Clin Auton Res DOI 10.1007/s10286-014-0228-z
REVIEW ARTICLE
David Streeten Memorial Lecture presented at the 24th International Symposium on the Autonomic nervous System Irwin Schatz
Received: 29 January 2014 / Accepted: 29 January 2014 Ó Springer-Verlag Berlin Heidelberg 2014
I am deeply honored to have been invited to give this annual David Streeten lecture, and to follow such distinguished past speakers such as Wouter Wieling, who, you may recall, took you on a tour of the autonomic nervous system in only 30 s. That must have been quite a trip and a lot of fun! Well done, Wouter. Or Frank Abboud discussing sensory signals in the development of neurogenic hypertension. That was almost certainly extraordinarily erudite and scholarly, or David Goldstein speaking on Catecholamines 101. Knowing David it was clearly not an ordinary 101 type lecture. Well, this talk will not deal with the facts, hypotheses, discoveries and challenges of a particular aspect of autonomic science, but instead, will, I hope, tell a tale of what medical scientists have done right in the past and, unfortunately, what, in my opinion, they may have done wrong. But first, I must tell those of you who do not happen to know very much about David Streeten, a little bit about him. He was a good friend, and a superb colleague to many of us. An extraordinary scientist, he was brilliant, gifted, stubborn, self confident and selfless, all at the same time. He told me an interesting, and instructive story about his career at The University of Michigan that demonstrates the sort of selfless person he was. He was in Ann Arbor working as a young faculty member in the laboratory of a famous endocrinologist, who, as you will see, needs to remain nameless in this presentation. One day, David, upon reviewing his records realized that he had accumulated a group of patients, each I. Schatz (&) University of Hawaii School of Medicine Honolulu, Honolulu, Hawaii e-mail: [email protected]
of whom had severe hypertension resistant to treatment, were hypokalemic and each with markedly elevated levels of aldosterone. He further discovered that the majority of this cohort had clearly detectable apparent adrenal masses on imaging. Excited, he told his boss about these findings, but, unfortunately, heard nothing from him subsequently. He later discovered that his mentor had published a summary of these patients, without either including Streeten’s name as a coauthor or even acknowledging his important participation. Thus, was primary hyperaldosteronism first described. Such may be the fate of some younger investigators, even today, but David took this in stride with a maturity and wisdom most of us would find to be surprising for his age. I paraphrase David ‘‘Oh, well, he was an egomaniac and in the end I made a valuable contribution to the field of endocrine hypertension’’. Such was David Streeten, and I am proud to give this lecture in his honor. I believe that every one of us is born with an innate sense of goodness, which subsequently evolves into knowing what is right and what is wrong; as you have matured into your professional lives it is expressed as a bioethical imperative: to do no harm to your patients. We all try to live up to that––but we recognize that working long hours and suffering the bone numbing fatigue that we all must endure, makes adhering to this concept difficult. This vital credo of not doing any harm to our patients likely becomes battered and bruised and driven out of our sensibilities during the harrowing years of our medical education. Unfortunately, what most often happens is that as we mature into young trainees patients are no longer called patients, they evolve into cases, which then become diagnoses: Mrs. Jones is no longer the very pleasant elderly gray haired lady in room 420, but is now the CA of the lung with wide spread metastases, or even worse, and please
123
Clin Auton Res
forgive me for using this awful American term, the gomer in room 420. We have all done it; we depersonalize our relationships with our patients to the extent that our essential humanity almost becomes extinguished and disappears. This is ghastly and may ultimately severely distort our role as their healers and even as medical scientists. But I submit to you that a spark of that humanity still exists in your soul, and only needs to be awakened by a prod from someone, perhaps even me, and perhaps by this tale of personal revelation. It was June of 1965 and I was a young, newly minted cardiologist on my first job. It was early evening and, as was my wont, I was leafing through a copy of the Archives of Internal Medicine. I glanced at a paper entitled ‘‘The Tuskegee Study of Untreated Syphilis: the 30th year of observation’’. I had to reread it several times, because I could not believe what I had read. I wanted to make sure that I had not missed something, that my understanding of the details of the paper was correct. This experiment had been started in 1932 by several very prestigious medical scientists, who happened to be leaders of the US Public Health Service, which was then the precursor of the Centers for Disease Control, and subsequently the National Institutes of Health. These investigators had recruited 412 African American men with confirmed tertiary syphilis and 204 identical but nonsyphilitic males as controls. These groups consisted of