Trials and tribulations

By tracing the development of ethical standards for medical experiments involving human beings, Susan Lederer has, in Subjected to Science, added an important chapter to the history of medicine and recorded for the first time the history of the American anti-vivisection movement.

Lederer discovered that 19th-century humanists were the first to realise that unrestrained experimentation on animals would culminate in scientific exploration of vulnerable people. Their main concern was the amelioration of increasingly harsh living conditions for animals in urban communities. But when told that a South American physician had injected five patients with the bacillus of yellow fever, and that similar examples of human vivisection or non-therapeutic experimentation could be found in United States hospitals, the American Humanist Association, in 1897, appointed a committee to study the practice of experimenting on human beings. Thereafter, the issue of human vivisection was closely identified with animal welfare, and the American Medical Association was repeatedly reminded of the problem both by antivivisectionists, (who were trying to stop all animal experiments) and by vivisection reformers (like the AHA) who were only pressing for legislation to regulate these experiments.

Lederer is keen to make these points since she detected early a reluctance on the part of historians to look seriously at the conduct of human experimentation before the second world war. For example, she insists that, in his account of the Tuskegee Syphilis Study, J. H. Jones was wrong to maintain that in the 1930s there was "no system of normative ethics on human experimentation that compelled medical researchers to temper their scientific curiosity with respect for the patients' rights". Lederer herself has taken the position that "at no time were American investigations free to do whatever they pleased with their human subjects" and that "although lacking in enforcement policies, and far from perfect, ethical guidelines were influencing the conduct of research with both human and animal subjects before World War II". Nevertheless, at one point in her story, she is forced to admit that when, in 1916, the chairman of an AMA Council on the Defence of Medical Research tried to amend the asociation's code of ethics to include the responsibility of experiments to patients, he met with so much opposition from heads of clinical and research departments that clinical investigators were left "without any formal guidelines until the 1940s, when the AMA amended the code to require voluntary consent of the subject and prior animal testing".

Subjected to Science is addressed to the US citizens who, a short time ago, were outraged to discover that federally sponsored research projects included not only the Tuskegee Syphilis Study (the study of untreated syphilis in African-American men that began in 1932 and was brought to a crashing halt 40 years later by public outcry) but also nerve gas and mustard gas experiments on American soldiers during the second world war, and radiation experiments on dying patients, pregnant women and mentally retarded children during the Cold war. The book deals mainly with events before 1940, and Lederer has done her best to find impartial answers to the following questions. Did American physicians routinely perform non-therapeutic experiments on their patients? Who served as subjects of hese experiments and what risks did they encounter? Did physicians obtain permission for experimentation from patients and their families? What were the limits on human experimentation and how were they enforced?

First to be described is the position of US physicians at the beginning of the century, when knowledge acquired in the laboratory was establishing a new basis for therapeutic practice (and causing some concern) but there was, as yet, no pressure on young doctors to have research qualifications. We are then given the reasons why, in their attempts to stop doctors from increasingly stepping across the invisible line separating legitimate medical practices from practices that trespass on human or animal rights, the AHA found it necessary to join the forces with antivivisection and child protection societies and the reasons why leaders of the medical profession, while increasingly admitting the need for ethical constants, still remained fiercely opposed to any legislation. Finally, we come to a rash of new developments between the two world wars - which greatly increased the range and frequency of human experimentation - and the stage reached, in the US, by the time the Nuremberg trials of Nazi physicians for crimes against humanity made the problem of human vivisection one of general concern. Given the subtitle of her book, Lederer might have been expected to stop at this point. There is, however, an important epilogue from which we learn that 50 years after the AHA unsuccessfully called in 1916 for federal and state laws to protect children and other vulnerable persons from exploitation at the hands of experimenters, there appeared in the New England Journal of Medicine an article describing 22 research projects that in one way or another were risking the health and life of human subjects. The public outcry that followed this expose hastened the establishment of the present federal protections for human subjects of biomedical research. But even today, questions about human and animal rights, and what it means to be both human and humane, continue to disturb the public conscience.

Lederer has many heroic as well as shocking stories to tell, and she never allows us to forget that in relation to human vivisection both people under duress (for example, prisoners, soldiers and inmates of all institutions including hospitals) and ignorant persons (such as infants and mentally retarded children) are vulnerable. She also reminds us that one of many factors aggravating the present situation is a constant demand by universities and teaching hospitals for young doctors with research qualifications.

Alice Stewart is senior research fellow, department of epidemiology, University of Birmingham.