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A medical lesson from history

In September, the Centre for Medicine after the Holocaust (CMATH) announced the signing of the ‘Galilee Declaration’. This Declaration calls upon all medical schools and other healthcare institutions to incorporate the study of medicine and the Holocaust. The CMATH’s primary mission is to challenge doctors, nurses and bioscientists to personally confront the medical ethics of the Holocaust and to apply that knowledge to contemporary practice and research. The Declaration has been signed by close to 100 members of the international medical community and academic scholars, and “endorsements continue to grow”.

The Declaration seeks to encourage “healthcare professionals to study, teach, research and learn from the behaviour of German medical professionals and scientists — the best in the world at the time — who played a central and indispensable role in the design and implementation of the Holocaust”.

CMATH Executive Director Dr Sheldon Rubenfeld said the “Galilee Declaration is a powerful call to action for all healthcare professionals and organisations”.

Dr Rubenfeld, a physician and Professor of Internal Medicine at Baylor College of Medicine in the Texas Medical Centre, US, founded the CMATH in 2010. He has been active in Holocaust education for two decades.

He explained to the Medical Independent (MI) what motivated him personally to become involved in this particular area of education.

“As a physician, I was startled to stand on a ramp at Auschwitz where selections of arriving prisoners for either the gas chambers or slave labour [arrived] and realise that a fellow physician, Dr Josef Mengele was the one making the selections,” Dr Rubenfeld told MI.

“Why was a physician with a PhD needed to do the sorting and why did he do it? I took offense and that began my campaign to challenge physicians, nurses, bioscientists and healthcare policy-makers to personally confront the ethics of the Holocaust and apply that knowledge to contemporary clinical medicine, human subjects research and healthcare policy.”

Significant involvement

According to the CMATH, the scale of professional doctors’ involvement in the Holocaust was very significant. Thousands of doctors joined the Nazi party. As noted in a 2016 article for the Association of American Medical Colleges News (AAMC NEWS) written by Dr Rubenfeld and Dr Raul Artal, the impact of Nazism on medicine attacked the very core of the doctor-patient relationship.

“Nazi physicians claimed the moral high ground by transforming the Hippocratic Oath from a doctor-patient relationship to a state-Völkskorper — or nation’s body — relationship,” the doctors wrote in AAMC NEWS.

“They justified the sterilisation or elimination of ‘lives not worth living’ as a merciful preventive measure, simultaneously ending the suffering of the genetically-inferior and preventing transmission of their presumably hereditary harmful traits.”

The Galilee Declaration was originally drafted at the Second International Conference on Medicine in the Holocaust and Beyond, held in May this year in the western Galilee, Israel.

The final Declaration published in September points out that “professionals from science, medicine and other healthcare and social science fields played decisive roles in justifying, developing and carrying out some of the most appalling atrocities of the Third Reich”.

This included “the compulsory sterilisation and medicalised murder of Germans, Austrians and other lives deemed unworthy of living; unethical, brutal experimentation on hospital patients and prisoners; and the unprecedented persecution, including mass murder, and the Holocaust — the unique, partially-medicalised genocide of Jews and many others.

“Health professionals were prominent among the Nazi perpetrators and their collaborators with these heinous crimes, which were ostensibly designed to improve the health of the German population.”

Doctors who had been involved in the Holocaust were among those tried in Nuremberg following the end of World War II.

“Between 1939 and 1945, at least 70 medical research projects involving cruel and often lethal experimentation on human subjects were conducted in Nazi concentration camps,” according to the US Holocaust Memorial Museum (www.ushmm.org).

“The Medical Case, the first of 12 subsequent Nuremberg proceedings tried by the American Nuremberg Military Tribunal, began on 25 October, 1946. Twenty-three physicians, scientists and other senior officials in the Nazi medical administration and the army were put on trial. Seven of the accused were sentenced to death and executed; nine were sentenced to long prison sentences; and seven were acquitted.

“Several major perpetrators were never tried for their crimes, among them Josef Mengele, doctor at Auschwitz-Birkenau, who escaped to South America; and Horst Schumann, who was judged physically unfit to stand trial in the 1960s.”

However, according to Dr Rubenfeld and Dr Artal in their AAMC NEWS article, the Nuremberg doctors’ trial  “focused primarily on the medical experiments rather than the egregious violations of medical ethics in clinical medicine and healthcare policy”.

Knowledge

Given the scale of the Holocaust, is there enough awareness internationally among contemporary doctors regarding the pivotal role that medicine and doctors played in the Holocaust?

Dr Hedy S Wald is Clinical Professor of Family Medicine at Warren Alpert Medical School of Brown University, Providence, Rhode Island, US. She was written widely on the subject, including a 2009 article she co-authored in The Lancet titled ‘Learning from the past: Medicine and the Holocaust’.

While it would be expected that most doctors would have heard about the role of medicine in the Holocaust in some way given that “education on research ethics should include the Nuremberg Code, a set of research ethics principles for human experimentation established as a result of the Nuremberg trials at the end of World War II (as well as the Declaration of Helsinki), this cannot be assumed,” Dr Wald told MI.

