Recently, a series of police killings of unarmed African Americans, including George Floyd and Breonna Taylor, has renewed attention to the history of abuses and institutional racism in the United States. This national conversation has led to institutional name changes (for example, removing Woodrow Wilson’s name from the Princeton University School of Public and International Affairs) and removal of monuments (such as the statues of Christopher Columbus and former Mayor Frank Rizzo in Philadelphia) whose namesakes supported white supremacy. In medicine, named lectureships, professorships, and other honorifics are used to solidify the legacies of individuals deemed important. In a moment with calls for diversity, inclusion, equity, and antiracism, physicians can use this as an opportunity to reflect on who is honored and whether they speak to current values.
In 2019, the Society for Investigative Dermatology (SID) board of directors discontinued the prestigious leadership lectureship and travel awards in Kligman’s name (originally established in 2007) because of “membership concerns regarding Dr. Kligman’s past clinical research practices.” Kligman was indisputably a giant in dermatology. His accomplishments included the development of tretinoin (Retin-A) for acne and wrinkle treatment, pioneering fungus studies, and the original description of the human hair cycle. Although the general public might not know his name, Kligman arguably influenced dermatology and the modern skin-care industry more than anyone else.
Yet underneath his achievements lies a troubling history of human experimentation and direct harm to vulnerable and marginalized people. Kligman’s work was often not only controversial but also unethical.
From the 1950s through the 1970s — detailed in Allen Hornblum’s book, Acres of Skin — as a faculty member at the University of Pennsylvania, Kligman led human subject research on prisoners, mostly African Americans with limited literacy.* These inmates were primarily involved in cosmetic and pharmaceutical testing but were also inoculated with infections and received biopsies and injections. The experiments included exposure to chemicals such as dioxin, a carcinogen and component of Agent Orange, which Kligman argued was too minimal an amount to cause harm.
His other studies investigated radioactive and hallucinogenic compounds in partnership with the U.S. government and pharmaceutical companies. Kligman published many studies detailing intentional inoculation of human subjects: herpes simplex and vaccinia virus, human papillomavirus, and Candida. Children with mental disabilities were infected with fungal infections of the scalp. Many of these studies were conducted without formal ethical review, although formal ethical review did not begin in the United States until the late 1960s and 1970s.
This history of experimentation on prisoners alone is troubling. In his own words to the Philadelphia Bulletin in 1966, Kligman described his first visit to Holmesburg Prison in 1951, when called to treat a fungal outbreak: “All I saw before me were acres of skin. It was like a farmer seeing a fertile field for the first time.” In his reminiscing, it seems as though he saw prisoners as objects for experimentation. He also said: “It was years before the authorities knew that I was conducting various studies on prisoner volunteers. Things were simpler then. Informed consent was unheard of. No one asked me what I was doing. It was a wonderful time.”
Kligman seemed to think that lack of required informed consent and oversight made prisoners an ideal population for studies. Kligman paid prisoners for their participation, a practice that by the 1970s was widely understood as coercion and corruption of consent. These inmates had little access to money and were mostly unconvicted detainees awaiting trial, and many could not afford bail.
The American medical establishment did not widely condemn experimentation using prisoners until the 1970s, and Kligman was certainly not alone in this kind of work. Prior to this time, however, the vulnerability of prisoners was well-known; notably, the non-legally binding Nuremberg Code, created after World War II in 1947 in response to Nazi human experimentation, banned such exploitative and unethical studies. Still, despite this, the U.S. government, academic institutions, and companies continued to support experimentation on prisoners. This context is important, but it does not absolve Kligman’s decision to engage in such studies.
The medical community — as well as the University of Pennsylvania and Pennsylvania State University — must ask themselves, given his practices, whether Kligman should still be used as an exemplar of research and leadership. His prison experiments were non-therapeutic, meaning the various agents he tested were not meant to benefit the human subjects themselves. This group of mostly African American men endured harms for the benefit of everyone.
Given the oppressed and coerced status of prisoners, as noted in 1973 U.S. Senate hearings led by Sen. Edward Kennedy, the practice of prisoner experimentation was unethical even if these men provided consent and even with remuneration. This milieu of medical abuses (including Holmesburg Prison, but most prominently, the U.S. Public Health Service’s Tuskegee Study of Untreated Syphilis in the Negro Male, commonly referred to as Tuskegee) led to the creation of the Belmont Report in 1978. The report established the first public national body to address U.S. bioethics policy and continues to inform human subject research oversight by institutional review boards.
Kligman, who died in 2010, never engaged in meaningful discussions about the harms from his prison studies. In 2006, to the New York Times, he said: “My view is that shutting the prison experiments down was a big mistake. … I still don’t see there having been anything wrong with what we were doing.” When 298 former inmates sued the University of Pennsylvania in 2000, the suit was dismissed due to the expiration of the statute of limitations; other settlements to individuals were paid by Kligman, the University of Pennsylvania, and the City of Philadelphia.
Some may question the fairness of judging historical figures by today’s standards. However, even with more than 30 years hindsight, Kligman would not acknowledge even any possible harm, and he and others benefited financially and professionally from the misdeeds. Indeed, his best-known achievement, Retin-A, was born in Holmesburg Prison. Thus, the SID was correct to remove Kligman’s name, and other institutions that still honor his name should do the same.
It must be recognized that names such as Kligman’s may be tied to donations and/or contractual obligations, and decisions to remove them may be fraught when such money supports people and work unconnected to the wrongdoing. Regardless, academic institutions must not only remove such names from honorifics, but must also fulfill the affirmative obligation to teach about the full context of what was done. In Kligman’s case, he did advance dermatology and skin care, and that should be recognized. But it must also be discussed that he did so on the backs of exploited prisoners. We can both acknowledge his research advances and critique his ethical failings.
In a time when protests consistently remind us that Black lives matter, we must remember Kligman’s experimental human subjects, who were mostly Black men, including Leodus Jones and Edward “Yusef” Anthony, and whose lives were treated as if they mattered less.
We urge all in medicine, as well as Penn and Penn State, to reconsider honorifics, with Kligman as an example, and to make substantive efforts toward equity and addressing health disparities. We must send a message of inclusivity, loud and clear, and embrace names that honor current values.
Adewole Adamson, M.D., M.P.P., is an assistant professor of internal medicine, division of dermatology, at Dell Medical School at the University of Texas at Austin. Jules Lipoff, M.D., is an assistant professor in the department of dermatology, Perelman School of Medicine, at the University of Pennsylvania. A version of this piece was previously published in the Journal of the American Medical Association Dermatology.