The Tuskegee Syphilis Study dominates discussions of racism and American medical research. There are compelling reasons for this; a forty-year, government-sponsored study of untreated syphilis in African American men is unique in the history of medical research. But racism has not been unique in American medicine, nor has the research exploitation of men, women, and children of color. Looking at investigations beyond the no-treatment syphilis study in which African Americans participated as research subjects is one way to enlarge our understanding of the ways in which racism structured the interactions of American medical researchers and black subjects.
The Tuskegee Syphilis Study is an infamous event in the history of American medical research. There are good reasons, however, to question whether research is, in fact, the most appropriate lens for viewing the study. I argue that the conduct of the white government physicians may be better understood in the context of the history of human dissection, a history in which racism figured prominently. The Public Health Service investigators who staffed the study over four decades regarded their African American subjects neither as patients, nor as experimental subjects, but as cadavers, who had been identified while still alive.
As historian James Jones has noted, the Tuskegee Syphilis Study did not originate as a fully developed research plan with clearly identified objectives or end points. The study began when the Julius Rosenwald Fund, citing the adverse economic effects of the Great Depression, withdrew its funds for treating African Americans diagnosed with syphilis. At this point, Dr. Taliaferro Clark of the Public Health Service identified “a ready-made situation” in which to study the effects of untreated syphilis in Macon County. He proposed a short-term study, six months or one year, to follow a group of men infected with syphilis who had received no treatment. But when this initial assessment period ended in 1933 and Dr. Raymond Vonderlehr, the acting director of the Division of Venereal Diseases at the Public Health Service, assumed control, the study took a dramatic new course. Rather than ending as planned, Vonderlehr dictated that investigators would follow the men until their deaths.
Susan Lederer is assistant professor in the Section of the History of Medicine in the Yale School of Medicine.
Printed by permission of Susan Lederer.
Critical to the revamping of the Tuskegee Study was provision for postmortem examination to confirm the effects of untreated syphilis. In 1933, Vonderlehr noted that “the proper procedure is the continuance of the observation of the Negro men used in the study with the idea of eventually bringing them to autopsy.”1 Like a twentieth-century version of Burke and Hare, the notorious nineteenth-century Edinburgh resurrectionists, Vonderlehr and his PHS colleagues identified bodies for dissection while the individuals were still alive.2 In so doing, the PHS investigators adopted a variety of methods to preserve the integrity of the bodies; in order to avoid contaminating the data, they prevented the men from gaining access to medical treatment for syphilis. They forged links with physicians in Macon and the surrounding counties to get the dead to the autopsy table as quickly as possible. Unlike Burke and Hare, the PHS doctors did not smother or strangle their subjects; instead they allowed syphilis to take its toll.
At the same time, investigators devoted considerable effort to obtaining legal permission for performing an autopsy on study participants from surviving family members. In order to obtain consent for postmortem examinations, PHS investigators offered strong, even coercive incentives. After 1935, families who gave permission for autopsy received a $50 burial stipend. The $35 families received ($15 went to the pathologist) enabled them to bury their loved one. Made possible by funds from the Milbank Memorial Fund, the stipends were withheld if families refused to authorize an autopsy. To facilitate further the consent process, Vonderlehr assigned black nurse Eunice Rivers the delicate task of approaching families to obtain consent for autopsy. She proved extraordinarily successful in obtaining familial permission. In a 1953 Public Health Reports paper, Rivers noted “only one refusal in 20 years and 145 autopsies obtained.”3 Even one refusal, however, is noteworthy. Some families chose to exercise the right to refuse an autopsy, even in the face of such powerful inducements as the “burial insurance.”
