Racism and Research: the Case of the Tuskegee Syphilis Study

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Racism and Research: The Case of the Tuskegee Syphilis Study

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Citation Brandt, Allan M. 1978. "Racism and research: The case of the Tuskegee Syphilis study." The Hastings Center Report 8(6): 21-29.

Published Version http://www.jstor.org/stable/3561468

Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:3372911

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Racism and Research: The Case of the Tuskegee Syphilis Study by ALLAN M. BRANDT

ale for Americanracism.3 Essentially primitive peoples, it was argued,could not be assimilatedinto a complex, white In 1932 the U.S. PublicHealth Service (USPHS) initiated civilization.Scientists speculated that in the strugglefor sur- an experimentin MaconCounty, Alabama, to determinethe vival the Negro in Americawas doomed.Particularly prone naturalcourse of untreated,latent syphilis in black males. to disease, vice, and crime, black Americanscould not be The test comprised400 syphiliticmen, as well as 200 unin- helpedby educationor philanthropy.Social Darwinistsana- fectedmen who servedas controls.The firstpublished report lyzed census data to predict the virtual extinction of the of the studyappeared in 1936 with subsequentpapers issued Negro in the twentiethcentury, for they believed the Negro every four to six years, throughthe 1960s. When penicillin race in Americawas in the throes of a degenerativeevolu- becamewidely availableby the early 1950s as the preferred tionaryprocess.4 treatmentfor syphilis,the men did not receive therapy.In The medical professionsupported these findingsof late fact on severaloccasions, the USPHSactually sought to pre- nineteenth-and earlytwentieth-century anthropologists, eth- vent treatment.Moreover, a committeeat the federallyop- nologists, and biologists. Physiciansstudying the effects of eratedCenter for Disease Controldecided in 1969 that the emancipationon health concluded almost universallythat study shouldbe continued.Only in 1972, when accountsof freedom had caused the mental, moral, and physical dete- the studyfirst appeared in the nationalpress, did the Depart- riorationof the black population.5They substantiatedthis ment of Health,Education and Welfarehalt the experiment. argumentby citing examplesin the comparativeanatomy of At that time seventy-fourof the test subjectswere still alive; the black and white races. As Dr. W. T. Englishwrote: "A at least twenty-eight,but perhapsmore than 100, had died careful inspectionreveals the body of the negro a mass of directlyfrom advancedsyphilitic lesions.1 In August 1972, minordefects and imperfectionsfrom the crown of the head HEW appointedan investigatorypanel which issued a report to the soles of the feet.. .." Cranial structures, wide nasal the followingyear. The panel found the studyto have been apertures,receding chins, projectingjaws, all typed the Ne- "ethically unjustified,"and argued that penicillin should gro as the lowest species in the Darwinianhierarchy.7 have been providedto the men.2 Interestin racialdifferences centered on the sexualnature This articleattempts to place the TuskegeeStudy in a his- of blacks.The Negro, doctorsexplained, possessed an exces- toricalcontext and to assess its ethicalimplications. Despite sive sexual desire,which threatenedthe very foundationsof the mediaattention which the studyreceived, the HEWFinal white society. As one physiciannoted in the Journalof the Report, and the criticismexpressed by several professional American Medical Association, "The negro springs from a organizations,the experimenthas been largely misunder- southernrace, and as such his sexual appetiteis strong;all stood. The mostbasic questionsof how the studywas under- of his environmentsstimulate this appetite,and as a general taken in the firstplace and why it continuedfor forty years rule his emotional type of religion certainly does not de- were never addressedby the HEW investigation.Moreover, crease it."8 Doctors reported a complete lack of morality on the panel misconstruedthe natureof the experiment,failing the part of blacks: to consult documentsavailable at the National important Virtue in the negro race is like angels' visits-few and far Archiveswhich bear significantlyon its ethical assessment. between.In a of sixteen I have never examined the in which values are practice years Only by examining specific ways a virgin negro over fourteen years of age.9 engagedin scientificresearch can the study be understood. A particularlyominous feature of this overzealoussexuality, doctors was the blackmales' desire for whitewomen. Racismand MedicalOpinion argued, "A perversionfrom which most races are exempt,"wrote A brief reviewof the prevailingscientific thought regard- Dr. English,"prompts the negro'sinclination towards white ing race and heredityin the earlytwentieth century is funda- women,whereas other races inclinetowards females of their mental for an understandingof the TuskegeeStudy. By the own."10Though English estimatedthe "graymatter of the turn of the century,Darwinism had provideda new ration- negro brain"to be at least a thousandyears behindthat of the white races, his genital organswere overdeveloped.As Dr. WilliamLee Howardnoted: ALLAN M. BRANDT is a doctoralcandidate in the Department of History, Columbia University. He is presently writing a The attacks on defenseless white women are evidences of social history of venereal disease in the United States. Mr. racial instinctsthat are about as amenableto ethical culture Brandt was a student intern at The Hastings Center in 1977. as is the inherentodor of the race .... When education will

