Doctors Gone Bad

1. Doctors Gone Bad Human Subject Experimentation (1915 – the present) Torturers Murderers and Despots Martin Donohoe

2. “When a doctor [goes] wrong, he is the first of criminals. He has nerve and he has knowledge.” - Sherlock Holmes to Dr. Watson, Arthur Conan Doyle

3. Armenian Genocide (1915-1917) • Dr Mehmet Resid (Ottoman middle manager, started Butchers’ Brigade) • “Those Armenian bandits were a bunch of harmful microbes pestering the body of this nation. A doctor’s duty is to kill microbes…”

4. Nazi Medicine • Guiding philosophy = Hegelian (rational utility) • Social Darwinism - parallels in American and British Eugenics Movement • medical journals relatively silent • Ethics reduces morality to efficiency, economics, and aesthetics

5. Nazi Medicine • An arm of state policy • Focus on racial purity • from eugenic sterilization (370,000) • to involuntary euthanasia (70,000) • to large-scale genocide (over 6 million)

6. Nazi Medicine • Individual worth stated in economic terms; propaganda re obligations to the state • “I Accuse” • “Mathematics in the Service of Political Education”

7. Nazi Medicine • Doctoring the nation more important than doctoring individuals - Nazism as “applied biology” (Rudolph Hess) • Focus on preventive medicine and public health: anti-tobacco and anti-alcohol campaigns, environmental toxins, organic farming • to improve Aryan stock • Nazi soldiers given anabolic steroids to increase aggressiveness • cf. professional athletes doping

8. Nazi Physicians • 52,000 physicians • National Socialist Party Members • Jewish physicians ostracized/killed/committed suicide; replaced by young Aryans • today 0.2% of German physicians are Jews, c/w 17% pre-Nazis • 5% of non-Aryan physicians committed suicide; 25% murdered

9. Nazi Physicians • Economic hard times, physicians salaries rise, academic perks • Blutkitt (“blood cement”)

10. Nazi “Physician-Researchers”(Torturers) • Dr. Sigmund Rascher - coagulation/amputation studies; hypothermia experiments • Dr. Karl Gebhart: heteroplastic (inter-species) transplantation experiments • 2016 – US govt. plans to lift moratorium on funding of certain types of chimeras

11. Nazi “Physician-Researchers”(Torturers) • Drs. Karl Clausberg and Viktor Brack: X-irradiation/sterilization • Drs. Joachim Mrugowsky, Erwin Ding-Schuler, and Waldemar Hoven: IV phenol and gasoline executions

12. Nazi “Physician-Researchers”(Torturers) • Dr. Friedrich Wegener (formerly “Wegener’s Granulomatosis”; now granulomatosis with polyangiitis): German pathologist, Nazi party member, autopsied a prisoner with oxygen injected into his bloodstream in an embolism study; may have participated in experiments on concentration camp inmates

13. Nazi “Physician-Researchers”(Torturers) • Dr Hans Conrad Reiter (formerly “Reiter’s Syndrome”, now “reactive arthritis”): senior Nazi official • Dr. Joseph Mengele: Septicemia/twin vivisection studies • Dr. Hans Eppinger – water deprivation experiments, “father of modern hepatology”

14. Nazi “Physician-Researchers”(Torturers) • Dr Hans Asperger • One of the first to describe autism (“children in opposition to Nazi Party values) • Extensive cooperation with Nazis • Evidence that he personally transferred/approved of transfers of children to concentration camps • Did not save any children • Later falsely called himself a resistor • Asperger’s Syndrome diagnosis now subsumed into autism spectrum disorder

15. Nazi Medical “Ethicists” • Ethics instruction widespread • Eugen Stähl: Teacher, directed euthanasia program at Grafeneck Castle, where 10,000 mentally ill patients were gassed and cremated • Rudolf Ramm: author of ethics textbook, editor-in-chief of J Germ Med Assn: laid out ethical arguments for “Final Solution” • Executed after conviction by Soviet military tribunal, 1945

16. “Indirect Participants” • Prof. J Hallevorden: “If you are going to kill all these people at least take the brains out so that the material could be utilized … the more (brains) the better….I accepted these brains of course. Where they came from and how they came to me was really none of my business.”

