Publications in the field of Pharmacology of Anesthesia; Surgical Shock; Hypnoties; Narcotics; Measurement of Subjective Responses and the Influence of Drugs Thereon; Measurement of Central Nervous System Depressants. Studies on ethics of human experimentation. New Book: Research and the Individual near completion.

In Harvard University, Chairman of the Standing Committee on Human Studies. Chairman of an ad hoc Committee, Harvard Medical School, to Reexamine the Definition of Death.

At the Massachusetts General Hospital, Formerly Chairman of the Committee on Research. At present Chairman of the Subcommittee on Human Studies. Member of the Trustees Committee on Research and the Individual under the Chairmanship of the Right Reverend Henry Knox Sherrill.

STATEMENT OF DR. HENRY K. BEECHER, DORR PROFESSOR OF RESEARCH IN ANESTHESIA, HARVARD UNIVERSITY AND CHIEF, DEPARTMENT OF ANESTHESIA, MASSACHUSETTS GENERAL HOSPITAL, BOSTON, MASS.

Dr. BEECHER. Senator Mondale, this afternoon's discussion has been focused almost entirely on surgery of the heart. I would like to say at once I have no competence in that area. But I should like to occupy my time, if I may, to point out a number of very broad unresolved problems that do need study-not that I know the answers to these problems, but I can raise a great many questions.

I profoundly believe that issues that stem from that could be handled by a very small group, a widely diversified group such as that proposed in the resolution. I would like to proceed on that basis.

Senator MONDALE. If you would, please.

Dr. BEECHER. With the extraordinary recent expansion of medical studies in man, it seems unquestionably clear that old ethical problems will change in relative importance, and that new and unsuspected problems will arise.

The great expansion of medical studies in man is to be found not only in quantity, but also in kind.

There are, for example, the rather new problems that have arisen with the transplantation of tissues and organs. Since this has come into prominence, as we all know-many of these problems are truly new under the sun.

The expansion of medical experimentation is wonderfully fine, and much has been accomplished, and much remains to be done of course. In this one can see extraordinary opportunities, especially for young men. In this connection, there are two facts we must take into account here must not lose sight of. The very properly ambitious young man knows that in this country at the present time he will never attain to a professorship, a tenure post in a major university unless he has done research of a creditable sort. University hospitals, for better or worse, are dominated by those who have done research, or those who are doing research.

Now, that is the first point.

The second point is that vast sums of money are available for these young men very properly so and I am glad that that is so. But we must realize these two facts taken together put extraordinarily great pressures on the young man-pressures that might lead many to take short cuts occasionally. We have to face up to these things. Most errors here are owing to thoughtlessness or carelessness. Merely calling attention to them will do much toward correction.

All the more reason, then, I think for the activation of the resolution before the Senate. It is essential that the limitations as well as the degrees of freedom be spelled out. I think all men of good will will agree that science is not the highest value under which all other orders of values have to be subordinated; that science must be inserted into the order of values. There are limits which even medical science cannot go beyond, without violating, I think, higher moral rules. For one example, the confidential relationships between doctor and patients.

These limits, these degrees of freedom need to be spelled out, not in terms of rigid codes, which are so hampering and so unhelpful, but in terms of spirit. Lines can be clarified, I think, by study-study by a multidisciplinary group.

It has seemed to me our concern in medical experimentation has been limited too sharply perhaps to the welfare of the individual. This is understandable. This view is deeply ingrained in our culture, and one to which I subscribe wholeheartedly. But at the same time society itself has rights. In one sense there is conflict between the rights of the individual and the rights of society, and we need to have careful thought given to these things, such as the Commission could offer.

I think this conflict can very easily be exaggerated, that the two points of view can be reconciled. Certainly society is the protector of the individual. Society must maintain control over situations which inevitably lead to sacrifice of some for the common good. For example, in kidney dialysis, there are already sound precedents in some limited situations for the dominance of the rights of society over those of the individual, for example. We see this in the compulsory reporting of venereal disease, on fluoridation of water in some communities, in the requirement of vaccination, in the military draft, for that matter. In all of these areas, the welfare of society does take precedence over the rights of the individual.

Nonetheless, there are conflicts between the rights of society and the rights of the individual where the choices are among shades of gray. And I think these shades of gray areas deserve study. I think a commission such as that proposed could offer a very great help here.