The HastingsCenter 21 I I

reduce the size of the negro'spenis as well as bring about the possibilities for mass treatment. The USPHS found Macon sensitivenessof the terminalfibers which exist in the Cauca- County, Alabama, in which the town of Tuskegee is located, sian, then will it also be able to prevent the African's birth- to have the highest syphilis rate of the six counties surveyed. right to sexual madness and excess." The Rosenwald Study concluded that mass treatment could be One southern medical "Castration Instead successfully implemented among rural blacks.19Although journal proposed it is doubtful that the funds would have been allo- of Lynching," as retribution for black sexual crimes. "An necessary cated even in the best economic conditions, after the econ- impressive trial by a ghost-like kuklux klan [sic] and a 'ghost' or to the would make omy collapsed in 1929, the findings were ignored. It is, how- physician surgeon perform operation ironic that the to it an event the would never noted the edi- ever, Tuskegee Study came be based on 'patient' forget," of Rosenwald torial.12 findings the Study that demonstrated the possibilities of treatment. to these lust and un- mass According physicians, immorality, Three in Dr. Taliaferro Chief of stable families, and reversion to barbaric tendencies made years later, 1932, Clark, the USPHS Venereal blacks to venereal diseases. One doctor esti- Disease Division and author of the especially prone Rosenwald mated that over 50 of all over the of Study report, decided that conditions in Macon percent Negroes age merited were free of disease as County renewed attention. Clark believed the high twenty-five syphilitic.13 Virtually of offered an "unusual for slaves, were now overwhelmed it, to in- prevalence syphilis opportunity" they by according observation. From its the USPHS the formed medical opinion. Moreover, doctors believed that inception, regarded Tuskegee Study as a classic in nature,"* rather than treatment for venereal disease among blacks was impossible, "study an experiment.20As long as was so in Ma- particularly because in its latent stage the symptoms of syph- syphilis prevalent con and most of the blacks went untreated life, ilis become quiescent. As Dr. Thomas W. Murrell wrote: throughout it seemed only natural to Clark that it would be valuable to They come for treatment at the beginning and at the end. observe the consequences. He described it as a "ready-made When there are visible manifestationsor when harried by situation."21Surgeon General H. S. Cumming wrote to R. R. pain, they readily come, for as a race they are not averse to Moton, Director of the Tuskegee Institute: but tell them not, look well and feel well, physic; though they The recent control demonstrationcarried out in Ma- that are still diseased. Here rates science a syphilis they ignorance con with the financialassistance of the Julius Rosen- fool... 14 County, wald Fund, revealed the presence of an unusually high rate Even the best educated black, according to Murrell, could in this county and, what is more remarkable,the fact that 99 not be convinced to seek treatment for syphilis.15Venereal per cent of this group was entirely without previous treat- disease, according to some doctors, threatened the future of ment. This combination,together with the expected coopera- the race. The medical profession attributed the low birth rate tion of your hospital, offers an unparalleledopportunity for among blacks to the high prevalence of venereal disease carryingon this piece of scientific research which probably which caused stillbirths and miscarriages. Moreover, the cannot be duplicated anywhere else in the world.22 rates of were to lead to increased in- high syphilis thought no formal to have been writ- and crime. One doctor at the turn of the cen- Although protocol appears sanity writing several letters of Clark and what the estimated that the number of insane had in- ten, Cumming suggest tury Negroes USPHS to find. Clark indicated that it would be im- creased thirteen-fold since the end of the Civil War.'1 Dr. hoped portant to see how disease affected the daily lives of the men: Murrell's conclusion echoed the most informed anthropo- logical and ethnological data: The results of these studies of case recordssuggest the desira- bility of making a further study of the effect of untreated So the scourge sweeps among them. Those that are treated syphilison the humaneconomy among people now living and are only half cured, and the effort to assimilate a complex engaged in their daily pursuits.23 civilization driving their diseased minds until the results are criminal records.Perhaps here, in conjunctionwith tubercu- It also seems that the USPHS believed the experiment might losis, will be the end of the negro problem. Disease will ac- demonstrate that antisyphilitic treatment was unnecessary. complish what man cannot do.17 As Cumming noted: "It is expected the results of this study may have a marked bearing on the treatment, or conversely This particular configuration of ideas formed the core of the non-necessity of treatment, of cases of latent syphilis."24 medical concerning blacks, sex, and disease in the opinion The immediate source of Cumming's hypothesis appears twentieth Doctors generally discounted socio- early century. to have been the famous Oslo Study of untreated syphilis. Be- economic of the state of black health, explanations arguing tween 1890 and 1910, Professor C. Boeck, the chief of the that better medical care could not alter the evolutionary scheme.'8 These the for ex- assumptions provide backdrop *In 1865, ClaudeBernard, the famous Frenchphysiologist, out- amining the Tuskegee Syphilis Study. linedthe distinctionbetween a "studyin nature"and experimentation. A studyin naturerequired simple observation, an essentiallypassive which The of the act, while experimentationdemanded intervention alteredthe Origins Experiment originalcondition. The TuskegeeStudy was thus clearlynot a study in nature.The act of alteredthe conditions. from the Julius Rosenwald very diagnosis original In 1929, under a grant Fund, "Itis on this verypossibility of actingor not actingon a body,"wrote the USPHS conducted studies in the rural South to determine Bernard,"that the distinctionwill exclusivelyrest betweensciences the prevalence of syphilis among blacks and explore the callscincfalledsciences of observationn and sciencesens called experimental."

22 Hastings Center Report, December 1978 I

