Nuremberg And Tuskegee: Lessons For Contemporary American Medicine

NUREMBERGANDTUSKEGEE:LESSONSFORCONTEMPORARYAMERICANMEDICINEDavidM.Pressel,MD,PhDWilmington,DelawareTheactivitiesofGermandoctorsduring theNaziregimearewellknownanddocumented.Theyincludeeffortsateugenicsterilizationandeuthanasia,gruesomemedicalexperimentation,andcontributionstogenocide.TheGermanmedicalprofessionembracedtheNaziideologyofracialsuperiority.Nazidoctorsenthusiasticallypervertedtraditionalmedicalmoresofviewingeachpatientasafullindividualtowardsamisguidedsenseofprotectingtheracialwell-beingofthenationfromtheperceivedthreatofcertaingroupsofpeople.Similarly,some20th-centuryAmericanphysiciansengagedinactivitiespromptedbyamisguidedsenseofpatients'worthasindividuals.ThisessaywillexaminetheethicalproblemsofNazimedicineandethicalmisstepsintheUnitedStatesinthecontextofchallengesforcontemporaryphysicians,particularlythewayinwhichwerefertoourpatients.(JNatlMedAssoc.2003;95:1216-1225.)Keywords:Nazidoctors*medicalethics+TuskegeeSyphilisStudy*eugenicsThe19thcenturysawtheintroductionofscien-tificideasthroughoutthewesternworldwhosedevelopmentandapplicationintheUnitedStatesandGermanywouldhavetragic,albeitdifferent,andlong-lastingconsequencesforeachcountry.ThepublicationofCharlesDarwin'sOntheOriginofSpeciesin1859introducedtheworldtotheideasofevolutionthroughnaturalselection.SocialDarwinismmodifiedtheideasdevelopedfromobservationofthenaturalworldandappliedthemtohumansocietywiththememorablephrase\"sur-vivalofthefittest.\"Twenty-fouryearslaterin1883,Darwin'scousin,SirFrancisGalton,coinedtheterm\"eugenics\"todenotethescienceofimprovingthehereditaryhealthofsocietythrough(2003.FromtheDepartmentofPediatrics,Alfred1.duPontHospitalforChildren.SendcorrespondenceandreprintrequestsforJNat!MedAssoc.2003;95:1216-1225to:DavidM.Pressel,MD,PhD,DepartmentofPediatrics,Alfred1.duPontHospitalforChildren,1600RocklandRoad,POBox269,Wilmington,DE19899;phone:(302)651-5956;fax:(302)651-5948;e-mail:[email protected].'Effortsatpositiveeugenicsweretoenhanceprocreationamongdesirablemembersofsociety,whilenegativeeugenicsdenot-edattemptstohinderthereproductionofthoseviewedasunwantedandinferior.2AmericanandGermanphysiciansinthe19thand20thcenturiessubscribedtoeugenictheoriesand viewedsomeindividualsorclassesofsocietyasinferiorandlessthanfullhumanbeings.Thepracticesthatresultedfromthisvaluationofpeople'sworthtosociety,withunfortunateconsequencesforthosedebasedpeople,areimportantforcontemporaryclinicianstounderstandwhenfacingmanychallengesintoday'smedicalpractice.EugenicsandRacialHygieneWhilethemedicalcommunitiesofmanycoun-triessubscribedtoeugenictheoriesattheendofthe19thcentury,thismovementinGermanyflour-ishedunderthebannerofracialhygiene(Rassen-hygiene).Beginningwiththeactivitiesofphysi-ciansWilhemSchallmayerandAlfredPloetzinthelate19thcentury,ideasofstateinterventiontocon-trolaperceiveddegenerationofGermansocietybyeugenicmeansadvancedthroughtheGermanmed-JOURNALOFTHENATIONALMEDICALASSOCIATIONVOL.95,NO.12,DECEMBER20031216

NUREMBERGANDTUSKEGEEicalestablishment.3In1905,PloetzandpsychiatristErnstRudinestablished theSocietyforRacialHygiene,which,in1921,advocatedaprogramofvoluntaryeugenicsterilization.4Bythe1920s,racialhygienebecamepartofmainstreamGermanmedicine.Journalswerepublisheddevotedtoracialhygieneandacademicinstitutionswereestablishedforthespecificpurposeofracialhygienicresearch.3'5In1923,FritzLenz,astudentofPloetz,becamethefirstprofessorofracialhygieneattheUniversityofMunich.5OtmarvonVerschuer,directoroftheFrankfurtInstituteforRacialHygiene,servedasamentorforJosefMengeleduringhisdoctoralresearchandsubse-quentconcentrationcampcareer.6ThethrustofthisGermaneugenicmovementwasprotectionofthebloodpurityoftheGermanpeopleandNordicracefromthethreatening influencesofpeoplethoughttobegeneticallyunfit.Germanphysicians'con-cernwiththepresumedinferiorityofpeopleasdic-tatedbyracialhygienictheoryprovidedfertilegroundfortheNaziideologyofAryanracialsupremacytogerminate.RacialhygienewouldassumeitsmostvirulentmanifestationwhencoupledwithNazism'srabidnationalism.HitlerandtheNaziscametopowerasaresultofthepoliticalandeconomicchaosinGermanyafterdefeatinthefirstWorldWarandtheGreatDepression.Racialhygienetheoriesresonat-edwithHitler'sownNaziideologyofprotectingthebloodpurityoftheGermanpeople,orVolk,fromthethreatofperceivedinferiorraces-inpar-ticulartheJews.ItisknownthatHitlerstudiedtheworkoftheaforementionedphysicianFritzLenzwhenwritingMeinKampfinLandsbergprison.7LenzlaudedtheNationalSocialismideologyaspoliticallyrepresenting\"appliedbiology.\"5InMeinKampf,HitlerusedmedicalmetaphorstodescribethethreatfromJewsas\"theJewishdisease.\"8TheyaredepictedasinfectingtheGermannationthroughsuchimageryas\"bacillus,\"8\"parasites,\"8and\"bloodsuckers.\"8HitleroutlinedhiseugenicvisionofsocietyasonenotonlyfreefromJewsbutwhere\"onlythehealthybegetchildren...and[where] converselyitmustbeconsideredreprehen-sibletowithholdhealthychildrenfromthenation.\"8Hefurtheroutlinedtheroleofthemedicalprofessioninthisraciallybasedsociety.\"...thestatemustactastheguardianofamil-lennialfuture...Itmustputthemostmodernmed-icalmeansintheserviceofthisknowledge.Itmustdeclareunfitforpropagationallwhoareinanywayvisiblysickorwhohaveinheritedadiseaseandcanthereforepassiton...