[The genesis of informed consent in the context of medical research ethics 1900-1931]

At the turn of the 20th century, the problem of human experimentation and the need to obtain consent became more important among medical practitioners and the general public. The case of the venereologist Albert Neisser, among others, is used to trace the development of research ethics standards in Germany between the end of the 19th century and 1931. The concept of informed consent, which originated in research ethics, is also of central importance in clinical ethics today.

Belmont in Europe: A Mostly Indirect Influence

This paper traces the reception of the Belmont Report in Europe and its influence on the development of European research ethics thinking and European research ethics systems. It is very difficult to trace a clear, linear reception history because it is difficult to disentangle the influence of the Report from the influence of concurrent developments, such as the 1975 revision of the World Medical Association Declaration of Helsinki and the requirement for research ethics review in the Vancouver Group's 1978 "Uniform Requirements for Manuscript Submission." The Report's insistence that the focus of research ethics should be the rights and interests of the individual research subject, and the use of an ethical framework and not ethical theory as the basis of analysis and justification of recommendations, were nevertheless very important for the development of research ethics. The divergence between Europe and the US in the governance of non-biomedical research can at least partly be explained by the absence of strong drivers for the introduction of research ethics committees outside of biomedicine in Europe, and by the ability of non-biomedical researchers to mobilize effectively against the introduction of such committees.

A Master Mariner's Left Testicle and the Law of Surgical Consent in Mid-20th Century Canada

Canadian medical and legal historians have given little attention to the history of medical malpractice law. This article examines one aspect of this subject, the litigation that arose over issues of consent in advanced surgeries, by offering a contextualized case study of Marshall v. Curry (1933). In Marshall, a master mariner from Nova Scotia sued for $10,000 in damages for negligence and assault after a surgeon removed his left testicle without his approval during a hernia operation. Marshall lost at trial, but the Nova Scotia Supreme Court decision became precedent for the principle that doctors could undertake more aggressive procedures without consent only if the patient's life or health were in immediate danger. This study considers why these cases became more common by the early twentieth century, teases out the changing law of consent, and suggests what the case tells us about judicial attitudes towards patients and doctors.

[Clinical information, informed consent and medical deontology. A recent relationship]

In Spain, the right to clinical information and informed consent as a practical expression of the principle of autonomy, are legal conquests achieved in the late twentieth century. From the law they have been transferred to the codes of medical deontology. The aim of this work is to study the pace of this transfer. Historical review of the different codes of medical deontology in Spain since the Civil War, seeking the presence of these ideas in them. Until code of medical deontology of 1979, the idea of clinical information did not appear in the contemporary deontological norm, and the rules on consent did so in very restricted cases. As of that date, their appearance is progressive in the successive codes. Currently, both concepts are fully developed in Spanish deontological regulations. Medical Deontology has take on the ideas of patient information and informed consent. This has been a long process which have brought considerable changes the deontological orientations of the traditional form of doctor-patient relationship. In these aspects, medical deontology has drifted, from emphasizing the prudence of the doctor, to emphasize the duty to inform and give ample space to the patient's decisions, which he recognizes as an autonomous and reflective moral agent, capable of taking his own decisions about your health.

BODIES R US: Ethical Views on the Commercialization of the Dead in Medical Education and Research

With the ongoing and expanding use of willed bodies in medical education and research, there has been a concomitant rise in the need for willed bodies and an increase in the means of supplying these bodies. A relatively recent development to enlarge this supply has been the growth of for- profit willed body companies ("body brokers") in the United States. These companies advertise for donors, cover all cremation and other fees for the donor, distribute the bodies or body parts nationally and internationally, and charge their users for access to the body or body parts. In doing so, they generate substantial profits. This review examines the historical development of willed body programs, the legal and economic aspects of willed body programs, and then provides an ethical framework for the use of willed bodies. The ethical principles described include detailed informed consent from the donors, comprehensive and transparent information about the process from the body donation organizations, and societal input on the proper and legal handling of willed bodies. Based on the ethical principles outlined, it is recommended that there be no commercialization or commodification of willed bodies, and that programs that use willed bodies should not generate profit.

