University of Louisiana Health Care Ethics Discussion Questions & Responses

Red attached file and watch video before answering the questions.

There should be absolutely no spelling or grammar errors. You may use your book or other resources, but you must cite the resource(s) both in-text and a reference list per APA guidelines. Minimum 250 words for initial post. Minimum 150 words for each student response (2)

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1. Carefully analyze this case. When you examine the paper and the appendix, what information appears to have been gained from this study? Th at is, what kind of argument can be made for the benefits of the study?

2. What do you believe were the motives for the people to become involved in the study, specifically: The subjects? The PHS personnel? The Tuskegee staff ? The Macon County physicians? Nurse Rivers?

3. What kind of criticisms can you offer of this study?

4. What were the factors underlying the cessation of the project?

5. Could this project (or one similar to it involving AIDS or radiation effects) be conducted today?

Post your discussion and then respond to the postings of 2 other students.  What are your thoughts on the ethical controversy item he/she posted?  Do you see other implications of the ethical controversy?

I will not be able to upload the students post for the response to them until I have uploading my initial response and then waiting 30 minutes. I will upload the two posts then.

POS 1

So far only one other student has made a post, I’m still waiting for one more. Here’s the first one though! 150 word reply.  What are your thoughts on the ethical controversy item he/she posted?  Do you see other implications of the ethical controversy?Originally, the Tuskegee Syphilis study’s intention was to identify and treat the disease. None of the men knew that they were a part of this study, all they knew was that they were going to be provided free health care and treatment for “bad blood.” When the men were diagnosed with syphilis the doctors never informed them nor treated them for it. I think that is very wrong and this approach was completely against patient’s rights. There was however, important information gained from this study. The study showed that the men spread the syphilis to their wives and when the babies were born they had syphilis too. Also, over 100 people died from not being treated. Would have we known this information without conducting this study? We may never know. I believe that the doctor’s motives were unethical and they could have gone about the study in a different way. It was beneficial in several ways but it also cost the lives of many. I understand that the times were different in the 20th century, but the doctors were technically killing people, which is murder, and the people did not even know nor have a say. After watching the video and reading the article I am very optimist that a similar study could be going on today regarding AIDS or even autism. I am sure it would be to a certain extent, however, you never really know these days. I hope for all of our sake, that we are not a part of this study.

POST 2

here is the second students reply. I’m sorry it took so long! After reviewing and studying the Tuskegee Syphilis Study, it is apparent that researchers did not respect the primary ethical principles of human research. Violation of all three ethical principles (respect of persons, beneficence, and justice) is apparent throughout the process of the experiment. The most obvious moral issue stems from the fact that “participants were lied to about their condition, lied to about the treatment they were receiving, and selected based on race, gender, and economic class.” This demonstrates the violation of the first ethical principal-Respect. It is clear in the fact that participants were not told the purpose of the study or given an explanation of terminology. Researchers also failed to inform persons that they had syphilis, meaning they had to test them without their consent. The Principle of Beneficence was violated by researchers when the subjects were lied to, and enticed, or enticed in, with cheap incentives, including free hot meals, bus rides, and placebos as free treatment, with the objective of attaining their consent to participate in the experiment. Lastly, the Principle of Justice was infringed on when researchers decided to purposely NOT treat the men for their disease which allowed a very curable disease to kill them for the purpose of observation. The study unashamedly undervalued and disrespected participants’ rights, placing them in danger. Even after Penicillin became available, participants were still denied treatment. Informed Consent is a critical ethical requirement in biomedical research efforts involving human subjects, and a central component to making research ethical. Under this principle, experts are obligated to ensure that subjects are given comprehensive information about any procedures involved in the study; in this case, the implications of an individual’s participation in specific medical procedures must be broken down and explained with terms easy for a non-professional to understand. This enables a person to give either informed consent or informed refusal. Ultimately, this project or one similar in nature could not be legally or publically conducted in today’s environment due to a firm adherence to ethical principles and respect for human rights. The extreme unethical and immoral nature of the study, as well as its violation of experimental human rights, are the reasons that strict legal implications have been put in place to protect participants in future experiments.

NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE
Bad Blood:
A Case Study of the Tuskegee Syphilis Project
by
A.W. Fourtner, C.R. Fourtner and C.F. Herreid
University at Buffalo, State University of New York
The Disease
Syphilis is a venereal disease spread during sexual intercourse. It can
also be passed from mother to child during pregnancy. It is caused
by a corkscrew-shaped bacterium called a spirochete, Treponema
pallidum. This microscopic organism resides in many organs of
the body but causes sores or ulcers (called chancres) to appear
on the skin of the penis, vagina, mouth, and occasionally in the
rectum, or on the tongue, lips, or breast. During sex the bacteria
leave the sores of one person and enter the moist membranes of
their partner’s penis, vagina, mouth, or rectum.
Once the spirochetes wiggle inside a victim, they begin to multiple
at an amazing rate. (Some bacteria have a doubling rate of 30
minutes. You may want to consider how many bacteria you might
have in 12 hours if one bacterium entered your body doubling
at that rate.) The spirochetes then enter the lymph circulation,
which carries them to nearby lymph glands that may swell in
response to the infection.
This first stage of the disease (called primary syphilis) lasts only a
few weeks and usually causes hard red sores or ulcers to develop
on the genitals of the victim, who can then pass the disease on
to someone else. During this primary stage, a blood test will not
reveal the disease but the bacteria can be scraped from the sores.
The sores soon heal and some people may recover entirely without
treatment.
Secondary syphilis develops two to six weeks after the sores heal. Then flu-like symptoms appear with fever,
headache, eye inflammation, malaise, and joint pain, along with a skin rash and mouth and genital sores.
These symptoms are a clear sign that the spirochetes have traveled throughout the body by way of the lymph
and blood systems, where they now can be readily detected by a blood test (e.g., the Wassermann test). Scalp
hair may drop out to give a “moth-eaten” look to the head. This secondary stage ends in a few weeks as the
sores heal.
Signs of the disease may never reappear even though the bacteria continue to live in the person. However, in
about 25% of those originally infected, symptoms will flare up again in a late or tertiary stage syphilis.
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NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE
Almost any organ can be attacked, such as the cardiovascular system, producing leaking heart valves and
aneurysms—balloon-like bulges in the aorta that may burst, leading to instant death. Gummy or rubbery
tumors filled with spirochetes and covered by a dried crust of pus may develop on the skin. The bones may
deteriorate as in osteomyelitis or tuberculosis and may produce disfiguring facial mutilations as nasal and
palate bones are eaten away. If the nervous system is infected, a stumbling foot-slapping gait may occur or,
more severely, paralysis, senility, blindness, and insanity.
The Health Program
The cause of syphilis, the stages of the disease’s development, and the complications that can result from
untreated syphilis were all known to medical science in the early 1900s. In 1905, German scientists
Hoffman and Schaudinn isolated the bacterium that causes syphilis. In 1907, the Wassermann blood test
was developed, enabling physicians to diagnose the disease. Three years later, German scientist Paul Ehrlich
created an arsenic compound called salvarsan to treat syphilis. Together with mercury, it was either injected
or rubbed onto the skin and often produced serious and occasionally fatal reactions in patients. Treatment
was painful and usually required more than a year to complete.
In 1908, Congress established the Division of Venereal Diseases in the United States Public Health Service.
Within a year, 44 states had organized separate bureaus for venereal disease control. Unfortunately, free
treatment clinics operated only in urban areas for many years. Data collected in a survey begun in 1926
of 25 communities across the United States indicated that the incidence of syphilis among patients under
observation was “4.05 cases per 1,000 population, the rate for whites being 4 per 1,000, and that for
Negroes 7.2 per 1,000.”
In 1929, Dr. Hugh S. Cumming, the Surgeon General of the United States Public Health Service (PHS),
asked the Julius Rosenwald Fund for financial support to study the control of venereal disease in the rural
South. The Rosenwald Fund was a philanthropic organization that played a key role in promoting the
welfare of African-Americans. The Fund agreed to help the PHS in developing health programs for southern
African-Americans.
One of the Fund’s major goals was to encourage their grantees to use black personnel whenever possible as a
means to promote professional integration. Thus, the mission of the Fund seemed to fit well with the plans
of the PHS. Macon County, Alabama, was selected as one of five syphilis-control demonstration programs
in February 1930. The local Tuskegee Institute endorsed the program. The Institute and its John A. Andrew
Memorial Hospital were staffed and administered entirely by African-American physicians and nurses: “The
