Beyond consent: the potential for atrocity

Abstract

With disbelief the world received news of medical experiments performed on the inmates of concentration camps in Nazi Germany.1 The subsequent trial of 23 defendants, 20 of whom were medically qualified, in Nuremberg yielded 16 guilty verdicts and seven death sentences. What was perhaps so incredulous was not that such atrocities could be perpetrated by Nazis, but that they could have involved doctors. In his opening remarks at the trial Brigadier General Telford Taylor, the American Chief of Council, noted: `To kill, to maim, and to torture is criminal under all modern systems of law... yet these [physician] defendants, all of whom were fully able to comprehend the nature of their acts... are responsible for wholesale murder and unspeakably cruel tortures.'2 During the eight-month trial a detailed catalogue of medical experimentation was presented to the court. For example, at Dachau between 1942-1944 there was a series of experiments designed to examine aspects of aviation medicine, involving high-altitude experiments, the effects of freezing water baths and the enforced drinking of sea-water. In Buchenwald and Ravensbruck throughout the war, a series of studies examined the simulation and treatment of battlefield injuries, such as exposure to mustard gas, phosphorus burns, bone transplantation, and sulfanilimide treatments. In Dachau, Buchenwald and Sachsenhausen during 1941-1945 there were a variety of infectious disease studies involving the deliberate infection of inmates with malaria, epidemic jaundice and typhus. Finally, in Auschwitz, Buchenwald and Ravensbruck there were a number of eugenic and lethal experiments involving sterilization and poisoned bullets. Similar, though less widely acknowledged, were the medical experiments performed in Japanese facilities during the Second World War.3 Nuremberg may have been the first major public exposition of how doctors can become instruments in unethical medical experimentation, but it is tragically not the last, nor regrettably the most recent. During the Doctors' Trial in Nuremberg the defendants cited similar forms of human experimentation that had taken place in the USA.4 Names were named and details listed, but little note was taken by the American prosecutors. Indeed the medical representative of the American Medical Association present at the trial, Andrew C. Ivy, stated that no American prisoner had ever been experimented on against his will.5 However, despite their heinous crimes against humanity, on this point the defendants were correct—and Ivy was wrong. The USA before, during and after the war was the host to a series of medical experiments that bore some striking similarities. Furthermore, although the 10 principles of ethical research that became known as the Nuremberg Code were drafted by the American team in Germany, it is notable that the Code was never taken to heart by American physicians, who preferred to view the document as applying not to them, but to the barbaric physicians in Nazi Germany.5 Then, as now, a utilitarian approach to biomedical research was commonly upheld as justification. `This is done for the greater good' possibly thought the New York team that from 1963 deliberately infected the mentally retarded with hepatitis at Willowbrook, an institution on Staten Island, so that experimental vaccines could be tested.6 The `benefit to society' may have been the touchstone of the Tuskegee investigators who between 1932 and 1972 followed a group of poor black Alabama farm workers to learn about the natural history of syphilis.7 In the process, and to avoid disruption of their experiment, they denied the men the benefits of penicillin therapy and subjected them to various investigations including regular lumbar punctures, which they passed off as treatments for so-called `bad blood'. The `advance of science' may have been the vision of those at the Jewish Chronic Disease Hospital in Brooklyn, who in the early 1960s injected live cancer cells into elderly debilitated cancer patients without their consent.8 These abuses of human research ethics were brought to light often not by our own colleagues, but by the media.9