2
Ethical Implications from the Tuskegee Syphilis Study
Dr. Joseph Costa, D.H.Sc., PA-C
Health Policy and Management
MPH 525
Allison Erickson
April 2013
Table of Contents
Chapter Page
1. Introduction4Ethics and Human Rights4General Ideology4Four
Principles52. Tuskegee Syphilis Study6Background6Cultural
Influence7Origins of the Study8The Study Itself9Selecting
Subjects9Methods Used10The Results and Implications113.
Implications of the Tuskegee Study13Future Repercussions13Reduced
Trust13Examples of the Mistrust144. Current Ethical Guidelines for
Research15Belmont Report15Basic Ethical Principles155. Summary176.
Recommendations18 References21
Chapter 1
Introduction
Ethics and Human Rights
General Ideology
The basis of morality, ethics, and human rights began its modern
development during the Holocaust and World War II. Events like
these were a catalyst for the development of the United Nations. In
1948, the United Nations created the Universal Declaration of Human
Rights in which it became an international human rights instrument
(Nixon & Forman, 2008). Within this declaration, the rights and
freedoms were expanded in the International Covenant on Civil and
Political Rights, as well as the International Covenant on
Economic, Social and Cultural Rights. In addition to these, there
have been over 100 human rights instruments added. Through these
iterations, international human rights have come to be
characterized as universal, indivisible, interrelated and
interdependent (Nixon & Forman, 2008).
Human rights, internationally, focuses on protecting the
dignity, equality, and unalienable rights of all people (Nixon
& Forman, 2008). This focus translates into an abiding
attention to the poor, vulnerable and marginalized those people
routinely excluded from the benefits and opportunities of the
political, economic and social mainstream (Nixon & Forman,
2008). Additionally, the philosopher Peter Singer has expressed
that all individuals capable of helping other in preventing
physical and mental harm, must (Eleftheriadis, 2012). Singer stated
his moral principle by saying,
If it is in our power to prevent something bad from happening,
without thereby sacrificing something of comparable moral
importance, we ought to morally do it. By sacrificing something of
comparable moral importance I mean without causing anything else
comparably bad to happen, or doing something that is wrong in
itself, or failing to promote some moral good, comparable in
significance to the bad thing we can prevent. (Eleftheriadis, 2012,
p. 272).
This statement made by Singer emphasizes that the distance
separating us from other individuals does not become relevant when
a moral duty is required. So he includes that we cannot
discriminate against someone merely because he is far away from us
(Eleftheriadis, 2012).
Four Principles
Judgments, decisions, and actions made by leaders in any field
rely on the four principles: Respect for persons, beneficence,
nonmaleficence, and justice. Within respect for persons, there are
four different elements including autonomy, truth telling,
confidentiality, and fidelity. Autonomy requires that one act
toward others in a way that enables them to be self-governing.
Basically, this is that right to be left alone (Burke &
Friedman, 2011, p. 91). This can be both a negative and a liberty
right. Negative because an individual can refuse treatment, a
liberty right because an individual can choose to be free from
interference. However, the liberty right of autonomy is inviolable
as long as the choice does not interfere with rights of other
persons. Burke and Friedman (2011) indicate, the law recognizes
that individual (liberty) rights cannot be allowed to put society
at risk, generally (p. 91). When pursuing a course of action,
individuals need to be rational and uncoerced. Though, when an
individual has limited rational thinking from a mental or physical
condition that can leave the person without much autonomy.
Nonetheless, these individuals are owed respect and provided means
for expressing autonomy. In regards to any treatment, autonomy is
the underlying factor behind consent for the treatment.
The second element of respect for persons is truth telling.
Although fairly self-explanatory, truth-telling requires the
honesty of leadership and subordinates. Even if the truth hurts and
individual, it must happen. Kantians believe that it is a sign of
respect to be truthful. Loss of trust because of lying would bring
into being much more ungood than good (Burke & Friedman, 2011,
p. 91). Thirdly, confidentiality requires that leaders keep secret
what has been learned about those being served. However, there are
legal requirements that morally justify exceptions to
confidentiality. Ethically (and legally), information can be shared
only on a need-to-know basis (Burke & Friedman, 2011, p. 91).
Lastly, the fourth element of respect for persons is fidelity,
which is the duty one has at keeping ones word. This element is
often times related to promise keeping. As stated by Burke and
Friedman (2011), Keeping ones promises and being faithful in our
relationships and interactions not only treat persons with respect,
but further the delivery of services (p. 91).
