Rie, Michael A. MD
Associate Professor of Anesthesiology; Department of Anesthesiology/Critical Care; Associate Scholar in Ethics; University of Kentucky College of Medicine; Lexington, Kentucky; Marie2@insightbb.com
Enduring Contributions of Henry K. Beecher to Medicine Science, and Society
Lowenstein E, McPeek B, eds. Philadelphia: Lippincott Williams & Wilkins, Vol. 45, No. 4 and Vol. 46, No. 1 of International Anesthesiology Clinics, 2007 and 2008. 239 pages.
In his 1985 Rovenstine Lecture, Keats opined that the most important research that can be performed by an anesthesiologist is that which affects the entire practice of medicine and named Henry Beecher such an individual. Today many may find Beecher's contributions to human research ethics, health policy, health law, and governmental institutional affairs to be even broader in the 21st century than at the time of his death in 1976. If one realizes that Dr. Beecher never had formal training in anesthesia and was trained as a surgeon, his contributions are all the more astounding for a single human being.
This is an engaging volume that captures the life and times of a gifted, hardworking, and inventive anesthesiologist of humble background and means who founded the first anesthesia research laboratory and an academic teaching department that created a fertile environment for productive minds in clinical anesthesia, critical care medicine, pain management, medical technology, and safety science. The diversity, talent and respect of those who worked and trained in Beecher's department are elegantly covered in recollections from Bernard Briggs (age 94) recalling his experiences in the MGH operating rooms of the 1940s; Susan Learmonth, Beecher's first “part-time” child bearing anesthesia resident of the 1950s; and Konrad Falke, a German anesthesia fellow in the early 1970s, who went on to describe the physiologic mechanisms of improved oxygenation produced by positive end expiratory pressure (PEEP), extracorporeal membrane oxygenation (ECMO), and nitric oxide (the last in conjunction with Dr. Warren Zapol). Falke's memoir is particularly important because he captures the historical links between Beecher's 1930's work as a research fellow in Nobel Laureate August Krogh's physiology laboratories and Beecher's lifelong affection for Europe, especially Scandinavia. When one pieces together these early research experiences in the physiology of oxygenation in the 1930s with the even earlier chapter of Michael Gionfriddo capturing Beecher's seminal medical student observations of respiratory disturbances of patients after laparotomy, one can see the tremendous contributions of Beecher to the further development by Myron Laver of arterial blood oxygen measurements and the founding of the Respiratory Intensive Care Unit at the Massachusetts General Hospital by Henning Pontoppidan, Henrik Bendixen, and John Hedley-Whyte. All were advances with major impact on clinical practice today.
This volume has been written to commemorate the establishment of the Henry K. Beecher Professorship in Anesthesia and Critical Care Medicine at the Harvard Medical School. Dr. Warren Zapol, who recently stepped down as Chairman of the MGH Department of Anesthesia and Critical Care Medicine, raised the endowment funds for the Beecher Chair (in part through patent royalties from nitric oxide) on the occasion of the 40th anniversary of Dr. Beecher's major work, “Ethics and Clinical Research.” which appeared in 1966 in an 8-page article of the New England Journal of Medicine and is reproduced in this volume. Though anesthesiologists may remember Beecher's other major writings on the placebo effect of surgery, theories of pain and pain management, and the subjective nature of pain as detailed in other chapters of this volume, his contributions to the unknown field of bioethics in medicine, human subject research, the doctrine of informed consent in medicine and American health law, and the subsequent creation of the Belmont Commission to develop a national regulatory policy of human subject protection for research funded by United States governmental agencies, are all thoughtfully outlined.
This third portion covers previously unknown materials of how Beecher came to be involved in developing and implementing his seminal papers in human subject protection in medical research and the organization of a Harvard Medical School committee culminating in a 1968 JAMA article, “Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death.” As Lowenstein explains, Beecher and the committee were soon accused of creating a mechanism to facilitate the acquisition of usable human organs for transplantation. Public and media arguments notwithstanding, the concept of death of the whole brain survives virtually intact 40 years later and was adopted as a definition of death by the President's Commission on Bioethics in the 1980s as well as state statutes defining death. One wonders how Beecher would react to today's national policies for obtaining organs for transplantation from seriously brain injured “but not brain dead individuals” for the Donation after Cardiac Death (DCD) protocols recently authorized in the United States. Early concerns on this issue were already part of professional discussion as far back as the early 1940s, as Lowenstein details.
Friedenfeld's chapter reviewing Beecher's private papers in historical detail concerning “Ethics and Clinical Research” provides important new material that should become mandatory readings for integrated ethics education for medical students, residents, and all practitioners of the healing arts. Basic bioethics curricula in universities will be enriched by this “inside the medical profession and its insular culture” both in the 1960s and even more so today as medicine moves from an exclusive focus on care of the individual to care of whole populations. Were “Harry” alive today, he might be momentarily taken aback by how the simple doctrine of informed consent to human experimentation has become so much broader and complex in the world of patients, health care professionals, and the larger society. Beecher hoped to get the medical profession quietly and internally to adopt standards for human subject protection without public disclosure. In this hope he did not succeed and disclosure and transparency in human subject research may have swung too far in the opposite direction in the eyes of some contemporary researchers.
For young people beginning professional careers today, reading this book may help to understand how Beecher transformed an early medical specialty into what anesthesia has become today. May they all learn from the lessons of their forbears so as not to repeat some of the ethical transgressions on their patients in the future.
Michael A. Rie, MD
Associate Professor of Anesthesiology
Department of Anesthesiology/Critical Care
Associate Scholar in Ethics
University of Kentucky College of Medicine