17. Doctors and Resistance • Pockets of resistance: Catholics, Marxists, Dutch • Drs Eugene Lazowski and Stanislaw Matulewicz created a fake typhus epidemic during the German invasion of Poland (1939) • Germans fooled, quarantined area, many Jews escaped death

18. Consequences for Physicians • Nuremberg Doctors’ Trials: 23 German physicians tried; 16 found guilty • 7 hanged (incl. Gebhardt, Brack, Hoven, and Mrugowsky) • Hallevorden committed suicide before trial • Rascher died before trial • Ramm executed after conviction by Soviet military tribunal, 1945 • Mengele fled for Argentina (remains verified 1985)

19. Nuremberg Trials • Otto Ambros (chemist) – invented sarin (nerve gas), convicted of mass murder at Nuremberg Trials, later freed and worked with US chemical industry on thalidomide

20. Nuremberg Trials

21. Nuremberg Code • Voluntary consent is absolutely essential • Avoidance of unnecessary physical and mental suffering • Option to quit/responsibility to terminate • Other safeguards

22. Declaration of Geneva • “I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient” • “I will not use my medical knowledge contrary to the laws of humanity.” • “It is unethical for physicians to employ scientific knowledge to imperil health or destroy life.” • Declaration, respect for protections for health care workers routinely violated throughout world

23. Declaration of Helsinki • Patients’ rights to respect, self determination, informed decision-making • Investigators’ duties: primacy of subjects’ welfare, ethical considerations take precedence over laws and regulation • Allows for surrogate consent

24. New Common Rule Provisions (2018) • Improves readability of consent forms • Creates additional exemptions for low risk studies • Eliminates continuing review for others • Requires single-IRB review for multi-institutional studies conducted in the US

25. Federal Policy for Human Subject Protection (Common Rule) Revisions • Recommendations: • Studies must not violate domestic and international laws • Voluntary consent absolutely essential • Address special problems and needs of developing countries • Provide treatment and compensation for research-related injuries • US must wait sovereign immunity and other procedural obstacles regarding developing country studies

26. Japanese Abuses in WW II • Extensive biological and chemical weapons program involving prisoners of war • Over 10,000 doctors and researchers involved (led by Shiro Ishii, Chief Medical Officer of the Imperial Japanese Army)

27. Japanese Abuses in WW II • “Experiments:” • Deliberate infections with plague, cholera, typhoid, anthrax, and TB • Testing of drugs and vaccines not previously tested in animals • Surgeries (for training purposes) without anesthesia, followed by vivisection/death • Detonation of bombs, followed by vivisections • Number of victims unclear, likely in six figure range • Subjects referred to as maruta (“logs”)

28. Japanese Abuses in WW II • Many participants later achieved positions of prominence in Japanese medical schools and societies • E.g., Tokyo Prefectural University, Olympic Committee, Green Cross, Japanese NIH, and private sector companies

29. Japanese Abuses in WW II • U.S. government made secret deal with Ishii and top collaborators - 250,000 yen and immunity from prosecution in exchange for exclusive access to data • Japanese scientists brought to Fort Detrick, MD, to help establish U.S. biological/chemical weapons program

30. Japanese Abuses in WW II • U.S. government made secret deal with Ishii and top collaborators - 250,000 yen and immunity from prosecution in exchange for exclusive access to data • Japanese scientists brought to Fort Detrick, MD, to help establish U.S. biological/chemical weapons program • Ishii variously reported in US, South Korea, and Japan; later worked at free clinic for children; converted to Catholicism 1 yr before death from throat cancer in 1967 • U.S. has never apologized for protecting these war criminals

31. U.S. Abuses in WW II • Classified tests exposing tens of thousands of soldiers and Japanese internment camp victims to mustard gas • Veterans sworn to secrecy • Veil of secrecy lifted in 1990s, but VA only contacted 620 vets between then and late 2000s; many denied care • Investigation led to law requiring VA to re-examine all claims

32. US Abuses in WW II • US Studies on prisoners in WW II: • Gonorrhea • Gas gangrene • Dengue fever • Malaria

33. Post-WW II • Over 700 Nazi rocket scientists and their families brought to the U.S. (including Werner von Braun) to help build nuclear missile program • Operation Paperclip

34. U.S. Immigration Policy • U.S. government excluded Jewish refugees from Nazi Germany from coming to the U.S. in the 1930s; turned SS St. Louis with 900 Jewish refugees back from Miami )1/3 later murdered by Nazis)

