Ärztliches Gewissen bedeutet mehr, als nur Regeln zu befolgen...

Rules of conscience
Fiona Godlee, editor, BMJ
fgodlee@bmj.com

How often this week have we heard the phrase "but I was only following the rules" as details of MPs’ expense claims were splashed across the media? They may have been following the rules but we expected something better: that they would follow their consciences.

Just obeying the rules has long been insufficient for doctors. The judges at Nuremberg made clear that obeying commands from superiors didn’t remove personal accountability. Doctors couldn’t deviate from their ethical obligations even if a country’s laws allowed or demanded otherwise. The World Medical Association is meeting as I write. Its most noteworthy contribution has been the drafting of the Helsinki Declaration on Ethical Principles for Medical Research Involving Human Subjects. Both this and the World Medical Association’s International Code of Ethics contain the crucial statement that a doctor’s or investigator’s conscience and duty of care must transcend national laws.

So deeply ingrained is this ethic in health care that it’s surprising, even shocking, to find that the same code isn’t shared by psychologists, at least in the United States. As Kenneth Pope and Thomas Gutheil explain (doi:10.1136/bmj.b1653), the American Psychological Association has taken a series of decisions in recent years that seem more about politics than professionalism and have put psychologists seriously at odds with other health professions. After the 9/11 attacks, the APA changed its ethics code to allow members to set aside ethical responsibilities if the law requires them to do so. And in 2005 the APA agreed to allow members to take part in the interrogation of detainees, something that is rightly forbidden by medical associations.
Some won’t be shocked. They will agree with the APA that psychologists don’t have the same duty of care as doctors and that their skills can be usefully applied to developing and monitoring interrogation techniques. After all, the APA calls interrogation "a psychological endeavour". Recent disclosures have shown that psychologists helped to develop methods that the Red Cross has called "tantamount to torture".

As Pope and Gutheil explain, the APA has squared its collective conscience by excluding detainees from its list of vulnerable groups, which includes people with diminished capacity to consent, research participants, subordinates, and employees. One ethicist I spoke to was reminded of how German doctors, who before the second world war had the most enlightened rules on the protection of humans involved in research, classified Jews and other detainees as non-human and therefore not eligible for ethical protection.

Ethical standards are also being fudged at the US Food and Drug Administration. As Michael Goodyear and colleagues explain (doi:10.1136/bmj.b1559), trials performed outside the United States will no longer have to conform to the Helsinki Declaration even though they will be used to support licensing of drugs in the United States. Instead they will be regulated by the Good Clinical Practice guidelines: not an aspirational ethical code but a manual describing existing procedure for industry sponsored trials. This double standard could give the impression that the FDA "is more interested in facilitating research than respecting the rights of people who are subjects of research".

Cite this as: BMJ 2009;338:b1972