It is my hope that the proposed Commission will examine these problems, and give us guidance we do not now have. To take another example, there is the problem of experimentation in children. If it is needed for their benefit, fine, all is well. But what about experimentation in children not for their direct benefit. A strict experimentation of English law forbids this. Our laws are very often derived from English law, but not necessarily so. American law is silent in this area. There are no true American precedents anywhere else to guide us here-although two irrelevant cases are often dragged into this connection. they are truly irrelevant-there are no precedents to guide us. Here is another area where the proposed Commission could study with profit. To turn to another aspect of this problem, of the problems before us this afternoon, one hears a good deal of talk these days that the Government is in these difficult days going to limit the support that it has to applied research. I would not want anything I am about to say to be misconstrued here. If there is to be such a limitation, such a limitation should not obscure the fact that in my view, such an action would be catastrophic. I should like to make one or two points relative to this.

I know the European scene very well. We do have preeminence in experimentation in this country. If we lose this by deingration of basic

science, we are going to lose this preeminent position, I am very certain. To make my point clear, I would like to say a word about basic and applied science.

Now, some have argued there is only good science and bad science, and I think that is a very very useless point of view. Such a view is I think ridiculous.

As far as I am concerned, truly basic science is a science that is interested in the discovery and establishment of new concepts. All else is applied science-whether it is carred out at the bedside of a sick man, or carried out in a biochemistry laboratory. The bedside of a sick man is a fascinating place. Certainly it is the site of application of much "applied science," but it can also be in the most fundamental sense the site of discovery of new concepts in basic science. Let us take a look at a few examples.

Several years ago I planned a series of 20 Lowell lectures that had as its theme disease and the advancement of basic science. At this time a score of distinguished scientists (four Nobel laureates) participated in demonstrating with their own work that truly basic, conceptual science, can have its origins at the bedside. An abundance of examples comes to mind: Linus Pauling's interest in molecular disease arose from his concern about abnormal forms of hemoglobin. Neurophysiologists have long been interested in the biochemistry of potassium ion. Recent basic advances in knowledge of this ion have come from studies of dehydration. Knowledge of the physiology of the endocrine glands is largely indebted to the fundamental leads found in disease of the endocrine glands. The anatomy of the central nervous system has been learned in large part from the study of cerebral vascular accidents, the so-called shock.

Such diverse matters as the discovery and understanding of vitamins, the development of microbiology, even the advance of genetics in the study of hereditary factors in disease, all of these leave no room for doubt that basic science can be advanced by study of the disease process. One can borrow a figure from the physicists, and think of man in one sense as a black box. The characteristics of the normal body are studied, and just as the physician places what he calls aperturbation, stress, on his black box, and studies the resulting situation, disease, affecting the human body is a stress which resulting provides a situation worthy of our study.

Nature certainly presents us with far bolder experiments than we would ever dare to carry out ourselves.

To change the subject, since I have been interested in ethical matters for the last decade, I have frequently been asked about the heart transplantations.

I have no quarrel with what has been done. To me this represents a desperate effort to save a desperate situation. I think it is right. I think it is good. I think that the primary issue here is care of the patient.

Now, the fact that certain good things have come out of this, that we have learned about transplantation in general from these things, is all to the good. But the basic issue here is that these individuals were sick patients, and desperate efforts were made to handle a desperate situation.

Just as attention to various unethical procedures has focused our thought on the necessity to straighten out our practices, so also in

an opposite sense Barnard's first heart transplant-a legitimate, desperate effort to save a desperate situation-focused the public's attention on a great need. This excitement and the educational effect resulting from it will in all probability lead to the acquisition of funds and the stimulation of investigators so that the problems, not only of hearts but of other organs as well, will be solved far sooner than would otherwise be the case. While granting a preeminent place to the individual's rights, it would be very wrong to overlook the fact that society has rights too.

A considerable debate is at present under way concerning whether or not further heart transplants should be attempted until the rejec tion phenomenon in general is better understood and better controlled. Another imponderable in the heart transplant situation is that it is difficult to judge with accuracy the prognosis in survival time of the prospective recipient without transplantation.

All of these problems exist. Most of them are outside of my field of competence. But all of us can recognize that these problems do exist. A commission such as that proposed could clarify the issues.

