|Year : 2013 | Volume
| Issue : 2 | Page : 191-194
Ups and downs in the history of medical ethics
Vice Chancellor, Yenepoya University, Mangalore, Karnataka, India
|Date of Web Publication||13-Dec-2013|
Vice Chancellor, Yenepoya University, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chandramohan P. Ups and downs in the history of medical ethics. Arch Med Health Sci 2013;1:191-4
Ethics is defined as norms of conduct that distinguishes between desirable and undesirable behavior. Ethics related to medical practice research and public health policies for health care delivery had always been considered to be of paramount importance from the beginning of the history of human civilization. India has a rich heritage in this regard. During the "Ayurvedic period" between 600 BC and 800 AD, ethics in health care delivery and medical education were most judiciously enforced. In Europe, the Greek physician, Hippocrates, first came out with a three-worded phrase "DO NO HARM," which was subsequently converted to 181-worded Hippocratic oath recited by medical students at graduation ceremonies. But, till renaissance, there were no regulatory mechanisms to control the ethical violations in medical practice and research. Subsequently, in 1803, Thomas Percival published his creation "Code of Medical Ethics." Codes were revised and replaced when ethical issues arose and caused public concern from time to time. A brief description of some important ethical issues in history and the regulatory mechanisms that came up is given in this article.
Ethical guidelines for medical practice and their violations are as old as the history of human civilization. During the phase of River Valley Civilizations and Agrarian Civilizations, the people in general were morally stronger and medical practice and medical education were also ethically strong-based.
When we look through the history of India, one can easily say that the golden age of Indian System of Medicine was between 600 B.C. and 800 A.D. The renowned historian, Mr. P. C. Ray called this period as the "Ayurvedic Period."  The ethical conduct in both healthcare delivery system, medical education and medical research was most judiciously enforced. Any lapse invited strong social disapproval. Arthashastra written by Kautilya prescribed death penalty for some of the worst forms of unethical practices in medicine.  Before admitting the students to the School of Medicine in Nalanda University, the students were meticulously screened to determine whether he had the right aptitude and attitude to learn the art of "Healing the Ailing."
In Europe, during the time of Hippocrat and Gallen, the father figures in the history of modern medicine, there were surgeons like Hirophilus Erasistratus, etc., who dissected live human bodies, mostly the victims of war, without anesthesia to study the human anatomy. Hippocrats (460 BC to 377 BC) vehemently opposed this cruelty, which resulted in the origin of the famous "Hippocratic Oath."  The essential component of the Hippocratic code of ethics was based on the principle of non-maleficence and came out as a three-worded phrase "DO NO HARM," which subsequently evolved into the 181-worded Hippocratic Oath recited at Graduation ceremonies. Invention of anesthesia, aseptic surgery etc. changed the situation. During the intellectual revolution of 18 th century (Renaissance), Thomas Percival published "Code of Medical Ethics" in 1803.  In 1846, the American Medical Association came out with its own Code of Ethics, which was modified in 1897. In 1858, the General Medical Council (GMC) of U.K. came out with a code of Ethics through a Parliament Act, and in 1898, Germany came forward with its Ethics of Science and medicine. In 1956, Medical Council of India enacted its regulations on Code of Medical Ethics, which was revised in 2002 and 2007. In 1972, a separate Code of Medical Ethics for practitioners of Indian system of medicine came into being.
The Code of Ethics originated so far can be chronologically arranged as shown in [Table 1].
Everybody believed that a new generation of medical practitioners committed to Hippocratic Oath was coming up. The greatest blow to this belief occurred with the Nuremberg Trial.
Nuremberg Trial , was conducted in the city of Nuremberg in Germany to try war criminals between 20 th of November 1945 and 1 st of October 1949 where case was heard by an international Jury. This was followed by Doctors Trial conducted by U.S. Jury in the same city of Nuremberg in the palace of Justice against 20 doctors including Karl Brandt, the personal Physician of Adolph Hitler, who used the innocent prisoners in concentration camps, mentally retarded children, terminally ill patients etc. for human experimentation without their consent and ultimately killed them under the guise of Euthanasia. Seven were sentenced to death, seven were acquitted, and the remaining were sentenced to imprisonment from ten years to life time.
