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When Ethics "Evolve," Beware

The editors of Nature opine that medical ethics have evolved, and need to evolve with the times. They point to past abuses, considered acceptable at the time, that are now deemed abhorrent, reckless and repugnant. We're more careful now, they assure readers. But when ethics evolve, watch out.

The editors were filled with righteous indignation in their February 9 editorial.1 In 1944, the U.S. government had allowed John Cutler, a physician with the U.S. Public Health Service, to infect Guatemalans with syphilis and gonorrhea without their consent in order to test a prophylactic. It was all for the good, of course; who wouldn't want to use science, with its controlled experimental methods, to find a cure for devastating diseases that afflict millions?

In all, 1,308 prisoners were infected. Some of them are still alive today, having suffered ever since. In the same issue of Nature,2 Matthew Walter described other examples of ethics gone awry ("Human experiments: First do harm"). But before we condemn past abusers for their "Hypocritical Oaths," the editors warned, we need to honestly assess how ethics evolve. The "barbarous experiments" in post-war Guatemala raise serious questions about how historians will judge today's "acceptable" practices.

Most unsettling is the fact that Guatemala was not an isolated case. The editors and Walter dredged up a litany of disturbing incidents from recent memory:

  • In 1941, "US physician William Black infected children, including a 12-month-old baby, with the herpes virus." His work was eventually published in the Journal of Pediatrics.
  • Residents of a psychiatric hospital were infected with influenza. It is doubtful any of them could have given their consent. "It might be tempting to explain away such research abuses as the work of rogue scientists," the editors said, "but the Michigan study was conducted by a leading researcher of the time, Thomas Francis Jr., and his young colleague, Jonas Salk, who went on to develop the polio vaccine."
  • In 1963, "a team run by Chester Southam injected tumor cells into extremely infirm patients at the Jewish Hospital for Chronic Disease in New York without informing them that the shots contained cancer," the list continued. "Southam was later put on probation by the New York State medical licensing board, but many researchers defended the work and he was later elected president of the American Association for Cancer Research."

As for Cutler, his abuses did not end in Guatemala. He returned to the U.S. and continued subjecting American prisoners, mental patients and soldiers to infection with sexually transmitted diseases. Some of his methods, described by Walter, are sickening. He actually lied to get the cooperation of test patients:

The commission says there is no evidence that Cutler sought or obtained consent from participants, although in some cases he did get permission from commanding officers, prison officials and doctors who oversaw the patients at the psychiatric hospital. In a letter to his supervisor, John Mahoney, director of the VDRL, Cutler openly admits to deceiving patients at the psychiatric hospital, whom he was injecting with syphilis and later treating. "This double talk keeps me hopping," Cutler wrote.
To add insult to injury, Cutler couldn't claim any successes. He never published his work on prophylactic methods. "The experiments were not only unconscionable violations of ethics, the bioethics commission charges, they were also poorly conceived and executed." One would hope to see justice catch up with this monster. Instead, his career took off:
Despite the failures, the work burnished Cutler's credentials. A few months after he arrived home, the World Health Organization sent Cutler to India to lead a team demonstrating how to diagnose and treat venereal diseases. In the 1960s, he became a lead researcher in the infamous Tuskegee experiment in Alabama, in which hundreds of black men with syphilis were studied for decades without receiving treatment. He flourished in the Public Health Service and later became a professor of international health at the University of Pittsburgh in Pennsylvania. He died in 2003, well before details of the Guatemala experiments were exposed.
Having set the stage, let's return to the topic of whether ethics can, or should, evolve. The editors seem conflicted. They begin with a clear statement of principle:
Ethical boundaries for experiments on humans can be stated very simply. "The limits of justifiable experimentation upon our fellow creatures are well and clearly defined," Canadian physician William Osler, one of the grand old men of U.S. medicine, wrote more than a century ago. "For man absolute safety and full consent are the conditions which make such tests allowable."
Living in this age of post-Nazi enlightenment, we should have memorized the Nuremburg Code of medical ethics (1946-1947), Matthew Walter's slide show reminds us, that "experimenters must obtain voluntary consent from participants and should avoid unnecessary harm." In 2010, President Barack Obama issued a formal apology to Guatemala for the past abuses. These reminders in Nature appear to uphold standards that, by definition, stand.

Yet mysteriously, the editors claim that ethics have evolved and should evolve. Notice this convoluted statement that mixes stasis and evolution in the same sentence: "Although US standards have evolved, the concepts of informed consent and safety still underpin research on humans." On one hand they call us to engage in serious soul-searching:

What kind of work deemed as accepted today will be denounced by future generations? The question is one that all researchers should bear in mind, because history may judge them more harshly than their peers do. One example could be denial of treatment to sick people through the use of placebos in clinical trials and the ways in which some of these trials are carried out in developing nations, amid accusations of abuse of poor, uneducated participants. Broadening to other types of research, attitudes to work on embryonic stem cells may harden. And future generations may extend the protection currently in place for humans to cover other species, such as chimpanzees.
On the other hand, they preach that ethical standards need to evolve with the times::
There is, of course, clear water between the Guatemalan experiments and chimpanzee research. The Guatemala research was illegal, even in the 1940s, and most of the data did not prove useful and went unpublished. Still, as with research on embryonic stem cells, there is considerable debate about the ethics of using chimpanzees as experimental subjects. In these and other cases, nations would do well to heed some of the lessons that emerged from the investigation of the experiments in Guatemala. Governments and other funders of research must exert full oversight, provide as much transparency as possible and ensure that regulations are clear, strong and evolve with the times.
Perhaps they mean evolve by orthogenesis. In that "straight-line" theory of evolution (popular in the early 20th century), things evolve toward a goal. Maybe we are getting warmer, as we move toward the ultimate ethical standard. Better oversight, regulation and transparency will ensure we get there.

Charles Darwin, however, preached that natural selection was directionless and contingent. Stephen Jay Gould emphasized that point: rewind the tape of evolution, start over, and you will likely get completely different results. Darwin also applied his concept of natural selection to the human mind and emotions. According to his view (undoubtedly shared by the editors of Nature), the ethics we call standards today had no direction or goal; they just "are" -- as are the feelings of happiness or disgust we feel comparing our values with those of 1941. By extension, the ethics of 2050, or 2100, may castigate what we praise, and may glorify what we despise.

The editors of Nature can't quite stomach the logical conclusion of their evolutionary views. Their admiration of evolution is tempered by the recognition that society needs absolutes. One cannot call past abuses "unconscionable" without a conscience. One cannot judge past abuses without a standard to judge by. Darwin's most prominent living advocate, Richard Dawkins, has admitted he wouldn't want to live in a country operating by natural selection. He prefers living in a nominally Judeo-Christian society, one that still believes in the rule of law based on unchanging ethics, that grants him the freedom to operate his business of undermining the Judeo-Christian world view.

The editors were noticeably silent about North Korea, where experimentation on human prisoners is rampant, leading to untold horrors of pain and suffering -- where the victims are expected to praise the Dear Leader for allowing them to serve him in that way. Who are the editors to accuse them? How can they know whether in some future epoch, historians will judge harshly not the North Koreans, but the editors of Nature for their barbarous, disgusting, abhorrent suggestion that what Cutler did was wrong?

Let the evolver beware.

References:

1. Editorial, "Hypocritical Oaths," Nature 482 (09 February 2012), p. 132, doi:10.1038/482132a.

2. Matthew Walter, "Human experiments: First do harm," Nature News Feature, vol. 482 (08 February 2012), issue 7384.