Moral outcome of nuremberg trials

This kind of trial is called a crossover trial because patients in the trial cross over at predetermined time points from the placebo to the treatment arm and vice versa [ 14 ].

However, these non-conventional design options are not applicable in all situations; more importantly, in some cases, measuring the effectiveness of the new treatment as compared with placebo is less relevant than confronting the new treatment, within a clinical setting, with the established standard treatment for the illness under study.

In such cases, there is the possibility to conduct an active-controlled trial ACT. Even though it might appear that there is a clear ethical and scientific rationale to the use of active controls in place of placebo controls, the conduct of ACTs is nonetheless controversial. This issue, known as the problem of assay sensitivity , is a subject of critical discussion [ 16 , 17 ].

In most of the ethical regulations and research guidelines, the use of placebo controls is subjected to a delicate tradeoff between the stringency of the scientific rationale for using it, and the possibility of harm for participating patients. RCTs involve, by definition, randomisation and often blindfolding of participants. These two epistemic devices are needed in order to rule out the most obvious perturbations of the trial result due to the interference from the investigators or the patients themselves.

However, randomisation and blinding may come to conflict with the individual interests of those participating in the trial. A first reason for this conflict is that, when randomisation and blinding are in place, patients cannot enjoy individualised treatment decisions responding to their condition [ 18 ]. This, however, is something patients explicitly consent to when they endorse trial participation.

Randomisation between the two arms of the study does, however, raise a further ethical concern that is not so easily dismissed. By entering an active-controlled RCT, participating patients stand a chance of receiving the treatment that will eventually turn out to be inferior.

This is especially problematic if the experimental treatment proves to be worse than the standard that was available outside of trial, since it is a recognised ethical principle that patients should receive the best proven standard of care whenever feasible see [ 3 ]. Apparently, then, randomisation harms trial participants that, by entering the trial, may be denied the best standard of care available.

The view that is currently prevalent in the ethical literature is that equipoise , denoting an epistemic state of indifference between two treatments, can relieve this ethical tension. Notwithstanding its success as an ethical paradigm, however, equipoise has critics. A first problem is that of identifying under which conditions equipoise is present given a particular clinical question [ 21 ].

Furthermore, an all but obvious point is whose equipoise or indifference should be morally relevant. While the currently predominant notion, based upon considering the state of knowledge of the scientific community, appears as the most reasonable choice, other options may have a sound rationale as well. For instance, at least for some conditions, equipoise of the participating patients should be just as relevant, since we can hardly expect a patient to be indifferent between, say, an invasive surgical procedure and a therapy based on oral drug administration [ 22 ].

Despite the problems just mentioned, however, equipoise remains a workable ethical paradigm for adjudicating the ethics of clinical trials, routinely used by ethical boards in research hospitals in taking decisions about the approval of new studies. It is worth mentioning, in closing the section, that medical investigators and biostatisticians in the past have strived for finding a methodological solution in order to minimise the chance that patients are exposed to the less effective treatment.

Techniques such as unequal randomisation—i. However, such methodological solutions pose more ethical problems than they solve, given the difficulty of justifying the ethics of enrolling in the trial the patients that end up in the non-preferred arm. As discussed in opening the section, in clinical research, there exists a gap between those who are exposed to the risk of a medical intervention—the trial participants—and those who are the intended beneficiaries of the trial results—future patients and society at large.

The existence of this gap has informed the conception of most ethical guidelines that are currently in use, which were created with a keen eye to protecting participants from the risks and the burdens of research. Mostly, two considerations speak against it. The first point is the observation that the sole effect of such strict regulation in developed countries has been that of encouraging the outsourcing of trials conduct to countries where standards for the protection of participants are lower.

This is clearly an issue, also due to the fact that both the national states involved and the prospective participants individually often find themselves in a situation of economic vulnerability and captivity towards the large pharmaceutical groups that are running the trial see [ 24 ] and [ 25 ].

Thus, strong protection norms prove ultimately ineffective in warranting high levels of protection to participants in a globalised setting, appearing on the contrary to foster new forms of exploitation.

Negotiating the adequate level of protection that can be set as a global standard for medical research has proven challenging, as testified by the continuing effort in revising of the Helsinki Declaration [ 26 ].

