A Last Resort: Legitimizing Medical Experiments in the Colony 

It is something that is considered to be self-evident today: in order to test a new pharmaceutical drug, a randomized controlled trial should be set up and the informed consent of those participating is needed. Before the Second World War, however, few such guidelines existed in print. Rather, medical ethics were implicit and flexible. This obviously did not mean that doctors and researchers had unlimited freedom to experiment on human subjects. But, in colonized regions such as Indonesia, they were often under less control and freer to test experimental therapies and try new things than in Europe.¹ This raises the question of where doctors and researchers placed ethical boundaries within this range. How to trace these? To what extent did extreme conditions, such as life-threatening situations, stretch such boundaries? Did class and/or racism play a role in this?  

Medical experiments in colonial Indonesia 

My own research focuses on the late-colonial period in Indonesia. German medical historian Wolfgang U. Eckart² has called the colonial setting a “laboratory”: an environment for medical testing freer or less regulated than Europe. For instance, the Netherlands already established a Centraal Medisch Tuchtcollege (Central Board of Medical Examiners) in the twenties, which hosted criminal trials against physicians, pharmacists and more – think of doctors vaccinating children without their parents’ consent, patients receiving injections they did not ask for, and so on.³ In colonial Indonesia, however, it was the regular courts that dealt with medical misconduct – it also appears that such cases were rarely brought to court, except when Europeans or their (indentured) staff were mistreated.⁴ Moreover, doctors working in far-off areas were barely under any supervision, while missionary hospitals were mostly staffed by uncertified nurses, now and then visited by a physician.⁵ Finally, doctors that were employed by companies primarily served the owners and not necessarily the patients. The specificity of the colonial setting created a space in which, according to a Dutch doctor working in Indonesia at the time, human subject research was done “by many a corporate doctor (…) sneakily yet practically”.⁶

But why would they want to perform (risky) experiments next to their busy practice in the first place? Quite some European doctors in the colony hoped to use the results of their research in publications that would benefit their career and maybe get them a prominent job back home. In these publications, they often legitimized why they took certain risks with patients, for example by referring to successful tests done with the same drug by others or by explaining how the chemical composition of a drug would benefit the patient. This practice of legitimization, however, was manifested rather differently in what I would call the “last resort”-experiment. 

Patients beyond rescue 

In last resort cases, doctors assumed the patient was more or less beyond rescue. In such cases, trying a pharmaceutical that was in some way considered a “rational” choice was accepted, at least by colleagues in the field. Doctor J.A. Slot (Belinju), for instance, wrote in 1929: “Every treatment, that has even the slightest theoretical chance of healing, is in my opinion justified when it comes to a disease with such a high mortality.”⁷ Evidence backing the possible benefits of a drug were, for example, the successes of other physicians, the chemical similarity to a normally used drug (that perhaps was not available due to remoteness of the hospital or war), or a pharmaceutical firm’s promises about its effectiveness. There is, however, an obvious bias here: doctors almost exclusively published stories about last resort remedies that actually worked. After all, only then did it benefit their own career and could it inspire larger-scale trials. Contemporaries were aware of this; dr. S.F.W. van Hasselt (Surabaya) wrote already in 1902 that evidence for new drugs is usually very selective, “and when it comes to lethal cases, they will apologize and comfort by saying that these were already advanced too far, so that nothing could have really been done”.⁸ Van Hasselt thus already acknowledged that some colleagues used the “last resort” as an excuse to experiment on patients.  

Diagnosing the desperation 

In order to legitimize an experiment as a last resort to save a person’s life (or sight, hearing, limb…), the physician had to underline the emergency of the situation to his colleagues. In the 1900-1942 editions of the Geneeskundig Tijdschrift voor Nederlandsch-Indië (Medical Journal of the Dutch Indies, GTNI for short), perhaps the most important journal for doctors in colonial Indonesia to publish in, I have found 58 cases in which a doctor legitimized an experiment this way. Quite often, the physician’s own experience was quoted as evidence for the gravity of the illness. Writing about a hemophiliac Chinese employee with a large wound, dr. R. Römer (Deli) mentioned that his “experience with him made me fear the worst”, and therefore tried something “at my wits’ end”.⁹ Similarly, dr. J. Haga (Malang) also simply “knew that the child had a small chance of recovering” – and therefore experimented.¹⁰  

Experiences of other doctors or the status quo of research could also be invoked as determining factors in deciding on an experimental treatment. Dr. H.B. van Buuren (Weltevreden) shared the story of a woman with a large tumor in a meeting in Batavia on the 22^nd of July, 1920. He had “assumed to be justified in this desperate case to do an experiment with a treatment about which he had read somewhere.¹¹ Dr. P.J. van der Schaar chose to do a larger trial on patients of the psychiatric hospital of Magelang who suffered from late-stage syphilis. He considered it common knowledge that the existing therapy did not work well, which left the physician “insufficiently armed” against “the severity of the paralytic suffering”, and therefore his attempt to help these patients with injections of yaws seemed “by all means justified”.¹²