The Physician's Duty to Warn Their Patients About the Risks Associated with Medical Intervention: A Review and Discussion

Since the landmark case of Montgomery v Lanarkshire in 20151, much has been written in medical press regarding the implications for medical practice. The moral duty - varied though it has been over this time, has been discussed since the earliest days of the medical profession. The law has sought to define this duty in response to changes in society, and the nature of the relationship between doctor and patient. The moral and legal duty are intrinsically linked, but the latter must surely follow the former for "the law has little to do with morally required forms of communication in the clinic and in the research environment."2 The common law nature of this process has resulted in an inconsistent and often tortuous path as societal standards have shifted. Accordingly, the ultimate definition of the legal doctrine, "informed consent," has changed since its relatively recent entry into the medicolegal vocabulary. These parallel shifts in the legal and moral duty to disclose risk have resulted in a confusing melee of evidence and recommendations for clinicians. We address the development of the law of "informed consent," as the legal mirror of the moral duty upon a clinician to disclose risk to their patient.

Risk and Reputation: Obstetricians, Cesareans, and Consent

When physicians performed cesarean sections in the nineteenth century, they customarily sought agreement from all present before proceeding. In contrast, after the introduction of electronic fetal monitoring in the late 1960s, obstetricians obtained permission for a cesarean by offering a choice that ensured consent-give birth by cesarean or give birth vaginally to a damaged or dead baby. This article argues that the manner in which physicians obtained consent for cesareans in the nineteenth century was one factor that kept the cesarean rate low, while the manner in which physicians obtained consent in the late twentieth and early twenty-first centuries was one factor driving up the cesarean rate. The dissimilar approaches to consent did serve a common purpose, however. Each preserved physicians' reputations. With the surgery likely to end in a woman's death in the nineteenth century, consensus ensured that a bad outcome would be a shared burden. And because the fetal monitor, in exaggerating the risks of vaginal birth, changed the nature of the malpractice climate for obstetricians, the late-twentieth-century approach to consent similarly protected physicians. As one early twenty-first-century obstetrician quipped, "You don't get sued for doing a C-section. You get sued for not doing a C-section."

A Troubled Past? Reassessing Ethics in the History of Tissue Culture

Recent books, articles and plays about the 'immortal' HeLa cell line have prompted renewed interest in the history of tissue culture methods that were first employed in 1907 and became common experimental tools during the twentieth century. Many of these sources claim tissue cultures like HeLa had a "troubled past" because medical researchers did not seek informed consent before using tissues in research, contravening a long held desire for self-determination on the part of patients and the public. In this article, I argue these claims are unfair and misleading. No professional guidelines required informed consent for tissue culture during the early and mid twentieth century, and popular sources expressed no concern at the widespread use of human tissues in research. When calls for informed consent did emerge in the 1970s and 1980s, moreover, they reflected specific political changes and often emanated from medical researchers themselves. I conclude by arguing that more balanced histories of tissue culture can make a decisive contribution to public debates today: by refuting a false dichotomy between science and its publics, and showing how ethical concepts such as informed consent arise from a historically specific engagement between professional and social groups.

Henry Knowles Beecher, Jay Katz, and the Transformation of Research with Human Beings