\"'TheracialideologiesoftheNazisfithandinglovewiththeexistingracialhygienictheoriesofGermanmedicineandwerereadilyadoptedbybothindividualGermanphysiciansandmedicalinstitu-tionsofwhichtheNazisassumed powerinJanuary1933.GermanphysiciansweredisproportionatelyrepresentedintheNazipartyandaffiliatedorgani-zations.During1933-1945,closetohalfofalleli-giblephysiciansjoinedtheNaziparty,ahigherper-centaffiliationthanforanyotherprofession orelementofGermansociety.7ThemutualembraceofNazismandGermanmedicineelevatedtheearlyracialhygieniststoaprofessionalpinnacle.PloetzwashonoredwithadegreefromMunichUniversityandanacademicappointmentinstigatedbyHitlerhimself.7ThecoverillustrationoftheleadingGermanmedicaljournal,DeutschesArzteblatt,initsJuly1,1933issue,emphasizedthenewnatureofGermanmedicinebypairingtheswastikaandthecaduceus.Thesamejournalonemonthlaterintro-ducedthenow-infamousphrase,\"LebensunwertesLeben-Lifeunworthyoflife.\"9RobertLifton,inhisanalysisoftheroleofGermanphysiciansduringtheNaziera,hasstressedafundamentalshiftintheparadigmforbeingaGermandoctor.TheprimaryconcernoftheGermandoctorshiftedfromthecompassionatecareofasingle patienttotheracialwell-beingoftheentireGermanpeople.BelievingtheGermannationwasillandindangerfromtheinfluenceofunfit,inferiorhumans,Nazidoctorsactedtoeliminatethesepeoplefromthesocietycommitting\"therapyviamassmurder.\"'0UnderthebannerofNationalSocialismandact-ingwiththeconvictionthattheywerefulfillingaroleconsistentwiththeircallingashealers,someGermanphysiciansembarkedonaseriesofpro-gramsthathavesinceepitomizedthedebasementofmedicine.BeginningwithapurgeofJewishphysiciansfromtheranksofGermanmedicineandcontinuingwithforcedeugenicsterilizationandeuthanasia,Germandoctorsculminatedtheireffortstoeliminateperceivedinferiorbeingsfromsocietythroughgenocideandinfamouslybrutalmedicalexperiments.NaziMedicineIn1933,atthetimeoftheNaziascenttopower,approximately13%ofallGermanphysicianswere1217JOURNAL OFTHENATIONALMEDICALASSOCIATIONVOL.95,NO.12,DECEMBER2003

NUREMBERGANDTUSKEGEEJews.\"Jewswereforcedfromthemedicalprofes-sioninGermanythroughacombinedmeansofleg-islation,reorganizationofthe profession,andout-rightphysicalbrutality.Beginningwiththe1935NurembergRaceLawsthatexcludedJewsfromholdingGermancitizenship,aprogressiveseriesofordinancesrestrictedboththecivilrightsofJewsandtheabilityofJewishphysicianstopracticemedicine.By1938,thenumberofJewishphysi-cianshaddeclinedtoabout9%oftheirpre-1933level.Atthattime,theremainingJewishdoctorshadtheirmedicallicensesrevokedandweredis-paraginglyretitled\"treatersofthesick.\"\"TheirsolefunctionremainedcaringfortheJewishpopu-lationofGermany-peoplethat\"Aryan\"physi-ciansscornedandwereprohibitedfromtreating.7Inadditiontonationallegislationaimedatpro-scribingJewishphysicians,organizedGermanmedicineaggressivelypursuedthisend.Jewishofficialsweredismissedfromnationalmedicalorganizations,Jewishfacultyandstudentswereforcedoutofmedicalschools,andJewishprivatepracticephysicianswereeliminatedfrominsurancepanelfunds.7HarassmentofJewishdoctorsthroughboycotts,vandalismoftheiroffices,assault,andextralegalimprisonmentbyNazisandtheirphysiciansympathizersfurtherrestrictedtheabilityofJewstopracticemedicine.7WhilethepurgeofJewishphysiciansfromthemedicalpro-fessionhadstrongideologicalmotives,economicincentivesalsoencouragedunemployedyoungGermandoctorstoassumethepositionsandincomesofexpelledJewishdoctors.5TheeliminationofJewsfromthemedicalpro-fessionwasthefirststepontheroadtothe\"mil-lennialfuture\"ofaGermansocietycleansedfromthemalevolentthreatsofraciallyinferiorpeople.InJuly1933,shortlyaftertheNaziscametopower,theregimepromulgatedtheSterilizationAct,or\"LawforthePreventionofGeneticallyDiseasedDescendants.\"5Thisinvoluntarysterilizationlawmandatedthatphysiciansperformeugenicsteril-izationsonindividuals-evenagainsttheirwill-iftheyhadmedicalconditionsviewedasathreattothebloodpurityofGermansociety.Includedunderthislawwerepeopleafflictedwiththepresump-tivelyhereditaryillnessesoffeeble-mindedness,schizophrenia,manicdepression,epilepsy,alco-holism,Huntington'schorea, geneticblindness,deafness,orseverephysicalcongenitaldeformity.4Toimplementthelaw,181genetichealthcourtswereestablished,eachpresided overbytwodoctorsandalawyer.Theyreviewedandauthorizedsteril-izationofcasesreferredprimarilybyphysiciansbutalsoguardiansorinstitutions.Intheperiod1934-1945,between300,000to400,000personsweresterilized.5WiththedehumanizingviewpointthatNazidoctorshadofmanyoftheirpatients,theymovedreadilyfromsterilizingpatientstokillingthem.TheeugenicsterilizationprogramwasexpandedtoencompasswhatwaseuphemisticallycalledeuthanasiabydirectorderofHitlertocoincidewiththeoutbreakofthesecondWorldWar.'0SensitiveevenbyNazistandards,thepracticesandpublicknowledgeoftheeuthanasiaprogram,knownbytheabbreviationofitsBerlinChancelleryaddress\"T4,\"weretightlycon-trolled.Initiallybegunwiththekillingofseverelyhandicappednewborns,theprogramwasexpandedtoinclude older