And sometimes, outright desperation was enough. Otto Deggeller, experimenting with formaldehyde sodium bisulfite on plague patients in Malang, simply stated that he had tried this on a “hopeless” seven-year old Indonesian girl because “nobody here knows what to do and after all there is nothing to lose”.¹³ A.C. van der Togt (Aceh) had multiple patients suffering from dysentery for whom “months of long treatment with pretty much all known drugs had not been able to bring healing” before he eventually tried curing them with his experimental sugar enemas.¹⁴

Consent and vulnerability 

Although it may be considered indispensable today, patients’ consent was not necessarily asked in early twentieth-century Indonesia. Often it was simply a patients’ own choice whether to take a drug or not, sometimes pressure was subtly implied (e.g. in the case of travelling eye doctors such as J. Tijssen, fig. 1), and occasionally force was used.¹⁵ Last-resort experiments, however, often employed another kind of consent: hypothetical consent. Nowadays, this term is used to describe situations in which the patient is not (or no longer) able to give consent and thus the doctor decides whether it is in the best interest of the patient, to initiate or proceed with a certain treatment. A patient may not be able to give consent due to unconsciousness, inability to speak, mental state, or an impassible language barrier.¹⁶ Many of the last-resort experiments in colonial Indonesia were such situations, or were at least presented as such. After all, most European doctors and nurses could not even communicate with their patients as they did not speak the local languages.¹⁷ Does that mean the experiments could all be justified under the present concept of hypothetical consent? 

The American professor of psychology and law, Gideon Yaffe, writes that “appeals to hypothetical consent are really just assertions to the effect that paternalistic behavior is in this instance justified”.¹⁸ In doctor-patient relationships, there is always a danger of paternalism.¹⁹ In the case of the European physician and the Indonesian patient, it is almost inherent, reflecting the complex dynamics of power, race, and class at play in the colonial setting.²⁰ 

Such dynamics can be seen in the GTNI as well. Of all “last resort” articles, around 75% mention that the patients were either Indonesian, Chinese, or very likely one of these (in case they were indentured laborers on Sumatra). Moreover, test groups in articles about experiments on indentured laborers were generally much larger than those in other studies. Besides a handful of Japanese and unidentified patients, there is only one case in which it becomes clear that the patient was European. Within the colonial system, however, not only race, but class played a role as well. The majority of patients were indentured laborers, who were allegedly the lowest class in society.²¹ One could tentatively conclude, that being non-European and/or part of a lower class made a patient vulnerable to last-resort-type experiments. It thus seems that Slot’s statement that every treatment is worth a try was only true for those whose autonomy was not (fully) respected. 

Then and now 

In late-colonial Indonesia, it was not uncommon for doctors to attempt an experiment on patients who were considered beyond rescue. Such experiments have saved lives or ended lives faster, but they have also boosted doctors’ careers and overruled patients autonomies. Some patients were more vulnerable than others: in particular being non-European and of the lower classes of society impacted patient autonomy. Consent was not asked in such cases; rather hypothetical consent was crudely assumed. 

Where does this leave us today? More research is currently being done on racism, class and medical misconduct, yet the topic remains understudied.²² In colonial Indonesia, extreme situations made certain groups more vulnerable to becoming experimental subjects than others. Class and race played a structural role in this and continue to do so today. Reflecting on the past can make us aware of these very real challenges that shape medicine today. 

