DISCLAIMER The following is a staff memorandum or other working document prepared for the members of the Advisory Committee on Human Radiation Experiments. It should not be construed as representing the final conclusions of fact or interpretation of the issues. All staff memoranda are subject to revision based on further information and analysis. For conclusions and recommendations of the Advisory Committee, readers are advised to consult the Final Report to be published in 1995. TAB G -- DRAFT -- FOR DISCUSSION PURPOSES-- TO: Members of the Advisory Committee on Human Radiation Experiments FROM: Advisory Committee DATE: January 13, 1995 RE: Ethics Oral History Project--Preliminary Findings I. INTRODUCTION Over the past four months, staff working on the Ethics Oral History Project have interviewed twelve physicians who participated in biomedical research during the period 1944-1974 in order to gain insight into the ethical climate of human biomedical experimentation during the Cold War era (see Appendix A). In addition, staff interviewed two individuals who were not themselves biomedical scientists but who were intimately involved with ethical and legal aspects of human experimentation in their roles as administrators at the National Institutes of Health (NIH) during the 1950's. Prior to selecting these individuals, staff solicited suggestions from a panel of expert consultants (see Appendix B). The twelve physicians interviewed were drawn from a variety of disciplines, including radiology, infectious diseases, pharmacology, and hematology. They have also worked in several different institutional settings throughout their careers, including government facilities (both military and non-military), universities, and pharmaceutical companies, and have conducted experiments with a variety of subject populations. The individuals who were chosen were viewed to be leaders in their disciplines or, through their writings, had shown a particular interest in and sensitivity to the ethical dimensions of biomedical experimentation. Some of our interviewees were clearly pioneers in the field of research ethics, while others confronted ethical issues in the course of their research but were not themselves contributors to the field of research ethics. Although we realized that selecting those with special interest in these issues could potentially skew our findings, we believed that such individuals could offer valuable insight not only on their own experiences but also on the attitudes of their colleagues who might have had less concern about the ethical aspects of human experimentation. Certain common denominators are reflected in the careers of those interviewed as well. Most of the subjects graduated from medical school between 1931 and 1947, with one graduating in 1955. Most completed some form of military service. All are men, and all were born and raised in the United States. These similarities themselves reflect the more homogeneous composition of the medical 1 profession as it existed during the period under study. II. PRELIMINARY FINDINGS On certain issues, the responses of those interviewed were uniform. None of the physicians interviewed recalled receiving formal training in medical ethics, including ethical issues in human experimentation, at any time during his medical training. Further, with two exceptions, none recalled any formal institutional review of research protocols being required prior to the early 1960's. The two exceptions recalled were the Armed Forces Epidemiological Board (AFEB), which was charged with reviewing infectious disease research using healthy subjects, and the NIH Clinical Center, which conducted research on both healthy subjects and patients. Our findings also, for the most part, confirmed the claim of some historians that the Nuremberg Code had little salience for American biomedical researchers. Few recalled any discussion relating to the Code at the time of its issuance, although they certainly remembered the atrocities of the Nazi doctors and the war crimes trials in Nuremberg. More differences were found concerning the need to inform research subjects as well as the need to seek their consent. Some asserted that doctors did not tell their subjects--be they patients or healthy persons--the nature of their involvement in research during this period, while others recalled providing information to their subjects about what they were doing. It should be noted, however, that even those physicians who did recall informing subjects regarding their involvement in research did not necessarily practice what we would today consider "informed consent". In an attempt to synthesize the data collected, we have considered several preliminary "hypotheses." These preliminary hypotheses are not exclusive--as the interviews are re-read and more interviews or follow-up questions are conducted, some hypotheses may be refined or discarded and new ones proposed. Hypothesis 1: Changes in Funding and Organization of Medical Research in the Post-War Period Did Not Foster Sensitivity to the Ethical Dimensions of Human Subject Research During World War II the level of funding and organization of medical research increased dramatically. Historian David Rothman has offered an apt summary of this transformation: "a cottage industry turned into a national program." 