20Chapter 17. From Hippocrates to Madrid: The Birth of Professional Ethics

I was twenty when I first saw the Hippocratic Oath printed on paper. It was at Baku Medical University, in the dean’s office lobby, in a frame under glass. An ordinary sheet of paper—yellowed, with that characteristic official typeface. And three paragraphs of text that, as I was told then, had defined the ethics of the medical profession for the next two and a half thousand years.

“I will apply methods of treatment for the benefit of the sick according to my ability and judgment, abstaining from doing harm or injustice. I will not give anyone a deadly drug if asked for one, nor will I suggest a way to such a plan… I will not perform lithotomy, leaving that to those who practice it. Whatever house I enter, I will enter for the benefit of the sick, keeping far from any intentional, unjust, or harmful act… Whatever I see or hear, whether in the course of treatment or outside it, concerning the lives of people that should never be disclosed, I will keep silent, regarding such things as sacred secrets.”

This is an excerpt from a text that Greek tradition attributes to Hippocrates of Kos, who lived in the fifth and fourth centuries BCE. Modern medical historians believe that Hippocrates himself is unlikely to have written this oath in its entirety; its more or less final version took shape later, in the Hellenistic era. But the point isn’t precise attribution. The point is that even two and a half thousand years ago, physicians were trying to articulate what they would not do—even if asked.

I will not prescribe poison. I will not perform an abortion by forbidden means. I will not have sexual relations with a patient. I will preserve the secrecy of what I hear. I will not employ methods in which I am not competent.

Simple principles. And—as we will see in this chapter—principles that humanity has violated in the field of psychiatry almost constantly throughout its short scientific history.

The first expansion of the Hippocratic Oath in the modern era. Who dared to touch the ancient code? Thomas Percival—an English physician from Manchester. 1803. From his pen comes a book with a long, ponderous title: “Medical Ethics, or a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons.” This is the first modern systematic code of medical ethics. The hospital corridors of Manchester. Physicians trapped in conflicts. Percival writes precisely for them. His goal is to bring order to chaos: relations among physicians, with patients, with the public. And then—a blow. A revelation of the accustomed order. It is in Percival that the requirement of informed consent—in modern terminology—first emerges. The physician is no longer a god. The patient learns the truth about his own flesh and decides his own fate.

The American Medical Association, founded in 1847, adopted its first Code of Ethics, based on the work of Percival. It was an important step: for the first time, a large professional community committed itself to following a single set of rules.

But in the early twentieth century, a gaping crack was exposed: even the most venerable codes crumble to dust when doctors are caught in the grip of total pressure. The 1930s and ‘40s. A significant portion of the German medical elite — the very people whose lips had spoken the Hippocratic oath — stepped into the darkness. They became part of the T4 program. The mass m•••••••g of the mentally ill, of children with developmental disabilities, of the elderly from nursing homes. From 1939 to 1941. Special centers — Hadamar, Grafeneck, Hartheim, and others. There people were herded into gas chambers. Seventy thousand lives dissolved in the suffocating air. In 1941 the program was formally closed. But can a mechanism of k••••••g be stopped by an order? The k••••••gs continued. Decentralized. Quiet. In hospital wards. D•••h came in the form of injections and starvation. Another hundred thousand l••••.

This was not done by marginal figures. It was done by professors of psychiatry, chief physicians of clinics, university lecturers. Some of them sincerely believed they were carrying out an important task of “racial hygiene.” Some simply obeyed. The Hippocratic oath did not stand in the way of any of it.

After the Second World War, the world medical community, shaken by what it had seen, attempted to build a new ethics — this time with international mechanisms.

In 1947 the Nuremberg Code was adopted — ten points that became the foundation of clinical research ethics. The first point of the code: “The voluntary consent of the human subject is absolutely essential.” After Nuremberg this became commonplace. Before Nuremberg, it was not.

In 1948 the World Medical Association adopted the Declaration of Geneva — a modern revision of the Hippocratic oath. In 1964 the WMA adopted the Declaration of Helsinki, which remains to this day the international standard for the ethics of biomedical research.

But for psychiatry this was not enough. Psychiatry is a special domain of medicine. In it, the doctor makes decisions not only about the patient’s body but also about his freedom (involuntary hospitalization), about his will (medication-based sedation), about his rights (legal capacity). And it was precisely here — at the very moment when the first international ethical standards were being created — that one of the darkest chapters of the twentieth century was unfolding.

We have already spoken of Soviet punitive psychiatry. The case of Leonid Plyushch at the Serbsky Institute. The case of General Grigorenko. Hundreds and thousands of people declared “sluggish schizophrenics” ended up in special psychiatric hospitals, where they received haloperidol in doses exceeding therapeutic levels, sulfazine crosses, forced insulin. All of this was done by doctors. Doctors with medical diplomas, with professorial degrees, with academic titles. They had all taken the Hippocratic oath.

By the early 1970s, the Western medical community had gathered substantial evidence about what was happening behind the “iron curtain.” This information came partly from dissidents’ own publications—Vladimir Bukovsky’s collection, Pyotr Grigorenko’s works, and Semyon Gluzman’s testimonies. Partly from journalistic investigations. And partly from Soviet psychiatrists who had emigrated to the West.