The modern history of experimentation with human beings is notable for its ethical lacunae, when even the clearest directives fail to prevent violations of subjects' rights and welfare. One such lacuna occurred during the 25 years between 1947, when the Nuremberg Code was articulated in the judgment passed on the men who had performed medical experiments in the Nazi concentration camps, and 1972, when the revelation of the 40-year-long Tuskegee Syphilis Study shocked the public and pushed Congress to adopt legislation that eventually transformed the governance of human subjects research. The work that Henry Beecher and Jay Katz did on the ethics of human experimentation beginning in 1964-which was mutually supportive but also divergent in its premises and prescriptions-played a prominent role in the policy-making processes. Beecher, whose detailed disclosure of the ethical lapses of leading researchers in his renowned 1966 New England Journal of Medicine article initiated the policy reform process, proved less influential in shaping those reforms than Katz. Ultimately, Beecher was one of the last and best exemplars of "medical ethics," while Katz-in his service on the Tuskegee Syphilis Study Ad Hoc Advisory Panel and in his testimony before, and work with, the Senate Health subcommittee-was an early practitioner of bioethics, a field in which the rules are not all written and applied by the medical profession but arise through a messier process involving outsiders and formal regulatory decisions.

Acid Brothers: Henry Beecher, Timothy Leary, and the psychedelic of the century

Henry Knowles Beecher, an icon of human research ethics, and Timothy Francis Leary, a guru of the counterculture, are bound together in history by the synthetic hallucinogen lysergic acid diethylamide (LSD). Both were associated with Harvard University during a critical period in their careers and of drastic social change. To all appearances the first was a paragon of the establishment and a constructive if complex hero, the second a rebel and a criminal, a rogue and a scoundrel. Although there is no evidence they ever met, Beecher's indirect struggle with Leary over control of the 20th century's most celebrated psychedelic was at the very heart of his views about the legitimate, responsible investigator. That struggle also proves to be a revealing bellwether of the increasingly formalized scrutiny of human experiments that was then taking shape.

Elements for adequate informed consent in the surgical context

Given a history of atrocities and violations of ethical principles, several documents and regulations have been issued by a wide variety of organizations. They aim at ensuring that health care and clinical research adhere to defined ethical principles. A fundamental component was devised to ensure that the individual has been provided the necessary information to make an informed decision regarding health care or participation in clinical research. This article summarizes the history and regulations for informed consent and discusses suggested components for adequate consent forms for daily clinical practice in surgery as well as clinical research.

Clinical research before informed consent

Clinical research with patient-subjects was routinely conducted without informed consent for research participation prior to 1966. The aim of this article is to illuminate the moral climate of clinical research at this time, with particular attention to placebo-controlled trials in which patient-subjects often were not informed that they were participating in research or that they might receive a placebo intervention rather than standard medical treatment or an experimental treatment for their condition. An especially valuable window into the thinking of clinical investigators about their relationship with patient-subjects in the era before informed consent is afforded by reflection on two articles published by psychiatric researchers in 1966 and 1967, at the point of transition between clinical research conducted under the guise of medical care and clinical research based on consent following an invitation to participate and disclosure of material information about the study. Historical inquiry relating to the practice of clinical research without informed consent helps to put into perspective the moral progress associated with soliciting consent following disclosure of pertinent information; it also helps to shed light on an important issue in contemporary research ethics: the conditions under which it is ethical to conduct clinical research without informed consent.

"Case Neisser": experimental design, the beginnings of immunology, and informed consent

In 1892, Albert L. Neisser (1855-1916), the professor of dermatology and venereology at the University of Breslau (Prussia), undertook two series of clinical experiments: one to test whether serum from syphilitic patients had a prophylactic value against contracting syphilis, and the other to test whether such serum had a therapeutic value for syphilitic patients. The first experiment was based on the erroneous scientific hypothesis called "Colles's law," which posited that a fetus that was syphilitic due to the father's disease could in utero immunize its mother against syphilis. Neisser acknowledged that neither experiment achieved its goal. However, when his work was published, Neisser was criticized not for the various errors of experimental design that should have been recognizable to him, but because of his failure to obtain the consent of his non-syphilitic subjects. The political furor that followed led to the first governmental edict to require informed consent of participants in clinical research. This essay examines how Neisser's generally forgotten investigation into therapies for syphilis led to some of the first regulations about informed consent.