Oslo Venereal Clinic, withheld treatment from almost two of treating latent syphilis, suggested that existing knowledge thousand patients infected with syphilis. He was convinced did not apply to Negroes. Although he had called the Oslo that therapies then available, primarily mercurial ointment, Study "a never-to-be-repeated human experiment,"32 he were of no value. When arsenic therapy became widely avail- served as an expert consultant to the Tuskegee Study: able after Paul Ehrlich's historic of "606," by 1910, discovery I think that such a study as you have contemplatedwould be the was abandoned. E. Boeck's successor, study Bruusgaard, of immense value. It will be necessary of course in the con- conducted a of 473 of the untreated follow-up study patients siderationof the results to evaluate the special factors intro- from 1925 to 1927. He found that 27.9 of these percent pa- duced by a selection of the materialfrom negro males. Syph- tients had a and now mani- undergone "spontaneous cure," ilis in the negro is in many respectsalmost a differentdisease fested no of the disease. he estimated symptoms Moreover, from syphilis in the white.33 that as many as 70 percent of all syphilitics went through life without inconvenience from the disease.25 His study, how- Dr. O. C. Wenger, chief of the federally operated venereal ever, clearly acknowledged the dangers of untreated syphilis disease clinic at Hot Springs, Arkansas, praised Moore's for the remaining 30 percent. judgment, adding, "This study will emphasize those differ- Thus every major textbook of syphilis at the time of the ences."34On another occasion he advised Clark, "We must Tuskegee Study's inception strongly advocated treating remember we are dealing with a group of people who are syphilis even in its latent stages, which follow the initial in- illiterate, have no conception of time, and whose personal flammatory reaction. In discussing the Oslo Study, Dr. J. E. history is always indefinite."35 Moore, one of the nation's leading venereologists wrote, The doctors who devised and directed the Tuskegee Study "This summary of Bruusgaard's study is by no means in- accepted the mainstream assumptions regarding blacks and and tended to suggest that syphilis be allowed to pass un- venereal disease. The premise that blacks, promiscuous the treated."26If a complete cure could not be effected, at least lustful, would not seek or continue treatment, shaped "natural" because the most devastating effects of the disease could be avoided. study. A test of untreated syphilis seemed never be the Although the standard therapies of the time, arsenical com- the USPHS presumed the men would treated; made that a pounds and bismuth injection, involved certain dangers be- Tuskegee Study self-fulfilling prophecy. cause of their toxicity, the alternatives were much worse. As the Oslo Study had shown, untreated syphilis could lead to Selecting the Subjects cardiovascular disease, insanity, and premature death.27 Moore wrote in his 1933 textbook: Clark sent Dr. Raymond Vonderlehr to Tuskegee in Sep- tember 1932 to assemble a sample of men with latent syph- it a measurablerisk of its own, Though imposes slight though ilis for the experiment. The basic design of the study called treatment diminishesthe risk from In la- markedly syphilis. for the selection of syphilitic black males between the ages tent as I shall show, the of syphilis, probability progression, of twenty-five and sixty, a thorough physical examination or death is reduced from a 25-30 relapse, probable percent including x-rays, and finally, a spinal tap to determine the without treatmentto about 5 with it; and the percent gravity incidence of neuro-syphilis.3(;They had no intention of pro- of the if it is diminished.28 relapse occurs, markedly viding any treatment for the infected men.:7 The USPHS "Another compelling reason for treatment," noted Moore, originally scheduled the whole experiment to last six months; "exists in the fact that every patient with latent syphilis may it seemed to be both a simple and inexpensive project. to be be, and perhaps is, infectious for others."29In 1932, the year The task of collecting the sample, however, proved Vonderlehr in which the Tuskegee Study began, the USPHS sponsored more difficult than the USPHS had supposed. and published a paper by Moore and six other syphilis ex- canvassed the largely illiterate, poverty-stricken population farmers in search of test sub- perts that strongly argued for treating latent syphilis.30 of sharecroppers and tenant men over to The Oslo Study, therefore, could not have provided justi- jects. If his circulars requested only twenty-five he was fication for the USPHS to undertake a study that did not attend his clinics, none would appear, suspecting he was forced to test entail treatment. Rather, the suppositions that conditions in conducting draft physicals. Therefore, and men who did not fit the Tuskegee existed "naturally" and that the men would not be large numbers of women experi- This involved considerable treated anyway provided the experiment's rationale. In turn, ment's specifications. expense had the Macon Board of these two assumptions rested on the prevailing medical atti- since the USPHS promised County treat those who were infected, but not tudes concerning blacks, sex, and disease. For example, Health that it would in the Clark wrote to Vonderlehr about the Clark explained the prevalence of venereal disease in Macon included study.38 "It never once occured to me that we would be County by emphasizing promiscuity among blacks: situation: called upon to treat a large part of the county as return for state of affairsis due to the of doctors,rather low This paucity the privilege of making this study.... I am anxious to keep the in this section, intelligenceof Negro population depressed the expenditures for treatment down to the lowest possible and the common sex economic conditions, very promiscuous point because it is the one item of expenditure in connection which not contribute relations of this populationgroup only with the study most difficult to defend despite our knowl- of but also contributeto the to the spread syphilis prevailing edge of the need therefor."39Vonderlehr responded: "If we indifferencewith regardto treatment.31 could find from 100 to 200 cases ... we would not have to individuals In fact, Moore, who had written so persuasively in favor do another Wassermann on useless .. ."4