1 [David J. Rothman, Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making, Basic Books, a Division of Harper Collins Publishers, Inc., USA, 1991, p. 30] Among the many effects of this metamorphosis was the creation of "medical investigator" as a new career track open to a relatively large number of American physicians. As with most 2 academically-oriented careers, original research and frequent publication were the foundations upon which successful careers were built. In the excitement of exploring the unknown--and with the unremitting pressure to publish--it seems that some researchers in this period lost track of the fact that their research subjects were often also patients and always still human beings. One interview subject had the following to say, based on his experiences as an administrator at the NIH Clinical Center during the 1950s (which he offered to illustrate what he clearly saw as a more general truth): One of the things you should never do if you go to the Clinical Center is get room 101, it's at the end of the hall. Room 101 was next to the laboratory and patients who had that room were often [approached]: 'hello, I'm doctor so-and-so, mind if I get some blood?' [It was] a very convenient place to be. . . . The investigators . . . forgot that these were real people. Plain simply forgot. Another interview subject offered a similar appraisal of the impact of the professional imperatives of academic medical research on the treatment of patients: Doctors who were doing research wanted to be professors, and in order to be a professor, you have to have lots of publications, so your highest priority is to conduct research and publish it. You're the doctor. Here's a patient that you want to experiment on. . . . Is it going to contribute to your research if you inform that patient? That's not in your interest. Your interest is to have that patient participate, so do you tell him or her? No. . . . because there's a conflict between informed consent and the ability to conduct research and the physicians is interested not in the patient's welfare, he's interested in his or her [own] welfare. When this researcher was questioned as to how such an attitude could be adopted by the same physicians who had taken the Hippocratic Oath, he explained: "The Hippocratic Oath was not developed for physician investigators. An investigator was a new departure in medical history in 1945, 1946." The confusion of roles between investigator and therapist was demonstrated as well by the experience of the investigator who worked at Illinois' Manteno State Hospital in the early 1940's, where investigators infected schizophrenics with malaria--both as an attempt to treat their illness through what was known as "fever therapy" and in the hope of developing a treatment for the infectious disease. He acknowledged the potential conflict of interest in such dual-purpose research: I think that [the researchers] believed that they were possibly helping these people with the fever therapy. 3 But I'm also sure thatthey were biased by the fact that they needed patients, needed subjects, to try the malaria program and that there were two competing forces in the decision making. A not very comfortable way to do business. One interview subject saw an almost inevitable progression from the vast increases in funding for medical research during the postwar years, to the sloppiness (or even hubris) of some medical researchers, and, finally, to an increased level of professional and public awareness of problems in human experimentation that began to develop in the late 1950s or early 1960s: What happened then is the volume of investigation going on by medical school academics was enormously increased. Beginning about 1948, the government began pushing money at us, and we could enlarge our staffs. We had support for laboratories, and went into it on a scale never previously done. As a result of that, I think there was so much medical investigation going on, that accidents happened, they got called to people's attention, people began thinking about this and wondering if we were totally right in doing this without consulting the patient and explaining exactly what was going on. It would be incorrect to suggest that the ethical issues confronted by medical investigators in this period were new; organized medical research in the United States dates back at least to the turn of the century. However, unprecedented levels of public funding, as well as the intellectual excitement and professional pressure that researchers experienced during this "Golden Era" of medical research, led some physicians to take liberties with patients to further research goals. Hypothesis 2: Investigators Perceived a Greater Responsibility to Inform Healthy Research Subjects and Obtain Their Consent than They Did to Inform Research Subjects Who Were Patients under Their Direct Care or Control and Obtain Their Consent One question with which we entered this project was whether investigators were more likely to inform healthy research subjects and obtain their consent, than they would in sick patients, as well as whether researchers would be more likely to conduct certain experiments on already sick patients than they would in healthy subjects. Based on these interviews, some evidence exists to support both conclusions, albeit not unequivocally. The