This paper aims at analyzing the film of Miss Evers’ Boys from the view of research ethical principles. It sheds light on the choices adopted by the main characters including Miss Evers and how their actions squared with their professional code of

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This paper aims at analyzing the film of Miss Evers’ Boys from the view of research ethical principles. It sheds light on the choices adopted by the main characters including Miss Evers and how their actions squared with their professional code of ethics. The paper tries to answer two main questions. What does this reveal about professional codes of ethics? What does this reveal about the characters’ moral reasoning in the scientific research?

Written by

Wasim Al-Habil

The paper analyzes the film “Miss Evers’ Boys,” which is based on the true story represented in Tuskegee Syphilis Study. The first part discusses the main ethical issues which this case talks about. Then, the light is focused on major characters who involved in this case like a nurse “Evers” and doctor “Broadus” and how they behaved with the ethical side of the study. The analysis will be grounded on the American Nurse and Doctor Association Code of Ethics.

In terms of the main ethical issue, the Public Health Service (PHS) decided in 1932 to conduct a study in Macon County, Alabama to examine the sequences of untreated syphilis in African-American patients by using the facilities of the Tuskegee Institute. African-American people, who lived in poverty and lacked the medical health care, were told that they would be given some financial and food assistances and free examinations for “bad blood,” a term which is locally used to refer to different ailments. Hundreds of African-Americans were involved in the experiment which was called “The Tuskegee Study of Untreated Syphilis in the Negro Male.” However, the true nature of the study was never revealed or explained to them. The disease was not treated even after 1943 when penicillin became available as a safe and effective treatment. The case got worse when some of these people were prevented from being treated when they were seeking for it during the World War II. The study assumed that it would continue until the death of the last one of its subjects. The story was broken in 1972 by the Washington Star and the ethical side emerged to incriminate the medical side of the Tuskegee study.

Some might argue that there were no major ethical problems with the experiment when it began because it was conducted for sake of promoting public health and there was no clear effective treatment for the disease. The unethical part of the issues involved later when the focus started to be only on the medical side of the case regardless the human right of existence during the availability of the treatment.

From the first glance, the medical research is generally based on the theory of teleology that judges actions to be good or bad on the account of its consequences; rather than its means. The researchers were seeking for achieving certain medical results in light of its effect on the patients, not in terms of treating the sick patients while the treatment was available. They did not care about the health of human beings for the sake of achieving scientific medical results, which in turn violates the code of ethics of medicine. The Code of Ethics of Medical Doctor states that doctor has to “refrain from denying treatment to [your] patient because of a judgment based on discrimination.” This was violated clearly by the whole study.

Some of the main ethical questions that should be raised include the following:

  1. Was the purpose of the experiment ethical to obtain information on the syphilitic damage which these men were suffering from?

  2. Had the patients been treated properly and whether had any been told the nature of the study?

  3. Are the untreated syphilitics still followed for autopsy?

  4. Why was the study permitted to continue for many years even after the time when penicillin became the effective drug of choice against the disease?

  5. Why were the patients prevented from getting the treatment when they were required to get?

By the time when the story became to public, hundreds of men had died from syphilis and many members of their families had become infected by the disease especially after the treatment was available and no one of the patients benefited from it. It is obvious that the justifications, which had been proposed for starting the study in 1932, were no longer relevant or ethical. Even from the teleological view, the consequences of the study were horrible if it is measured by the number of the lost souls which could be saved if they were given the treatment.

One of the prominent persons who involved in this case and had a major role was the African-American Miss Evers (in real life Nurse Rivers). Rivers, PHS nurse, was assigned to monitor the experiment and to ensure the cooperation of the patients throughout the time of the experiment. Although she had some concerns about the goals and requirements of the study including the lack of informing the patients of their conditions and the treatment for syphilis, she thought that her job as a professional nurse was to follow the orders of doctors. According to American Nurses Association Code of Ethics, a nurse is required “to protect the public from misinformation and misrepresentation and to maintain the integrity of nursing.” Nurse Rivers violated this principle of Code of Ethics by misinforming the patients about their real medical status and hiding information that there was no treatment for the syphilis (when the penicillin became available).

Within this context, she was behaving according to the conventional logic (stage 3 & 4), that can be classified as ethnocentric (Kohlberg – Six Stages of Moral Development). She was motivated by a need to belong to the group of the medical team by conforming to the medical norms and rules (stage 3). Moreover, she was attached to respecting law and order that controlled the study (stage 4). She is a rational-oriented woman who prefers reasoning on sympathy and feelings. Therefore, she decided not to go with her lover on the account of leaving her job.

On the other hand, she believed that the patients in this study were better off because they received better medical care for diseases, other than syphilis, that most African-American patients in the area did not enjoy. Besides this, they had the chance to get some food and money which was important for these poor people. Her justification, here, is based on a narrow view of the utilitarian philosophy as she believed that the participation of these patients would be good for them. Indeed, she knew that there was no effective treatment for syphilis and these people were earning more than losing based on the best available alternatives.