23 The HastingsCenter Significantly, the attempt to develop the sample contra- treatment." Clark explained to Moore: dicted the the USPHS had made prediction initially regarding We have not commencedthe This the of the disease in Macon Overall rates yet spinal punctures. oper- prevalence County. ation will be deferredto the last in order not to disturb of fell well below as to the unduly syphilis expectations; opposed our field work adverse the sub- USPHS of 35 20 of those tested by any reports by patients projection percent, percent to because of some sensa- were diseased.41 those who had jected spinal puncture disagreeable actually Moreover, sought tions this These are and received treatment far exceeded the following procedure. negroes very igno- previous expecta- rant and influenced that would be of minor tions of the USPHS. Clark noted in a letter to Vonderlehr: easily by things significancein a more intelligent group.48 I find your report of March 6th quite interestingbut regret The letter to the subjects announcing the spinal tap read: the necessity for Wassermanning[sic] . . . such a large number of individualsin order to uncover this relatively limited Some time ago you were given a thorough examinationand numberof untreatedcases.42 since that time we hope you have gotten a great deal of treatment for bad blood. You will now be last chance Further difficulties arose in the to given your enlisting subjects par- to get a second examination.This examinationis a very spe- in the to be "Wassermanned," and to ticipate experiment, cial one and after it is finished you will be given a special return for a subsequent series of examinations. Vonderlehr treatmentif it is believed are in a conditionto stand it.... elicited the you found that only the offer of treatment coopera- REMEMBERTHIS IS YOUR LAST CHANCEFOR SPECIAL tion of the men. were told were ill and were They they prom- FREE TREATMENT. BE SURE TO MEET THE NURSE.49 ised free care. Offered therapy, they became willing subjects.43 The USPHS did not tell the men that they were The HEW investigation did not uncover this crucial fact: the participants in an experiment; on the contrary, the subjects men participated in the study under the guise of treatment. believed they were being treated for "bad blood"-the rural Despite the fact that their assumption regarding preva- South's colloquialism for syphilis. They thought they were lence and black attitudes toward treatment had proved participating in a public health demonstration similar to the wrong, the USPHS decided in the summer of 1933 to con- one that had been conducted by the Julius Rosenwald Fund tinue the study. Once again, it seemed only "natural"to pur- in Tuskegee several years earlier. In the end, the men were sue the research since the sample already existed, and with so eager for medical care that the number of defaulters in a depressed economy, the cost of treatment appeared pro- the experiment proved to be insignificant.44 hibitive-although there is no indication it was ever consid- To preserve the subjects' interest, Vonderlehr gave most ered. Vonderlehr first suggested extending the study in letters of the men mercurial ointment, a noneffective drug, while to Clark and Wenger: some of the men received younger apparently inadequate At the end of this projectwe shall have a considerablenum- of This Vonderlehr to dosages neoarsphenamine.45 required ber of cases presentingvarious complicationsof syphilis,who write to Clark He feared the frequently requesting supplies. have received only mercury and may still be consideredun- would fail if the men were not offered treatment. experiment treatedin the modernsense of therapy.Should these cases be It is desirableand essential if the study is to be a success to followed over a period of from five to ten years many inter- maintain the interest of each of the cases examined by me esting facts could be learned regardingthe course and com- through to the time when the spinal puncture can be complications of untreatedsyphilis.50 of several hundred dollars for for pleted. Expenditure drugs "As I see "we have no further inter- these men would be well worth while if their interestand co- it," responded Wenger, est in these patients until they die."51Apparently, the physi- operationwould be maintainedin so doing.... It is my desire cians engaged in the experiment believed that only autopsies to keep the main purposeof the work from the negroesin the could scientifically confirm the findings of the study. Surgeon county and continue their interestin treatment.That is what General Cumming explained this in a letter to R. R. Moton, the vast majoritywants and the examinationseems relatively requesting the continued cooperation of the Tuskegee Insti- unimportantto them in comparison.It would probablycause tute Hospital: the entire experimentto collapse if the clinics were stopped before the work is completed.46 This study which was predominantlyclinical in character of severe in- On another occasion he explained: points to the frequent occurrence complications the variousvital of the and indicatesthat Dozens of patients have been sent away without treatment volving organs body as a disease does a deal of Since clin- duringthe past two weeks and it would have been impossible syphilis great damage. ical observations are not considered final in the medical to continue without the free distributionof drugs because of world, it is our desire to continue observation on the cases the unfavorableimpression made on the negro.47 selected for the recent study and if possible to bring a per- The readiness of the test subjects to participate of course centage of these cases to autopsy so that pathological con- contradicted the notion that blacks would not seek or con- firmationmay be made of the disease processes.52 tinue therapy. The final procedure of the experiment was to be a spinal Bringing the men to autopsy required the USPHS to de- tap to test for evidence of neuro-syphilis. The USPHS pre- vise a further series of deceptions and inducements. Wenger sented this purely diagnostic exam, which often entails con- warned Vonderlehr that the men must not realize that they siderable pain and complications, to the men as a "special would be autopsied:

24 Hastings Center Report, December 1978 There is one dangerin the latterplan and that is if the colored They simply do not like spinal punctures.A few of those who population become aware that accepting free hospital care were tapped are enthusiasticover the results but to most, the means a post-mortem,every darkey will leave Macon County suggestion causes violent shaking of the head; others claim and it will hurt [Dr. Eugene] Dibble's hospital.'53 they were robbed of their procreativepowers (regardlessof the fact that I claim it stimulatesthem).59 "Naturally," responded Vonderlehr, "it is not my intention to let it be generally known that the main object of the pres- Letters to the subjects announcing an impending USPHS ent activities is the bringing of the men to necropsy."54The visit to Tuskegee explained: "[The doctor] wants to make subjects' trust in the USPHS made the plan viable. The a special examination to find out how you have been feeling USPHS gave Dr. Dibble, the Director of the Tuskegee Insti- and whether the treatment has improved your health."60In tute Hospital, an interim appointment to the Public Health fact, after the first six months of the study, the USPHS had Service. As Wenger noted: furnished no treatment whatsoever. because it difficult to the men to One thing is certain. The only way we are going to get post- Finally, proved persuade come to the when became the mortemsis to have the demise take place in Dibble'shospital hospital they severely ill, and when these colored folks are told that Doctor Dibble is USPHS promised to cover their burial expenses. The Mil- bank Memorial Fund $50 man now a Government doctor too they will have more confi- provided approximately per dence.55* for this purpose beginning in 1935. This was a particularly strong inducement as funeral rites constituted an important After the USPHS approved the continuation of the ex- component of the cultural life of rural blacks.61 One report periment in 1933, Vonderlehr decided that it would be nec- of the study concluded, "Without this suasion it would, we essary to select a group of healthy, uninfected men to serve believe, have been impossible to secure the cooperation of as controls. Vonderlehr, who had succeeded Clark as Chief the group and their families."62 of the Venereal Disease Division, sent Dr. J. R. Heller to Reports of the study's findings, which appeared regularly Tuskegee to gather the control group. Heller distributed in the medical press beginning in 1936, consistently cited the drugs (noneffective) to these men, which suggests that they ravages of untreated syphilis. The first paper, read at the also believed they were undergoing treatment.5;' Control 1936 American Medical Association annual meeting, found subjects who became syphilitic were simply transferred to "that syphilis in this period [latency] tends to greatly increase the test group-a strikingly inept violation of standard re- the frequency of manifestations of cardiovascular disease."63 search procedure.57 Only 16 percent of the subjects gave no sign of morbidity The USPHS offered several inducements to maintain con- as opposed to 61 percent of the controls. Ten years later, a tact and to procure the continued cooperation of the men. report noted coldly, "The fact that nearly twice as large a Eunice Rivers, a black nurse, was hired to follow their health proportion of the syphilitic individuals as of the control and to secure approval for autopsies. She gave the men non- group has died is a very striking one." Life expectancy, con- effective medicines-"spring tonic" and aspirin-as well as cluded the doctors, is reduced by about 20 percent.64 transportation and hot meals on the days of their examina- A 1955 article found that slightly more than 30 percent tions.58 More important, Nurse Rivers provided continuity of the test group autopsied had died directly from advanced to the project over the entire forty-year period. By supplying syphilitic lesions of either the cardiovascular or the central "medicinals," the USPHS was able to continue to deceive the nervous system.65 Another published account stated, "Re- participants, who believed that they were receiving therapy view of those still living reveals that an appreciable number the from the government doctors. Deceit was integral to have late complications of syphilis which probably will re- study. When the test subjects complained about spinal taps sult, for some at least, in contributing materially to the ulti- one doctor wrote: mate cause of death.""6In 1950, Dr. Wenger had concluded, "We now know, where we could only surmise before, that we *Thedegree of blackcooperation in conductingthe studyremains have contributed to their ailments and shortened their unclearand would be impossibleto properlyassess in an articleof this lives."67As black physician Vernal Cave, a member of the length.It seemscertain that some members of the TuskegeeInstitute HEW panel, later wrote, "They proved a point, then proved staffsuch as R. R. Motonand EugeneDibble understood the nature a then a of the experimentand gave their supportto it. There is, however, point, proved point."68 evidencethat some blackswho assistedthe USPHSphysicians were During the forty years of the experiment the USPHS had not aware of the deceptivenature of the experiment.Dr. Joshua sought on several occasions to ensure that the subjects did Williams,an intern at the John A. Andrew MemorialHospital not receive treatment from other sources. To this end, Von- in assistedVonderlehr in blood (TuskegeeInstitute) 1932, taking derlehr met with of local black doctors in 1934, to samplesof the test subjects.In 1973he told the HEWpanel: "I know groups we thoughtit was merelya servicegroup organized to helpthe people ask their cooperation in not treating the men. Lists of sub- in thearea. We didn't know it wasa researchproject at all at thetime." jects were distributed to Macon County physicians along (See, "Transcriptof Proceedings,"Tuskegee Syphilis Study Ad Hoc with letters them to refer these men back to the National requesting AdvisoryPanel, February 23, 1973,Unpublished typescript. USPHS if care.69 The USPHS warned the Ala- Libraryof Medicine,Bethesda, Maryland.) It is also apparentthat they sought EuniceRivers, the black nursewho had primaryresponsibility for bama Health Department not to treat the test subjects when not maintainingcontact with the men over the forty years,did fully they took a mobile VD unit into Tuskegee in the early understandthe of the In blackinvolve- dangers experiment. anyevent, In the drafted several and told mentin the studyin no way mitigatesthe racialassumptions of the 1940s.T0 1941, Army subjects experiment,but rather,demonstrates their power. them to begin antisyphilitic treatment immediately. The

