perception of a risk­ 'Unless than a coldly scientific exercise. The film's producers were benefit ratio may impugn an experiment or procedure that ractices apparently unaware of the controversy that raged at the ultimately becomes accepted by society on the basis of Je such time of the experiment, and that pediatricians were ex­ its own evaluation of price and profit. Pappworth, for tremely resistant to the idea of not giving high concentra­ example, was particularly critical of coronary angiography, ,rial re­ tions of oxygen to premature babies who otherwise might for he believed that little could be done to treat coronary should die of respiratory failure. Indeed, the controversy is still artery disease even after it had been radiologically defined. . Most, alive. A report in Lancet in 1974 (5) argues that the aban­ Thus, unless he is dealing with a flagrant violation, the ~ady to donment. of high oxygen treatment led to many more ethics of the finger-pointer concern me. If he is assailing editor infant respiratory deaths than the number of blind children a past event, he is applying today's standards to yesterday'S imenta­ that would have resulted had high level oxygen therapy action. If he condemns a contemporary practice, he may f Medi~ been continued. do 30 in ignorance of its future benefits. others Today, of course, increased oxygen concentrations are Jlished. Sensation a lism again used to help premature infants with respiratory are sO distress syndromes to survive, but dangerous blood levels If various professional types do not hesitate to bend ;gestion of the gas can be prevented by the use of techniques of ethics to their own advantage, what can one expect lay )uld be blood oxygen analysis available now but not formerly. analysts to do? Few news items are potentially more sensa­ '!league The irony is that the BBC film could have made a valid tional than charges of "research" doctors maltreating hu­ ight or criticism of the experiments, because appropriate animal , to aC­ tnan beings (the secretary who transcribed my original V of a dictation of this passage wrote, "research doctors' mouths • The narrator presumably referred to a study by Pat'l. Hoeck, and eating human beings"-perhaps a more accurate rendition De La Cruz (4), carried out in Washington. D.C., in which grades III or ~ editor IV retrolental fibroplasia developed in 7 of 28 premature Infants exposed :lor eX- of the idea some reporters wish to convey). Often muck- .- "to high oxygen levels.

Ingelflnger • Medical Ethics 69. 1975 265 studies were not carried out until after the human experi­ reasons, many of wl1ich have been expressed by ment had been completed (6). 51 the validity of this argumen! does not impress me, [] One other aspect of the BBe program is wryly amusing. my concern today about the nonuse of prisoners fOr me~ .". I appear briefly-very briefly-in the film to comment cal experimentation involvel!" another issue-that of

266 August 1975 • Annals of Internal Medicine· Volume 83 • Number 2 , others, subjects are selected, how consent is obtained, and how has attempted to improve th~ ~se 'bf drugs. For over a me, but the study is actually carried out. This type of committee decade, doctors have been expose9. .to congested instruc­ or medi. was originally called a "Protection Committee" but the tions as to the good and bad effects of this or that pre­ of dis- name was changed to "Consent" because the term "pro­ scription drug. But how effecti>'e-has this process been? tection" is pejorative. So now we have a euphemism mis­ Only after Congressional hearing§,.;:.:and other forms of ners has labeling a committee that unequivocally is a protection pUblicity was the improper use of chloramphenicol gradual­ ary with committee. ly curtailed. And even now, large"~care"efforts by the gov­ ;hip not. 3. An Ethical Advisory Board (or Boards) established ernment, the AM A, and the American College of Physi­ ctaEty of in the NIH to advise funding agencies concerning the cians still appear necessary to inculcate the profession at or m£ee­ ethical aspects of applications involving human subjects. large with the basic principles of good antibiotic usage. urges as 4. A National Commission for the Protection of Human Furthermore, when this mass of regulatory chicken wire , troops? Subjects of Biomedical and Behavioral Research. This com­ is wrapped around a researcher what will happen? Many a :t in any mission, already at work, is to study and promulgate basic would-be investigator will be appalled by the rigmarole country ethical principles, study and define consent procedures to in valved and may enter private practice, where, ironically :, will be be used when prisoners, children and institutionalized enough, he will be able to "experiment" with relatively alth, his subjects are involved, and to make special recommenda­ fewer constraints. Popular belief to the contrary, much ro gloria tions concerning fetal research and psychosurgery. systematic research, such as the much-touted randomized unologic 