A second argument that has been raised against the current paradigm concerns the issue of paternalism [ 27 ], i. A patient participating in a trial might wish to take a higher level of risk for the sake of an individually gauged perceived benefit, for instance, by taking a chance with an innovative and promising treatment. Or, more controversially, a patient might wish to take part in a research from which she knowingly stands no chance of receiving any benefit, for the sake of benefiting other patients or posterity.

The issues discussed in this review stem from general features of clinical research and the RCT methodology, such as the need to subject patients to blindfolding and random allocation between treatment arms, or the point that medical research and practice respond to different ethical standards.

In closing this review, the author will examine the context of oncological research more specifically. As a consequence, most of the ethical issues we discussed through this chapter—for instance, the legitimacy of the use of placebo or the risk of therapeutic misconception—arise in the context of testing anticancer drugs to a preeminent point. Surgical procedures will not be considered in the following discussion, even though they represent the front-line intervention against several tumours, due to the fact that they are not typically evaluated through RCTs [ 30 ].

In addition to the questions already explored through the review, however, oncological research presents a whole new family of ethical issues as the field goes through the so-called genomic revolution. The completion of the Human Genome Project has brought about the potential for a profound transformation of the understanding and managing of non-infective diseases. The offshoot is personalised or precision medicine, or the idea of proceeding from the genetic and molecular hallmarks of common diseases in order to design and administer situationally the least harmful and most effective treatment [ 31 ].

Molecular biology, and the quest for molecularly targeted agents, are playing an increasingly major role also in oncological research [ 32 ]. While traditional anticancer agents target, in a non-specific manner, all fast-dividing cells, novel molecularly-based agents are expected to act in a selective manner on precise nodes of cellular pathways that are mutated or dysregulated in cancer cells.

The two most renowned of these compounds are Gleevec imatinib in chronic myelogenous leukaemia CML and Herceptin trastuzumab in breast cancers characterised by overexpression of HER2 receptor. Targeted cancer therapies give doctors a better way to tailor cancer treatment, especially when a target is present in some but not all tumours of a particular type, as is the case for HER2.

Targeted treatments also hold the promise of being more selective of cancer cells versus normal cells with respect to traditional chemotherapeutics, thus harming fewer healthy cells, reducing side effects, and improving the quality of life.

Targeted treatments represent the major way forward in oncological research, and they are a solid clinical reality for the management of some disease subclasses, such as the already cited CML. Despite this, the development and use in the clinics of targeted agents is as yet underexplored in its ethical consequences.

From the point of view of the clinical practice, the most serious issues are raised by concerns of distributive justice, especially face the escalating costs of molecular agents [ 33 ]. However, the focus of this review is the context of clinical research, and of clinical trials in particular.

As a matter of fact, the testing of targeted agents is an even more neglected topic in the ethical literature; in the following, the author will present some observations based on original research.

The reader should be warned, though, that the complexity and breadth of the issues involved far exceeds the scope of this review. When patients that have the same kind of tumour, but harbouring different molecular lesions, are exposed to a targeted compound, the response can vary dramatically to the point that not only the magnitude, but also the direction of the treatment effect may be different across molecularly identified subgroups.

This is particularly relevant for the testing of such drugs, as it means that the beneficial effect of the targeted agent in trial is often restricted to a small class of the initially eligible patients, and the class of patients that would benefit often cannot be determined prior to beginning the study [ 34 ].

Thus, in a study testing a targeted agent, only a small fraction of the participating patients have a prospect to benefit from the experimental treatment at all. While apparently this seems true of conventional RCTs as well, a closer inspection reveals the ethical issue as specific of targeted therapies.

In the case of a treatment that has universal application, like a conventional cytotoxic agent, whether the trial is successful or not, it will have established a conclusion that is relevant also for the patients that were participating—this prospectively justifies their participation.

However, this is admittedly not the case for participants in a targeted therapy trial—at the outset of the trial, it is known that the conclusion about the new therapy will at best have a relevance only for a small fraction of these patients.

This unprecedented ethical issue can indeed be alleviated in case there exist means—such as reliable tests or biomarkers—to single out for trial participation only those patients which are likely to respond; at the time being, however, this is unfortunately not often the case. Furthermore, the possibility of conducting trials only on a highly selected population of patients raises a new set of concerns. It has been argued that precision medicine calls for a shift in the drug testing paradigm, from the current one based on large RCTs and the centrality of statistical evidence, to one based on shorter, smaller trials that combine the statistical evidence from the trial with causal knowledge coming from the lab [ 35 ].

