BMJ No 7120 Volume 315
Education and debate Saturday 29 November 1997
They were cheap and available: prisoners as research subjects in twentieth century America
Allen M HornblumOn 20 August 1947 Gerhard Rose, one of Germany's most respected physicians, stood in the prisoner's dock at the Palace of Justice in Nuremberg, Germany, awaiting his sentence for "murders, tortures, and other atrocities committed in the name of medical science." Dr Rose, the department head for tropical medicine of the Robert Koch Institute, was on trial along with 22 of his medical colleagues, for perpetrating "ghastly" and "hideous" experiments on concentration camp prisoners during the war.(1)
At one point in the trial when the chief prosecution witness, Dr Andrew C Ivy of the medical school of the University of Illinois, underscored the basic principle "that human experimental subjects must be volunteers," Dr Rose and his defence counsel vigorously objected, arguing that the United States was guilty of similar medical practices and giving several examples to support this contention.(1)
| Summary points |
| From the early years of this century, the use of prison inmates as raw material for medical experiments became an increasingly valuable component of American scientific research |
| Testimony by American medical experts at Nuremberg allowed American physicians and researchers to believe that the Nuremberg Code was directed only at Nazi scientists |
| Postwar American research grew rapidly as prisoners became the backbone of a lucrative system predicated on utilitarian interests |
| Uneducated and financially desperate prisoners "volunteered" for medical experiments that ranged from tropical and sexually transmitted diseases to polio, cancer, and chemical warfare |
Early experiments on prisoners in US
The Nazi doctor's first example of American complicity concerned the medical experiments of Dr Richard P Strong, who performed a series of studies in 1906 with "cholera virus upon inmates of the Bilibid Prison in Manila." The Philippine Islands experiment on prisoners already sentenced to death resulted in 13 fatalities and was eventually attributed to a bottle of bubonic plague serum having been substituted mistakenly for a bottle of cholera serum.(2-5) Strong, who later became professor of tropical medicine at Harvard University, was not deterred by the error and continued experiments on Philippine prisoners. His beriberi experiments six years later also resulted in death, but survivors were compensated with cigars and cigarettes.
Another German physician on trial for his life at Nuremberg, Dr Georg August Weltz, the chief of the Institute for Aviation Medicine in Munich, offered the name of another American doctor who used prisoners on behalf of medical science. Dr Joseph Goldberger, a public health official, sought to unravel the mystery of pellagra, a deadly and at times disfiguring disease that was particularly virulent in the southern United States. Goldberger parted company with medical colleagues who blamed the disease on everything from poor sanitation and personal habits to spoiled corn and flawed hereditary traits for the disease. He believed pellagra was due to the provincial and poor diet in the south, which supplied calories but not protein. Milk, vegetables, and fresh meat, he theorised, were the missing staples.
To prove his theory, Goldberger convinced Governor Earl Brewer of Mississippi to allow him to perform an experiment on a dozen inmates of Rankin Farm prison. His plan was simple: to "induce pellagra in white adult males, the one group in the population that statistics had shown was the least likely to contract the disease."(6) The inmate volunteers - after a promise of a pardon - were gradually weened away from their normal diet and given a steady supply of cornbread, sweet potatoes, grits, and rice. Complaints grew as the men suffered from lethargy, dizziness, and pains in their backs, sides, and legs. Soon skin lesions began to appear and the "red flame" of pellagra was identified on each of the test subjects. The governor kept his promise and pardoned the men. One test subject said he had been through "a thousand hells," whereas another swore he would choose a "lifetime of hard labor" rather than go through such a "hellish experiment" again.(6)
As part of their defence strategy, the Nazi doctors on trial at Nuremberg named other examples of dubious human experimentation in American prisons, but those few cases paled in comparison to what transpired after Nuremberg. Though American doctors, lawyers, and justices at the Doctors' Trial excoriated Nazi physicians and denounced the German medical establishment for horrific and pseudoscientific experiments on prisoners, the American medical community disassociated itself from the implications of the trial and from the subsequent code of ethical research principles - the Nuremberg Code - that all doctors were supposed to observe. By the end of the war, America's rapidly emerging scientific dominance was not to be hamstrung by a code of medical conduct that was perceived by the American Medical Association to be directed specifically towards "the brutalities of Nazi physicians."(7) Moreover, even though American jurists enumerated 10 human rights principles to safeguard the lives of research subjects - and imposed the death penalty on seven members of the Nazi medical hierarchy for violating such principles - self interest, utilitarianism, and the aura of science militated against the adoption of the Nuremberg Code in the United States. Research subjects, particularly prisoners, were considered too valuable.