element of "opportunism," i.e., experimenting on sick patients since they are sick anyway and available to physicians, was recounted in several interviews. One researcher, who was involved in pain management studies in post-operative patients at Harvard in the 1950's explained rather bluntly: 4 [M]ostly, I'm ashamed to say, it was as if, and I'm putting this very crudely purposely, as if you'd ordered a bunch of rats from a laboratory and you had experimental subjects available to you. They were never asked by anybody. They might have guessed they were involved in something because a young woman would come around every hour and ask them how they were and quantified their pain. . . .We never made any efforts to find out if they guessed that they were part of it. Other researchers reiterated the "opportunism" theme. One physician recalled a study he conducted in the 1940's while he was a professor at Emory University, using as subjects patients with bacterial endocarditis, a then always fatal disease. He recalled that he thought it would be interesting to use the new technique of cardiac catheterization to compare the number of bacteria in the blood at different points in circulation. In retrospect, [This is] something I wouldn't dare do now. It would do no good for the patient. They had to come to the lab and lie on a fluoroscopic table for a couple of hours, a catheter was put into the heart, a femoral needle was put in so we could get femoral arterial blood and so on. . . . All I could say at the end was that these poor people were lying there and we had nothing to offer them and it might have given them some comfort that a lot of people were paying attention to them for this one study. I don't remember ever asking their permission to do it. I did go around and see them, of course, and said we want to do a study on you in the x-ray department, we'll do it tomorrow morning, and they said yes. There was never any question. Such a thing as informed consent, that term didn't even exist at that time. . . . [I]f I were ever on a hospital ethics committee today, I wouldn't ever pass on that particular study. One radiologist recalled an experiment in which he assisted during his training on a metabolic unit at Moffett Hospital in San Francisco in 1956-57. At the time, the adrenal gland was hot stuff. ACTH [Adrenocorticotropic Hormone] had just become available and it was an important tool for exploring the function of the adrenal gland. . . This was the project I was involved in during that year, the study of adrenal function in patients with thyroid disease, both hypo- and hyperthyroid disease. So what did we do? I'd find some patients in the hospital and I'd add a little ACTH to their infusion and collect urines and measure output of urinary corticoids. . .I didn't consider it dangerous. But I didn't consider it necessary to inform them either. So far as they were concerned, this was part of their treatment. They didn't know, and no 5 one had asked me to tell them. As far as I know, informed consent was not practiced anyplace in that hospital at the time. This physician viewed the above experiment as in conformity not only with the practices of the particular hospital but also in accord with the high degree of professional autonomy and respect that was accorded to the physician in this era. In 1945, '50, the doctor. . .was king or queen. It never occurred to a doctor to ask for consent for anything. . . . People say, oh, injection with plutonium, why didn't the doctor tell the patient? Doctors weren't in the habit of telling the patients anything. They were in charge and nobody questioned their authority. Now that seems egregious. But at the time, that's the way the world was. Another investigator, who was a professor of medicine at Yale during the 1950's and '60's, recalled instances when oncologists there were overly aggressive in pursuing experimental therapies with terminal patients. [I]t's very easy to talk a terminal patient into taking that medication or to try that compound or whatever the substance is. . . .Sometimes the oncologists [got] way overenthused using it. It's very easy when you have a dying patient to say, look you're going to die. Why don't you let me try this substance on you? I don't think if they have informed consent or not it makes much difference at that point. Another investigator, who conducted research in hepatic disease beginning in the 1940's, went so far as to suggest that sick patients are a more vulnerable population than are prisoners. One of the real ludicrous aspects of talking about a prisoner being a captive, and therefore needing more protection than others, is, there's nobody more captive than a sick patient. You've got pain. You feel awful. You've got this one person who's going to help you. You do anything he says. You're a captive. You can't, especially if you're sick and dying, discharge the doctor and get another one without a great deal of trauma and possible loss of lifesaving measures. In contrast, there is some evidence from these interviews that more caution was employed and more information provided to healthy subjects, who were often referred to as "volunteers." One investigator, who conducted vaccine research with healthy subjects under the auspices of AFEB recalled that the risks of exposure to diseases such as