Nuremberg Code , is a set of ethical principles for human experimentation in medical research framed in the year 1948 following the verdict in the Doctors Trial on August 20 th 1947. There were ten important clauses in the Nuremberg Code. The code explains how to take a valid informed consent from an experimental human subject and explains the different phases of clinical research to make sure that human subjects are used only after successful completion of lab and animal experimentation. The code also insists that human experimentation should be done only by qualified scientists and doctors.
Nuremberg Code was the first international document that advocated voluntary participation and informed consent for all human experimentation in medical research. Unfortunately, though Nuremberg Code had a regulatory mechanism to control unethical human experimentation in medical research, incidences of ethical violations continued. A few examples of such incidences are narrated below:
Gautemala Trial (1946-48)  was a project of the U.S. Public Health Department to study the transmission of syphilis through direct contact and effect of Penicillin against syphilis. One thousand three hundred innocent people consisted of prisoners of Indiana soldiers, sex workers, mentally handicapped and orphans; 83 of them died at the various stages of syphilis. Dr. Cutler was the main person behind this ethical tragedy and he went to Tuskeejee after this cruel trial, which was described by Obama's Bioethics Commission as ethically impossible because all the four principles of ethics viz, Autonomy, Beneficence, Non-maleficence, and justice were violated.
Thalidomide Tragedy of 1950:  Thalidomide was a drug used to control sleep, nausea, and vomiting, associated with morning sickness in pregnant women. Soon it was proved that the drug causes severe congenital anomalies. But, the medical community never revealed the new invention to the patients and continued to use the drug. Later, it was found that 12,000 babies were born with severe congenital deformities. This became a major issue in United States and led to further enactment in the form of "KEFAUVER AMENDMENTS" to the food, drugs and cosmetics Act of U.S.A.
Tuskeejee Syphilis Study 1932-72:  The notorious Tuskeejee Syphilis study was conducted by the United States Public Health Service to study the natural history of syphilis. Four hundred low-income African Americans who were infected by syphilis were observed for 40 years consecutively without giving any treatment inspite of the fact that definite curative treatment was available from 1950 onwards without informing the patients or their relatives. In 1973, this was noticed by the public and became a political issue, and the Government was forced to withdraw the study in 1973 due to political pressure. In 1977, President Clinton apologized to the participants and their families and said "What was done cannot be undone, but we can end the silence-we can stop turning our heads away, we can look at you in the eye and finally say, on behalf of the American people, what the U.S. Government did was shameful and sorry. U.S. Govt. disbursed 119 billion as compensation.
Belmont Report:  This incident also resulted in the genesis of a new Act viz., National Research Act of 1974. As per provisions of the Act, a National Commission was constituted for the protection of human participants in bio-medical research, behavioral research. The Commission drafted the historic "BELMONT REPORT" in 1979 April 18, which is now considered as the landmark document on ethics of human participants in medical research. The three principles that highlighted in Belmont Report are (i) Respect for persons and informed consent, (ii) Beneficence, and (iii) Justice. The content of the Belmont Report can be summarized as depicted in [Table 2].
Helsinki Declaration of 1964 
Contain ethical regulations governing the medical research involving human experimentation. World Medical Association took the initiative in bringing out this landmark declaration on ethics related to bio-medical research. The declaration spells out the rules related to the various ethical issues in clinical and non-therapeutic medical research. The issues addressed in Helsinki declaration are:
- Research in human should be based on research from lab and animal experimentation.
- The research protocols should be reviewed by an independent and competent committee prior to the initiation of research.
- Informed consent from human participants is mandatory.
- Research should be carried out only by medically/scientifically qualified persons.
- The risk involved in the research should not exceed the benefits.
Helsinki Declaration could bring down the incidence of ethical violations in bio-medical research to considerable extent. But, we can see the animal instincts of man again prevailing over all these regulations. One of the major ethical violations that was brought to light after the Helsinki declaration was by Beecher of Haward Medical School. Hospitalized patients were injected with plutonium without their consent to study the toxicity of plutonium. Beecher brought out 12 similar instances of unethical practices in medical research. Several other examples of similar nature can be narrated, but I feel that such an attempt will make this article too lengthy.
