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The Ethical Governance of German Physicians, 1890–1939: Are There Lessons from History?

Published online by Cambridge University Press:  14 January 2011

Robert Dingwall
Affiliation:
University College, London
Vienna Rozelle
Affiliation:
Nottingham Trent University

Abstract

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Copyright
Copyright © Donald Critchlow and Cambridge University Press 2011

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References

1. On the origin myths of occupations, see Whittaker, Elvi W. and Olesen, Virginia L., “The Faces of Florence Nightingale: Functions of the Heroine Legend in an Occupational Sub-culture,” Human Organization 23 (1964): 123–30CrossRefGoogle Scholar. An application to bioethics can be found in de Vries, Raymond, Dingwall, Robert, and Orfali, Kristina, “The Moral Organization of the Professions: Bioethics in the United States and France,” Current Sociology 57 (2009): 555–80CrossRefGoogle ScholarPubMed. See also Sass, Hans-Martin, “Reichsrundschreiben 1931: Pre-Nuremberg German Regulations Concerning New Therapy and Human Experimentation,” Journal of Medicine and Philosophy 8 (1983): 99.CrossRefGoogle ScholarPubMed

2. Beecher, Henry K., “Ethics and Clinical Research,” New England Journal of Medicine 74 (1966): 1354–60CrossRefGoogle Scholar. Pappworth, Maurice H., “Human Guinea Pigs: A Warning,” Twentieth Century Magazine (1962): 66–75Google Scholar; Bolton, T., “Consent and the Construction of the Volunteer: Institutional Settings of Experimental Research on Human Beings in Britain During the Cold War” (Ph.D. thesis, University of Kent, 2008).Google Scholar

3. Lederer, Susan E., Subjected to Science: Human Experimentation in America Before the Second World War (Baltimore, 1995)Google Scholar; Halpern, Sydney A., Lesser Harms: The Morality of Risk in Medical Research (Chicago, 2004).CrossRefGoogle Scholar

4. Hazelgrove, Jenny, “The Old Faith and the New Science: The Nuremberg Code and Human Experimentation Ethics in Britain, 1946–73,” Social History of Medicine 15 (2002): 109–35.CrossRefGoogle ScholarPubMed

5. The U.S. pioneers of medical education reform at Johns Hopkins, for example, do not appear to have copied this aspect of German medicine, from which they otherwise borrowed extensively. See, for instance, Barry, John M., The Great Influenza (New York, 2005).Google Scholar

6. E.g., Blackbourn, David and Eley, Geoff, The Peculiarities of German History: Bourgeois Society and Politics in Nineteent-Century Germany (Oxford, 1984)CrossRefGoogle Scholar; Peukert, Detlev J. K., The Weimar Republic: The Crisis of Classical Modernity, trans. Deveson, Richard, new ed. (1991; repr., London, 1993).Google Scholar

7. A lengthy tradition of theoretical work by sociologists on the nature of social problems, going back to the 1920s, is usefully summarized in Loseke, Donileen, Thinking About Social Problems: An Introduction to Constructionist Perspectives (Piscataway, N.J., 2003).Google Scholar

8. Percival, Thomas, Medical Ethics; or, a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons: to Which Is Added an Appendix; Containing a Discourse on Hospital Duties; Also Notes and Illustrations (London: Johnson and Bickerstaffe, 1803)Google Scholar. Percival’s work was preceded by a number of other eighteenth-century writings in a similar vein; see Maehle, Andreas-Holger, Doctors, Honour, and the Law: Medical Ethics in Imperial Germany (Basingstoke, 2009).CrossRefGoogle Scholar

9. Dracoby, Alex, “Ethics and Experimentation on Human Subjects in Mid-Nineteenth-Century France: The Story of the 1859 Syphilis Experiments,” Bulletin of the History of Medicine 77 (2003): 332–66.CrossRefGoogle Scholar

10. Elkeles, Barbara, Der moralische Diskurs über das medizinische Menschenexperiment im 19. Jahrhunder (Stuttgart, 1996), 48; Lederer, Subjected to Science, 1–14.Google Scholar

11. Lederer, Subjected to Science, 7.

12. Maehle, Andreas-Holger, “Assault and Battery, or Legitimate Treatment?Gesnerus 57 (2000): 206–21.Google ScholarPubMed

13. Frewer, Andreas and Neumann, Josef N., eds., Medizingeschichte und Medizinethik: Kontroversen und Begründungsansätze, 1900–1950 (Frankfurt am Main, 2001)Google Scholar. See also Meyer, Paulette, “Physiatrie and German Maternal Feminism: Dr. Anna Fischer-Dückelmann Critiques Academic Medicine,” Canadian Bulletin of Medical History 23 (2006): 145–82CrossRefGoogle ScholarPubMed; Veressayev, Vikenty, The Memoirs of a Physician, trans. Linden, Simeon (New York, 1916), 259Google Scholar; “Royal Commission on Vivisection: Fourth Report,” British Medical Journal (1908): 1695.