typhus were always fully disclosed to potential healthy subjects and that their consent was obtained. Since many of these studies were conducted in other countries with non-English 6 speaking persons, the disclosure was given in the volunteer's language. This researcher stated: "If I gave someone something that could make them sick or kill them and hadn't told them, I'm a murderer." Two physicians who conducted research with prisoners stated that they obtained written permission from their subjects. One, who conducted malaria research (which required giving the disease to the prisoners) recalled that the impetus to do so came from the legal department of the University of Chicago, where he was a professor at the time. He reflected that written informed consent was not common during this period: [This was] not common at all. But we did make a serious attempt to get [written consent] and the contents were controlled entirely by the University lawyers who were almost exclusively concerned with protecting us from liability. [He] would suffer almost any imaginable and unimaginable harm, including death. And yet it would be crazy to sign it but in a sense, the authority and the prestige of the investigator often overrode the normal common sense position of the patient. The second investigator conducted research on prisoners in Lexington, Kentucky to better understand the nature of addiction. He stated that he obtained written consent from the beginning of his research in 1935. He recalled that the suggestion to do so came from a neighbor who was a lawyer. This suggestion was apparently consonant with his own sensibilities: You hate to give anybody advice and turn them loose and expose them to the possibility of harm. . . . I think caution is very important in all human relationships. The older I get, the more I realize that. I was conscious of it then. However, despite the fact that he obtained written informed consent, this researcher too appears to have shared the "opportunistic" view of some of the physicians discussed above in the patient context; indeed, in some respects he saw his subjects as patients. He stated that since these prisoners were already addicts his research was morally justifiable. The experience of the Bureau of Prisons and the experience we've had subsequently is once an addict, always an addict. You really can't contaminate them or make their any addiction any worse or any better by what you do. As a matter of fact, I think we, in some ways, helped these people. . . [they] already had this disease. Although many of those interviewed stated that healthy subjects were better informed and more cautiously treated than were patients, counterexamples were given as well. One investigator described 7 secret, army-sponsored research in which hallucinogens were administered to healthy subjects without their knowledge or consent. These experiments were carried out at Boston Psychiatric Hospital between 1952 and 1954. The idea was that we were supposed to give hallucinogens or possible hallucinogens to healthy volunteers and see if we could worm out of them secret information. And it went like this: a volunteer would be told, now we're going to ask you a lot of questions, but under no circumstances tell us your mother's maiden name or your social security number, I forget what. I refused to participate in this because it was so mindless that a psychologist did the interviewing and then we'd give them a drug and ask them a number of questions and sure enough, one of the questions was what is your mother's maiden name. Well, it was laughable in retrospect. . . . [the volunteers] weren't informed about anything. In reflecting, "not with pride" on his participation in this experiment, this investigator explained it as follows: "It wasn't that we were Nazis and said if we ask for consent we lose our subjects, it was just that we were so ethically insensitive that it never occurred to us that you ought to level with people that they were in an experiment." Counterexamples in which an effort was made to explain the risk and to obtain a patient's consent for non-therapeutic research were found as well. One investigator, a hematologist who conducted tracer studies to determine red cell turnover in rheumatoid arthritis patients at the Brigham Hospital in the early 1950's recalled how he and his colleagues decided whether to pursue a particular project: There was no oversight [committee]. Within our research group, we usually would sit down with our boss or preceptor, and talk about the type of research we were interested in, what we wished to pursue, and then we would design the study and go ahead with it. Of course it was his judgment, pretty much, and ours as well, as to whether or not things were ethical or not ethical, humane or not humane. . .we had no guidelines, although I always recall telling the patient I was going to give them a small amount of radioactivity when the studies were performed. When asked whether patients were told that the experiment had no therapeutic value, he further recalled: I think we usually told them we were interested in finding out the mechanism for anemia. This wasn't going to help them any. Would they be willing to do it? And usually 8 they would agree. I can think of a rare instance where they wouldn't. Regarding the information given