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Sixty years ago the world learned of the
moral depravity of twenty German physicians and three
Schutstaffel(SS) administrators tried and convicted at the Nuremberg
Medical Trial for their part in the brutal human experiments during
the Holocaust. In fact, there were thousands of physician
perpetrators and accomplices. Many of them committed suicide and
some died of natural causes during or following the war.
Unfortunately, the majority of these perpetrators escaped justice
and were even honored by the world medical community and restored to
positions of prominence and respect.
It is generally accepted that ethical codes and professional
standards for human experimentation originated in Nuremberg after
World War II. However, in 1931 the Reich promulgated extremely
detailed and strict precautions, which were contained in Guidelines
for New Therapy and Human Experimentation. These 14 measures were
ironically the efforts of a Jewish physician, Dr Julius Moses, a
general practitioner and German politician who, in 1930, alerted the
public to the deaths of seventy-five children, which were caused by
pediatricians who experimented with vaccinations. His public
campaign proposed the aforementioned medical guidelines that some
legal historians suggest would have provided a sound basis for the
prosecution and conviction of the defendants at Nuremberg.
Medicine played an integral and pertinent role in Nazi ideology and
subsequent implementation of the tragedies during the Holocaust. In
the decades since WWII, there have been many instances of mass
murder, and many of them had roots in racism. What took place in
Germany not only had its roots in racism but in racism that found
boisterous support from mainstream medicine. The core values of
medicine were profoundly and violently disrupted as the German
medical profession lent itself to the perceptions and priorities of
the Third Reich. Today, one of the main questions relevant to
society in general and to healthcare professionals in particular is:
How could science and medicine be abused in such a way that
physicians became murderers?
Bioethicists have in subsequent years discussed this question and
expounded on the moral lessons learned from the Nuremberg Trials.
The fundamental ten-point ethical code for human experimentation
formulated as a result of the Nuremberg Doctors’ Trial has been the
basis of all subsequent ethical codes in modern medicine. Still
other important ethical challenges rise from the study of medicine
in Nazi Germany. These concerns that have continuing relevance were
not addressed at Nuremberg. This paper will discuss some of them
very briefly.
Abuse of Power
The German medical profession was unified into a hierarchical and
state-regulated organization called the Nazi Physician's League.
This body played a vital role in the construction of Nazi racial
policy and all the subsequent programs. The Nazi medical
organizations demanded that "health care" be replaced by "health
leadership." Physicians were granted unprecedented power and
prestige, and thusly they proceeded to abuse their authority and
influence. The seemingly limitless control over life and death held
a certain attraction for some physicians who, by virtue of their
profession, already exercised such power.
The Role of Pseudoscience: Social Darwinism, Eugenics and Racial
Hygiene
In Germany, Social Darwinism came to be known as racial hygiene,
which expanded rapidly after World War I when it became established
as a respectable part of German biomedical science. Racial hygiene
became intertwined with rabid anti-Semitism and was absorbed into
the doctrine of the National Socialist Party. In April 1933, Hitler
ordered that the German medical profession be moved to the forefront
of the race question, making racial hygiene the task of the German
physicians who responded without reservation. Medical analogy was
often used in Nazi policy. For example, the government often argued
that the "body" of the German people was threatened by "inferior"
races. Rudolf Hess, a leading Nazi, declared National Socialism as
an "applied biology." As an inherent part of the race question, Jews
were considered a medical problem, which was to be solved in the
camps. The German medical community embraced racial science as a
medical specialty, which together with the abuse of authority and
other factors provided the framework through which crimes against
humanity were destined to take place.
Collusion in the Exclusion of Jewish Physicians from Medical
Practice
In 1929, the National Socialist Physicians' League was formed with
the double purpose of coordinating Nazi medical policy as well as
ridding the profession of Jews. The term "Jewish medicine" came to
be used, as a metaphor for all that was wrong with modern medical
science and practice. A series of legal measures ensured that Jewish
physicians were dismissed from their positions and forbidden to
practice their medicine on non-Jews, and eventually by 1938 their
licenses were removed. These vacated medical positions were rapidly
filled by German non-Jewish physicians who voiced little protest at
the removal of their Jewish colleagues.