Family influence and psychiatric care: physical treatments in Devon mental hospitals, c. 1920 to the 1970s

'What is it that appears to make the mentally ill so vulnerable to therapeutic experimentation?'(1) One commentator wrote in the 1990s, regarding mental hospitals as repressive, coercive and custodial institutions where medical staff subjected patients to orgies of experimentation. A careful study of surviving documents of the Devon County Lunatic Asylum (DCLA), however, paints a different picture. Rather than medical staff, patients' relatives and the wider community exercised a considerable influence over a patient's hospital admission and discharge, rendering the therapeutic regime in the middle of the 20th century the result of intense negotiations between the hospital and third parties.

"Something of an adventure": postwar NIH research ethos and the Guatemala STD experiments

The STD experiments in Guatemala from 1946-1948 have earned a place of infamy in the history of medical ethics. But if the Guatemala STD experiments were so "ethically impossible," how did the U.S. government approve their funding? Although much of the literature has targeted the failings of Dr. John Cutler, we focus on the institutional context and research ethos that shaped the outcome of the research. After the end of WWII, Dr. Cassius Van Slyke reconstructed the federal research contracts process into a grant program. The inaugural NIH study section recommended approval of the Guatemala STD experiments at its first meeting. The funding and oversight process of the Guatemala research was marked with serious conflicts of interest and a lack of oversight, and it was this structure, as opposed to merely a maleficent individual, that allowed the Guatemala STD experiments to proceed. We conclude that while current research regulations are designed to prevent the abuses perpetrated on the subjects of the Guatemala STD experiments, it takes a comprehensive understanding of research ethics through professional education to achieve the longstanding ideal of the responsible investigator, and ensure ethical research under any regulatory scheme.

The human rights context for ethical requirements for involving people with intellectual disability in medical research

BACKGROUND

The history of ethical guidelines addresses protection of human rights in the face of violations. Examples of such violations in research involving people with intellectual disabilities (ID) abound. We explore this history in an effort to understand the apparently stringent criteria for the inclusion of people with ID in research, and differences between medical and other research within a single jurisdiction.

METHOD

The history of the Helsinki Declaration and informed consent within medical research, and high-profile examples of ethical misconduct involving people with ID and other groups are reviewed. The UN Convention on the Rights of Persons with Disabilities is then examined for its research implications. This background is used to examine a current anomaly within an Australian context for the inclusion of people with ID without decisional capacity in medical versus other types of research.

RESULTS

Ethical guidelines have often failed to protect the human rights of people with ID and other vulnerable groups. Contrasting requirements within an Australian jurisdiction for medical and other research would seem to have originated in early deference to medical authority for making decisions on behalf of patients.

CONCLUSIONS

Stringent ethical requirements are likely to continue to challenge researchers in ID. A human rights perspective provides a framework for engaging both researchers and vulnerable participant groups.

The rights and wrongs of intentional exposure research: contextualising the Guatemala STD inoculation study

In its recent review of the US Public Health Service Sexually Transmitted Disease Inoculation Study, conducted in Guatemala from 1946 to 1948, the Presidential Commission for the Study of Bioethical Issues identified a number of egregious ethical violations, but failed to adequately address issues associated with the intentional exposure research design in particular. As a result, a common public misconception that the study was wrong because researchers purposefully infected their subjects has been left standing. In fact, human subjects have been exposed to disease pathogens for experimental purposes for centuries, and this study design remains an important scientific tool today. It shares key features with other types of widely accepted research on human subjects and can be conducted ethically, provided certain safeguards are implemented. That these safeguards were not implemented in Guatemala is what made that study wrong, rather than the fact of intentional exposure itself. To preserve public trust in the clinical research enterprise, this conclusion ought to be stated explicitly and emphasised.

Ethical evasion or happenstance and hubris? The U.S. Public Health Service STD Inoculation Study

It's tempting to explain the Guatemala STD inoculation study as an attempt to evade the strictures of U.S research ethics. In fact, the researchers appear to have had benign reasons for going abroad. Only after they reached Guatemala did the study fly out of control.