Beneficence receives its roots from the Hippocratic tradition,
and is defined as acting with charity and kindness (Burke &
Friedman, 2011, p. 91). The balance of benefits and harm is the
framework of this principle. Leaders are called to do all that can
be done for persons served under beneficence and to act in the best
interest of those being served. Nonmaleficence also has roots in
medicine and can be defined as doing no harm. Although
nonmaleficence allows for specific moral duties and rules, there
are some exceptions of doing no harm. For example, with consent, a
medical professional may need to inflict harm to avoid more serious
harm or would compromise truth telling if the truth would cause
more physical and/or mental harm to an individual. Lastly, justice
has a plethora of definitions that are personal and collective
definitions. Aristotle defined justice as equals being treated
equally, and unequals being treated unequally a concept common to
public policy analysis (Burke & Friedman, 2011, p. 92). Justice
is also defined as fairness. Because of the vast number of
definitions, leaders act justly through the application of treating
subordinates equally.
Chapter 2
Tuskegee Syphilis Study
Background
Cultural Influence
(Note: the words and phrases used in quotations in the following
sections do not reflect the views of this author.)
At the turn of the 20th Century, American racism had a new
rationale provided by Darwinism. Essentially primitive peoples, it
was argued, could not be assimilated into a complex, which
civilization. Scientists speculated that in the struggle for
survival the Negro in America was doomed (Brandt, 1978, p. 21).
Using census data, social Darwinists predicted the extinction of
African Americans throughout the 20th Century, for which it was
believed that the African American race would be subject to
degenerative evolutionary process. Biologists, anthropologists, and
ethnologists supported these findings through the later 19th and
early 20th Centuries. Brandt (1978) indicates, Physicians studying
the effects of emancipation on health concluded almost universally
that freedom had caused the mental, moral, and physical
deterioration of the black population (p. 21). Dr. W.T. English was
quoted saying, A careful inspection reveals the body of the negro a
mass of minor defects and imperfections from the crown of the head
to soles of the feet (Brandt, 1978, p. 21). Many physicians agreed
with Englishs analysis by including that the wide nasal openings,
receding chins, and projecting jaws left African Americans as one
of the lowest species in the Darwinian hierarchy.
The sexual nature of African Americans became the central focus
in racial differences. One physician noted in the Journal of the
American Medical Association that, The negro springs from a
southern race, and as such his sexual appetite is strong; all of
his environments stimulate this appetite, and as a general rule his
emotional type of religion certainly does not decrease it (Brandt,
1978, p. 21). The sexual practices of the African American
community were deeply scrutinized with southern physicians
promoting castration instead of lynching for sexual crimes
committed by an African American individual.
According to these physicians, lust and immorality, unstable
families, and reversion to barbaric tendencies made blacks
especially prone to venereal diseases. One doctor estimated that
over 50 percent of all Negroes over that age of twenty-five were
syphilitic. Virtually free of disease as slaves, they were now
overwhelmed by it, according to informed medical opinion. (Brandt,
1978, p. 22).
Doctors believed that treatment for diseases like syphilis among
the African American population were impossible because in latent
stages of infection, symptoms are rather quiet. With quiet symptoms
in latent stages, physicians believe that even the most educated
African American would not seek treatment for syphilis.
Additionally, at the turn of the century many doctors attributed
low birth rates, high miscarriage rates, and high crime and
insanity rates to syphilis. The configuration of these ideas
created a core medical opinion concerning African Americans, sex,
and disease in the 20th Century. Doctors generally discounted
socioeconomic explanations of the state of black health, arguing
that better medical care could not alter the evolutionary scheme
(Brandt, 1978, p. 22). All of these assumptions created the
backdrop for the Tuskegee Syphilis Study.
Origins of the Study
In 1929, the United States Public Health Service (USPHS)
conducted studies rural communities in Southern America exploring
the prevalence of syphilis among African Americans the possibility
of mass treatment. These studies were under a grant from the Julius
Rosenwald Fund. The highest rate of syphilis in a six county radius
was in Macon County, Alabama, in which the town of Tuskegee is
located. Dr. Taliaferro Clark, the Chief of the USPHS Venereal
Disease Division and the author of the Rosenwald Study, concluded
that the syphilis conditions in Macon County merited attention.
Clark believed the high prevalence of syphilis offered an unusual
opportunity for observation. From its inception, the USPHS regarded
the Tuskegee Study as a classic study in nature, rather than an
experiment (Brandt, 1978, p. 22).