uneducated, poor sharecroppers living in Macon County, Georgia. They were enticed into the study by the promise of free life-long medical care provided by a full-time nurse and, eventual free burial. They were all said to have given oral permission for this investigation. One wonders what oral agreement meant in those days, and how much was understood and made clear to these men. It is important to know that they were not permitted to receive the then current recommended therapy of Arsenicals for syphilis, nor were they ever given penicillin when it first became available for public use in 1945, nor in the subsequent years of study of their tertiary syphilis. The goal of this effort, supported by funds from the Federal government was to determine the natural history of late syphilis, unfettered by treatment. In other words, of these 412 subjects how many of them would die from their disease, how many would develop the heart and blood vessel complications of late syphilis, and how many would have a relatively benign subsequent course. These outcomes were not known then and it was felt that this information was vital to the understanding of untreated syphilis. And yet it was clear that in 1945, penicillin absolutely cured primary syphilis, as no other previous treatment had, and when given in proper doses, the spirochete that caused it did not develop resistance to its use. The feeling was that
123
it very likely had a similar impact on secondary and tertiary forms of the disease, but conclusive data were not available to confirm this. My first response to all of this was disbelief. Was I missing something? Had I misinterpreted some vital portion of the experiment? Unfortunately, my understanding was absolutely correct; from 1933 until 1963 a group of black, syphilitic men in the southern US received no anti-syphilis therapy––even after penicillin had become available––so that researchers from the Public Health Service could ‘‘establish a more knowledgeable syphilis control program’’. I was astounded and outraged. My immediate reaction was to compose a letter to the senior author of the paper, expressing my astonishment and outrage. This had been my practice for years; if angry about something, write a letter and see how you feel about it the next morning. This was a pretty good way of blowing off steam without being excessively intemperate, immature or inappropriate. What I said was ‘‘I am utterly astounded that physicians allow patients with potentially fatal disease to remain untreated when effective therapy is available. I assume that the information extracted is worth their sacrifice. If this is the case then the US Public Health Service and those physicians associated with it in this study need to reevaluate their moral judgments in this regard’’ (Fig. 1). I put the letter in my desk drawer, recognizing that I needed to cool off and to see if I felt the same way the next morning and whether I really wanted to send this letter. In retrospect it was being sent to a group of powerful medical scientists who could have an important negative impact on my future academic career, although this thought did not occur to me at the time. I had never done anything quite like this before; I thought of myself as a standard issue, young, somewhat overly self-confident cardiologist––nothing more. The letter was mailed but I never received a reply. The issue gradually faded from memory, and the study continued. In 1974, some 9 years later, an enterprising reporter, leafing through files, found my letter; attached to it was a note from one of the authors of the original paper (Fig. 2). Apparently, I was the sole physician who had ever complained publicly about the study. After the reporter wrote his article it was widely reprinted; and a veritable firestorm of media attention ensued. The New York Times investigated and an editorial resulted; NBC sent a team out for a television interview, and so on. Soon Congress got into the act and held a number of hearings. Senator Kennedy introduced legislation; this culminated ultimately in the development of strict requirements for human research and the implementation of so-called Institutional Review Boards––these were
Clin Auton Res
Fig. 1 Self explanatory
really local committees to review all requests for human research with very strict guidelines, and with the ABSOLUTE requirement for all experimental subjects to give written informed consent. The operative word here is ‘‘requirement’’. Prior to this there were a series of recommendations, guidelines and strongly worded suggestions about the protection of human subjects, but without any proviso that ignoring this law was illegal and would result in legal action. Although it took a few years, in 1996 President Clinton issued a public apology at the white House to the remaining
eight persons still alive from the Tuskegee study. But what surprised and shocked me most were the number of prominent medical scientists who disagreed with my analysis and wrote to tell me so. For instance, Dr. Richard Kampmeier, a distinguished syphilis expert, Professor of Medicine at Vanderbilt Medical School and for 25 years the editor of the Southern Medical Journal, wrote the following, and I paraphrase: ‘‘this is a tempest in a teapot; it is unclear that giving penicillin would have cured these subjects’’. The operative word, of course, is ‘‘unclear’’.
