Summer II 2012: Group 3: Unethical Research in Guatemala

Abstract

From 1946 to 1948, the United States Public Health Service (USPHS), Venereal Disease Laboratory (VDRL), and Pan-American Sanitary Bureau collaborated with Guatemalan agencies to research studies involving the multitudinous exposure of sexually transmitted diseases with human beings (HHS, “Report on Findings…”). Records show that more than 5,500 Guatemalan prisoners, patients, soldiers, commercial sex workers, orphans, and children were affected by the research and around 1,300 individuals were deliberately exposed to various sexually transmitted diseases. Some 700 patients of the original 1,300 were supposedly treated with antibiotics, although it is not entirely clear based on written documentation. Moreover, the Public Health Service Commission determined that at least 83 participants in the experiment died and many subjects did not give formal consent for research on their bodies in Guatemala (Humphrey, “Speaker…”). As a result, the United States’ stances on medical ethicality have been highly debatable since October 2010.


Introduction

On October 1, 2010, Barack Obama and the United States government formally apologized to Guatemalan officials and those involved for the secret study conducted in the 1940s (Morgan, “U.S.: 1940s STD Experiments…”). Although the events occurred more than sixty-six years ago, a drastic amount of attention has been brought to the United States and Guatemala for the unlawful and unethical study of years past. As a result, the central question of whether or not the suffering of a few people is justified for the greater good has come to surface. Moreover, there is a heated debate about how the United States should compensate Guatemalan citizens for its actions in the 1940s and the United States’ stance on medical ethics (Silverman, “Should…”).


Background

Purpose

American doctors led by John Charles Cutler purposely infected Guatemalan soldiers, commercial sex workers (CSWs), and prisoners with syphilis, gonorrhea, and other sexually transmitted diseases in order to study the effects of penicillin. American doctors first paid commercial sex workers to spread one of the diseases by having intercourse with prisoners and soldiers. Later, doctors inoculated Guatemalan soldiers and prisoners with the disease through spinal taps (Global HEED, "Bioethics and U.S. Public Health…”). There were four distinct purposes driving the experiment: (1) to determine how syphilis and other bacteria is transmitted through the human body; (2) to assess the treatments of penicillin and other products on the human body; (3) to compare the performance of treatments; and (4) to discuss the potential remittance of untreated sexually transmitted diseases. The design, implementation, and execution of the experiment were highly unethical in many respects such as the deliberate exposure of sexually transmitted diseases to unknowing patients, serious health threats, experimentation in crowded populations, and lack of consent thereof.

Hypothesis

When the doctors first started research in Guatemala, they believed they could expand the current procedure used in the U.S. Army and Navy for preventing diseases.  The previous method consisted of chemical prophylaxis: urination, washing with soap and water, and injecting a protein into the penis for gonorrhea prevention.  In order to prevent syphilis, the treatment consisted of rubbing calomel ointment over the penis and pubic region (Presidential Commission, "Ethically Impossible…”).  Moreover, the doctors wanted to test the effects oral penicillin and a prophylaxis wash had on syphilis, gonorrhea, and chancroid.  Penicillin had positive prevention results when tested on rabbits and it was believed that it could be successful when used on humans.  Dr. Cutler believed they would “provide conclusive answers to a large number of questions of great importance, not only in the matter of prophylaxis but also concerning progress of national and international control of venereal disease then in action or proposed for the future,” as stated in “Ethically Impossible” STD Research in Guatemala from 1946 to 1948. 

Design

The location in Guatemala was chosen because of the availability of commercial sex workers, nearby prison facilities, and nearby school facilities. Since prostitutes were able to freely enter and leave nearby prison facilities, researchers found it natural to utilize existing facilities for their experiments. Initially, prostitutes would visit the facility where researchers would ensure they had a specific disease and then allow the prostitutes to have intercourse with prisoners so that they would also contract the disease. Although researchers stated that they did not explicitly watch the sexual contact and transmission, they timed the event and made careful documentation about the transmittal of each infectious disease. Later in the experiment’s progression however, researchers began to directly infect patients with the disease rather than incorporating sexual contact (HHS, “Report on Findings…”).