The researchers had written no formal protocol for the study,
but had the intent of observing how syphilis affected the daily
lives of men. Among those advocating for the study was Surgeon
General H.S. Cumming. Cummings advocacy came from the Oslo Study
between 1890 and 1910. The Oslo Study, carried out by Professor C.
Boeck at the Oslo Venereal Clinic, intentionally withheld treatment
to almost two thousand syphilitic patients. Cummings theory was
that the treatments available at the time would do more harm than
good, therefore, Cumming wanted to research the natural course of
syphilis without treatment. According to results from the Oslo
Study, 70 percent of the patients went through life without
inconvenience from the disease. However, the remaining 30 percent
experienced dramatic dangers of syphilis including cardiovascular
disease, insanity, and premature death (Brandt, 1978). After the
Oslo Study, Dr. J.E. Moore suggested that syphilis should not be
allowed to pass untreated. The year that the Tuskegee Study began,
in 1932, Moore published a paper with six other syphilis experts
that strongly argued for the treatment of syphilis. Therefore, it
is believed that the Oslo Study could not have provided
justification for the USPHS to perform a study that did not entail
the treatment of syphilis (Brandt, 1978). Concluding, The doctors
who devised and directed the Tuskegee Study accepted the mainstream
assumptions regarding blacks and venereal disease. The premise that
blacks, promiscuous and lustful, would not seek or continue
treatment, shaped the study (Brandt, 1978, p. 23). Leaving room for
the lack of treatment seemed natural to the USPHS because many
presumed the men would never seek treatment in the first place.
The Study Itself
Selecting Subjects
The basic design of the study called for syphilitic African
American individuals between the ages of 25 and 60 years old. Every
subject was to receive a full physical examination with x-rays and
a spinal tap to check for neuro-syphilis. [The researchers] had no
intention of providing treatment for the infected men (Brandt,
1978). When tasked with collecting subjects for the study, the
researchers found it more difficult than anticipated. Therefore,
researchers were forced to test large numbers of women and men who
did not fit the original qualifications. When the challenges in
obtaining subjects for the study grew, Dr. Raymond Vonderlehr found
that the only way to obtain willing research subjects was to
include the promise of free care. With this offer, many became
willing participants. The USPHS did not tell the men that they were
participants in an experiment; on the contrary, the subjects
believed they were being treated for bad blood the rural Souths
colloquialism for syphilis (Brandt, 1978, p. 24). To help preserve
the subjects trust and interest, Vonderlehr provided the men with
mercurial ointment, knowing full well that it was a noneffective
drug. After the USPHS approved continuing the experiment in 1933,
Vonderlehr decided it necessary to include a control group. The
controls were healthy, uninfected men.
Methods Used
In all, the study initially involved 600 African American
individuals 399 with syphilis and 201 who did not have the disease
(Centers for Disease Control and Prevention (CDC), 2011). The
researchers based the experiment on deception. In a letter to the
participants about a spinal tap, it stated, Remember, this is your
last chance for special free treatment. Be sure to meet with the
nurse (Brandt, 1978, p. 24). Brandt (1978) indicates further that
the, physicians involved with the study believed that only
autopsies could scientifically confirm the findings of the study
(p. 24). To increase the deception, the USPHS hired Eunice Rivers,
an African American nurse, to give the men the noneffective
medicine with spring tonic and aspirin, as well as follow the mens
health and secure approval for autopsies (Brandt, 1978). More
important, Nurse Rivers provided continuity to the project over the
entire forty-year period. By supplying medicinals, the USPHS was
able to continue to deceive the participants, who believed that
they were receiving therapy from government doctors (Brandt, 1978,
p. 25). When subjects of the study became severely ill, in order to
persuade continued participation, the researches promised to cover
burial expenses.
During the 40 years of the study, the USPHS sought on several
occasions to make sure the subjects did not receive treatment from
other sources. Vonderlehr went as far as meeting with groups of
African American doctors in Macon County to ask for the cooperation
of not providing treatment if study subjects asked for it.
The USPHS warned the Alabama Health Department not to treat the
test subjects when they took a mobile VD unit into Tuskegee in the
early 1940s. In 1941, the Army drafted several subjects and told
them to begin antisyphilitic treatment immediately. The USPHS
supplied the draft board with a list of 256 names they desired to
have excluded from treatment, and the board complied. (Brandt,
1978, p. 25-26).