The human capacity to reflect and decide: bioethics and the reconfiguration of the research subject in the British biomedical sciences

This article examines how a fundamental element of the British bioethical assemblage - the literature on informed consent published between 1980 and 2000, a period when bioethics became a powerful force in the UK--has influenced contemporary understandings of the research subject. Drawing on Foucault, the article argues that this corpus of texts has created a sphere of possibilities in which research subjects can imagine themselves as human beings who reflect and decide whether they want to participate in medical experimentation. In particular, it shows how the narratives found in these texts portray relationships between researchers and their human subjects as 'paternalistic', and calls for their replacement by new, more ethical relationships characterized by both 'dialogue' and 'respect' and articulated around subjects who can 'think and take decisions'. It also discusses the different strategies- using patient information sheets, a list of possible questions and invitations to take time to reflect--which the bioethical literature has developed in order to realise these new, ethical relationships. As the article suggests, these narratives and strategies provide researchers and research subjects with models and examples of how to interact with each other that are very different from the ones that prevailed before the emergence of bioethics.

From sidaway to pearce and beyond: is the legal regulation of consent any better following a quarter of a century of judicial scrutiny?

In 1987, following a period of increasing judicial activity, Margaret Brazier published her insightful article on the legal regulation of consent: Patient autonomy and consent to treatment: the role of the law? In her article, she exposed the flaws in the law following the House of Lords case of Sidaway. She considered the strengths and weaknesses of the alternative standards of disclosure: the professional or Bolam standard, the reasonable patient standard, and the particular patient standard. After noting that all of these standards have their problems, she suggested that the best way forward was for a national law and ethics commission to explore the issues before revising the law by legislation. Almost a quarter of a century following her article, Professor Brazier's criticisms remain aposite. In this article, I explain her view of the law in 1987 and then I examine the current law through the lens of her article and conclude that her recommendations still have strength.

In quest of constitutional principles of "neurolaw"

The growing use of brain imaging technology and the developing of cognitive neuroscience pose unaccustomed challenges to legal systems. Until now, the fields of Law much affected are the civil and criminal law and procedure, but the constitutional dimension of "neurolaw" cannot be easily underestimated. As the capacity to investigate and to trace brain mechanisms and functional neural activities increases, it becomes urgent the recognition and definition of the unalienable rights and fundamental values in respect of this new techno-scientific power, that must be protected and safeguard at "constitutional level" of norms such as: human dignity, personal identity, authenticity and the pursuit of individual "happiness". As the same as for the law regulating research and experimentation on human genome adopted in the past years, one may also argue if the above mentioned fundamental principles of "neurolaw" must be fixed and disciplined also at European and International level.

Statistical power, the Belmont report, and the ethics of clinical trials

Achieving a good clinical trial design increases the likelihood that a trial will take place as planned, including that data will be obtained from a sufficient number of participants, and the total number of participants will be the minimal required to gain the knowledge sought. A good trial design also increases the likelihood that the knowledge sought by the experiment will be forthcoming. Achieving such a design is more than good sense-it is ethically required in experiments when participants are at risk of harm. This paper argues that doing a power analysis effectively contributes to ensuring that a trial design is good. The ethical importance of good trial design has long been recognized for trials in which there is risk of serious harm to participants. However, whether the quality of a trial design, when the risk to participants is only minimal, is an ethical issue is rarely discussed. This paper argues that even in cases when the risk is minimal, the quality of the trial design is an ethical issue, and that this is reflected in the emphasis the Belmont Report places on the importance of the benefit of knowledge gained by society. The paper also argues that good trial design is required for true informed consent.

Mandatory versus voluntary consent for newborn screening?