1. For instance, pharmaceutical companies appeared to keep track and control over tests with their new products in Europe, but did not check on what happened with their drugs in the colonies: Bayer Archives Leverkusen, 166-005 Prüfungsvorschriften 1908-1926. ↩︎
2. Wolfgang U. Eckart, ‘The Colony as Laboratory: German Sleeping Sickness Campaigns in German East Africa and in Togo, 1900-1914’ History and Philosophy of the Life Sciences 24:1 (2002) 69-89. ↩︎
3. Nationaal Archief, 2.09.21 Inventaris van het archief van het Centraal Medisch Tuchtcollege, 1931-1975. ↩︎
4. For instance: ‘De Ampullen Zaak’, Geneeskundig Tijdschrift voor Nederlandsch-Indië 77:39 (1937) 2330-2399; ‘Verslag der Rechtszaak Dr. W.R.O.G. Visum et Repertum, No. 1 (1937)’ GTNI 78:44 (1938) 2711-2797. ↩︎
5. For instance: Katholiek Documentatie Centrum Nijmegen, KomMissieMemoires 146, 183, 247, 370, 531. ↩︎
6. [“op listige en toch practisch uitvoerbare wijze”] C. Bonne, ‘De ontwikkeling der geneeskundige wetenschappen in Nederlandsch-Indië in de periode 1911-1935’, in: Feestbundel 1936 Geneeskundig Tijdschrift voor Ned.-Indië (Batavia: G. Kolff, 1936) 16-44, 31. ↩︎
7. J.A. Slot, ‘Eenige gevallen van gedeeltelijke en geheele remming van de Beenmergverrichtingen’ GTNI 69 (1929) 381-392, 385-386. ↩︎
8. S.F.W. van Hasselt, ‘De Cholera-Afdeeling van het Militair Hospitaal te Soerabaia van af 31 Juli t/m 31 December 1901’ GTNI 42 (1902) 459-495, 491. ↩︎
9. R. Römer, ‘Adrenaline als haemostaticum’ GTNI 44 (1904) 32-39, 39. ↩︎
10. J. Haga, ‘Een ervaring uit de praktijk met de bacteriophagotherapie bij bacillaire dysenterie’ GTNI 81:10 (1941) 467-476, 471. ↩︎
11. Vergadering Batavia 22 juli 1920, GTNI 60 (1920) cii. ↩︎
12. P.J. van der Schaar, ‘Entingen met Framboesia bij lijders aan Dementia Paralytica’ GTNI 73:18 (1933) 1138-1145, 1142. ↩︎
13. O. Deggeler, ‘Behandeling van pestlijders met intraveneuse injecties van formaldehyd-natrium-bisulfurosum’ GTNI 55 (1915) 26-34, 30. ↩︎
14. A.C. van der Togt, ‘Rietsuikerlavementen bij amoebendysenterie’ GTNI 61 (1921) 395-402, 399. ↩︎
15. A. Ellinger, ‘Palingbloed bij staphylomata anteriora van de cornea en bij chronische ontstekingen der cornea en selera’ GTNI 40 (1900) 607-617, 612; A. Deutman, ‘De oogheelkundige verzorging der bevolking in Nederlandsch-Indië’ GTNI 77:51 (1937) 3269-3274; Gani Jaelani, ‘Preserving the Resources: Plantations and Mines Workers’ Hygiene’ Archipel 104 (2023) 33-56; Frank Okker, Tumult: het levensverhaal van Madelon Szekely-Lulofs (Amsterdam/Antwerpen: Atlas, 2008); Gust Baermann, Rapport XIII-XX, 1919-1925 Serdang Doctor Fonds, Hospitaal Petoemboekan, Oostkust van Sumatra (Medan: Varekamp & Co., 1926) 79; W.J. Bais, Over verbreiding en bestrijding van eenige ziekten onder de arbeiders in de tropen (Amsterdam: Koloniaal Instituut, 1920) 27, 112. ↩︎
16. For instance in the case of a constantly bleeding unconscious Chinese woman in Cepu, who received experimental treatment with milk injections by Otto Deggeler: O. Deggeler, ‘Melklavementen als bloedstelpend middel’ GTNI 47 (1907) 7-10, 9. Another example, also by Deggeler, is the abovementioned one of the plague patients in Malang, who were delirious with fever and made it difficult for him to inject them with his experimental treatment of fonabisit. ↩︎
17. Raden Adjeng Kartini, letter to E.H. Zeehandelaar (October 11, 1901), published in: Raden Adjeng Kartini (ed. J.H. Abendanon), Door duisternis tot licht (Den Haag: N.V. Electr. Drukkerij ‚Luctor et Emergo‘, 1923) 144; Liesbeth Hesselink, ‘The early years of nursing in the Dutch East Indies, 1895-1920’ in: Sue Hawkins and Helen Sweet (eds.), Colonial caring: a history of colonial and post-colonial nursing (Manchester: Manchester University Press, 2018) 145-168, 151. ↩︎
18. Gideon Yaffe, ‘Hypothetical consent’ in: Peter Schaber and Andreas Müller (eds.), The Routledge Handbook of the Ethics of Consent (London: Taylor and Francis, 2018) 95-104, 99. ↩︎
19. John Kleinig, ‘Paternalism and consent’ in: Schaber and Müller, The Routledge Handbook, 140-152. ↩︎
20. The category of race is not a biological given but a social and cultural construct. ↩︎
21. Abdoel Gafar, ‘Indrukken en uitkomsten der tuberculosebehandeling in de C.B.Z. te Semarang’ GTNI 77:47 (1937) 2912-2922, 2913 ↩︎
22. Some examples: Mirjam Faissner and Esther Braun, ‘The ethics of coercion in mental healthcare: the role of structural racism’ Journal of Medical Ethics 50:7 (2024) 476-481; Bushra Zafreen Amin, ‘Ethical considerations of recruiting migrant workers for clinical trials’ Journal of Medical Ethics 47:6 (2021) 434-436; M. Gambino, ‘Fevered decisions: race, ethics, and clinical vulnerability in the malaria treatment of neurosyphilis, 1922-1953’ Hastings Center Report 45 (2015) 39-46, 46; M. Brazier, ‘Exploitation and enrichment: the paradox of medical experimentation’ Journal of Medical Ethics 34:3 (2008) 180-183, 181-182. ↩︎