By Rafael Escandon<\/p>\n
Every June, I reflect on how Henry Knowles Beecher<\/a> must have felt – 60 years ago – in the days before his classic, Ethics and Clinical Research<\/a> (E&CR) was published. From my first reading of it, I thought Beecher\u2019s effort was remarkably brave and have considered him a personal hero ever since. As I learned more about how E&CR<\/em><\/strong> was developed, I added New England Journal of Medicine editor Joseph Garland to my heroes list. As E&CR<\/em><\/strong> celebrated its 60th<\/sup> anniversary in June 2026, I\u2019m adding a tribute to a third hero.<\/p>\n My June reflections got a jump-start this year as I listened to a repeat of \u201cThe Cowboy Philosopher<\/a>\u201d episode of the Hidden Brain<\/em> Podcast. Originally conceived as a story about fallen heroes, the host tells the story of Riley Shepard \u2013 a talented and freewheeling American singer, writer and salesman who died in 2009 without being recognized for his greatest achievement. Shepard is described not as a whistleblower, but rather as a con man, an unreliable parent, and someone known by many names in both life and death. His transgressions aside, Shepard somehow had the fortitude to put together an Encyclopedia of American Folk Music<\/a> \u2013 a work so well referenced that no publisher appreciated its brilliance at the time. His correspondence with an archivist at the Library of Congress gives insight into the work\u2019s complexity and importance – And it was those descriptions that got me thinking about Beecher\u2019s process for preparing his March 1965 Brook Lodge presentation<\/a>; largely regarded as the precursor of what became the bombshell, E&CR<\/em><\/strong>. \u00a0Such fastidiousness also reminded me of someone else \u2013 a figure who\u2019s never received his just recognition in American bioethics circles.<\/p>\n Beecher\u2019s E&CR<\/em><\/strong> is one of the best-known works in research bioethics. It catalogued twenty-two examples, masterfully pared down from an original fifty, through Beecher\u2019s collaboration with then NEJM editor Joseph Garland<\/a>. In E&CR<\/em><\/strong>, a broad swath of research transgressions was exposed: participants included in research without their knowledge, without their consent, or without any prospect of direct benefit. Other studies yielded limited to no generalizable knowledge, were superfluous, and others were shockingly brutal, bizarre and indulgent. E&CR\u2019s <\/em><\/strong>publication catalyzed a change in the future of research governance in the United States and inspired mandates for institutional review boards, solidified informed consent requirements, and influenced the principles included in the Belmont Report<\/a>. Somewhat peculiarly, E&CR<\/em><\/strong> contains only five references; with four of the five citing either published works and a papal encyclical. Reference number three is the curious outlier: Pappworth, MH. Personal communication<\/em>.<\/p>\n Many historians and ethicists<\/a> rightly regard Joesph Garland as an unsung hero by his decision to overrule his colleagues and both edit and publish E&CR<\/em><\/strong> in NEJM. In both roles, Garland was masterful. But it\u2019s the influence of Maurice Pappworth, a British physician with the same convictions as Beecher\u2019s, that is sadly overlooked. Pappworth\u2019s public exposes in England predated Beecher\u2019s in the US by several years, and it was to Pappworth that Beecher reached<\/a> out for counsel as he conceived what became E&CR<\/em><\/strong>.<\/p>\n Beyond their interest in research ethics, Beecher and Pappworth had other interesting similarities. Both changed and anglicized their surnames (from formerly Henry Unangst to Beecher, and Maurice Papperovich to Pappworth). Though Beecher was older by six years, they completed their medical education at approximately the same time, and both served as military physicians during World War II.<\/p>\n Pappworth had passed the notoriously difficult examination for membership into the Royal College of Physicians in 1936, an accomplishment that should have opened London’s teaching hospitals and opportunities for specialization to him – In a cruel display of classism and likely antisemitism, it did not.<\/a> So, while Beecher was beginning his academic career at one of America\u2019s most prestigious medical schools, Pappworth was unable to secure an appointment as a consultant (attending) physician anywhere in England.