Although Vonderlehr and the USPHS made efforts to ensure the men
would not treated, by the early 1950s, many of the men had secured
some treatment without the researchers knowledge. With the
development of penicillin, about 30 percent of the test subjects
had received this form of treatment, but about seven and a half
percent of those received adequate doses to treat syphilis (Brandt,
1978).
The Results and Implications
The study continued well into the 1970s, with data and autopsies
still being collected. Dr. J. Lawton Smith stated, You will never
have another study like this; take advantage of it (Brandt, 1978,
p. 26) when responding to the debate of whether to continue or end
the study. On August 28, 1972, the Department of Health, Education,
and Welfare (HEW) formed the Tuskegee Syphilis Study Ad Hoc
Advisory Panel in response to the criticism the press description
of the experiment had created. This panel consisted of nine
members, five of which were African American. The focus of the
panel was regarding two issues: 1) Was the study justified in 1932
and had the subjects given informed consent? 2) Should penicillin
have been provided when it became available in the 1950s? (Brandt,
1978). The group issued the report in June of 1973.
By focusing on the issues of penicillin therapy and informed
consent, the Final Report and the investigation betrayed a basic
misunderstanding of the experiments purposes and design. The HEW
report implied that the failure to provide penicillin constituted
the studys major ethical misjudgment; implicit was the assumption
that no adequate therapy existed prior to penicillinIndeed there is
no evidence that the USPHS ever considered providing penicillin.
(Brandt, 1978, p. 26-27).
The other focus of the report was on informed consent. Those on
the panel declared the experiment ethically unjustified due to
failing to obtain the informed consent of the study participants.
The Final Reports statement, Submitting voluntarily is not informed
consent, indicated that the panel believed that the men had
volunteered for the experiment (Brandt, 1978, p. 27). However, it
is important to note that the National Archives records make it
clear that the men did not submit voluntarily. The men were told,
and believed, that free treatment was being provided by expert
government doctors for a serious disease.
The Tuskegee Study reveals much about the beliefs within the
medical community about the nature of African Americans. The entire
health community was jeopardized after the study because of leaving
a communicable disease untreated. There can be little doubt that
the Tuskegee researchers regarded their subjects as less than
human. As a result, the ethical canons of experimenting on human
subjects were completely disregarded (Brandt, 1978, p. 27). Through
the course of the study, there was never any significant protest
within the medical community. Additionally, the bureaucratic nature
of the government did not seek reassessment of the ethics and
scientific value of the Tuskegee experiment. It was the press
accounts in 1972 that finally created the realization that the
study should be discontinued. Brandt (1978) says in finalizing, In
retrospect the Tuskegee Study revealed more about the pathology of
racism than it did about the pathology of syphilis; more about the
nature of scientific inquiry than the nature of the disease process
(p. 27).
Finally, a class-action lawsuit was filed on behalf of the study
participants and the families of the participants in the summer of
1973. In 1974, a $10 million out-of-court settlement was reached.
As part of the settlement, the U.S. government promised to give
lifetime medical benefits and burial services to all living
participants (CDC, 2011). The Tuskegee Health Benefit Program
(THBP) was set up to provide the medical services. In 1975, wives,
widows, and children were added to the program and in 1995, the
program expanded to include health and medical benefits. According
to the CDC (2011), the last study participant passed in January of
2004 and the last widow receiving benefits passed in 2009.
Currently, there are 15 children who are receiving medical and
health benefits.
Chapter 3
Implications of the Tuskegee Study
Future Repercussions
Reduced Trust
The Tuskegee Syphilis Study has become known as one of the most
abusive uses of authority on the part of medical researchers. This
abuse of authority has left many African Americans skeptical about
research participation. Deception, exploitation, and deprivation of
treatment in the Tuskegee Study were the root cause of the mistrust
that was born from the study. Within weeks of the first press
reports of Tuskegee, African American press and leadership began to
synonymize the name Tuskegee with the work genocide (Fairchild
& Bayer, 1999).
Examples of the Mistrust
In the mid-1980s, when the AIDS epidemic was becoming more
highly recognized, New York City proposed a way of interrupting the
spread of the disease through a needle-exchange program. African
American leadership gave voice to their dismay and fury, rooted in
suspicions that the failure to provide adequate treatment to drug
users represented a form of genocidal neglect (Fairchild &
Bayer, 1999). Political opposition to the needle exchange program
came from both law enforcement and the African American community.