The HastingsCenter 25 USPHS supplied the draft board with a list of 256 names cide whether or not to terminate the study. Although one they desired to have excluded from treatment, and the board doctor argued that the study should be stopped and the men complied.7" treated, the consensus was to continue. Dr. J. Lawton Smith In spite of these efforts, by the early 1950s many of the remarked, "You will never have another study like this; take men had secured some treatment on their own. By 1952, advantage of it."7TA memo prepared by Dr. James B. Lucas, almost 30 percent of the test subjects had received some Assistant Chief of the Venereal Disease Branch, stated: penicillin, although only 7.5 percent had received what could "Nothing learned will prevent, find, or cure a single case of be considered adequate doses.72 Vonderlehr wrote to one of infectious syphilis or bring us closer to our basic mission of the participating physicians, "I hope that the availability of controlling venereal disease in the United States."77He con- antibiotics has not interfered too much with this project."73 cluded, however, that the study should be continued "along A report published in 1955 considered whether the treat- its present lines." When the first accounts of the experiment ment that some of the men had obtained had "defeated" the appeared in the national press in July 1972, data were still study. The article attempted to explain the relatively low ex- being collected and autopsies performed.78 posure to penicillin in an age of antibiotics, suggesting as a reason: stoicism of "the these men as a group; they still re- The HEW Final Report gard hospitals and medicines with suspicion and prefer an occasional dose of time-honored herbs or tonics to modern HEW finally formed the Tuskegee Syphilis Study Ad Hoc drugs."74The authors failed to note that the men believed Advisory Panel on August 28, 1972, in response to criticism they already were under the care of the government doctors that the press descriptions of the experiment had triggered. and thus saw no need to seek treatment elsewhere. Any The panel, composed of nine members, five of them black, treatment which the men might have received, concluded concentrated on two issues. First, was the study justified in the report, had been insufficient to compromise the experi- 1932 and had the men given their informed consent? Second, ment. should penicillin have been provided when it became avail- When the USPHS evaluated the status of the study in the able in the early 1950s? The panel was also charged with 1960s they continued to rationalize the racial aspects of the determining if the study should be terminated and assessing experiment. For example, the minutes of a 1965 meeting at current policies regarding experimentation with human sub- the Center for Disease Control recorded: jects.79The group issued their report in June 1973. on the issues of and in- Racial issue was mentioned Will not affect the By focusing penicillin therapy briefly. study. formed the Final and the be- can be handled these were at consent, Report investigation Any questions by saying people a basic of the the that would no them. are trayed misunderstanding experiment's purposes point therapy longer help They and The HEW that the failure to better medical care than would under other design. report implied pro- getting they any vide constituted the ethical circumstances.75 penicillin study's major misjudg- ment; implicit was the assumption that no adequate therapy A group of physicians met again at the CDC in 1969 to de- existed prior to penicillin. Nonetheless medical authorities

Claude Bernard on Human Experimentation (1865) From the HEW Final Report (1973) Experiments,then, may be performedon man, but within 1. In retrospect, the Public Health Service Study of what limits? It is our duty and our right to perform an UntreatedSyphilis in the Male Negro in Macon County, experimenton man wheneverit can save his life, cure him Alabama, was ethically unjustifiedin 1932. This judge- or gain him some personalbenefit. The principleof med- ment made in 1973 aboutthe conduct of the study in 1932 ical and surgical morality, therefore, consists in never is made with the advantageof hindsightacutely sharpened performingon man an experimentwhich might be harm- over some forty years, concerningan activity in a different ful to him to any extent, even though the result might be age with differentsocial standards.Nevertheless, one fun- highly advantageousto science, i.e., to the health of others. damental ethical rule is that a person should not be sub- But performing experiments and operations exclusively jected to avoidable risk of death or physical harm unless from the point of view of the patient'sown advantagedoes he freely and intelligentlyconsents. There is no evidence not preventtheir turningout profitablyto science. ... For that such consent was obtained from the participantsin we must not deceive ourselves,morals do not forbid mak- this study. ing experimentson one's neighboror on one's self. Chris- 2. Because of the paucity of informationavailable to- tian morals forbid only one thing, doing ill to one's neigh- day on the manner in which the study was conceived, de- bor. So, among the experimentsthat may be tried on man, signed and sustained, a scientific justificationfor a short those that can only harm are forbidden, those that are term demonstrationstudy cannot be ruled out. However, innocent are permissible,and those that may do good are the conduct of the longitudinalstudy as initially reported obligatory.Claude Bernard,An Introductionto the Study in 1936 and throughthe years is judgedto be scientifically of Experimental Medicine (1865). Trans. by Henry C. unsound and its results are disproportionatelymeager Green (New York: Dover Publications,1957). comparedwith knownrisks to humansubjects involved....

26 HastingsCenter Report, December 1978 firmly believed in the efficacy of arsenotherapy for treating ford University wrote in 1974, "The lack of treatment was syphilis at the time of the experiment's inception in 1932. not contrived by the USPHS but was an established fact of The panel further failed to recognize that the entire study which they proposed to take advantage."86Several doctors had been predicated on nontreatment. Provision of effective who participated in the study continued to justify the experi- medication would have violated the rationale of the experiment. Dr. J. R. Heller, who on one occasion had referred to ment-to study the natural course of the disease until death. the test subjects as the "Ethiopian population," told reporters On several occasions, in fact, the USPHS had prevented the in 1972: men from there no receiving proper treatment. Indeed, is evi- I don't see should be shocked or horrified.There dence that the USPHS ever considered why they providing penicillin. was no racial side to this. It just to be in a black The other focus of the Final consent- happened Report-informed community.I feel this was a perfectly straightforwardstudy, also served to obscure the historical facts of the experiment. ethical, with controls. Part of our mission as physi- In of the and which the perfectly light deceptions exploitations experi- cians is to find out what happens to individualswith disease ment perpetrated, it is an understatement to declare, as the and without disease.87 Report did, that the experiment was "ethically unjustified," because it failed to obtain informed consent from the sub- These apologies, as well as the HEW Final Report, ignore jects. The Final Report's statement, "Submitting voluntarily many of the essential ethical issues which the study poses, is not informed consent," indicated that the panel believed The Tuskegee Study reveals the persistence of beliefs within that the men had volunteered for the experiment.80 The rec- the medical profession about the nature of blacks, sex, and ords in the National Archives make clear that the men did disease-beliefs that had tragic repercussions long after their not submit voluntarily to an experiment; they were told and alleged "scientific" bases were known to be incorrect. Most they believed that they were getting free treatment from strikingly, the entire health of a community was jeopardized expert government doctors for a serious disease. The failure by leaving a communicable disease untreated.88There can be of the HEW Final Report to expose this critical fact-that little doubt that the Tuskegee researchers regarded their the USPHS lied to the subjects-calls into question the subjects as less than human.89As a result, the ethical canons thoroughness and credibility of their investigation. of experimenting on human subjects were completely disre- Failure to place the study in a historical context also made garded. it impossible for the investigation to deal with the essentially The study also raises significant questions about profes- racist nature of the experiment. The panel treated the study sional self-regulation and scientific bureaucracy. Once the as an aberration, well-intentioned but misguided.81 More- USPHS decided to extend the experiment in the summer of over, concern that the Final Report might be viewed as a 1933, it was unlikely that the test would be halted short of critique of human experimentation in general seems to have the men's deaths. The experiment was widely reported for severely limited the scope of the inquiry. The Final Report forty years without evoking any significant protest within the is quick to remind the reader on two occasions: "The posi- medical community. Nor did any bureaucratic mechanism tion of the Panel must not be construed to be a general re- exist within the government for the periodic reassessment of pudiation of scientific research with human subjects."82The the Tuskegee experiment's ethics and scientific value. The Report assures us that a better designed experiment could USPHS sent physicians to Tuskegee every several years to have been justified: check on the study's progress, but never subjected the morality or usefulness of the experiment to serious scrutiny. Only It is that a scientific in 1932 of untreated possible study syph- the press accounts of 1972 finally punctured the continued conceived with a clear and conducted ilis, properly protocol rationalizations of the USPHS and brought the study to an with suitable who understood the subjects fully implications end. Even the HEW investigation was compromised by fear of their have been in the involvement, might justified pre- that it would be considered a threat to future human experi- penicillin era. This is especially true when one considersthe mentation. uncertain nature of the results of treatment of late latent In retrospect the Tuskegee Study revealed more about the and the toxic natureof then syphilis highly therapeuticagents pathology of racism than it did about the pathology of syph- available.83 ilis; more about the nature of scientific inquiry than the na- The This statement is questionable in view of the proven dangers ture of the disease process. injustice committed by the outlined the of untreated syphilis known in 1932. experiment went well beyond the facts in press The and Since the publication of the HEW Final Report, a defense and the HEW Final Report. degree of deception As of the Tuskegee Study has emerged. These arguments, most damages have been seriously underestimated. this history of the notion that science is a value-free clearly articulated by Dr. R. H. Kampmeier in the Southern the study suggests, Medical Journal, center on the limited knowledge of effec- discipline must be rejected. The need for greater vigilance in the in which sooial values and atti- tive therapy for latent syphilis when the experiment began. assessing specific ways behavior is indicated. Kampmeier argues that by 1950, penicillin would have been tudes affect professional clearly of no value for these men.84 Others have suggested that the men were fortunate to have been spared the highly toxic REFERENCES treatments of the earlier period.85 Moreover, even these contemporary defenses assume that the men never would 'The best generalaccounts of the studyare "The40-Year Death have been treated anyway. As Dr. Charles Barnett of Stan- Watch," Medical World News (August 18, 1972), pp. 15-17; and

