Steps still being taken to undo damage of "America's Nuremberg".
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Nuremberg's legacy: some ethical reflections.
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Advisory Committees↗
Nuremberg lamentation: for the forgotten victims of medical science.
Fifty years after the Nuremberg medical trial there remain many unanswered questions about the role of the German medical profession during the Third Reich. Other than the question of human experimentation, important ethical challenges arising from medicine in Nazi Germany which have continuing relevance were not addressed at Nuremberg. The underlying moral question is that of the exercise of professional power and its impact on vulnerable people seeking medical care. Sensitisation to the obligations of professional power may be achieved by an annual commemoration and lament to the memory of the victims of medical abuse which would serve as a recurring reminder of the physician's vulnerability and fallibility.
Codes of Ethics↗
[Case management for maintaining occupational status of handicapped patients. A model trial by the Bavarian federal district office].
Under the German social security system, medical benefits and services fall under the health insurance system, while vocational ones are the responsibility of the employment offices. In seamless transition cases, health funds almost exclusively rely on the relevant provisions of Book three--employment promotion--of the Social Code. Notwithstanding, sickness benefits frequently extend over the maximum period possible, i.e., 18 months, although the presence of disablement has been confirmed much earlier, and transition into unemployment certainly is no perspective either. Case Managements targeted at keeping disabled persons in employment have now been set up in several Bavarian employment offices. In close cooperation with the health funds' medical services, as well as in a number of other instances, they undertake early interventions to maintain employment, thus seeking to stem the traditional further course of disabled people still employed into the long waiting lines faced with at the rehabilitation agencies, or into unemployment and subsequent costly occupational reorientation, with continued joblessness awaiting them afterwards. The Case Management approach set out and analyzed in this article is intended as a model to be taken up elsewhere, having proven its benefit for people with disabilities while being cost-effective from an overall economic perspective due to its preventing the need to grant unemployment benefits and costly retraining. Guided by rehabilitation counsellors, the Case Managements are directed at rehabilitees and companies alike, and may take action through technical work aids, integration allowances, or skills adjustment programmes. For speedier, focussed implementation of the services offered, they "purchase" support and back-up from experienced agencies in the field, drawing on so-called "free" funding resources available under book three of the Social Code. Very good results using the model outlined have already been reported by the Nuremberg, Traunstein and Würzburg employment offices.
Case Management↗
Legal aspects of clinical trials in Israel.
Clinical trials were mainly the concern of medical ethics until the first code on this subject was laid down in a judgment given by a military tribunal in Nuremberg in 1947. In 1964 the World Medical Association adopted the Declaration of Helsinki, which was revised in 1975, regarding clinical trials and research. The Declaration of Helsinki and the developments in the pharmacological and pharmaceutical sciences led to legislation regarding clinical trials and human experimentation. In Israel it is forbidden to use any drug that is not registered. In order to register a drug, evidence of quality, safety and efficacy is necessary, and the means by which these factors are proved is the clinical trial, which demands appropriate legislation. Developments in various medical fields, as well as new treatment techniques, brought about the need for more comprehensive legislation on experimentation on human beings and embryos. In Israel, this field is covered by two enactments, the first on drugs and the second on any other experimentation on human beings. However, these enactments are frame laws, which lay down the rule that no clinical trial may be carried out without the prior approval of the Ministry of Health. They also state the minimum conditions to be met, and provide the Ministry with the authority to add any conditions at any time, as well as the right to stop the trial. The Declaration of Helsinki serves as the minimal legal basis for clinical trials. Some legal problems relating to the clinical trial remain unsolved and are left to the discretion of the Ministry of Health. The author makes some observations and suggestions with regard to matters of consent, incompetents as subjects, the right of withdrawal, and the power of the Ministry.
Clinical Trials as Topic↗
Health hazards from fine asbestos dusts. An analysis of 70,656 occupational preventive medical investigations from 1973 to the end of 1986.