5. Congress, quite apart from this ethical bureaucracy, clinical trial, is intellectually somewhat humdrum. If its t. Should may pass special laws, such as declaring moratoriums on intrinsic laboriousness and complexity are compounded by ? Should research involving fetuses and psychosurgery. many additional conditions and specifications, other in­ rvice, be Surely the creation of this bureau9"atic hierarchy is vestigators will turn to the laboratory bench at the expense w blood laudable in its objectives, but is it practical, and is it of conducting the ultim::l,tely crucial testing in man. Jear im. logical? What will it do to medical research, and most im­ Let us agree that ethical human experimentation must be ?elled to portant, will it make medical research more ethical? inculcated into the practices of the community of clinical 'le. I do Think of the man-hours that must be devoted by con­ researchers. We do need a list of ten ethical command­ mditions sultants, staff and secretaries, of the reams of minutes, ments. A national commission to debate the nature of such 1 as sub­ certificates, statements, and documents that must be pre­ commandments may well serve a good purpose, although lives of pared, duplicated and circulated. Think of the problem of one may wonder if the diverse elements of the Commis­ 10 other­ recruiting informed and unbiased judges to sit on these sion really can reach any consensus. Or will eternal ethical unfair is various committees. Think of the assignment of the consent veri'ties be determined by 6 to 5 votes?* And even should committees: if they are really to police day-by-day experi­ the Commission reach some agreement, will its report be mentation, obviously they have to be around day-by-day. accepted either by the President (recall the Commission on And then, when this bureaucracy of ethics is added to that Obscenity)' or by many of the public (recall the Commis­ ms tried which already exists to evaluate a research proposal on the sion on Marijuana)? promul­ basis of its scientific merits, one has another example of Institutional Ethical Review bodies such as now exist examine a situation where the number of inspectors threatens to also can serve effectively and act as constant reminders and spiralis outnumber the inspectees. deterrents. But all the rest, a hierarchy of review bodies, mts into The logical basis for a bureaucracy of ethics is also and interminable regulations in the futile pursuit of cover­ close to dubious. It appears quite unlikely that a person's moral ing all contingencies not only are superfluous: they ap­ ing, and seeJsibilities can be legislated. Squads of inspectors and a proach the absurd. And to the extent that the absurd is luestion, multitude of writs cannot control the habits and mores of a interjected to bring about ethical behavior, to that extent te trichi­ society, as the futile efforts to enforce prohibition or to ethical regulations become, if not unethical, at least anti­ le ethics contain drug abuse make all too clear. The reaction of ethical. r demo­ bureaucracy to these frustrating facts is predictable: if it I prefer- cannot force a man to entertain certain abstract principles Ethics on the Slippery Slope of moral behavior, it can at least regulate all the tangible My fifth example of the unethical in medical ethics deals ulations, consequences of whatever principles he may have. It can with the untoward effects on public opinion and attitudes Federal create an ever growing pile of rules and administrative when medical ethics becomes a subject of misuse, of un­ tigatiolJ3 procedures to keep the investigator toeing the line. If, Jervised, due preoccupation, or of voguish exploitation. To illustrate moreover, all the contingencies are to be covered, the lines such misuse, I have selected extreme examples not at all of small print will have to be spun forth in endless skeins. representative of the mainstream of medical ethics. Yet it I institu­ But once a rule book becomes too thick its utility dimin­ )proving is just these extremes that in unwarranted proportion cap­ ishes. All can remember and honor the simple rule that you ture attention and influence the public. Ideally, ethics and t institu­ shall not hit b~low the belt, but if there are countless ex­ science should in mutualistic fashion foster finer medical mplying ceptions, when such blows might be allowed, or when practice and research. Innumerable are the problems that ltation. blows on the chest are forbidden, then the force of the call for a concerted effort of this kind. Instead, such is the :t be ap- basic ethic is weakened, the details become more important activity than their essence, the letter of the takes precedence • About 3 weeks after presentation of this paper, the Commission voted lIly dis­ S to 1 (2 members absent) in favor of permitting certain strictly defined OVer its spirit. types of fetal research. At least one subsidiary issue, however, did lead tor hoW A good example is the fine print with which the FDA- to a 5 to 4 split.

