Medical assault

In Undue Risk, Jonathan Moreno, professor of medical ethics at the University of Virginia, tells the disturbing story of the U.S. government’s secret experiments on its own citizens. Driven primarily by Cold War fears, the state subjected hundreds of individuals, and at times entire communities, to radiation, harmful chemicals, dangerous drugs, and assorted pathogens to see how the human body and mind would react. The publicity generated by the eventual public exposure of radiation experiments led to the formation of a presidential commission, which Moreno joined in 1994. After serving as a senior staff member on the commission, Moreno concluded that more thoroughgoing investigative reporting was required in order to uncover the full range of secret experimentation. He further wished to place these experiments within the context of 20th century international rivalries and ultimately to explain how such insidious activities could have occurred in an open, democratic society.

The result of Moreno’s efforts is Undue Risk, a book that chronicles the full scope of the U.S. government’s medical assault on its own citizens. Moreno begins by outlining the development of human experimentation in the United States during the first half of the century, then considers at length German and Japanese medical atrocities during World War II and the uses to which their findings were later put by the U.S. government. The second half of the book segues into the often bizarre and always disquieting medical investigations conducted in the United States during the Cold War. Moreno concludes with an overview of medical-military policies and practices during the Gulf War and beyond.

Interpretation gap

Although a single narrative thread runs through the book, Moreno is in some respects surprisingly reluctant to give his own ultimate assessment. As a result, different readers might come to disparate conclusions about the author’s aims. Some might see Undue Risk as something of a horror story, one in which innocent people are not only unwittingly used as guinea pigs but, at least in one case, are tortured and killed for dubious purposes. The most horrifying example is that of Harold Blauer, a middle-aged tennis coach who, in 1952, checked himself into Bellevue Hospital to be treated for depression. Blauer was quickly transferred to a psychiatric institute that was conducting secret research for the Army Chemical Corps. The army was interested in the possible military uses of hallucinogenic drugs, and Blauer was selected to test powerful mescaline derivatives. His unpleasant initial druggings led to vigorous protests, but Blauer was threatened with confinement in an insane asylum if he did not comply. His fifth injection–16 times larger than his highest previous dose–resulted in an excruciatingly painful death roughly two hours later. A “classic cover-up” followed, which successfully concealed the truth for several decades.

Blauer’s case, however, was extreme. Most other experimental subjects suffered, if at all, from relatively minor health complications. The U.S. government, moreover, enacted regulations shortly after World War II that should have prevented such atrocities from occurring and that should have ensured that all medical experiments be conducted in an open and ethical manner. Prompted by revelations about Nazi Germany, the United States adopted the rigorously progressive Nuremberg Code, which clearly stated that only fully informed volunteers could be subjected to any such procedures. But since the code itself was unfathomably classified as secret, its provisions were never widely disseminated, let alone put into effect. Given such complicating factors, a more worldly reader might view Undue Risk not as a horror story but rather as a classical tragedy, an ironic tale in which good intentions are undermined by an antidemocratic cult of secrecy as well as by garden-variety bureaucratic ineptitude and individual misconduct.

A determinedly optimistic reader, on the other hand, might come to a completely different conclusion. One could conceivably view the book as something of a classical comedy, a story in which foreboding portents vanish in the end as opposing forces are reconciled and harmony restored. This admittedly farfetched reading would emphasize that the veil of secrecy was eventually (if perhaps never fully) lifted and that, thanks largely to crusading journalists and ethicists, a rigorous code of medical conduct was eventually enforced. The panglossian reader might focus attention on the story, related near the end of the book, of the heroic men and women of “91 Bravo.” These soldiers voluntarily–indeed, seemingly almost joyfully–allow themselves to serve as experimental subjects in the interest of helping their country and, ultimately, humankind. Human experimental data are needed by scientists seeking to counter the effects of chemical and biological warfare and even by those attempting to create vaccines against such mundane maladies as “travelers’ diarrhea” (a disease that is evidently especially debilitating on naval ships). For such purposes, military researchers can turn to the individuals of 91 Bravo, a few of whom periodically, without coercion, undergo grueling procedures needed for diarrhea research.