She added: “Most are unaware of the magnitude of the role of physicians and other healthcare professionals individually and as a profession in the Holocaust. At no other time in history have physicians and the medical establishment been so decisively implicated in such crimes on such a large scale.”

But Dr Wald maintained that there is a growing acknowledgment in the medical community that this is a history that needs to be known and lessons learned from it.

“There is increasing interest in deriving essential lessons for doctors and trainees, throughout the professional life cycle, by studying the history of medicine; in this case, medicine’s darkest hours,” she said.

“There is work to be done. Responses to a 2013 survey of all Liaison Committee for Medical Education (LCME)-accredited medical schools in the US and Canada revealed that ‘only 22 of 140 (16 per cent) have any required curricular elements on the roles of physicians in the Holocaust.’”

Prof Pól Ó Dochartaigh, Registrar and Deputy President of National University of Ireland Galway, is the author of Germans and Jews Since The Holocaust (Palgrave), published in 2015. While he makes it clear that medicine is not one of his areas of particular expertise, he has some interesting observations in general about professionals working in Germany, including in medicine, in the post-World War II period.

“When Germany was divided in 1949, and for decades afterwards, the GDR [East Germany] leadership turned the discovery of Nazis in the West German establishment (lawyers, teachers, politicians, civil servants, etc) into something of a national pastime,” Prof Ó Dochartaigh told MI.

“In particular, those who were either unrepentant or who had not been held accountable for their crimes often continued on in their professions, or in political life. The GDR had some ghosts of its own in this regard, by the way, but they were few in number.

“Specifically, they even incorporated some of this research into their medical training.”

Prof Ó Dochartaigh pointed out that he had no medical expertise to judge the way in which this was done or how it impacted on the medical profession.

“But the wider point is that in this, as in many walks of life, coming to terms with the experience of the Nazi period was frequently subservient to the political needs of the post-War period, specifically, propagandising in a divided Germany (and Europe). In both East and West, it might be added,” he said.

Holocaust teaching approaches

Dr Rubenfeld believes that courses on medicine after the Holocaust should be specifically taught to medical students and not just generally among undergraduates.

“Some European universities offer courses about medicine during the Third Reich. Prof Paul Weindling at Oxford Brookes University in the UK and Prof Dr Volker Roelcke at the Justus Liebig University in Giessen, Germany, have studied, taught, researched and published about this topic for decades,” Dr Rubenfeld tells MI.

“There are other European scholars who do the same. Their primary audiences may be undergraduate rather than medical students and what is needed is an academic chair at a medical school to promote medicine after the Holocaust as an academic discipline.

“CMATH has convened two international scholars’ workshops on medicine after the Holocaust in Houston in 2015 and Israel in 2017. The third will be in Berlin in May 2019.”

But in his experience, promoting this area, he has found some resistance in academic institutions he says.

“There is a great deal of resistance to incorporating this history into the medical school curriculum, which is primarily devoted to science, technology, and the mechanics of medicine,” he tells MI.

“This history shows the medical profession in a very bad light. It also dispels the myths that Nazi physicians were coerced, crazy, incompetent, sadistic and few in number. The biggest myths that are dispelled are that there is no ethical basis for the behaviour of Nazi physicians and that Western liberal democracies are incapable of similar atrocities. None of this is comfortable for medical faculty to learn or teach.”

Prof Wald says that the history of the Holocaust creates a “moral imperative” for medical trainees to confront.

It is important, says Dr Wald, because “from 1933-1945, presumed healers within mainstream medicine sworn to uphold the Hippocratic Oath turned into killers. This included healthcare professionals individually and within medical and scientific establishments.

“This creates an educational, moral imperative for healthcare trainees and professionals to confront and grapple with how traditional Hippocratic virtues morphed into unspeakable evil and to develop ethical vigilance and resilience to assure ‘never again’. 

“I have published in the journal Academic Medicine (2015) with Dr Shmuel Reis about the crucial need for a curriculum on medicine’s central role in the Holocaust to support healthy professional identity formation in healthcare professions education.

“Such curricula are needed as a ‘pre-emptive approach’ to foster awareness of risks of abuse of power and to learn from the medical and scientific establishments’ use of science to help legitimise persecution, murder, and ultimately genocide.”

In terms of the current situation in Ireland, a spokesperson for the Faculty of Health Sciences at Trinity College Dublin told MI that “medicine during World War II is covered in the curriculum as part of research ethics”. This newspaper contacted the other medical educational institutions in Ireland regarding this area, but no more got back to us by press time.

Lack of awareness

From his two-decade experience working in this area, Dr Rubenfeld told this newspaper that he does not believe there is sufficient awareness in contemporary medicine regarding doctors and the Holocaust.

“There was a comprehensive effort by German medicine to cover-up their crimes,” said Dr Rubenfeld.