In the post-Second World War era, we see a quantum jump in the field of science and technology, which brought in many sophisticated gadgets in the diagnosis and treatment of diseases, especially through the fields of Imageology, Endoscopy, Electronic Monitoring devices, and the various life-supporting systems. With the introduction of these expensive gadgets in the regular practice of medicine, the gap in the healthcare delivery system for the rich and the poor widened beyond anybody's imagination. Unethical practices became rampant in the selection of patients and in the purchase of equipments required.
Ethical issues related to implementation of public health policies are often quite complex and difficult to handle.  India, a country with second largest population in the world, confronted some of the worst forms of ethical dilemmas in the implementation of public health policies. Some of the case studies reported from around the world are narrated below.
- Pertussis Vaccination and brain damage:- This has always been a subject of medical controversy. One report from England says that coverage of pertussis vaccination dropped from more than 78% in 1971 to 37% in 1974 as a result of the apprehension generated in the public about the neurological complication about pertussis vaccination.  This lack of coverage with pertussis vaccination resulted in one of the largest epidemics of pertussis in England.  Some of the parents of the affected children moved this to the British High Court, and an amount of six million pounds had to be distributed to the children who developed brain damage after pertussis vaccination. 
Two principles of ethics viz.
- Beneficence of protecting huge mass of children from pertussis infection conflicting with violation of non-maleficence of inducing brain damage to the vaccinated children.
- The relationship between dental caries and fluoride deficiency is a well-known entity. To prevent this problem, the policy of fluoridation of water was adopted in certain areas considered to be endemic for low fluoride levels in water.  But, precise demarcation of low fluoride level areas and normal fluoride level areas was practically difficult, and some people developed undesirable side-effects of fluoride viz., Down syndrome and oral cancer. Adding fluoride to water supply was interpreted as compulsory medication to people who have normal fluoride levels causing damage.
- The three ethical principles viz., Beneficence of preventing dental caries in fluoride-deficient areas and violation of non-maleficence to people in fluoridation of areas with normal level of fluoride and violation of justice through compulsory medication.
- A person with HIV infection was prevented from marriage by the government authorities, and this was challenged in the judiciary and the Supreme Court of India gave a landmark judgment that the attempt of a person with HIV AIDS to get married is an offence because such a marriage would spread disease and put his partners life in danger. 
- In 1977, the government of India banned the sale of non-iodized salt to prevent and bring down the incidence of goiters. , This resulted in an ethical problem of injustice because the people in the non-endemic areas with normal iodine levels in the blood had to buy relatively expensive iodized salt in the place of cheaper non-iodized salt. Added to this, there were reports that some people in the non-endemic areas developed signs of thyrotoxicosis. The government had to reconsider the matter and lifted the ban on non-iodized salt on September 13, 2000. 
- Ethics whether it is related to medical practice, medical research, or public health policies prescribes the right conduct that distinguishes between the desirable and the undesirable behavior.
In conclusion, the rapid development in science and technology revolutionized the fields of medical practice, research, and public health policies. It is now possible to prevent diseases effectively, diagnose disease faster and more precisely, and treat more objectively and effectively. Medical Management has become quite easier and effective with refined medications, which are more specific with less side-effects. Surgical treatment has also become less invasive with minimal morbidity, faster recovery, and better stasis. Inspite of all these advancement, the medical profession is at crossroads because of the ethical and legal dilemmas. When medical fraternity becomes more and more technology-dependent, the market forces influence the decision making of doctors , and make them forget their responsibility to keep the patients' interest over all other situations. Non-maleficence should be always the guiding force for doctors to take their decision whether it is choice of antibiotics, anti-epileptic, or any other drug that had become very complex in situations like transplant, surgery, clinical research, gene therapy, assitatory production, euthanasia, etc.; the doctors should never deviate at least from the three-worded Hippocrative oath viz., "DO NO HARM."
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[Table 1], [Table 2]