Every year in my intro biology course, I try to do one discussion of bioethics. One lecture is not much, but this is a course where we try to introduce students to the history and philosophy of science, and I think it’s an important issue, so I try to squeeze in a little bit. So we spend one day talking about eugenics and the Tuskegee syphilis study, and I have them read Gould’s Carrie Buck’s Daughter, and I try to provoke them into arguing with me, or at least questioning a few default assumptions.
This semester, though, I’m going to have them read something with some subtler concerns. I’m going to ask them to read about the invention of the modern speculum. It was surprisingly problematic.
It was designed by a doctor, James Marion Sims, who detested examining women’s genitals.
Sims didn’t want to have to look at a woman’s genitals. “If there was anything I hated, it was investigating the organs of the female pelvis,” Sims wrote in the autobiography he half completed before he died. This was a time when men and women interacted in very strict, pre-determined ways. Early illustrations from medical textbooks show doctors examining women’s pelvic areas by reaching their arms up beneath the layers of skirts and feeling around, literally blindly. A doctor was specifically instructed to reassure a female patient that he was not looking at her private parts by doing one of two things: gazing off into the distance or maintaining eye contact with her the entire time.
Doctors were men, and they disliked having to treat women’s diseases, which is not an auspicious attitude. But he had to deal with a serious problem: fistulas, holes that formed between the vagina and either the colon or bladder. So he was a responsible doctor who dealt with his patients’ illnesses, despite his discomfort with them.
But now comes the weird part: this was 1845, in Alabama. His patients were slaves. There was a chronic problem with fistulas because these women were breeding stock, kept in a state of pregnancy with minimal care. He was testing all of his procedures on slave women.
But when a patient came to Sims with an especially painful fistula, he wrote, “this poor girl was in such a condition that I was obliged to find out what was the matter with her.” He was eager to figure out a way to surgically seal up the hole, and happy to use slave women as his test subjects.
The idea for the speculum came to Sims while treating a white patient who had been thrown from a horse. After he helped her “reposition her uterus,” he had an idea. He fetched a slave, had her lay on her back with her legs up, and inserted the bent handle of a silver gravy spoon into her vagina. That’s right, the very first modern speculum was made out of a bent gravy spoon.
I guess informed consent isn’t an issue with a slave — just tell them to hop up on a table, spread their legs, and let the doctor stick a gravy spoon into their vaginas. And then he started a whole series of surgical experiments to correct fistulas.
This new access allowed Sims to start performing surgery on the fistulas. Eventually he came up with a method for sealing them. He performed many of his experimental procedures without the benefit of anesthesia, and some of these slave women were operated on up to 30 times. Even at the time he was working, there were concerns about the ethics of his experiments. “All kinds of whispers were beginning to circulate around town,” wrote Seal Harris in a biography published in the 1950s, “dark rumors that it was a terrible thing for Sims to be allowed to keep on using human beings as experimental animals for his unproven surgical theories.” There is still an ongoing debate over whether or not to celebrate Sims’s legacy.
His subjects were not willing — they were enslaved black women, used as guinea pigs, and apparently subjected to painful and unnecessary surgical procedures, all to develop a general method for treating this problem. And he was successful! He did create tools and techniques to alleviate a chronic and painful malady! So were his methods warranted?
I have my opinions, but I’ll be interested to hear what students think of it.
Never without informed consent. Period.
Your students are fortunate to have you as a professor. All my science classes (high school and college) were very boring and dry. All of them were just interested in telling us facts to memorize.
I think his methods were completely unwarranted. Just because something good came out of it doesn’t warrant a harmful action. People who support the Hiroshima and Nagasaki bombings say the same thing: it resulted in a quick end to the war.
I do something similar in one of my classes, but using The Tragedy of Fritz Haber and the invention of fertilizer.
I’m wondering how far we could be already if our ethics had had to catch up with our scientific possibilities in order to make progress. Sure, people argue “but look at the good of it!” Am I not happy to have the Pill now even though it was tested under unethical circumstances? Duh, I’m pretty sure we’d have found it eventually, maybe (only maybe) it would have been delayed, but how far would we be today if poor women of colour had been treated as full members of society back in the 1970′?
it reminds me of the Star Trek: Voyager episode where B’Lanna refuses to go through with a lifesaving procedure because it was developed by the Star Trek equivalent of Dr Mengele through unwilling experimentation. The procedure is undergone without her consent because the ship cannot do without its chief engineer.
A great example of why I think Voyager had some of the best Trek episodes.
I thought the headline was a typo…but no.
Going to be an interesting class, for sure.
wat was that old aphorism? oh yeah: The ends do NOT justify the means
No, his methods were not warranted. As Giliell suggests, it could have and would have been developed under more humane conditions. The end doesn’t justify the means.