Between and , 12 additional trials were carried out, during which police chiefs, intelligence service commanders, officials from various ministries, doctors, judges and other officials of the Nazi regime were tried.

At the Yalta Conference the leaders of the allies had agreed that an international tribunal would try the main Nazi leaders , who were held responsible for the outbreak of the Second World War and for the war crimes committed during the conflict. This resolution was confirmed at the Potsdam Conference, which was held in July After the end of the war, the devastation was so great and the war crimes that came to light so heinous that the Allies confirmed the determination that exemplary punishments must be imposed on those responsible for the extermination of millions of human beings.

On August 8, , representatives of the United States, France, Great Britain, and the Soviet Union signed the London Charter , a document that set out the principles and procedures by which the Nuremberg trials would be governed. The verdict of the first trial was published by the court on October 1, : out of a total of 24 defendants, 12 were sentenced to death by hanging, 3 were acquitted, 3 were sentenced to life imprisonment and 4 were sentenced to various periods from prison.

Biden never explains how he derived the content of this good natural law or how to account for any law at all given Darwinian assumptions taught in our schools and mandated by our courts. Of course, even though natural law theory has its problems, it does recognize the existence of a higher law.

Ultimately, however, natural law, in order to remain stable, must presuppose the foundation of biblical law.

Some people understood the dilemma of how to account for moral absolutes in a society that officially discounts God. Yale law professor Arthur Leff was perplexed that an agnostic culture even wants enduring values. In a lecture delivered at Duke University in , Leff expressed his bewilderment:. I want to believe—and so do you—in a complete, transcendent and immanent set of propositions about right and wrong, findable rules that authoritatively and unambiguously direct us how to live righteously.

I also want to believe—and so do you—in no such thing, but rather that we are wholly free, not only to choose for ourselves what we ought to do, but to decide for ourselves, individual and as a species, what we ought to be. What we want, Heaven help us, is simultaneously to be perfectly ruled and perfectly free, that is, at the same time to discover the right and the good and to create it.

Who are you to impose your morality on me? Putting it that way makes clear that if we are looking for an evaluation, we must actually be looking for an evaluator : some machine for the generation of judgments on states of affairs. If the evaluation is to be beyond question, then the evaluator and its evaluative processes must be similarly insulated.

If it is to fulfil its role, the evaluator must be the unjudged judge, the unruled legislator, the premise maker who rests on no premises, the uncreated creator of values. The so-called death of God turns out not to have been His funeral; it also seems to have effected the total elimination of any coherent, or even more-than-momentarily convincing, ethical or legal system dependant upon final authoritative, extrasystemic premises.

How does the modernist create a moral center in the Darwinian struggle for life? Being kind, for example, has a good result. In a courtroom flooded by lights for the newsreel cameras, five hundred spectators and 21 defendants -- some shielding their eyes from the glare behind dark glasses -- waited for the unprecedented trial to begin.

Walter Cronkite, Journalist : Sitting there for the first time and seeing these 21 men who had caused such horror in the world I actually felt sick, kind of. They had come into the dock as if this was not a fair proceeding, as if they knew they were going to hang already, why go through this whole thing. Narrator : As the eight judges, led by Lord Geoffrey Lawrence of England -- took their places on the bench, the air was thick with anticipation.

The international tribunal was empowered to decide the fate of each defendant -- including a sentence of death. William Jackson : That was an indication of his ability of try to find an opening to present what he wanted to say rather then what he was being asked. Narrator : Each defendant pleaded "not guilty. He had labored over his opening statement for weeks. Robert Jackson archival : "The privilege of opening the first trial in history for crimes against the peace of the world imposes a grave responsibility.

The wrongs which we seek to condemn and punish have been so calculated, so malignant and so devastating that civilization can not tolerate their being ignored, because it can not survive their being repeated. Whitney Harris, Prosecutor : That set the tone not only for the speech which followed but for the entire trial. This was not a trial of Germans alone. This was a trial for humanity. This was a trial to prevent tyranny from raising its head again in any place in the world.

Narrator : The trial unfolding in Nuremberg was not without controversy. In the months leading up to Allied victory, voices calling for vengeance had been numerous and forceful. As the long and bloody war in Europe was winding down, Allied leaders began to address what should be done with the Nazis. Soviet Premier Joseph Stalin preferred show trials, followed quickly by mass executions.