disabledchildrenandadultssuf-feringfrommentalillness.Dr.LeoAlexander,whotestifiedatNurembergregardingmedicalpracticesinNaziGermany,pointedouttheruthlessutilitari-anviewofthemedicalkillingprogramanditsfore-shadowingofgenocide.'2Allwhowereincapableofworkwereconsideredforextermination.PhysicianswereinvolvedineveryaspectoftheT-4killingprogramandempowered-notordered-byHitler'sdecreetomurdertheirpatients.5Physi-cians,mostlypsychiatrists,whoneversawthepatientbutreviewedreportssentbypsychiatricinstitutions,wereresponsibleforselectingpatientsforkilling.'2Thekillingmethodologiesweredevel-opedbyandatthediscretionofindividualphysi-cians.Theyincludedstarvation,lethalinjection,andgassingfirstwithcarbonmonoxideandlaterwithcyanidegas(ZyklonB).'0\"2Promptedbycon-cernforthepublicperceptionofpatientsbeingkilled,physiciansfalsifiedthediagnosesondeathcertificates.Ultimately,protests,particularlyfromtheCatholicChurch,forcedthe cessationoftheT-4programafterapproximately70,000individualshadbeenkilledbythesummerof1941.Nonetheless,physicianscontinuedtomurdertheirpatientsuntiltheendofthewar.5TheconcentrationcampactivitiesofNazidoc-torsarewidelyknown.Giventheavailabilityofpeoplewhohadbeenstrippednotonlyofalllegalrightsbutalsoofeventheirfundamentalstatusasahumanbeing,NazidoctorshadfreereigntoengageinnotoriouslycruelmedicalexperimentsJOURNALOFTHENATIONALMEDICALASSOCIATIONVOL.95,NO.12,DECEMBER20031218

NUREMBERGANDTUSKEGEEandactivelyparticipateinthegenocidalaimsoftheNaziregime.Concentrationcampexperimentswereboth motivatedbymilitaryproblemsfacingthewareffortandpromptedbytheideologicaleugenicaimsofGermansocietyandmedicine.ExperimentsconductedfortheLuftwaffeatDachauconcentrationcampontheeffectsofhypothermiaandhighaltitudeonprisonersaremostwellknown.\"3Uniqueinmedicalhistory,theseexperimentsweredeliberatelydesignedtobelethal.Otherwar-effort inspiredactivitiesincludedstudiesonthefeasibilityoflimbtransplantsandtreatmentofartificiallyinflictedbums,wounds,andinfections.3\"2Examplesofideologicallymoti-vatedconcentrationcampresearchincludedexper-imentsontechniquesofforcedmasssterilizationbymeansofirradiationorinjectionofcausticmaterial,'2thenotorioustwinexperimentsofJosefMengele,'0\"4andeffortstoestablishananthropo-logicalanatomiccollectionofmurderedJewsattheUniversityofStrasbourg.'0\"12Nazidoctorsactivelyparticipatedinthegenoci-dalactivitiesofconcentrationcampsthroughcor-ruptionoftraditionalmedicalrolesbytheunderly-ingNaziideology.TheyappliedtechnologyandtechniquesdevelopedthroughtheT-4euthanasiaprogramtomassmurder,'2aswellasthetechnicalproblemsofdisposalofthevastnumbersofcorpses.'0Therampantovercrowding,malnutrition,andinadequatesanitationpresentinconcentrationcampsgeneratedthepotentialforepidemicinfec-tionsthatthreatenednotonlyprisonersbutalsotheirGermanoverseers.TheNazidoctorsoversawlaborcampinfectioncontrolthroughselectionofpotentiallycontagiousprisonersforthegascham-ber.'0Finally,Nazidoctors,exercisingtheultimatemedicalpoweroverlifeanddeath,performedtheselectionsatconcentrationcampsthatdeterminedwhowasfitforslavelaborandwhowastobeexterminated.'0Indeed,thephysician'sresponsibil-ityforsuchselectionswasmandatedbydirectorderfromHimmler,'swhilethecommandantofAuschwitz,RudolphHoess,alsorequiredNazidoctors,membersoftheSS,toperformpoliticalexecutionsbylethalinjection'6andtobepresentforotherkillings.'6NurembergMedicalTrialAfterthesecondWorldWar,theattitudesofNazidoctorsandatrocitiestheycommittedinthenameofmedicalsciencewere exposedattheNurembergMedicalTrial.Atthe time, thetrialitself,along withthecourt'sarticulationofmedicalethicsinthe10-pointNurembergCode,wasnotwidelyseeninitscontemporarylightasalandmarkstatementinmedicalethicsandjurisprudence.'7IntheUnitedStates,Nazidoctorswere viewedasdementedsociopaths,archetypesofevil.Asaresult,theethicallessonsofNurembergdidnotseemrelevanttothepracticeofAmericanmedi-cine.AsKatzsuccinctlystated,theNurembergcode\"wasagoodcodeforbarbariansbutanunnecessarycodeforordinaryphysician-scien-tists.\"1'8Still,thoseNaziphysicianswhowerenotbroughttojusticewereabletoresumerespectablecareersunmarredbyfurthercriminalbehavior.ManyoftheargumentsadvancedbytheNazidoc-tors(both beforethewarandatthetrial)tojustifytheiractivitiesechoedsimilarsentimentsexpressedbyAmericanphysiciansengagedinunethicalmed-icalactivities.WhiletherecanbenocomparisonbetweenthemagnitudeofcrimesofNazidoctorsandlapsesof20th-centuryAmericandoctors,thereisasimilarityinthecontributingbeliefthatsomepeoplearelessworthythanothers.TheNazidoctorsattheNurembergMedicalTrialbasedpartoftheirdefenseontheclaimthatconcen-trationcampmedicalexperimentationwassimilartostudiesperformedbydoctorsfromotherwesterncountriesonprisoners,sometimeswithouttheircon-sent.Thedefenseattorneysspecificallycitedmalar-iaexperimentsconductedon AmericanprisonersattheStatevillePenitentiaryinIllinois.ThealliedprosecutorsrefutedthisdefensestrategythroughthetestimonyofanAmericanexpertwitness,Dr.AndrewIvy.Ivy'stestimony,thoughitdistortedthehistoricalrecordpertainingtothemalariaexperi-ments,wasabletoseveranyethicallinkbetweentheGermanmedicalatrocitiesandU.S.researchprac-tices.'9However,byglossingovertheethicalques-tionsraisedbythedefense,Ivyandorganizedmed-icinefailedtoconfrontproblematicissuesinAmericanmedicalresearchandclinicalpractice.AmericanMedicalResearchEthicsAmericanresearchandclinicalpracticesborelittleresemblancetotheextremesofmalevolentcrueltyexhibitedbyNazimedicine.Yet,theactivi-tiesofmanyAmericaninvestigatorsseeminglydis-playedsimilardismissiveattitudestowardsthefun-damentalworthoftheirresearchsubjectsasindividualpeople.The NurembergCodeandpar-1219JOURNALOFTHENATIONALMEDICALASSOCIATIONVOL.95,NO.12,DECEMBER2003