The HastingsCenter 27 1.

Dolores Katz, "Why 430 Blacks with Syphilis Went Uncured for 40 16"Deteriorationof the American Negro," Atlanta Journal-Record Years," Detroit Free Press (November 5, 1972). The mortality figure of Medicine 5 (July 1903), 288. is based on a published report of the study which appeared in 1955. 17Murrell,"Syphilis in the Negro; Its Bearing on the Race Prob- See Jesse J. Peters, James H. Peers, Sidney Olansky, John C. Cutler, lem," p. 307. and GeraldineGleeson, "UntreatedSyphilis in the Male Negro: Path- 18"Theanatomical and physiological conditions of the African must ologic Findings in Syphilitic and Nonsyphilitic Patients,"Journal of be understood,his place in the anthropologicalscale realized, and his Chronic Diseases 1 (February 1955), 127-48. The article estimated biological basis accepted as being unchangeable by man, before we that 30.4 percent of the untreated men would die from syphilitic shall be able to govern his natural uncontrollable sexual passions." lesions. See, "As Ye Sow That Shall Ye Also Reap," Atlanta Journal-Record 2Final Report of the Tuskegee Syphilis Study Ad Hoc Advisory of Medicine 1 (June 1899), 266. Panel, Department of Health, Education, and Welfare (Washington, 19Taliaferro Clark, The Control of Syphilis in Southern Rural D.C.: GPO, 1973). (Hereafter, HEW Final Report). Areas (Chicago: Julius Rosenwald Fund, 1932), 53-58. Approxi- 3See George M. Frederickson,The Black Image in the White Mind mately 35 percent of the inhabitants of Macon County who were (New York: Harper and Row, 1971), pp. 228-55. Also, John H. examined were found to be syphilitic. Haller, Outcasts From Evolution (Urbana, Ill.: University of Illinois 20See Claude Bernard, An Introduction to the Study of Experi- Press, 1971), pp. 40-68. mental Medicine (New York: Dover, 1865, 1957), pp. 5-26. 4Frederickson,pp. 247-49. 21TaliaferroClark to M. M. Davis, October 29, 1932. Records of 5"Deteriorationof the American Negro," Atlanta Journal-Record the USPHS Venereal Disease Division, Record Group 90, Box 239, of Medicine 5 (July 1903), 287-88. See also J. A. Rodgers, "The Ef- National Archives, Washington National Record Center, Suitland, fect of Freedom upon the Psychological Development of the Negro," Maryland. (Hereafter, NA-WNRC). Materials in this collection Proceedings of the American Medico-Psychological Association 7 which relate to the early history of the study were apparently never (1900), 88-99. "From the most healthy race in the country forty years consulted by the HEW investigation. Included are letters, reports, ago," concluded Dr. Henry McHatton, "he is today the most dis- and memoranda written by the physicians engaged in the study. eased." "The Sexual Status of the Negro-Past and Present,"Ameri- 22H. S. Cumming to R. R. Moton, September 20, 1932, NA- can Journal of Dermatology and Genito-UrinaryDiseases 10 (Janu- WNRC. ary 1906), 7-9. 23Clarkto Davis, October 29, 1932, NA-WNRC. 6W. T. English, "The Negro Problem from the Physician'sPoint of 24Cummingto Moton, September20, 1932, NA-WNRC. View," Atlanta Journal-Recordof Medicine 5 (October 1903), 461. 2oBruusgaardwas able to locate 309 living patients, as well as rec- See also, "Racial Anatomical Peculiarities," New York Medical ords from 164 who were diseased. His findings were published as Journal 63 (April 1896), 500-01. "Ueber das Schicksal der nicihtspecifizch behandeltenLuetiken," Ar- 7"RacialAnatomical Peculiarities,"p. 501. Also, Charles S. Bacon, chives of Dermatology and Syphilis 157 (1929), 309-32. The best "The Race Problem," Medicine (Detroit) 9 (May 1903), 338-43. discussion of the Boeck-Bruusgaarddata is E. Gurney Clark and 8H. H. Hazen, "Syphilis in the American Negro," Journal of the Niels Danbolt, "The Oslo Study of the Natural History of Untreated American Medical Association 63 (August 8, 1914), 463. For deeper Syphilis,"Journal of Chronic Diseases 2 (September 1955), 311-44. backgroundinto the historicalrelationship of racism and sexuality see 26JosephEarle Moore, ThleModern Treatment of Sypliilis (Balti- WinthropD. Jordan, White Over Black (Chapel Hill: University of more: Charles C. Thomas, 1933), p. 24. North Carolina Press, 1968; Pelican Books, 1969), pp. 32-40. 27Moore, pp. 231-47; see also John H. Stokes, Modern Clinical ODanielDavid Quillian, "Racial Peculiarities:A Cause of the Prev- Syphilology (Philadelphia: W. B. Saunders, 1928), pp. 231-39. alence of Syphilis in Negroes," American Journal of Dermatology 28Moore, p. 237. and Genito-UrinaryDiseases 10 (July 1906), p. 277. 29Moore,p. 236. 10English,p. 463. s?J. E. Moore, H. N. Cole, P. A. O'Leary,J. H. Stokes, U. J. Wile, 11WilliamLee Howard, "The Negro as a Distinct Ethnic Factor T. Clark, T. Parran, J. H. Usilton, "Cooperative Clinical Studies in in Civilization," Medicine (Detroit) 9 (June 1903), 424. See also, the Treatment of Syphilis: Latent Syphilis," Venereal Disease Infor- Thomas W. Murrell, "Syphilis in the American Negro," Journal of mation 13 (September 20, 1932), 351. The authors also concluded the American Medical Association 54 (March 12, 1910), 848. that the latently syphilitic were potential carriers of the disease, thus 12"CastrationInstead of Lynching," Atlanta Journal-Record of meriting treatment. Medicine 8 (October 1906), 457. The editorial added: "The badge of 31Clark to Paul A. O'Leary, September 27, 1932, NA-WNRC. disgrace and emasculation might be branded upon the face or fore- O'Leary, of the Mayo Clinic, misunderstoodthe design of the study, head, as a warning, in the form of an 'R,' emblematic of the crime for replying: "The investigation which you are planning in Alabama is which this punishment was and will be inflicted." indeed an intriguing one, particularly because of the opportunity it I 13SearleHarris, "The Future of the Negro from the Standpoint of affords of observing treatment in a previously untreated group. as- the Southern Alabama Medical Journal 14 (January sure you such a study is of interest to me, and I shall look forward to Physician," NA- 1902), 62. Other articles on the prevalence of venereal disease among its report in the future." O'Leary to Clark, October 3, 1932, blacks are: H. L. McNeil, "Syphilisin the Southern Negro," Journal WNRC. of the American Medical Association 67 (September 30, 1916), 1001- a2Joseph Earle Moore, "Latent Syphilis," unpublished typescript Social 04; Ernest Boas, "The Relative Prevalence of Syphilis Among (n.d.), p. 7. American Social Hygiene Association Papers, Philip of Minne- Negroes and Whites," Social Hygiene 1 (September 1915), 610-16. Welfare History Archives Center, University Minnesota, Doctors went to considerabletrouble to distinguish the morbidity and apolis, Minnesota. mortality of various diseases among blacks and whites. See, for exam- 33Moore to Clark, September 28, 1932, NA-WNRC. Moore had ple, Marion M. Torchia, "TuberculosisAmong American Negroes: written in his textbook, "In late syphilis the negro is particularly Medical Research on a Racial Disease, 1830-1950," Journal of the prone to the development of bone or cardiovascular lesions." See History of Medicine and Allied Sciences 32 (July 1977), 252-79. Moore, The Modern Treatment of Syphilis, p. 35. C. to October NA-WNRC. 14ThomasW. Murrell, "Syphilis in the Negro: Its Bearing on the 340. Wenger Clark, 3, 1932, Race Problem," American Journal of Dermatology and Genito-Uri- 35Wengerto Clark, September 29, 1932, NA-WNRC. nary Diseases 10 (August 1906), 307. 36ClarkMemorandum, September 26, 1932, NA-WNRC. See also, 15"Evenamong the educated, only a very few will carry out the Clark to Davis, October 29, 1932, NA-WNRC. most elementary instructions as to personal hygiene. One thing you 37As Clark wrote: "You will observe that our plan has nothing to cannot do, and that is to convince the negro that he has a disease that do with treatment. It is purely a diagnostic procedure carried out to he cannot see or feel. This is due to lack of concentrationrather than determine what has happened to the syphilitic Negro who has had no lack of faith; even if he does believe, he does not care; a child of treatment." Clark to Paul A. O'Leary, September 27, 1932, NA- fancy, the sensations of the passing hour are his only guides to the WNRC. future." Murrell, "Syphilis in the American Negro," p. 847. 38D. G. Gill to O. C. Wenger, October 10, 1932, NA-WNRC.