123
Clin Auton Res Fig. 2 Self explanatory
When I wrote to Kampmeier and asked the simple question: ‘‘if you or your family had late syphilis, would you have refused penicillin’’, he evaded answering. He was one among several prominent experts who implied that I was naı¨ve and did not understand the realities of clinical research.
123
My point was and is that the study had to be terminated whenever it became clear that penicillin, given in adequate doses, could likely cure some patients with late syphilis and halt the complications of heart and aortic disease, as it did with all patients with the early form of the disease.
Clin Auton Res
None of the critics adequately addressed this key issue. As the years went by, I thought that the subject had been exhaustively dealt with but unfortunately, we have recently learned about a series of clinical research studies that seemed to have ignored the blatantly unethical characteristics of the Tuskegee experience. For instance, in 1946, Dr. John Cutler of the US Public Health Service (a participant in the Tuskegee study), while in Guatemala, infected prostitutes with the Syphilis spirochete in an attempt to transmit the disease to prisoners and soldiers. When this did not provide sufficient numbers of infected subjects, he directly inoculated them to see how subsequent penicillin affected their disease. The PHS provided funds for the study. The subjects were not informed of the details and Cutler’s superiors, both at the PHS and in Guatemala, agreed to these experiments. The results were never published. Professor Susan Reverby discovered these facts upon reviewing Cutler’s papers. The findings stimulated severe criticism from the Congress and the US State department. In 1963, mentally disabled children at the Willowbrook State Hospital in New York were exposed to Hepatitis A virus in order to determine the natural history of this disease. Neither the subjects nor their guardians gave permission for this ‘‘experiment’’. Chronically ill, mostly demented patients at the Jewish Chronic Disease Hospital in New York in 1963, with presumably weakened immune systems were inoculated with live cancer cells in order to determine any difference in their response. There was no informed consent. These are but three of several similar obvious violations of bioethical norms occurring soon after the disclosure of the Tuskegee experiment. One would have thought that the lessons learned from Tuskegee would have ended such transgressions. And yet, in the year 2000, there appeared a lengthy review of the Tuskegee study, again in the Archives of Internal Medicine, that came to the same conclusion that Kampmeier did: that the chances of curing or ameliorating syphilis in this group were unproven and therefore the study was justified. The logic of this comment was dubious at best, in my view. It was clear to me that even if ONE of the Tuskegee subjects had their life saved or had the onset of aortitis prevented by the timely administration of Penicillin, then the argument for continuing it was morally and ethically unjustified. Was I wrong to send that letter? I do not think so. But the retention of these opinions among some leaders of medicine, even in the recent past is extraordinarily troubling. Did they not learn that among the primary goals of all practitioners is to DO NO HARM?
