Medical Ethics & Medical Ethics & Human Human

ExperimentationExperimentation

Backdrop to this ClassBackdrop to this Class

Many aspects of medical ethicsMany aspects of medical ethics Patient-physician encounterPatient-physician encounter TreatmentTreatment Experimental subjectsExperimental subjects Limits to technologyLimits to technology

All are 19All are 19thth & 20 & 20thth century century developmentsdevelopments

Previous ethical codes had different Previous ethical codes had different focusfocus

Hippocratic OathHippocratic Oath– Legitimate practice of learned Legitimate practice of learned

physiciansphysicians– Less mention of patientsLess mention of patients

Do no harmDo no harmMaintain confidentialityMaintain confidentiality

Thomas Percival: Thomas Percival: Medical EthicsMedical Ethics– Legimation strategyLegimation strategy

AMA Code of Ethics (1847)AMA Code of Ethics (1847)– Restore medical legitimacyRestore medical legitimacy– Obligation of patient to physcianObligation of patient to physcian– Obligation of physician to colleaguesObligation of physician to colleagues

CMA Code of Ethics (1867)CMA Code of Ethics (1867)– Consolidate authority of regular Consolidate authority of regular

medicinemedicine– Concerned about homeopathic medicineConcerned about homeopathic medicine

Other reality was that patients were Other reality was that patients were not regularly exposed to not regularly exposed to experimentation prior to 19experimentation prior to 19thth century century

Stagnation of medical therapeuticsStagnation of medical therapeutics

Old theories rejected, but not the Old theories rejected, but not the therapeutics that accompanied themtherapeutics that accompanied them

Rejecting old therapies tantamount Rejecting old therapies tantamount to admitting other medical sects to admitting other medical sects were more correctwere more correct

Some experimentation had occurredSome experimentation had occurred

Smallpox inoculation: 1721Smallpox inoculation: 1721

Jenner’s work with smallpox vaccineJenner’s work with smallpox vaccine– No evidence of consentNo evidence of consent

Hospitals as Sites of Medical Hospitals as Sites of Medical ExperimentationExperimentation

Associated with rise of the hospital Associated with rise of the hospital as site of medical treatmentas site of medical treatment

Bad reputation Bad reputation Confinement of infectious casesConfinement of infectious cases Fears of experimentation by Fears of experimentation by

unscrupulous physiciansunscrupulous physicians

Autopsy used to improve diagnostic Autopsy used to improve diagnostic accuracyaccuracy

Feared by lay peopleFeared by lay people Associated with dissectionAssociated with dissection

Primarily a preoccupation of the Primarily a preoccupation of the poorer classespoorer classes

Rise of the Medical LaboratoryRise of the Medical Laboratory

First emerged in France in last half of First emerged in France in last half of 1919thth century century

Helped physicians understand how Helped physicians understand how diseases workeddiseases worked

Advanced medical therapeuticsAdvanced medical therapeutics

Claude Bernard Claude Bernard (1813-1878)(1813-1878)

Believed the lab Believed the lab was the future of was the future of medicinemedicine

““It is what we think It is what we think we know already we know already that prevents us that prevents us from learning”from learning”

Discovered glycogenic function of the Discovered glycogenic function of the liverliver

Pasteur built upon the reputation of Pasteur built upon the reputation of the lab as the new locus of medical the lab as the new locus of medical knowledgeknowledge

Medical scientist replaced medical Medical scientist replaced medical clinician as the new model of medical clinician as the new model of medical progressprogress

Animal ExperimentationAnimal Experimentation

Much knowledge was gained from Much knowledge was gained from vivi-sectionvivi-section

Used cats & dogs as experimental Used cats & dogs as experimental subjectssubjects

Ways of procuring research animals Ways of procuring research animals sometimes dubioussometimes dubious

Opposition mounted Opposition mounted

SPCA formed in Britain in 1824SPCA formed in Britain in 1824 Became RSPCA in 1840Became RSPCA in 1840 Began to oppose vivi-section after Began to oppose vivi-section after

development of anaesthesia in 1850sdevelopment of anaesthesia in 1850s Believed animals should be Believed animals should be

aneasthetized, then euthanizedaneasthetized, then euthanized Opposed use of cats, dogs, horsesOpposed use of cats, dogs, horses

1874 Royal Commission1874 Royal Commission Lobby group set up led by Frances Lobby group set up led by Frances

Power-CobbePower-Cobbe Had considerable popular supportHad considerable popular support

– eg: George Bernard Shaweg: George Bernard Shaw Cobbe continued to lobby for Cobbe continued to lobby for

abolition of animal experimentation abolition of animal experimentation

Frances Power-Frances Power-Cobbe (1822-1904)Cobbe (1822-1904)

Wide-ranging Wide-ranging interests in interests in feminism, social feminism, social justice, animal justice, animal rightsrights

Anti-vivisectionists had complex Anti-vivisectionists had complex reasons for opposition to use of reasons for opposition to use of animalsanimals– CrueltyCruelty– Feared it would blunt sensibilities of Feared it would blunt sensibilities of

young physiciansyoung physicians– Opened door to human experimentationOpened door to human experimentation

Another Royal Commission in 1Another Royal Commission in 1stst decade of 20decade of 20thth century century

Human ExperimentationHuman Experimentation

Also problematicAlso problematic 1919thth century standards were quire century standards were quire

differentdifferent

James Marion Sims James Marion Sims (1813-1883)(1813-1883)

Celebrated as the Celebrated as the “founder of “founder of modern modern gynecology”gynecology”