The realisation that incarcerated criminals had new utility as human guinea pigs did not emerge until the second world war. Earlier efforts at using prisoners were not embraced by the orthodox medical community, which thought such practices were the preserve of unsophisticated medical eccentrics investigating offbeat scientific theories. For example, between 1918 and 1922 a doctor in the state prison system in California was "transplanting testicles from recently executed convicts to senile and devitalized men."(8)
| By 1920, the procedure had been altered so that "animal glands were substituted for the human and were grafted to the recipient's testes." Dr L L Stanley, the resident physician at San Quentin Prison (California), where the operations were performed, recommended that the material to be used was "best taken from a ram, goat or boar" aged between a year and 18 months. Hundreds of San Quentin inmates received injections of animal testicular substance; some received a piece of ram's testicle the size of a silver dollar, which was implanted into the scrotum or abdominal wall. The innovative researcher on prisoners was convinced that the procedures had a "decided effect" on everything from "general athenia" to renewed "sexual stimulation."(8) |  | |
| At San Quentin inmates received testicular implants |
He also believed he was "fortunate" the operations - which he called "practically painless and harmless" - could be carried out in a prison because of the regimented lifestyle of prisoners.
One prewar experiment that was less dramatic than testicular
transplants, but captured the public's attention due to extensive
newspaper coverage, was the series of tuberculosis experiments at
Denver's National Jewish Hospital in 1934. After years of trials on
animals, Dr H J Corper claimed a tuberculosis vaccine he had been
developing was "now ready for trial on human beings."(9)
Two convicts from the Colorado Pe For the most part, however, experiments on prisoners during the early
decades of the century were uncommon medical oddities of dubious
worth. Surprisingly, the practice received a big boost with the
outbreak of the second world war. With American soldiers
fighting and dying in Europe and the South Pacific, a whole new
industry utilising "human material" was about to emerge that would
shape researchers' behaviour for decades to come.
By the summer of 1942, American prisoners in state penal
systems had embarked on a series of dangerous medical experiments,
including injections of blood from beef cattle as a new source of
plasma, atropine studies, and experiments with sleeping sickness,
sandfly fever, and dengue fever.(14,15) Federal prisoners
were recruited to participate in medical experiments that ran the gamut
from exposure to gonorrhoea and malaria to induction of gas
gangrene.(16)
One of the more widely publicised prison experiments during the war
years, and one that was mentioned prominently at the Nuremberg
Doctors' Trial, was the series of malaria studies at Stateville
Penitentiary in Illinois. Over 400 prisoners were involved in this two
year study investigating treatment and purported cure of malaria. One
popular account of the experiment was Nathan Leopold's book,
Life Plus 99 Years. An enthusiastic participant in the
dangerous study, Leopold was one of the famous killers in the 1924
Leopold and Loeb case. He proudly proclaimed that even though the
inmates had to contend with periodic mosquito bites, raging fevers,
nausea, vomiting, blackouts, endless untested medicinal potions, and
occasional relapses, "no one squawked. They all took it like men."
(17) The highly publicised Stateville Prison malaria
experiments received much public praise. An editorial in one newspaper
proudly wrote that "these one-time enemies to society appreciate to
the fullest extent just how completely this is everybody's
war."(18)
The war years had become the transforming moment for human
experimentation in America and particularly for penal institutions as a
site of such scientific endeavors. What had once been a small,
underfunded, unsophisticated cottage industry had blossomed into a well
financed, broad clinical research programme investigating avant garde
procedures, cures, and treatments. Human experimentation had been
legitimised and prisoners had become the guinea pigs of choice for
scores of inspired researchers. Public opposition to such medical
initiatives was scant. The overriding goal was to win the war in Europe
and Asia; everything else was secondary, including research ethics and
the issue of consent. Millions of American fighters were risking life
and limb daily; at the very least, lawbreakers could contribute to the
war effort with similar commitment. And they did. One close observer
described it as "another shining light in the galaxy of wartime
achievement" by imprisoned Americans.(19)
Curiously, once the war was over, there was no decline of medical
experimentation in prisons. Battlefield victories were replaced by
medical triumphs as the focus of governmental concern, and prisoners
were once again the subjects of choice for research. The eradication of
disease had become the enemy, and postwar budgetary priorities
supported this societal mission. For example, in the last year of the
war, the National Institute of Health received about $700,000, which
had climbed to $36 million by 1955, and over 10 times that just 10
years later. In 1970, $1.5 billion was awarded to some 11,000 grant
