In the 1914 case of Schloendorff v. Society of New York Hospital, Justice Cardozo of the New York Court of Appeals declared that “Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages.” These words planted the seed for the informed consent doctrine, which is the right for a patient to evaluate medical options knowledgeably and to exercise autonomy in the decision-making process. The goal of this doctrine is to “protect patients from the imbalance of knowledge within the physician-patient relationship” by allowing the patient to determine which operations doctors can and cannot perform on his body. Though nowadays doctors are expected to notify patients of the details and risks that a procedure entails, medical history demonstrates that this was not always the case. Throughout the 19th century, American medicine operated under a model of beneficence. According to Jonathan Will, doctor of bioethics and law, this model prioritized doctors’ discretion over patients’ preferences and encouraged physicians to deceive patients and withhold information doctors perceived as “detrimental to the patient’s prognosis.” Despite doctors’ widespread use of beneficence, Americans were aware, as early as 1914 from the Schloendorff case, of every patient’s right to permit or refuse certain bodily operations. Why then did doctors commit such heinous acts of deception and mistreatment in instances like the 1927 case of Buck v. Bell and the forty-year-long Tuskegee Study of Untreated Syphilis? We cannot attribute the atrocities of America’s medical history solely to Will’s notion of medical beneficence. However, we can more thoroughly comprehend the behavior of the Tuskegee doctors and the Progressive Era eugenicists, by viewing their actions as the product of beneficence, medical education, and social attitudes of the 20th century, all of which shaped their skewed perceptions of morality. Because these three factors taught members of the medical field that concern for the common good trumped the value of individual rights, physicians’ actions often clashed with modern standards of acceptable conduct.
Though we view doctors’ actions during the Progressive Era as questionable today, the public had faith in their abilities and discretion at the time because of the medical schooling they had completed. The educational background of many southern physicians fostered a mutual understanding of a “doctor knows best” mentality. Perhaps the most notorious illustration of this outlook is the Tuskegee Study of Untreated Syphilis, a 40-year-long experiment that began in 1932 and sought to observe the natural course of syphilis in a group of black males in Alabama (Brandt 18). Consistent with the beneficence model, the Tuskegee doctors wove benevolent deception throughout their interactions with the subjects, believing it was in the patients’ best interests to know as little detail as possible about the kind of “special treatment” they were receiving. As one survivor of the study, Mr. Pollard, stated, he and the other subjects assumed the doctors were simply trying to cure their “bad blood”. However, the doctors never specified exactly what “bad blood” meant. Such ambiguity was necessary to execute the true objective of the experiment, which was to confirm the doctors’ belief that disease susceptibility varied from race to race. This notion stemmed from medical education of the 1900s, as the architects of the Tuskegee Study graduated from the University of Virginia Medical School. This school was renowned for its curriculum of “racial medicine,” which taught students that racial groups differed in their likelihood of contracting certain diseases. Because this belief in race-based medicine was taught in university courses, it was largely perceived as fact, rather than prejudice. Not only did most of the doctors of the study graduate from this medical school, but they were also members of the United States Public Health Service, a federal organization whose purpose was to eliminate disease from the American population. The doctors’ national-level positions were so effective in influencing the public to regard them as knowledgeable figures of authority that even professional communities of colored people did not perceive them as enemies. Consequently, patients did whatever doctors instructed them to do without question. Therefore, in the context of the 1930s, previous medical training seemed to justify doctors’ use of patient deception and ambiguity.
Besides the southern doctors’ training in race-based medicine, the prevalent racist sentiments of the 20th century added kindling to the fire of patient and subject mistreatment. For instance, many southern doctors of the 1900s asserted that all blacks were promiscuous, unintelligent, poor, and both morally and physically dirty, all of which contributed to their propensity to disease, crime, and degeneracy. This harsh stereotype gave rise to the belief that the black race would not survive in America’s Darwinian society and was doomed to extinction, unsalvageable by education or philanthropy. These racist attitudes toward blacks shaped the Tuskegee doctors’ treatment of the patients “simply as subjects in a ‘study,’ not as human beings.” In other words, the physicians did not believe the black population deserved equal treatment, as that was reserved only for those they considered to be human to the fullest extent of the word. Hence, from the doctors’ perspectives, the social context of racism legitimized their controversial behavior at the time.
