Book Review

The Nazi Doctors and the Nuremberg Code: Human Rights in Human Experimentation

N Engl J Med 1993; 328:1429-1430May 13, 1993

Article

The Nazi Doctors and the Nuremberg Code: Human Rights in Human Experimentation
Edited by George J. Annas and Michael A. Grodin. 371 pp. New York, Oxford University Press, 1992. $29.95. ISBN: 0-19-507042-9

In August 1947, 15 Nazi physicians were convicted by one of the Nuremberg tribunals of immersing concentration-camp inmates in freezing solutions, exploding them in low-pressure chambers, infecting them with typhus, forcing them to drink sea water, and killing them in order to study their defleshed skeletons, all in the name of science. In deciding the case, the tribunal enunciated a set of ethical principles for experimentation with human subjects that came to be known as the Nuremberg Code.

The first and central principle of the code states, “The voluntary consent of the human subject is absolutely essential.” But Jay Katz, perhaps the most insightful contributor to this unusual collection of essays and documentation on the code, points out that the tribunal erroneously assumed that the principle of voluntary consent had been firmly embodied in medical ethics up to that time (which it had not) and that it was the gravamen of the doctors' offenses. On the contrary, as is excruciatingly evident from the detailed accounts of the “experiments,” the doctors committed these crimes against humanity because they were able to deny the humanity of their subjects and even, at some level, must have been satisfying bizarrely sadistic impulses.

Another essayist, Leonard Glantz, observes: “These matters [informed consent] were of no concern to the Nazi doctors. From their perspective [it] was more akin to animal research . . . [although it] would violate current animal research regulations.” Consent was not even an issue.

Other contributors suggest the inadequacy of the Nuremberg Code's provisions to address issues such as those in the Nancy Cruzan case and those in the controversy over the use of fetal tissue for research. Indeed, the code is not helpful in drawing distinctions between clinical research and therapy. What seems to me too sharp a focus in the book on the informed-consent principle results in an inadequate treatment of the recent court case on the propriety of a Food and Drug Administration waiver of the informed-consent requirement for use of an investigational new drug; in that case the drugs covered by the waiver might have been needed to protect troops in combat against the effects of Iraqi-dispensed poison gas.

Yet an examination of the post-Nuremberg record by still other contributors suggests that the informed-consent issue is still alive. The medicolegal community in the United States has not been without sin. Examples cited include the Tuskegee syphilis experiment, continued until 1972; experiments conducted at the Jewish Chronic Disease Hospital in which live cancer cells were injected into chronically ill and debilitated patients in 1963; the administration by the Central Intelligence Agency of mind-altering drugs to unwitting subjects beginning in 1953; and the Supreme Court-sanctioned exposure by the Army of a serviceman to lysergic acid diethylamide (LSD) while telling him he was testing the effectiveness of protective clothing against chemical warfare.

The book is rich in data both on the Nazi doctors' trial and on the subsequent history of the informed-consent doctrine in clinical research. It contains the full documentation on the Nuremberg tribunal, including the impressive opening statement of Brigadier General Telford Taylor, chief counsel for the prosecution; the 1931 Reich Circular on human experimentation (as well as the 1933 law against cruelty to animals); and the text of the World Medical Association declarations on clinical research adopted in 1964, 1975, 1983, and 1989 (Helsinki I, II, III, and IV). It also contains full documentation on the FDA waiver of informed consent in the Gulf War situation described above.

For anyone interested in the problems of clinical research on human subjects, this compendium should be a valuable reference work and a source of insights as well as relevant facts. Because it addresses a complex problem from the perspective of what may be the most extreme cases imaginable, it casts deep shadows, even while illuminating parts of its subject. But at the same time it serves to remind the reader of the temptations to which even the most scrupulous physicians, operating on the frontiers of clinical research, are exposed.

Adam Yarmolinsky
University of Maryland, Baltimore, MD 21228