applicants, nearly a third of them performing
experimentation.(20) Called "the gilded age of research"
by Professor David Rothman, this new era of laissez-faire attitudes in
the laboratory ushered in a frenzy for research on prisoners that
lasted for over a quarter century.(20) Rothman argues that a
"utilitarian ethic" was able to dominate the field of human
experimentation because "the benefits seemed so much greater than the
costs" and because "there were no groups or individuals prominently
opposing such an ethic."(21)
One individual who contributed greatly to the postwar acceptance
of prisoners as appropriate subjects for research was Andrew C Ivy, an
eminent researcher and vice president of the University of Illinois
Medical School. Asked by the American Medical Association to be its
representative at the Nuremberg Doctors' Trial and the prosecution's
key witness on American medical ethics, Ivy testified to the high
ethical standards of American researchers during the war, including
those working in penal institutions. No American prisoner, Ivy
reiterated, had ever been experimented on against his will. Defence
counsel strongly objected to Ivy's sanitised portrayal of American
prison research and peppered him with questions about numerous penal
experiments both before and during the war.(22) Dr Ivy
remained intransigent; he did not believe that official coercion was
necessarily inherent in a prison environment and restated his belief
that prisoners in the United States had a choice as to whether they
should participate in clinical experiments. Ivy articulated three
"principles" for establishing ethical prison research: if "the
consent of the subject was obtained"; if the experiment was based on
"animal experimentation"; and if it was directed by
"scientifically qualified persons" the medical procedure was
acceptable.(22) For American researchers anxious to utilise
the thousands of potential subjects behind bars, Ivy's emphasis on
acquiring voluntary consent from experimental subjects represented a
seal of approval. In fact, the seal of approval came less than a year
after the Doctors' Trial, when the journal of the American Medical
Association published a "special article" that endorsed the
"ideal" medical practice used in the Stateville malaria
experiments, where Ivy claimed his principles had been
implemented.(23)
Although the Doctors' Trial culminated in the establishment of the
Nuremberg Code - whose first principle emphasised that the human subject
"should have legal capacity to give consent ... exercise free power
of choice, without the element of force ... constraint or
coercion" - the American medical community either claimed ignorance of
the document or ignored it.(24) The first principle of the
code seemed to preclude the use of prisoners, but Ivy, America's star
witness on medical ethics, extolled the virtues of just such scientific
practices. The muddy ethical waters that resulted from the dual codes
allowed American medical researchers to follow their own moral
guidelines or utilitarian interests.
The result was tremendous expansion in prison experimentation in
postwar America. Federal prisoners, for example, were enlisted in a
broad range of clinical studies that included athlete's foot,
histoplasmosis, infectious hepatitis, syphilis, and amoebic dysentery,
and in additional malaria experiments.(25) State prisoners
were considered to be equally valuable and were soon utilised for
studies of syphilis, malaria, influenza, viral hepatitis, and flash
burns "which might result from atomic bomb
attacks."(26-30) Some of these postwar medical initiatives
were scientifically unsound and placed prisoners at great risk. Louis
Boy, for example, a prisoner in Sing Sing (New York), volunteered to
become a human blood cleaning agent for a young "girl dying of
cancer."(31) For 24 hours the prisoner and the 8 year old
girl were laid side by side, "their circulatory systems linked
together with rubber tubing," in the hope that her cancerous
"poisoned blood" would be cleansed as it proceeded through his
body. Unfortunately, the risky experiment proved unsuccessful and the
girl died. However, public interest in the human drama resulted in the
prisoner, a lifer, receiving a Christmas gift from the governor - his
freedom.(32)
One physician intimate with the study four decades ago recently said
that prisoners were a "stable group of people" that contributed to
the "assurance of continuity." Researchers, he argued, clearly
found it "more difficult to work with unrestrained, unrestricted"
test subjects (C Southam, personal communication). By the 1960s, new drug testing regulations mandated by the Food
and Drug Administration permitted increased human experimentation as
large pharmaceutical companies sought stronger relationships with penal
institutions. Phase I drug testing now required larger pools of healthy
subjects for non-therapeutic experiments, and using hospital patients
was thought to be inadequate. Prisoners, on the other hand, were in
abundance and, as one pharmaceutical company researcher commented,
"guaranteed to show up" (G Wachs, personal communication).
The rush to acquire prison testing sites, combined with a relaxed
ethical atmosphere and little governmental oversight, provided a
financial opportunity for some opportunistic physicians, while at the
same time jeopardising the health of the unsophisticated test subjects.
