Background
A few weeks ago my HLTH 410 class discussed several infamous clinical trials that were conducted on human subjects, one of which was the Bowery Series. The Bowery Series was a set of experiments performed on homeless, alcoholic men from New York’s skid row from 1951-1966. More than twelve hundred participants in the Bowery Series were subjected to perineal biopsies of the prostate gland, and, if these tissues samples proved to be cancerous, prostatectomies, surgical castrations, and estrogen treatments. Although some of the aforementioned treatments are now viewed as standard, not one of them was common or even established at the time of the series. For compensation, these men were provided with a clean bed and three meals for several days as well as free “treatment” should they be diagnosed as having prostate cancer (treatment being incredibly painful, invasive procedures like prostatectomies that had not been proven to work).
Conflict:
The basic moral principles of autonomy and non-maleficence are clearly violated by the researchers of the Bowery Series. The true dilemma arises when one considers whether non-maleficence towards the Bowery Series participants should be placed above the potential beneficence of future prostate cancer patients. In other words, is subjecting homeless, alcoholic men to radical, painful, and invasive surgeries morally justified if it could potentially lead to better outcomes for men with prostate cancer?
Discussion
As outlined in Tom Beauchamp and Jim Childress’ Principles of Biomedical Ethics, humans share basic moral principles of justice, non-maleficence, beneficence, and autonomy (Beauchamp and Childress 2009). In the case of the Bowery Series, the principles of autonomy and non-maleficence were violated. Earlier this semester, we discussed how society usually grants vulnerable populations extra protections and obligations to keep them in. However, the vulnerable population in Bowery Series was not protected. Instead, they were exploited. As stated by Aronowitz, the Bowery experiments were conducted on homeless, alcoholic men from New York’s skid row because they could not conduct them on people with more power. Due to their position in society and the moral implications of alcoholism, these men were seen as having lower moral status and thus, less autonomy, than wealthier individuals at a nearby Presbyterian hospital (Aronowitz 2014).
Participants’ autonomy was further violated and undermined through manipulation by the Bowery Series’ researchers’ recruitment methods. Informed consent requires that the patient has given his or her permission for the intervention be taken, that the patient’s decision be voluntary, that the patient understands what he or she is consenting to. Although it is unknown as to whether or not some kind of consent was obtained from the subjects of the Bowery studies, it can be inferred that the Bowery Series research subjects’ decisions to participate in the study was neither voluntary nor informed. In fact, the Bowery series recruiters coerced, or at the very least manipulated their research subjects. The argument could be made that each party was getting what they wanted (the researchers, subjects to perform surgeries on and the homeless men, food and shelter). However, by offering homeless men food and shelter in return for their participation (two resources that this vulnerable population lacked but needed to survive) the researchers really only offered these men only one “choice”: join the study. Since these were relatively new procedures with unknown consequences, it is also fair to assume that the decision to participate in the study was not an informed decision. Additionally, consenting to one thing (i.e. prostatectomy) does not consent you to everything that is entailed with it (incontinence, impotence, etc.).
It is difficult to discern whether or not the researchers could be considered beneficent for providing free cancer treatment to their research subjects. The researchers very well might have been more concerned with answering questions pertaining to the prevention, diagnosis, and treatment of prostate cancer than the good of their research subjects. And yes, the procedures were incredibly painful and invasive and many resulted in complications. However, it is hard to imagine that these researchers didn’t at least believe that these procedures might benefit the homeless, alcoholic men that presented with prostate cancer. Additionally, these researchers surely wanted to benefit future patients with prostate cancer.
I recognize that medical research, especially medical research pertaining to the efficacy of invasive procedures, could not be advanced without violating the principle of non-maleficence to some degree. However, in this case I believe that the researchers’ obligations to protect a vulnerable population by preventing harm and increased risk (non-maleficence) should have taken precedence over their obligations to be beneficent (especially considering that they did not know whether or not the procedures would benefit future patients).
This case is very similar to “Well & Good: A Case Study Approach to Health Care Ethics” Case 3.1 that we recently discussed in class. Just as the director of the Alzheimer’s study should take extra care to ensure that the Alzheimer’s patients who are mentally incapable of giving informed consent should are not harmed (Thomas and Waluchow 2014), so too should the Bowery Series’ researchers have granted the homeless men extra protections instead of exploiting them. These researchers should have obtained informed consent from volunteers, not coerced homeless men into participating in their study.
Works Cited:
Aronowitz, Robert. “From Skid Row to Main Street: The Bowery Series and the Transformation of Prostate Cancer, 1951-1966.” Bulletin of the History of Medicine 88.2 (2014): 287–318. PubMed. Web.
Beauchamp, Tom L, and James F. Childress. Principles of Biomedical Ethics. New York: Oxford University Press, 2009. Print.
Thomas, John E., and Wilfrid J. Waluchow. Well and Good: A Case Study Approach to Health Care Ethics. 4th ed. Toronto: Broadview, 2014. Print.
I am familiar with this case and think you have done a great job analyzing its ethical issues. To play devils advocate, I want to discuss how these researchers were acting under the principle of beneficence. When you read the original case, Dr. Hudson was genuinely trying to redefine how prostate cancer was thought of in the mind of the public. Prior to this research, this diagnosis would be considered a death sentence and by the time the diagnosis was made it would be to late to cure. Dr. Hudson also claims that he thought of these patients as friends and wanted what was best for them. It is hard to place blame in this case because it happened prior to standardized bioethical principles. Dr. Hudson was using his best judgement and thought whole heartedly that these procedures would be benefitting these men more than it would harm them. This study also gave these men standard medical care, which they did not have access to prior. In Dr. Hudson’s eyes, he was acting beneficently. We also must consider the lasting impact this study has had on treatment and diagnosis of prostate cancer. It has led to mass biopsies, screening asymptomatic people (so they can catch the cancer before it is too late), and an overall change in attitudes towards prostate cancer. Dr. Hudson transformed prostate cancer from a death sentence to a curable disease.
Excellent job of explaining the case. I am also in your 410 course. In class, we discussed who is responsible for doing what is best for the patient? I believe that the doctor or researcher is not fully responsible for determining what is best for the patient. I believe that society has to take a larger responsibility, especially for vulnerable populations. In research things get more complicated because you have to balance the good for the patient against the greater good. I do not think it is fair to place all the blame on Dr. Hudson because it seems that he truly thought that he was doing what was best for these men and he came up with a life saving treatment for many men to come. I am torn in who is to blame because i know that there may have been societal forces that pushed these men into homelessness and made them vulnerable, but at the same time that does not give researches the right to take advantage of them. But, Dr. Hudson did provide food and shelter, which can be considered a basic form of treatment that the public did not offer to them. I want to compare this to the Tuskegee case, but this case is different because Dr. Hudson actually thought he was doing for the men, whereas in the Tuskegee case the doctors actively did nothing for the patients.
Having never heard of this case before, I think you did a great job explaining the situation. What stood out to me the most about this case was the discussion on autonomy. Having homeless, alcoholic men (“patients”) be subject to treatment described as painful and invasive is bad enough, especially if many of these treatments were proven ineffective. However, reading that these participants’ decisions were neither voluntary nor informed is exasperating. One of the obligations of researchers is to inform their participants of exactly what to expect in participating in an experiment. In this case, according to Elise, it can be said that the recruiters coerced/manipulated the research subjects. I agree with Elise’s interpretation that although these homeless men were offered food and shelter, they were not given a “choice” – they had one option: to participate or continue to suffer. In such extreme situations, I believe researchers have an even greater obligation to their participants and should be mandated to obtain concrete informed consent.