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Active Learning and Research
Active Learning and Research
Philosopher Patrick Derr teaches courses on medical and environmental ethics. He is particularly interested in ethical issues surrounding HIV/AIDS and inadequacies in current codes of ethical conduct for medical research.

Meet the researchers: What's missing from codes of medical ethics

Interview with Professor Patrick Derr
Medical researchers today are expected to adhere to internationally recognized codes of medical ethics. Among other things, these codes contain provisions designed to protect the interests of people who act as subjects for medical research.

A review of two separate vaccine research trials conducted in the mid-20th century has led philosophy professor Patrick Derr to identify what he views as a critical consideration absent from current codes, a consideration also relevant to objections raised to "North-South" medical research—research conducted by First World researchers on Third World subjects. In March 2005, Derr presented a paper on his findings to a plenary session of the 2005 Africa Genome Initiative Conference in Nairobi, Kenya.

In a recent conversation, summarized below, Derr discussed his work on ethical conduct for medical research, as well as the research opportunities open to philosophy undergraduates at Clark.

What are the two vaccine research trials that led you to determine what was missing from current codes of medical ethics as relates to human subjects?

It is pretty obvious that something is missing from the codes—controversies about "North-South" biomedical research have been growing in ferocity for several years. The hard part was figuring out what was missing.

I use cases as teaching material in my medical ethics courses. The two cases that this research focused on involved Drs. Saul Krugman and Gerhard Rose. Krugman, an American, developed the vaccine for hepatitis B. Rose, a German, worked on vaccines for typhus.

Could you explain these in more detail?

Both projects were driven by military necessity. During the Korean War, hepatitis was disabling almost as many American and U.N. soldiers as bullets. The U.S. Armed Forces Epidemiological Research Board funded Krugman's research. At the time not much was known about hepatitis, including the fact that hepatitis A and B are completely different diseases.

To obtain test subjects Krugman turned to Willowbrook State Hospital, which housed approximately 6,000 severely retarded children living in absolutely deplorable, unsanitary conditions. Over the course of several years, he injected approximately 800 severely retarded children with hepatitis A, or hepatitis B, or with first one and then, later, the other. His research was approved by every level of government, as well as by his colleagues at New York University.

The use of Willowbrook children wasn't particularly controversial at the time, in large part because, given the terrible conditions at Willowbrook, the children in Krugman's research were actually better off than the children in the institution's general population. Children admitted to Willowbrook had an almost 100% chance of contracting hepatitis, shigella, measles and a number of other diseases which, combined, would pose a severe challenge to their immune systems.

Krugman only worked with newly admitted patients because he couldn't use children already exposed to hepatitis. Newly admitted children, instead of going into a feces-covered ward, would go into Krugman's nice clean research unit. The children would be given hepatitis, but they'd get really good medical care. Assuming they recovered, they'd be placed in with the general Willowbrook population. But at least they wouldn't get hepatitis on top of the other diseases. The research was ultimately successful, and for his development of a hepatitis B vaccine, Krugman received every honor that American medicine can bestow, including the Lasker Prize.

And Dr. Gerhard Rose's work on typhus?

Well, now we go back to the Nuremberg War Crimes Trials following the end of World War II. One of the German doctors who was tried and convicted was Dr. Gerhard Rose, one of the world's top authorities on tropical medicine and a department head at the prestigious Koch Institute in Berlin. The way that Rose's research was conducted was in many ways comparable to that of Krugman, but instead of receiving awards he received a sentence of life imprisonment, although that was later reduced.

At the beginning of World War II, while working in China on international public health issues, Rose was drafted by the Luftwaffe and ordered to return to Germany. By the end of the war he was brigadier general in charge of the Luftwaffe's tropical medicine program.

In Southern Russia at that time, as many German soldiers were being disabled by typhus as by Russian bullets, and Rose was asked to supervise the development of a typhus vaccine. Concentration camp inmates were used as test subjects. Typhus was rampant in the camps. Terrible things were done by some of the people studying typhus, particularly by Dr. Ding-Schuler. But Rose himself designed and supervised only two typhus trials, and they were notably different from the other trials. First, they were technically well designed—they were good science. Second, the subject survival rate was very high. While more than 90% of the subjects in Ding-Schuler's trials were killed, more than two-thirds of the subjects in Rose's trials survived. Ironically, one of the reasons that Rose was easy to convict at Nuremberg was because there were so many inmates who survived to testify against him.

It's notable that Rose was one of the only prestigious academic physicians in Germany who did not join the Nazi party. (Physicians had a higher membership rate than any other profession.) While nominally in charge of the typhus project, Rose repeatedly refused to use his power to obtain more subjects for Ding-Schuler. In the two trials which he designed, Rose used his power to compel the staff in the camps to give only 1/100 of the dose of typhus they'd used in all the other trials. In fact, from his position at the Koch institute, he had caused a scandal by protesting violently to the SS against the use of prisoners for biomedical research. (Incidentally, a number of other physicians who refused to use prisoners for experiments had already been put into concentration camps by this time.)