The 1988 needle exchange program, which was developed by New York
Citys health commissioner, was proposed as a small experiment
designed to determine whether the innovation could reduce the
incidence of HIV infection among users.
In denouncing the experiment, Benjamin Ward, the Citys African
American Police Commissioner, alluded to the Tuskegee syphilis
trials when he explained that his community felt a particular
sensitivity to doctors conducting experiments, and they too
frequently seem to be conducted against blacks. (Fairchild &
Bayer, 1999).
However, by the mid-1990s, the African American opposition to
needle exchange had almost vanished because of the successful
results that were becoming apparent.
Another example includes studies conductive by health
departments, with support from the CDC, to conduct studies of HIV
infection in the population by testing blood samples, removing all
personal identifiers. Because the samples of blood had no personal
identifiers, ethical review boards deemed the study ethical without
any problems. However, anonymization precluded notification of
infected individuals (Fairchild & Bayer, 1999). The criticism
this study faced was regarding the informing of individuals if
tested positive for HIV, knowing that treatment was available. CDC
officials indicated the sole purpose of the study was to detect
populations most at risk of developing HIV, not for seeking
diagnosis.
Chapter 4
Current Ethical Guidelines for Research
Belmont Report
Basic Ethical Principles
The Belmont Report provides ethical principles and guidelines
for protecting human research subjects and was developed by the
HEW. Many ethical guidelines are similar with the four principles
aforementioned. The first basic ethical guideline is respect for
persons, in which there are two separate moral requirements: 1)
Individuals should be treated as autonomous agents, and 2) Persons
with diminished autonomy are entitled to protection (University of
Iowa (UIowa), n.d.). Application of this principle means that
subjects, to the degree capable, be given an opportunity to choose
what should or should not happen. Within the informed consent
process, there are three elements: 1) Information, 2)
Comprehension, and 3) Voluntariness. Information means the subject
knows, that the procedure is neither necessary for their care nor
perhaps fully understood, can decide whether they wish to
participate in the furthering knowledge (UIowa, n.d.).
Comprehension means that the information being conveyed by the
researcher is told in a manner and context that can be understood
by the participant. However, it may be necessary for the
information being presented to be adapted to meet the intellectual
needs of the participant. Lastly, voluntariness is the agreement to
participate voluntarily, free from coercion and undue
influence.
The second basic ethical guideline is beneficence. This
guideline means that every person involved with a research study is
treated in an ethical manner by respecting the decisions of the
participants and protection from harm. Also, beneficence means
making an effort to secure the well-being of the participants. Two
general rules have been formulated around beneficence: 1) Do not
harm, 2) Maximize possible benefits and minimize possible harms.
When applying this guideline, it is important to determine whether
the risks that will be presented to subjects are justifiable risks.
The elements of a risk and benefit assessment include the nature
and scope of the risks and benefits and the systematic assessment
of risks and benefits. Assessment of justifiability of research
should reflect at least the following considerations:
Brutal or inhuman treatment of human subjects is never morally
justified. Risks should be reduced to those necessary to achieve
the research objective. When research involves significant risk of
serious impairment, review committees should be extraordinarily
insistent on the justification of the risk. When vulnerable
populations are involved in research, the appropriateness of
involving them should itself be demonstrated. Relevant risks and
benefits must be thoroughly arrayed in documents and procedures
used in the informed consent process. (UIowa, n.d.).
Finally, justice means that there is a sense of fairness in
distribution with research precipitants. Selecting research
subjects must be scrutinized to determine whether the subjects are
being systematically selected for reasons directly related to the
study at hand. There are two levels of justice relevant to the
selection of study participants. First, social justice requires
that the can be a distinction drawn between the classes of
subjects. It can thus be considered a matter of social justice if
there is an order of preference in the selection of classes, like
adults before children. Secondly, individual justice requires that
the researchers exhibit fairness. Thus, they should not offer
potentially beneficial research only to some patients who are in
favor or select only undesirable persons for risky research (UIowa,
n.d.).
Chapter 5
Summary
The premise for basic human rights, especially with research
participants, has come from many horrific and unethical practices
in the late 1800s and through the middle of the 1900s. Events like
the Tuskegee Syphilis Study prompted the need for the development
of guidelines that researchers must abide by when conducting
studies. The Tuskegee Syphilis Study not only medically deprived
African American males from needed treatment, but the researchers
actively and knowingly deceived the participants. Many would argue
that this studys implications had much to do with racial pathology
and little to do with medical pathology. Culturally, many white
individuals saw the African American population as evolutionarily
lower than many other humans. Therefore, the Tuskegee Study
researchers entered the experiment with preconceived notions about
the African American population.