The Relationship of the Physician to the State
Racial hygiene, as mentioned earlier, was to be the task of the
German physicians who, after the social suffering endured following
World War I, were ready to hear and heed Hitler's call, "You, you
National Socialist doctors, I cannot do without you for a single
day, not a single hour. If not for you, if you fail me, then all is
lost. For what good are our struggles if the health of our people is
in danger?" He, Hitler, was, of course, referring to radicalized
racial hygiene. The German physicians responded by joining the Nazi
Party earlier and in greater numbers than any other professional
group, so that by 1942 nearly half of Germany's doctors were members
of the Nazi Party. This support was not passive, as is evidenced by
the fact that 26% of the medical profession served as storm troopers
and 7% were members of the SS. Physicians had accepted a special
role in the reconstruction of the state. Major German medical
organizations and medical journals were also ardent supporters of
the Nazi regime, and regularly published articles that promoted and
supported Nazi racist ideology. With a strong state to back the
medical profession, racial hygiene became powerfully dangerous.
Forced Sterilization
Genetic courts, presided over by a lawyer and two doctors, were
established to adjudicate the Sterilization Law, which required
physicians to register every case of genetic illness, and to
recommend forcible sterilization. An estimate of the total number of
sterilized Germans ranges from 350,000 to 400,000. Today's commonly
accepted bioethical ideals of patient autonomy, beneficence,
non-maleficence, justice and confidentiality did not exist under the
Sterilization Act. In fact, these ethical concepts later came about
precisely because of these physicians' ethical improprieties
exhibited during the Holocaust. German physicians not only designed
the laws for their profession to follow but also benefited from
them.
Implementation of the Nuremberg Laws
Medical terminology was used frequently by the Nazis to medicalize
their social policies, especially toward Jews who were commonly
referred to as parasites, alien bacteria or a diseased race.
Systematic transfer of Jews to the ghettos was accomplished under
the pretense of quarantine, where we know thousands of Jews were
murdered under the guise of disinfection. The Nuremberg Laws were
perceived by the German medical community as public health measures.
The German Medical Association perpetrated the belief that Jews
suffered from specific and numerous diseases, warning against the
mixing of Jewish and non-Jewish blood. The Marital Health Law
required the full involvement and support of the medical community
as requiring all individuals seeking marriage to submit to a medical
examination. Leading German medical journals applauded the Nuremberg
Laws, further aiding in establishing physicians as instruments of
the racist Nazi policies.
Economic Pressure Affecting Medical Practice
German doctors benefited financially from the racist policies
prospering during the Third Reich. They profited from the exclusion
of the Jewish physicians and their subsequent non-Jewish
replacements along with new job opportunities created in the newly
formed Reich Health offices served to make the medical profession a
monolith of support to the Reich's social policies. Even the
fundamental argument for forcible euthanasia was an economic one.
Some German physicians received payment for the euthanasia
procedures. Academic appointments and salary support in German
medical schools depended on loyalty to the Nazi party. Medical
companies too had financial incentives to develop technologies that
were to serve the Nazi policies of sterilization, euthanasia and
eventually mass extermination.
Euthanasia
As racial hygiene became incorporated into National Socialist
policy, the idea of terminating those with "lives not worthy of
living" became integrated into the medical community. The
Hippocratic Oath was dismissed as a vestige of "ancient times" and a
"higher" civil morality was adhered to: that of the health of the
state and not the unconditional preservation of valueless lives.
With the onset of the war, a directive was issued that required
doctors to register any child born with congenital defects with the
local health authorities, thus violating the ethical stance of
confidentiality. Physicians then proceeded to select out the
eligible files for extermination that they themselves implemented in
the many killing centers throughout Germany. The program was
expanded to include nonproductive adults, especially mentally ill
patients. The physicians involved were among the leading figures in
the German medical community. Doctors were completely responsible
for the design, implementation and execution of this task, in doing
so had forsaken the duties to their patients and foresworn their
oaths as physicians. They had gone from healers to murderers.
"Holistic" Medicine –German Public Health Programs for Germans Only
A powerful holistic trend emerged in Germany after World War I.
Aspects of wholeness came to be identified with the Nazi fight
against everything racially foreign. Disabled persons were seen as
an offense to the values of wholeness, as were Jews. Accordingly
Nazi medicine turned away from the sick and useless, and toward the
healthy who had the most to contribute to the German nation, the
Volk. Most German medical professionals adopted the idea of racial
hygiene as a massive public health measure. They focused on disease
prevention and education, and generated powerful and effective
public health programs, including vigorous anti-tobacco,
anti-alcohol and environmental toxins campaigns. These public health
programs excluded Jews, Communists and other "undesirables."
Physician Participation in Mass Extermination – Genocide
The ultimate decision to gas the Jews emerged from the fact that the
technical apparatus for the destruction of the mentally ill was
already in existence. The same physicians who had gained experience
from the euthanasia program followed the transfer of the gas
chambers to the death camps, where they were charged with the tasks
of selection, deportation and execution of appropriate subjects in
implementing the Final Solution. Physician participation in the
death factories came in many forms: supervision and implementation
of the infamous selections upon arrival; advice as to how to keep
the selections running smoothly; dispatching ill prisoners to the
gas chambers; determination of the death of the victims;
consultation regarding the efficient operation of the crematoria;
administration of lethal injections and, of course, exploitation of
camp inmates as subjects for human experimentation. Medical doctors
were the final common pathways of the Nazi vision of therapy via
mass murder.