28 Hastings Center Report, December 1978 _

39Clarkto Vonderlehr, January 25, 1933, NA-WNRC. ologic Findings in Syphilitic and Non-Syphilitic Patients,"Journal of 40Vonderlehrto Clark, February 28, 1933, NA-WNRC. Chronic Diseases 1 (February 1955), 127-48. 41Vonderlehrto Clark, November 2, 1932, NA-WNRC. Also, Von- 66SidneyOlansky, Stanley H. Schuman,Jesse J. Peters, C. A. Smith, derlehr to Clark, February 6, 1933, NA-WNRC. and Dorothy S. Rambo, "Untreated Syphilis in the Male Negro, X. 42Clarkto Vonderlehr, March 9, 1933, NA-WNRC. Twenty Years of Clinical Observation of Untreated Syphilitic and 43Vonderlehrlater explained: "The reason treatment was given to Presumably Nonsyphilitic Groups," Journal of Chronic Diseases 4 many of these men was twofold: First, when the study was started in (August 1956), 184. the fall of 1932, no plans had been made for its continuation and a 670. C. Wenger, "UntreatedSyphilis in Male Negro," unpublished few of the patients were treated before we fully realized the need for typescript, 1950, p. 3. Tuskegee Files, Center for Disease Control, At- continuing the project on a permanent basis. Second it was difficult lanta, Georgia. (Hereafter TF-CDC). to hold the interest of the group of Negroes in Macon County unless 68VernalG. Cave, "Proper Uses and Abuses of the Health Care some treatmentwas given." Vonderlehrto Austin V. Diebert, Decem- Delivery System for Minorities with Special Reference to the Tuske- ber 5, 1938, Tuskegee Syphilis Study Ad Hoc Advisory Panel Papers, gee Syphilis Study," Journal of the National Medical Association 67 Box 1, National Library of Medicine, Bethesda, Maryland. (Here- (January 1975), 83. after, TSS-NLM). This collection contains the materials assembled 69See for example, Vonderlehr to B. W. Booth, April 18, 1934; by the HEW investigation in 1972. Vonderlehr to E. R. Lett, November 20, 1933, NA-WNRC. 44Vonderlehrto Clark, February 6, 1933, NA-WNRC. 70"Transcriptof Proceedings-Tuskegee Syphilis Ad Hoc Advisory 45H. S. Cumming to J. N. Baker, August 5, 1933, NA-WNRC. Panel," February23, 1973, unpublishedtypescript, TSS-NLM, Box 1. 46January22, 1933; January 12, 1933, NA-WNRC. 71Raymond Vonderlehr to Murray Smith, April 30, 1942; and 47Vonderlehrto Clark, January28, 1933, NA-WNRC. Smith to Vonderlehr, June 8, 1942, TSS-NLM, Box 1. 48Clarkto Moore, March 25, 1933, NA-WNRC. 72StanleyH. Schuman,Sidney Olansky,Eunice Rivers, C. A. Smith, 49Macon County Health Department, "Letter to Subjects," n.d., and Dorothy S. Rambo, "Untreated Syphilis in the Male Negro: NA-WNRC. Background and Current Status of Patients in the Tuskegee Study," 50Vonderlehrto Clark, April 8, 1933, NA-WNRC. See also, Von- Journal of Chronic Diseases 2 (November 1955), 550-53. derlehr to Wenger, July 18, 1933, NA-WNRC. 73RaymondVonderlehr to Stanley H. Schuman, February 5, 1952. 51Wengerto Vonderlehr, July 21, 1933, NA-WNRC. The italics TSS-NLM, Box 2. are Wenger's. 74Schumanet al., p. 550. 52Cummingto Moton, July 27, 1933, NA-WNRC. 75"Minutes, April 5, 1965" unpublished typescript, TSS-NLM, 53Wengerto Vonderlehr, July 21, 1933, NA-WNRC. Box 1. 54Vonderlehrto Murray Smith, July 27, 1933, NA-WNRC. 76"TuskegeeAd Hoc Committee Meeting-Minutes, February 6, 55Wengerto Vonderlehr, August 5, 1933, NA-WNRC. 1969," TF-CDC. 56Vonderlehrto Wenger, October 24, 1933, NA-WNRC. Controls 77JamesB. Lucas to William J. Brown, September 10, 1970, TF- were given salicylates. CDC. 57Austin V. Diebert and Martha C. Bruyere, "Untreated Syphilis 78ElizabethM. Kennebrew to Arnold C. Schroeter, February 24, in the Male Negro, III," Venereal Disease Information 27 (December 1971, TSS-NLM, Box 1. 1946), 301-14. 79See Medical Tribune (September 13, 1972), pp. 1, 20; and Re- 58Eunice Rivers, Stanley Schuman, Lloyd Simpson, Sidney Olan- port on HEW's Tuskegee Report," Medical World News (September sky, "Twenty-Yearsof Followup Experience In a Long-Range Med- 14, 1973), pp. 57-58. ical Study," Public Health Reports 68 (April 1953), 391-95. In this 80HEWFinal Report, p. 7. article Nurse Rivers explains her role in the experiment. She wrote: 81Thenotable exception is Jay Katz's eloquent "ReservationsAbout "Because of the low educational status of the majorityof the patients, the Panel Report on Charge 1," HEW Final Report, pp. 14-15. it was impossible to appeal to them from a purely scientific approach. 82HEWFinal Report, pp. 8, 12. Therefore, various methods were used to maintain their interest. Free 83HEWFinal Report, pp. 8, 12. medicines, burial assistance or insurance (the project being referred 84SeeR. H. Kampmeier,"The Tuskegee Study of Untreated Syph- to as 'Miss Rivers'Lodge'), free hot meals on the days of examination, ilis," Southern Medical Journal 65 (October 1972), 1247-51; and transportationto and from the hospital, and an opportunityto stop in "Final Report on the 'Tuskegee Syphilis Study,'" Southern Medical town on the returntrip to shop or visit with their friends on the streets Journal 67 (November 1974), 1349-53. all helped. In spite of these attractions, there were some who refused 85LeonardJ. Goldwater, "The Tuskegee Study in Historical Per- their examinations because they were not sick and did not see that spective," unpublished typescript, TSS-NLM; see also "Treponemes they were being benefitted."(p. 393). and Tuskegee," Lancet (June 23, 1973), p. 1438; and Louis Lasagna, 59Austin V. Diebert to Raymond Vonderlehr, March 20, 1939, The VD Epidemic (Philadelphia: Temple University Press, 1975), TSS-NLM, Box 1. pp. 64-66. 60MurraySmith to Subjects, (1938), TSS-NLM, Box 1. See also, 86Quotedin "Debate Revives on the PHS Study," Medical World Sidney Olansky to John C. Cutler, November 6, 1951, TSS-NLM, News (April 19, 1974), p. 37. Box 2. 87Heller to Vonderlehr, November 28, 1933, NA-WNRC; quoted 61TheUSPHS originally requestedthat the Julius Rosenwald Fund in Medical Tribune (August 23, 1972), p. 14. meet this expense. See Cumming to Davis, October 4, 1934, NA- 88Althoughit is now known that syphilis is rarely infectious after WNRC. This money was usually divided between the undertaker, its early phase, at the time of the study's inception latent syphilis was pathologist, and hospital. Lloyd Isaacs to Raymond Vonderlehr, thought to be communicable. The fact that members of the control April 23, 1940, TSS-NLM, Box 1. group were placed in the test group when they became syphilitic 62StanleyH. Schuman,Sidney Olansky,Eunice Rivers, C. A. Smith, proves that at least some infectious men were denied treatment. Dorothy S. Rambo, "Untreated Syphilis in the Male Negro: Back- 89When the subjects are drawn from minority groups, especially ground and Current Status of Patients in the Tuskegee Study,"Jour- those with which the researcher cannot identify, basic human rights nal of Chronic Diseases 2 (November 1955), 555. may be compromised.Hans Jonas has clearly explicated the problem 63R. A. Vonderlehr and Taliaferro Clark, "Untreated Syphilis in in his "Philosophical Reflections on Experimentation,"Daedalus 98 the Male Negro," Venereal Disease Information 17 (September1936), (Spring 1969), 234-37. As Jonas writes: "If the properties we ad- 262. duced as the particular qualificationsof the members of the scientific 64J. R. Heller and P. T. Bruyere, "UntreatedSyphilis in the Male fraternity itself are taken as general criteria of selection, then one Negro: II. Mortality During 12 Years of Observation,"Venereal Dis- should look for additional subjects where a maximum of identifica- ease Information 27 (February 1946), 34-38. tion, understanding,and spontaneity can be expected-that is, among 65JesseJ. Peters, James H. Peers, Sidney Olansky, John C. Cutler, the most highly motivated, the most highly educated, and the least and Geraldine Gleeson, "UntreatedSyphilis in the Male Negro: Path- 'captive' members of the community."

The Hastings Center 29