MEDICAL ETHICS


Never again


Allan Gaw recounts the origin of Te Nuremberg Code on human research and considers its modern-day relevance


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HE court had been in session for 139 days; it had heard the testimony of 85 witnesses and received more than


1,400 documents in evidence. Now the legal battle was over and the courtroom was hushed in anticipation of the outcome. Twenty-three defendants awaited their fate at the hands of a panel of American judges. Te date was 19 August 1947; the court – the Palace of Justice in the bombed-out city of Nuremberg in occupied post-war Germany; the hearing one of the most famous in legal history – the Nazi Doctors’ Trial. In a judgement running to more than 50,000 words, pronouncing the guilt of 16 of the defendants and sending seven to their deaths, a small introductory section of around 500 words entitled, “Permissible Medical Experiments” might have been overlooked. However, this was to be the enduring legacy of the trial – 10 carefully weighed and worded standards for the conduct of human research, which have since become known as the Nuremberg Code. Te precise authorship of the Code is


unknown. Te trial’s chief counsel for the prosecution believed it was from the hand of one of the four judges. Others have suggested that two physicians were the chief architects of the Code: Andrew Ivy and Leo Alexander. Ivy was an eminent physician and


physiologist who, perhaps because he had been actively involved in research involving prisoners, had been invited to serve as the American Medical Association’s adviser to the Nuremberg prosecutors. Alexander was an Austrian- born, American physician who served first as a medical war crimes investigator and


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then as medical expert to the trial. Both men played an active role in the


proceedings and they submitted several sets of ethical principles to the court. However, because of the lack of documentary evidence detailing the judges’ thinking while draſting their ruling, we can only speculate as to the relative importance of each man’s contribution.


The Doctors’ Trial In the Doctors’ Trial, or more formally Te United States vs. Karl Brandt et al, the 23 defendants were indicted on a number of counts, including war crimes and crimes against humanity. As the war had neared its conclusion,


details of the medical experimentation in concentration camps first began to reach the world press. Te public needed no convincing that the Nazi doctors involved were guilty of unethical practices and almost unimaginable cruelty. In order for them to face criminal charges, however, the American prosecutors faced a dilemma. Te defendants would claim their


innocence, stating that they were acting in accordance with German military law and that their American medical counterparts were involved in similar practices. As such, it was clearly paramount to distinguish the practices of the physicians in the dock from those of Allied researchers. Te prosecution also had to define what they believed to be ethically permissible experimentation and what was not. Within the final Code three main


themes were evident. First that the absolute need for informed consent is a sine qua non of clinical research; second


that a study participant’s rights are given precedence over those of the investigator; and third that the investigator has clear obligations regarding the design and conduct of the study.


Reception Te Nuremberg Code was largely ignored by the medical profession for 20 years aſter its publication, especially in the US and the UK. Tis may have been due to the circumstances that prompted the Code – a series of medical atrocities conducted by Nazis during a war – that were seen as irrelevant and unconnected with medical practices in other countries. Although some have viewed the Code as


a component of International Common Law, it carried no legal force and was at best a voluntary code of research ethics. However, the voluntary nature of such a code may be viewed as its principal strength in that the best possible, and most liberated, scientific environments are created not within the straightjackets of legislation, but within the relative flexibility afforded by a professional guideline. Unfortunately, against this contention is


the evidence of history. Time and again we have learned that we cannot rely on the “informed, conscientious, compassionate, responsible investigator” guided merely by a voluntary code of conduct. For the safety of trial participants that investigator must also be constrained by the rule of law.


Relevance Te Nuremberg Code has been described by many as the most important document ever written on human research ethics. Is


SUMMONS


PHOTOGRAPHS: SCIENCE & SOCIETY; MARY EVANS/PICTURE ALLIANCE/DPA


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