Her social background and abilities allowed her to become a highly trusted person within the community of patients and to maintain strong relationships with their families. For several years after end of the experiment, she refused to believe it had harmed the men. She did not see a major ethical problem with the study except that the patients were not told directly and clearly that they had syphilis. This point might seem unethical in terms that the medical service was not “provided so as best to promote the public interest” as Bayles outlined in his article, The Professions (p.92). This unethical side became clearer when the penicillin became available.

It seems hard to evaluate the position that nurse Rivers took in terms of the ethical side of the study. In one hand, if one observes her financial conditions when she involved, salary and other monetary benefits, hiding information from patients, and her part in purchasing corpses for autopsy, the evil side of her role will obviously be clear. Teleology can be seen here that she judged the situation according to its beneficial consequences to herself on the account of the patients. On the other hand, if one observes her role as a professional nurse, her belief that patients had great benefits from the study, and her truthful and honest feelings for the patients and their families, there will be no room for any evil. In other words, she thought that she achieved her needs through meeting the needs of the patients as well. Nonetheless, many people, including me, who judge her position from outside may think that she played unethical role in this case. However, to draw objective moral knowledge, one should put himself in the seat of nurse Rivers with all the surrounding circumstances and events to make the right judgment as Dewey indicated in his article Moral Judgment and Knowledge (1932, p.333).

From the view of the principle based logic that states “treat everyone as an end; rather than as a treatment to your end,” Nurse Rivers did not intend to harm any patient in this experiment and she did not see a major unethical manner in dealing with them. It was hard for a nurse to follow her concerns about ethics since all the doctors surrounding her did not have ethical concerns about the case. Moreover, the study was not a secret and it was discussed in many professional conferences and panels without questions about its ethical side. Many other papers were published in professional peer-reviewed journals without referring to any unethical issue. Moreover, the study itself was funded by governmental money. Even though if nurse Rivers made some evil things, she did not see any wrong with what she did based on the common sense (intuition) about ethics in the study. If any nurse believes that she is a professional person who was trained to follow doctors’ orders as a sign of her acceptable job performance, and who clearly see all the people in her profession handling an issue without any concerns that it may be unethical thing to do, she would have the same position. Thus, nurse Rivers’ position in terms of the professional ethics of the study might be justified even if it was not undoubtedly right.

Nurse Rivers did not meet one of the Friedrich’s dual standards of administrative responsibility, which are technical knowledge and popular sentiment. In fact, nurse River did not have a problem with what Friedrich calls the technical knowledge because she considered the scientific standards of her career as a professional. However, Friedrich may argue that the irresponsibility was caused because nurse Rivers failed to consider the references of people. In fact, the unethical actions, which are not treating the disease when penicillin became available as an effective treatment as well as not allowing patients to be treated when they were seeking for it, makes the case clear that nurse Rivers failed to consider the public preferences and the public health . According to American Nurses Association Code of Ethics, nurse is required to “provide services with respect for human dignity and the uniqueness of the client, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.” It is obvious that neither the study nor Miss Rivers were committed to this principle especially when one of the patients went to another clinic to get the penicillin but his name was on the black list.

Friedrich would argue that it was important that nurse Rivers meets his second standard by considering “what would be the reaction of the public” (Friedrich, p.406) to her participation in the experiment. Her decision to continue her effective participation to ensure the patients’ cooperation during the time of the Tuskegee experiment ignored the sentiment and reaction of people. Thus, because nurse Rivers failed to be responsive to the public interests, she illustrated the lack of accountability. In other words, she was able to demonstrate more responsibility of public service if she quitted this study because of the unethical issues involved. In sum, Friedrich’s position may be that even though nurse Rivers was responsible for acting according to technical standards, she was irresponsible in regard to the preferences of people. The American Nurses Association Code of Ethics   states that “the nurse collaborates with members of the health professions and other citizens in promoting community and national efforts to meet the health needs of the public.” Her patients were in need but she and the medical team failed to recognize this fact.

On the other hand, Finer would argue that neither professional standards nor popular sentiment might have solved the lack of accountability in nurse Rivers’ case. The scientific standards were followed by nurse Rivers because she acted as a professional nurse whose first duty is to obey the doctors’ orders. However, her professional peers were not able to recognize the unethical position that she held. Moreover, the professional standards seemed to be responsible for the lack of accountability because the standards in this profession did not distinguish any problem with ethics in a well-known experiment for long time. In other words, although the ethical side of the study was clearly questionable, not one of the professionals, for more than thirty years, thought that the Tuskegee experiment might seem to be in conflict with their standards. In brief, Finer would think that Friedrich’s professional standards led to the lack of accountability while at the same time these standards should work to maintain it.

