Agustín del Cañizo Fernández-Roldán
(1997). Study of the spontaneous evolution of syphilis in black patients
Agustín del Cañizo Fernández-Roldán
Departamento de Cirugía. Universidad de Salamanca (Spain).
Correspondence: Agustín del Cañizo Fernández-Roldán. Facultad de Medicina. Alfonso X El Sabio s/n. 37007 Salamanca (España).
Received 26 January 2004; accepted 19 April 2004
Miss Evers' Boys (1997) is a movie based on a real fact happened in the State of Alabama (United States), where it was carried out a research work that begun in 1932 and was prolonged up to 1972. It consisted on watching the evolution of syphilis in black male patients, who were not given any anti-syphilitic treatment at any moment.
Once the fact was public, a great polemic on the ethics of the research with human fellows was originated and publications dealt with this case.
The movie, faithful as for the bottom of the problem, it’s made as a novel about a research team’s nurse and four black participants patients.
Keywords: Bio-ethics, Ethics, Research, Syphilis.
Title: Miss Evers' Boys
Country: United States of America
Director: Joseph Sargent
Music: Charles Bernstein
Script: David Feldshuh and Walter Bernstein
Cast: Alfre Woodard, Thom Gossom, Von Coulter, Laurence Fishburne…
Runtime: 113 minutes
Genre: drama/ historical
Synopsis: In 1932, the syphilis had become an epidemic in the communities of the rural south of United States. So it, authorities decided to create a special program of treatment in the Tuskegee Hospital, the only hospital for black population existing in those days. When the funds diminished, the program became an experiment to study the fatal illness evolution when the treatment to these patients was denied.
Movie made for TV
In 1932 the PHS (Public Health Service) of the United States decided to carry out a study on the syphilis evolution in the black population of Tuskegee, in the County of Macon (Alabama). Financed with federal funds it was thought as a study of cases and controls. For this reason, about four hundred syphilitic black males and another similar group of two hundred non-syphilitic that served as control were selected. Their objective was to compare health and longevity in the syphilitic non-treated population versus control group1.
Fellows selected for the study were offered some material advantages, even sanitary, but in no case syphilis treatment was included. No information was given about the nature of their illness and they were only said that they had Bad Blood 2.
In the thirties, the scientific community had certain trust in syphilis treatment although there was no true specific therapy. However in 1936, it was proven that the complications were much more frequent in those infected patients that in the control group. Ten years later it was clear that the number of deaths doubled for the syphilitic ones. No treatment was given, although penicillin was available in the forty’s decade and later it would be known that without antibiotic its hope of life decreased by twenty percent. Those who received by physicians treatment before 1972 were not related to the study.
The research continued without substantial changes and thirteen papers were published in medical journals until 1972. At this point the journalist J. Heller published a report on this topic in the New York Times, in that moment the scandal began and the experiment ceased.
The justification given by the researchers was that they didn’t make anything else but to observe the natural course of the disease.
Taking as a base the previously pointed out fact, the movie mainly impacts in two subjects: the ethic of the procedure and the racial question.
A nurse that collaborated in the study acts as a narrator during the course of her explanation to the Senate’s committee which investigated the case (figures 1 and 2). Ms. Evers, a black nurse, begins reciting the Florence Nightingale’s Infirmary Oath. She tries to justify the study because of the advantages achieved by the black population of Tuskegee: for the first time the American government worried about the black ones and free medical attendance was offered. For her, the most important thing was that this concern was perceived by coloured people. Here, it is already present the racist component.
At the beginning, the research was financed by a foundation established in Chicago and the selected black population, when the diagnosis was carried out, received rubs with mercury as treatment. It is interesting, at this point of the movie to point out how the process of informing the patients is carried out. Following the advice of black sanitary staff, in a clearly paternalistic attitude, the name of the disease was hidden and, just as it really happened, they decided to communicate them they have poisoned blood. In order to explain how this situation has arrived, the white physician (figure 3) who conducts the experiment uses a completely incomprehensible scientific terminology for his fellows. Then, nurse Evers gives a lesson about how it is possible to explain a medical process with understandable words to novice people and of scarce cultural formation.
In the period that the research begins, 1932, it didn't exist any regulating standards concerning the experimentation with human fellows. It was not until the Second World War finished, when nazi experiences in concentration camps were known and Nuremberg code was created. In this code the risk/benefit concepts and an informed consent are present for the first time. However, the problem of lacking information is present during the whole development of the movie. One of the main characters who is able to find out everything, requests explanations about this absence of information, standing out the sanitary personnel's paternalism. In one moment, he states: "they are black, not children."
At the first stage of the trial, the patients received the standard treatment (figure 4). The true design is elaborated when the Chicago foundation cancelled the funds, and the government decided to keep on with the research suppressing the whole treatment. There was a previous similar study carried out in Norway about the syphilis evolution. But the so-called Oslo report, published in 1841, when any anti-luetic treatment didn't exist, was referred to a white population. Now, it pretended to prove if the evolution of the disease was the same in the black population. (figure 5).