Virtually every infant in the United States undergoes a heel stick within the first week of life to test for a variety of metabolic, endocrine, and hematological conditions as part of state-run universal newborn screening (NBS) programs. The history of this mandatory public health program is examined, as well as whether the policy was morally justifiable. Three changes in NBS practice necessitate a re-evaluation of the mandatory nature of NBS. First is the adoption of NBS for hemoglobinopathies in the 1980s that led to the identification of many sickle cell carriers and carriers of other hemoglobin variants. In all other contexts, carrier testing requires consent, and there is no moral rationale why NBS ought to be exceptional. Second is the application of tandem mass spectrometry (MS/MS) to NBS in the 1990s that led to the identification of many metabolic conditions and variants, some of which were not treatable and others of which had unknown clinical relevance. To the extent that the conditions do not need emergent diagnosis and treatment, there is less justification for mandatory screening. Third, there is great interest in using residual blood spots for research, and the cornerstone of research ethics is the voluntary consent of the participant (or his or her proxy). These three changes support revising mandatory NBS with a tiered consent process to best balance respect for parental autonomy and the promotion of children's health.

A written consent five centuries ago

The term informed consent does not have long historical roots. Until recent centuries, healthcare professionals were not held responsible for providing information to patients. The author reports a written consent from Anatolia dated almost five centuries ago. The contract was signed in 1539 in Gaziantep, Turkey (formerly known as Aintab, Ottoman Empire). The document, of course, differs from modern counterparts. It lacks details of interventions. The author believes this to be the first written consent in medical history. Further investigations of court registers should be made to ascertain the earliest date of their appearance.

Retrospective access to data: the ENGAGE consent experience

The rapid emergence of large-scale genetic databases raises issues at the nexus of medical law and ethics, as well as the need, at both national and international levels, for an appropriate and effective framework for their governance. This is even more so for retrospective access to data for secondary uses, wherein the original consent did not foresee such use. The first part of this paper provides a brief historical overview of the ethical and legal frameworks governing consent issues in biobanking generally, before turning to the secondary use of retrospective data in epidemiological biobanks. Such use raises particularly complex issues when (1) the original consent provided is restricted; (2) the minor research subject reaches legal age; (3) the research subject dies; or (4) samples and data were obtained during medical care. Our analysis demonstrates the inconclusive, and even contradictory, nature of guidelines and confirms the current lack of compatible regulations. The second part of this paper uses the European Network for Genetic and Genomic Epidemiology (ENGAGE Consortium) as a case study to illustrate the challenges of research using previously collected data sets in Europe. Our study of 52 ENGAGE consent forms and information documents shows that a broad range of mechanisms were developed to enable secondary use of the data that are part of the ENGAGE Consortium.

Informed consent in experimentation involving mentally impaired persons: ethical issues

The problem of experimentation involving subjects whose mental condition prevents them from understanding information and providing proper informed consent has been addressed in various codes, declarations, conventions, treaties and regulations adopted by national, international and supranational institutions and authorities. This article summarizes the basic ethical criteria these documents provide and stresses the historical development from the nearly total exclusion of incapacitated subjects, established in the mid-twentieth century, to their contemporary inclusion in clinical trials on certain ethical conditions. The problem of proxy consent by legal representatives for participation in clinical trials is addressed particularly in reference to current Italian regulations. Exceptions to human experimentation requirements in emergency situations are also briefly discussed.

Piercing the veil: ethical issues in ethnographic research

It is not unusual for researchers in ethnography (and sometimes Institutional Review Boards) to assume that research of "public" behavior is morally unproblematic. I examine an historical case of ethnographic research and the sustained moral outrage to the research expressed by the subjects of that research. I suggest that the moral outrage was legitimate and articulate some of the ethical issues underlying that outrage. I argue that morally problematic Ethnographic research of public behavior can derive from research practice that includes a tendency to collapse the distinction between harm and moral wrong, a failure to take account of recent work on ethical issues in privacy; failure to appreciate the deception involved in ethnographers' failure to reveal their role as researchers to subjects and finally a failure to appropriately weigh the moral significance of issues of invasion of privacy and inflicted insight in both the research process and subsequent publication of research.