NUREMBERGANDTUSKEGEEticularlytheenjoindermandatingvoluntarycon-sentwasnotadoptedaspartofAmericanmedicalresearchethicsafterthesecondWorldWar.Theenormousexpansionandinitialbeneficentauraofsciencethatsurroundedbiomedicalresearch,alongwithanethicofself-sacrificeengenderedbythewar,contributedtoutilitarianpracticesintheUnitedStatesthatendangeredsubjectsinsome-timesill-conceivedstudieswithnebulousbenefitstoscience.Theexecutionoftheseethicallydubiousexperimentswasfacilitatedbytheuseofresearchsubjectsfromvulnerablepopulations,includingconvictsandthementallyincompetent.In1966,HenryBeecherpublishedalandmarkindictmentoftheethicsofmainstreamAmericanmedicalresearch.Heprovidedexamples of22pub-lishedresearchprojects (culledfromalargerlist)thatriskedthehealthorlifeofthesubjectfornotherapeutic benefitbutforonlythepotentialadvancementof\"science.\"Inalmostallcases,nomentionwasmadeofthesubjects'consenttopar-ticipateintheresearch.Beecher,indrawingneed-edattentiontotheethicalerrorsinvolved,conclud-edthattheseresearchersactedfromapparent\"thoughtlessnessandcarelessness,notawillfuldisregardofthepatient'srights...\"20Yet,asubse-quentreviewoftheoriginalpublishedarticlessug-gestedthattheutilitarianmotivesoftheresearcherscontributedtothepeculiarselectionofindividualsforthestudiesinquestion.Thesubjectsforalmostallofthe22studieswereincapacitatedinsomeway:thementallyill,chronicalcoholics,charitypatients,theveryyoungorold,theterminallyill,andservicemen.2'VulnerablepopulationswerewidelyusedforresearchbyAmericanindustry,academicmedicine,andthemilitary.Experimentsontheeffectsofradiationandmind-alteringsub-stancesonunsuspectingand uninformedciviliansandmilitarypersonnelwereprompted bynationalsecurityconcernsamidthewartimemindsetoftheColdWar.Thementalitythatmotivatedtheseandotherstudiesviewedthesubjects\"aspropertywithoutbasichumanrights.\"22Attemptsatjustify-ingsuchresearchbyinvokingthewell-beingofthenationechoedasimilardefensestrategyofferedbytheNazidoctorsatNuremberg.22TuskegeeSyphilisStudyPerhapsthebest-knownethicallyproblematicresearchprojectinAmericanmedicalhistorywastheTuskegeeSyphilisStudydatingfrom1932to1972.TheTuskegeestudy,widely reviewedinboththeprofessionalandlaypress,beganafteraninitiallookattheepidemiologyandfeasibilityofpartialtreatmentofserologicallyconfirmedsyphilisinblackmen.In1932,thePublicHealthService,inconjunctionwithphysiciansblackandwhiteaswellasbothnationalandlocalmedicalorganiza-tions,enrolledapproximately400impoverishedblackmenwithlatentandtertiarysyphilisinalon-gitudinalstudyofthenaturalhistoryofuntreatedsyphilis.Themenwerenotnecessarilytoldtheyhadsyphilisandwererecruitedintothestudywithinducements,suchasaburialstipend,promisesoffreetreatment(initiallygiventosomemen),andhotmealsonclinicdays.Evenafterthewidespreadavailabilityofpenicillin,thesubjectsweredeniedtreatment. Insomecases,workersinvolvedinthestudyactivelypreventedthemenfromreceivingpenicillinforotherailments.Thestudyconcludedformanyofthemenwithdeathandautopsy,whileforothersthestudyendedafterthepublicoutcrywhenJeanHelleroftheAssociatedPressfirstreportedthetrial'sstory.23InterpretationsoftheTuskegeestudyremaincontroversialandhavebeenthesubjectofongoingdebate.24Someauthorshavedefendedthestudyasconsistentwiththestateof1930s'medicalethicsandlambastedthemediafordistortinginformationtogamerheadlines.25Othershaveseenthestudyasanexampleofagovernment-sponsoredgenocidalconspiracy.Ithasalsoengendereddebateregardingtheuseofethicallytainteddata.26Discriminationinmedicine,publicizedwiththerevelationsoftheTuskegeestudy,hasmadeAfricanAmericansleeryofparticipatinginvalidmedicalresearch.24TheTuskegeestudyhasbecomeemblematicofissuesofracisminmedicineandtheabuseofauthoritytoexploitvulnerablepeople.Whileitsethicswillalwaysbedebated,itisclearthattheTuskegeestudyservesastheforemostexampleofAmericanmedi-cine'sexploitationofthoseamongthemostvulner-ableandunwelcomeinoursociety-poorblacksafflictedwithasociallystigmatizingdisease.AmericanMedicalRacialBiasGermanphysiciansdrewsupportfromandlegitimatedtheir racialmedicalpolicesbypointingtoAmericanpracticesofimmigrationrestriction,miscegenationlawsandthetreatmentofAmericanblacksbythesocietyatlargeandorganizedmedi-cineinparticular.OneyearafterGermanJewsJOURNALOFTHENATIONALMEDICALASSOCIATIONVOL.95,NO.12,DECEMBER20031220

