Every year in my intro biology course, I try to do one discussion of bioethics. One lecture is not much, but this is a course where we try to introduce students to the history and philosophy of science, and I think it's an important issue, so I try to squeeze in a little bit. So we spend one day talking about eugenics and the Tuskegee syphilis study, and I have them read Gould's Carrie Buck's Daughter, and I try to provoke them into arguing with me, or at least questioning a few default assumptions.
This semester, though, I'm going to have them read something with some subtler concerns. I'm going to ask them to read about the invention of the modern speculum. It was surprisingly problematic.
It was designed by a doctor, James Marion Sims, who detested examining women's genitals.
Sims didn’t want to have to look at a woman’s genitals. “If there was anything I hated, it was investigating the organs of the female pelvis,” Sims wrote in the autobiography he half completed before he died. This was a time when men and women interacted in very strict, pre-determined ways. Early illustrations from medical textbooks show doctors examining women’s pelvic areas by reaching their arms up beneath the layers of skirts and feeling around, literally blindly. A doctor was specifically instructed to reassure a female patient that he was not looking at her private parts by doing one of two things: gazing off into the distance or maintaining eye contact with her the entire time.
Doctors were men, and they disliked having to treat women's diseases, which is not an auspicious attitude. But he had to deal with a serious problem: fistulas, holes that formed between the vagina and either the colon or bladder. So he was a responsible doctor who dealt with his patients' illnesses, despite his discomfort with them.
But now comes the weird part: this was 1845, in Alabama. His patients were slaves. There was a chronic problem with fistulas because these women were breeding stock, kept in a state of pregnancy with minimal care. He was testing all of his procedures on slave women.
But when a patient came to Sims with an especially painful fistula, he wrote, “this poor girl was in such a condition that I was obliged to find out what was the matter with her.” He was eager to figure out a way to surgically seal up the hole, and happy to use slave women as his test subjects.
The idea for the speculum came to Sims while treating a white patient who had been thrown from a horse. After he helped her “reposition her uterus,” he had an idea. He fetched a slave, had her lay on her back with her legs up, and inserted the bent handle of a silver gravy spoon into her vagina. That’s right, the very first modern speculum was made out of a bent gravy spoon.
I guess informed consent isn't an issue with a slave -- just tell them to hop up on a table, spread their legs, and let the doctor stick a gravy spoon into their vaginas. And then he started a whole series of surgical experiments to correct fistulas.
This new access allowed Sims to start performing surgery on the fistulas. Eventually he came up with a method for sealing them. He performed many of his experimental procedures without the benefit of anesthesia, and some of these slave women were operated on up to 30 times. Even at the time he was working, there were concerns about the ethics of his experiments. “All kinds of whispers were beginning to circulate around town,” wrote Seal Harris in a biography published in the 1950s, “dark rumors that it was a terrible thing for Sims to be allowed to keep on using human beings as experimental animals for his unproven surgical theories.” There is still an ongoing debate over whether or not to celebrate Sims’s legacy.
His subjects were not willing -- they were enslaved black women, used as guinea pigs, and apparently subjected to painful and unnecessary surgical procedures, all to develop a general method for treating this problem. And he was successful! He did create tools and techniques to alleviate a chronic and painful malady! So were his methods warranted?
I have my opinions, but I'll be interested to hear what students think of it.
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. . . I'm divided on this one. I don't think his methods were justified, but if you came to me and could somehow guarantee that in exchange for randomly selecting 100,000 people for involuntary medical testing you could completely cure cancer in all its myriad forms, I'd probably have to think about it hard.
Why resort to canned examples--now long "settled"--when there are so many live controversies?
There are and have for years now been qualified medical doctors attending to people kept under conditions by the U.S. military at camps in Cuba in conditions which are clear instances of enduring war crimes; many of these people were tortured, while under a medical doctor's supervision--supposedly for the "safety" of the victim. Why should doctors lend themselves to these circumstances--then, now or ever again?
Chemical and pharmaceutical companies are routinely making a test-lab out of open nature with potential for irreversable harm to the environment and any or, at worst, all of its biota. Why should that be permitted?
Researchers, engineers and technicians--the key professions responsible for the conception and creation of most modern technology--are, with rare exceptions, generally held harmless for the consequences, even when easily foreseeable or sometimes even predicted catastrophes--even terrible ones. Why should that be when negligent drivers, or doctors or those tending to animals are routinely held legally accountable for their negligent acts?
And, if you prefer to concern yourself with the matter of adequate informed consent from classes of patients which are in positions of unusual subordination and dependancy, why not take contemporary examples: in Israel, all Palestinians living under Israeli occupation in the West Bank, or Gaza, need official permits in order to enter Israel for any and all purposes including for medical appointments and treatments of whatever kind. Those pemits are granted or denied at the sole discretion of the Israeli authorities and each and every one requires approval by a Shin Bet intelligence agency inspector. This requirement is routinely used to extort collaboration from present or potential patients--including parents seeking life-saving treatment for their infant children. [See, for documentation, a documentary film aired over Al Jazeera channels and available at its website.
"Agents of Israel" : The story of Palestinian collaborators used by Israel over the years to assassinate high-ranking Palestinian figures.
There, for your consideration, is a completely captive class of vulnerable people, including medical patients with serious, life-threatening conditions--for science ethics' study purposes--which you could discuss with your students.
How many of them, I wonder, would listen to such accounts? How many would make no excuses for the Israeli practices? How many would find the story as outrageous as I do?