<\/p>\n In contrast to Beecher, Pappworth became an independent physician and postgraduate tutor for the RCP membership exam he passed in 1936. It was serving in that tutoring capacity that proved seminal to Pappworth\u2019s future as a research ethics watchdog. His postgraduate students – mostly junior doctors rotating through London’s teaching hospitals – relayed troubling accounts of what they were witnessing. From patients undergoing cardiac catheterization without consent, to children having liver biopsies as teaching exercises, to prisoners and the institutionalized used as experimental material, Pappworth was appalled. He began by writing letters to the editors of journals criticizing published works he considered unethical, but these critiques were often rejected for publication<\/a>.<\/p>\n Pappworth fastidiously collected further evidence and, in 1962, published fourteen examples of ethically dubious research in the UK quarterly magazine Twentieth Century<\/em>, under the title “Human Guinea Pigs: A Warning<\/em><\/strong>.” The piece was blunt and derisive, and the British medical establishment was extremely displeased. He was told by colleagues to be quiet<\/a>. He ignored them and ultimately published a full-length book with more than 200 exactingly referenced unethical studies entitled: Human Guinea Pigs: Experimentation on Man<\/a> in 1967 \u2013 a year after E&CR<\/em><\/strong> landed in NEJM.<\/p>\n It was the 1962 Twentieth Century<\/em> article that Beecher read and was captivated by. It showed Beecher that a public case about medical ethics could be made with sufficient impact in mainstream print. After reading it, Beecher wrote to him in January 1965 seeking help<\/a>. Their correspondence ran over the next year – the period of the Brook Lodge presentation and through the development of what became E&CR<\/em><\/strong>. Pappworth generously provided cases, citations and documented examples of abuses to Beecher. Pappworth\u2019s elegantly referenced evidence, and Beecher\u2019s academic credentials offered Pappworth validation and a colleague with professional cache – things he\u2019d been denied for decades in the UK.<\/p>\n Their early correspondence reveals shared ideals and likely provided each mutual reassurance, as Beecher wrote in his January 1965 letter<\/a>: \u201cI agree heartily with your thesis and indeed have often spoken along the same lines myself<\/em>.\u201d Interestingly, this differed from the position Beecher ultimately took in E&CR<\/em><\/strong> of not naming names. It was this that became the most consequential moral divergence between them. Pappworth believed that only by naming and shaming could any expos\u00e9 be a future deterrent, and further, that anonymizing was a capitulation. Beecher and Garland believed their choice to omit the identities of individual study authors was essential, and that by not doing so, the medical profession\u2019s ability to self-regulate was at stake.<\/p>\n In a July 1966 letter to Pappworth<\/a>, Beecher claimed his position was also shaped by legal advice from a Harvard law professor who warned him that named researchers could face criminal prosecution – an outcome Beecher (and Harvard) were unwilling to risk. Beecher later explained his reasoning with a phrase that captured his revised strategy: “I have no wish to point a finger at individuals. I was pointing to an all-too-general practice<\/em>.” Pappworth believed that letting authors remain anonymous left them unaccountable, and thus in Human Guinea Pigs, full citations were included – a reflection of his conviction that the medical establishment would protect its own unless the names of those responsible were listed.<\/p>\n E&CR<\/em><\/strong> earned its canonical status because it was presented in an understandable form and reached the right audience at the right moment. And while Pappworth and Beecher disagreed on if and how to hold doctors accountable, it was Pappworth who provided much of the moral courage and inspiration to publicly say what was previously unsayable<\/a>. Notwithstanding that the final version of E&CR<\/em><\/strong> includes Pappworth, MH,<\/em> only in the footnotes, without him, this historic article that catalyzed such a change in human research ethics might never have publicly resonated.<\/p>\n So, every June going forward, I\u2019m honoring Maurice Pappworth as the hero to modern research bioethics that he was, one who should rightly keep company with Henry Beecher and Joseph Garland.<\/p>\n