NUREMBERGANDTUSKEGEEwererestrictedfrompracticingmedicine,aGermanracialhygienejournalerroneouslynoted,in1939,therefusaloftheAmericanMedicalAssociationtoadmitblackphysicianstoitsmem-bership.5WhiletheAMAdidhaveblackphysicianmembers,itsmembershiprequirementsincludedbelongingtolocalmedicalsocieties.Thus,mem-bershipofmanyblackdoctors,particularlythosefromsouthernstateswhosemedicalsocietiesweresegregated,wasprecluded.27In1939,theAMAagreedtoarequestfromtheNationalMedicalAssociationtodeletefromsubsequentAmericanmedicaldirectoriesthespecialnotation,\"Col.,\"thatappearedafterthenamesofblackmembers.28'29Evenintothe1950sand1960s,theAMAcontin-uedtodebatethequestionofsegregationamongits\"constituentandcomponentsocietieshavingrestrictivemembershipprovisionsbasedonrace...\"30Atthesametime,blackswerebarredfromone-thirdofaccreditedAmericanmedicalschools,sohistoricallyblackinstitutionstrainedthe vastmajorityofAfrican-Americanphysicians.3'SegregationpermeatedtheAmericanmedicalsys-temintheearlyandmid-20thcenturyasitdidoth-erareasofAmericansociety.Racialbarriers,par-ticularlyinthesouth,restrictedblackpatientsfromreceivingcareatmoremodernwhite-onlyhospitalsandpreventedblackphysiciansfrompracticingatthosehospitals,relegatingthemtosubstandardsegregatedfacilities.32AmericanEugenicSterilizationTheUnitedStatespracticedinvoluntarysterili-zationwellbeforetheGermanexperienceduringtheNaziera.ThisAmericanexperienceservedasanimportantmodelfortheimplementationofNazisterilizationpolicybyGermanphysicians.5Eugeni-cistsintheUnitedStatesweremotivatedbycon-cernfortheweakeningofAmericanbiologicalstockthroughthebirthandmedicalmaintenanceofindividualsviewedasdefective,33alongwithracistfearsofthelargenumbersofnon-NorthernEuropeanimmigrants.34ThefearengenderedbytheeugenicallyunfitofAmericansocietyenabledthepassageoflegislationallowingstated-sponsoredinvoluntarysterilization.In1907,Indianawasthefirststatewithsuchlawsonthebooks.4Bythe1940s,29morestateshadsimilarstatutes.35BytheoutbreakofthesecondWorldWar,upwardsof30,000peoplehadbeensubjectedtoinvoluntarysterilizationintheUnitedStates:morethanhalfoftheminCaliforniaalone.35Evenfollowingtherev-elationsoftheNurembergtrials,eugenicsteriliza-tionintheUnitedStatesslowedbutdidnotceaseuntilthe1970s.Theimplementationofforcedsterilizationpoli-cieshadthesupportofnotjuststatelegislaturesbutalsothejudicialsystemandmedicalestablishment.The1927SupremeCourtrulingsinBuckvs.BellheldaVirginiastatuteallowingtheinvoluntarysterilizationofCarrieBuck,a17-year-oldfemalecommittedtoamentalinstitutiontobeconstitu-tional.\"TheprinciplethatsustainscompulsoryvaccinationisbroadenoughtocovercuttingFallopiantubes...Itisbetterforalltheworldifinsteadofwaitingtoexecutedegenerativeoff-springforcrime,orletthemstarvefortheirimbe-cility,societycanpreventthosewhoaremanifestlyunfitfromcontinuingtheirkind...Threegenera-tionsofimbecilesareenough.\"36Theoft-quotedmajorityopinionofOliverWendellHolmeselo-quentlyillustratesthatmainstreamAmericansoci-etyalsoheldsomeindividualsasbeingunworthyoflife.ItwasquotedbydefenseattorneysatNurembergaspartoftheircasejustifyingtheactiv-itiesofNaziwarcriminals.37EditorialwritersofmajorAmericanmedicaljournals,includingJAMAandtheNewEnglandJournalofMedicine,alsoexpressedsimilarsenti-mentstowardsindividualsviewedasinferior.Editorialsdescribedthepossiblesubjectsofeugenicsterilizationas\"unfit,\"38\"incompetents,\"39\"misfits,\"39\"defective,\"or\"Nature'smistakes.\"41ComparingGermanandAmericansterilizationprograms,ananonymouseditorialinJAMAnotedmethodologicalbutnotmoraldifferencesbetweenthetwoprograms.\"InGermany,masssterilizationispresumablybeingcarriedout.Amoregradualevolutionofthepracticeandprincipleshasoccurredinthiscountry.Judgingfromtheuncer-tainbiologicfoundationonwhichhumansteriliza-tionrests,thelatterwouldseemalessdangerousprocedure.Whilerecognizingthepossiblepoten-tialvalueofsterilization,themedicalprofessioncanperhapsserveitspurposebestbyretainingascientificdetachmentinassessingthebiologicandsocialresultsoftheprogramsnowinforce.\"42ContemporaryMedicalPracticesTheevolvingrevelationsoftheNurembergMedicalTrialandtheTuskegeeSyphilisStudyresultedinprofoundchangesinthepracticeofmed-1221JOURNAL OFTHENATIONALMEDICALASSOCIATIONVOL.95,NO.12,DECEMBER2003

NUREMBERGANDTUSKEGEEicineandresearchintheUnitedStates.Today,researchonhumansisregulatedbythegovernmentandoverseenbyinstitutionalreviewboards.Similarly,legislationseverelylimitsorprohibitsexperimentsonincarceratedindividuals.Advancesincontraceptivetechnologyhavelargelybypassedethicalissuesraisedbyeugenicsterilization.Yet,eth-icalconcernsremaininmanyareasofmedicinewhereissuesregardingperceptionsofpatients' statusashumanbeingsandrelativeworthareconcerned.Itistemptingtothinkthatphysiciansandotherhealth-careprovidersareremovedfromtheprejudicesandbiasesofthelargersociety.Thisishardlythecase.Healthcareprovidersmirrortherestoftheworldinharboringnegativeanddehumanizingopinionstowards peopledifferentfromthemselves.Physiciansandother healthcareprovidersengageineverydaypracticesthatjudgeanddehu-manizethepeopleforwhomtheycare.Ingrainedfearsandprejudicesregardingthepatientwhoishomeless,poor,uneducated,asubstanceabuser,aminority,orotherwisedisadvantagedbecomeinad-vertentlyapparentinthelanguageused.Oldterms-suchas\"mongoloid,\"\"cretin,\"\"moron,\"and\"imbecile\"implicitlyprejudicialandonceusedasanacceptablemeansofprofessionalcom-munication,havefortunatelyfallenbythewayside.However,anyonewhohasworkedinahospitalwardorinanemergencydepartment,orspenttimeatanursingstationorstaffloungeisfamiliarwiththepejorativeandderogatorylanguageusedtodescribecertainpatients.Patientsmaybedismissedas\"gomers,\"\"crocks,\"or\"dirtballs.