That said, given the way the average person behaved in the past it would probably be almost impossible to find some major discovery or improvement done before the late 20th century which wasn’t somehow tainted in a similar way — especially if you want to go pre-18th century. So the pragmatic approach in most situations is that what is done, is done. We do not believe in supernatural “essences” which hang on to otherwise useful or beneficial relics and ideas, tainting them forever at the spiritual level.
No amount of success or advancement of scientific knowledge ever justifies medical procedures performed without full, free and informed consent. Sims behaved in a grossly unethical manner even by the low standards of the period, and his success should not be llowed to overshadow the humanity of his victims, and lest we forget, that is emphatically what they were; victims. Victims of a man who saw them as nothing more than lab rats to be used to satiate his professional curiosity. That is simply unforgiveable
As twas brillig (stevem) says @ 7, the ends do not justify the means, and that should not be a difficult moral calculus for anyone with a shred of respect for the value of human life and dignity.
There are cases where the ends/means calculation are difficult and nuanced. Imminence of threat, for instance, creates a lower standard. I’ve occasionally argued that cures that have not gone through full testing, for severe and rapid conditions, should be administered to volunteers who have had the risks explained to them. (An example here would be an Ebola treatment–the moment you have reason to believe it might work, you present it to patients in that light, and let them decide their fate as best they can.)
This, however, was the deliberate calculus that says that one person’s suffering is more important than another’s. The tools were not being developed on the patients they were meant to help, but rather, on another group designated as guinea pigs. That’s way past the line of exigent circumstance.
having sed that stuff about “ends” and “means”, the converse is also so. As Sastra points out, the means do not (necessarily) villify the ends. That is, in this case, even though the means were horrific and terrible, the device is still an important medical implement. Direct the horror at the perpetrator and his methods, the instrument was not the _cause_ of the mistreatment, it was merely the result. So, remember: the MEANS were nasty, the speculum is just an instrument that resulted, not the nasty perpetrator of all the horrific actions.
It does show how far we have come in terms of research ethics and consent. An important and interesting question is how do you get consent from someone who is mentally impaired from severe mental illness or dementia and is the consent valid. It also depends on how risky the research is to the person. Higher risk means the person has to have higher level of understanding
And, of course, one of the major ethical conundrums over the last century was whether or not to use the data acquired by Nazi doctors through basically deliberate torture of their patients. Information about system shock and other conditions that would have been difficult to learn any other way, but that many people didn’t want used because that could retroactively say it was okay to have done that.
There is, after all, a reason why the core statements of modern medical ethics are known as the Nuremburg Code.
No. He could have easily developed the same techniques using ethical research methods. There were plenty of women at that time desperate enough to allow him to experiment on them willingly.
OTOH, I see no use in not using the speculum now because of its origins. I’d rather work on ending the current injustices and unethical medical practices. Sims is an example–a bad example. Use him as an example of how research should NOT be done and move on.
Do these hard lines apply to non-human animals? If not, why not? What about chimpanzees? And does a chimpanzee get less consideration than a human with disabilities that render the human at an equivalent level of sapience to a chimpanzee?
The whole time I was reading this I was thinking about PZ’s previously-stated stance on animal experimentation, up to and including surgery without anaesthetic, and how most of the justifications for it come down to utilitarian, ends-justify-the-means considerations. I am curious to hear what his position is when it’s humans at the sharp end, so to speak, rather than a sentient creature from another species.
@Saad, the bombing of Hiroshima and Nagasaki was a political decision. The scientists involved had absolutely no say in the matter. They developed the bomb with Germany in mind, not Japan. But keep in mind that if either Germany or Japan had developed it, they would have had NO HESITATION to use it.
Why (and in what circumstances) would sapience make any difference? As Bentham said, “The question is not, Can they reason? nor, Can they talk? but Can they suffer?”
Chimps may be terrible moral doctors, but that doesn’t mean they aren’t patients or that we can’t treat them as such. We don’t judge medical patients based on how they might treat us (to exact revenge, let’s say, or to pay back the favor), but based on what their condition is and what we’re actually able to do for them.
@13 – When I had a German folklore class (30 years ago! Yikes!) the professor spent a class period explaining that some of the stories were collected by Nazis as part of the German propaganda machine. They also collected demographic information from the story tellers, so a folktale might be prefaced with “told by a 35 year old man from village X.”
I thought it was overkill, but it was my first introduction to ethics in academic research. It doesn’t come up that often for English majors.