For the period from 1973 to the end of 1986, 70,656 data sets on occupational preventive medical examinations in employees exposed occupationally to asbestos dust (G 1.2) were made available to us by the Central Registry for Employees Exposed to Asbestos Dust (ZAS). On the basis of this data, an analysis of asbestosis risk was to be made in relation to specific areas of work, taking into consideration the beginning and duration of exposure. Proceedings for declaratory appraisal in accordance with occupational disease no. 4103 were instituted in 1760 cases in the report period. In accordance with the character of the available data, the X-ray findings in the lungs were available from the persons investigated as parameters of possible asbestosis risk on the basis of coding consistent with the International Pneumoconiosis Classification (ILO U/C 1971 and/or ILO 1980 West Germany). The major result of the statistical analyses on the mainframe macrocomputer of the University of Erlangen-Nuremberg was that the relatively highest risk of asbestosis was present in persons whose exposure began before 1955. On the other hand, with increasing duration of exposure, an unequivocal rise of the asbestosis risk could not be detected on the basis of the overall population. In relation to the individual fields of work, the relatively highest risk of asbestosis was shown to be in the asbestos textile and paper industry, as well as in the asbestos cement industry. No detectable risk of asbestosis was present in the fields of mining, traffic and health service and for women in the industrial sectors of building material, gas and water, catering trade, building, commerce as well as banking and insurance. Accordingly, it can be assumed that certain fields of work are or were exposed to such a small extent or not at all that a risk of asbestosis which is relevant in terms of occupational medicine is no longer to be assumed or was not to be assumed. This applies above all to certain work in the frictional coating (brake lining) and asbestos paper industry. Furthermore, the analysis of the data material did not provide any unequivocal indications that inhalative smoking habits have a negative effect on the risk of asbestosis. In principle, it can be stated that the occupational preventive medical investigations according to G 1.2 are effective.(ABSTRACT TRUNCATED AT 400 WORDS)
Adult↗
Nuremberg and the issue of wartime experiments on US prisoners. The Green Committee.
Defense attorneys at the Nuremberg Medical Trial argued that no ethical difference existed between experiments in Nazi concentration camps and research in US prisons. Investigations that had taken place in an Illinois prison became an early focus of this argument. Andrew C. Ivy, MD, whom the American Medical Association had selected as a consultant to the Nuremberg prosecutors, responded to courtroom criticism of research in his home state by encouraging the Illinois governor to establish a committee to evaluate prison research. The governor named a committee and accepted Ivy's offer to chair the panel. Late in the trial, Ivy testified--drawing on the authority of this committee--that research on US prisoners was ethically ideal. However, the governor's committee had never met. After the trial's conclusion, the committee report was published in JAMA, where it became a source of support for experimentation on prisoners.
Advisory Committees↗
Gerontopsychological studies using NAI ('Nürnberger Alters-Inventar') on patients with organic psychosyndrome (DSM III, Category 1) treated with centrophenoxine in a double blind, comparative, randomized clinical trial.
A double blind clinical trial was performed on 50 persons (25 men, 25 women) over the age 60 (average age: 77 years). They suffered from dementias of medium level (DSM III, Category 1, ICD No. 299), and had been residents in an old age home longer than 3 months at the start of the trial. The patients were treated first for 2 weeks by placebo tablets and their initial performance was recorded during this period by using the Nuremberg Gerontopsychological Inventory (NAI). This was then followed by a treatment for 8 weeks with the nootropic drug, centrophenoxine (CPH), the dose of which was 2 g/day distributed in 2 x 2 tablets of Helfergin500 (Promonta, Hamburg, FRG), or with placebo tablets of identical size, then the NAI test was repeated again. Verum or placebo treatment was selected randomly and the code was revealed only after having elaborated all the results of the trial. During the treatment period four drop-outs occurred for intercurrent diseases. Evaluation was based on a semi-quantitative, intra-individual comparison of the performance before and after treatment. The results obtained suggest that CPH treatment may be useful in dementias of medium level in quite old groups of patients, since 48% of the verum group displayed improvements in the memory functions against 28% of the placebo group. CPH seems to be a useful and harmless drug in the treatment and most probably also in prevention of the dementias.
Aged↗