Procedure

Dr. Cutler arrived in Guatemala in August of 1946. The researchers started out by purposely infecting prostitutes, and using them to spread syphilis to Guatemalan soldiers and prisoners. The sex workers were inoculated by taking gonorrheal pus, and inserting it into the woman’s cervix. All of the women contracted the disease when using this method (Presidential Commission, ”Ethically Impossible…”). They found that “naturally” spreading the diseases was had ineffective results, so on February 15, 1947, they began inoculating all of the subjects with gonorrhea by either swabbing the urethra with the infection (superficial inoculation), inserting the infection with a toothpick (deep inoculation), or injecting it into the spinal fluid of the subjects. They chose to use gonorrhea instead of syphilis because it was more “reliable and straightforward” (Walter, “Human Experiments:…”). The researchers later moved to working in a psychiatric hospital because prisoners were uncooperative and refused to give blood samples. Many of the same methods of inoculation were also used in the psychiatric hospital, and included inoculation in the rectum, urethra, eyes, cisternal punctures, and orally. Between August 1947 and July 1948, nine sexual intercourse experiments and 32 artificial inoculation experiments were conducted. They succeeded in spreading the diseases using the artificial inoculation with 97.8% being infected using the deep inoculation method (Presidential Commission, “Ethically Impossible…”).

Treatment was defined as three preparations of penicillin with a concentration of 300,000 units. Dr. Cutler considered this to be “adequate” treatment, when other studies showed that up to 3.4 million units of penicillin given over 7-8 days was more adequate treatment. Some subjects were intentionally given lower doses in order to make observations on serologic patterns of relapse, and others were considered to have failed treatment (HHS, “Report on Findings…”). Dr. Cutler claimed that all patients were given adequate treatment, while his reports show differently. According to records for the intentional exposure experiments for gonorrhea, syphilis, and chancroid; out of 1,308 intentionally infected subjects, 678 were documented to have been given some kind of treatment (Presidential Commission, “Ethically Impossible…”).

Results

Experiments ended in December of 1948, although some minor research may have continued into the early 1950s. Dr. Cutler’s experiments were not deemed successful in part because he had to rely on extreme methods of infecting patients. Dr. Cutler sent his report on his STD studies to the VDRL in September of 1952 but he edited out details and requested that the report be kept confidential. The only results to our knowledge show the type of treatment that was considered to be adequate for each disease. For syphilis, patients were given ≥ 3.4 million units of penicillin, for gonorrhea they were given 300,000 units of penicillin, and for chancroid patients received 1 gram of sulfathiazole (HHS, “Report on Findings…”). These treatments were listed as "adequate," but there are no details regarding the results of the treatments. The only published data from the exposure and prophylaxis experiments is misleading and cites another published study. Moreover, the experiments are not included in historical reviews of STD research (Presidential Commission, “Ethically Impossible…”).


Benefits vs. Risks

The largest risk is endangering others' lives, which the experiment did because there were 83 fatalities during the two-year period (Presidential Commission, “Ethically Impossible…”).  It can be questioned whether the doctors considered that there could be a national outbreak of the diseases, but there is no documentation.  With the poor methods and knowledge of birth control during the 1940s in Guatemala, sexually transmitted diseases could easily have been spread by sexual contact and through birth.  A portion of this research that was not planned out was the lifelong effects on the patients that would arise from unsuccessful research.  Some of the long-term effects of syphilis include damage to brain, nerves, eyes, heart, blood vessels, and muscles leading up to gradual blindness, mental illness, and even death.  Syphilis in pregnant women can also cause stillbirth and birth defects.  Gonorrhea can lead to pelvic inflammatory disease in women, which can cause death.  Furthermore, it can make men sterile, and also spread to the blood or joints (Idaho Department of Health and Welfare, “The Naked Truth”).  

The benefits of the research are harder to see, but there are some.  For example, Dr. Cutler initiated a venereal disease treatment program at the Guatemalan military hospital, he trained the local doctors, and treated orphans for malaria.  He also provided treatments for 142 people who had a venereal disease, but were not exposed to it as part of the research (Walter, “Human Experiments…”).  There are innumerable theoretical benefits supporting the research, with a simple cure for the disease taking precedence.  There are countless possibilities that could have come from successful research, such as pill-based cures for sexually transmitted diseases, and the research could have led to even more benefits in varying medical fields.  Researchers could have learned more about the diseases themselves, such as the rate of transmission, and early symptoms to look for to provide the soonest possible treatment.  With successful results coming from penicillin or the prophylaxis, it could have opened up doors to finding other cures for diseases using the same methods.  From a patient perspective, there is always the possibility of having one of the diseases before the researchers came to Guatemala, and finding the opportunity to receive treatments without having to pay any medical bills.  For the subjects that were prisoners, the research was a channel for them to give back to society from their position behind bars.