14. E.g., Browne, Lennox, “A Successful Case of Partial Excision of the Larynx, on Account of Intralaryngeal Epithelioma,” British Medical Journal 1 (1887): 272–74CrossRefGoogle ScholarPubMed. There seems to be some evidence that the woman involved was clearly in a terminal condition and had given a degree of consent to the procedure, so it is less harshly directly criticized by other authors. See Lederer, Subjected to Science, 11; Wagener, D. J. Theo, The History of Oncology (Houten, Netherlands, 2009), 31.Google Scholar

15. Gradmann, Christoph, “A Harmony of Illusions: Clinical and Experimental Testing of Robert Koch’s Tuberculin, 1890–1900,” Studies in History and Philosophy of Science Part C: Studies in History and Philosophy of Biological and Biomedical Sciences 35 (2004): 465–81CrossRefGoogle Scholar. Gradmann suggests that there was a considerable degree of hypocrisy in some of these criticisms, coming from rival physicians whose own practices were equally questionable. See p. 476.

16. Lederer, Subjected to Science, 13.

17. Ibid., 10–11.

18. Dingwall, Robert, Marie Rafferty, Anne, and Webster, Charles, An Introduction to the Social History of Nursing (London, 1988), 19–24.Google Scholar

19. Numbers, Ronald, “William Beaumont and the Ethics of Human Experimentation,” Journal of the History of Biology 12 (1979): 113–35CrossRefGoogle Scholar. Numbers notes that human experimentation begins with what might be termed “natural experiments,”people with various abnormalities, such as fistulas, that permitted access to internal organs as in Beaumont’s work with Alexis St. Martin in the 1820s and 1830s. This opportunism may be distinguishable from the deliberate interventions being performed by the 1870s.

20. Ramsey, Matthew, Professional and Popular Medicine in France, 1770–1830: The Social World of Medical Practice (Cambridge, 1988).Google Scholar

21. Dingwall, Robert, “Le Verouillage du marché: Les pharmacies anglaises dans la course à la licence, 1794–1868,” in Profession pharmacien: Le regard des sciences sociales, ed. Lasselain, José (Paris, 1995), 15–22Google Scholar; Weindling, Paul, Health, Race, and German Politics Between National Unification and Nazism, 1870–1945 (Cambridge, 1993)Google Scholar; Maehle, Andreas-Holger, “Professional Ethics and Discipline: The Prussian Medical Courts of Honour, 1899–1920,” Medizinhistorisches Journal 34 (1999): 309–38Google ScholarPubMed; Steffen, Monika, “The Medical Profession and the State in France,” Journal of Public Policy 7 (1987): 189–208CrossRefGoogle Scholar; Hildreth, Martha L., “Medical Rivalries and Medical Politics in France: The Physicians Union Movement and the Medical Assistance Law of 1893,” Journal of the History of Medicine and Allied Sciences 42 (1987): 5–29.CrossRefGoogle ScholarPubMed

22. Weindling, Health, Race, and German Politics, 18–25.

23. Shamos, Morris Herbert, The Myth of Scientific Literacy (New Brunswick, 1995).Google Scholar

24. Weindling, Health, Race, and German Politics, 14–18.

25. Elkeles, Barbara, “Wissenschaft, Medizinethik und gesellschaftliches Umfeld: Die Diskussion um den Heliversuch um 1900,” in Frewer, and Neumann, , Medizingeschichte und Medizinethik, 22–23.Google Scholar

26. Maehle, “Professional Ethics and Discipline,” 309–38. Other German states had previously introduced similar provisions, but a uniform national jurisdiction was not adopted until 1935.