Total Disregard for Informed Consent
Under the Nazi regime the most fundamental ethical rule of a
patient's right to informed consent was totally abused. German
physicians sterilized and euthanized patients with absolute
disregard for patient consent. The use of Jews and other prisoners,
as research material presents one of the clearest and most obvious
links between Nazi atrocities and medical doctors. Informed consent
was the first and foremost principle set down in the Nuremberg Code,
and remains the highest fundamental value in medicine today.
Sadistic Medical Experiments
The crimes that were at the core of Nazi medical experiments
involved not only torture and murder but also the exploitation of
human beings to serve the goals of science. Some of Germany's most
prestigious medical institutions were involved. This was not the
work of madmen, but rather qualified and competent physicians. It
was these medical experiments that caught the world's attention in
1946 at the Nuremberg Doctors' Trial, and led directly to the
establishment of the 10-point Nuremberg Code whose intent was to
protect the rights of humans involved in medical research. A review
of the major moral arguments presented by defendants at the
Nuremberg Trials sheds light not only on the moral rationales that
were given for the experiments but also for the involvement of
biomedicine in the broad sweep of what the prosecution termed
"crimes against humanity." Not one of the defendants apologized for
taking a role in various experiments conducted in the camps.
Instead, they attempted to explain and justify their actions, often
couching their defense in explicitly moral terms.
Physicians Sacrifice the Interests of the Few to Benefit the
Majority
Nazi physicians became doctors of the Volk, responsible to the
greater nation and not to their individual patients. Even at
Nuremberg the defense argued that it was reasonable to sacrifice the
interests of the few to benefit the majority. The defense pointed
out that throughout history medical researchers in Western countries
have used versions of utilitarianism to justify dangerous
experiments on prisoners and institutionalized persons. This case in
point raises the most difficult and most plausible moral argument in
defense of human experimentation, even today.
The Role of the Physician in Times of War
The euthanasia operation was consciously timed by Hitler to coincide
with the invasion of Poland. "Worthless" individuals were killed in
order to make room for wounded German soldiers. The starvation of
the mentally ill and other "useless eaters" became an official
medical strategy to save food for the army. Many of the barbaric
experiments were carried out in the name of science to improve the
conditions of the German pilots and soldiers. One of the recurring
defense themes at the Nuremberg Doctors' Trial was that "all is
permissible" in times of war and that the experiments were justified
in order to improve the security and the defense of the German
nation and its soldiers.
The Jewish Doctors: Professional Functioning in Extreme Situations
In the ghettos and camps, the disaster was predominantly medical:
hunger and starvation made everyone more susceptible to disease. The
Jewish doctors were recruited because the SS needed them to maintain
the actual medical work. Medical practice in the camps and the
ghettos carried all of the worries and uncertainties that it did
anywhere at the time, as well as many that were specifically related
to life in a Nazi ghetto or concentration camp. The medical and
medically related needs were immense, making the ethical problems
encountered by the prisoner doctors very different from those they
had encountered before. For prisoner doctors to remain healers was
profoundly heroic and equally paradoxical. Most of these doctors
perished together with their fellow Jews, but some survived to tell
their stories. Many committed suicide years after the war.
In contrast to the warped and unethical use of medicine by the Nazi
doctors, the Jewish doctors generally tried to practice true
medicine in the ghettos and camps. These different settings had very
diverse medical arrangements, but the problems and ethical dilemmas
that the Jewish physicians were confronted with were similar despite
the different prevailing circumstances in a ghetto or camp.
Some of the survivor physicians state that their patients were the
reason for their survival. On the other hand, there are numerous
examples of how some chose to remain behind with their patients,
even when they had the chance to save themselves.
They were the only ones in direct contact with the sick patients,
and were constantly compromising their personal integrity and
professionalism by stealing, lying to the Germans, faking diagnoses
or laboratory test results, or changing them in order to try to save
fellow prisoners' lives. These prisoner doctors were the ones who
had to decide how to make the optimal use of the meager supplies.
Often, the only thing they had were their words of comfort.