Truth, trust, and confidence in surgery, 1890-1910: patient autonomy, communication, and consent

During the late nineteenth century, there was a dramatic rise in the number of surgical procedures that doctors were prepared to attempt. This article discusses why there was also a rise in the number of people who were prepared to submit to all of these operations. Contrary to popular assumptions, many nineteenth- century patients did not lack effective autonomy. Their consent to surgery could not be taken for granted, especially as surgery was expensive compared with many other forms of treatment. Persuading patients that surgery could help them was an active process, and patients and their friends were often provided with pertinent information, especially in cases in which the doctors themselves had doubts about an operation. Faith in the theoretical possibility of safe surgery may have been just as important in contributing to doctors' increased willingness to operate as any improvement in practical results. A key factor in the rising popularity of surgery with both doctors and patients was not so much better surgical results as it was confidence in the possibility of better surgical results and the ways in which this confidence was communicated from doctors to patients.

A history of ethics and law in the intensive care unit

Because they provide potential benefit at great personal and public cost, the intensive care unit (ICU) and the interventions rendered therein have become symbols of both the promise and the limitations of medical technology. At the same time, the ICU has served as an arena in which many of the ethical and legal dilemmas created by that technology have been defined and debated. This article outlines major events in the history of ethics and law in the ICU, covering the evolution of ICUs, ethical principles, informed consent and the law, medical decision-making, cardiopulmonary resuscitation, withholding and withdrawing life-sustaining therapy, legal cases involving life support, advance directives, prognostication, and futility and the allocation of medical resources. Advancement of the ethical principle of respect for patient autonomy in ICUs increasingly is in conflict with physicians' concern about their own prerogatives and with the just distribution of medical resources.

Exploitation and enrichment: the paradox of medical experimentation

Modern medicine is built on a long history of medical experimentation. Experiments in the past often exploited more vulnerable patients. Questionable ethics litter the history of medicine. Without such experiments, however, millions of lives would be forfeited. This paper asks whether all the "unethical" experiments of the past were unjustifiable, and do we still exploit the poorer members of the community today? It concludes by wondering if Harris is right in his advocacy of a moral duty to participate in medical research.

Aspects of informed consent in medical practice in the eastern Mediterranean region during the 17th and 18th centuries

Informed consent is a question of central importance in contemporary medical ethics, and clinical practice is inconceivable without considering the issues it raises. Although it is often vigorously argued that consent, informed or otherwise, is a recent phenomenon and that no sources testify to its existence before the 20th century, it is difficult to accept that a process for regulating the common and fundamental parameters in the relationship between doctor and patient and the planning of treatment had not concerned previous eras. A review of the Registers of the Islamic Court of Candia (Heraklion) in Crete, a series of records that touches on, among other things, matters of medical interest, reveals that the concept of informed consent was not only known during a period that stretched from the mid-17th to the early 19th century, but it was concerned with the same principles that prevail or have been a point of contention today. An extension of this study into other periods may thus provide contemporary researchers with material and information valuable in the discussion of today's bioethical issues.

[Smallpox in Ferrara in the nineteenth century]

The aim of this work was to analyse the mortality for smallpox and the methods used during the nineteenth-century to control epidemics. Most of the historical material was found in the Historical Archives of the Ferrara City Council. Over the whole period in question, there were 710 deaths in Ferrara (366 males and 344 females). The highest number was found in the years 1816, 1829, 1834, 1842, 1849, 1871 and 1891. Data analysis shows that most deaths occurred during the first half of the century. Subsequently, the phenomenon declined to almost zero. Males were more affected and nearly 70% of the deaths occurred under 5 years of age, 50%of which during the first year of life. At that time, the "guidelines" adopted were analogous to those currently followed when a new vaccination programme is started. The inspiring principles were the active and free supply of vaccine, universal vaccination, the informed consent of the population, the involvement of educators and also monetary rewards to the most industrious doctors in the practice of vaccination. In Ferrara vaccination began in 1801, but was only consistently implemented in 1812. By the end of the 19th century the number of persons vaccinated had increased from 3% to 7%. Vaccination initiatives assumed great importance among the population of Ferrara, in spite of initial resistance and suspicion of a practice which most people found incomprehensible.

