The accompanying articles by Zenilman1 and Lombardo2 describe the Guatemalan sexually transmitted disease (STD) studies and provide some historical and ethical context. What I write is a personal opinion with a focus on what reaction we should have to the role Thomas Parran played in these studies. The focus is on Parran because he has been a hero within the STD community. He is considered the founder of modern STD control in the United States and forced our nation to openly discuss and confront the problems and challenges STDs present. The Thomas Parran Award is given annually by the American Sexually Transmitted Diseases Association (ASTDA) to a member for long and distinguished contributions in the field of STD research and prevention. It is an honor for the recipient and commemorates Parran’s achievements.
However, the revelations concerning human experimentation with a variety of sexually transmitted agents, while Parran was Surgeon General, raise questions. Parran himself was not personally involved in performing this research. However, Parran, as the leading scientist and senior administrative officer, was aware of these projects and was noted in the correspondence to be a strong supporter of them. The most odious of the projects is the one performed by Cutler in Guatemala in 1946 to 1948, when 1308 human subjects were intentionally exposed to agents of STD, without their knowledge.3(p6) The correspondence files and study data were deposited by Cutler in an archive at the University of Pittsburgh and only uncovered in 2003.4 To read some of Cutler’s notes detailing the experiments as they were performed is, to put it politely, a stomach-turning experience. The incredible inhumanity of these actions and the deceit involved are absolutely mind boggling. However, as noted, Parran himself was not physically involved, yet he was knowledgeable. One of the more disconcerting aspects is that Cutler was not a rogue scientist; his experiments received full-fledged support from the relevant scientific community. Syphilis was the central subject, and there were important questions. Penicillin had just been introduced. How was it best used? Serologic diagnosis was unreliable. Studying the serologic response after a defined exposure could improve diagnosis, and there were patriotic pressures: the country was still in a wartime mood, and syphilis had been an important cause of manpower loss for the Army. Certainly, all important issues but the lengths to which some scientists went in search of scientific “truth” are totally unacceptable.
When the National Institutes of Health Syphilis Study section approved the project in February 1946, it was approved “for the Guatemala study dealing with experimental transmission of syphilis to human volunteers.”3(p31) I would like to focus on the last word; volunteers…the issue of consent in the Guatemala experiments. As you might expect, these experiments have been the subject of much heated discussion at STD meetings the past few years. When lack of informed consent is raised as a criticism, there is typically a counterargument that says we must view what happened in 1946 in an appropriate historical context and that rules regarding informed consent were not well defined in 1946. I reject this argument. It is not “presentism” (judging the past based on our present perspective and values) to raise the issue because, by 1946, informed consent was well discussed. Certainly, during the Nuremburg trials, informed consent figured prominently. The second trial known as the “Doctor’s Trial” (December 1946–August 1947) had in its charges “…to perform medical experiments upon concentration camp inmates, and other living human subjects, without their consent….”5
In our context, the major question is this: what was the attitude toward informed consent during the Guatemala studies (beyond the obvious fact that none was obtained)? Of particular relevance is that informed consent, specifically in the context of STDs, was accepted by the very same researchers who ignored it in Guatemala. There had been earlier experiments infecting human subjects with STD agents. One notable project, performed by many of the same investigators between 1943 and 1945, was a study of experimental gonococcal urethritis at a U.S. Federal prison in Terre Haute, Indiana.
We know from this project that Parran was aware of issues of human consent. He was at first opposed to the Terre Haute project, but when finally convinced it was worthwhile, he endorsed it with the proviso that appropriate human consent had to be obtained. In 1942, Parran wrote a letter in support of the human infection experiments, saying that such experiments are “justifiable if the human subjects are selected on a voluntary basis.”3(p17) Also, consent is prominently discussed on page 3 of the study publication.6 Thus, 4 years before the Guatemala project, Parran was insisting that a subject’s consent must be obtained before experimental infection. There are no such concerns expressed anywhere in the files about the Guatemala project.
There is an implication of prejudice here: consent is required for human experimentation (even for those who were imprisoned) in the United States, but it is not necessary for human experimentation in Guatemala where all experiments were performed, as far as we know, without the knowledge of the subjects.
Parran had to be aware of this. The President of the United States, Harry Truman, in 1945, received a sign “The buck stops here” that was placed prominently on his desk during his tenure in office. When it came to the STD infections of human subjects being done in an unethical manner, the buck stopped with Parran. He was not unknowing. He knew what was planned, and he followed the progress of the studies. All these were done at a time when failure to obtain consent was already acknowledged as wrong. This single point of informed consent is enough to make me want to see Parran’s name removed from the ASTDA Lifetime Achievement Award.
A note of irony here. Decades earlier, another giant of the STD field had had his reputation damaged for inoculating subjects with syphilitic serum “without having ascertained the consent of these persons or their legal representatives.”7 In 1892, Albert Neisser (discoverer of the gonococcus) had given the serum to 4 prostitutes, hoping it would be a prophylactic immunization. After a trial in 1900, he was fined 400 marks, and ethical guidelines for research on humans were established in Prussia that prohibited research if “the person in question is a minor or not fully competent on other grounds” or “the person concerned has not declared unequivocally that he consents to the intervention.”8
Thomas Parran’s name was placed on our award to honor him for his achievements, and now, we must acknowledge some very significant failings. His legacy must include both.
A personal aside. I received the Parran Award more than 20 years ago. I remember at the time, in my acceptance talk, remarking as to what a high it was to receive the award. I was pleased that my peers had recognized my contributions and honored to have my name placed next to Parran’s. Today, I’m still proud that I was selected for this achievement award by the ASTDA, but pride in seeing my name next to Parran’s…not so much!
We do not need an award with an asterisk. I do not want to see us spend time explaining why we are honoring him, with annual qualifiers reflecting what we know of these abhorrent human experimental studies. The question before us is whether or not we should remove Thomas Parran’s name from the ASTDA award.
My vote is, Parran’s name goes.
1. Zenilman J. The Guatemala sexually transmitted disease studies: What happened. Sex Transm Dis 2013; 40: 277–279.
2. Lombardo PA. When heroes stumble. Sex Transm Dis 2013; 40: 280.
3. United States Presidential Commission for the Study of Bioethical Issues. “Ethically Impossible” STD Research in Guatemala from 1946 to 1948. Washington: The Commission, 2011: 6. Available at: http://bioethics.gov/cms/sites/default/files/Ethically-Impossible_PCSBI.pdf
. Accessed October 30, 2012.
4. CDC Records of Dr. John C. Cutler. National Archives, Atlanta, GA. Available at: http://www.archives.gov/research/health/cdc-cutler-records/
. Accessed October 30, 2012.
6. Mahoney JF, van Slyke CJ, Cutler JC, et al.. Experimental gonococcic urethritis in human volunteers. Am J Syph Gonorrhea Vener Dis 1946; 30: 1–39.
7. Benedek TG. Albert L. Neisser (1855–1916), Microbiologist and venereologist. Available at: http://www.antimicrobe.org/h04c.files/history/Neisser.pdf
. Accessed October 30, 2012.
8. Schneider WH. The establishment of institutional review boards in the U.S. Background history. Available at: http://www.iupui.edu/˜histwhs/G504.dir/irbhist.html
. Accessed October 30, 2012.