The World Psychiatric Association’s (WPA) initial response was tepid. Founded in 1961, the WPA lacked clear ethical guidelines at the time. It had charters and general statements, but no formal code to reference.

This changed in 1977 at the WPA’s VI Congress in Honolulu. During the General Assembly, the Hawaii Declaration was adopted—the first code of ethics in history specifically designed for psychiatrists.

The Hawaii Declaration contained ten articles. Its author was Swedish medical ethics professor Clarence Blomquist from the Karolinska Institute. The first article directly addressed the situation in the USSR: it condemned the political abuse of psychiatry—the use of psychiatric diagnoses and methods to persecute dissenters.

The Declaration outlined several fundamental principles that seem self-evident today but were revolutionary in 1977:

— Psychiatry’s purpose is to treat mental disorders and promote mental health. Not political control. Not social hygiene. Not “reeducation.”

— A psychiatrist must treat patients with the same respect shown to colleagues. Therapeutic relationships are built on mutual trust.

— Patients have the right to make informed decisions about their treatment.

— Involuntary treatment is permissible only when a patient is incapacitated by illness and only when treatment is lifesaving. Such cases must be open to independent review.

— Patient confidentiality is absolute, with few clearly defined exceptions (e.g., immediate danger to others’ lives).

— A psychiatrist must never use professional authority to degrade human dignity.

The Hawaii Declaration wasn’t legally binding. But it became a moral benchmark that national psychiatric societies could cite in disputes with governments.

Immediately after Honolulu, pressure on the USSR’s All-Union Society of Psychiatrists and Narcologists intensified. In 1983, ahead of the next WPA Congress in Vienna—where the expulsion of Soviet psychiatry was on the agenda—the Soviet society voluntarily withdrew. This was, in essence, an admission—however reluctant.

In 1989, after perestroika began, the Soviet side publicly acknowledged political abuse for the first time and agreed to readmission procedures. In 1991, an international team of experts visiting the USSR confirmed that overt forms of abuse had ceased. Soviet society was brought back into the WPA.

It was one of the rare victories of the international scientific and ethical community over state violence. It was not complete — the aftermath of punitive psychiatry was felt for a long time and is still felt today across the post-Soviet space. But as a precedent, it was the moment when world psychiatry told the state: “no.”

By the mid-1990s, the picture had become clearer. The Hawaii Declaration — for all its apparent monolithism — had developed a crack. Yes, it had served as a shield in the narrow context of confronting Soviet punitive psychiatry. But the shadow of the old enemy dispersed, and new threats emerged from the darkness: euthanasia, the death penalty and the click of a trigger in which a doctor takes part, genetic research — an intrusion into the very code of life, entanglement with the pharmaceutical industry, the fraying line separating doctor from patient. None of these issues was explicitly covered by the Hawaii Declaration. The text kept a deathly silence.

In 1993, at the World Congress of Psychiatrists in Rio de Janeiro, the WPA instructed its Ethics Committee to draft an updated and expanded document. The work was led by Augusto Castagnolli-Bubis of Argentina, then continued by Ahmed Okasha of Egypt. The document went through several revisions and rounds of coordination with national societies, the WPA Council, and the Executive Committee.

In August 1996, at the 10th World Congress of Psychiatrists in Madrid, the Madrid Declaration on Ethical Standards for Psychiatric Practice was adopted.

The Madrid Declaration is considerably broader than the Hawaii Declaration. It includes seven general guiding principles and a number of specific sections addressing particular situations. Let us list some of the key provisions.

Patient autonomy. The patient is a partner in the therapeutic process. He has the right to information about his illness, about the proposed treatment, about its alternatives, about the risks and prospects. The decision on treatment is made jointly.

Boundaries of the clinical relationship. A thin red line. The Madrid Declaration comes down on this taboo directly and unequivocally: a sexual relationship between psychiatrist and patient is an absolute prohibition. But why? The mystery lies in the wording of the document itself. “Consent on the part of the patient is considered compromised by the knowledge the psychiatrist possesses about the patient, and by the power differential that gives the psychiatrist special authority over the patient.” Knowledge is a weapon. Power is a lever. Consent under these circumstances amounts to ruthless exploitation. The hidden sexual dynamic. It pulses in the shadow of any relationship, like a smoldering fuse. But the moment a patient steps into the therapist’s office, that hidden spark flares into the open. If the therapist does not manage this fire properly, the flame burns the patient from within, condemning them to suffering. The pain becomes unbearable when the therapist crosses the line. Uses seductive statements. Casts inappropriate glances. Every word is poison, every gesture a noose. And so the declaration’s verdict leaves no loopholes. Under no circumstances should a psychiatrist engage in any form of sexual behavior with a patient. No excuses. Regardless of whether the behavior is initiated by the patient or by the therapist himself.