The answer to this question apparently was no. These investigators were not evil, but they made decisions that we now consider unethical; they chose vulnerable individuals who, either through ignorance or a desire to curry favor by agreeing to participate, were not fully informed of the risks. Do they ever learn? Can WE ever learn? How close are these studies to the horrors of the Nazi experiments of World War 2? When thinking about these events, the question of why these events occurred comes up. There are several hypotheses that are raised that may suggest a cause. First: is there something about our arduous medical education process that tends to drive our innate humanity from us? Some experts in medical education believe that in our need to foster objectivity in our students, in our goal to provide expert medical care, unfettered by emotion, we end up by suppressing our empathy for our patients. Is there any evidence for this hypothesis? There is copious anecdotal experience, but nothing that is confirmative. There is no question that we are influenced in our professional behavior by our supervisors and our peers, but is this phenomenon enough to transform us into physicians who lack empathy, which then manifests itself in unethical behavior towards patients? Those of us who have some experience in medical education see students entering their training who are clearly altruistic with copious amounts of empathy, and who, upon graduation, seem to have lost this altruism and empathy, to be replaced by an inability to relate to their patients and an indifference to their patients suffering. Second, do medical scientists lag behind community sensibilities when it comes to changing moral and ethical standards? Certainly, the lack of medical adherence to the concepts of the Nuremburg proclamations, the subsequent statements from the World Health Association and the guidelines from the United States government suggest that we, as medical scientists, ignored these and responded when we were forced to adhere to the new requirements. It was only when the strongly worded suggestions and guidelines evolved into actual rules and regulations––which by ignoring make it impossible to continue research on human subjects––that science started to pay attention. And yet, in spite of these somewhat compelling arguments, I think that the vast majority of physicians, today, when presented with the facts of these experiments, would have rejected them as being unethical and immoral. In the final analysis, every clinical researcher must apply the simple dictum: would I agree to this experiment on my family or me if I were presented with this choice. This is the fundamental question that we all must answer.
123
Clin Auton Res
In the future you may be presented with issues where ethical and moral ambiguities arise: these clearly are not limited to the circumscribed areas of clinical research, but will almost certainly encompass patient care responsibilities in which you are directly involved: please listen to that spark of humanity that lies within each of you and choose the response that you know is the ethically and morally correct one.
123
I have to conclude that that battered and bruised ethical base that exists in each of us, that that innate feeling of knowing right from wrong, must, periodically, be aroused and we must remember, always, to live up to the personal expectations we first had upon entering medical school and to do no harm.
REVIEW ARTICLE
David Streeten Memorial Lecture presented at the 24th International Symposium on the Autonomic nervous System Irwin Schatz
Received: 29 January 2014 / Accepted: 29 January 2014 Ó Springer-Verlag Berlin Heidelberg 2014
I am deeply honored to have been invited to give this annual David Streeten lecture, and to follow such distinguished past speakers such as Wouter Wieling, who, you may recall, took you on a tour of the autonomic nervous system in only 30 s. That must have been quite a trip and a lot of fun! Well done, Wouter. Or Frank Abboud discussing sensory signals in the development of neurogenic hypertension. That was almost certainly extraordinarily erudite and scholarly, or David Goldstein speaking on Catecholamines 101. Knowing David it was clearly not an ordinary 101 type lecture. Well, this talk will not deal with the facts, hypotheses, discoveries and challenges of a particular aspect of autonomic science, but instead, will, I hope, tell a tale of what medical scientists have done right in the past and, unfortunately, what, in my opinion, they may have done wrong. But first, I must tell those of you who do not happen to know very much about David Streeten, a little bit about him. He was a good friend, and a superb colleague to many of us. An extraordinary scientist, he was brilliant, gifted, stubborn, self confident and selfless, all at the same time. He told me an interesting, and instructive story about his career at The University of Michigan that demonstrates the sort of selfless person he was. He was in Ann Arbor working as a young faculty member in the laboratory of a famous endocrinologist, who, as you will see, needs to remain nameless in this presentation. One day, David, upon reviewing his records realized that he had accumulated a group of patients, each I. Schatz (&) University of Hawaii School of Medicine Honolulu, Honolulu, Hawaii e-mail: [email protected]