Full consent

Although Undue Risk may be unusually open to divergent interpretations, Moreno does clearly state his own position on a number of key issues. He is determined to expose the sins of the U.S. government, to shed light on its dirty secrets, and to uphold the autonomy and dignity of the individual against the claims of state power. Moreno unambiguously highlights his own ethical position, consistently contending that the ends never justify the means, that secrecy allows abuses and thwarts democracy, and that security considerations must never trump basic morality. He also clearly allows that national security is a legitimate concern and that human experimentation is sometimes not only justifiable but necessary. Since U.S. soldiers and civilians are potentially threatened by biological, chemical, and other sophisticated weapons, knowledge about their effects on humans is required. Moreno insists, however, that ethical experimentation demands the fully informed consent of the subjects, with no hint of coercion or bribery.

Moreno also unambiguously and unapologetically cleaves to the path of science when assessing the actual harm done to experimental subjects. In many but by no means all instances, he contends that relatively little damage was actually done. Most of the unwitting recipients of plutonium injections in the 1940s and 1950s, for example, apparently suffered only moderate ill effects. Such scientifically based assessments have earned Moreno the outrage of several readers who, on the basis of personal experience or testimonials, contest the scientific evidence. One reviewer, whose opinions are posted on the amazon.com Web pages devoted to the book, accuses Moreno of participating, as part of the official panel that examined the plutonium injection scandal, in a massive “whitewash.” Another writes, as if personally to Moreno, that “I find it very sad that for some reason you need to obliterate the sanctity of humanity from your daily life.” Clearly, some of the victims of state experimentation think that the procedures they underwent had far more debilitating consequences than Moreno would allow. Such bitter sentiments notwithstanding, there is much to recommend in Moreno’s position. Scientific findings often contradict the personal suspicions of individuals who want to identify a clear cause of their maladies, but rational public policy requires the careful use of scientific assessments. The case that Moreno makes for the demands of national security and scientific inquiry, moreover, is reasonable and well-argued, and his insistence that medical researchers maintain high ethical standards is unassailable. Moreno never takes the easy way out. Instead, he confronts head-on the paradoxes of those who would insist on the rigorous use of biomedical ethics while continuing to act effectively in this complex world we all inhabit. As such, I sincerely hope that this book is read and taken to heart by all persons involved, however peripherally, in experimentation on human subjects.

But although Undue Risk is an extremely good book, both in regard to its quality of argument and research and its moral concern, I must conclude that it falls short of being a great book. In large part its flaws come automatically from the format the author has chosen and the audience that he and his publisher are seeking. The book is written as a narrative, as a story that seeks to entertain. Analysis makes appearances, but storytelling is primary. To enliven the tale, personalities and personal attributes are described in some detail. The reader is informed, for example, about Andrew Ivy’s athletic abilities, Stanley Gottlieb’s fondness for goats, and Anna Rosenberg’s “diminutive, stylish [and] bejeweled” appearance. One can easily imagine a zealous editor insisting that Moreno provide a human interest angle. Perhaps such personal touches help sell books, but only at the risk of distracting from the compelling issues at hand.

Murky lessons

Moreno’s strategy in writing a popular account also prevented him from adequately explaining and justifying his positions. Although his stance on specific ethical issues is always clear, his ultimate position on the lessons to be drawn from the larger story remains murky, allowing the divergent readings outlined above. The complex reasoning that lies behind Moreno’s ethical stance remains completely invisible. Although one can understand why he would not want to burden a popular account with weighty philosophizing, he could at least have offered the reader some guidance in the endnotes. Moreno is, after all, a professor of medical ethics. Instead, the endnotes provide nothing but immediate sources, and even there they are cumbersome to use, discouraging further inquiry.

Finally, Moreno might have admitted that many of his pronouncements are controversial. Some observers have come to different conclusions, for example, in regard to the harm caused by certain experimental procedures, as the reviews at amazon.com make clear. That such opinions may lack scientific credibility is to some extent beside the point. I for one would like to see Moreno’s rebuttal to the allegation that he was party to a whitewash, and, at a minimum, I would like to see him acknowledge the existence of such critiques. Yet, in the end, it is all too easy to criticize an author for not writing the book that the critic would ultimately like to read. Moreno may not have even been aware of the critical reaction his book would provoke from some quarters. Taken on its own terms, Undue Risk is a fascinating, important, and courageous work, one that deserves to be widely read and carefully heeded.