Why did these investigators who were willing to withhold treatment for syphilis, to deceive the men about the nature of their participation, to mislabel diagnostic tests as therapy, go to such lengths to insure that families gave consent for postmortems? In part, investigators found working with families served their interests. Not only did burial insurance serve as incentive for gaining permission, but Rivers explained how community knowledge of the cash payments encouraged individuals to report deaths of participants: “They would let me know when somebody died because in those days $50 was a whole heap of money for a funeral.”4
Placing the Tuskegee Study in the context of human dissection may also explain the investigators’ extraordinary compliance with rules regarding autopsy and the simultaneous breach of the operative rules regarding human experimentation. Even before the American Medical Association adopted its first formal principles regarding human experimentation in 1946, leading American medical researchers had identified by the early twentieth century several necessary conditions for ethical human experimentation. These included prior animal studies, consent of the patient/subject, and responsibility for harm to the subjects. The PHS investigators breached these conditions in the conduct of the Tuskegee Study, but they had apparently not violated any laws. Although federal and state legislatures had considered proposals for regulating human experimentation in the first two decades of the twentieth century, no laws governing the conduct of human research were enacted until 1974 (on the heels of public disclosures about the Tuskegee Syphilis Study).5
Unlike the case of human experimentation, state laws regulated access to dead human bodies for dissection and autopsy. By 1932, when the Tuskegee Study began, many American state legislatures had enacted statutes regulating the disposition and use of dead human bodies. Some of the laws explicitly noted the physician’s responsibility to obtain consent from family members before a postmortem examination.6 As attorney George Weinmann noted in 1929, “the general rule is that the unauthorized autopsy of a dead human body is a tort, giving rise to a cause of action for damages.”7 An increasing number of Americans pursued lawsuits against hospitals and physicians for performing unauthorized autopsies on family members. Successful suits with monetary damages prompted pathologists and hospital administrators to urge more attention to the methods of obtaining written consent for autopsy as a protection against both individuals and institutions. There is some indication that African Americans and other ethnic groups were asked for permission. Explaining how Memorial Hospital improved a higher rate of cooperation with requests for autopsy, New York physician William Hoffman noted that doctors approached the family in business suits rather than white uniforms and avoided such words with “gruesome connotations” as autopsy, inquest, or necropsy. Using this new approach, Hoffman reported for the six months between July and December 1932 that of the seventy-one deaths in the hospital, the families of “All Germans, Danes, Irish, Negroes and all Italians but one consented to autopsy.”8
In the state of Alabama, an anatomical practice act permitted the distribution of unclaimed dead human bodies to medical schools for “the advancement of medical science.” The law included provisions to allow surviving friends and family members to claim the body, so long as they could provide the money for burial. Although anatomical acts did not materially alter the social origins of the dead bodies available for dissection (in the 1920s, for example, interstate shipment of dead black bodies to northern medical schools continued), the law protected (atleast, in theory) both whites and African Americans with money for burial from being turned over to medical schools.9 Intent on getting postmortem evidence for the syphilis study, PHS investigators scrupulously complied with the legal requirements for family permission for the autopsy. For Vonderlehr and his colleagues at the Public Health Service, the dead took precedence over the living.
In the thirteen papers from the Tuskegee Syphilis Study published between 1936 and 1973, investigators identified the study participants as “syphilitics,” “patients,” or “syphilitic Negro males.” In no published paper did investigators characterize the men as research subjects, but in 1955 the men were, for the first time, described as “volunteers with social incentives.”10 Once the study had ended amid a flurry of news reports and congressional hearings, some of the survivors of the study recalled being used as “guinea pigs” by government doctors. The equation of African Americans with laboratory animals has a history nearly as long as the term human guinea pig (introduced in 1906 by British writer George Bernard Shaw).
In the 1940s a University of Pennsylvania researcher elaborated a number of parallels between his Negro research subjects and laboratory animals. In an afterdinner speech intended to divert his colleagues, William Osler Abbott described some of his problems using “professional guinea pigs.” In 1931 Abbott and his coworker T. Grier Miller had developed a new technique for rapidly intubating the human intestine from mouth to rectum.11 Although advised to try the new device on animals, Miller and Abbott apparently never performed the animal studies. After numerous self-experiments, they attempted to locate subjects in the hospital wards, and finally turned to healthy men and women who would agree to the procedure. During the height of the depression, Abbott and Miller approached a young relief administrator, hoping to gain cooperation in using unemployed men as subjects. Unlike her counterpart in Chicago who sent men on relief to laboratories to participate in research for payment, the Philadelphia administrator refused to send men to Abbott’s laboratory, especially when she learned that they would be required to swallow a flexible twelve-foot tube to which a rubber balloon was attached and inflated once inside the intestine.12
Frustrated by the employment bureau, Abbott asked the wives of his colleagues to distribute slips of paper instructing beggars to come to the hospital for a job paying $2 a day. He also used the bridge over the Schuylkill River as a “hunting ground” for potential participants, to no avail. Finally, his secretary suggested that the doctors call in their black janitor; they eventually promised Harry fifty cents for every healthy human subject who appeared at the laboratory door at 8:30 A.M. in a sober and fasting state.