One of the best examples of this unfortunate but all too common
scenario was the controversial career of Dr Austin Stough. Claimed to
have grossed close to $1 million a year, Stough - and the pharmaceutical
companies he worked for - profited handsomely, while the inmates he used
were made ill and some even died in an extended series of drug tests
and blood plasma projects in Oklahoma, Arkansas, and
Alabama.(34) Stough's high volume plasmapheresis programme
attracted great commercial interest, but his poorly trained staff and
shoddy operations resulted in inmate volunteers receiving the wrong
blood type and as many as 30 inmates a month contracting viral
hepatitis. "They're dropping like flies out here," wrote one
alarmed inmate to the outside world.(34)
Throughout the 1960s the use of prisoners as research subjects remained
popular as prisons tested everything from tropical diseases and
respiratory infections to infectious hepatitis and "pain tolerance
studies."(35-39) In rare cases, some prisons became
supermarkets of investigatory opportunity for zealous physicians
representing aggressive private and public sector institutions. In
Holmesburg Prison, for instance, a county facility in Philadelphia, an
array of studies explored everything from simple detergents and diet
drinks to dioxin and chemical warfare agents. The long list of sponsors
included major pharmaceutical houses and diverse entities such as RJ
Reynolds, Dow Chemical, and the United States
Army.(40)
By the early 1970s, social and political indifference to human
experimentation had begun to shift. Events as disparate as drug scares
(thalidomide), hospital embarrassments (the use of 22 senile patients
for live cancer cell studies at the Jewish Chronic Disease Hospital in
New York City), alarming articles in professional journals (Dr Henry
Beecher's analysis of unethical medical studies(41)), and
popular books (Jessica Mitford's Kind and Usual
Punishment(39)) contributed to a growing
repugnance towards scientific experiments on unwitting and
institutionalised populations. By 1973, with the controversial
revelations surrounding the Tuskegee syphilis experiments, lawmakers
and the general public had been chastened by the cavalier use of
vulnerable populations for non-therapeutic medical studies. Legislation
was beginning to be introduced "to limit the use of prison inmates in
medical research"(42); prison administrators were voicing
"serious doubts about the ability of prisoners to volunteer for any
form of medical research"(43); and prison research
programmes were being terminated, especially the more controversial
ones such as the decade-long studies in Oregon and Washington that
irradiated the testicles of prison
inmates.(44)
The pendulum that represented the public's acceptance of human
experimentation had not only swung, but had swung decisively. Even
physicians who had been long time advocates of the practice were forced
to concede that scientific investigators and drug companies could
continue their work without the use of prisoners.(45) Some
doctors - Dr Albert Sabin, for example - resisted the new ethical current
and continued to argue that prisoners were "a stable, long-time
permanent study group" perfect for medical research.(46)
By 1975, only 12 state prison systems were hosting medical experiments,
and their numbers were declining rapidly.(47) Less than a
year later, the federal government announced the end of medical
research on federal prisoners.(48)
After a quarter century of unrestrained use of prison inmates as
cheap and available raw material for medical experimentation, the once
widely accepted practice had come to an end. Victims of scientific and
social forces, prisoners were still shunned, but they were no longer
seen as the human equivalent of laboratory guinea pigs. Though some
researchers initially resisted this new medical ethic, it gradually
encompassed the entire medical community and terminated any thought of
"the wealth of test material that there is in
penitentiaries."(49)
Funding: None.
(Accepted 9 October 1997) Department of Urban Studies,
Correspondence to: 7100
Bustleton Ave,
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35 Prisoners help test drug for malaria. New York
Times 1966 March 16.
36 Schmeck HM Jr. Scientists trace a sneeze's spread. New
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37 Sullivan W. Scientist reports isolating 2 strains of hepatitis.
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38 Vaccination reported for infectious hepatitis. New York
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40 Hornblum A M. Acres of skin. New York: Routledge
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42 HR 16160, 93rd Congress, 2nd session, July 29, 1974.
43 Tyler H R Jr, Carlson N A. HR 3603. Use of federal prisoners in
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pigs. Washington Post National Weekly Edition 1994
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The second world war
Postwar experimentation
In the 1950s, American prisons hosted an increasing variety of
non-therapeutic medical experiments, some of which captured national
headlines because of the perceived dangers of the tests. The Ohio state
prison system, for example, allowed researchers from the
Sloan-Kettering Institute for Cancer Research to inject over 100
inmates with live cancer cells. The study was designed to examine
"the natural killing off process of the human body"; inmates were
informed they faced "no grave danger. Any cancer that took would
spread slowly ... and could be removed surgically."(33)
Inmates received a dollar or two a day for participating in this skin study in the mid-1950s Prison experiments during the 1960s
The end of prison experimentation
Conflict of interest: None.
Temple University,
Philadelphia,
PA 19122-2585, USA
Allen M
Hornblum,
instructor
Philadelphia,
PA 19149,
USA
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