[An age of medical paternalism?--Reflections on medical disclosure and patient consent in 19th century Germany]

Research on the history of medical ethics in Germany still regards the nineteenth century as the age of medical paternalism. The authoritarian manner of German physicians is particularly emphasised by assuming that patients were normally not involved in decisions about serious therapeutic measures. This paper will analyse if and how physicians dealt with the issues of medical disclosure and of patient consent concerning surgery and other painful interventions in the first half of the nineteenth century. Physicians rarely dealt with this problem in their articles on medical ethics but reflected, instead, on the issues of disclosure and consent in descriptions of risky therapeutic interventions. They devoted considerable attention to the description of the decision making process, particularly in medical case reports on life-threatening surgery. The benefits hoped for and the risks of the surgical intervention were frequently explained in detail. It was important for them not only to legitimise their adventurous course of action by obtaining patients' consent but also to demonstrate that the seriously ill patients in reality played the active, demanding part in the decision on life-threatening surgery. It is remarkable that, even where patients from lower social classes were concerned, physicians stressed the necessity of obtaining their consent for risky surgical interventions. However, it cannot be established with certainty if the patients were comprehensively informed by the physicians about the risks involved. Nevertheless, physicians' awareness of the necessity of such disclosure, as expressed by their rhetorical "self-fashioning" in the published case reports, is beyond doubt.

[Patient's consent to treatment with reference to the development of medical ethics]

In the paper the development of the patient's rights to informed consent to treatment has been discussed with reference to codes of medical ethics. The expression of the patient's rights and recognition of his/her active part in the course of treatment was proceeding gradually and parallel to the evolution of the subjective term "patient". Nowadays the patient's rights are determined by many declarations and international conventions, e.g. the Human Rights and Dignity Convention (1996). The so-called informed consent includes the right to the complete information about the course of treatment as well as the risk taken especially during surgical treatment and the right of a shared decision to choose the treatment. Patients who are unconscious and those with limited consciousness constitute the problem that is still being solved. It is expected that along with the development of medical ethics, the medico-legal regulations concerning the above mentioned issues will be specified soon. Besides the obligatory legal regulations, in many difficult cases the assessment and decision whether the patient's consent is informed or not, burden only a physician's conscience.

Surgeons' silence: a history of informed consent in orthopaedics

The moment of decision to proceed with surgical intervention is charged with some of the deepest uncertainties in medicine, but has long been cloaked under the confidence asserted by the traditionally custodial surgeon. This paper reviews the history and ethical basis for informed surgical consent. Beginning with theoretical foundations and the changing ethics of medical decision making since the ancient Greeks, it then reviews how the stage was set for informed consent by technological breakthroughs that made surgical interventions tolerable and acceptably safe. Finally, the legal generation of the doctrine of informed consent is reviewed and the current state of disclosure, shared decision-making, and uncertainty explored.

Basic problems of medical ethics in Russia in a historical context

The paper provides a short overview of key problems of medical ethics in the Russian and Soviet contexts--confidentiality, informed consent, human experimentation, abortion, euthanasia, organ and tissue transplantation, abuse of psychiatry. In Soviet ideology common interests were declared superior to private ones. Hence, medical confidentiality was viewed as a bourgeois survival. On the other hand, diagnosis was normally not disclosed to a patient in the case of an incurable disease (especially cancer). Due to the strong paternalistic traditions of Russian medicine the idea of informed consent is still disputed by many physicians. Abortions were first legalized in Soviet Russia in 1920. A brief history of this landmark event is provided. However, abortions were forbidden in 1936 and legalized again only in 1955. Active euthanasia was legalized in Soviet Russia in 1922 but for a short period. Federal law regulating human transplantation was adopted only in 1992 and based on the presumed consent model. Until then forensic autopsy and procurement of cadaver organs were viewed as equal procedures. In 1960s-1980s there was a practice of declaring political dissidents insane in their involuntary treatment.