Abbott’s first subject, Flip Lawall, “tall, broad-shouldered, black as the ace of spades, and by profession a light-weight prize fighter,” was joined by several other young black men.13 Employing this population as research subjects, Abbott insisted, was not without problems. Alluding in a stereotypical fashion to the men’s penchant for thievery, Abbott complained that his “animals” also enjoyed a larger intake of corn liquor, pork chops, and chewing tobacco than the white rats in the medical school. He described how, on one occasion, he had attempted to insert a flexible rubber tube into one man’s duodenum using fluoroscopic guidance, when he noticed a small piece of metal. Recognizing the tip of a .38 caliber revolver bullet, Abbott confronted his subject who admitted that the previous night his jealous “sweetheart” had shot him after seeing him with another woman earlier in the evening. Such events, Abbott explained, “led me to wish at times I could keep my animals in metabolism cages.”14
Abbott encountered more serious problems in the spring of 1935 when he scheduled an exhibit on intestinal intubation for the American Medical Association meeting in Atlantic City. Arranging for the men to be intubated at a local hospital before their appearance at the convention, Abbott was stunned when his “guinea pigs” threatened to walk out at the last minute unless they received double pay. Only an impassioned eleventh-hour appeal to the third-year medical school class and the offer of the same pay received by the “striking blackamoors” enabled Abbott to continue the demonstration using student volunteers. He fired all the black subjects and refused to have anything more to do with them.
After several months, Abbott reconsidered his position. “Those boys may have been short on morals but they were long in gut,” he remarked, “and in the end I went to Harry once again to throw out a feeler.” He discovered that his “boys” had “graduated from stealing inkwells to house furnishings;” all but two had been convicted of burglary, and his first subject, Flip Lawall, was serving a ten-year sentence in the state penitentiary for a rape conviction.
An advertisement in a local newspaper brought a fresh group of potential subjects to Abbott’s laboratory. Some of the men and women who answered the ad winced at the description of swallowing the tubes, and many others apparently quailed at Abbott’s insistence that they sign a statement prepared by the university attorney outlining every step of the experiment and stating that subjects recognized and accepted any risks associated with the procedure. (The document was more of an indemnification agreement than a consent form.) Abbott ended up with a roster of subjects, young and old, white and black, male and female, although he noted that his “clientele” generally dwindled down to hefty, older women, the human counterpart of the “big, lazy, overweight bitch [from the animal house] that could be counted upon to lie and wag her tail while being worked over.”15
Abbott’s intubation experiments differed in a number of important ways from the Tuskegee Syphilis Study. His initial black subjects were all ostensibly healthy men, who knew that they were receiving payment for their participation in research. They were not patients. What the men actually understood about the risks associated with swallowing the tubes and the frequent X rays is impossible to know. Abbott did refer to his own efforts to safeguard them from the effects of “overfrequent” radiation, but, given his instrumental attitude toward the men, it seems unlikely that he explained the risks in any detail. Assumptions about race informed the investigator’s attitudes toward the men, their reliability, and their level of comprehension.
Abbott jokingly equated his professional guinea pigs with laboratory animals, but reliance on Harry the janitor to arrange for the men to come to the lab bears remarkable similarity to the ways in which laboratories obtained both animals and human cadavers for study. Black technicians, janitors, and caretakers routinely located and supplied these materials—alive and dead. At Johns Hopkins University, for example, the surgeon Willis Gatch recalled how each January William Halsted would call him into his office to inform him that he was ready to start his experimental work in the Hunterian Laboratory. Gatch would then hire a Negro boy to procure dogs and instruct him on how to etherize them.16 In similar fashion, Nurse Rivers functioned as a conduit for the bodies of black men needed for postmortem examinations.
A year after Abbott recounted his problems with professional guinea pigs, novelist Richard Wright used his own experience as a porter in a medical research facility to make a larger point about racism and American society. In a 1942 Harper’s Magazine article, Wright described how he had spent the winter of 1932 working in a laboratory at the Michael Reese Hospital in Chicago. In addition to scrubbing floors, cleaning up after diabetic dogs, shaving rabbits, and feeding guinea pigs and mice, Wright recalled how he and the other Negro porters “would gape in wonder at doctors examining animals” and ponder the “indecipherable scientific jargon” on the cage labels. Curious about one of the experiments, he asked a doctor about one of the animals, only to be rebuffed. On another occasion in the laboratory, two of Wright’s fellow porters began to fight; in the process they knocked over many of the animal cages, killing some animals and freeing others. Anxious to save their jobs, the porters attempted to restore order in the lab. Relying on memory and guesswork, they filled cages with the same numbers of animals, replacing dead stock with live animals, and waited for the doctors to notice. To their surprise, no questions were ever raised about the incident, prompting Wright to speculate:
We often wondered what went on in the laboratories after that secret disaster. Was some scientific hypothesis, well on its way to validation and ultimate public use, discarded because of unexpected findings on that cold winter morning? Was some tested principle given a new and strange refinement because of fresh, remarkable evidence? Did some brooding researcher get a wild, if brief, glimpse of a new scientific truth? At any rate we never heard.17
Wright’s conclusion belied the title he gave the story: “What You Don’t Know Won’t Hurt You: A Belated Report on the Progress of Medical Research.” Not knowing was neither a benefit to the porters kept in ignorance about the experiments, nor a boon to the medical researchers who were uninformed about the wholesale switching of the laboratory animals.
