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September 1999
Volume 63 |
Number 9
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| Henry K. Beecher,
M.D.: Contrarian (1904-1976) |
Vincent J. Kopp, M.D.
Henry Knowles Beecher, M.D., is one of the most influential personalities
in the history of anesthesiology and medicine. The list of his
achievements, honors and publications is as impressive as the
role of medical leaders he mentored. Yet Beecher remains a hidden
presence behind the visible facade of modern medicine. To those
who knew him, he was gregarious, imposing and energetically committed
to controversy. To those who opposed him, he was a genteel but
persistent adversary. It is impossible to conceive of modern medicine
without his contributions, all of which derive from his contrarian
views on a wide range of important issues. His legacy is the influence
that his views and work have had on medical science, academic
anesthesiology, medical ethics and society's standards regarding
patients' rights and the definition of death.
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.
By adopting Beecher, he had a name that associated him with the
great 19th century American abolitionist and preacher, Lyman Beecher,
his preacher son Henry Ward Beecher and his daughter, author Harriet
Beecher Stowe.
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. Fortunately for anesthesiology, he was persuaded
to study medicine instead. 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.
Medical Ethics and Society
If paternity of clinical research's "gold standard" was
not enough to win fame, Beecher's involvement in two other controversies
earned him a place in medical history's annals. 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 the person 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 Neuremberg 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.
The most apocalyptic contribution Beecher made was to
form the committee and write 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," became
the sentinel event in the now 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. That his work set the stage for landmark
legal decisions in the Karen Ann Quinilan and Nancy Cruzon cases
and others, thus the genesis of modern biomedical ethics, is less
apparent but no less real.
Conclusion
Contrarian, colleague, mentor, public figure -- no matter
how he is viewed -- Henry K. Beecher left a vivid impression on
anesthesiology. Of more importance is the indelible mark he has
left on medical practice in Western culture. It is likely few
who knew him when he was engaged in the controversies he loved
saw the future he envisioned. Whether they went with him or against
him at a given moment of controversy, it is likely only Beecher
sensed where his contrarian positions would lead. Henry Knowles
Beecher shaped more than anesthesiology. He shaped the world in
which anesthesiology is practiced. Few in our profession can be
said to have done as much.
Vincent J. Kopp, M.D., is Assistant Professor
of Anesthesiology and Pediatrics and Adjunct Assistant Professor
of Social Medicine, Department of Anesthesiology, University of
North Carolina at Chapel Hill School of Medicine, Chapel Hill,
North Carolina.
References:
- Greene NM. Henry Knowles Beecher, 1904-1976 (obituary). Anesthesiology.
1976; 45:377-378.
- Welch CE. Henry K. Beecher (obituary). N Engl J Med. 1976;
295:730.
- Gravenstein JS. Henry K. Beecher: The introduction of anesthesia
into the university. Anesthesiology. 1998; 88:245-253.
- Beecher HK, Todd DP. A study of deaths associated with anesthesia
and surgery. Ann Surg. 1954; 149:2-34.
- Papper EM. The origin of the Association of University Anesthesiologists.
Anesth Analg. 1992; 74:436-453.
- Beecher HK. Pain in men wounded in battle. Ann Surg. 1946;
123:96-105.
- Beecher HK. The powerful placebo. JAMA. 1955; 159:1602-1606.
- Beecher HK. Measurements of Subjective Responses: Quantitative
Effects of Drugs. New York: Oxford University Press, 1959.
- Beecher HK. Ethics and experimental therapy. JAMA. 1963; 186:858-859.
- Kopp VJ. Henry Knowles Beecher and the development of informed
consent in anesthesia research. Anesthesiology. 1999; 90:1756-1765.
- Beecher HK. Ethics and clinical research. N Engl J Med. 1966;
274:1354-1360.
- A definition of irreversible coma: A report of the ad hoc
committee of the Harvard Medical School to examine the definition
of brain death. JAMA. 1968; 205:337-340.
- Van Norman GA. A matter of life and death: What every anesthesiologist
should know about the medical, legal and ethical aspects of
declaring brain death. Anesthesiology. 1999:275-287.
- . Rothman DJ. Strangers at the bedside: How law and bioethics
transformed medical decision making. Basic Books, 1991.
* Dr. Miller presented his paper, "Henry Knowles
Beecher: A Man of Controversy" at the Third International Symposium
on the History of Anesthesia, Atlanta, Georgia, March 30, 1992.
This paper is available through the Wood Library-Museum of Anesthesiology,
Park Ridge, IL.
** On October 20, 1996, during the 1996 ASA
Annual Meeting, three of Henry K. BeecherÕs former residents,
Arthur S. Keats, M.D., Nicholas M. Greene, M.D., and George E.
Battit, M.D., held a videotaped panel discussion of their recollections
about Dr. Beecher. Titled ÒRemembering Henry K. Beecher, M.D.,Ó
this video became part of the ÒLiving History of AnesthesiologyÓ
collection at the Wood Library-Museum of Anesthesiology. The biographical
and anecdotal information contained in this video paints a lively
picture of Beecher as an energetic mentor and leader of these
respected anesthesiologists. I have used this information and
information obtained through conversations with other former Beecher
trainees, some of whom wish to remain anonymous, as well as anecdotes
shared in conversations with J.S. Gravenstein, M.D., Leroy D.
Vandam, M.D., Dr. Miller and Dr. Greene to construct a vivid,
yet accurate, picture of Henry K. BeecherÕs complex biography.
*** Kopp VJ. Henry Knowles Beecher and the
redefinition of death. Bull Anesth Hist. 1997; 15:6-8.
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