Similarly, pairing prejudice with medical beneficence would more thoroughly explain eugenicists’ mistreatment of individuals than beneficence alone could. Extending from the racism of the Tuskegee doctors, Progressive Era eugenicists also opposed the proliferation of the black race and any other group of people deemed “unfit” for reproduction. They feared the spread of any types of traits that could potentially taint the genetic makeup of the American people. One eugenicist physician remarked, “Time and time again the feebleminded individual has been pointed out as a menace to the mental stability of the future generations of this country. These unfortunates manifest a propensity for begetting numerous offspring, without responsibility for the present or regard for the future.” Because eugenicists insisted on perfecting the genetic makeup of mankind, they strongly advocated the sterilization of prostitutes, alcoholics, criminals, the impoverished, the deaf, the blind, those with mental disabilities or physical deformities, and others who possessed undesirable characteristics. Given that eugenicists lacked sound proof that such traits were hereditary and harmful to the future of America, it would not be unreasonable to say that racism and prejudice, not scientific evidence, was the driving force for sterilization initiatives. Thus, the subjective attitudes of the early 1900s are another factor critical to understanding the actions of Progressive Era eugenicists.
As for the political implications of those social attitudes, human experimentation and sterilization would not have gained so much federal support had national public health organizations not been dominated by advocates of race-based medicine and eugenic theory. In the notorious 1927 Supreme Court case of Buck v. Bell, Justice Oliver Wendell Holmes upheld the Virginia sterilization bill, indicating the powerful influence that eugenics rationale had upon sectors of the federal government. But, the upholding itself was not enough for Justice Holmes, who uttered the infamous phrase, “Three generations of imbeciles are enough” when referring to client Carrie Buck’s alleged lineage of mental disability. His use of such charged language indicates that eugenics theory significantly impacted his decision to legalize coercive state intervention in sterilization cases. This institutionalization of eugenics succeeded because graduates from the University of Virginia Medical School dominated executive roles in United States Public Health Service (USPHS), a federal public health organization. The tight bond between these two establishments “assured a continuity of personnel trained within a similar institutional and social culture, and ensured a commonality of belief about African Americans, sexually transmitted disease, and public health.” In other words, doctors trained at the University of Virginia later assumed federal positions in the USPHS, allowing for the perpetuation of racial medicine, prejudiced sentiments, and eugenics principles in experiments like the Tuskegee Study and Buck v. Bell. The resulting “dynasty” of Tuskegee medical professionals parallels the alleged “reign of doctors” involved in eugenics and sterilization. Ultimately, the lessons in racial medicine taught at the University of Virginia in conjunction with the widespread racism of the Progressive Era led to an institutionalization of eugenics beliefs that permeated federal infrastructure.
Considering the fact that public health advocates and eugenicists shared the common goal of maximizing benefits for the whole of society, eugenics was not entirely “bad.” The idea that public welfare overrides individual concerns serves as the foundational underpinning for both public health initiatives and eugenics. At the time of the Progressive Era, it was not unheard of for physicians to advocate “appropriate and kindly segregation” to “weed out” morally, physically, and mentally impaired individuals from civilization; such individuals posed a threat to society because they could pass on their defects to successive generations. Dr. Woods Hutchinson, who spoke in 1912 before the American Public Health Association, even proposed performing careful examinations on children as young as three years old and isolating the flawed ones in a “special environment.” Similarly, the notion of sterilization exemplifies this prioritization of “the good of society” because it seeks to eliminate defective members of society in order to improve the human germ plasm. With such an optimistically phrased objective, sterilization became a popular practice of the early 1900s. In fact, eugenics and public health shared common methods in disease prevention, which included the following: segregation of mentally impaired individuals in institutions, which paralleled quarantine of diseased persons; sterilization as an elimination of disease-causing agents and as a mode of inducing infertility; immigration restrictions to prevent the influx of contaminated or genetically defective foreigners. Through this sharing of techniques, public health workers and eugenicists established a common “cultural ethic” that promoted the rights of the masses over those of the individual. For all of these reasons, eugenics became virtually synonymous with public health as “eugenics meant not just having good genes but also being a good parent, raising good children, and promoting good health for future generations.” Though we are accustomed to classifying eugenics as strictly “bad” and public health as generally “good,” a comparison of their purposes and approaches reveals commonly-overlooked similarities that demonstrate why doctors’ disreputable behaviors were considered acceptable in the context of the 20th century.
