Dr. Blumenthal is professor of community health and associate dean for community programs, Morehouse School of Medicine, Atlanta, Georgia; e-mail: email@example.com.
In Tennessee Williams' one-act play Suddenly Last Summer, Mrs. Venable, a wealthy New Orleans society matron, believes—or claims to believe—that her niece by marriage, Catherine Holley, is mad. The evidence: Catherine's eyewitness account of the death of Mrs. Venable's son, Sebastian, a sordid story that involves promiscuous homosexuality and pedophilia on the part of Sebastian, and even cannibalism by those on whom he preyed. Were the story to be widely accepted, the Venable family name would be badly sullied and Sebastian would not be remembered as the sensitive poet that Mrs. Venable feels him to have been.
Mrs. Venable has had Catherine hospitalized at St. Mary's, a private Catholic mental institution, but now wants to transfer her to Lion's Watch, a public institution where Dr. Cucrowicz has been experimenting with psychosurgery. The operation, Mrs. Venable insists, would cure Catherine (or would at least render her tale less than credible).
The play, written in the 1950s but set in the 1930s, reflects Williams' own family experience: His sister Rose underwent a lobotomy at the insistence of their domineering mother. The play is filled with poetic imagery and with symbolism representing one creature devouring another—a Venus flytrap in the Venable garden, birds preying on hatchling sea turtles during the Venables' trip to the Encantada Islands, and ultimately the cannibalism exhibited by Sebastian's slayers.
Dr. Cucrowicz (“It's a Polish word that means sugar, so let's keep it simple and call me Dr. Sugar”) is confronted with two ethical problems that are much more widely recognized and debated today than they were in the 1930s, or in the 1950s: first, financial conflict of interest in research; and second, the ethical conduct of research on humans. Mrs. Venable will support his research financially only if he complies with her wishes, and her wishes call for performing an experimental procedure on an individual whose ability to provide informed consent is presumably impaired.
He must address these problems with only his own moral compass to guide him. Institutions at the time in which the play was set had no policies requiring the disclosure of financial relationships with the sponsors of research, and there were no institutional review boards to scrutinize the conditions under which the research would be conducted. The fact that many of the recent scandals regarding financial relationships between scientists and research sponsors have involved psychiatric research lends an aura of prescience to Williams' play.
Dr. Cucrowicz's research has already violated principles and policies to which we now subscribe: He has no concern about operating on “criminal psychopaths that the State turns over to us” (nor does the state have any concern about turning them over), but conducting risky experimental surgery on a patient from the doctor's own social stratum is a different matter. Today, of course, it is precisely convicted criminals—prisoners—who are afforded among the greatest degrees of protection of any category of research subject. Yet Williams' narrative reflects the attitudes and practices of his day.
Mrs. Venable provides an indirect answer to Dr. Cucrowicz's question about the prospects for support of his research by her foundation: “Aren't we always more interested in a thing that concerns us personally, Doctor?” She reminds the present-day reader that, indeed, a great deal of current financial support for research has materialized because of personal interests—whether those of a legislator whose wife has had breast cancer or those of a private individual with the wealth (Michael J. Fox) or entrepreneurship (Susan G. Komen's sister, Nancy) to create a foundation.
The pressure on Dr. Cucrowicz is considerable: If he will agree with Mrs. Venable that Catherine's story is a psychotic hallucination and that she would benefit from psychosurgery, he will be able to pursue his research with the financial support and the “right patients” that he seeks. But at the play's conclusion, the doctor indicates the direction in which he will turn: “I think we ought at least to consider the possibility,” he says, “that the girl's story could be true.” In the end, the ethical choice, though difficult, is impossible to overlook.
Daniel S. Blumenthal, MD, MPH