\"Pediatriciansmaydescribeadysmorphicchildasan\"FLK,\"orfunnylookingkid,whileneurologistsmaycareforpatientswhoare\"gorkedout.\"Thefieldofpsychi-atryisperhapsmostlikelytoincludepatientswhomaybeviewedasunlikeorinferiortothehealth-careprovider.Itisnowonderthatmedicaljargonisrepletewithdisparagingtermsusedtodescribementallyillpatients\"wacko,\"\"nutcase,\"\"loony,\"or\"fruitcake.\"Inanybranchofmedicine,profes-sionalsmaybeheardtodeprecatetheworth ofcer-tainpatientsbynotingthattheremayhavebeen\"noguardatthegenepool,\"orthatsomepeopleshouldbe\"toodumbtobreed.\"OnecanimaginethattheNaziandAmericandoctorswhoparticipatedinsomeoftheaforementionedmedicalpracticesreferredtotheirpatients,singledoutfor\"specialtreatment,\"insimilardisparagingfashion.Demeaninglanguagetodescribepatientshasbeendocumentedanecdotallyinboththeprofes-sionalliterature4345andinthelaypress.Useofsuch languagerepresentsacleardeparturefromthecompassionateandrespectfulbehavioraphysicianshouldideallydisplay.LeidermanandGrisso,intheirstudyofthe\"gomer\"designation,emphasizedthatthecircumstancesofa\"gomer\"patientconfermerepatienthoodasopposedtopersonhooduponthatindividual.48Notrestricted toraceorclassdis-tinctions,theyfoundhousestaffusedthetermtodescribepatientswhohadsuffereddeteriorationoftheirmentalcapacityandlosttheabilitytofulfillnormaladultsocialroles.Otherauthorshavealsopointedoutthatcliniciansusesuchdemeaninglan-guageasadefensemechanism;toprotectthem-selvesfromthepainandabsurditiesoftheworldinwhichtheypractice.49'50GeorgeandDundesreport-edanapocryphalstoryofaphysicianwhowassuedfortheuseofderogatoryslanginfrontofapatientandemphasizethatuseofsuchlanguagesaysmoreabouttheuserthanthepatient.5'Whileusedout-wardlyinajocularfashionaspartofthevernacularofmedicine'ssubcultureandinwardlyasacynicalbarrieragainstourlackofomnipotenceandperson-alfrailty,disparaginglanguagepointstoimportantunderlyingcaregiverprejudices.Theuseofslangterminologyisoftenappliedtothosepatientswithdistinctivemedicalandsocialcircumstances,buthealthcareproviders'biasesmayextendfurtherandreflectcommonprejudicesofourlargersociety.Studieswhichhaveexaminedhealth-careproviders'attitudeshaveshowntheyalsostig-matizepatientswhoareidentifiedwithtraditionallydisadvantagedgroupsbecauseofrace,sexualorien-tation,orsocialcircumstances.Physiciansandmed-icalstudentshavenegativeandstigmatizingatti-tudestowardshomosexuals andpatientswithAIDS.5254Patients'racealsoalterstheperceptionoftheirillnessbymedicalstudentsandphysicians.55'56Clinicianssharethelargersociety'snegativepercep-tionsofpeoplewithmentalillness;wishingtoavoidcontactwiththem,wantingsomeoneelsetodealwiththeirproblemsthroughincreasedspecialistreferral,57'58andfearingpotentialviolence.59'60Healthcareprofessionals,bothdoctorsandnurses,holdnegativelybiasedviewsofpeoplewhoaresub-stanceabusers.6163Curiously,thesedemeaningcon-victionsarenottemperedbybutratherincreasewithgreaterclinicalexperience.6'Patientswhoarethefocusofhealthcareproviders'demeaninganddehu-manizingviewsmaycertainlybeawareofthefeel-JOURNALOFTHENATIONALMEDICALASSOCIATIONVOL.95,NO.12,DECEMBER20031222

NUREMBERGANDTUSKEGEEingsoftheircaregivers.Peoplebelongingtoclassesofsocietytradition-allyviewedasinferior,whohavebeenvictimsofdiscrimination,areatriskforreceivingpoormed-icalcare.Ampleresearchhasdocumenteddispari-tiesinhealthcarequalitybasedonracialorethnicfactors.Thesestudieshaveconsistentlyshownthatmembershipinastigmatizedracial/ethnicminorityisassociatedwithreceivinglowerqualityhealth-care.Theproblemiswidespreadandhasbeendoc-umentedinAfricanAmericans,Latinos,Asians,andNativeAmericans.M4Discriminationinhealth-careencompassesallaspectsofdiagnosisandtreatmentwhetherhealthmaintenance,suchasdif-ferencesinratesofmammograms,Papsmears,vaccinations,andprenatalcare;ortreatmentforheartdisease, cancer,surgicalprocedures,andanalgesiaforpaincontrol.Suchdifferencespersistevenwhenpotentialconfoundingfactors,suchassocioeconomicstatus,healthinsurance,andclini-calcondition,aretakenintoaccount.65Authorsana-lyzingthesedifferencesinhealthcaredeliveryhavepostulatedcrossculturalcommunicationdifficul-ties,culturaldifferencesinpatients'perceptionsofillness,orotherpoorlycontrolledunclearmedicalfactors.Themostconcerning,althoughnotsurpris-ing,reasonforrecognizeddisparitiesinhealthcarewouldberacialorculturalbias.Suchabiasishopefullyunconsciousratherthanovertbigotry.Giventhatpatientsaremorelikelytobesatisfiedwithandprefercarefromaphysicianoftheirownculturalgroup,66itwouldnotbesurprisingtofindthatphysicianssimilarlyprefertocareforpatientsconcordantwiththeirculturalgroup.Traditionalviewsholdhealthcareproviderstoahighermoralstandardofbehaviorthanmostothermembersofthecommunity.Theidealimageofaphysicianisofonewhoprovidescompassionatehealingregardlessofhisorherownpersonalfeel-ings.Yet,physicianscanholdwidespreadnegativeattitudestowardsthedisadvantaged,unconvention-al,andminoritymembersofsociety.Theseatti-tudescanimpactpatientcare.Itmaybetemptingtothinkthatvariationsseeninhealthcarepracticesandoutcomesareduetomultifactorialculture,economic,orgeneticdifferencesandtoignoretheinherentprejudicesandbiasesinphysicians'atti-tudesandpractices.WilliamOslerdeclared,\"Perhapsnosinsoeasilybesetsusasasenseofself-satisfiedsuperioritytoothers...moreoftenitisanattitudeofmindwhicheitherleadstobigotryandprejudiceortosuchavauntingconceitinthetruthofone'sownbeliefsandpositions,thatthereisnoroomfortoleranceofwaysandthoughtswhicharenotasoursare.