demonstrations would provide training for private physicians, white and colored, in the elements of venereal
disease treatments and the more extensive distribution of antisyphilitic drugs and the promotion of wider
use of state diagnostic laboratory facilities.”
In 1930, Macon County had 27,000 residents, 82 percent of whom were African-Americans, most living in
rural poverty in shacks with dirt floors, no plumbing, and poor sanitation. This was the target population,
people who “had never in their lives been treated by a doctor.” Public health officials arriving on the scene
announced they had come to test people for “bad blood.” The term included a host of maladies and later
surveys suggest that few people connected that term with syphilis.
The syphilis control study in Macon County turned up the alarming news that 36 percent of the AfricanAmerican population had syphilis. The medical director of the Rosenwald Fund was concerned about the
racial connotations of the findings, saying “There is bound to be danger that the impression will be given
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that syphilis in the South is a Negro problem rather than one of both races.” The PHS officer assured the
Fund and the Tuskegee Institute that demonstrations would not be used to attack the images of black
Americans. He argued that the high syphilis rates were not due to “inherent racial susceptibility” but could
be explained by “differences in their respective social and economic status.” However, the PHS failed to
persuade the Fund that more work could break the cycle of poverty and disease in Macon County. So when
the PHS officers suggested a larger scale extension of the work, the Rosenwald Fund trustees voted against
the new project.
Building on what had been learned during the Rosenwald Fund demonstrations and the four other sites, the
PHS covered the nation with the Wassermann tests. Both blacks and whites were reached with extensive
testing, and in some areas mobile treatment clinics were available.
The Experiment
As the PHS officers analyzed the data for the final Rosenwald Fund report in September of 1932, and
realizing that funding for the project would be discontinued, the idea for a new study evolved into the
Tuskegee Study of Untreated Syphilis in the Negro Male. The idea was to convert the original treatment
program into a nontherapeutic human experiment aimed at compiling data on the progression of the disease
on untreated African-American males.
There was precedence for such a study. One had been conducted in Oslo, Norway, at the turn of the century
on a population of white males and females. An impressive amount of information had been gathered
from these patients concerning the progression of the disease. However, questions of manifestation and
progression of syphilis in individuals of African descent had not been studied. In light of the discovery that
African natives had some rather unique diseases (for example, sickle cell anemia—a disease of red blood
cells), a study of a population of African males could reveal biological differences during the course of the
disease. (Later, the argument that supported continuation of the study may even have been reinforced in the
early 1950s when it was suggested that native Africans with the sickle cell trait were less susceptible to the
ravages of malaria.)
In fact, Dr. Joseph Earle Moore of the Venereal Disease Clinic of the Johns Hopkins University School of
Medicine stated when consulted, “Syphilis in the Negro is in many respects almost a different disease from
syphilis in the white.” The PHS doctors felt that this study would emphasize and delineate these differences.
Moreover, whereas the Oslo study was retrospective (looking back at old cases), the Macon Study would be a
better prospective study, following the progress of the disease through time.
It was estimated that of the 1,400 patients in Macon County admitted to treatment under the Rosenwald
Fund, not one had received the full course of medication prescribed as standard therapy for syphilis. The
PHS officials decided that these men could be considered untreated because they had not received enough
treatment to cure them. In the county there was a well-equipped teaching hospital (the John A. Andrew
Memorial Hospital at the Tuskegee Institute) that could be used for scientific purposes.
Over the next months in 1932, cooperation was insured from the Alabama State Board of Health, the
Macon County Health Department, and the Tuskegee Institute. However, Dr. J.N. Baker, the state health
officer, received one important concession in exchange for his approval. Everyone found to have syphilis
would have to be treated. Although this would not cure them—the nine-month study was too short—it
would keep them non-infectious. Dr. Baker also argued that local physicians be involved.
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NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE
Dr. Raymond Vonderlehr was chosen for the field work that began in October 1932. Dr. Vonderlehr began
his work in Alabama by spreading the word that a new syphilis control demonstration was beginning and
that government doctors were giving free blood tests. Black people came to schoolhouses and churches for
