J7ournal ofMedical Ethics 1999;25:353-358 J Med Ethics: first published as 10.1136/jme.25.4.353 on 1 August 1999. Downloaded from

Book reviews

Acres of Skin Nazi reference is convenient but slip- be judged inadequate. In general the shod. At the centre of Nazi transgres- prisoners were so attracted by the sion was a public policy-enforced by compensation that, after twenty years Allen M Hornblum, New York and a ruthless dictator-which declared of experimentation the participants London, Routledge, 1998, 297 pages, whole subgroups within human soci- were angry when two of their col- £19.99. ety to have "lives not worth living". leagues testified against the experi- The willing complicity of many Ger- ments before congress (page 198). Acres of Skin presents an angry, mans and German physicians with However imperfect the consent might distressing and provoking description these policies remains a huge warning have been, we must conclude that of human experimentation within the to all of us. Nevertheless, it was in the consent was obtained for these experi- American prison system. Specifically, context of the totalitarian govern- ments. it focuses upon experiments con- ments that the great transgressions Hornblum suggests that many pris- ducted by investigators from the Uni- against human dignity occurred in the oners were injured by their participa- versity of Pennsylvania at the nearby Holmesburg Prison, from 1951 until twentieth century. In Nazi Germany tion, but does not objectively docu- experiments designed to involve severe ment the extent and seriousness of 1974. The research was halted follow- ing congressional hearings in 1973 suffering, often to end in the death of such injuries. This is important. Years copyright. the were part of a racist pseu- ago Comroe pointed out that five which revealed incidents of misuse or subject, potential misuse ofvulnerable popula- doscientific insanity and were ap- patients died before the first successful tions (pages 194-197). proved at the highest level.' 2 No such mitral valve replacement. He did so Hornblum documents disturbing pattern supported the Holmesburg critically, asking whether it was the transgressions of appropriate context experiment nor is it fair to suggest surgeon or the patients who were the whether and care in performing human experi- equivalent amoral behaviour by Dr heroes and also questioning ments. If his recounting of the use of Kligman or his collaborators. these desperate patients were afforded mind-altering drugs under defence Like Annas and Grodin, Hornblum the opportunity to make a truly http://jme.bmj.com/ department or CIA contracts is the uses the Nuremberg Code, developed informed consent.3 In a closing chap- most disturbing, he is equally upset to justify prosecution ofwar criminals, ter Hornblum rails on about Retin-A about the testing of Retin-A which has as his reference. However, the earlier, (a potent and useful acne medicine), proven useful in acne treatment. His 1931 Reich's Health Council Circu- its irritating properties and the role of treatment seems biased. Nevertheless, lar: Regulations on New Therapy and Holmesburg "guinea pigs" in its devel- as a clinical researcher and former Human Experimentation, and the sub- opment. I am troubled by an author faculty member at the University of sequent Helsinki Declarations (I - IV) who links irritated skin to Nazi Pennsylvania I felt compelled to do a seem superior.2 These codes do not transgressions. Clearly some prisoners on September 26, 2021 by guest. Protected little background reading' 2 and pose a hang so much on the essential princi- were scarred by dermatological ex- few questions for myself: ple of consent-which occupies some periments, but they continued to one-third of the verbiage in the volunteer and after twenty years it 1. Is Hornblum's comparison with Nuremberg Code and better address seems a majority of prisoners involved Nazi abuses justifiable? critical medical requirements neces- would have chosen to continue their 2. Should the Nuremberg Code be sary for safe and appropriate human involvement. the reference code? experimentation. In addition, these Hornblum does an excellent job of 3. Is he correct in isolating prison codes do not suggest a "guilt by portraying the coercive aspects of experimentation as particularly association" conclusion. None of the prison life and the restrictions upon egregious? codes seem to address the importance prisoners which made participation 4. Does he fairly assess risk and of external scientific and ethical re- attractive. He even presents moder- injury? view, both for determining the legiti- ately convincing information which 5. Did America make a correct deci- macy of a proposed experiment and suggests that prisoners are not par- sion in subsequently excluding the need to terminate an experiment. ticularly good experimental subjects. prisoners from the pool for neces- Hornblum states that consent pro- Yet, the drug to protect infants from sary human experimentation. cedures were inadequate. None the fatal blood cell destruction if they are less, our perspectives have changed born to mothers with incompatible I have grown weary of the often dramatically and analysis of civilian blood types was developed with the hysterical tone now dominating practice in the early 1950s and 60s for cooperation of convicts at Sing Sing. It American public debate and this book obtaining consent for therapeutic or would appear that both prisoners and jangled those raw nerve ends. The experimental interventions would also society benefited from these activities. 354 Book reviews J Med Ethics: first published as 10.1136/jme.25.4.353 on 1 August 1999. Downloaded from