concerning the use of a 59I, a radioactive tracer, he stated: "We used to tell people that that was the equivalent of maybe having an extra x-ray examination or an extra amount of radiation they might get from being in Denver, Colorado for a few months." These counterexamples indicate that it is not possible to state categorically that research with healthy subjects always was preceded by disclosure and consent while research with sick patients never was. However, certainly it can be said that sick patients under the care of a physician were more easily made the subjects of research--both potentially therapeutic and explicitly non-therapeutic--than were healthy persons. Such a finding could perhaps be predicted, since patients are more accessible and less able to distinguish between therapy and experimentation. In addition, research on patients can be more easily rationalized by the physician, since it might conceivably benefit the patient, and since the patient is receiving therapeutic treatment from the physician at the same time. This latter, "quid-pro-quo" justification seems to have been manifested particularly when class or race differences existed between doctor and patient. Discussing research in charity patients, one investigator stated, "We were taking care of them, and felt we had a right to get some return from them, since it wouldn't be in professional fees and since our taxes were paying their hospital bills." Finally, it should be noted that the physicians who described "opportunistic" experiments in patients considered their actions to constitute minimal risk to the patients. Whether greater risk would have led to greater caution and/or greater disclosure is difficult to determine from these interviews. Hypothesis 3: American Physicians in the Late 1940s and Early 1950s Were Only Dimly Aware of the Ethical Implications of the Nuremberg Medical Trial Understanding the extent to which the researchers who engaged in human radiation experimentation were and should have been cognizant of the principles of the Nuremberg Code is an important part of the Committee's task. The "should have been" question will be explored by an examination of other primary and secondary documentary sources. But this oral history project offers an important opportunity to explore the extent to which researchers were aware of Nuremberg; we questioned our interview subjects extensively on this topic. On the whole, the physicians interviewed did not view the Nuremberg Code and its dictates for human experimentation as a profound historical event heralding a new, more ethical era for biomedical research in the years immediately following its issuance. While the majority of those interviewed were generally familiar with the atrocities committed by Nazi doctors and the legal trials in Nuremberg, most of them did not recall discussing either the trial or the resulting Code with their peers at the time, or considering the Code to affect their behavior. Nor did they view its precepts as binding on U.S. 9 investigators, despite the fact that the AMA House of Delegates adopted the principle of voluntary informed consent in 1946. Those interviewed suggested several reasons why this was true. One investigator who conducted research using prisoners recalled being only dimly aware of the Nuremberg Code principles, but did not think that awareness by investigators at that time of its tenets would have changed their behavior, because "we were so convinced of the rightness of our position that I don't think we would have modified it much, depending on that Code." Other researchers stated that, regardless of whether their practices were in accord with the Nuremberg Code when it was issued, they and their colleagues did not view it as binding on them because of the ethical gulf they perceived between themselves and the Nazi doctors who were being prosecuted. Stated one, "The publicity about the kind of work they had done was often so atrocious and so unlike research going on in this country that people thought that's a mistake that happened over there with those Nazi doctors." Similarly, another reflected, "They [the Nazi doctors] were animals. They were hanged for it. . .it's a matter of magnitude. Those things that were done. . .people didn't survive those. I mean, they were vicious." A third stated, "I was aware of it, but only to the extent of what we thought the application to the ethics of the war, particularly the Germans and the Japanese. We really didn't think of it in terms of how it had any application to anything we were doing." One researcher, who worked in the field of radiology, did, however, offer a starkly different view of Nuremberg's impact: I must say that I think that one of the things that is clear from . . . the '50's and '60's was that the Nuremberg Principles were surely familiar to everyone that I came across. And that these principles, in and of themselves, formed some kind of a reasonable background whereby judgements could be made. . . . It was a part of the history of the day. . . . It [Nuremberg] was surely something, at least in the environment I was in, we were aware of and that affected the thinking of everyone who was involved in clinical investigation. But, even with this strong statement, the general sense that emerges from the whole body of interviews is that American medical researchers did not see the relevance of Nuremberg Medical Trial to their own work, at least in the late 1940s and early 1950s. The above excerpts suggest that many viewed the Nuremberg Code as a good code for barbarians, but not necessary for or applicable to them. Such a conclusion is not meant to imply that researchers who were unaware of Nuremberg operated in a moral vacuum. To the contrary, these interviews suggest that , in the absence of uniform and nationally applicable regulations, at least some researchers were influenced by their inner moral conviction, their institutional affiliation, and, less often, sanction by their medical community. 