From 1932 to 1972, the U.S. Public Health Service (USPHS) sponsored an observational study of syphilis in black men in Macon County, Alabama. This trial has come to be known as the Tuskegee syphilis study. Six hundred black men, 399 with syphilis and 201 without, were observed for forty years to chart the effects of untreated syphilis. Perhaps the most famous example of unethical modern medical research in the United States, three features of the Tuskegee syphilis study are instructive: its racism, its perseverance, and its lack of scientific value.
The racism of the Tuskegee syphilis study is evident in its design, its justification, and its implications. The misguided popularity of social Darwinism at the turn of the twentieth century is perhaps the most generous explanation available for the views expressed by Joseph Earle Moore (1892-1957), one of the nation’s leading venereologists, and Taliaferro Clark (1867-1948), chief of the USPHS Venereal Disease Division. Previously, Moore had argued for the treatment of syphilis to (1) diminish its effects on the patient and (2) limit its possible spread. In reviewing the design for the Tuskegee syphilis study, he suggested, surprisingly, that it would be a laudable study. Perhaps to mollify any concerns about the racist nature of the design, Moore suggested that syphilis in the black male would be an almost entirely different disease than syphilis in the white male. It is unclear why he made this claim, but even if it were true, it would not diminish the effects on the patient or eliminate the spread of the disease, primarily, of course, to other blacks. In the buildup to the syphilis study, Clark offered a more overtly racist justification for the experiment. He argued that the low intelligence of blacks meant that they would not seek treatment for syphilis. Observing, and not treating, was justified because these men would not choose to be treated anyway.
Offering dubious or overtly racist justifications, the Tuskegee syphilis study condemned these black men and their sexual partners to continual exposure to syphilis and its painful effects. The study also condemned Macon County, a primarily black county, to a robust population of syphilitic men and thereby guaranteed the continued presence and spread of the disease.
The Tuskegee syphilis study faced a number of obstacles and setbacks that could have easily ended the study. For starters, it was difficult to entice subjects to be tested and, once tested, to return for other exams. Ironically, the researchers successfully enticed subjects to enter the trial by offering them treatment. This, of course, is a surprising turn because (1) treatment was the very thing that the investigators had predicted the black population would not seek, and (2) it was a lie—there was no plan to treat these men for syphilis.
The covert nature of the experiment precluded telling the men that getting treated elsewhere would be detrimental to the study. Accordingly, there was also a constant risk that these men would get treatment through other sources. To eliminate this possibility, the USPHS secured the agreements of local doctors, the Alabama Health Department, and the U.S. Army. Each group agreed to exclude subjects of the study from the antisyphilitic treatments they offered (or, in the case of the Army, required of) others. In the 1950s, penicillin became the standard treatment for syphilis. Though it cannot undo previous complications, penicillin does prevent the disease from producing further complications. By and large, though, subjects failed to procure adequate doses of penicillin during the course of the study.
This study was also under the purview of the Center for Disease Control and could have been cancelled at any given review point. In 1965 the study was reviewed, and the reviewers concluded that it should continue and that the "race issue," if it were brought up at a later date, could be deflected.
The scientific value of the Tuskegee syphilis study was limited by its aim, its execution, and its origin. At the time the study was planned, there already existed some modestly effective treatments for syphilis. This, at the very least, raises serious questions about the value of an observational study. Without any clear benefits for the subjects or the possibility of promising scientific knowledge, the aim of the trial is unclear. That no improvement on existing diagnostic or treatment options was being pursued is further confirmed by the researchers’ response to the introduction of a highly effective treatment for syphilis (penicillin)—they did all they could to keep the subjects from taking it.
During the execution of the trial, control subjects, who started the study without evidence of syphilitic infection, were transferred to the study group if, at a later date, they were positively diagnosed with syphilis. As any student of science can attest, transferring subjects from the control group to the study group is sure to muddy the results.
The origins of the Tuskegee syphilis study are as significant as any other limit on its ultimate scientific value. The planning of the study depended upon a particularly racist version of social Darwinism. Without critiquing this view, one can still note that the trial continued even after this view was no longer accepted in the scientific community. Designed around a problematic and ultimately untenable perspective, the results of the study lack any scientific or medical value.
A LESSON FOR RESEARCH ETHICS
In courses on medical ethics and research ethics around the country (and perhaps even further), the Tuskegee syphilis study, alongside the Nazi experiments during World War II (1939-1945) and the Willowbrook studies of hepatitis in mentally disabled children from 1956 to 1971, is used as an example of medical research gone wrong. The difference is that the Nazi experiments and the Willowbrook studies both produced useful knowledge (the Nazi experiments produced a wide array of knowledge about the physiological workings and limits of the human body, and the Willowbrook studies correctly identified the distinction and the possibility of inoculation for hepatitis A and B), while the syphilis study produced nothing of value. The Tuskegee syphilis study reminds us that medical research can use ethically impermissible methods to achieve many things, but medical research can also fail to accomplish anything more than an expression of the worst of our social views.