And this makes it better…how? They developed the bomb to kill a lot of civilians all at once with minimal risk and inconvenience to the bombers. And they were willing to risk ills up to and including not being sure that the atmosphere wouldn’t catch on fire when the bomb went off in order to ensure that the US dominated the world. While I have a great deal of sympathy with their desire to not live in a world dominated by Nazi Germany or Imperial Japan, by mid-1943 it was clear that that was not a real risk and they should have stopped. Or at least stopped trying seriously. At that point, they weren’t working to prevent the Nazis from winning, they were working to make sure that the US dominated the world. And nothing else.
@13: I would suggest that the Nazi doctors’ protocols were so poor that their data should be treated as suspect even if you happened upon some that was performed in accordance with the highest ethical protocols. A more interesting question might be whether to use the Tuskeegee data. That was a good experiment scientifically, just unethical as crap.
No amount of success or advancement of scientific knowledge ever justifies medical procedures performed without full, free and informed consent.
So much for animal testing. BTW, I completely agree with you.
The scientists involved had absolutely no say in the matter
Saying “no” is “having a say”
His methods weren’t warranted. However, given that he’s already done his experiments and the results are available, refusing to use the results of them as a matter of principle is pointlessly wasteful; it won’t undo a single one of them. (That goes for a lot of things.)
Animals are not people. This is a willful misreading.
Animals are not people. This is a willful misreading.
I used Gregory’s quote (“No amount of success or advancement of scientific knowledge ever justifies medical procedures performed without full, free and informed consent”) specifically because it deals with the important issue of consent – something a nonverbal animal cannot give. I certainly wasn’t willfully misreading what he wrote; I understood him perfectly and wasn’t trying to mis-characterize him, either. If he thinks I should apologize, I will.
It’s going to be hard to come up with a rule regarding consent that eliminates nonverbal nonhuman self-aware organisms from requirements for consent and which also encompasses nonverbal or damaged humans. This is a serious issue and not a mere philosophical quibble.
Non-human animals can’t give consent. Therefore, there is no point in trying to apply the IRB standard to them. Also, there are a lot of different non-human animals and experiments and lab conditions which might be appropriate to one might be completely inappropriate to another. Consider what the animal in question needs and what its capacity is when deciding whether a specific use is ethical or not.
It’s also not possible to get consent from people who are dead yet, in the absence of evidence that they wouldn’t want us to try to bring them back to life, we give CPR and ACLS to attempt to reverse the death. Babies can’t consent so we get proxies. And so on. But for an adult human animal that is alert, oriented, and can understand the risks and benefits of the procedure or study and give or withhold consent, informed consent is the only way to go.
next, you get consent by offering reimbursement for time and effort for the volunteer test subjects. Of course, those human test subjects are typically drawn from the lower class that need the money. Is it still ethical to get consent via reimbursement? How much is sufficient? how many HIV (and other) vaccines are being test in low income areas of Africa for the (greater) benefit of more industrial nations?
Even getting ‘consent’, while imperative, does not eliminate the ethical issues.
dianne @19:
You make good points, but this old chestnut should really be put to rest.
No. Hell no.
dianne, #19:
Adding to Rob Grigjanis’ other point… Even if it were likely that Germany would develop a bomb, that wouldn’t mean they should have built one and used it against the Germans. So, I’d try to set that aside as a separate question.
What isn’t clear to me is that this fact (about the low risk, certainly not the nonthreatening character of Nazism) was something scientists/engineers in question knew. Based on what I’ve read, there were a few chances for back-channel dialogue between physicists in Germany and outside. So, there was some (apparently rather vague) info about the state of the Nazi program from Heisenberg, to many others, via Bohr — that’s one example that comes to mind. But of course there could’ve been a lot more along those lines which I don’t know about.
However, some sort of miscommunication, misinterpretation, reading things into vague hints which possibly weren’t intended, etc., just made it harder for anyone to pin down exactly what the facts were at the time. That’s my general impression of it, anyway. They certainly weren’t free to openly discuss at length how things were progressing. They had to assume a lot of things and projected that it would just be a matter of time before the Nazis built a bomb — but that’s not a simple calculation of risk based on all of the facts we have access to now.
Besides, come on, at the time it was hard enough to get quantum physicists to give a straightforward account of anything at all, much less about something that might make them look really bad.
well I do not think that Dr. Sims was very ethical at all I think he was probably abusive but he did help to make an important contribution to medical treatment.
Even a stopped clock is right twice a day.
I have been thinking about the bomb lately because of the speech by the sec of defense.
I just do not see any other purpose to building them or using them other then Mutual Assured Destruction. Even if the Germans had developed the bomb just how would our also developing it have been a defense out side of M.A.D.?
excuse me that should be very unethical
key boards how do they work?
uncle frogy
ghee I give up I am going to go do something else my brain is not cooperating today.
uncle frogy
I don’t think his methods were justified. But to be honest, if you could somehow guarantee a cure for all forms of cancer in exchange for some involuntary human experimentation (like if you had to randomly select 100,000 people for an involuntary trial, myself included in the pool of people drawn), I’d have to think about it. That’s a lot of human suffering you could ameliorate.
