AMA Journal of Ethics^®

Abstract

The Holocaust differs from other instances of mass murder in that it was medically sanctioned genocide. Modern health care ethics was born of the Holocaust, and this article describes numerous misconceptions about medicine’s key roles in several events prior to and during the Holocaust. This article also illuminates lessons that should be formally integrated into all health professions ethics curricula.

Birth of Modern Health Care Ethics

Health care ethics is often taught using cases of health professionals’ ethical transgressions in research and has been said to originate in the 1960s, in response to unethical experimentation.¹ Specifically, some have argued that health care ethics was born of Nazi experimentation abuses and the subsequent Nuremberg Code.² But these views reflect fundamental misconceptions, because health care ethics did not arise exclusively from Nazi crimes in human experimentation. Rather, modern health care ethics has its roots in what transpired prior to and during the Holocaust—the murder of 6 million Jews.

Unlike other instances of genocide, the Holocaust was unique because of Nazi health professionals’ leadership in the conceptualization, design, and implementation of several murderous programs that led directly to extermination and torture of millions of people. As such, the Holocaust has been called the seminal event of the 20th century in the historiography of bioethics.³ Medicine, of course, was not alone in supporting National Socialism, but it differed from the other professions by virtue of its explicit commitment to preventing human suffering. Medicine was abused to the extreme before and during the Holocaust, and today nearly every health care ethics issue (eg, value of human life, dual loyalties, power and authority, professionalism and ethics education) can be better understood by considering the Holocaust’s legacies.

Lessons for Health Professions Education

Eugenics. As a scientifically and politically motivated attempt to improve humankind, eugenics existed in the first half of the 20th century in many countries, led by the United States.⁴ In Germany, eugenics was called racial hygiene and modeled on the American eugenics movement.⁵ When negative eugenics merged with German National Socialism, racism was medicalized to rid society of chronically ill people and others whose lives were considered unworthy, burdensome, and threatening to Aryan “hereditary health.” The first German eugenic initiative was legal coercive sterilization, which progressed to the notorious “euthanasia” (medically sanctioned murder) program that was a next step on the path to the systematic murder of millions of people.⁶ Students should learn this history, which informs current debates about care of the dying, the disabled, and people with minoritized racial and ethnic identities and about genetics and reproductive health care.

Complicity. It is a misconception that physicians were forced to comply with Nazi demands. It’s true that Nazi politicians needed physicians to implement eugenic programs, but physicians didn’t join reluctantly. Most joined eagerly, earlier, and in much greater numbers than other professionals.⁷ Diagnoses by Nazi physicians were ascribed to those social and racial minorities perceived as “sick elements” threatening to “hereditary public health.”⁶ Health professions students should explore possible reasons for physicians’ avid involvement in the Holocaust: obedience to state authority, group identity, abuse of professional power, and hierarchy placement.^8,9 Reflection on and discussion of these and other reasons can help prompt students’ considerations about maintaining integrity and balancing their obligations to individuals and communities.

Academic physicians practicing and teaching mainstream medicine made Nazi crimes against humanity possible and efficient. 

Evil was mainstream. It’s also a misconception that physicians who joined the Nazi party were fringe elements of medicine. Despite German medicine being advanced and sophisticated, professionals from internationally revered institutions led and executed Nazi eugenic programs, including mass extermination.¹⁰ Academic physicians practicing and teaching mainstream medicine made Nazi crimes against humanity possible and efficient. Students should reflect on the roles of professional pride, or hubris, in relation to appropriate applications of medicine’s social, political, and technological power.

Nazi medical ethics. Another crucial misconception is that German physicians “abandoned” medical ethics to execute Nazi goals. In fact, Nazi physicians had strict, detailed ethical codes that prioritized their obligations to the state over their obligations to individuals. This conception of ethics was rigorously taught, with Germany being the first country in the world to mandate ethics classes in every medical school. Although Nazi medical ethics allowed patients to choose their physicians and labeled billing for unnecessary procedures unethical, these traditional conceptions of ethical values applied only to Aryan, able-bodied patients. Individuals perceived as threatening to the “racial purity” of the state were excluded from protection according to Nazi medical ethics. Furthermore, Nazi medical ethics lectures were delivered in medical schools by practicing physicians, some of whom were active participants in the eugenic programs. Teachers were carefully chosen from within Nazi party ranks and students provided with a textbook detailing the key ethical obligations of Nazi physicians: (1) physicians are “health leaders” with authoritarian, paternalistic roles; (2) physicians should rid society of Jews, disabled persons, and others deemed unfit contributors to the state; (3) physicians must denounce care for “hereditarily inferior” people; and (4) physicians must sterilize, abort, and “mercy kill” to secure “racial purity and hereditary health.”¹¹ Reflection on these truths of Nazi medical ethics can illuminate how even ethics education can be undermined by state influence and other powers external to a profession.

Limited scope of Nuremberg Trial. The Doctor’s Trial at Nuremberg (1946-1947) and the ensuing Nuremberg Code have been regarded as epochal in health care and research ethics.¹² The trial was concerned mainly with human experimentation abuses and not with the broader range of Nazi medical crimes,¹³ such as labeling some individuals’ “lives not worthy of living,” forced sterilization of 400 000 Germans with disabilities, and “euthanasia” of about 200 000 Germans.¹⁴ One reason for the trials’ limited scope was because Germany was the first nation to have uniform human subjects research guidelines, which Nazi physicians flagrantly ignored. A 1900 Prussian law, which specified that vulnerable subjects should not be exploited, among other traditional research ethics principles, was the model for the Reich Health Council Circular in 1931.¹⁵ Since victims of the Nazi’s infamously cruel experiments were perceived as subhuman, they were seen as outside their own research ethics’ applicability.¹¹

Nuremberg Code and human experimentation. It has been argued that the Nuremberg Code applied only to Nazi physicians and not to modern medical researchers,¹⁶ but this is false. Another misconception is that Nazi experiments were pseudoexperiments committed by crazed physicians; this is also false, as many of the Nazi experiments were accepted forms of science at the time, conducted not only in concentration camps but also in hospitals and clinics across Germany.¹⁷ The physicians involved in Nazi experiments never apologized but defended their actions using reasons such as these: subjects had volunteered, war made individuals’ expendable to promote the good of the state, and subjects were doomed to die anyway.¹⁶ Discussions with present-day health professions students should be held on the Doctor’s Trial and the ensuing Nuremberg Code and modern codes governing research, and students should reflect on the fragility of these codes under certain circumstances.

Medicine and the Holocaust Pedagogy

Misconceptions about the breadth and depth of Nazi physicians’ involvement in the Holocaust might help some avoid confronting the acute horror of medicine’s complicity in crimes against humanity during the Holocaust. But these misconceptions must be corrected, as they contribute to neglect of the ramifications of the Holocaust’s legacies today. Failure to teach Holocaust history has also exacerbated almost universal ignorance of its relevance to health care and political life today.^18,19 Additionally, while modern health care ethics values, principles, codes, and regulations are based on lessons learned from the Holocaust, they do not explicitly state this indebtedness. The lessons of the Holocaust are complex and emotionally and cognitively challenging for teachers and learners, but discomfort does not justify their distancing themselves from the history of the worst human and professional impulses that the Holocaust illuminated.Medicine was powerful in the era of National Socialism in Germany, and it is powerful today. Professional power and hubris enabled collusion with a racist political regime,²⁰ and present-day clinicians are not immune to corruption, racism, anti-Semitism, genetic bias, and disrespect for human dignity.²¹ Teachers and learners of health professions should become familiar with this legacy of the Holocaust, which offers great opportunities for growth.