However, critics of Buck v. Bell and of sterilization in general, would disagree with the assertion that eugenics was not rooted in evil. Take, for instance, Buck v. Bell Attorney Irving Whitehead, who proclaimed sterilization to be a recipe for tyranny. He believed this because state standards of sterilization had never been firmly established during the Progressive Era, so there was a lingering fear that eugenicists and doctors could wield a subjective, unchecked power to sterilize individuals. While Whitehead’s fear seems completely rational from a modern stance, those who support him without question most likely have not considered his viewpoint in the context of the 1900s, a time during which doctors were entrusted with great power in accordance with the beneficence model. As omniscient professionals, it only seemed fitting that physicians be endowed with virtually absolute authority. Other critics of eugenics include people like American historian and evolutionary biologist Stephen Jay Gould, who labeled sterilization as “a procedure of such dubious morality.” Gould gave this label upon finding that Carrie Buck’s daughter, Vivian, earned average grades in school, evidence that would suggest that she was not the mentally deficient girl that eugenicists made her out to be. Still, none could be sure if Vivian’s mental intelligence was “normal” due to a) her unresponsive nature in infanthood, and b) her mother and grandmother’s history of extremely poor IQ scores. But, as previously stated, eugenicists and doctors acted on their suspicions because they were trained in racial medicine and then expected to apply those learnings in a manner that benefitted the bulk of society, even if that meant forfeiting the welfare of the individual. Consequently, the claims of critics like Whitehead and Gould cannot be fully trusted because they may not acknowledge all the circumstances of the debate at hand.
Considering the degree to which racism and education influenced physicians and eugenicists of the Progressive Era, the beneficence model does not adequately account for the cases of patient injustice at the time. During the early 1900s, doctors faced with the challenge of serving either in the best interests of patients or of collective society often sided with the latter. The doctors’ educational background in racial medicine as well as prejudiced sentiments made it all the more difficult to discern scientifically-based actions from expressions of mere opinion. Nonetheless, racial medicine and eugenics resounded enough to pervade federal law and was further legitimated by its similarities to tenets of public health. As a result, the perspectives of doctors and eugenicists active in cases like the Tuskegee Study and Buck v. Bell tended to be myopic. But, if such rampant racism, eugenics theory, and beneficent mentality are not ubiquitous today, how is this relevant to the field of modern medicine? The answer lies in the lessons it offers about crossing into the gray areas of medical morality, such as genetic engineering and embryonic manipulation. Maintaining ethics in medicine and public health is like holding a stack of china; the tower of dishes teeters and with one misstep can easily shatter into a million pieces. What we are left with is a mess difficult to clean and an incident too impressive to forget, as are the faults of America’s past. And, though we cannot repair said faults, we can at least attempt to better understand the motivations of the fault-makers by evaluating their social contexts. Then, we can refine current methods accordingly to help prevent similar controversial blunders from recurring. In our hands we hold the precious plates of America’s future in public health, and we must handle them with care.
1. Will, Jonathan A, “A Brief Historical and Theoretical Perspective On Patient Autonomy and Medical Decision Making: Part II: The Autonomy Model,” Chest 139, no. 6 (2011):1493.
2. Will, “Part II: Autonomy,” 1493.
3. Will, “Part II: Autonomy,” 1495.
4. Will, Jonathan A, “A Brief Historical and Theoretical Perspective on Patient Autonomy and Medical Decision Making: Part I: The Beneficence Model,” Chest 139, no. 3 (2011): 669.
5. Brandt, Allan M, “Racism and Research: The Case of the Tuskegee Syphilis Study,” in Tuskegee’s Truths: Rethinking the Tuskegee Syphilis Study, ed. Susan M. Reverby (Chapel Hill: University of North Carolina Press, 2000), 18.
6. Will, “Part I: Beneficence,” 670.
7. “Testimony by Four Survivors from the United States Senate Hearings on Human Experimentation, 1973,” in Tuskegee’s Truths: Rethinking the Tuskegee Syphilis Study, ed. Susan M. Reverby (Chapel Hill: University North Carolina Press, 2000), 137–138.