Practiced in Practiced in Montgomery, Montgomery, AlabamaAlabama

Developed a new surgical procedure Developed a new surgical procedure to repair vaginal fistulasto repair vaginal fistulas

Result of long series of experiments Result of long series of experiments on black slaveson black slaves

Did surgery without anaesthesiaDid surgery without anaesthesia Alleged that many women died Alleged that many women died

during his experimentsduring his experiments

Sims’s legacy controversial to this Sims’s legacy controversial to this dayday

Similar problem with Pasteur’s work Similar problem with Pasteur’s work with rabies vaccinewith rabies vaccine

Medical Ethics in the 20Medical Ethics in the 20thth Century Century

Anti-vivisection movement raised Anti-vivisection movement raised consciousness of medical professionconsciousness of medical profession

Also aware animal models couldn’t Also aware animal models couldn’t always workalways work

Created set of rough guidelines for Created set of rough guidelines for human experimentationhuman experimentation

Must first, if possible, be tested on Must first, if possible, be tested on animalsanimals

Physician willing to experiment on Physician willing to experiment on self or family memberself or family member– Not always possibleNot always possible

Patient demonstrate willingness to Patient demonstrate willingness to submit to experimentsubmit to experiment– Often signified by paymentOften signified by payment

Max von Pettenkoffer opposed Koch’s Max von Pettenkoffer opposed Koch’s germ theory of choleragerm theory of cholera

Swallowed a sample of cholera bacilliSwallowed a sample of cholera bacilli He livedHe lived

Yellow fever Yellow fever experimentsexperiments

As early as 1807, it As early as 1807, it had been had been suspected that suspected that mosquitoes might mosquitoes might be vectorsbe vectors

Experimental work Experimental work by Carlos Finlay by Carlos Finlay (1833-1915) of (1833-1915) of Cuba in 1870sCuba in 1870s

Published paper in 1881Published paper in 1881 Hypothesized that it was mosquito Hypothesized that it was mosquito

borneborne Unable to experimentally Unable to experimentally

demonstrate the linkdemonstrate the link

Spanish-American war (1898)Spanish-American war (1898) Appalling mortality in American Appalling mortality in American

troopstroops

Walter Reed (1851-Walter Reed (1851-1902)1902)

Arrived in Havana Arrived in Havana after the war to after the war to investigate investigate outbreaks of outbreaks of typhoid fevertyphoid fever

Moved on to yellow Moved on to yellow feverfever

Two arms to the researchTwo arms to the research– Disprove miasma theoryDisprove miasma theory– Prove mosquito theoryProve mosquito theory

No animal models for the disease No animal models for the disease existedexisted

Forced to use human volunteersForced to use human volunteers

Initial experiments conducted on 2 Initial experiments conducted on 2 members of the commissionmembers of the commission

Both contracted disease; one diedBoth contracted disease; one died Tests on more volunteersTests on more volunteers

– Used written consentUsed written consent– Paid participantsPaid participants

$100 for participating$100 for participating$100 more if contracted disease$100 more if contracted disease

Payment problematicPayment problematic Changes motivation for volunteeringChanges motivation for volunteering Documentation that some volunteers Documentation that some volunteers

cried when they were not selectedcried when they were not selected

Other late 19Other late 19thth & early 20 & early 20thth century century human experiments did not even human experiments did not even attain this level of consentattain this level of consent

1891 Swedish experiments on 1891 Swedish experiments on smallpoxsmallpox

Used children recruited from an Used children recruited from an orphanageorphanage

Cheaper than calvesCheaper than calves

No government regulation of human No government regulation of human experimentationexperimentation

Britain had legislation re: animal Britain had legislation re: animal experimentationexperimentation

US had neitherUS had neither Resulted in experiments we would Resulted in experiments we would

deem unethical todaydeem unethical today

Experiment in US leper colonyExperiment in US leper colony Test hypothesis that leprosy & Test hypothesis that leprosy &

syphilis were same diseasesyphilis were same disease 6 girls with leprosy inoculated with 6 girls with leprosy inoculated with

syphilissyphilis Did not develop diseaseDid not develop disease Subsequently 12 more children Subsequently 12 more children

inoculatedinoculated

Drug toxicity tests on mental Drug toxicity tests on mental patientspatients

8 patients given increased doses and 8 patients given increased doses and responses documentedresponses documented

Justification: all were past the point Justification: all were past the point of recovery from their illnessof recovery from their illness

Experiment in Boston Experiment in Boston Test diagnostic utility of lumbar Test diagnostic utility of lumbar

puncturepuncture 45 children at or near death 45 children at or near death

underwent procedureunderwent procedure

Congressional hearings on human Congressional hearings on human experimentation in 1916experimentation in 1916

No bill passedNo bill passed AMA refused to amend Code of EthicsAMA refused to amend Code of Ethics Support for anti-vivisectionism & Support for anti-vivisectionism &

human experimentation wanedhuman experimentation waned Public more interested in successes Public more interested in successes

gained by these techniquesgained by these techniques

1922 discovery of insulin1922 discovery of insulin

Anxiety about human Anxiety about human experimentation did not re-emerge experimentation did not re-emerge until after Second World Waruntil after Second World War

Nuremburg Code (1947)Nuremburg Code (1947)

AMA adopted principle of informed AMA adopted principle of informed consent in 1946consent in 1946

Problems with ethical human Problems with ethical human experimentation continuedexperimentation continued

Tuskegee syphilis experiment (1932-Tuskegee syphilis experiment (1932-1972)1972)

LobotomyLobotomy

Compulsory sterilizationCompulsory sterilization

What can we learn from these What can we learn from these examples?examples?