\"67Oslerrecognizedtheuniversalityofthisviceof\"chauvinism,\"that\"wearealldippedinit,somelightly,othersdeeplygrained.\"67Throughoutthepastcentury,indifferentplacesandunderdifferentcircumstances,physicianshaveengagedinmisguidedandappallingpracticesbasedonaflawedvisionofcertainpeopleasinher-entlyinferiorandlessthanfullyhuman.Theanal-ogydrawnbetweenthepastpracticesofraciallymotivatedphysicians-Naziorotherwise-andcontemporaryphysiciansshouldnotbe miscon-struedassuggestingthatwearetheethicalheirstoMengele.NorshouldinvokingaNazianalogybeperceivedasequatingthemagnitudeof Nazidoc-tors'crimes withsomeunethicalAmericanmedicalpractices.Theanalogyisusedtoillustratethatunderlyingbiasedperceptionsofpeople'srelativeworthmayleadtodeplorableconsequences.REFERENCES1.SirFrancisGalton(1822-1911):Statisticianofeugenics[Editorial].JAMA.1965;194:666-667.2.KevlesDJ.Eugenicsandhumanrights.BMJ1999;319:435-438.3.BarondessJA.MedicineAgainstSociety:LessonsFromtheThirdReich.JAMA.1996;276:1657-1661.4.SofairAN.EugenicSterilizationandaQualifiedNaziAnalogy:TheUnitedStatesandGermany1930-1945.AnnInternMed.2000;132:312-319.5.ProctorRN.RacialHygiene:medicineundertheNazis.Cambridge,MA:HarvardUniversityPress;1988.6.ProctorRN.NaziDoctors,RacialMedicine,andHumanExperimentation.In:AnnasGJ,GrodinMA,eds.TheNaziDoctorsandtheNurembergCode.NewYork:OxfordUniversityPress;1992:17-31.7.KaterM.DoctorsUnderHitler.ChapelHill,NC:UniversityofNorthCarolinaPress;1989.8.HitlerA.MeinKampfBoston,MA:HoughtonMifflinCo;1943.9.Hanauske-Abel,HM.Notaslipperyslopeorsuddensub-version:Germanmedicineandnationalsocialismin1933.BMJ1996;313:1453-1463.10.LiftonRJ.TheNaziDoctors:MedicalKillingandthePsychologyofGenocide.NewYork:BasicBooks;1986.11.WeyersW,AckermanA,eds.DeathofMedicineinNaziGermany:DermatologyandDermatopathologyUndertheSwastika.Philadelphia,PA:ArdorScribendi, Ltd;1998.12.AlexanderL.MedicalScienceUnderDictatorship.NEnglJMed.1949;241:39-47.13.BergerR.NaziScience-TheDachauHypothermiaExperiments.NEnglJMed.1990;322:1435-1440.1223JOURNAL OFTHENATIONALMEDICALASSOCIATIONVOL.95,NO.12,DECEMBER2003

NUREMBERGANDTUSKEGEE14.SiedelmanWMengelMedicus:Medicine'sNaziHeritage.MilbankQ.1988;66:221-239.15.Muller-Hill,B.MurderousScience:EliminationbyScientificSelectionofJews,GypsiesandOthers,Germany1933-1945.NewYork:OxfordUniversityPress;1988.16.HoessR.DeathDealer:The MemoirsoftheSSKom-mandantatAuschwitz.Buffalo,NY:PrometheusBooks;1992.17.FadenR,LedererS,MorenoJ.U.S.MedicalResearches,theNurembergDoctorsTrial,andtheNurembergCode.JAMA.1996;276:1667-1671.18.KatzJ.TheConsentPrincipleoftheNurembergCode:ItsSignificanceThenandNow.In:AnnasGJ,GrodinMA.TheNaziDoctorsandtheNurembergCode.NewYork:OxfordUniversityPress;1992:227-239.19.HarknessJ.NurembergandtheIssueofWartimeExperimentsonU.S.Prisoners:TheGreenCommittee.JAMA.1996;276:1672-1675.20.BeecherHK.EthicsandClinicalResearch.NEnglJMed.1966;274:1354-1360.21.RothmanDJ.EthicsandHumanExperimentation:HenryBeecherRevisited.NEnglJMed.1987;317:1195-1199.22.AnnasG.TheNurembergCodeinU.S.Courts:EthicsVersusExpediency.In:AnnasGJ,GrodinMA.TheNaziDoctorsandtheNurembergCode.NewYork:OxfordUniversityPress;1992:201-222.23.JonesJH.BadBlood:TheTuskegeeSyphilisExperiment.NewYork:TheFreePress;1993.24.FairchildAL,BayerR.UsesandAbusesofTuskegee.Science1999;284:919-921.25.KampmeierRH.FinalReportonthe\"TuskegeeSyphilisStudy.\"SouthMedJ1974;67:1349-1353.26.McDonaldCJ.TheContributionoftheTuskegeeStudytoMedicalKnowledge.JNatl MedAssoc.1974;66:1-7.27.ResolutionUrgingThatMembershipintheAmericanMedicalAssociationBeNotDeniedSoleyonBasisofRace,Color,orCreed.JAMA.1939;112:2168.28.CommunicationsFromNationalMedicalAssociation,Inc.JAMA.1939;112:1352-1353.29.AbstractofMinutesofMeetingsofBoardofTrustees.JAMA.1939;l13:2064-2065.30.ResolutionsonRestrictiveMembershipProvisions.JAMA.1950;143:1086.31.SheaS,FulliloveMT.Entryof BlackandOtherMinorityStudentsintoU.S.MedicalSchools:HistoricalPerspectiveandRecentTrends.NEnglJMed.1985;313:933-940.32.BeardsleyEH.GoodbyetoJimCrow:TheDesegregationofSouthernHospitals,1945-1970.BullHistMed.1986;60:367-386.33.PernickM.EugenicsandPublicHealthinAmericanHistory.AmJPublicHealth.1997;87:1767-1772.34.VarmaJ.EugenicsandImmigrationRestriction:LessonsforTomorrow.JAMA.1996;275:734-737.35.RobitscherJ.EugenicSterilization.Springfield,IL:CharlesCThomas;1973.36.Buckvs.Bell.274,U.S.200,U.S.SupremeCourt,1927.37.LetterieG,FoxWLegalaspectsofinvoluntarysteriliza-tion.Fertility&Sterility.1990;53:391-398.38.Sterilizationanditspossibleaccomplishments[Editorial].NEnglJMed.1934;211:379-380.39.Theproblemofhumansterilization[Editorial].JAMA.1934;102:1609-1610.40.Humansterilization[Editorial].JAMA.1935;104:2000-2001.41.KennedyFTheproblemofsocialcontrolofthecongeni-taldefective:Education,Sterilization,Euthanasia.AmJPsych.1942;99:13-16.42.HumanSterilizationinGermanyandtheUnitedStates[Editorial].JAMA.1934;102:1501-1502.43.Hill,TE.TheERIncident.AnnInternMed.1992;116:867-868.44.Anonymous.Dirtball.JAMA.1982;247:3059-3060.45.Anonymous.Gomers.JAMA.1980;243:2333.46.ShenS.TheHouseofGod.NewYork:RichardMarekPublishers,Inc;1978.47.MarkelH.LearningtoTreatNotJudge.TheNewYorkTimes.2001;July17.F5.48.LeidermanDB,GrissoJean-Anne.TheGomerPhenom-enon.JHealthSocialBehavior1985;26:222-232.49.HeilicserB.Redefining\"Dirtball.