lngs/finger • Medical Ethics 267 ••

..' dominance of what one of ethics has become a preoccup-ation if not a vogue. Rule. fll medical ethics that the the makers scramble in competitiy~ haste to introduce some' ft name of ethics, anti-intellectualism and anti-science are new ethical A particularly objectionable con. pi encouraged, hostility to medicine is nourished, clinical in­ sequence is the trivialization~ of ethical 1\ 5i vestigation is compromised if not castrated, and, para­ good example is the idea that- "i~formed consent" must be is doxically enough, the cause of probity itself is harmed. obtained whenever a health worker wishes to examine, for Ethical principles are properly invoked to defend the purposes of research, not onry~a body, but also Di rights, and health of individuals or groups. But tissues removed for therapeutic reasons from that body the pendulum swings too far when tactics are used that and-unbelievably enough-the wastes that that body h~ denigrate scientific inquiry and creativity. Thus programs excreted. labelled as documentary, but more properly identified as "Mr. X," I must ask, "may I have permission to take a propaganda, the cruelty of animal piece of that cancer removed surgically from your the indifference of personnel, the heedlessness of liver, so that I may examine it under the electron micro­ the physician, and the arrogance of the scien- scope? You should realize, of course, that this examination tific In Wiseman's film, Primate, even the will in no way help you to get over your cancer." al crushing of carbon dioxide ice with a hammer is filmed in Or, if I want to compare the usefulness of two tests for oj a way to make the process look ominous. Senatorial occult blood in the stools, must I stand guard at various el rhetoric denounces the use of for experimental appropriately labelled doors and petition each entrant for al purposes. The consequences are what might be his authorizing signature? al Public confidence in medicine is Ridiculous and far-fetched? Far from it. Several institu_ P and the rank growth of malpractice threatens tions have or are contemplating such rules (10). d common sense patient care. The pUblic, instead of being Others, alarmed at the prospect of to examine induced to participate in medical experimentation--to join some frozen blood sample taken some years earlier, but the investigator in a common search for increased know 1- unable to find the sample's owners, are designing release a goal Hans Jonas (8) envisioned-is off, forms that all will be requested to sign, and that convinced that guineapigism will be its lot. Serious and will the institution or the physician blanket permission p humane concerns as to the allocation of scarce medical to study whatever tissues and wastes are collected. More­ a resources, the considered management of those with hope­ over, some legislative proposals would aggravate such less disease, and the pros and cons of abortion for in­ trivialization. A proposal in Massachusetts, for example, r dividual and societal purposes deteriorate into by would prohibit the use of any information obtained from activist groups ever ready to label the opposition as Nazi what is called "health consumers" for the purpose of pre- experimenters or fanatic inquisitors. Whenever medical a medical article-unless the written consent of ethics is used to promote an atmosphere so charged, its use each involved consumer is first obtained. is unethical. The ostensible reason for all such precautions is the Public fears of medical research are readily translated preservation of confidentiality, but confidentiality can be into legislation that is designed to alleviate those fears honored by the use of various strategems. Even the New but that-incidentally or purposefully-hamstrings the Journal of Medicine eliminated some five years search for new knowledge. In Massachusetts, for ago the use of patients' initials in any published report. proposals were considered that would have The goal of confidentiality, moreover, should be viewed barred all fetal research. That such maneuver­ in context. As far