Finer would also argue that Friedrich’s second standard does not only work in reality, but it also lacks the justification to be considered as a standard. Finer believes that public servants have no right to decide whatever is the appropriate value, action, or rule that ensures public good. According to Dunn (2003), Finer argues that “democratic government required that the preferences of citizens be expressed through an elected constitution” (p.65). Finer states that “the servants of public are not to decide their own course; they are to be responsible to the elected representative to the public” (p.7). In other words, it is the responsibility of representatives rather than public officials to decide the public good. Otherwise, the internal checks and control of professionals will lead, according to Finer, to corruption in public administration (Shafritz 2004). This argument consists with Finer’s perspective that the most effective way to ensure accountability of public officials in democratic system is through the external control of legislators and popular institutions. Thus, Finer would see nurse Rivers’ problem as a lack of an external authority to check whether she met the required accountability of public servants.

However, Friedrich may argue again that the problem is not the external checks which do not seem to be effective. The complexity of public administration requires professionals to deal with ethical decisions because they are the only ones who have the ability and the experience to enclose the proper understanding of how to deal with ethical issues. Outsiders, including the legislative power, who require any external check lack the scientific knowledge that trained servants have. In addition, the Tuskegee Syphilis Study was conducted under the supervision and support of the Public Health Service (PHS), which is obviously a department under the monitoring of the Congress. However, no external checks were effective or basically existed to consider the ethical part of the Tuskegee study. Thus, Friedrich may argue that the Congress was not able to decide whether nurse Rivers, and the study in general, had any unethical part of its procedure.

Another interesting character is Doctor Broadus who violated the ethical code of the medical doctor. The code of ethics states at the very beginning that a doctor has to “consider first the well-being of your patient.” Doctor Broadus was sympathetic with the patients at the beginning of the study. However, he did not maintain accurate and honest relationship with patients by hiding information about their actual medical diagnosis and the ultimate purpose of the study. In addition, when the penicillin became available he was shocked at the beginning that the treatment would not be given to the patients. However, he was influenced by the medical team in Washington D.C. and flipped to the other side.

He got tempted by achieving personal gain and selfish benefits by approving the study to continue and depriving the needy patients from getting the available treatment. He was greedy to make a professional name for himself on the account of the well-being of the patients which clearly violated the code of ethics. He wanted the continuation of the federal funding for the study on the account of the horrible consequences and damages that hurt the patients. It is very obvious that he violated the code of ethics of Clinical Research that a doctors must:

 “Recognize that considerations relating to the well-being of individual participants in research take precedence over the interests of science or society.”

 “Make sure that all research participants or their agents are fully informed and have consented to participate in the study. Refrain from using coercion or unconscionable inducements as a means of obtaining consent.”

 “Inform treating doctors of the involvement of their patients in any research project, the nature of the project and its ethical basis.”

 “Respect the participant’s right to withdraw from a study at any time without prejudice to medical treatment.” (Source: AMA Code of Ethics)

Code of ethics and the analysis of the movie reveal interesting facts about the professional ethics. The ethical codes of public administration are inherently conservative in that they socialize members to a collective identity, a proscribed role dedicated to the protection of pre-defined value(s). The core of that responsibility has been to maintain the integrity of democracy by faithfully executing the will of the people (patients in the movie), although how that will is re-presented and by who has been a perennial debate. At the start of public administration as a self conscious discipline, the call for professionalism was an effort to escape self-interested and corrupt action through science and rationality. Professionalism draws action toward certainty, objectivity and scientific truth; it offered the possibility of good government through expertise and authority. With expertise as the governor for discretion, Waldo argued the old question of how we ensure that we have good government (by having the good people govern), was converted into a technical problem (1948). Good government is accomplished by experts whose scientific knowledge is directed to the efficient achievement of politically defined ends. This was seen clearly by the medical team in the movie who tried to achieve certain scientific medical ends regardless of the human needs of the patients.

The identification of ethical behavior with adherence to technical expertise has not been without its strengths in public administration but it has also brought a number of ethical dilemmas. Professional ethics of any vocation maintain and presuppose the validity of established practices and part of this involves acceptance of core precepts. In public administration, that core precept has been technical rationalism, which precludes ethical reasoning because it maintains a focus on instrumental reasoning and external accountability to rules rather than moral agency and attention to ends (Pugh, 1991; Thompson; Adams and Balfour, 1998). And this is what Nurse Rivers and the medical team committed in Tuskegee Study. As a result, most conceptions of professional behavior in public administration that issue from the orthodoxy through the new public management have remained amoral in character.

