Too Hard to Face
http://www.100md.com
《美国精神病学与法律学报》
Dr. Caplan is The Emanuel and Robert Hart Professor of Bioethics and Chair of the Department of Medical Ethics and Director, Center for Bioethics, University of Pennsylvania, Philadelphia, PA.
Abstract
While the Holocaust is often placed at the genesis of bioethics, this relatively young field has not yet seriously explored the conduct of German scientists and physicians involved in the human subjects experiments of the Holocaust. We comfort ourselves with the beliefs that the individuals involved in the events of the Holocaust were mad or evil and unlike other scientists and physicians. Yet the evidence is that these professionals were educated and capable members of a technologically sophisticated society who believed they were somehow behaving morally within the context of their social-political situation. The first defendants at Nuremberg were physicians and public health officials. An examination of the trial transcripts provides data about what motivated these medical scientists to engage in human experimentation and mass murder and the extent to which ethics rationales were given for unparalleled moral wrong-doing in biomedicine. Bioethics must still address these beliefs and subject them to close scrutiny.
Why has it been so difficult for bioethics to deal with the Holocaust in general and the horrific experiments conducted in the concentration camps by German scientists and physicians in particular? It is not for want of invoking the analogy to Nazi behavior in current bioethical disputes.1 One does not have to look hard to find numerous references to the Holocaust in contemporary debates about abortion, stem cell research, fetal tissue research, animal experimentation, assisted suicide, the termination of hydration and nutrition for those in vegetative states, human experimentation, and many more contemporary topics. Yet, if one skims through the major anthologies and textbooks of the field of bioethics, the Holocaust and the brutal camp experiments merit hardly a mention.
Most histories of medical ethics locate the origins of bioethics in the ashes of the camps. The Nuremberg Code is frequently held up as the "constitution" of human subjects research. But very little is said about the actual experiments that generated this document. And even less, really nothing at all, is said about the ethical dilemmas the Nazi research raises. Why is this so?
One obvious reason is that the events of the Holocaust are so horrid that they speak for themselves. What more is there to say about mass murder and barbaric experimentation except that it was wrong?
Another reason is that many scholars have dismissed the research done in the camps as worthless and those involved in conducting it as lunatics and crackpots. What point is there in discussing research that is nothing more than torture disguised as science?2
Yet another reason for the absence of moral commentary is that there has been a tradition of trying to offer psychological explanations for the behavior of those involved in the killing so that moral explanations seem unnecessary. Those who went to work at the gas chambers and dissection rooms did so through adaptations of personality and character that make it difficult to hold them morally accountable for their conduct.3,4
Perhaps the most important reason for the absence of commentary on the ethics of the Holocaust and the ethics of the research done in the camps is that such questions open a door that few bioethicists want to traverse. If justifications can be given for why someone deemed mass murder appropriate in the name of public health or thought that it was right to freeze hapless men and women to death, or decompress them, or infect them with lethal doses of typhus, then to put the question plainly—what good is ethics?
Debunking the Myths of Incompetence, Madness, and Coercion
It is comforting to believe that health care professionals from a country that was the world leader in medicine at the time, who had pledged an oath to "do no harm" could not kill babies or conduct brutal, often lethal, experiments on starving inmates in concentration camps. It is comforting to believe that it is not possible to defend involuntary euthanasia, forced sterilization, and genocide in moral terms. It is comforting to believe that anyone who espouses racist, eugenic ideas cannot be a competent, introspective physician or scientist. Such beliefs are especially comforting to those who have to grapple with the moral legacy of Nazi science. Nazi medical crimes demonstrate that each of these beliefs is false.5
It is commonly believed that only madmen, charlatans, and incompetents among doctors, scientists, public health officials, and nurses could possibly have associated with those who ran the Nazi party. Among those who did their "research" in Auschwitz, Dachau, and other camps, some had obvious psychological problems, were lesser scientific lights or both.3 But there were also well-trained, reputable, and competent physicians and scientists who were also ardent Nazis. Some conducted experiments in the camps. Others decided who ought to be put to death. Human experimentation in the camps was not conducted only by those who were mentally unstable or on the periphery of science. Support for genocide was not confined to the fringe of German medicine and science. Not all who engaged in experimentation or murder were inept.5–8
Placing all the physicians, health professionals, and scientists who took part in the crimes of the Holocaust on the periphery of medicine and science allows another myth to flourish—that medicine and science went "mad" when Hitler took control of Germany and that competent and responsible physicians and scientists could not willingly have had anything to do with Nazism. However, the actions as well as the beliefs of German physicians and scientists under Nazism stand in glaring contrast to this myth.6,7
Once identified, the myths of incompetency and madness make absolutely no sense. How could flakes, crackpots, and incompetents have been the only ones supporting Nazism? Could the Nazis have had any chance of carrying out genocide on such a staggering, monumental scale against victims scattered over half the globe without the zealous help of competent biomedical and scientific authorities? The technical and logistical problems of collecting, transporting, exploiting, murdering, scavenging, and disposing of the bodies of millions from dozens of nations required competence and skill, not ineptitude and madness.