\"AnnEmergMed.1995;25:559-560.50.BoskC.OccupationalRitualsinPatientManagement.NEnglJMed.1980;303:71-76.51.GeorgeV,DundesA.TheGomer:AFigureofAmericanHospitalFolkSpeech.JAmerFolklore.1978;91:568-581.52.KellyJA,St.LawrenceJ,SmithS,etal.StigmatizationofAIDSPatientsbyPhysicians.AmJPublicHealth.1987;77:789-791.53.KellyJA,St.LawrenceJS,SmithS,etal.MedicalStudents' AttitudesTowardAIDSandHomosexualPatients.JMedEducation.1987;62:549-556.54.RoseL.HomophobiaAmongDoctors.BMJ1994;308:586-587.55.TrierweilerSJ,NeighborsHW,MundayC,etal.ClinicianattributionsassociatedwiththediagnosisofschizophreniainAfrican-Americanandnon-African-Americanpatients.JConsult-ingClinicalPsych.2000;68:171-175.56.RathoreSS,LenertLA,Weinfurt KP,etal.TheEffectsofPatientSexandRaceonMedicalStudents'RatingsofQualityofLife.JAMA.2000;108:561-566.57.LawrieSM,ParsonsC,PatrickJ,etal.Acontrolledtrialofgeneralpractitioners'attitudestopatientswithschizophrenia.HealthBulletin.1996;54:201-203.58.MirabiM, WeinmanML,MagnettiSM,etal.ProfessionalAttitudesTowardtheChronicMentallyIll.HospCommPsych.1985;36:404-405.59.Fabrega,H.DoesaClerkshipAffectStudents'ViewsofPsychiatricPatients?JNervMentDis.1995;183:736-742.60.PackerS,PrendergastP,WasylenkiD,etal.PsychiatricResidents'AttitudesTowardPatientsWithChronicMentalIllness.HospCommPsych.1994;45:1117-1121.61.GellerG,LevineDM,MamonJA,etal.Knowledge,Attitudes,andReportedPracticesofMedicalStudentsandHouseStaffRegardingtheDiagnosisandTreatmentofAlcoholism.JAMA.1989;261:3115-3120.62.Moodley-KunnieT.AttitudesandPerceptionsofHealthProfessionalsTowardSubstanceUseDisordersandSubstance-DependentIndividuals.IntJAddictions.1988;23:469-475.63.SelleckC.KnowledgeandAttitudesofRegisteredNursesTowardPerinatalSubstanceAbuse.JObsGynNeonatalNursing.1988;27:70-77.64.FiscellaK,FranksP,GoldM,etal.InequalityinQuality:JOURNALOFTHENATIONALMEDICALASSOCIATIONVOL.95,NO.12,DECEMBER20031224

NUREMBERGANDTUSKEGEEAddressingSocioeconomic,Racial,andEthnicDisparitiesinHealthCare.JAMA.2000;283:2579-2584.65.WilliamsD.Race,SocioeconomicStatus,andHealth:TheAddedEffectsofRacismandDiscrimination.AnnNYAcadSci.1999;896:173-188.66.SahaS,KomaromyM,KoepsellT,etal.Patient-PhysicianRacialConcordance andthePerceivedQualityandUseofHealthCare.ArchIntMed.1999;159:997-1004.67.Osler,WChauvinisminMedicine.In:Aequanimitasandotherpapersthathavestoodthetestoftime.Ed.JamesNelson.Norton&Co.Inc.NewYork;1963.WeWelcomeYourCommentsTheJournaloftheNationalMedicalAssociationwelcomesyourLetterstotheEditoraboutarti-clesthatappearintheJNMAorissuesrelevanttominorityhealthcare.Addresscorrespondencetoktaylor@nmanet.org.A0**.'TheDepartmentofAnesthesiologyattheUniversity ofTexasMedicalBranchinGalveston,Texasisrecruitingforafull-time,board-eligibleorboard-certifiedAnes-thesiologistfromanaccreditedinstitutionwithcomple-tionofaone-yearclinicalfellowship.Preferredrequire-mentsincludeaone-yeargeneralfellowshipandaone-yearpostdoctoralfellowshipinresearch.Responsibilitiesincludeprovidingclinicalanesthesia,instructingresidents,andsupervisingCRNAsinabusy25-roomoperatingsuiteperformingmorethan1,700casespermonth.Rotatingshifts(nights,weekendsandcall)arerequired.Annualaccruedvacationuptothreeweeks,plusfiveadditionaleducationaldays.Benefitspackageincludesmalpractice,medical,den-tal,disabilityandlifeinsurance.Retirementplansincludeemployer-matchedplanplus401Kand457B-allwithpre-taxmoney.UTMB,homeoftheoldestmed-icalschoolinTexas,islocatedonabeautifulsubtropi-calisland.SocialeventsincludeDickensontheStrand,NewOrleans-styleMardiGras,Caribbeanfestivals,out-doorsports(fishing,sailing,camping,horsebackriding,etc.).Culturalcentereventsincludeplaysandenter-tainmentbyworld-famousperformersattheGrand1894OperaHouse.Manyotheractivitiesawaityouonthishistoricisland.PleasesendaletterandC.V.to:DonaldS.Prough,M.D.,ProfessorandChair,DepartmentofAnesthesiology,UTMB,301UniversityBlvd.,Galveston,TX77555-0591,oremail:[email protected]:409-772-2965,Fax:409-772-4166.UTMBisanequalopportunity,affirmativeactioninstitution,whichproudlyvaluesdiversity.Candidatesofallback-groundsareencouragedtoapply.MEDICALUNIVERSITYOFSOUTHCAROLINAClinicalandResearchFacultyPositionsAvailableDepartmentofMedicine/CollegeofMedicineMedicalUniversityofSouthCarolinaDivisionofCardiologyDivisionofEndocrnology,DiabetesandMedicalGeneticsDivisionofGastroenterologyandHepatologyDivisionofGeneralInternalMedicine/GeriatricsDivisionofHematology/OncologyDivisionofInfectiousDiseaseDivisionofNephrologyDivisionofPulmonaryandCriticalCareDivisionofRheumatologyandImmunologyInterestedapplicantsmaylearnmorebyviewingourwebsiteatwww.musc.eduormayforwardaCVtoglanvilf@musc.eduortoFrancesGlanville,DepartmentofMedicine,96Jonathan;LucasStreet,POBox250623,Charleston,SC29425.MUSCisanEqualOpportunityEmployerandactivelyseeksdiversityinitsstudents,facultyandstaff.1225JOURNALOFTHENATIONALMEDICALASSOCIATIONVOL.95,NO.12,DECEMBER2003