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Hippocrates | Percival | AMA | Nuremberg | Geneva | Helsinki
Western medical ethics have evolved from the ancient Hippocratic Oath and western principles of gentlemanly honor. Standards of professional behavior were codified in the late17th century and officially adopted by medical associations as early as the mid-19th century. The ethics of medical research were more recently codified and adopted after abuses of ethical and moral standards by Nazi doctors in WWII concentration camps. Such abuses have not been exclusive to wartime. Doctors of the American Public Health Service committed ethical misconduct and racism in human research by denial of treatment for syphilis in 399 African-American men from 1932 to 1972 in Tuskegee, Alabama.
In the future medical ethics will adapt to changes in science and society, but must remain rooted in beneficence, respect for persons, and justice. Continuing evolution in medical ethics is occurring with the advent of new reproductive technologies, the Human Genome Project, cloning, stem cells, gene therapy and xenotransplantation. The origins of medical and research ethics are examined below.
Origins of Medical Ethics
Hippocratic Oath (400 BC)
Hippocrates is known as the Father of Medicine. Born in Greece (460 BC), he approached medicine and disease as something having a rational explanation rather than superstitious origins as was popular at that time. He pioneered many aspects of modern medicine that we take for granted; he accurately described the symptoms of disease, believed in preventative health practices, promoting personal hygiene and a good diet, and believed that the brain was the source of thoughts and feelings rather than the heart.
He founded a medical school and developed an Oath of Medical Ethics for physicians to follow. The Hippocratic Oath has formed the basis of more recent medical oaths taken by students as they begin the practice of medicine. The chief tenants of this Oath are:
- honor instructors in the medical arts
- pass on the Art only to those bound by the Oath
- practice for the benefit of patients; "do no harm"
- give no deadly medicine or substance to produce abortion
- enter homes for the benefit of the sick
- abstain from mischief and corruption
- doctor-patient confidentiality
Thomas Percival (1794)
The English physician, Thomas Percival (1740-1804) published a code of medical ethics for physicians that was adopted by American doctors and later was adapted and adopted by the American Medical Association (AMA). This was the first code of ethics to be adopted by a professional organization replacing the variously interpreted ethics of gentlemanly honor and thus providing a standard of behavior for medical professionals. The Percivalian code asserted the moral authority and independence of physicians in service to others, affirmed the profession's responsibility to care for the sick, and emphasized individual honor.
AMA Code of Ethics (1846)
The AMA Code of Ethics was adapted from the ethical code of conduct published in 1794 by Thomas Percival. This was the first code to be adopted by a national professional organization. The current AMA code of ethics (2001) has nine articles which is two more than the previous version (1980). These additions stress the responsibility the doctor has to the patient and the support of universal access to medical care. Provisions are also added to the revised Oath regarding a commitment to medical education and a responsibility for the betterment of public health. Other features of the Code are:
- dedication, competence, compassion and respect
- honesty and duty to report fraud or deception
- respect for the law
- respect for the rights of patients and colleagues
- respect for privacy and patient confidentiality
- continued education, study, and consultation with other professionals
- freedom of association and environment in the practice of the Art
- responsibility to make efforts to improve the community
Nuremberg Code (1947)
A result of the post-WWII trial of 23 Nazi doctors for crimes against humanity committed in the name of research, the Nuremberg Code represents the starting point in discussions about the ethical treatment of human subjects. German doctors, including the most infamous, Joseph Mengele, performed macabre medical experiments under the disguise of scientific research in Nazi concentration camps where prisoners were used without concern for their welfare. The Nuremberg Code is a set of 10 principles outlining the ethics of medical research and ensuring the rights of human subjects. The principles include:
- informed, voluntary consent
- research must be purposeful and necessary for the benefit of society
- research must be based on animal studies or other rational justification
- avoidance and protection from injury, and unnecessary physical and mental suffering
- risks to the subject shall not be greater than the humanitarian importance of the problem
- investigators must be scientifically qualified
- subject may terminate the experiment at any time
Declaration of Geneva (1948)
This oath was adopted by the World Medical Association after the atrocities committed in the name of research in WWII Nazi concentration camps. Key features of this code are:
- service to humanity
- respect and gratitude for instructors
- conscience and dignity in the practice of the Art
- dutiful attention to the health of the patient, colleagues and traditions of the Art
- practice in accordance with the laws of humanity, respect for human life from conception
- duty takes precedence over racial, religious, political or social prejudices
Declaration of Helsinki (1964)
This document has been revised several times since its publication in 1964 as a response to unethical medical experiments of the Nazis during WWII. The latest revision of the declaration (2000) states that "the well-being of the human subject should take precedence over the interest of science and society." Other of the Helsinki principles are that the doctor should only act in the patients best interest and that the health of the patient is the first concern. Many of the principles are incorporated in national research regulations.
The revised declaration also discusses the use of placebo, recommends that ethics committees have the obligation to monitor ongoing trials, and requires that researchers disclose to subjects details of funding and possible conflicts of interest. Finally, there is a recommendation that publishers decline studies not carried out in accordance with the declaration.