10 These influences are discussed below. One investigator, who conducted infectious disease research with healthy subjects in the 1940's under the auspices of the AFEB, asserted that informing volunteers of potential risks was a principle he derived from "having the right mother and father and knowing what's right and wrong." He stated that he learned right from wrong in his upbringing, including from his parents, his church, and his community. Therefore, the Nuremberg Code represented nothing new, he claimed, since he had long before internalized its precepts. Another researcher, who began studying addiction in prison volunteers in the 1930's, ascribed his early sensitivity to the need for written informed consent from these prisoners in part to his grounding as a "religious person" and to his decision to study ethics as an undergraduate. In addition to what might be termed "inner moral conviction," several researchers emphasized the influence of professional mentors in awakening their nascent sensitivities to the treatment of patients. A hematologist who went to medical school in the early 1940's with the intention of being a country practitioner but went on to conduct metabolic studies with radioactive tracers recalled: I don't recall ever hearing anything on doctor-patient relationships or how you should behave [during medical training]. Except from our interactions when we were in residency training with other senior residents and with our peers, we could observe the courtesies that they extended to patients, and we tried to imitate or to emulate them, but we were never given really formal training. If we were ever abrupt with a patient or negligent in any fashion, we were sometimes reprimanded and in that fashion [we] learned." When asked what would have constituted "negligent" treatment, he responded: "Not telling people what you were doing or doing something that was painful without giving them adequate instructions or something along those lines. Maybe taking them for a procedure without telling them where they were going." It should be noted, however, that these "courtesies" are quite different from, and insufficient in comparison to, what we would today view as proper informed consent. The behavior of one's mentors could lead a young investigator to withhold information from a subject as well, as previous examples illustrate. The physician who described surreptitiously administering ACTH to patients did so at the direction of his superiors, and he stated that other physicians in the hospital were aware of the experiment as well. Similarly, the investigator who recalled administering hallucinogens to healthy subjects without their knowledge of the nature of the substance was at an early point in his training and was guided by a much more senior investigator. The institutional context also appears to have influenced investigator behavior. As mentioned above, one investigator 11 working with prisoners was required to get written informed consent by the University. Another investigator recalled that his attempt to use prisoners as research subjects when he was at the University of Illinois in the 1940's was stymied by that University's legal department. Apparently influenced by negative press attention, the legal department created so many obstacles to the use of prisoners that it was easier for him to use nurses and medical students. Other institutional contexts seem to have promoted more cautious behavior as well. One investigator described a profound shift in attitude towards human experimentation when he moved from an academic position at the University of California at Los Angeles (UCLA) to the National Cancer Institute (NCI) at NIH in 1961. Whereas at UCLA there had been no formal oversight of research projects and informed consent of the patient was not required, NCI had a committee in place to review and approve protocols, and written informed consent of patients was required. Interviews with others suggests that the safeguards in place at the Clinical Center at the NIH were in the vanguard. Finally, although rare, peer pressure could prevent an investigator from overstepping the boundaries within his own discipline. One physician recalled: There was a physician in the field of hematology that used to take long needles and stick them into the portal vein and the hepatic artery and measure blood flow in patients. . . . He was subsequently censured by the Society of Hematology and his experiments were stopped. But he thought these were great experiments and I think he really felt he was making a great contribution. It should be emphasized that recollections of such instances of public sanction by those