After a forty-year period, the American public awakened and
realized the inhuman and unethical practice of the Tuskegee Study.
From this awakening arose a new standard of guidelines for
researchers and participants of a study known as the Belmont
Report. Within this report, one will find the proper ways of
allowing autonomy, beneficence, and justice in a research model.
All three elements open the door for research participants to be
treated fairly, with little harm, and with full choice in continued
participation.
Chapter 6
Recommendations
After reviewing the details of the Tuskegee Syphilis Study, this
author was shocked to read about the injustice and unethical
behaviors of medical professionals less than 40 years ago. There
are a number of areas that this author would change about the
study. First, the mindset of the researchers needed to change. This
author believes that the overarching problem with the study was how
the African American individuals were perceived in the first place.
However, this author understands that changing cultural viewpoints
is certainly not easy. Therefore, the next change that this author
would make in how the study was run would be to divide the subjects
into different stages syphilis. This author is skeptical that all
subjects had the same stage of syphilis as another, so determining
the stage would create knowledge of when to begin treatment. That
leads this author to the next point in how the real treatment would
need to be offered when it became available. In this case when
penicillin was shown to be a treatment, it would have needed to be
given immediately. Before penicillin was known to be a treatment,
the researchers should have made it known to the subjects that the
treatments available did not show promising healing aspects,
instead showing more negative effects. Lastly, when World War II
prompted the drafting of soldiers, this author would allow those
being drafted to receive the syphilis treatment from the military.
With men going to fight for the country, there is no reason why
there would be refusal for medical treatment.
Next, informed consent is a vital aspect of research and
participation. Individual autonomy requires that researchers
respect the choices of the participants. Additionally, researchers
are responsible for ensuring the well-being of participants, also
known as beneficence. This author believes that the only scenario
in which informed consent is not needed is in the case of a life or
death situation. For example, if an individual is involved in a
serious auto accident and a medical professional seeks to save the
individual, that medical professional will not ask the individual
if it is okay. Rather, that professional will perform the duties to
save the individuals life. Even if there is harm done to the
individual, but the life is saved, that is ethically appropriate.
However, in the case of an organized research study, this author
does not see any scenario that would dismiss informed consent. This
author believes the research studies of today are prized on the
informed consent of the participants and should remain such.
Lastly, when raising the question about waiving informed consent
for some areas of clinical investigation, this author sees a couple
problems surfacing. First, this author knows that the legal system
has quickly turned into an escape for individuals who feel have
been unethically treated. Even if an individual signs a piece of
paper acknowledging waiving consent, there can be negative
repercussions if something goes wrong. Waiving consent could
possibly lead to taking advantage of vulnerable populations, but
again, a vulnerable population is in the eyes of the beholder. If a
clinical investigation clearly waives consent and an unfortunate
event takes place during the investigation, the population being
studied could then be seen as vulnerable. All in all, however, this
author does not see any waive of consent during clinical study and
investigation ethically acceptable. The Belmont Report and
Nuremberg Code clearly give the guidelines that must be followed.
After reviewing the Nuremberg Codes history, the Tuskegee Syphilis
Study, and the Oslo Study, this author believes there have been too
many instances where consent, beneficence, and justice have been
overlooked and dismissed. Therefore, this author believes that the
research must oblige to the highest standard of treatment of
research participants.
References
Brandt, A.M., (1978). Racism and research: The case of the
Tuskegee Syphilis study. The Hastings Center Report 8(6),
21-29.
Burke, R.E., & Friedman, L.H., (2011). Essentials of
management and leadership in public health (1st ed.). Sudbury, MA:
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Centers for Disease Control and Prevention. (2011). The Tuskegee
timeline. Retrieved from: www.cdc.gov/tuskegee/timeline.thm
Eleftheriadis, P., (2012). A right to health care. Journal of
Law, Medicine, & Ethics, 268-285.
Fairchild, A.L. & Bayer, R., (1999). Uses and abuses of
Tuskegee. Science 284(5416).
Nixon, S., & Forman, L., (2008). Exploring synergies between
human rights and public health ethics: A whole greater than the sum
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University of Iowa. (n.d.). A summary of the Belmont Report.
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