27. French, Richard D., Antivivisection and Medical Science in Victorian Society (Princeton, 1975), 36.Google Scholar

28. Radford, Mike, Animal Welfare Law in Britain: Regulation and Responsibility (Oxford, 2001).Google Scholar

29. Bynum, William, “Reflections on the History of Human Experimentation,” in The Use of Human Beings in Research: With Special Reference to Clinical Trials, ed. Spicker, Stuart F., Alon, Ilai, Vries, Andre de, and Engelhardt, H. Tristram Jr. (Dordrecht, 1988), 41.Google Scholar

30. Maio, Giovanni, “Das Humanexperiment vor und nach Nürnberg: Überlegungen zum Menschenversuch und zum Einwilligungsbegriff in der französischen Diskussion des 19. und 20. Jahrhunderts,” in Medizin und Ethik im Zeichen von Auschwitz, ed. Wiesemann, C. and Frewer, Andreas (Jena, 1996), 46Google Scholar: “Das Erstaunen des französischen Beobachters bezieht sich vornehmlich darauf, dass die genannten Regelungen den Forschern offiziel das Recht zum Experimentieren verliehen und damit die Notwendigkeit des nicht-therapeutischen Versuchs bekräftigen.”See also Maio, Giovanni, ‘Medizinhistorische Überlegungen zur Medizinethik, 1900–1950: Das Humanexperiment in Deutschland und Frankreich,” in Frewer, and Neumann, , Medizingeschichte und Medizinethik, 374–84.Google Scholar

31. Elkeles, Barbara, “Medizinische Menschenversuche gegen Ende des neunzehnten Jahrhunderts und der Fall Neisser: Rechtfertigung und Kritik,” Medizinhistorisches Journal 1/2 (1985): 136Google Scholar; Elkeles, Barbara, “The German Debate on Human Experimentation Between 1880 and 1914,” in Roelcke, Volcker and Maio, Giovanni, eds., Twentieth-Century Ethics of Human Subjects Research: Historical Perspectives on Values, Practices, and Regulations (Stuttgart, 2004).Google Scholar

32. This was equivalent to about half of Neisser’s annual income, so it was a serious penalty. Vollman, Jochen and Winau, Rolf, “The Prussian Regulation of 1900: Early Ethical Standards for Human Experimentation in Germany,” IRB: Ethics and Human Research 18 (1996): 10.CrossRefGoogle Scholar

33. Elkeles, Der moralische Diskurs, 206–8, 221–24; Vollman and Winau, “The Prussian Regulation of 1900,” 10. See also Elkeles, “The German Debate,” 29, and Maehle, Doctors, Honour, and the Law, 83.

34. An English translation can be found as an appendix to Vollman and Winau, “The Prussian Regulation of 1900,” 11.

35. Moll, Albert, Ärztliche Ethik: Die Pflichten des Arztes in allen Beziehungen seiner Thätigkeit (Stuttgart, 1902).Google Scholar

36. Maehle, “Assault and Battery,” 206–21; Maehle, Doctors, Honour, and the Law, 84–86 and 110–18.

37. Elkeles, Der moralische Diskurs, 62.

38. Kater, Michael H., “Professionalization and Socialization of Physicians in Wilhelmine and Weimar Germany,” Journal of Contemporary History 20 (1985): 678–84CrossRefGoogle ScholarPubMed; Maehle, “Professional Ethics and Discipline,”314.

39. Maehle, “Professional Ethics and Discipline,” 314.

40. Elkeles, “German Debate,” 21.

41. Blackbourn and Eley, Peculiarities of German History, 190–95 and 221–23.

42. Maehle, “Professional Ethics and Discipline,” 314.

43. Maehle, Doctors, Honour, and the Law, 85–86. Elkeles, “German Debate,” 28. Kater, “Professionalization and Socialization,” 680.

44. Elkeles, “German Debate,” 28.

45. Elkeles, “Medizinische Menschenversuche,” 147–48; Elkeles “Wissenschaft, Medizinethik und gesellschaftliches Umfeld,” 35. See also Winau, Rolf, “Medizin und Menschenversuch: Zur Geschichte des ‘informed consent,’” in Wiesemann, and Frewer, , Medizin und Ethik, 24.Google Scholar

46. Heinz-Peter Schmieddebach, “Medizinethik und ‘Rationalisierung’ im Umfeld des Ersten Weltkriegs,” in Frewer and Neumann, Medizingeschichte und Medizinethik, 57. See also Maehle, “Professional Ethics and Discipline,” 311: “He [Michael Hubenstorf] observed also a re-evaluation of medical ethics in the 1920s, away from the well-being of the individual patient towards that of the Volk, and an increasingly authoritarian style of professional politics.”