interviewed were rare. More common were recollections of research which made them uncomfortable at the time, or in retrospect. Despite such discomfort, those interviewed did not speak in opposition to the research being conducted by their peers. III. CONCLUSION Based on these interviews, some tentative conclusions may be drawn regarding the ethical milieu of medical research in the 1940's and '50's. First and foremost, this period was one of flux for the medical community. The rise in funds for research led to the development of the "physician investigator," which, as has been discussed, is a position with its own potential conflicts of interest, and, as well, its own professional agenda. This increased research occurred in the absence of an established, uniformly acknowledged code of conduct. Although undoubtedly much time will be spent by the Committee discussing whether and to what extent American investigators should be held accountable to the principles of the Nuremberg Code, these interviews demonstrate that, for the most part, they did not consider those principles to govern their conduct. 12 In the absence of an established code of conduct, other influences guided investigator behavior. Some, perhaps caught up in the excitement of research or the desire to advance their career, used patients as subjects of investigation without their knowledge or consent. Others relied on the power and prestige of their position to convince subjects to participate even when benefit was questionable or nonexistent, and even in the absence of complete information. On the other hand, some investigators drew from sources such as family, religion, or professional mentors, and concluded that it was not appropriate to use patients or volunteers as research subjects without their informed consent--although the requirements of that phrase varied among investigators. 13 Appendix A Interview Subjects (1) Herbert Abrams, M.D. Professor of Radiology at Stanford University, 1951-present. (2) John Arnold, M.D. Clinical Researcher who began career during WW II as an assistant in the malaria studies at Statesville Prison in Illinois. In 1970's, he publicly changed his mind regarding the use of prisoners as research subjects. (3) Paul Beeson, M.D.: Chairman of Department of Internal Medicine at Yale, 1952-1965. Organized one of first conferences of ethics appraising the 1964 Helsinki Declaration. (4) Thomas Chalmers, M.D.: Former Dean and President, Mount Sinai School of Medicine; consultant to Veterans Administration and Department of Defense. (5) Harry Dowling, M.D.: Clinical researcher in infectious diseases beginning prior to World War II. (6) Stuart Finch, M.D.: Head of Atom Bomb Casualty Commission; head of Clinical Investigation Committee at Yale in 1960's. (7) Clifton Himmelsbach, Clinical researcher on addiction, M.D.: beginning 1930's; studied prisoners. (8) Charles Kidd, Ph.D.: Chief, Office of Research Planning at NIH, 1949-1960. (9) Irving Ladimer, J.D., Associate director of the NIH Office S.J.D.: of Research Planning in the early 1950s; has written on legal and ethical aspects of human experimentation. (10) Louis Lasagna, M.D.: Dean, Sackler School of Graduate Biomedical Sciences; clinical pharmacologist; prolific writer on issues of public health and medical ethics. A-1 (11) Seymour Perry, M.D. Assistant Professor of Medicine at UCLA in the 1950's. Researcher, then Director, National Cancer Institute. Currently Senior Scholar for Medical Technology & Practice Patterns Institute. (12) Leonard Sagan, M.D., MPH:Associate Director in Department of Environmental Medicine, Palo Alto Medical Clinic, 1968-78; served as physician in nuclear medicine with Medical Research Branch, Division of Biology and Medicine, AEC, 1965-68. Has written widely on radiation risk assessment and health effects of radiation exposure. (13) Herman Wigodsky, M.D. Clinical pathologist who worked for Armed Forces Institute of Pathology. (14) Theodore Woodward, M.D. Was a member of the U.S.A. Typhus Fever Commission, the Commission on Epidemiological Survey, and Commission on Rickettsial Diseases, and served as President of the Armed Forces Epidemiological Board for twelve years. Organized Department of Infectious Diseases at University of Maryland School of Medicine and served as Chairman of Department of Medicine there from 1954-1981. A-2 APPENDIX B Expert Consultants On Oral History Project 1. John C. Fletcher, Ph.D. Kornfeld Professor of Biomedical Ethics Center for Biomedical Ethics University of Virginia Charlottesville, VA 2. Frederic L. Holmes, Ph.D. Chairman and Avalon Professor Section of the History of Medicine Yale University New Haven, CT 3. Albert Jonsen, Ph.D. Professor and Chairman Department of Medical History and Ethics University of Washington School of Medicine Seattle, WA 4. Robert Levine, M.D. Professor of Medicine and Chairman, Human Investigation Committee Yale University School of Medicine New Haven, CT 5. Robert J. Lifton, M.D. Professor of Psychiatry and Psychology John Jay College at the City University of New York New York, N.Y. 6. M. Susan Lindee, Ph.D. Assistant Professor Department of History and Sociology of Science University of Pennsylvania Philadelphia, PA 7. Charles Weiner, Ph.D. Professor of History of Science and Technology Massachusetts Institute of Technology Cambridge, MA B-1