VIEWPOINT

Seventy years ago, on August 20, 1947, the International Medical Tribunal in Nuremberg, Germany, delivered its verdict in the trial of 23 doctors and bureaucrats accused of war crimes and crimes against humanity for their roles in cruel and often lethal concentration camp medical experiments. As part of its judgment, the court articulated a 10-point set of rules for the conduct of human experiments that has come to be known as the Nuremberg Code. Among other requirements, the code called for the “voluntary consent” of the human research subject, an assessment of risks and benefits, and assurances of competent investigators. These concepts have become an important reference point for the ethical conduct of medical research. Yet, there has in the past been considerable debate among scholars about the code’s authorship, scope, and legal standing in both civilian and military science. Nonetheless, the Nuremberg Code has undoubtedly been a milestone in the history of biomedical research ethics.1- 3

Writings on medical ethics, laws, and regulations in a number of jurisdictions and countries, including a detailed and sophisticated set of guidelines from the Reich Ministry of the Interior in 1931, set the stage for the code. The same focus on voluntariness and risk that characterizes the code also suffuses these guidelines. What distinguishes the code is its context. As lead prosecutor Telford Taylor emphasized, although the Doctors’ Trial was at its heart a murder trial, it clearly implicated the ethical practices of medical experimenters and, by extension, the medical profession’s relationship to the state understood as an organized community living under a particular political structure. The embrace of Nazi ideology by German physicians, and the subsequent participation of some of their most distinguished leaders in the camp experiments, demonstrates the importance of professional independence from and resistance to the ideological and geopolitical ambitions of the authoritarian state.
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The circumstances in which the code was promulgated thus signified a tension between professional standards and duties to the state. There had long been an intense debate within the medical profession about its ethical obligations in the course of human experiments, dating back to 18th- and 19th-century objections against objectifying human beings for scientific purposes. The increased demands placed on modern states to promote the health and welfare of citizens in the 20th century required state agencies to respond to public pressure to protect participants in clinical trials. These debates were often stimulated by medical ethics transgressions or medical errors that attracted the wider attention of state agencies and the public at large, or by concerned physicians who regarded themselves as reformers and wished to improve their colleagues’ practices. At the center of that debate is the question of how to balance participants’ rights and welfare with the progress of medical science, for example, through professional guidelines and ethics codes or through greater state intervention, laws, and regulations. That the Nazi doctors’ crimes occurred despite the vigorous and sophisticated ethical debates of the time and place should serve as a cautionary tale for physicians today.
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