of whom had severe hypertension resistant to treatment, were hypokalemic and each with markedly elevated levels of aldosterone. He further discovered that the majority of this cohort had clearly detectable apparent adrenal masses on imaging. Excited, he told his boss about these findings, but, unfortunately, heard nothing from him subsequently. He later discovered that his mentor had published a summary of these patients, without either including Streeten’s name as a coauthor or even acknowledging his important participation. Thus, was primary hyperaldosteronism first described. Such may be the fate of some younger investigators, even today, but David took this in stride with a maturity and wisdom most of us would find to be surprising for his age. I paraphrase David ‘‘Oh, well, he was an egomaniac and in the end I made a valuable contribution to the field of endocrine hypertension’’. Such was David Streeten, and I am proud to give this lecture in his honor. I believe that every one of us is born with an innate sense of goodness, which subsequently evolves into knowing what is right and what is wrong; as you have matured into your professional lives it is expressed as a bioethical imperative: to do no harm to your patients. We all try to live up to that––but we recognize that working long hours and suffering the bone numbing fatigue that we all must endure, makes adhering to this concept difficult. This vital credo of not doing any harm to our patients likely becomes battered and bruised and driven out of our sensibilities during the harrowing years of our medical education. Unfortunately, what most often happens is that as we mature into young trainees patients are no longer called patients, they evolve into cases, which then become diagnoses: Mrs. Jones is no longer the very pleasant elderly gray haired lady in room 420, but is now the CA of the lung with wide spread metastases, or even worse, and please
123
Clin Auton Res
forgive me for using this awful American term, the gomer in room 420. We have all done it; we depersonalize our relationships with our patients to the extent that our essential humanity almost becomes extinguished and disappears. This is ghastly and may ultimately severely distort our role as their healers and even as medical scientists. But I submit to you that a spark of that humanity still exists in your soul, and only needs to be awakened by a prod from someone, perhaps even me, and perhaps by this tale of personal revelation. It was June of 1965 and I was a young, newly minted cardiologist on my first job. It was early evening and, as was my wont, I was leafing through a copy of the Archives of Internal Medicine. I glanced at a paper entitled ‘‘The Tuskegee Study of Untreated Syphilis: the 30th year of observation’’. I had to reread it several times, because I could not believe what I had read. I wanted to make sure that I had not missed something, that my understanding of the details of the paper was correct. This experiment had been started in 1932 by several very prestigious medical scientists, who happened to be leaders of the US Public Health Service, which was then the precursor of the Centers for Disease Control, and subsequently the National Institutes of Health. These investigators had recruited 412 African American men with confirmed tertiary syphilis and 204 identical but nonsyphilitic males as controls. These groups consisted of uneducated, poor sharecroppers living in Macon County, Georgia. They were enticed into the study by the promise of free life-long medical care provided by a full-time nurse and, eventual free burial. They were all said to have given oral permission for this investigation. One wonders what oral agreement meant in those days, and how much was understood and made clear to these men. It is important to know that they were not permitted to receive the then current recommended therapy of Arsenicals for syphilis, nor were they ever given penicillin when it first became available for public use in 1945, nor in the subsequent years of study of their tertiary syphilis. The goal of this effort, supported by funds from the Federal government was to determine the natural history of late syphilis, unfettered by treatment. In other words, of these 412 subjects how many of them would die from their disease, how many would develop the heart and blood vessel complications of late syphilis, and how many would have a relatively benign subsequent course. These outcomes were not known then and it was felt that this information was vital to the understanding of untreated syphilis. And yet it was clear that in 1945, penicillin absolutely cured primary syphilis, as no other previous treatment had, and when given in proper doses, the spirochete that caused it did not develop resistance to its use. The feeling was that