“The American military that conducted the Nuremberg Doctors Trial focused on the inhumane medical experiments, which was just a minor part of the medical war crimes committed by Nazi physicians. For example, they sterilised 400,000 German citizens and euthanised 200,000 German adults and children without consent for either.

“Along with chemists and engineers, they designed gas chambers for the involuntary euthanasia programmes that would provide the model for ‘the final solution to the Jewish problem’ and 4,500,000 deaths by gassing. The experiments involved less than 30,000 victims and not all perished.”

The CMATH has expanded since its inception to include panels and lecture series on specific topics, such as human subjects research, biomedical ethics and physician-assisted suicide and euthanasia, as well as an extensive online library of resources for educators.

It will organise its fifth tour for scholars and medical professionals to European medical sites relevant to the Holocaust from May 13-19, 2018. In 2019, it will co-sponsor the ‘Third International Scholars Workshop on Medicine after the Holocaust’ in Berlin, Germany.

Interestingly, Dr Rubenfeld also feels that there may be a cross-Atlantic  “blind-spot” in this area.

“There is a particular blind-spot regarding the legislative models and the moral and philanthropic support provided by American eugenicists to the German eugenics movement, the movement for better human breeding,” he told MI.

“For example, the first involuntary sterilisation legislation in the world was passed in Indiana in 1907 and declared constitutional by the US Supreme Court by an eight-to-one margin in 1927, six years before Hitler came to power. By the time Hitler became Chancellor in 1933 and instituted his own involuntary sterilisation law, a dozen countries, including the US, already had one.”

Relevance?

But is the teaching of this dark history to contemporary medical students important? Emphatically yes, said Dr Rubenfeld.

“German physicians and the German healthcare delivery system were the best in the world prior to World War II,” Dr Rubenfeld commented.

“The Nazi medicine programme was comprehensive, including clinical medicine (the care of patients), research including human subjects research, and healthcare policy. Because the Nazi physicians played an indispensable role in designing and implementing many of the policies and procedures that led to the Holocaust, anyone interested in contemporary medicine needs to know that history to avoid making similar mistakes.

“At this moment, the power to diagnose and possibly treat genetic disorders prenatally and in utero is increasing, creating the potential for the abuse of this power.

“At the other end of life, the ageing of the population, improved treatment of patients with chronic and/or serious illnesses and finite resources increase the pressure for physician-assisted suicide and euthanasia in the guise of relief of suffering.

“Nazi physicians encountered similar genetic and end-of-life issues. Because history helps us behave better, medical students need to examine the moral premises guiding Nazi physicians if they are to avoid similar immoral outcomes.”

Dr Wald agrees that studying and discussing this darkest point in humanity’s history can still provide important insights for modern medicine and young doctors.

“In general, studying the egregious role played by healthcare professionals in the Holocaust can ideally support reflective, ethically-vigilant and morally resilient healthcare professionals in a ‘pre-emptive approach’ for preventing abuse of power and fostering ethical behaviour,” she tells MI.

“There is a value of such teaching for ‘calibrating our moral compass’ within clinical and research practices.

“More specifically, such teaching for today’s medical students (and students of other healthcare professions as well as seasoned clinicians and researchers) can hopefully better equip these life-long learners with moral resilience as they inevitably face and need to navigate contemporary and future fundamental relevant dilemmas such as prejudice, dual loyalty, assisted reproduction and suicide, resource allocation, obtaining valid informed consent, use of ‘big data’, challenges of genomics and technology expansion, and human rights violations.”

Ethics

For Dr Rubenfeld, the scale of the Holocaust and the comprehensive role that medicine played in it means that there is no aspect of contemporary medical ethics that is not influenced by it.

“Because of Gleichschaltung, or co-ordination of all aspects of society toward a common goal, all of German medicine was reoriented during the Third Reich,” said Dr Rubenfeld.

“There is, therefore, no discussion of contemporary issues in medicine that would not be influenced by knowledge of the behaviour of German physicians during the Third Reich.

“For example, the rediscovery of Mendelian genetics in 1900 gave a scientific patina to the worldwide eugenics movement and biological determinism, much as the Human Genome Project has done.

“Human reproduction and end-of-life policies were promulgated, just as they are being done now in the US and especially in Europe, where euthanasia is commonly done. Providing medical care for the chronically ill and those with serious medical problems was a driving force for many of the Third Reich’s eugenics policies — they, too, had finite financial resources, just as we do today.”

Web resources on medicine and the Holocaust

Centre for Medicine after the Holocaust: (CMATH) http://www.medicineaftertheholocaust.org/

Copy of Galilee Declaration: http://www.medicineaftertheholocaust.org/galilee-declaration/

US Holocaust Memorial Museum: www.ushmm.org

Maimonides Institute for Medicine, Ethics and the Holocaust (MIMEH): http://www.mimeh.org/

Holocaust Education Trust Ireland, an independent, non-profit national charity that aims to educate and inform people about the Holocaust: http://hetireland.org

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