The Holocaust differs from other instances of genocide in that it involved the active participation of medicine and science. The Nazis turned to biomedicine specifically for help in carrying out genocide after their early experience using specially trained troops to murder in Poland and the Soviet Union proved impractical.4
Another myth that has flourished in the absence of a serious analysis of the moral rationales proffered by those in German biomedicine who participated in the Holocaust is that those who participated were coerced. Many doctors, nurses, and scientists in Germany and other nations have consoled themselves about the complicity of German medicine and science in genocide with the fable that, once the Nazi regime seized power, the cooperation of the biomedical and scientific establishments was only secured by force.3,6,7 Even then, as this myth has it, cooperation among doctors, scientists, and public health officials with Nazism was grudging.
The myths of incompetence, madness, and coercion have obscured the truth about the behavior of biomedicine under Nazism. Most of those who participated did so because they believed it was the right thing to do. This helps to explain the relative silence in the field of bioethics about both the conduct and justifications of those in biomedicine who were so intimately involved with the Nazi state.
Why Does Bioethics Have So Little to Say About the Holocaust?
If one dates the field of bioethics from the creation of the first bioethics institutes and university programs in the United States in the mid-1960s, then the field is roughly 40 years old. Incredibly, no book-length bioethics study exists that examines the actions, policies, abuses, crimes, or rationales of German doctors and biomedical scientists.
There has been almost no discussion of the roles played by medicine and science during the Nazi era in the bioethics literature. Rather than see Nazi biomedicine as morally bad, the field of bioethics has generally accepted the myths that Nazi biomedicine was inept, mad, or coerced.
By subscribing to these myths, bioethics has been able to avoid a painful confrontation with the fact that many of those who committed the crimes of the Holocaust were competent physicians and scientists who acted from strong moral convictions. Not one of the doctors or public health officials on trial at Nuremberg pleaded for mercy on the grounds of insanity. A few claimed they were merely following legitimate orders, but almost no one alleged coercion.9
When called to account at Nuremburg and other trials for their actions, Nazi doctors, scientists, and public health officials were surprisingly forthright about their reasons for their conduct. The same cannot be said for the ethical evaluations offered in Germany and in the Western World for their crimes.
The puzzle of how it came to be that physicians and scientists who committed so many crimes and caused so much suffering and death did so in the belief that they were morally right cries out for analysis, discussion, and debate. But it is tremendously painful for those in bioethics to have to undertake such an analysis.
It is often presumed, if only tacitly, by those who teach bioethics that those who know what is ethical will not behave in immoral ways. What is the point of having bioethics, of teaching courses on ethics to medical, nursing and public health students, if the vilest and most horrendous of deeds and policies can be justified by moral reasons? Bioethics has been speechless in the face of the crimes of Nazi doctors and biomedical scientists precisely because so many of these doctors and scientists believed they were doing what was morally right to do.
Experimentation in the Camps
There were at least 26 different types of experiments conducted for the explicit purpose of research in concentration camps or using concentration camp inmates in Germany, Poland, and France during the Nazi era.8 Among the studies in which human beings were used in research were: the analysis of high-altitude decompression on the human body; attempts to make sea water drinkable; the efficacy of sulfanilamide for treating gunshot wounds; the feasibility of bone, muscle, and joint transplantations; the ability to treat burns caused by incendiary bombs; the efficacy of polygal for treating trauma-related bleeding; the efficacy of high-dose radiation in causing sterility; the efficacy of phenol (gasoline) injections as a euthanasia agent; the efficacy of electroshock therapy; the symptoms and course of noma (starvation-caused cutaneous gangrene); the postmortem examination of skeletons and brains to assess the effects of starvation; the efficacy of surgical techniques for sterilizing women; and the impact of stress and starvation on ovulation, menstruation, and cancerous growths in the female reproductive organs. A variety of other studies were carried out on twins, dwarves, and those with congenital defects. Some camp inmates were used as subjects to train medical students in surgery. Jewish physicians in one camp surreptitiously recorded observations about the impact of starvation on the body.