Moreover, it is clear that prisoners social scientists. He simply takes it for The research and policy process were free to refuse participation with granted. Furthermore, readers con- both fail for related reasons. Social no adverse consequences and still cerned with medical ethics will find scientists themselves exist within the sought to participate. Consent was the book a double disappointment. "constituency" of one or the other set deficient, protocols were deficient. But Despite the promise on the back cover of theoretical assumptions. Their re- the modern era of controlled trials that the analysis of welfare policy will search typically seeks to verify their began only a few years before the include "effective health care", health preferred presumptions or to falsitf Holmesburg experience and the steps issues are only tangentially touched those of their opponents, but it fails to necessary to minimise abuse were on. Even the one passing reference to employ sufficient scientific rigour be- developing in parallel in the civilian Medicaid, as absorbing half of all wel- cause the researchers have acquiesced society. (The Econonist noted in Octo- fare expenditure, is made in the course in a series of constraints which under- ber 1998 that publication of the first of establishing Epstein's opening argu- mine the adequacy and rationality of randomised controlled trial occurred ment that the rhetoric of the welfare their procedures. Prominent among in 1948 - streptomycin usage in debate focuses disproportionately on these unchallenged axioms is the need tuberculosis. ') one narrow area - poverty - which for fiscal restraint. In summary, this is a useful and accounts for a mere ten per cent of the In the first place this sets arbitrary provocative study. It would have been total welfare budget. The curious limits on the cost of research and thus better if the author had been less intensity of popular and political con- tempts researchers to take method- overtly biased and had better studied cern with what is a minor slice of pub- ological short cuts - for example, the the concurrent evolution in human lic spending forms the backdrop to the failure to use genuine randomised experimental studies outside of argument of the book. prison. Two more issues warrant controlled trials - which is often com- The main body of the volume is a pounded by researcher bias and prac- attention. First, I find human experi- detailed and damning critique of the mentation necessary, despite its haz- tices embodying "limited rationality", research of recent decades on poverty all of which result in an inability to ards while Hornblum asserts that and certain associated problems "progress is optional" (page 244). develop adequate tests of causation. (specified in consecutive chapters as The imperative of fiscal prudence also Secondly, in his passionate distaste for family structures and intergenera- the Holmesburg Prison experiments, drives the policy process to seek out tional dependency; work and work- low cost welfare solutions. Hornblum diminishes the horrors suf- lessness; training programmes for wel- Epstein believes that these condi-copyright. fered in the camps of the Axis powers fare recipients, and the role of and I find that offensive. tions have produced an increasing personal social services in policies to consensus between conservatives and combat poverty). There then follows a liberals that the core objective of References final chapter advocating an as yet welfare policy should be "social effi- 1 Lifton RJ. The Nazi doctos: mdicdal kill- untried policy of "generosity" which ciency" and that any policy must be ilg anid the psychology of gcocidce. starts from the premise that the author shown to have an immediate, positive Oxford: Basic Books, a subsidiary of has demonstrated the total failure of Perseus Books, LLC, 1986. impact on social cohesion and eco- 2 Annas GJ, Grodin MA, eds. I'lie Nazi the research process to establish a nomic productivity without even shorthttp://jme.bmj.com/ doctors anid the Nnremberg Code.Oxford rational basis for choosing between term disruptive consequences. In and New York: Oxford Universitv existing policy strategies. At this point these circumstances the liberal camp Press, 1992. it becomes clear that the foregoing cri- 3 Comroe JH. Ret-o has lost confidence in insti- Spectroscope: ooisiglhls tique of welfare research is an expensive into miiedical discover%. Menlo Park, simply tutional interventions and modified its Calif: Von Gehr Press, 1977. oversized legitimating prologue to a 4 Trial and error. The Ecoiioinii.st 1998 polemical climax in which the need for proposals to supplement tentative and Oct 31. Also available in archives at cheap forms of "social engineering" www.economist.com. a radical and expensive programme of social and cultural engineering is pro- with minimal gestures of help through MARK HILBERMAN posed in terms. personal social services for "hard on September 26, 2021 by guest. Protected Reddstone, Colorado, USA passionately vague Epstein places his critique ofwelfare cases". Above all, both sides have con- research within an analysis of the verged on work as the solution to all ideological nexus out of which both social ills. Welfare in America: research and policy emerge. He distin- In the detailed critique of specific How Social science guishes two main theoretical posi- research and its relation to policv tions, the conservative and the liberal. development Epstein's anatomisation Fails the Poor The former tends to locate the cause of ideological processes largely gives of poverty in the moral or "charactero- way to a perspective composed in William M Epstein, Madison, logical" deficiencies of individuals and equal parts of a positivistic research Wisconsin Press, 267 pages, [35.95 broadly favours market solutions. The methodology of impossible purity and (hb) [15.95 (sc). latter is inclined to see the causes of a functionalist model of society which poverty as lying in institutional defects is not only curiously at odds with the The title of William Epstein's book and to advocate state intervention. So framing argument about ideological suggests that the author's primary far, so unremarkable. He goes on, conflict but which has at its heart an purpose is a moral one; to call social however, to claim that research in the oddly old-fashioned and un-nuanced scientists to account for failing the social sciences has signally failed to concept of socialisation as a learning poor. Yet it is hard to detect any provide scientific verification of either process pure and simple. The sociol- coherent moral framework or even set of assumptions but has acted as the ogy of the book is thus mildly schizoid political philosophy from which he has legitimating vehicle of "mythic be- and detached from the author's appar- derived a duty to the poor as a neces- liefs" which then masquerade as fac- ently sui genieris ethical stance - after all sary part of the professional ethic of tual propositions. functionalism, notoriously, has been