8. Brandt, “Racism,” 18.
9. Paul A. Lombardo and Gregory M. Dorr, “Eugenics, Medical Education, and the Public Health Service: Another Perspective on the Tuskegee Syphilis Experiment,” Bulletin of the History of Medicine 80, no. 2 (2006): 292.
10. Lombardo and Dorr, “Eugenics,” 292.
11. Lombardo and Dorr, “Eugenics,” 315.
12. Allen, L.C, “The Negro Health Problem,” American Journal of Public Health 5 (1915): 203.
13. Brandt, “Racism,” 16.
14. Lombardo and Dorr, “Eugenics,” 295.
15. Ravenel, M. P, “Evolution and Preventive Medicine,” American Journal of Public Health 14 (1924): 1016.
16. Hutchinson, Woods, “The Importance of Negative Eugenics Or the Prevention of Ill-Bornness,” American Journal of Public Health 3 (1913): 241.
17. U.S. Supreme Court, Buck v. Bell, 1927, 274th ed, Vol. 200, 5.
18. U.S. Supreme Court, Buck v. Bell, 5.
19. Lombardo and Dorr, “Eugenics,” 304.
20. Lombardo and Dorr, “Eugenics,” 306; U.S. Supreme Court, Buck v. Bell, 2.
21. Hutchinson, “Negative Eugenics,” 242.
22. Hutchinson, “Negative Eugenics,” 240.
23. Pernick, Martin S, “Eugenics and Public Health in American History,” American Journal of Public Health 87 (1997): 1769.
24. Lombardo and Dorr, “Eugenics,” 296.
25. Pernick, “Eugenics and Public Health,” 1769.
26. U.S. Supreme Court, Buck v. Bell, 2.
27. U.S. Supreme Court, Buck v. Bell, 2.
28. Gould, Stephen Jay, “Carrie Buck’s daughter: a popular, quasi-scientific idea can be a powerful tool for injustice. (This View Of Life),” Natural History 111, no. 6 (July-August 2002): 6.
29. Gould, “Carrie Buck’s Daughter,” 3–5.
Allen, L. C. “The Negro Health Problem.” American Journal of Public Health 5 (1915): 194–203.
Brandt, Allan M. “Racism and Research: The Case of the Tuskegee Syphilis Study.” In Tuskegee’s Truths: Rethinking the Tuskegee Syphilis Study, edited by Susan M. Reverby, 15–33. Chapel Hill: University North Carolina Press, 2000.
U.S. Supreme Court. Buck v. Bell. 274th ed. Vol. 200, 1927.
Gould, Stephen Jay. “Carrie Buck’s daughter: a popular, quasi-scientific idea can be a powerful tool for injustice. (This View Of Life).” Natural History 111, no. 6 (July-August 2002): 3–6.
Hutchinson, Woods. “The Importance of Negative Eugenics Or the Prevention of Ill-Bornness.” American Journal of Public Health 3 (1913): 238–242.
Lombardo, Paul A. and Gregory M. Dorr. “Eugenics, Medical Education, and the Public Health Service: Another Perspective on the Tuskegee Syphilis Experiment.” Bulletin of the History of Medicine 80, no. 2 (2006): 291–316.
Pernick, Martin S. “Eugenics and Public Health in American History.” American Journal of Public Health 87 (1997): 1767–1772.
Ravenel, M. P. “Evolution and Preventive Medicine.” American Journal of Public Health 14 (1924): 1016–1019.
“Testimony by Four Survivors from the United States Senate Hearings on Human Experimentation, 1973.” In Tuskegee’s Truths: Rethinking the Tuskegee Syphilis Study, edited by Susan M. Reverby, 136–149. Chapel Hill: University of North Carolina Press, 2000.
Will, Jonathan A. “A Brief Historical and Theoretical Perspective on Patient Autonomy and Medical Decision Making: Part I: The Beneficence Model.” Chest 139, no. 3 (2011): 669–673.
Will, Jonathan A. “A Brief Historical and Theoretical Perspective On Patient Autonomy And Medical Decision Making: Part Ii: The Autonomy Model.” Chest 139, no. 6 (2011):1491–1497.