examination—most had never before seen a doctor. Several hundred men over 25 years old were identified
as Wassermann-positive who had not been treated for “bad blood” and had been infected for over five years.
Cardiovascular problems seemed particularly evident in this population in the early days, reaffirming that
Negroes might be different in their response. But nervous system involvement was not evident.
As Dr. Vonderlehr approached the end of his few months of study, he suggested to his superior, Dr. Clark,
that the work continue for five to 10 years because “many interesting facts could be learned regarding the
course and complications of untreated syphilis.” Dr. Clark retired a few months later and in June 1933 Dr.
Vonderlehr was promoted to director of the Division of Venereal Diseases of the PHS.
This promotion began a bureaucratic pattern over the next four decades that saw the position of director go to a
physician who had worked on the Tuskegee Study. Dr. Vonderlehr spent much of the summer of 1933 working
out the study’s logistics, which would enable the PHS to follow the men’s health through their lifetime. This
included gaining permission from the men and their families to perform an autopsy at the time of their death,
thus providing the scientific community with a detailed microscopic description of the diseased organs.
Neither the syphilitics nor the controls (those men free of syphilis who were added to the project) were
informed of the study’s true objective. These men knew only that they were receiving treatment for “bad
blood” and money for burial. Burial stipends began in 1935 funded by the Milbank Memorial Fund.
The skill of the African-American nurse, Eunice Rivers, and the cooperation of the local health providers
(most of them white males), were essential in this project. They understood the project details and the fact
that the patients’ available medical care (other than valid treatment for syphilis) was far better than that for
most African-Americans in Macon County. The local draft board agreed to exclude the men in the study from
medical treatment when that became an issue during the early 1940s. State health officials also cooperated.
The study was not kept secret from the national medical community in general. Dr. Vonderlehr in 1933
contacted a large number of experts in the field of venereal disease and related medical complications.
Most responded with support for the study. The American Heart Association asked for clarification of the
scientific validity, then subsequently expressed great doubt and criticism concerning the tests and procedures.
Dr. Vonderlehr remained convinced that the study was valid and would prove that syphilis affected AfricanAmericans differently than those of European descent. As director of the PHS Venereal Disease Division, he
controlled the funds necessary to conduct the study, as did his successors.
Key to the cooperation of the men in the Tuskegee Study was the African-American PHS nurse assigned to
monitor them. She quickly gained their trust. She dealt with their problems. The physicians came to respect
her ability to deal with the men. She not only attempted to keep the men in the study, many times she
prevented them from receiving medical care from the PHS treatment clinics offering neoarsphenamine and
bismuth (the treatment for syphilis) during the late 1930s and early 1940s. She never advocated treating the
men. She knew these treatment drugs had side affects. As a nurse, she had been trained to follow doctor’s
orders. By the time penicillin became available for the treatment of syphilis, not treating these men had
become a routine procedure, which she did not question. She truly felt that these men were better off
because of the routine medical examinations, distribution of aspirin pink pills that relieved aches and pains,
and personal nursing care. She never thought of the men as victims; she was aware of the Oslo study: “This
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is the way I saw it: that they were studying the Negro, just like they were studying the white man, see,
making a comparison.” She retired from active nursing in 1965, but assisted during the annual checkups
until the experiment ended.
By 1943, when the Division of Venereal Diseases began treating syphilitic patients nationwide with
penicillin, the men in the Tuskegee study were not considered patients. They were viewed as experimental
subjects and were denied antibiotic treatment. The PHS officials insisted that the Study offered even more of
an opportunity to study these men as a “control against which to project not only the results obtained with
the rapid schedules of therapy for syphilis but also the costs involved in finding and placing under treatment
the infected individuals.” There is no evidence that the study had ever been discussed in the light of the
Nuremberg Code, a set of ethical principles for human experimentation developed during the trials of Nazi
physicians in the aftermath of World War II. Again, the study had become routine.
In 1951, Dr. Trygve Gjustland, then the current director of the Oslo Study, joined the Tuskegee group
to review the experiment. He offered suggestions on updating records and reviewing criteria. No one
questioned the issue of contamination (men with partial treatment) or ethics. In 1952, the study began