Science vs. Morality

The Story of Federico Ramos

Federico Ramos was a soldier in the Guatemalan army in 1948 when he was 23 years old. He was ordered to report to a clinic where he was given an injection in his right arm and a few coins as compensation. This same event reoccurred several different times throughout a few months during his stay in Guatemala; he believes that the doctors were purposely infecting him with a venereal disease. It wasn’t until he was 40 that he was diagnosed with syphilis and gonorrhea, and now he cannot pay for the necessary medication. For nearly twenty years, Ramos has suffered through pain and bleeding during urination, and has also passed the diseases onto his wife and children. His son had also endured the same symptoms as his father, and his daughter was born with cankers on her head, which has led to hair loss (Walter, “Human Experiments…”). This brings up the issue of who should be responsible for paying for that medication that Federico Ramos cannot afford? Ramos and some other survivors sued the United States government and the United States Department of Justice requested that the case be dismissed. However, in September of 2011, a panel of the Presidential Bioethics Commission recommended that the government set up a compensation system for participants that were harmed by the research. Officials are still trying to decide how to judge the actions of Cutler’s team, and determine if they knew they were violating medical ethics of their time (Walter, “Human Experiments…”).

Drawing the Line Between Morality and Justice

It is clear to see that the United States government did not know where to draw the line between experimentation and justice of the Guatemalan people. There are three main issues of morality: (1) the acts of violence beginning in 1946; (2) the failure of the United States to provide relief, compensation, and treatment to the victims of the incident and their families; (3) failure to put legal and ethical prohibitions in place to prevent any further unethical human experiments. The horrifying reality is that the experiment was kept secret for 64 years, only being announced publicly in 2010. 5,128 children, orphans, Guatemalan Indians, leprosy patients, mental patients, soldiers, sex workers and other citizens became test subjects in a non-consensual human experiment between the years of 1946 and 1948. United States health officials intentionally infected 1,308 of these victims with sexually transmitted diseases and immorally left over 600 of them untreated (Barclay, Eliza).

Counteracting the United States

An alliance has recently been organized to seek justice for the thousands of Guatemalans that suffered and are still suffering from the United States' experimentation in Guatemala. This alliance proposes principles and goals for President Obama, Congress, and federal agencies to follow to bring justice back to these affected people. The alliance proposed that the victims, families, heirs, and descendants receive equal treatment compared to those of the Tuskegee syphilis experiments. It was also proposed that the United States should revise current laws and ethical standards, while also improving legal and ethics training of public health officials and investigators. This is to ensure that the strongest human subject protections are put into place to prevent any further misconduct, to provide just repercussions, to make sure victims of any conflict are rightfully compensated, and to make sure that these protections are applied worldwide. The alliance also believes that the United States should truthfully disclose any information regarding people involved with the approval, conducting, funding, authorizing, and condoning of the experiment (Garcia, Robert).

Disclosure

To this date, the experiment has received only a small amount of media attention, little sustained public attention, zero rectification for the victims, and no further action to prevent future related issues. Hillary Clinton and President Barrack Obama have since made apologetic statements to President Alvaro Colom, who addressed these experiments as “a crime against humanity.” Hillary was reported saying, “The conduct exhibited during the study does not represent the values of the US, or our commitment to human dignity and great respect for the people of Guatemala” (Garcia, Robert).

More recent findings show that some of the experiments conducted were more shocking than previously known. Seven woman with epilepsy that were being housed in a Guatemalan insane asylum were injected with syphilis and later contracted bacterial meningitis. One of the more disturbing procedures involved a female syphilis patient that also had an undisclosed terminal illness. Researchers, eager to see what an additional disease would do, infected her with the gonorrhea in her eyes and elsewhere. The patient died six months after this wrongful experiment was conducted (Press, Associated).

Further Action

Although it may seem that the United States is on the right track by officially apologizing and admitting their wrongdoings, it is our belief that further action must be taken to make things right. The government kept this matter a secret for nearly 64 years and is nothing short of immoral and unjust. When the lives of so many innocent people are jeopardized, it is ethically unacceptable to condone experimentation like the United States' actions in Guatemala. It is obvious to us that these experiments were not held in a controlled or justified manner due to the fact that healthy people were unknowingly infected by diseases that could be fatal if untreated. Researchers even went as far as paying prostitutes infected with syphilis to have sex with prisoners so that the disease would spread. It is clear that in this case, the morality of the people involved should have outweighed and overcome the urge to make a significant breakthrough in the world of science.


Conclusion

Through careful examination of the related study’s documents and external sources, we have found that many of the researchers’ actions were unethical even by their practical standards during the relative time period. Despite the potential benefits and breakthroughs in future scientific fields, a similar experiment in modern day would not and should not be permitted based on standardized regulations in the biomedical field. Furthermore, we find that the United States’ actions in Guatemala are not indicative of any form of blatant racism, discrimination, or medical imperialism. It is our belief based on written documentation that the United States chose to use Guatemala for its experiments solely on the availability of commercial sex workers and the actions of the researchers are not indicative of the country as a whole (Morgan, “U.S.: 1940s STD Experiments…”).