So, what defense does Rose offer at his trial at Nuremberg? The same defense as Krugman: that his subjects were medically better off being in his study than being in the general institution. And, of course, the factual claim is true. The mortality rate among Rose's research subjects was lower than the general mortality rate in the camps. An inmate's best chance of surviving typhus was to participate Rose's research.

So there seems to be little difference in the ways that Rose's and Krugman's research was conducted from an ethical standpoint. In neither case did test subjects have the ability to say no to participation.

Right. In fact, under the international codes of ethics in medical research now in force, it can be argued that Rose's research was morally better than Krugman's. On some points, such as free and informed consent, their research was indistinguishable. On others, such as health benefits to the subject, the defense which worked for Krugman worked even better for Rose.

Are you suggesting that Rose should not have been convicted? Or that Krugman should not have received the Lasker prize?

No. I believe that in both of these cases, the judgment of history is correct. And that is the view of almost every expert who has studied the cases, that Rose deserved to be punished, and Krugman deserved to be honored. The problem is the codes. There's something really important missing from all the international codes of medical ethics. What principle could be added that would explain why Rose should have been punished, while Krugman should not? That's the issue I've been chewing on, on and off, for more than a decade.

And your conclusion is?

I think the missing consideration is the issue of who's going to benefit from the research. That's not touched on in any of the prevailing codes, except perhaps to say that the research should be "for the good of mankind." But there's never anything said about which mankind. And it turns out that which mankind matters.

Suppose we ask this question: will the populations from which test subjects were drawn in these two cases—other Willowbrook children or other concentration camp inmates—benefit from whatever new vaccine is developed? Or will the vaccines only be administered to other, unrelated populations?

One thing that we can say with absolute certainty is that none of the other concentration camp inmates would have been given a new typhus vaccine. We know enough about Rose, the Final Solution and Nazi science to say that Rose couldn't possibly have believed that any of the inmates at Ravensbrook would ever be vaccinated against typhus.

On the other hand, for a variety of reasons, I think we can be confident that, had the vaccine been developed a little sooner, Krugman would have seen to it that among the first people to get a hepatitis vaccine would be other patients at Willowbrook.

So proposals for medical research should be evaluated to see if people similar to the test subjects will reap the benefits of any research findings.

Yes. And the question of who benefits is also the key to the controversy about current North-South medical research. Research is morally odious when the local community will not be the first, or among the first, to receive the benefits of the research. That lines up perfectly with the outrage about certain HIV/AIDS trials, for example, when a population in Africa is used to test a vaccine for a strain of HIV that only exists in North America, Europe and Japan. Although Africans might eventually benefit indirectly from any HIV/AIDS vaccine research, they cannot possibly be among the first to benefit from a vaccine against a strain of the virus to which they are not currently exposed.

I know you've had an undergraduate, Gioia Persuitte, assisting you with your research on Rose and Krugman. What opportunities to participate in research are available to philosophy undergraduates?

Senior philosophy majors are encouraged to complete a senior honors thesis. I think it's a really good experience and students do really interesting research.

But Gioia is not a philosophy major. What I'm doing with her is a research apprenticeship. All faculty in my department offer apprenticeships, and they're all different. My colleague Gary Overvold is editor of Idealistic Studies. (We're one of the only small philosophy departments in North America that publishes a serious professional journal.) Students who do apprenticeships with him typically learn what publishing an academic journal is all about. They also learn about the subfield of idealism, and get exposed to cutting edge research that hasn't been published yet. Michael Pakaluk's research apprentices work on classical languages, Plato, Aristotle and the ancient world. Judy DeCew focuses on problems in the philosophy of law and public policy. Her students work on issues in jurisprudence and learn to use research tools, like Lexus-Nexus, that they'll need in law school.

There are also several advanced philosophy courses, such as my case studies in environmental ethics, that engage students in research. In that course, students choose problems they want to work on. It could be issues surrounding the use of herbicides under power line rights of way, or whether American cities should encourage bicycle use the way foreign cities have. Perhaps they're interested in the controversy surrounding the supposed decimation of old growth forests on nearby Mt. Wachusett. A lot of the issues that they work on are local, which I think is really neat. Sometimes students choose to work in teams, an approach that mirrors what they're likely to encounter in the real world. During weekly meetings students in the course talk about their research and get feedback. By the end of the semester, they've usually produced really remarkable stuff. About half of their final products get published in some form or other. Clarkies can do really good research. They have initiative and they have passion.

It's nice to know that the study of philosophy has real world application.

Philosophy is like weightlifting for the mind. No matter what you choose to do, knowing how to think and write better will be an advantage. If anything can make you think better, philosophy can. Our majors go on to do all kinds of different things. I like teaching at Clark. I like Clarkies.

 

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