From this point, the tension between the racist problem and the morality of the study becomes more evident in the movie. The lack of information leads to a more and more apparent deceit; because the massages with mercury are substituted by liniment, and diagnostic lumbar punctures are practiced, making sick people to believe that both manoeuvres were therapeutic ones. Above this, the black physician co-director of the study resorts to the principle: "first of all, not to cause damage", the highest range one in the professional ethic. However, as it really happened, although the implied sanitary personnel was said that the treatment would begin to be given after six or eight months, when it became evident that it won't be this way, this same physician manifested that the most important thing was to demonstrate that there were not biological differences in the disease evolution between white and black populations and, furthermore, black physicians were equally qualified to investigate it. Convinced of the correct of their performance, as it is shown in the movie, he believed to be making history.
The moral problem was increased since 1942 when the use of penicillin became extensive. This antibiotic began to be used to treat different infections in the same Hospital of Tuskegee, but its application to the participants in the study on the syphilis was refused. Also a list with their names was elaborated in order to avoid its application by sanitary personnel unknowing the assay.
For justifying the research continuation the fact that penicillin can cause a mortal reaction in already infected patients was resorted, in an attitude still frequent in the medical attendance which is stated in the sentence: "it is demonstrated"… it is not said where neither by who.
However, some had access to the treatment without any reaction. In the movie, one of the main characters received penicillin because of his join to the Army.
In 1947, Code of Nuremberg appeared and, since 1964, biomedical research is tried to be regulated by the Declaration of Helsinki, in which, besides the informed consent, it is stated that in all human research fellows’ welfare should always prevail over science and society interests. Physician, more than a researcher, should be protector of life and their patient's health, and the fellow who participates in a study should receive the best available treatment. None of these ethical norms were applied in the study carried out in Tuskegee although it was prolonged up to 1972.
Money was among the incentives offered to individuals of experimentation in Tuskegee. In the movie, it is crudely shown in a funeral: black people were interred wrapped in a sack (figure 6) and the first compensation those patients received, had as a purpose to be able to finance a coffin. For many of them, this was the biggest amount of money they had never received in their life.
When the ethical research with human fellows was regulated, there was a special care in avoiding methods that could coerce people to participate: reduction of condemnation in prisoners or economic benefits to indigents.
Even so, nurse Evers is who makes more evident the moral tensions along the movie. Despite their sentimental attitude towards the main characters of the story and over the illness incidence in their lives, she shows an ambivalent behaviour. On the one hand, she perceives the advantages, above all social ones, opposite the racial question and, in her desire to keep on the experiment, she even transforms the professional secret concept that, logically, should be referred to the preservation of patients intimacy and she considers a to keep secret the deceit they are subjected to a moral duty.
But on the other hand, she realizes the damage which supposes not to receive the treatment and she pleads for patient to be administered the antibiotic, thinking to leave the program due to conscience problems. Finally, she stole penicillin in order to apply it to one of the fellows and, in this scene, it is curious to verify her efforts to inform him about the possibility of adverse reactions and her concern about. The patient makes the decision on receiving the treatment, though he already was in a phase of the disease in which he had his understanding capacity affected.
Amazingly, in their declaration, Evers finishes justifying the Tuskegee experiment because it pursued a "wider good", although standing out that it would never have been carried out in a white population. She also believed to have lived an historical moment and she considered that damages caused to patients could be justified by the benefits obtained for the black community in general.
This utilitarian attitude, which defends that it is licit to sacrifice the individual rights for the common good, had presided a great part of the medical research previous to the Second World War.
Forty years after their beginning, a commission ad hoc put an end to the study after having been aired in the press. In that moment, there were only one hundred and twenty-seven survivors of the four hundred and twelve black syphilitic participants. The survivors received treatment and a government's compensation which the relatives of the deceased ones also perceived. None of the researchers was sanctioned.
More than twenty years after going out to the public light the study of Tuskegee, the movie transmits the conflict already tried by noted specialists on bioethics: non ethic research carried out whit a racially discriminated and excluded population 3.
What has been disclosed as Miss Evers' Boys had a great importance in the development of the Bioethics. A little time after it was made public, and with the antecedent of the article published by Beecher4 in the New England Journal of Medicine where, in 1966, he gives a report on some experiments that were done out to the margin of the ethical requirements, it was considered that it was no longer enough to regulate one the research with the deontology codes and the Declaration of Helsinki and some minimum behaviour norms should be collected in a legislation.
With this objective, in 1974, the American Congress created a commission to approach the problem of the experimentation with human beings, formed not only by scientists but also by other professionals: philosophers, jurists, theologians, sociologists, etc. Four years later this commission made public its conclusions in the so-called Belmont report, in which, for the first time, appeared the later-on universally Bioethics Principles. It is evident that all, of them were broken in the research of Tuskegee:
Principle of charity, since the biggest good for patients was not looked for.
Principle of autonomy, not having obtained their consent based on an appropriate information and carrying out performances under deceit.
Principle of justice, because there was not an equal selection of fellows and it was used a such vulnerable population like black indigents, also offering them certain advantages as coercion.
Principle of no-balefulness, the highest moral category one from the Hippocratic age, because not to administer a suitable treatment is maleficent and it can become an homicide by omission.
Translated by: Ignacio Trujillano Martín
Translation overseen by: Juan Carlos Sánchez Gómez and Emilio Valverde Romero