35. U.S. Immigration Policy • Immigration quotas on “undesirables” throughout 20th and 21st Centuries (except when needed for dangerous labor) • Trump administration: Limits on refugee resettlement, attitudes towards Latinos and Muslims, indefinite detention of children, family separations

36. U.S. Immigration Policy • 2018: Israel bans Quakers from entering country • Due to support of boycotts, disinvestments, and sanctions protesting Israel’s occupation of West bank and East Jerusalem • Even though American Friends Service Committee received Nobel Peace Prize for helping to rescue Jews from Nazi-occupied Europe

37. Post-WW II • Reunification of East and West Germany • US ally • German Medical Association unanimously issues blunt, straightforward apology for its role in the Holocaust (2012)

38. Post-WW II • US ally • 1950: Science Council of Japan (equivalent to US NAS) vows that Japan “will never pursue scientific research for the purpose of war” • 1967: Extended to broadly proscribe military research

39. Post-WW II • 2015: Defense ministry starts small program to fund university research with both civilian and military applications • 2017: Massive budget increase • Japanese Constitution (written after WW II) renounces war and use/threat of force to resolve international conflicts • Yet Japan has world’s 7th most powerful military

40. Post-WW II Human Subject Experimentation • Dr James Ketchum (psychiatrist), L Wilson Green (scientist), Van Murray Sim – psychochemical warfare studies for US Army • Ketchum later joined faculty of University of Texas Medical School

41. Post-WW II Human Subject Experimentation:Tuskegee Syphilis Study • Longitudinal study of untreated syphilis in almost 400 African-Americans (and 200 African-Americans without syphilis) • Sponsored by USPHS • Racist assumptions that syphilis behaved “differently” in Blacks

42. Post-WW II Human Subject Experimentation:Tuskegee Syphilis Study • Mid-1940s: Penicillin accepted as treatment for all stages of syphilis • By 1972: 28 had died of syphilis, 100 were dead of related complications, 40 wives had been infected, and 19 children were born with congenital syphilis • 1972: Newspaper reports condemn; study ends

43. Post-WW II Human Subject Experimentation:Tuskegee Syphilis Study • 1970s: Participants and families compensated by federal government • $9 million settlement • 6,000 heirs of 600 subjects paid • Living participants who had syphilis paid $37,000; heirs of deceased participants $5,000; women and children infected with syphilis got lifetime medical and health benefits • 1997: President Clinton formally apologizes

44. Post-WW II Human Subject Experimentation:Tuskegee Syphilis Study • “The men’s status did not warrant ethical debate. They were subjects, not patients; clinical material, not sick people.” • Dr John Heller, Director of Venereal Diseases at PHS between 1943 and 1948 (interviewed in 1976)

45. Studies on Native Americans • Sterilizations • Radioactive iodine to study adaptation of thyroid gland to extreme cold • Forced removal of children to English language, religious schools (c.f., Australia, Canada) • Distrust and reluctance of minorities to participate in medical research

46. Post-WW II Human Subject Experimentation • Guatemala STD study (1946-8) • Country suggested by Guatemalan physician, Juan Funes • U.S. researchers deliberately infected 1,308 prisoners, military conscripts, prostitutes, orphans (provided by Sisters of Charity), and mental health patients with gonorrhea and syphilis • Scientists treated 87% of those infected (10% later required re-treatment), lost track of 13%

47. Post-WW II Human Subject Experimentation • Guatemala STD study (1946-8) • Wives, children, and grandchildren treated, but sexual contacts not traced • Study approved by Guatemalan government • Received material for resource-starved institutions in return • Subjects received cigarettes for participating

48. Post-WW II Human Subject Experimentation • Guatemala STD study (1946-8) • U.S. apologized (2010), spent $1 million to study research ethics, gave $775,000 to fight STDs in Guatemala • Class action lawsuit against U.S. government, Johns Hopkins, Rockefeller Foundation, and Giron (pharmaceutical company) filed on behalf of 700 victims/relatives

49. Post-WW II Human Subject Experimentation • Guatemala STD study (1946-8) • Dr. John Cutler (research coordinator): “Unless the law winks occasionally, you have no progress in medicine” • In 1943, Cutler infected volunteer federal prisoners in Indiana with gonorrhea in exchange for cash

50. Post-WW II Human Subject Experimentation • Guatemala STD study (1946-8) • After Guatemala, Cutler oversaw the Tuskegee Syphilis Study • Was acting dean at University of Pittsburgh in 1960s