123
it very likely had a similar impact on secondary and tertiary forms of the disease, but conclusive data were not available to confirm this. My first response to all of this was disbelief. Was I missing something? Had I misinterpreted some vital portion of the experiment? Unfortunately, my understanding was absolutely correct; from 1933 until 1963 a group of black, syphilitic men in the southern US received no anti-syphilis therapy––even after penicillin had become available––so that researchers from the Public Health Service could ‘‘establish a more knowledgeable syphilis control program’’. I was astounded and outraged. My immediate reaction was to compose a letter to the senior author of the paper, expressing my astonishment and outrage. This had been my practice for years; if angry about something, write a letter and see how you feel about it the next morning. This was a pretty good way of blowing off steam without being excessively intemperate, immature or inappropriate. What I said was ‘‘I am utterly astounded that physicians allow patients with potentially fatal disease to remain untreated when effective therapy is available. I assume that the information extracted is worth their sacrifice. If this is the case then the US Public Health Service and those physicians associated with it in this study need to reevaluate their moral judgments in this regard’’ (Fig. 1). I put the letter in my desk drawer, recognizing that I needed to cool off and to see if I felt the same way the next morning and whether I really wanted to send this letter. In retrospect it was being sent to a group of powerful medical scientists who could have an important negative impact on my future academic career, although this thought did not occur to me at the time. I had never done anything quite like this before; I thought of myself as a standard issue, young, somewhat overly self-confident cardiologist––nothing more. The letter was mailed but I never received a reply. The issue gradually faded from memory, and the study continued. In 1974, some 9 years later, an enterprising reporter, leafing through files, found my letter; attached to it was a note from one of the authors of the original paper (Fig. 2). Apparently, I was the sole physician who had ever complained publicly about the study. After the reporter wrote his article it was widely reprinted; and a veritable firestorm of media attention ensued. The New York Times investigated and an editorial resulted; NBC sent a team out for a television interview, and so on. Soon Congress got into the act and held a number of hearings. Senator Kennedy introduced legislation; this culminated ultimately in the development of strict requirements for human research and the implementation of so-called Institutional Review Boards––these were
Clin Auton Res
Fig. 1 Self explanatory
really local committees to review all requests for human research with very strict guidelines, and with the ABSOLUTE requirement for all experimental subjects to give written informed consent. The operative word here is ‘‘requirement’’. Prior to this there were a series of recommendations, guidelines and strongly worded suggestions about the protection of human subjects, but without any proviso that ignoring this law was illegal and would result in legal action. Although it took a few years, in 1996 President Clinton issued a public apology at the white House to the remaining
eight persons still alive from the Tuskegee study. But what surprised and shocked me most were the number of prominent medical scientists who disagreed with my analysis and wrote to tell me so. For instance, Dr. Richard Kampmeier, a distinguished syphilis expert, Professor of Medicine at Vanderbilt Medical School and for 25 years the editor of the Southern Medical Journal, wrote the following, and I paraphrase: ‘‘this is a tempest in a teapot; it is unclear that giving penicillin would have cured these subjects’’. The operative word, of course, is ‘‘unclear’’.
123
Clin Auton Res Fig. 2 Self explanatory
When I wrote to Kampmeier and asked the simple question: ‘‘if you or your family had late syphilis, would you have refused penicillin’’, he evaded answering. He was one among several prominent experts who implied that I was naı¨ve and did not understand the realities of clinical research.
123
My point was and is that the study had to be terminated whenever it became clear that penicillin, given in adequate doses, could likely cure some patients with late syphilis and halt the complications of heart and aortic disease, as it did with all patients with the early form of the disease.