A second difficulty posed by the ethic of technical rationality is that it fostered a modus operandi that is elitist and inherently anti-democratic. Waldo wrote of this danger in The Administrative State when he noted that administration by elite professionals subverts democracy and becomes rule by the philosopher kings (1948). Professional administrators who have mastered a body of knowledge that informs their judgments are disinclined to value input from a disorganized cacophony of citizens who may perceive their needs differently. The esoteric language that accompanies specialized training, and the tendency of organizations to value what they can measure rather than worker-citizen’s need or their interactions further reinforces the disaffection of citizens from government processes. The conceptual strands that identify values to guide professional behavior in public Administration are multiple but the story that has emerged is a progression from a call for science and neutrality during the Progressive Era to recognition of the inescapably political character of practice by the 1940’s.

In recent years, there are two competing streams of thought that guide administrative action. One is driven by logic drawn from public choice economics and business that has constructed government as a proxy for market-customer relations where the central tenet of human behavior is self interest (represented by the personal benefits possessed by Rivers and Broadus), and the alternative which has defined and elaborated an ethic that emphasizes fairness, justice, representation and participation in public administration. The latter draws on the political logic of democratic citizenship and civil society to enhance representative democracy and Constitutional values. Scholars in this vein have sought to establish a professional ethic informed by the regime values of the Constitution (Rohr, 1978), an agential perspective attentive to institutional values (Wamsley, et al, 1996), social equity (Frederickson, 1990) and procedural values that enhance representative democracy by accountability to citizenry (Alexander and Richmond, 2003; Stivers, 1990, 1994; King and Stivers, 1998; Cooper, 1998).

Those who advocate for the “new public service” encourage administrators to view themselves as “professional citizens,” to develop horizontal ties with citizenry, and inform political mandates through active citizen-administrator relationships, thereby shoring up the rather shaky process of formal legal democracy. The professional ethic emerging from this body of work is grounded in a pragmatic recognition of the limitations of representative democracy and the political logic of popular sovereignty. Scholars exhort administrators to first honor their relationship and responsibility to citizenry and secondarily to honor organizational missives (Cooper, 1998).

Political accountability is further represented and supported in the ASPA Code of Ethics which asserts that administrators are responsible when their decisions are attentive to the democratic principles that ground public administration (Hejka-Ekins, 1988; Pugh, 1991). The Code (first approved in 1984, revised in 1994) enjoins its members to exercise discretionary authority to “work to improve and change laws and policies that are counter-productive or obsolete,” and to “promote constitutional principles of equality, fairness, representativeness, responsiveness, and due process in protecting citizens’ rights.”

In summery, professional models of public administration are idealized in the sense that they assume political mandates will be legitimate and will embody the just if not the good. Discretion, when supported, is in service of political mandate – not in opposition. Justification of action is grounded on technical expertise and utilitarian logic, emphasizing the importance of serving the public interest. All models presuppose democratic accountability. This described ethics which encourages moral agency, strong citizen identification, and the political logic of democracy and Constitutionalism, is intended to support administrative action when the organizational rules run out (Fox, 2001).

Typical ethical challenges presented in the literature involve self-interested action wherein the individual administrator or powerful interests subvert the public interest for individual gain, or the administrator confronts “competing public sources of obligation” requiring a determination of which has legitimacy (Harmon, 1995, p.100). Responsible action has meant accommodation to external sources of morality, most often privileging accountability and obligations to organizational hierarchy or the larger public interest rather than individual judgments and agency regarding right action (Harmon, 1995).

Circumstances in which the administrator must determine how to proceed because a political mandate and the corresponding rules are inherently harmful is seldom, if ever,

addressed. In the circumstance of corruption, familiar models offer the choice to obey, seek support from authority higher in the organizational hierarchy, whistle blow, or resign. Alternatively, given a conflict between what an agency regards as an appropriate course of action and a political mandate, senior level administrators have the opportunity under a separation of powers to “choose their Constitutional masters” (Rohr, 1985). Front line administrators, however, are in another circumstance: they are not encouraged to exercise agency or build political support for alternative courses of action.

Nonetheless, street-level workers are de facto policy makers operating at some remove from accountability because their work is not directly observable (Lipsky, 1980; Maynard-Moody and Musheno, 2003). As Maynard-Moody and Musheno note, “street level work is, ironically, rule saturated but not rule bound” because “rules and procedures can never universally fit each case and every circumstance” (2003, p.10). Front line workers typically use their personal value system, or cultural frame to discern which rules apply in a given context (Maynard-Moody and Musheno, 2003). Accountability of front line work is further attenuated if citizens are involuntary and do not serve as a reference group for the bureaucracy that ‘serves’ them (Lipsky, 1980:28). The problem we bring forward is that current ethical frameworks provide insufficient support for discretionary action that protects citizens from harm. Moreover, we argue that front line works are typically not masked from the impact of their actions on citizens. When front line administrators are aware that enactment of a policy will result in harm, they need a logic that supports the protection of citizenry and the citizens’ needs.

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