In reality, of course, it’s never like that – there’s almost always more ethical options and that type of rationalization tends to be used to excuse unethical behavior after the fact.
@Dianne
We had this discussion a few years back. As far as the US government knew (and which appears to be the case from studies done after the war of historical documents), the Japanese government was settling in to severely bleed the US during an invasion of Japan itself. Hence the million-plus expected US casualties and multiple that in Japanese casualties. The alternative – a continuation of the war without the invasion – was worse, since Japan had a massive rice crop failure in 1945 and was facing mass starvation in 1946 (as in 17+ million people starving to death).
The atomic bomb was the least awful decision in that case, especially since they had to prove that it was worse than merely another massive conventional bombing raid. You can find a pretty good explanation of the case for using it in the book Downfall.
The OP did not say anything about the morality of BUILDING the bomb, only dropping it on two cities in Japan. That’s what I was commenting on. But, I guess firebombing Tokyo, which killed many more civilians than the two nuclear devices put together, was A-OK because scientists didn’t do it.
Oppenheimer wanted to release all the secrets to the bomb to the entire world, hardly indicatiave of desire for world domination; in response the military and politicians withdrew his clearance.
Bad methods.
Useful results.
I’m not a fan of the speculum, but I’m not going to toss something useful just because it came from a shitty source.
I am, however, going to side-eye the source.
Saad @2 – actually, I support the use of the two nuclear devices on Japan because, of all the options available, this one had the greatest probability of the least loss of life. All of the other options (barring Japan’s leadership coming to their senses and surrendering – which was not going to happen) carried probable casualty rates in the millions.
sundoga
Except for, you know, the bit where the Japanese Supreme Council a) weren’t actually intimidated by the bombing of Hiroshima, on the grounds that it hadn’t done any more damage than literally dozens of other Allied bombings of cities. And the bit where they hadn’t even heard about the Nagasaki bomb yet when they decided to surrender unconditionally. And the bit where they were already planning surrender but wanted some conditions on it and were willing to keep going to get them (and they did get the major concession they wanted, which was immunity from prosecution for the Emperor). And, especially, the bit where the event that prompted Japan’s surrender to the Allies had shit-all to do with anything that the Allies did or didn’t do and everything to do with the fact that Stalin had just violated the neutrality pact between the Soviet Union and Japan by invading Manchuria. You know, all these little historical facts that people who approve of nuking people like to ignore.
It is a common fallacy I see that begins on the assumption that the unethical alternative must have some kind of utilitarian advantage over the ethical one. This is the basic “good is dumb” fallacy.
But of course it does not have to be so.
If he had obtained consent from his subjects it is entirely possible that he may have invented those procedures faster, or with a better methodology. A willing subject who understands what is being done to her and why could easily be a subject who also provides more, and more useful, feedback with respect to the things he was trying to do. He could have gotten more information from each subject that way, and perhaps would have had to do fewer procedures. Fistula repair surgery may have become available years earlier in that case.
Or maybe, if poor women of colour had been treated as full members of society back then, and given the opportunities that came with such status, a poor woman of colour would have been the one to discover fistula repair surgery, years, if not generations, sooner.
(Or perhaps the people in the west would have been more readily exposed to and familiar with the work of Sushruta and wouldn’t have to spend their energies reinventing procedures already known by “brown” people in the 6th century BC, though I’m not sure if the fistula surgery mentioned in this article http://en.wikipedia.org/wiki/Sushruta_Samhita is the same kind of fistula surgery for the same indication or not.)
Please provide the reasoning by which you conclude that that particular option really did have the “greatest probability” of the “least loss of life”.
Show us your numbers for those probability calculations.
WITHOUT resort to racist assumptions like the Japanese people being fanatics who are guaranteed to fight to the death, or such obedient sheep that they would obey without question the orders of a fanatical government to fight to the death, rather than turning on and overthrowing that leadership, much as the Italians did when THEIR homeland was invaded by the allies.
wcorvi, #16
Then you support the intentional obliteration of civilians including babies and children.
The “war would have dragged on for years” argument doesn’t even get off the ground. It was a war. That’s what wars do. When countries start wars they should expect their soldiers to be dying. People who don’t want to go kill each other shouldn’t have to pay with their lives. Should the Iraqis have dropped a couple of nukes on the U.S. out of concern that the war was dragging on and they were losing thousands of people on their side?
Sorry, wcorvia. My comment above is to sundoga at #37.