Henry K. Beecher
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Henry K. Beecher, M.D. was an important figure in the history of anesthesiology and medicine characterized variously as gregarious, imposing and as a genteel but persistent controversialist with contrarian views on a wide range of important issues, including medical science, academic anesthesiology, medical ethics and society's standards regarding patients' rights and the definition of death.[1]
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[edit] Background and Education
The first of two children, Beecher was born in Peck, Kansas, in 1904. His birth name was Harry Unangst. Harry was the name those who knew him used, but Henry became the name of his public persona. His last name, Unangst, translates loosely from German to mean "without fear." Elliott V. Miller, M.D., says it accurately describes his defining trait.* Yet, for reasons that are unknown, he replaced Unangst with Beecher in his 20s.
Beecher worked and borrowed to attend the University of Kansas. He earned an A.B. degree in 1926 and an A.M. degree in 1927 in physical chemistry. His goal was to earn a Ph.D. in chemistry at the Sorbonne. However, in 1928, he entered Harvard Medical School where he developed a keen interest in respiratory physiology, becoming adept at doing physiology experiments. As a student, he earned research fellowships in 1929, 1930 and 1931. He won two Warren Triennial Prizes for papers published in the Journal of Applied Physiology in 1933. In his last year of medical school, he conducted a study of postoperative pneumonia in which he proved the role of aspiration of vomitus. This and his previous medical student work caught the attention of Edward Churchill, M.D., Professor of Surgery at Harvard. An early pioneer in the thoracic surgery field, Dr. Churchill took a keen interest in Beecher's scientific work and became his professional mentor.
In 1932, Beecher graduated cum laude from Harvard Medical School. After two years of surgical training under Churchill at Massachusetts General Hospital (MGH), he went to Denmark as a Mosely Fellow in 1935 to work in the physiology laboratory of Nobel Laureate August Krogh. Upon his return in 1936, directed by Dr. Churchill, Beecher left surgery to become Anaesthetist-in-Chief at MGH and Instructor in Anaesthesia at Harvard Medical School. Beecher wanted to receive formal training in anesthesia from either Ralph M. Waters, M.D., or John S. Lundy, M.D., but was dissuaded from doing so by Dr. Churchill. In 1939, he rose to Associate Professor, and in 1941, he was named Henry Isaiah Dorr Professor of Anaesthesia Research, becoming the first occupant of an endowed chair in anesthesiology in America. That Beecher ascended to this position without ever receiving formal training in anesthesia is ironic, given the extent to which he had already shaped anesthesiology as a medical discipline rooted in applied basic sciences. It is also a fact that prevented him from gaining ASA membership until 1938, when he qualified under grandfather provisions. Except for service in the U.S. Army in North Africa and Italy during World War II (with Dr. Churchill), Beecher completed his entire professional career at Harvard and MGH, stepping down as Chair in 1969 after gaining departmental status for the Division of Anaesthesia.**
Between 1939 and his retirement in 1969, Beecher used his prominent academic position to break new ground in anesthesia. By applying academic standards to anesthesia research and clinical care, he advanced anesthesiology as a medical specialty with unique scientific potential. His early work on the effects of surgery on respiratory function helped define the role of controlled ventilation. Beecher's commitment to patient safety took root in his early career. In his reports to the Trustees of the Dorr Professorship, Beecher documented improvements in morbidity and mortality directly related to the use of specially trained physicians instead of medical students and interns to deliver anesthesia at MGH. At the same time, however, he also maintained a nurse anesthesia school along side his residency program. His landmark study of factors contributing to mortality associated with surgery and anesthesia, the oft-quoted Beecher and Todd study, was one of the earliest multicenter studies conducted in America. Its focus on the safety of anesthesia also made it a unique application of epidemiology to the field. That this study's results startled many in the anesthesia community and were published in the surgical literature helped solidify Beecher's reputation as a contrarian. Nonetheless, perhaps more than any other, this study stimulated awareness about the need for vigilance when using muscle relaxants.
Beecher's relationship with organized anesthesiology was not smooth. As mentioned, he was barred from ASA membership, even as he ascended to become Anaesthetist-in-Chief at MGH, until 1938. A close look at his publication list reveals only a handful of papers, and none of the most important ones was published in the anesthesia literature. Further, he chaffed under ASA's position on a range of subjects, from employment and compensation structure to the use of the word "anesthesiology" to describe the field. Concerned as he was with such distinctions and the status of the academic anesthesia practice in particular, he joined with Robert D. Dripps, M.D., Austin Lamont, M.D., and E.M. Papper, M.D., to form the Association of University Anesthetists (as it was originally named) in 1953.