This is the absolute and inviolable rule. No interpretations. No gray areas. It prohibits not just the act itself, but the very atmosphere where such an act could even become conceivable. The prohibition applies not only to current patients but—in many jurisdictions—to former ones as well. In the United States, for example, psychiatrist-patient sexual contact is no longer merely an ethical violation in most states but a criminal offense, legally equated with sexual assault. Why such severity? The answer lies in the inherent nature of therapy itself: the asymmetry of power. An invisible yet profound imbalance turns therapeutic relationships into a trap where genuine consent simply cannot exist. It is impossible by design.

Euthanasia, torture, capital punishment. The Madrid Declaration takes an unequivocal stance: psychiatrists must not participate in euthanasia (understood here as actively ending a patient’s life—the document predates modern debates about medically assisted dying); they must not engage in torture; and they must not assess condemned prisoners to determine their “fitness for execution” if such assessments serve the purpose of carrying out a death sentence.

Sex selection. In 1996, this was a controversial and emerging issue. The Madrid Declaration explicitly opposes psychiatric involvement in any sex-selective embryo procedures unless medically justified—such as in cases of sex-linked genetic disorders.

The patient’s family. Families are recognized as part of the therapeutic process—their interests should be considered, but the patient’s well-being always takes precedence.

In subsequent years, additional provisions were adopted at congresses in Hamburg (1999) and Yokohama (2002), addressing psychiatric interactions with the media, ethnic and cultural discrimination, genetic research and counseling, and conflicts of interest between psychiatrists, pharmaceutical companies, and insurers.

The next major step came in 2020. Acknowledging that the Madrid Declaration, despite its thoroughness, no longer covered all contemporary ethical dilemmas, the WPA introduced a new document—the WPA Code of Ethics for Psychiatry. Published in 2021 in World Psychiatry, the Code is structured into four sections:

— Clinical Practice — Psychiatric Education — Research and Publications — Public Mental Health

Unlike earlier prohibitive language, the Code adopts an affirmative approach—defining what psychiatrists should do, not just what they must avoid. It emphasizes family and caregiver involvement, equitable resource allocation (with special attention to developing nations and underserved regions), and the ethical obligation of psychiatrists to engage in lifelong learning.

Another crucial document in play is the UN Convention on the Rights of Persons with Disabilities (CRPD), adopted by the UN General Assembly in 2006. For the first time in international law, this Convention placed the rights of individuals with mental disorders on equal footing with those of other citizens. It has been signed and ratified by the majority of the world’s nations. The Republic of Azerbaijan ratified the Convention in 2009.

At first glance, everything seems in order. We have the Declaration of Hawaii. We have the Declaration of Madrid. We have the WPA Code of Ethics (2020). We have the UN Convention. We have national ethical codes for physicians. We have regulatory bodies, exam boards, licensing agencies, and insurance companies.

But step out of this neatly framed space and look at what really happens in real practitioners’ offices across real countries—the picture is starkly different.

A psychiatrist whose case I examine in detail in Chapter 23—the one who prescribed “sex therapy” to a patient suffering from OCD for thirteen years—violated every provision of the Madrid Declaration concerning clinician-patient boundaries. Yet he faced no consequences: no disciplinary action, no loss of license, not even public exposure.

A psychiatrist. One of the most respected institutions in the post-Soviet academic world. We’ll return to him in Chapter 23. For now, let’s stick to facts. He prescribed antipsychotics. At the same time, he wrote prayers for his patients. And “monitored the effects.” Let’s pause. What’s wrong with this? The 2020 Code. A core principle. Verbatim: “Psychiatrists recognize that their primary obligation in the clinical setting is to promote patient well-being, based on the best available evidence and clinical experience.” Best available evidence. Clinical experience. Prayer is not an evidence-based treatment for schizophrenia. This isn’t debatable. It’s an established fact. Combining it with evidence-based treatment within the same clinical encounter is an ethical violation. Period. Yet he combined them. Repeatedly. Day after day. Patient after patient. And no one stopped him.

In my country, Azerbaijan—as in most post-Soviet republics—ethical codes for national psychiatric associations exist, but enforcement mechanisms are weak or nonexistent. Licenses are rarely revoked for ethical breaches. Review boards convene infrequently. Patients who file complaints often face professional solidarity among colleagues protecting the offender.

Worse still. The entire body of international documents—Hawaii, Madrid, WPA 2020, the UN Convention—proves to be an illusion. A shield protecting only licensed psychiatrists. And partially, psychologists. Now for the true nightmare. None of these ethical codes apply to energy healers, past-life regression therapists, theta healers, esoteric “coaches,” or self-proclaimed authors of “unique methods.” None. Zero. They never promised confidentiality. They never swore not to engage in sexual relationships with clients. They face no obligation to avoid political misuse of their “methods.” They’re not doctors. They’re subject to no disciplinary action from any professional body—for one simple reason: they don’t belong to any. They exist outside the law.

Here lies the central paradox of our time. We’ve built an ironclad system of ethical oversight for those who take the Hippocratic Oath. Every move a doctor makes is monitored. Every mistake is punished. Yet those who currently handle the emotional pain of post-Soviet citizens most actively—those with hundreds of thousands of desperate clients flocking to them, those whose pockets swell with millions of rubles and manats—they’ve sworn no oaths. None whatsoever. And no one can hold them accountable for their services. No one.

It is these very figures we’ll turn to in the following chapters.