as I know, most of us are the subjects of ings were directed against abortion rather than toward dossiers compiled by businessmen, by credit bureaus and, promoting more ethical experimentation is widely sus­ often enough, by government. In such dossiers the nosey pected. Fortunately, the initial bill was modified, and the can discover our foibles and faults, listed not relent- nature of existing laws continues to be examined. but at times erroneously. Countless people already Nevertheless the mere threat of such laws, intensified have access to hospital records, and once peer review aDd by the results of the Edelin trial and the indictment in national health insurance are the order of the day, our Boston of four other fetal researchers for "grave-robbing," privacy will be further eroded. To worry in such a setting, has already exerted a deleterious effect on research. A where sobriety, and sex life may be recorded in­ basic genetic study, for depends on the use of minute detail, about someone discovering that our urine human neonatal foreskins, which otherwise would be dis­ contained oxalate crystals is like pulling down the shade carded after circumcision. Physicians who once supplied another inch in a room completely bugged for the investigator with this material are now hesitant to do sound. so. In another institution, in vitro cultivation of the virus The costs of this trivialization of medical ethics are of infantile gastroenteritis has come to a halt because hu­ siderable. For minor in behalf of confidentiality, man fetal intestinal tissue essential for the organ culture is jor advances in medical knowledge may have to be no longer available. And as pointed out in Science ficed. More alarming, however, is the dilution and (9) development of a flexible amnioscope was turned down depreciation of the important a proliferation of the by an institutional review committee because this com­ trivial. The patient, asked to sign countless releases mittee "thought the situation too risky with respect to the , may respond with a blanket refusal or with law." In the climate that has developed, moreover, meClical proforma signature. The physician, immersed in a

268 August 1975 • Annals of Internal Medicine' Volume 83 • Number 2

~"-~.<:',~ '~." '~f- "'~'t'"~..;' . ,,~". , :e.Li#~'~ , - ~~.. ~.~:iiII;'Ii\l·· ..... _...... - ....< """"i'H ..-!iii.' ..... e. RUle. fusion of unimportant detail will lose sight of, and respect greater contact. The elaborate a~d unavoidably formal in­ ;e some fOf, the important issues. Perhaps he will feel compelled to terchange of a conference such a~. held by the ~ational lIe COlI_ practice defensive ethics-no more honorable than defen­ Academy of Sciences will not do by itself. Ethicists should, lves. 1\ sive medicine. For medical ethics, in short, trivialization as Paul Ramsey did, 'spend months"at"a university hospitaL mUst be is self-defeating. Investigators should involve ethicjstsjn their early planning. line, for Physicians should attend seminars in ethics and philosophy Discussion but also such as those currently sponsored"oy'the ~ational Endow­ 3.t body, The ethicist, real or so-called, finds as he examines ment for the Humanities for health professionals. Local lady has medicine, a pimple here, an inappropriate secretion there, discussion groups should be formed, and at least one such Of even a more widespread but far from universal be­ group functions twice a month in the Boston area under o take a havioral aberration. On such anecdotal evidence, a case the aegis of the Harvard School of Public Health. The om your may be constructed suggesting that medicine is worse than value of these meetings is not-I emphasize not-the for­ 1 micro­ it is. mulation of new ethical concepts, and certainly not the nination I have used similar tactics in criticizing medical ethics elaboration of new ordinances; rather it is the opportunity and may have implied a far more unfavorable impression given to each to become aware of the other's ideas. A tests for of this social science than I actually hold. But if medical national organization promoting such