February 4th, 2021
Engaging with History: Why Do the Actions of Nazi Physicians Matter in Medicine Today?
The reflections and photos in this post are a result of the immersive experience I had via the Fellowship at Auschwitz for the Study of Professional Ethics in 2016.
Many assume that Nazi physicians were antisocial, sadistic psychopaths. But viewing the perpetrators of the Holocaust as morally deficient is simply inaccurate; in fact, the Nazis physicians were often well-known, highly respected individuals at the tops of their fields. The Nazi philosophy was based on scientific and historical factors that developed over many years and culminated in the Holocaust. In the actions of Nazi physicians, we can see how many important principles in the practice of medicine were broken. Studying the actions of Nazi physicians reinforces that we may all be capable of violating these principles, and we must be constantly vigilant to maintain our compassionate, humanistic, ethical practice of medicine.
Enhancing patients’ right to healthcare
The Nazis had a warped view of “public health” that centered on “racial hygiene,” a concept that represented the evolution of ideas introduced in Charles Darwin’s Origin of Species. By 1920, the phrase “life unworthy of life” was commonplace in Germany in referring to terminally ill patients and psychiatric patients. When Nazi doctor Fritz Klein was asked how he was able to murder people after having taken the Hippocratic Oath, he responded, “Of course I am a doctor and I want to preserve life. And out of respect for human life, I would remove a gangrenous appendix from a diseased body. The Jew is the gangrenous appendix in the body of mankind.” The moment we believe that certain groups of people, whether elders, socioeconomically disadvantaged, incarcerated, disabled, or with whatever other trait we choose, are less worthy of healthcare is the moment we start to invalidate their humanity and their worthiness of life. The American healthcare system unfortunately often makes it difficult to ensure that all groups receive equitable healthcare. Thus, it is our job as physicians to advocate for our patients to the best of our ability at the individual, state, and national levels.
Informed consent is critical in clinical medicine and research
The Nazi doctors enacted a variety of non-consensual human experiments. These experiments included determining the “most effective” means of killing people (e.g., injections of phenol vs. starvation vs. gassing), freezing subjects to identify effective treatments for hypothermia, and bone grafting experiments to test the efficacy of newly developed medications. The purpose of many of these experiments was to identify efficient methods for killing people the Nazis deemed “undesirable” and to perform general basic science research in which a given Nazi doctor had a special interest. From post-war scrutiny of these experiments arose the Nuremberg Code, a set of guidelines that outlines principles of research ethics in human experimentation. From consent in research projects to day-to-day consent for medical procedures, it is critical that we ensure our patients are well-informed of the risks of the procedure to which they are consenting and that they are voluntarily agreeing to undergo the intervention.
Importance of challenging the hierarchy
The sociological phenomenon of people’s willingness to follow orders also played a prominent role in the actions of the Nazi physicians. Stanley Milgram’s famous 1961 obedience experiment showed that people exhibit a chilling willingness to follow orders, particularly when there seems to be a greater cause and an authoritative figure giving orders. In his testimony in the Nuremberg Trials, defendant Dr. Karl Brandt was asked whether the ultimate responsibility for the medical crimes that took place in the Nazi concentration camps should fall on the state or on the physicians. Dr. Brandt responded, “In my view, this responsibility is taken away from the physician because the physician is merely an instrument. The feeling of a special professional, ethical obligation has to subordinate itself to the totalitarian nature of the war.” The dissemination of responsibility from an individual to a group of people can enable individuals to engage in unethical actions. Impenetrable hierarchies in medicine continue to exist to varying degrees, often differing between specialties and institutions. However, the idea that strict adherence to a hierarchy can negatively affect patient safety and patient care is commonly taught in medical schools. As a result, there are measures in place that intentionally disrupt the chain of authority in medical practice. For example, a patient’s nurse may be specifically sought out during a medical team’s rounds to ensure that any of his or her concerns are addressed. Formal avenues exist for medical students to lodge concerns regarding mistreatment of themselves or patients. Centers of professionalism and ethics abound in medical schools to address these types of violations.
Taking action against dehumanization and decreased empathy in medicine
In their participation in concentration camps, Nazi doctors were able to psychologically distance themselves from their actions by dehumanizing prisoners (e.g., using prisoner numbers instead of names, stripping people of their clothing and other belongings, viewing individuals as animals instead of people). In the modern practice of medicine, constant exposure to the pain and suffering of other people often has a numbing effect. Medical professionals may eventually become less susceptible to having an emotional response to another person in pain. It is a well-studied phenomenon that medical students become decreasingly empathic as their training progresses. This apathy towards pain and suffering that may develop over time in physicians is concerning, because it may enable a similar apathy when immoral actions occur. Those who commit evil do not necessarily have evil motives. This decreasing empathy and lack of self-awareness in the medical profession is a systemic problem that physicians should be aware of and which needs to be continually addressed. Some possible interventions, many of which are already occurring, are to include courses and activities in medical practice that enable reflection and empathy. Examples include patient memorial services, reflective writings, and facilitated small-group discussions on the role of empathy in medicine. Encouraging and enabling physicians to have other roles in their lives can also be helpful, as a person who functions as a physician, a mother, a wife, and an active community member has the opportunity to re-orient herself and look at her role as a physician from other perspectives.
Ultimately, every historical age has its own outlook and attempts to solve the problems it faces in unique ways; it is by studying how these historical problems arose and the results of their attempted solutions that we can start to have a basis for solving problems of our own time. By learning from the atrocities committed by Nazi physicians, we can hope to avoid similar actions in the future and hopefully better the practice of medicine.
Alexander L. Medical science under dictatorship. N Engl J Med 1949 Jul 14; 241:39. (https://doi.org/10.1056/NEJM194907142410201)
Chen D et al. A cross-sectional measurement of medical student empathy. J Gen Intern Med 2007 Oct; 22:1434. (https://doi.org/10.1007/s11606-007-0298-x)
Lifton RJ. The Nazi doctors: Medical killing and the psychology of genocide. 1986. New York: Basic Books.
Milgram S. Behavioral study of obedience. J Abnorm Psychol 1963 Oct; 67:371. (https://doi.org/10.1037/h0040525)