The question of whether any of these activities carried out in the name of medical or scientific research on nonconsenting, coerced human beings deserves the label of "research" or "experimentation" is controversial.2 When the description of research is broadened further to include the intentional killing of human beings to establish what methods are most efficient, references to "research" and "experimentation" begin to seem completely strained. Injecting a half-starved young girl with phenol to see how quickly she will die or trying out various forms of phosgene gas on camp inmates in the hope of finding cheap, clean, and efficient modes of killing, so the state can effectively conduct genocide is not the sort of activity associated with the term "research."
But murder and genocide are not the same as intentionally causing someone to suffer and die to fulfill a scientific goal. Killing for scientific purposes, while certainly as evil as murder in the service of racial hygiene, is, nonetheless, morally different. The crimes that were at the core of Nazi medical experiments involves not only torture and murder but also the exploitation of human beings to serve the goals of science. To describe what happened in language other than that of human experimentation blurs the nature of the wrongdoing. The evil inherent in Nazi medical experimentation was not simply that people suffered and died but that they were exploited for science and medicine as they died.
A summary report prepared for the American military about the hypothermia experiments has been cited in the peer-reviewed literature of medicine more than two dozen times since the end of World War II. Not only were the data examined and referenced, they were applied. British air-sea rescue experts used the Nazi data to modify rescue techniques for those exposed to cold water.8 The force of the question, should the data be used, is diminished not only because there are reasons to doubt the reliability and exclusivity of the data but because the question has already been answered—Nazi data have been used by many scientists from many nations.
There is another moral issue that does not hinge on the answer to the question of whether the research was well-designed or the findings of enduring scientific value. How did physicians and scientists convince themselves that murderous experimentation was morally justified?
No one understood the need for justification more clearly than the doctors and scientists put on trial for their crimes after the conclusion of the war. The defendants admitted that dangerous and even lethal experiments had been conducted on nonconsenting persons in prisons and other institutions. Some protested attempts by the prosecution, in its effort to highlight the barbarity of what they had done, to demean or disparage the caliber of their research. No one apologized for taking a role in various experiments conducted in the camps. Instead, those put on trial attempted to explain and justify what they had done, often couching their defense in explicitly moral terms.
The Ethics of Evil
Probably the most succinct précis of the moral arguments brought forward by physicians, public health officials, and scientists in defense of their participation both in experimentation in the concentration camps and in the "final solution" can be found in the transcripts of the Nuremberg trials. The first group of individuals to be put on trial by the allies were physicians and public health officials. The role they had played in conducting or tolerating cruel and often lethal experiments in the camps dominated the trials.8 As it happens, the same arguments that were brought forward in defense of the camp experiments were also used to justify participation in mass murder and attempts at the forced sterilization of camp inmates. 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 hypothermia and phosgene gas experiments, but also for the involvement of biomedicine in the broad sweep of what the prosecution termed "crimes against humanity."
One of the most common moral rationales given at the trials was that no wrong had been done, because those who were subjects had volunteered. Prisoners might be freed, some defendants argued, if they survived the experiments. The prospects of release and pardon were mentioned very frequently during the trial, since they were the basis for the claim that people participated voluntarily in the experiments.9 On this line of thinking, experimentation was justified, because it might actually have benefitted the subjects.
The major flaw in this moral rationale is simply that it was false. A British newspaper, the London Sunday Observer, in 1989, found a man who had survived the hypothermia experiments that involved prolonged submersion in tanks of freezing water. He had been sent to Dachau because of his political beliefs.
He said that the researchers told him that if he survived the hypothermia experiments and then the decompression experiments, he might be freed. He was not. He said no prisoners were. However, he was given a medal by the Reich on the recommendation of the experimenters. The medal was given in recognition of the contributions he had made to medical science!
Another of the key rationales on the part of those put on trial was that only people who were doomed to die were used for biomedical purposes.9 Time and again, the doctors who froze screaming subjects to death or watched their brains explode as the result of rapid decompression stated that only prisoners condemned to death were used. It seemed morally defensible to physicians and scientists to learn from what they saw as the inevitable deaths of camp inmates.
A third ethical rationale for performing brutal experiments on innocent subjects was that participation in lethal research offered expiation to the subjects. By being injected, frozen, or transplanted, subjects could cleanse themselves of their crimes. Suffering prior to death as a way to atone for sin seemed to be a morally acceptable rationale for causing misery in those who were guilty of crimes.
The problem with this ethical defense is that those who were experimented on or made to suffer by German physicians and scientists were never guilty of any crime other than that of belonging to a despised ethnic or racial minority or for holding unacceptable political views. Even if those who were experimented on or killed had been guilty of some serious crime, would it have been moral to use medical experimentation or the risk of death as a form of punishment or expiation? It is hard to see how these goals square with the goals of medicine or health care. It is impossible to see how such a position is persuasive with respect to incompetent persons and children.