47. Howard-Jones, Norman, “Human Experimentation in Historical and Ethical Perspectives,” Social Science and Medicine 16 (1982): 1435.CrossRefGoogle ScholarPubMed

48. Frewer, Andreas, “Entwicklungsprozesse auf dem Weg zur Moral des NS-Staates: Diskussionen im Spiegel der Zeitschrift, Ethik,’” in Frewer, and Neumann, , Medizingeschichte und Medizinethik, 144Google Scholar: “1922 wurde dann mit der Zeitschrift ‘Ethik, Pädagogik und Hygene des Geschlechtslebens’dann ein eigenes forum gegründet. Es handelt sich um die international erste Zeitschrift, die den Begriff ‘Ethik’im Titel eines von Ärzten geführten Wissenschaftsorgans führte und sich im Schwerpunkt medizinethischen Fragen widmete.”

49. Grodin, Michael, “Historical Origins of the Nuremberg Code,” in Annas, George J. and Grodin, Michael A, eds., The Nazi Doctors and the Nuremberg Code: Human Rights in Human Experimentation (New York, 1992), 129Google Scholar; see also Pross, Christian and Aly, Gotz, eds., Der Wert des Menschen: Medizin in Deutschland, 1918–1945 (Berlin, 1989), 92–93.Google Scholar

50. Liebenau, Jonathan, Medical Science and Medical Industry: The Formation of the American Pharmaceutical Industry (Baltimore, 1987).CrossRefGoogle Scholar

51. Quoted by Howard-Jones, “Human Experimentation,” 1435.

52. Heinz-Peter Schmieddebach, “Medizinethik und ‘Rationalisierung’ im Umfeld des Ersten Weltkriegs,” in Frewer and Neumann, Medizingeschichte und Medizinethik, 57, ed. Frewer and Neumann, also 79: “In der Schrift von Bindig und Hoche über die Freigabe der Vernichtung ‘lebensunwerten Lebens,’ die in ihrer ersten Auflage 1920 erschien, bildet die im Ersten Weltkrieg entstandene Kombination von rücksichtslosem Effektivitätsdenken und kriegsbezogener Gewaltanwendung geradezu das Grundprinzip, von dem her die Überlegungen und Legitimierungen der Menschentötung abgeleitet sind.” (In the text of Bindig and Hoche, concerning the permissibility of the destruction of “life not worthy of living,” which was first published in 1920, the combination of a ruthless drive for efficiency and the war-related application of violence downright constitute the basic rationale, from which the considerations and legitimizations of “manslaughter” were derived.)

53. Grodin, “Historical Origins of the Nuremberg Code,” 129.

54. Howard-Jones, “Human Experimentation,” 1436. See also Grodin, “Historical Origins of the Nuremberg Code,” 129.

55. 1931 German Guidelines on Human Experimentation,” International Digest of Health Legislation 31 (1980): 408–11.Google Scholar

56. Grodin, “Historical Origins of the Nuremberg Code,” 129.

57. “1931 German Guidelines on Human Experimentation,” 408. See also Norman Howard-Jones and Zenon Bankowski, Medical Experimentation and the Protection of Human Rights, proceedings of the XIIth CIOMS Round Table Conference, Cascais, Portugal, 30 November–1 December 1978. 65–67: “These guidelines were valid up to 1945,” Sass, “Reichsrundschreiben 1931,” 100: “The Richtlininen (guidelines) remained binding law in Germany even during the period of the Third Reich,” and Hans-Martin Sass, “Comparative Models and Goals for the Regulation of Human Research,” in Spicker et al., Use of Human Beings in Research, 51. “The Richtlinien remained binding law through the end of the German Reich in 1945.”

58. Howard-Jones, “Human Experimentation,” 1436.

59. “1931 German Guidelines on human experimentation.” See also Sass, “Reichsrundschreiben 1931,” which also reproduces the German text and offers a slightly different translation.

60. Howard-Jones, “Human Experimentation,” 1443.

61. Howard-Jones and Bankowski, Medical Experimentation and the Protection of Human Rights, 66, see also Grodin, “Historical Origins of the Nuremberg Code,” 129: “This document contains almost all of the points subsequently cited in the Nuremberg Code. Some would even argue that the guidelines are even more inclusive and formalistic than the Nuremberg Code in that they demand complete responsibility of the medical profession for carrying out human experimentation,” Howard-Jones, “Human Experimentation,” 1436: “The Nuremberg Code of 1947 comprises no significant advance on the 1931 German Guidelines,” and Sass, “Comparative Models and Goals,” 51: “They were stricter and more detailed than the Nuremberg code of 1947 and the Helsinki Declaration issued in 1964.”