The United States of America prides itself on justice and morals. If we want to keep up this reputation, people need to speak and act assertively. It is our belief that this uncharacteristic property of our country—frivolously endangering a large population—is not the way to go about a purposeful scientific experiment. By risking the lives of thousands of people, sexually transmitted diseases could have turned into a national outbreak because of the lack of safe sex practices in Guatemala at the time. Although a few benefits could have come from these experiments, we believe that the risks and wrongdoings far outnumber them.


Works Cited

Barclay, Eliza. "Commission: Researchers Knew Of Ethical Problems In Guatemala STD Study." NPR. NPR, n.d. Web. 10 Aug. 2012. <http://www.npr.org/blogs/health/2011/08/30/140056804/commission-researchers-knew-of-ethical-problems-in-guatemala-std-study>.

Garcia, Robert. "Justice for Guatemalan People: The U.S. STD Atrocities | Green Justice | Land of Sunshine | KCET." KCET. Green Justice, 29 June 2012. Web. 10 Aug. 2012.
<http://www.kcet.org/socal/departures/landofsunshine/green-justice/justice-for-guatemala-the-us-std-atrocities.html>.

Global HEED. "Bioethics and U.S. Public Health Service Syphilis Experiments in Guatemala - Global Heed." Global Heed. Kevin Kang, 17 July 2012. Web. 06 Aug. 2012. <http://globalheedemory.weebly.com/1/post/2012/03/bioethics-and-us-public-health-service-experiments-in-guatemala.html>.

"Gonorrhea Information, Effects, Symptoms, Treatment." The Naked Truth - Gonorrhea. Idaho Department of Health and Welfare, 2 July 2012. Web. 09 Aug. 2012. <http://www.nakedtruth.idaho.gov/gonorrhea.aspx>.

HHS. "Report on Findings from the U.S. Public Health Service Sexually Transmitted Disease Inoculation Study of 1946–1948, Based on Review of Archived Papers of John Cutler, MD, at the University of Pittsburgh." Report on Findings from the U.S. Public Health Service Sexually Transmitted Disease Inoculation Study of 1946–1948, Based on Review of Archived Papers of John Cutler, MD, at the University of Pittsburgh. HHS, n.d. Web. 06 Aug. 2012. <http://www.hhs.gov/1946inoculationstudy/cdc_rept-std_inoc_study.html>.

Humphrey, Nancy. "Speaker Traces History of Research Gone Awry (11/3/11)." Speaker Traces History of Research Gone Awry (11/3/11). VUMC Reporter, 03 Nov. 2011. Web. 06 Aug. 2012. <http://www.mc.vanderbilt.edu/reporter/index.html?ID=11649>.

Morgan, David. "U.S.: 1940s STD Experiments "Clearly Unethical"" CBSNews. CBS Interactive, 01 Oct. 2010. Web. 06 Aug. 2012. <http://www.cbsnews.com/8301-503543_162-20018272-503543.html>.

Press, Associated. "Shocking New Details of US STD Experiments in Guatemala." The Guardian. Guardian News and Media, 30 Aug. 2011. Web. 10 Aug. 2012. <http://www.guardian.co.uk/world/2011/aug/30/guatemala-experiments>.

Silverman, Ed. "Should The US Compensate Injured Trial Patients?" Pharmalot. Pharmalot, 1 Sept. 2011. Web. 06 Aug. 2012. <http://www.pharmalot.com/2011/09/should-the-us-compensate-injured-trial-patients/>.

"Syphilis Information, Effects, Symptoms, Treatment." The Naked Truth - Syphilis. Idaho Department of Health and Welfare, 2 July 2012. Web. 09 Aug. 2012. <http://www.nakedtruth.idaho.gov/syphilis.aspx>.

Walter, Matthew. "Human Experiments: First, Do Harm." Nature.com. Nature Publishing Group, 08 Feb. 2012. Web. 09 Aug. 2012. <http://www.nature.com/news/human-experiments-first-do-harm-1.9980>.