In order to preserve life, the prisoner physicians sometimes had to
take lives. This profound ethical issue confronted the Jewish
physicians in many of the ghettos where a ban was decreed on Jewish
births, and in the camps where pregnancies were forbidden. Jewish
doctors performed secret abortions in order to protect the pregnant
women from the SS. In other circumstances, they were compelled to
end the lives of their patients who endangered the whole infirmary
or camp for one reason or another. People often requested the Jewish
doctors who worked in their vicinity for help to end their own
lives. As doctors who had taken the oath to save lives, many of them
refused requests of help in suicide, sometimes later regretting the
decision in the face of dismal suffering.
The Nazi physicians performed selections not only at the "ramp" on
arrival at the camps but in the medical blocks as well. The prisoner
physicians witnessed the cruel Nazi selections in these barracks.
Sometimes, they gained knowledge of the cruel experiments being
performed by the Nazi doctors. There were times when they were
coerced to cooperate with the Nazi doctors in order to insure their
own survival and that of their patients.
The contrast between the Nazi's use of medicine to inflict pain and
suffering on innocent victims and the Jewish doctors' attempts, in
the absence of even the most basic tools, to alleviate suffering and
preserve life demonstrates the diametrically opposed purposes to
which medical skills could be used. These doctors' stories
demonstrate how indomitable are human tolerance and the capacity to
survive through caring for another person. Doctors as such, in
caring for their patients, found a reason to fight the battle for
survival. The innumerable incidents in which they chose to make
ethical choices, in the firm belief that the suffering would
otherwise be excruciating, must take into consideration the
circumstances of the time. Their actions reflected the whole
spectrum of human behaviors under these circumstances.
Sixty years after Nuremberg, it is opportune to go back and examine
how the best and the brightest people in medical science became
parties to evil. Today, physicians need to examine the historical,
social, and legal bases of their profound power and influence,
including the tragic example of the exploitation and abuse of those
powers by the German medical community during the Holocaust.
It is clear that what Nazi doctors, nurses, biologists, and public
health officials did was immoral. Condemnation, however, is not
sufficient. After all, many of those who committed crimes did so in
the firm belief in the moral rectitude of their actions.
The Holocaust differs from other instances of genocide in that it
involved the active participation of both medicine and science. Most
of the German non-Jewish doctors were neither mad nor coerced into
cooperation with the Nazi regime. These physicians were not
bystanders but were instead extremely influential in constructing
and implementing the policies of the Nazi state. The Nazis
medicalized politics as much as they politicized medicine.
Organized efforts to educate about the ethos of medicine in the
historical context should be imperative for all medical and other
healthcare profession students. We have learned that ethos is not
only a set of principles, but that in order for them to be
significant they must be translated into positive actions. Ethics
are not immutable but rather are malleable and can be shaped by
external forces and by us. History beckons us to scrutinize not only
the past, but ourselves too, in our current efforts to find
expressions of responsible use of medical science. Examination of
the events of the Holocaust and the complicity of German medicine
can provide a lens that can help in this difficult but compelling
task.
In conclusion, I quote from Elie Wiesel's article from The New
England Journal of Medicine, in April 2005: "Without Conscience."
It is impossible to study the history of German medicine during the
Nazi period in isolation from German education in general. Who or
what is to blame for the creation of the assassins in white coats?
In their eyes, the victims did not belong to humankind; they were
abstractions. The Nazi doctors were able to manipulate their bodies,
play with their brains, mutilate their future without remorse; they
tortured them in a thousand ways before putting an end to their
lives.
Yet, inside the concentration camps, among the prisoners, medicine
remained a noble profession. More or less everywhere, doctors
without instruments or medications tried desperately to relieve the
suffering and misfortune of their fellow prisoners, sometimes at the
price of their own health or their own lives. I knew several such
doctors. For them, each human being represented not an abstract idea
but a universe with its secrets, its treasures, its sources of
anguish, and its poor possibilities for victory, however fleeting,
over Death and its disciples. In an inhumane universe, they had
remained humane.
When I think about the Nazi doctors, the medical executioners, I
lose hope. To find it again, I think about the others, the
victim-doctors; I see again their burning gazes, their ashen faces.
Why did some know how to bring honor to humankind, while others
renounced humankind with hatred? It is a question of choice. A
choice that even now belongs to us — to uniformed soldiers, but even
more so to doctors. The killers could have decided not to kill.
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This paper was presented at an International Conference: The
Holocaust, Medicine and Medical Ethics marking the International
Holocaust Remembrance Day, under the auspices of Yad Vashem and the
Technion Medical School, Beit Wolyn - Yad Vashem’s Holocaust
Educational Center, 24-25 January 2007. It was also presented at an
International Conference: Bioethics Today in the Mirror of Future
Generations under the auspices of UNESCO Chair in Bioethics,
International Center for Health, Law and Ethics, University of
Haifa, Eilat, 11-14 February 2007.
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