62. Sass, “Comparative Models and Goals,” 54.

63. Howard-Jones, “Human Experimentation,” 1436. This is of course consistent with the argument that they operated more as terms in a contract of employment than as specific regulations.

64. Elkeles, “Medizinische Menschenversuche,” 144: “Um einen Konsens über das moralisch Zulässige zu bekommen, schlägt er eine Diskussion durch Forscher, Ärzte, Juristen und andere gebildete Männer’ vor.” (To arrive at a consensus with regards to what is ethically permissible, he suggests a discussion between researchers, doctors, lawyers, and other educated men.)

65. Peukert, Weimar Republic, 129–46 and 222–30.

66. Elkeles, “Medizinische Menschenversuche,” 135: “Schon in der ersten Phase der Aufarbeitung dieser Ungeheuerlichkeiten wurde klar, dass die Wurzeln der Medizin ohne Menschlichkeit’ jedoch tiefer und historisch früher lagen als im Nationalsozialismus, dass sie, wie Viktor von Weinzäcker es ausdrückt, begünstigt wurden ,durch die Denkweise einer Medizin, welche den Menschen betrachtet wie ein chemisches Molekül oder einen Frosch oder ein Versuchskaninchen.’”

67. Elkeles, “Medizinische Menschenversuche,” 140–41: “Die Einhaltung bestimmter Forschungsrituale wird zu einer Zauberformel, motivierend, exculpierend, rechtfertigend, und macht weitere Erklärungen untergeordnet. Das beste Beispiel findet sich wieder im Bereich der Bakteriologie: Wer sich bei seinen Forschungen auf die Methode, wie sie Robert Koch etabliert hat, beruft, bedarf keiner weiteren Rechtfertigung seines Verfahrens und seiner Ziele. … Gleichzeitig stellt sich der Forschungseleve damit in den Nachfolgerschatten des großen Meisters, in eine als bestätigend und legitimierend empfundene Kontinuität.” See also Sass, “Comparative Models and Goals,” 55: “Guidelines and recommendations requiring formal procedures, e.g., written acknowledgement of informed consent or specific forms for establishing review boards and the issuance of their reports, and the pre-establishment of a set of material values to be protected, such as informed consent or immediate cessation of the experiment or treatment if requested by the research subject or required by the primum non nocere rule, give a higher percentage of responsibility to guiding and recommending agencies. This is especially the case if review committees expressly approve or propose the change of specific procedures. Regulations thus far relieve the individual scientist’s or physician’s responsibility enormously, transforming moral responsibilities into legal or procedural obligations.” See also Peukert, Weimar Republic, 138–40, on the wider context.

68. Frewer, “Entwicklungsprozesse auf dem Weg zur Moral,” 157: “Die dargestellten Entwicklungsprozesse beleuchten den medizinethischen Diskurs von der Weimarer Republik zum Nationalsozialismus und illustrieren die schrittweise Hinwendung der Medizinethik zu Biologismus und generativer Kollektivethik.”

69. Pross and Aly, Der Wert des Menschen, 92.

70. On “hard” and “soft” law, see Abbott, Kenneth W. and Snidal, Duncan, “Hard and Soft Law in International Governance,” International Organization 54 (2000): 421–56.CrossRefGoogle Scholar

71. Although these are given some recognition in the Mental Capacity Act 2005, which gives the NHS review system wide jurisdiction over certain groups of “vulnerable” people.

72. Sass, “Comparative Models and Goals,” 65.

73. Elkeles, “Medizinische Menschenversuche,” 148.

74. Ayres, Ian and Braithwaite, John, Responsive Regulation: Transcending the Deregulation Debate (Oxford, 1992).Google Scholar

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76. Black, Donald, The Behavior of Law (New York, 1976)Google Scholar; Grabosky, Peter and Braithwaite, John, Of Manners Gentle: Enforcement Strategies of Australian Business Regulatory Agencies (Melbourne, 1986).Google Scholar

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78. Suchman, Mark C., “Managing Legitimacy: Strategic and Institutional Approaches,” Academy of Management Review 20 (1995): 571–610CrossRefGoogle Scholar; Black, JuliaConstructing and Contesting Legitimacy and Accountability in Polycentric Regulatory Regimes,” Regulation & Governance 2 (2008): 137–64.CrossRefGoogle Scholar

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