mutual understand· various ethics is to achieve its goal of imbuing medical research ing is exemplified by the Institute of Society, Ethics and :rant for and practice with a loftier , both medical ethics the Life Sciences (the "Hastings Institute"). U nless int~­ and medicine will have to treat more vigorously the grations of this type are aggressively sought, ethics will l institu. pimples, the inappropriate secretions, and the behavioral not exercise the influence it should have in medical re­ :s (10). deviations. search and practice, and medical ethics itself will continue examine How can such goals be attained? to be tainted by unethical exploitation. lier, but One might, in the spirit of the day, establish committees, release commissions, and a gung-ho staff to regulate all those ACKNOWLEDGMENTS: Distinguished Teacher Award Lecture, presented at the 56th Annual Session of the American College of md that regulating medical ethics. A less Kafkaesque but no more Physicians, San Francisco, California, 8 Apri11975. :mission practical suggestion is to ask ethicists to police themselves Received and accepted 14 May 1975. . More. and those who would abuse their discipline. The answer, ... Requests for reprints should be addressed to Franz J. Ingelfinger, te such I hope I have convinced you, is not more fine print, not M.D., New England Journal of Medicine, 10 Shattuck Street, xample, :nore rulemakers. Boston, MA 02115. ~d from Rather, it depends on a continuing and ever more inten­ of pre­ sive consciousness building. The physician must become References lsent of more aware of the ethicist, and vice versa. With all that 1. PAPPWORTH MH: Human Guinea Pigs: Experimentation on Man. London, Routledge and Kegan Paul, Ltd., 1967 has been spoken and written, such advice might appear 2. BEECHER HK: Ethics and clinical research. N Engl J Med 274: i is the gratuitous. But a recent meeting, entitled "Experiments and 1354-1360, 1966 can be Research with Humans: A Conflict in Values," sponsored 3. PAPPWORTH MH: Ethics of human experimentation. Br Med J 2:505,1963 he New by the ~ational Academy of Sciences, showed that a huge 4. PATZ A, HOECK LE, DE LA CRUZ E: Studies on the effect of 'e years gap in understanding still separates the medical scientist high oxygen administration in retrolental fibroplasia. L Nursery rt. observations. Am J Ophthalmol 35: 1248-1252,1952 and the ethical philosopher. 5. BOLTON DPG, CROSS KW: Further observations on cost of pre­ viewed The investigators at this meeting by and large recited venting retrolental fibroplasia. Lancet 1:445-448, 1974 'jects of , the accomplishments of medical research-as if that were 6. ASHTON N, WARD B, SERPELL G: Role of oxygen in the genesis us and, of retrolental fibroplasia: a preliminary report. Br J Ophthalmol an issue! They were on the whole insensitive to the ethical 37: 513-520, 1953 e nosey pressures that society has generated. 7. ~IITFORO J: Experiments behind bars: doctors, drug companies, , relent· Some philosophers, on the other hand, insisted that the and prisoners. The Atlantic Monthly 231 :64-73, 1973 8. JONAS H: Philosophical reflections on experimenting with human already care of patients should be the result of categorical ab­ subjects. Daedalus, Spring:219-247, 1969 ewand , solutes, that a balance of risks and benefits should play no 9. CULLITON BJ: Fetal research. III. The impact of a Massa­ ay, our chusetts law. Science 187:1175-1176,1975 role. How abysmally ignorant of medical practice is such 10. ALTMAN LK: New rules spark controversy over human biologic setting. a position! It was all very disheartening*. materials. New York Times, 30 April 1974, p. 35 rded in Greater understanding can be achieved by promotion of 11. JONSEN AR: The ethics of experimentation. Science 188:98, r urine 100, 1975 12. GAYLIN W, GORovITZ S: Academy forum: science and its : shade -• Aiter presentation of this paper, similar opinions w,~re voiced by JOnsen (11) and Gaylin and Gorovitz (12). critics. Science 188:315, 1975 ~ht and

re con­ ty, ma­ e saco,.' nd the of the lses or with a a pro-

Ingelfinger • Medical Ethics 269