Maurice Pappworth’s activities in the late 1950s and 1960s affected this College in two main ways; in speeding the reform of its activities and in leading to its eventual British code on the ethics of human experimentation. To be sure, others were to catalyze both processes. Several Fellows had pressed the College to end its role as a mere obscurantist establishment club, something it was able to do once it acquired a reformist President in Robert Platt [Munk’s Roll, Vol.VII, p.470] and a new site in Regent’s Park. (Some of these Fellows also almost certainly believed that candidates needed teaching for the MRCP examination, and jobs at at least one hospital - the Central Middlesex in North London - were highly sought after because it ran special courses for housemen.) At Harvard the professor of anaesthesiology, Henry K Beecher, had publicly documented many examples of egregiously unethical research, while in London the editor of the BMJ, Hugh Clegg [Munk’s Roll, Vol.VII, p.103], was busy translating his dismay at their transatlantic counterparts into a World Medical Association document that eventually became the Declaration of Helsinki. Yet without Pappworth's particular brand of vehemence, which he carried into the public domain, the College would have been slower to act and solutions to these problems would have taken much longer.
Pappworth could conduct such campaigns because he was a lifelong outsider. Despite honours in his finals, with several prizes and working in the mid 1930s as a junior for Henry Cohen [Munk’s Roll, Vol.VII, p.106], he had been told that as a Jew he would never get a consultant job at a Liverpool teaching hospital. After the war (in which he finished as a lieutenant-colonel, having served in Italy, India and in the civil war in Greece), the message was the same. So, by now married, with a family, he settled down to several consultant posts in the home counties and concentrated on another interest: postgraduate teaching, in particular for the membership examination.
At the time the pass rate in the MRCP was dreadful - the level dropping to 15%. Part of the reason for this low figure was the unstated but obvious need to restrict entrants to medical senior registrar posts. But equally part of the problem, Pappworth maintained, was the appalling teaching in British medical schools; MRCP candidates were crammed with abstruse facts but could not examine a patient correctly. To remedy this, Pappworth held regular private courses in his rooms (and later in a public hall) to teach doctors what their elders in the teaching hospitals had been appointed to do - the elements of medicine. The cost was not small - a £1 note (that is, a twentieth of a housemans salary at the time) dropped into a bowl as the student left the two hour class - but the results were outstandingly good. On occasion half the successful candidates had been to his classes (and often his more expensive mock clinical examinations, held in peripheral mental hospitals as well). Many of today’s consultants will still own up to bitterness about the harshness of the set-up which led to so much anxiety and expense at a time when they should have been with their young families. Yet they will also acknowledge that not only did the system ensure that they really knew medicine backwards, but that they also owe their posts to Pappworth’s tutelage. Though this concentrated on the fundamentals of medicine, he did not eschew sharp words and sarcasm for the individual who got things wrong. Even so, at this time Pappworth was not only the best medical teacher in London, but probably throughout Britain as well. And he did not mince his words about the medical establishment and their individual failings, which he would document with unforgiving and remorseless accuracy.
Pappworth published his lectures in a clinical primer, but (though it went into three editions) it was not a comprehensive account even of elementary medicine and it reads in a curiously leaden way compared with the incisiveness of his spoken talks. His other major book, Human guinea pigs (London, Routledge and Kegan Paul, 1967), was far more readable and it was to have profound results on the way medical research was regarded - and conducted. For throughout the late 1950s and 1960s he became increasingly concerned by descriptions published in medical journals of unethical experiments on patients in both Britain and the USA, despite informal guidelines such as the Nuremberg Code. Several of his postgraduate students (particularly those working at the Postgraduate Medical School at Hammersmith) reinforced this concern, telling him of their anxieties in taking an active role in such research.
Pappworth wrote letters to the editors of journals publishing work he considered unethical, but these were often rejected for publication. Hence he collected together fourteen examples of ethically dubious research, publishing them in 1962 in a special issue of the influential quarterly The Twentieth Century. The first part of his articles title, Human guinea pigs: a warning, was used again for his later book. (Incidentally, this title repeated, without acknowledgement, or the author’s permission, the title of an earlier book by Kenneth Mellanby about conscientious objectors who had volunteered in wartime to take part in physiological and nutritional experiments). Pappworth’s book also included many more, now fully referenced, examples than the article - including experiments on children, the mentally defective and prison inmates. Often these had entailed cardiac catheterization, without any possible benefit to the patient or truly informed consent having been obtained, the sole reason seeming to be the advancement of knowledge or the experimenters career through prestigious publications.
The publications provoked a furore, with newspapers and television features devoted to them. Several members of the medical establishment advised Pappworth to keep his own counsel and not wash the profession's dirty linen in public, but he refused. Nevertheless, by then the World Medical Association had produced the first version of the Declaration of Helsinki, and some years later a report by a special College committee was published and eventually led to the formation of research ethics committees throughout the country.
Pappworth was acerbic in most aspects of his life: invited to address the residents at Hammersmith Hospital after his book had been published, within minutes he alienated an audience that had at first been largely sympathetic to his views by his personal comments about the consultants involved. He pressed home with vehemence his campaigns as much as he could, in the general media or professional publications. He was single-minded, and not until he retired did he spend much time at his house in Hampstead on photography (he also had a notable collection of water-colours and had married an artist, by whom he had three daughters) or on reading, mostly nonmedical philosophy. Even near the end of his life, in a commissioned article for the BMJ, he stated that: "My opinion remains that those who dirty the linen and not those who wash it should be criticized. Some do not wash linen in public or in private and the dirt is merely left to accumulate until it stinks." [1990, 301, 1456-60]
Inevitably such attitudes led to Pappworth's being disregarded in official circles, and in 1972 he spoke of belonging to a very select band of less than ten who had been Members of the College for over 35 years. Fortunately, however, a new generation was able to take a more objective view of his achievements, and in 1993 he was finally elected to the Fellowship. The spontaneous applause at the admission ceremony at the College was led by the then Harveian Librarian, Sir Christopher Booth, who had formerly been director of the research centre at Hammersmith Hospital. So not only did good sense prevail, but finally honour was done to a man who, however challenging and prickly, had done medicine and the wider world a considerable service.
Stephen Lock
[The Independent, 12 Nov 1994; Brit.med.J., 1994,309,1577; Fellowship Affairs, Apr 1997]
Post publication addition
Maurice Pappworth's papers are held in the Wellcome collection.
[https://wellcomecollection.org/works/h45bxkr3 accessed January 2022]