In an autobiographical account, Black Boy, first published in 1944, Wright included a number of incidents from his stay at the Michael Reese Hospital absent from the magazine article. Noting “the sharp line of racial division drawn by the hospital authorities,” he recalled how one of his jobs was to restrain dogs until they received an injection of Nembutal, after which a “young Jewish doctor” would slit their vocal chords, so that the animal howls would not disturb patients in other parts of the hospital. The sight of the dogs lifting their heads and soundlessly wailing made a powerful impression upon him. In his autobiography, Wright recorded how he considered going to the director’s office and telling him about the exchange of animals. Loyalty to his coworkers and dislike for the man led him to keep his silence.
The hospital kept us four Negroes, as though we were close kin to the animals we tended, huddled together down in the underworld corridors of the hospital, separated by a vast psychological distance from the significant processes of the rest of the hospital—just as America had kept us locked in the dark underworld of American life for three hundred years—and we had made our own code of ethics, values, loyalty.18
Professional codes of ethics did not always protect human subjects—white or black—from researchers. In rare cases, Americans, including African Americans, sought redress from the courts when physicians overstepped the bounds of experimentation. In the 1940s the mother of a young African American man sued a white physician in the District of Columbia whose surgical experiments caused severe injury to her son. Before the suit was eventually settled out of court, newspaper publicity about the case raised a number of questions about experiments on African Americans.
In 1940 John Bonner, a junior high school student, donated skin to a badly burned cousin for an experimental skin-grafting procedure. Although Bonner was only fifteen at the time, surgeon Robert Moran did not obtain parental consent before undertaking the surgical experiment in the charity clinic of Episcopal Hospital. In an effort to treat the burned woman, Moran surgically removed a flap of skin and formed a “tube of flesh” from the boy’s armpit to his waist, which he attached to the boy’s cousin. The two remained surgically joined for four days, when Bonner began to experience shock and anemia. The boy lost so much blood that he required several transfusions, and he spent nearly two months in the hospital recovering from his experience.19
In 1941 Margaret Moore, the boy’s mother, brought suit against the physician for assault and battery. Even though Bonner’s mother had not given her consent, the trial court ruled in favor of the physician, noting that a minor’s permission for the operation was sufficient in this case. Appealed to the District of Columbia Court of Appeals, the higher court ruled that although children could consent to medical therapy in exceptional cases, the Bonner case did not involve a therapeutic benefit for the boy.
Here the operation was entirely for the benefit of another and involved sacrifice on the part of the infant of fully two months of schooling, in addition to serious pain and possible results affecting his future life. This immature colored boy was subjected several times to treatment involving anesthesia, blood letting, and the removal of skin from his body, with at least some permanent marks of disfigurement.20
Although the appeals court instructed the lower court to retry the case, the parties reached an out-of-court settlement.21
The case of Bonner v. Moran has been discussed in the bioethics literature in the context of legal precedents for allowing healthy children to donate kidneys. But the suit may be important for other reasons as well. The ruling of the appellate court suggests that there were in fact some legal (and financial) constraints on white physicians whose experiments on black subjects ended in injury or harm to the participants. Less tangibly, the “newspaper notoriety” surrounding the boy’s heroism, which apparently resulted in public contributions of money for his future education, suggests a wider public appreciation for both the costs and benefits of human experimentation.
