What was the 1st code of medical ethics called?

On the 20th of August 1947, 16 German physicians were found guilty of heinous crimes against humanity. They had been willing participants in one of the largest examples of ethnic cleansing in modern history. During the Second World War, these Nazi doctors had conducted pseudoscientific medical experiments upon concentration camp prisoners and the stories that unfolded during their trial – The Doctors’ Trial – were filled with descriptions of torture, deliberate mutilation, and murder.

Though the nature of their crimes was undeniably impermissible, the doctors’ defence argued that their experiments were not so different from others that had been conducted prior to the war. They claimed that there was no international law governing what was, and what could not be, considered ethical human experiment. As a result, the judges presiding at this tribunal recognised the need for a comprehensive and sophisticated way to protect human research subjects. They drafted the Nuremberg Code: a set of ten principles centred upon the consent and autonomy of the patient, not the physician. 2017 marks 70 years since the creation of the Nuremberg Code, and its influence on human-rights law and the field of medical ethics is undeniable. Discover the history of medical ethics, from Hippocrates to the present day, in the interactive timeline below.

Featured image credit: An alchemist reading a book; his assistants stirring the cible on the other side of the room. Engraving by P.F. Basan after D. Teniers the younger, 1640/1650. Public domain via Wikimedia Commons. 

Charaka Samhita - one of the main texts of Ayurveda ("science of life") - For a discussion see: Menon, I.A., and Haberman, H.F. 1970 "The Medical Students' Oath of Ancient India." Medical History 14, no.3: 295-299

Hippocratic Oath - Classical and modern versions (full text) - Dalhousie's version

Oath of Maimonides and the Daily Prayer of a Physician (full text)

Thomas Percival. Medical Ethics. (1803) (DALWKK W 50 P429 1803F)
The English physician, Thomas Percival (1740-1804) in 1803 published his Medical Ethics; or, a Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons. This code, following in the tradition of the Hippocratic Oath was to influence the development of later codes of medical ethics. Indeed, the American Medical Association (AMA) adapted and adopted Percival's code for use by American physicians in 1847. 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.

American Medical Association (AMA) Code of Ethics (1847) (full text - pdf)
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

See a history of AMA Ethics

Nuremberg Code (1947) (full text)
The product of international law, this code deals with medical research on human subjects and arose out of the post-WWII trial of Nazi doctors for crimes against humanity committed in the name of research. The Nuremberg Code sets out 10 principles outlining the ethics of medical research and ensuring the rights of human subjects::

• 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 - rev. 2002) (full text)
This oath for physicians was adopted by the newly established (1948) World Medical Association largely in response the atrocities committed in the name of research in WWII Nazi concentration camps. It was also meant to update the Hippocratic Oath to make it more applicable to the modern era.

World Medical Association International Code of Medical Ethics (1949)(full text)
This was an attempt to develop international standards of medical ethics and sought to summarize the most important principles of medical ethics.

Declaration of Helsinki (Adopted 1964; latest amendment 2013)(full text)
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.

In addition to professional associations and governmental bodies, other organizations such as the Catholic Church have issued codes concerning matters of human health.

Religious Directives for Catholic Health Facilities (5th ed. 2009) (full text)
This document is written by the United States Conference of Catholic Bishops and is considered binding on not only Catholics but also non-Catholics who are associated with Catholic health facilities.

Instruction on Respect for Human Life (1987) (full text)
The Vatican's Congregation for the Doctrine of the Faith makes known its stance concerning "biomedical techniques which make it possible to intervene in the initial phase of the life of a human being and in the very processes of procreation and their conformity with the principles of Catholic morality".

Patient's Bill of Rights (1973, rev. 1992) (full text)
The Patient's Bill of Rights was first adopted by the American Hospital Association with the expectation that hospitals and health care institutions would support these rights in the interest of delivering effective patient care. It was also written partly as a response to the growing consumer health movement.

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Nuremburg Code

The Nuremberg Military Tribunal's decision in the case of the United States v Karl Brandt et al. includes what is now called the Nuremberg Code, a ten point statement delimiting permissible medical experimentation on human subjects. According to this statement, humane experimentation is justified only if its results benefit society and it is carried out in accord with basic principles that "satisfy moral, ethical, and legal concepts." To some extent the Nuremberg Code has been superseded by the Declaration of Helsinki as a guide for human experimentation.

--"Permissible Medical Experiments." Trials of War Criminals before the Nuremberg Military Tribunals under Control Council Law No. 10. Nuremberg October 1946 - April 1949, Washington. U.S. Government Printing Office (n.d.), vol. 2., pp. 181-182.

1. The voluntary consent of the human subject is absolutely essential. This means that the person involved should have legal capacity to give consent; should be situated as to be able to exercise free power of choice, without the intervention of any element of force, fraud, deceit, duress, over-reaching, or other ulterior form of constraint or coercion, and should have sufficient knowledge and comprehension of the elements of the subject matter involved as to enable him to make an understanding and enlightened decision. This latter element requires that before the acceptance of an affirmative decision by the experimental subject there should be made known to him the nature, duration, and purpose of the experiment; the method and means by which it is to be conducted; all inconveniences and hazards reasonably to be expected; and the effects upon his health or person which may possibly come from his participation in the experiment.

The duty and responsibility for ascertaining the quality of the consent rests upon each individual who initiates, directs or engages in the experiment. It is a personal duty and responsibility which may not be delegated to another with impunity.

2. The experiment should be such as to yield fruitful results for the good of society, unprocurable by other methods or means of study, and not random and unnecessary in nature.
3. The experiment should be so designed and based on the results of animal experimentation and a knowledge of the natural history of the disease or other problem under study that the anticipated results will justify the performance of the experiment.
4. The experiment should be so conducted as to avoid all unnecessary physical and mental suffering and injury.
5. No experiment should be conducted where there is an a priori reason to believe that death or disabling injury will occur; except, perhaps, in those experiments where the experimental physicians also serve as subjects.
6. The degree of risk to be taken should never exceed that determined by the humanitarian importance of the problem to be solved by the experiment.
7. Proper preparations should be made and adequate facilities provided to protect the experimental subject against even remote possibilities of injury disability or death.
8. The experiment should be conducted only by scientifically qualified persons. The highest degree of skill and care should be required through all stages of the experiment of those who conduct or engage in the experiment.
9. During the course of the experiment the human subject should be at liberty to bring the experiment to an end if he has reached the physical or mental state where continuation of the experiment seems to him to be impossible.
10. During the course of the experiment the scientist in charge must be prepared to terminate the experiment at any stage, if he has probable cause to believe, in the exercise of the good faith, superior skill and careful judgement required by him that a continuation of the experiment is likely to result in injury, disability, or death to the experimental subject.