Other significant biomedical areas: Unlike Oliver Wendell Holmes "Wonderful One-Hoss Shay" which disintegrated—

All at once and nothing first

Just as bubbles do when they burst.

Unlike this, human beings are likely to fail in a given part, hence the interest in transplanting a particular tissue or organ (Beyond middle age it is often patch, patch, patch!)

Sometimes, of course, the ailing organ can be compensated for by the administration of its missing secretion, Cortisone in Addison's Disease, or insulin in diabetes. Sometimes a mechanical device such as a heart valve will do; but at other times nothing less than a transplanted organ gives hope of prolonging life.

The lung is a likely organ to be transplanted. Of the nonpaired organs, experience with transplantation of the liver is promising. There is need for further study of transplantation of the endocrine

organs.

Surely there is a need for guidance as to who will be chosen and who won't be when facilities are sharply limited.

It is evident that the transplantation of tissues is not purely a medical problem. Perplexing questions abound; some are medical or partly medical and some are not. The Ciba Foundation symposium (1966) was primarily interested in transplantation; but it considered as pertinent, subjects as diverse as how and when a potential donor can be considered to be free of undue influence? How long should “life” be maintained in a patient with irrevocable brain damage? When does death occur in an unconscious patient maintained only on artificial aids to the circulation and the respiration? Are there ever circumstances when death may be mercifully advanced? Can a parent rightly refuse necessary treatment of his child?

Senator MONDALE. Would it be fair to say, as you ask these ques tions, that the question of the definition of death is more complicated in your judgment than perhaps in the judgment of Dr. Barnard?

Dr. BEECHER. I certainly am not one to pit myself against Dr. Barnard's views.

Senator MONDALE. It is easy, he is gone.

Dr. BEECHER. I know. It is rather unfair. For many reasons, the field of transplantation is only one, I think there is a great need to establish what is brain death. At least they are strong to me.

I know of 11 examples in Europe, Sir, where individuals whose hearts were still beating have served as donors for organs. So far as I know this has never been done in America. But it has been done in Western Europe. It presents us with a great problem.

If we can get a new definition of death, one which everybody will accept, the clergy, and doctors, and lawyers, then I think we can make significant advances here. Lacking a new definition of death, we are obliged to consign to the grave countless organs that could be used to save people who are still salvageable.

We are not infallible. And we might make a mistake. I think that mistakes in updating death is a very remote possibility, when the necessary precautions have been worked out. But one must admit it is possible. It is only human to err..

But on the other hand, we know we are consigning a great number of people to the grave, because we are not willing to face up to the possibility of redefining death. I think this is an extremely important point. I happen to be chairman of an ad hoc committee at Harvard that is grappling with this problem right now, the definition of death. Senator MONDALE. With the definition of death?

Dr. BEECHER. Yes-trying to see if we can state a new definition of death. The dean of the Harvard Medical School thought this was important enough to form an ad hoc committee to study it, Dr. Barnard, notwithstanding. It is far more radical, in my view, to fail to try to define brain death, with all of its helpful consequences, than it is to proceed as we are. I am not entirely alone in this area.

Then we have problems surrounding the use of civil prisoners. The use of prisoners in experimentation has a rather long history. During World War II both Federal and State prisoners made important contributions to malaria studies, the use of blood plasma, plasma fractions and plasma substitutes, and to trials of various new drugs.

During World War II the Governor of Illinois and the Department of Public Safety allowed penitentiary prisoners to serve voluntarily, but without any promise of pardon or reduction of sentences, in certain medical experiments.

Governor Green appointed a committee to advise him on the ethical problems involved, specifically the conditions under which prisoners might be permitted to serve as subjects in medical experiments and, second, under what conditions a reduction in time in prison might be granted as a reward for collaboration. The committee report was published in 1948.

The prisoner problem is a whole grab bag including other captive groups, for example, medical students, ward patients, and so on. I think captive groups in general do not present a very good source of volunteers, but there are exceptions to this. The reason is plain, wherever there are possibilities for coercion, we may not even be aware we are exerting coercion on individuals. So I have an inviolable rule that my students will never be used by me in experimentation. There are other things one could say along these same lines.

Then there is the whole field of invasion of privacy. This has come to be a serious matter in the hands of some investigators, especially