Cheston Jones

For my response, I want to contribute information about other cases that the United States has used human patients for testing that seems unethical. Doctors in Connecticut gave hepatitis to mentally ill patients in hopes of developing a vaccine for it through this exposure. A New York hospital injected chronically ill patients with live cancer cells to conduct research that proved fatal for those being injected. In Maryland, doctors used prisoners of a jail for experimentation by injecting a pandemic flu virus into there nasal cavity. All of these are more examples where United States doctors have conducted unethical experimentation on humans in the past.

http://www.bioethicsinternational.org/blog/2011/02/28/unethical-health-experiments-done-in-u-s/


Adam Doyle

I think you would have a hard time trying to find anyone who actually agrees with what Dr. Cutler did in Guatemala. Purposely infecting underprivileged people with infectuous diseases is a clearly horrendous act on the same level as the Nazi human experiments conducted by Mengele in the '40s. As far as I'm concerned, it comes down to an act of murder/assault by a reckless and destructive doctor (Cutler). There are plenty of ethical ways to study treatments (e.g. treating people who already have the disease), and purposely infecting people, especially through misleading means, is absolutely not necessary.


Emily Rudzinski

In 1988 in the case of B.N. v. K.K., a Ms. N. from Johns Hopkins Hospital in Baltimore had sexual relations only with a Dr. K. who knowingly had genital herpes. Dr. K. did not disclose his condition to Ms. K. and so she contracted the disease and sued Dr. K. The Maryland Court of Appeals ruled that not disclosing a sexually transmitted disease to a potential sexual partner is negligence.

In regards to the study done by Dr. John Charles Cutler in Guatemala, had the study been completed in the United States, the subjects would have had the right so sue considering they did not give consent and the infected people most likely did not disclose their conditions. In another case, Lockhart v. Loosen, the Oklahoma Supreme Court determined that Loosen should have disclosed her genital herpes with Lockhart’s husband or Lockhart herself. The fact that Loosen knowingly had genital herpes and transmitted it to Lockhart’s husband who then gave it to Mrs. Lockhart was seen as negligence. Dr. Cutler knowingly gave subjects sexually transmitted diseases and did not warn the sexual partners of the risk. Dr. Cutler could have been sued for negligence had this taken place in the United States.

In a similar case to Guatemala, the Tuskegee syphilis experiment, hundreds of African Americans were told they would be treated for bad blood which was the term for syphilis, anemia, and several other diseases. These subjects were not fully aware of the experiment nor were they all fully treated for the diseases. In a lawsuit filed by the NAACP against the U.S. Government, the government paid the survivors and surviving family members $9 million (Wikipedia).

In October of 2010, President Obama apologized for the experiments in Guatemala. The people of Tuskegee got immediate compensation after their experiment was shut down and revealed while the people of Guatemala still have no compensation. It is still unclear whether the people of the Guatemalan experiments were completely cured (Wikipedia). The U.S. Government may have taken responsibility for its actions but has not yet paid the price. The prisoners, commercial sex workers, and mental patients of Guatemala had no one on their side to stick up for them and still have not had justice.

Court of Appeals of Maryland. "B.N. v. K.K." Leagle. Leagle, Inc., n.d. Web. 11 Aug. 2012. <http://www.leagle.com/xmlResult.aspx?page=7>.

"LOCKHART v. LOOSEN." FindLaw, For Legal Professionals. Thomas Reuters, n.d. Web. 11 Aug. 2012. <http://caselaw.findlaw.com/ok-supreme-court/1213735.html>.

"Tuskegee Syphilis Experiment." Wikipedia. Wikimedia Foundation, 08 June 2012. Web. 11 Aug. 2012. <http://en.wikipedia.org/wiki/Tuskegee_syphilis_experiment>.


Anjana Addanki

There are many cases where individuals with a disease like HIV fail to mention they have it to their sexual partners. Not only is this illegal, it is immoral. One of the fundamental aspects of being a well functioning human in our society is to not intentionally endanger other people.

What scientists did in Guatemala was morally wrong. The pursuit of science is not a valid excuse to attempt dangerous experiments on people. These individuals were wrongly forced to spend the rest of their lives in agony. In many of these cases, the people the scientists preyed on were either handicapped or mentally ill. This makes the situation even worse because they were powerless to act back. A mentally handicapped patient named Berta was cruelly injected with syphilis and gonorrhea without her knowledge till she died.

Although, I am glad Obama issued an apology in 2010, I do not think that is adequate. As the wiki article mentioned, there are many children of those infected that should be allowed to get free treatment for any diseases they might have gotten as a result of their parents being affected intentionally.

News, NBC. "U.S. Apologizes for Guatemala STD Experiments." Msnbc.com. Msnbc Digital Network, 01 Oct. 2010. Web. 11 Aug. 2012. <http://www.msnbc.msn.com/id/39456324/ns/health-sexual_health/t/us-apologizes-guatemala-std-experiments/>.


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