The Bonner case, Abbott’s intestinal intubations, and the Tuskegee Syphilis Study illustrate different aspects of race and research in American medicine. Differences in study design, investigators, and subjects influenced the research experience, and race informed the conduct of these experiments as it did other aspects of American life. In the case of an “experiment in nature,” as investigators termed the no-treatment syphilis study, investigators actively deceived their “patients” to retain them in their studies. In such explicitly nontherapeutic studies as the intestinal intubations, white investigators needed cooperation from their subjects; they reserved their contempt for their “guinea pigs” even as they supplied the financial compensation required to recruit them. But Abbott’s experience also illustrates how research subjects attempted to negotiate the terms of their participation in research. Like the men in Abbott’s studies, John Bonner’s mother contested the terms of her son’s participation in medical research. Unlike Flip Lawall and the other men who lost their bid for higher wages, Margaret Moore proved successful in obtaining financial compensation for the injuries her son incurred at the hands of a surgical innovator. Looking at researchers and research subjects in the case of the Tuskegee Study and other experiments provides a broader context in which to view the ways in which racism structured what Richard Wright labeled “the dark underworld of American life.”22
1. Quoted in James H. Jones, Bad Blood (New York: Free Press, 1993), p. 132.
2. For Burke and Hare, see Ruth Richardson, Death Dissection and the Destitute (London: Routledge and Kegan Paul, 1987).
3. E. Rivers, S. Schuman, L. Simpson, and S. Olansky, “Twenty Years of Followup Experience in a Long-Range Medical Study,” Public Health Reports 68 (1953): 391–95 (quotation on p. 394).
4. Jones, Bad Blood, p. 154.
5. See Susan E. Lederer, Subjected to Science: Human Experimentation in America before the Second World War (Baltimore: Johns Hopkins University Press, 1995).
6. Autopsies undertaken for forensic purposes did not require familial consent. See George H. Weinmann, “A Survey of the Law Concerning Dead Human Bodies,” Bulletin of the National Research Council 73 (1929): 58.
7. Ibid., p. 58.
8. William J. Hoffman, “Postmortem Examinations: Method of Obtaining Permission,” Journal of the American Medical Association 101 (1933): 1199–1205.
9. There were some notable differences, however, in state laws. In 1913, for example, North Carolina’s statutes exempted the bodies of Confederate soldiers and their wives from dissection, and they further provided that no white body could be sent to a Negro medical college. See George B. Jenkins, “The Legal Status of Dissecting,” Anatomical Record 7 (1913): 387–99. See also D. C. Humphrey, “Dissection and Discrimination: The Social Origins of Cadavers in America, 1760–1915,” Bulletin of the New York Academy of Medicine 49 (1973): 819–27.
10. The words volunteers with social incentives appear on a chart comparing the Tuskegee Study with the all-European Norway (or Oslo) Study; see Stanley Schuman, Sidney Olansky, Eunice Rivers, C. A. Smith, and Dorothy S. Rambo, “Untreated Syphilis in the Male Negro,” Journal of Chronic Diseases 2 (1955): 545.
11. Abbott (1902–1943) received his M.D. from the University of Pennsylvania in 1928, where he also served as an instructor (1931–37), associate (1937–41), and assistant professor (1941–43). Abbott’s mother, Georgina Osler, was a niece of Sir William Osler. See William C. Stadie, “William Osler Abbott,” Transactions of the Association of American Physicians 58 (1944): 7–9. For the technique, see T. Grier Miller and W. Osler Abbott, “Intestinal Intubation: A Practical Technique,” American Journal of the Medical Sciences 187 (1934): 595–99.
12. In 1930, the Department of Pathology at the University of Illinois College of Medicine used 80 unemployed men ages 20–76 from the state employment bureau in studies of skin reactions and other procedures; see William F. Petersen and Samuel A. Levinson, “General Correlations in One Hundred So-Called Normal Men,” Archives of Pathology 9 (1930): 151–82.
13. See W. Osler Abbott, “The Problem of the Professional Guinea Pig,” Proceedings of the Charaka Club 10 (1941): 249–60.
14. Petersen and Levinson, “General Correlations.”
15. Abbott, “Problem of the Professional Guinea Pig,” p. 259.
16. Willis D. Gatch, “My Experiences with Dr. Halsted,” Surgery 32 (1952): 466–68.
17. Richard Wright, “What You Don’t Know Won’t Hurt You: A Belated Report on the Progress of Medical Research,” Harper’s Magazine 186 (1942): 58–61.
18. Richard Wright, Black Boy (New York: HarperPerennial, 1993), p. 370.
19. See “Use of Fifteen Year Old Boy as Skin Donor without Consent of Parents as Constituting Assault and Battery,” JAMA 120 (1942): 562–63.
20. Bonner v. Moran, 75 U.S. App. D.C. 156, 126 F.2d 121 (1941). See Sharon Romm, “Robert Emmet “Pete” Moran: Washington’s Myth and Master,” Aesthetic Plastic Surgery 14 (1990): 43–51.
21. See George J. Annas and Michael A. Grodin, The Nazi Doctors and the Nuremberg Code (New York: Oxford University Press, 1992), pp. 202–3.
22. Wright, Black Boy, p. 370.