to focus on the study of aging, as well as heart disease, because of the long-term data that had been
accumulated on the men. It became clear that syphilis generally shortened the lifespan of its victims and that
the tissue damage began while the young men were in the second stage of the disease (see tables in Appendix A).
In June 1965, Dr. Irwin J. Schatz became the first medical professional to object to the study. He suggested
a need for PHS to reevaluate their moral judgments. The PHS did not respond to his letter. In November
1966 Peter Buxtin, a PHS venereal disease interviewer and investigator, expressed his moral concerns about
the study. He continued to question the study within the PHS network.
In February of 1969, the PHS called together a blue ribbon panel to discuss the Tuskegee study. The
participants were all physicians, none of whom had training in medical ethics. In addition, none of them
were of African descent. At no point during the discussions did anyone remind the panel of PHS’s own
guidelines on human experimentation (established in February 1966). According to records, the original
study had been composed of 412 men with syphilis and 204 controls. In 1969, 56 syphilitic subjects and 36
controls were known to be living. A total of 373 men in both groups were known to be dead. The rest were
unaccounted for. The age of the survivors ranged from 59 to 85, one claiming to be 102. The outcome of
this meeting was that the study would continue. The doctors convinced themselves that the syphilis in the
Tuskegee men was too far along to be effectively treated by penicillin and that the men might actually suffer
severe complications from such therapy. Even the Macon County Medical Society, now made up of mostly
African-American physicians, agreed to assist the PHS. Each was given a list of patients to follow.
In the late 1960s, PHS physician, Dr. James Lucas, stated in a memorandum that the Tuskegee study was
“bad science” because it had been contaminated by treatment. PHS continued to put a positive spin on
the experiment by noting that the study had been keeping laboratories supplied with blood samples for
evaluating new blood tests for syphilis.
Peter Buxtin, who had left the PHS for law school, bothered by the study and the no-change attitude of the
PHS, contacted the Associated Press. Jean Heller, the reporter assigned to the story, did extensive research
into the Tuskegee experiment. When interviewed by her, the PHS officials provided her with much of
her information. They were men who had nothing to hide. The story broke on July 25, 1972. The study
immediately stopped.
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NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE
Appendix A
The following are a variety of data sets compiled from later publications of the Tuskegee study.
Table 1. 1963 viability data of Tuskegee group
Dead
Alive
Unknown
n.
%
n.
%
n.
%
Syphilitics
242
59
85
21
85
21
Controls
78
45
66
34
39
20
From: Rockwell, et al. (1964)
Table 2. Abnormal findings in 90 syphilitics and 65 controls
Abnormality
Syphylitics
Controls
n.
%
n.
%
Electrocardiographic
41
46
21
32
Cardiomegaly via X-ray
37
42
22
34
Peripheral neuropathy
12
13
5
8
Hypertension d. b .p. >90
38
43
29
45
Cardiac murmurs
24
27
20
31
Urine
28
36
21
33
From: Rockwell, et al. (1964)
Table 3. Aortic arch and myocardial abnormalities at autopsy
Aortic arch
Myocardial
n.
%
n.
%
Syphilitics (140)
62
44
48
34
Controls (54)
8
15
20
37
2
X2 P0.25
not different
From: Caldwell et al. (1973)
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NATIONAL CENTER FOR CASE STUDY TEACHING IN SCIENCE
Questions
1. Carefully analyze this case. When you examine the paper and the appendix, what information appears
to have been gained from this study? That is, what kind of argument can be made for the benefits of
the study?
2. What do you believe were the motives for the people to become involved in the study, specifically: The
subjects? The PHS personnel? The Tuskegee staff? The Macon County physicians? Nurse Rivers?
3. What kind of criticisms can you offer of this study?
4. What were the factors underlying the cessation of the project?
5. Could this project (or one similar to it involving AIDS or radiation effects) be conducted today?
References
Annas, G., and M. Grodin, eds. 1992. The Nazi Doctors and the Nuremberg Code. Oxford: Oxford University Press.
Barber, B. 1976. The Ethics of Experimentation with Human Subjects. Scientific American 234(2):25–31.
Caldwell, J.G. et al. 1973. Aortic regurgitation in the Tuskegee study of untreated syphilis. J. Chronic Dis.
26: 187–199.
Jones, J.H. 1993. Bad Blood: The Tuskegee Experiment. New York: Free Press.
Rockwell, D.H. et al. 1964. The Tuskegee study of untreated syphilis: the 30th year of observation. Arch. Inter.
Med. 116(4): 792–798.
Image credit: Detail from Michelangelo’s Last Judgment, Sistine Chapel, 1535–1541.
Case copyright held by the National Center for Case Study Teaching in Science, University at Buffalo, State University of New
York. Originally published February 24, 2000. Please see our usage guidelines, which outline our policy concerning permissible
reproduction of this work.
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