Beecher's greatest contribution to science and the academy came from his work in clinical pharmacology. His investigation of the relationship between subjective psychological states and objective drug responses began during World War II. In Pain in Men Wounded in Battle, he wrote, "Three-quarters of badly wounded men, although they have received no morphine for hours... have so little pain that they do not want pain relief medication, even though the questions raised remind them that such is available for the asking. This is a puzzling thing and perhaps justifies a little speculation." His systematic questioning of this observation led to his advocating placebo in all drug clinical trials, a practice he wanted extended to studies of surgical techniques as well. Through his advocacy, Beecher became, in effect, the father of the prospective, double-blind, placebo-controlled clinical trial.[2]
[edit] Medical Ethics and Society
Beecher is significant for his involvement in two other controversies. More than anyone, Beecher was responsible for initiating peer review of experimental protocols and assuring that informed consent was obtained in clinical research. He was also responsible for the redefinition of death from cardiovascular to neurologic in nature.*** In taking leading roles in these controversies, Beecher acted as the consummate contrarian.
After studying the Nazi medical experiments conducted during World War II, Beecher recognized that investigational subjects' rights were also being systematically abridged in United States facilities where federally funded research was conducted. His efforts to publicize these abridgments fell on deaf ears until 1966 when he published his landmark article, "Ethics and Clinical Research." In it he presented 22 representative examples (he had more) of experiments on humans conducted by unnamed (but renowned) investigators where basic, accepted standards of human subject treatment, as outlined in the Nuremberg Code of 1947, were disregarded. Following the article's publication, the National Institutes of Health and the Food and Drug Administration altered their investigator guidelines to require peer-reviewed superintendence and evidence of informed consent in all human experiments. In essence, Beecher's revelations caused creation of the Institutional Review Board system and informed consent standards that continue to be refined and monitored wherever federal dollars are expended.
Beecher also formed the committee and wrote the report that dealt with the problem of the hopelessly unconscious patient. The report, "A Definition of Irreversible Coma: Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death," was a key event in a three decades' long debate about when life ends, when it begins and who controls its events. In the published report, the committee took pains to delink the issues of brain death and organ transplantation. However, Beecher's papers at the Francis A. Countway Library of Medicine at Harvard reveal that adopting the brain death definition was linked from the outset to increasing organ availability as far back as 1968. That the issue concerning when donor organ harvest for allographic transplantation is permissible still bumps up against the issue of when is a human being dead illustrates the centrality and prescience of Beecher's work on the subject. His work would have relevance for the landmark legal decisions in the Karen Ann Quinlan and Nancy Cruzon cases.
[edit] Notes
- ^ The general literature commonly misattributes the term "placebo effect" to Henry K. Beecher's 1955 paper The Powerful Placebo when, in fact, it had been first used by Graves in 1920. In his 1955 paper, Beecher only speaks of placebo effects on specific occasions when he is contrasting them with drug effects. His 1955 paper constantly and correctly speaks of "placebo reactors" and "placebo non-reactors"; furthermore, Beecher (1952), Beecher, Keats, Mosteller, and Lasagna (1953), Beecher (1959), consistently and correctly speak of "placebo reactors" and "placebo non-reactors"; they never speak of any "placebo effect"; and, finally, in his Research and the Individual: Human Studies (1970), Beecher simply speaks of "placebos".
- ^ This was the extraordinary significance of his 1955 paper. It was not that the paper spoke of placebo reactions, its importance was that it stressed, for the first time, the necessity of double-blind, placebo-controlled clinical trials.
[edit] Sources
- Beecher, H.K., "Experimental Pharmacology and Measurement of the Subjective Response", Science, Vol.116, No.3007, (15 August 1952), pp.157-162.
- Beecher, H.K., Measurement of Subjective Responses: Quantitative Effects of Drugs, Oxford University Press, (New York), 1959.
- Beecher, H.K., Research and the Individual: Human Studies, Little, Brown, (Boston), 1970. [ISBN 0-7000-0168-9]
- Beecher, H.K., "The Powerful Placebo", Journal of the American Medical Association, Vol.159, No.17, (24 December 1955), pp.1602-1606.
- Beecher, H.K., Keats, A.S., Mosteller, F. & Lasagna, L., "The Effectiveness of Oral Analgesics (Morphine, Codeine, Acetylsalicylic Acid) and the Problem of Placebo "Reactors" and "Non-Reactors"", Journal of Pharmacology and Experimental Therapeutics, Vol.109, No.4, (December 1953), pp.393-400.
- Graves, T.C., "Commentary on a Case of Hystero-Epilepsy with Delayed Puberty: Treated with Testicular Extract", The Lancet, Vol.196, No.5075, (4 December 1920), pp.1134-1135.