Clin Auton Res
None of the critics adequately addressed this key issue. As the years went by, I thought that the subject had been exhaustively dealt with but unfortunately, we have recently learned about a series of clinical research studies that seemed to have ignored the blatantly unethical characteristics of the Tuskegee experience. For instance, in 1946, Dr. John Cutler of the US Public Health Service (a participant in the Tuskegee study), while in Guatemala, infected prostitutes with the Syphilis spirochete in an attempt to transmit the disease to prisoners and soldiers. When this did not provide sufficient numbers of infected subjects, he directly inoculated them to see how subsequent penicillin affected their disease. The PHS provided funds for the study. The subjects were not informed of the details and Cutler’s superiors, both at the PHS and in Guatemala, agreed to these experiments. The results were never published. Professor Susan Reverby discovered these facts upon reviewing Cutler’s papers. The findings stimulated severe criticism from the Congress and the US State department. In 1963, mentally disabled children at the Willowbrook State Hospital in New York were exposed to Hepatitis A virus in order to determine the natural history of this disease. Neither the subjects nor their guardians gave permission for this ‘‘experiment’’. Chronically ill, mostly demented patients at the Jewish Chronic Disease Hospital in New York in 1963, with presumably weakened immune systems were inoculated with live cancer cells in order to determine any difference in their response. There was no informed consent. These are but three of several similar obvious violations of bioethical norms occurring soon after the disclosure of the Tuskegee experiment. One would have thought that the lessons learned from Tuskegee would have ended such transgressions. And yet, in the year 2000, there appeared a lengthy review of the Tuskegee study, again in the Archives of Internal Medicine, that came to the same conclusion that Kampmeier did: that the chances of curing or ameliorating syphilis in this group were unproven and therefore the study was justified. The logic of this comment was dubious at best, in my view. It was clear to me that even if ONE of the Tuskegee subjects had their life saved or had the onset of aortitis prevented by the timely administration of Penicillin, then the argument for continuing it was morally and ethically unjustified. Was I wrong to send that letter? I do not think so. But the retention of these opinions among some leaders of medicine, even in the recent past is extraordinarily troubling. Did they not learn that among the primary goals of all practitioners is to DO NO HARM?
The answer to this question apparently was no. These investigators were not evil, but they made decisions that we now consider unethical; they chose vulnerable individuals who, either through ignorance or a desire to curry favor by agreeing to participate, were not fully informed of the risks. Do they ever learn? Can WE ever learn? How close are these studies to the horrors of the Nazi experiments of World War 2? When thinking about these events, the question of why these events occurred comes up. There are several hypotheses that are raised that may suggest a cause. First: is there something about our arduous medical education process that tends to drive our innate humanity from us? Some experts in medical education believe that in our need to foster objectivity in our students, in our goal to provide expert medical care, unfettered by emotion, we end up by suppressing our empathy for our patients. Is there any evidence for this hypothesis? There is copious anecdotal experience, but nothing that is confirmative. There is no question that we are influenced in our professional behavior by our supervisors and our peers, but is this phenomenon enough to transform us into physicians who lack empathy, which then manifests itself in unethical behavior towards patients? Those of us who have some experience in medical education see students entering their training who are clearly altruistic with copious amounts of empathy, and who, upon graduation, seem to have lost this altruism and empathy, to be replaced by an inability to relate to their patients and an indifference to their patients suffering. Second, do medical scientists lag behind community sensibilities when it comes to changing moral and ethical standards? Certainly, the lack of medical adherence to the concepts of the Nuremburg proclamations, the subsequent statements from the World Health Association and the guidelines from the United States government suggest that we, as medical scientists, ignored these and responded when we were forced to adhere to the new requirements. It was only when the strongly worded suggestions and guidelines evolved into actual rules and regulations––which by ignoring make it impossible to continue research on human subjects––that science started to pay attention. And yet, in spite of these somewhat compelling arguments, I think that the vast majority of physicians, today, when presented with the facts of these experiments, would have rejected them as being unethical and immoral. In the final analysis, every clinical researcher must apply the simple dictum: would I agree to this experiment on my family or me if I were presented with this choice. This is the fundamental question that we all must answer.
123
Clin Auton Res
In the future you may be presented with issues where ethical and moral ambiguities arise: these clearly are not limited to the circumscribed areas of clinical research, but will almost certainly encompass patient care responsibilities in which you are directly involved: please listen to that spark of humanity that lies within each of you and choose the response that you know is the ethically and morally correct one.
123
I have to conclude that that battered and bruised ethical base that exists in each of us, that that innate feeling of knowing right from wrong, must, periodically, be aroused and we must remember, always, to live up to the personal expectations we first had upon entering medical school and to do no harm.