President Franklin Roosevelt -- his health failing badly -- was hearing conflicting opinions from his cabinet. Roosevelt's influential Treasury Secretary, Henry Morganthau -- Jewish, and enraged by Nazi atrocities -- argued for summary executions of those he called "the arch criminals of this war. Whitney Harris : That was the concept that we would charge these leading defendants with conspiring, getting together and plotting to seize control of the German government and subjecting the German people to its dictatorial control, making the German people themselves victims if you like and eliminating freedom in Germany, eliminating democracy, establishing a ruthless dictatorship and then, having done that -- that's the conspiracy -- then committing the crimes that they did in the name of the German people.

Martha Minow, Professor of Law : It was difficult for the political figures to come to the view that after this rather brutal and longout war that something as refined and patient as a legal process should be pursued, but if someone is a prisoner of war, they are not supposed to be executed and, indeed, they are supposed to be given considerable protection.

So it would have violated at least the best versions of American law and British law to have summary executions. Jackson was wary. The trials would explore uncharted legal territory; convictions were by no means certain. If we want to shoot Germans as a matter of policy, let it be done as such. But don't hide the deed behind a court. John Barrett, Jackson's Biographer : Jackson hears from collegues at the Supreme Court and friends and contacts in the government, and he encounters a lot of skepticism about the time and difficulty of accomplishing this, skepticism about the benefits at the end of the process in terms of justice, in terms of deterrence.

Narrator : Still, Jackson was drawn to the challenge. The son of a small town businessman, Jackson never attended college. He had risen to become attorney general, then a Supreme Court justice. John Barrett : Robert Jackson was a lawyer's lawyer at each stage of his career. For twenty years in private practice, trials and appeals and tremendous success. And then Jackson on the bench of the Supreme Court being a very active and witty and colorful speaker in the courtroom and thinker and writer in his opinions Narrator : Now, at age fifty-three, Jackson exuded self-confidence and ambition, and was frustrated at being on the sidelines during World War Two, the century's great drama.

On May 2, he accepted Truman's offer. Robert Jackson : "I am convinced that we have an opportunity to bring to a just judgement those who have thought it safe to wage aggressive and ruthless war.

Narrator : The Supreme Court would soon adjourn for the summer. Jackson was sure he'd be back in time for the fall session. But he also knew that the trials would be controversial, and might hurt his chances of one day being named Chief Justice.

As Jackson assembled his legal team in Washington, the U. Army was gathering evidence of Nazi atrocities-the extent of which were finally being understood: the use of slave labor; the horrific extermination camps; the millions of murdered Jews. Benjamin Ferencz, U. Army Investigator : I was coming in there to prove the crimes.

We would come in. We would prepare a list of the evidence, proof of what transports had come into the camp, how many people had been registered as being killed on the various dates, the supposed cause of death -- which was obviously fictitious, such as "Auf der Flucht erschossen," shot while trying to escape They didn't look like human beings, many of them; they looked animal-like, almost.

Or like skeletons. He had brought his prized possessions -- 17 truckloads worth -- and expected to be treated like a dignitary. The following year, he became addicted to morphine while recovering from injuries sustained during a failed Nazi coup. His addiction led to manic-depressive behavior that twice forced him to be hospitalized.

He established the secret police, the Gestapo, instituted concentration camps for political opponents and commanded the Luftwaffe, Germany's air force. He was cunning, ostentatious, larger-than-life- regarded by many as the "Sun King" of the Third Reich.

He changed clothes several times a day, favoring brightly colored jackets, gaudy jewelry, and archaic Bavarian hunting outfits. Now he was the highest ranking Nazi prisoner of war. Hitler and his propaganda chief, Joseph Goebbels, had killed themselves. Now, Robert Jackson could send in civilian investigators to search for a paper trail of Nazi crimes. The results were stunning. Whitney Harris : I visited many Gestapo offices and I found documents lying around on the floor, saying "this man should be executed.

There were many many documents that were not destroyed that we obtained and were incriminating. Narrator : "I did not think men would ever be so foolish," Jackson wrote, "as to put in writing some of the things the Germans did.

The stupidity and the brutality of it would simply appall you. He was unsure how difficult the negotiations would be, but expected them to be brief. The Allies quickly came to agreement on a key point: the tribunal would not allow the Nazis to defend their actions by claiming the Allies had also committed crimes, such as killing civilians by carpet bombing German cities.

They just came up with kind of a blanket rule: we will find it no defense to say 'but you did it too.