The doctors from hell were the impetus for today’s research ethics

On 9 December 1946, an ice-cold day in the Nuremberg Palace of Justice, Judge Walter Beals strikes his gavel and the 23 defendants stand up. Twenty of them are doctors and the other three were their assistants.

Just over two months have passed since the Nazi top brass were sentenced in the same courtroom during the Nuremberg Trials – the first international court in history to prosecute war crimes and crimes against humanity. Twelve defendants were sentenced to death. 
 
Now is the turn of those who ranked just below the leading officials. A total of 12 such trials are to be held against various elements of Germany’s Nazi regime. The Doctors’ Trial is the first of these. It is the most horrifying and the one that will go on to have the greatest impact. 

Penetrating, evil eyes 

Vivien Spitz, a 22-year-old from Chicago, is tasked with the job of court reporter. Many of those present have stuffed newspaper under their clothes to keep warm, and she can hear it rustling when they move. Nuremberg is a bombed-out city where the heating has not yet been fully restored in the few houses that are still standing. 
 
Spitz studies the defendants as they stand up: their clothes are ragged. Some are wearing suits, others military uniforms stripped of insignia. Most have clenched teeth. She thinks they look embittered and arrogant, especially defendant number one, Dr Karl Brandt. He catches her eye and holds it with his penetrating – and what she describes as evil – eyes. It gives the young court clerk a chill down her spine and she lowers her gaze. 
 
The Chief Prosecutor, Telford Taylor, then begins his opening argument in which he accuses the defendants of murder, torture and other atrocities committed in the name of medical science. At least 7,000 people died in medical experiments, and an unknown number were subjected to enormous suffering and permanent injury. Many doctors were also responsible for selecting who should be sent to the gas chamber, and Taylor estimates that several hundred thousand victims suffered at the hands of the 23 defendants. 
 
For those present in the Palace of Justice, the next eight months will be a journey through the worst and most unimaginable brutality that a human can perpetrate. Vivien Spitz, the court clerk, lived to be 90 years old and spent the rest of her life processing her experiences with the Doctors’ Trial.

A research ethics milestone 

The verdicts came on 30 September and 1 October 1947. Brandt is sentenced to death along with six others. Nine are given a prison sentence, while seven are acquitted. It was membership in the SS, and not the atrocities that had been committed, that determined whether a defendant was handed down the death penalty. 

The verdicts in the Doctors’ Trial became a research ethics milestone. As a direct response to the verdicts, a set of ethical research principles – the Nuremberg Code – was created to prevent the repeat of such brutality. 
 
The Code sets out ethical standards for research on humans. The first principle is that voluntary consent of the human subject is absolutely essential. The experiment must yield fruitful results for the good of society that cannot be procured by other means, and should be designed to avoid all unnecessary suffering and injury. 
 
In light of this, the General Assembly of the World Medical Association adopted the Declaration of Geneva in 1948. It was intended as an oath in which all doctors pledge to dedicate their lives to the service of humanity. 

Infected patient with leprosy 

Professional ethics for doctors has its roots in antiquity, and the Hippocratic Oath dates back to 500–400 BC. Doctors who conducted research on humans nevertheless had to mostly rely on their own personal ethics. 
 
This self-regulation proved to be far from adequate, and the history of medical research on humans does not make for edifying reading. However, doctors who crossed the line were rarely punished. 
 
One of those whom the law caught up with was Gerhard Armauer Hansen, who is considered the most famous Norwegian doctor of all time because he discovered the leprosy bacillus – one of the bacteria that causes leprosy. He was thus the first to demonstrate that a bacillus can cause chronic illness in humans. 
 
In 1880, he asked 32-year-old Kari Nielsdatter, a leprosy sufferer, to come to his office. Nielsdatter was held down while Hansen injected into her eye a different type of leprosy to the one she had. Hansen was prosecuted for bodily harm, but defended his actions by saying that he would be able to remove a leprosy nodule from the eye if one had developed. The reason why he had not obtained consent from Kari Nielsdatter was simply that he considered it unlikely that he would get it. 
 
Hansen was stripped of his position at the Nursing Institution for Leprosy Patients in Bergen, but retained his post as the senior consultant for leprosy. He received broad support from the medical community in Norway, and there is no indication that the case damaged his reputation. 

The atrocities continued 

The Nazi doctors made a deeply disturbing impression on contemporary society, but the legal proceedings and the Nuremberg Code did not have the impact that many had expected. The abuse in the name of research did not stop. 
 
People with intellectual disabilities are among those most often subjected to ethical abuse. Confined to institutions, they have been easy targets. They have also had few opportunities to defend themselves or to even understand what they were being subjected to. 
 
The Swedish ‘caramel experiment for the feeble-minded’ is an example from right after the war. The experiment continued until 1953 and entailed giving the participants large amounts of sweets to see if the number of cavities in their teeth increased – which it did. 
 
In a book on medical ethics by Ruyter, Førde and Solbakk (Medisinsk og helsefaglig etikk), the authors claim that the problem with the Nuremberg Code was that the Nazi doctors were portrayed as monsters. The Code was perceived as a barrier to barbaric abuse, which made it irrelevant for the assessment of ethics in individual scientists’ own research. 
 
The Declaration of Helsinki was a new attempt to finally rid the world of unethical experiments. It was adopted by the World Medical Association in 1964 and specifically applies to research on humans. 
 
Research subjects must be informed about the purpose, methods, expected benefits and possible risks. It must also be made clear to them that they are free to withdraw from the study at any time. Only when this information has been provided can participants give their voluntary consent. 

National Research Ethics Committees 

The Declaration of Helsinki has been revised several times. In 1975, an extra requirement was added for research projects to be assessed by an independent ethics committee. 
 
In Norway, all medical and health-related research is subject to prior approval by the Regional Committees for Medical and Health Research Ethics (REK). 
 
Ruyter, Førde and Solbakk believe this has led to a significant reduction in obvious abuse. 
 
Sources: United States Holocaust Memorial Museum; Wikipedia; Leon N. Goldensohn: The Nuremberg Interviews; Vivien Spitz: Doctors from Hell; Knut W. Ruyter: Research ethics; Ruyter, Førde, Solbakk: Medisinsk og helsefaglig etikk; The Great Norwegian Encyclopedia; Paul Julian Weindling: Nazi Medicine and the Nuremberg Trials  
 
Translated from Norwegian by Carole Hognestad, Akasie språktjenester AS.