A fourth moral rationale, one that is especially astounding, even by the standards of self-delusion in evidence throughout the trial proceedings, was that scientists and physicians had to act in a value-neutral manner. They maintained that scientists and doctors are not responsible for—and have no expertise about—values and thus could not be held accountable for their actions. "...[I]f the experiment is ordered by the state, this moral responsibility of experimenter toward the experimental subject relates to the way in which the experiment is performed, not the experiment itself" (Ref. 9, p 542).
Some researchers only thought themselves responsible for the proper design and conduct of their research. They felt no moral responsibility for what had occurred in the camps because they did not have any expertise concerning moral matters. They claimed to have left decisions about these matters to others. In other words, they argued that scientists, to be scientists, could not take normative positions about their science.
The fifth moral justification for what had happened presented by many of the defendants was that they had done what they did for the defense and security of their country. All actions were taken to preserve the Reich during "total" war.
Germany was engaged in war at that time. Millions of soldiers had to give up their lives because they were called upon to fight by the state. The state employed the civilian population for work according to state requirements. The state ordered employment in chemical factories which was detrimental to health... . In the same way, the state ordered the medical men to make experiments with new weapons against dangerous diseases (Ref. 9, p 566).
The defendants maintained that total war, war in which the survival of the nation hangs in the balance, justifies exceptions to ordinary morality. Allied prosecutors had much to ponder in thinking about this defense in light of the fire-bombing of Dresden and Tokyo and the dropping of nuclear bombs on Hiroshima and Nagasaki.
The last rationale is the one that appears to carry the most weight among all the moral defenses offered. Many who conducted lethal experiments argued that it was reasonable to sacrifice the interests of the few to benefit the majority.
The most distinguished of the scientists who was put on trial, Gerhard Rose, the head of the Koch Institute of Tropical Medicine in Berlin, said that he initially opposed performing potentially lethal experiments to create a vaccine for typhus on camp inmates. But he came to believe that it made no sense not to risk the lives of 100 or 200 men in pursuit of a vaccine, when 1000 men a day were dying of typhus on the Eastern front. What, he asked, were the deaths of 100 men compared with the possible benefit of getting a prophylactic vaccine capable of saving tens of thousands? Rose, because he admitted that he had anguished about his own moral duty when asked by the Wehrmacht to perform the typhus experiments in a concentration camp, raises the most difficult and most plausible moral argument in defense of lethal experimentation.
The prosecution encountered some difficulty with Rose’s argument. The defense team for Rose noted that the Allies themselves justified the compulsory drafting of men for military service throughout the war, knowing many would certainly die, on the grounds that the sacrifice of the few to save the many was morally just. Moreover, they also pointed out, throughout history medical researchers in Western countries have used versions of utilitarianism to justify dangerous experiments on prisoners and institutionalized persons.
Justifying the sacrifice of the few to benefit the majority is a position that must be taken seriously as a moral argument. In the context of the Nazi regime it is fair to point out that the sacrifice is not borne equally by all, as is true of a compulsory draft that allows no exceptions. It is also true that many would argue that no degree of benefit should permit intrusions into certain fundamental rights.
Crude utilitarianism is a position that sometimes rears its head in contemporary bioethics debates. For example, some argue that we ought not to spend scarce social resources on certain groups within our society, such as the elderly, so that other groups, such as children, may have greater benefits. Those who want to invoke the Nazi analogy may be able to show that this form of crude utilitarian thinking does motivate some of the policies or actions taken by contemporary biomedical scientists and health care professionals, but they should do so with great caution.
In closely reviewing the statements that accompany the six major moral rationales for murder, torture, and mutilation conducted in the camps—freedom was a possible benefit, only the condemned were used, expiation was a possible benefit, a lack of moral expertise, the need to preserve the state in conditions of total war, and the morality of sacrificing a few to benefit many—it becomes clear that the conduct of those who worked in the concentration camps was sometimes guided by moral rationales. It is also clear that all of these moral arguments were nested within a biomedical interpretation of the danger facing Germany.
Physicians could justify their actions, whether direct involvement with euthanasia and lethal experiments, or, merely support for Hitler and the Reich, on the grounds that the Jew, the homosexual, the congenitally handicapped, and the Slav posed a threat, a biological threat, a genetic threat, to the existence and future of the Reich. The appropriate response to such a threat was to eliminate it, just as a physician must eliminate a burst appendix by means of surgery or a dangerous bacterium by using penicillin.5
Viewing specific ethnic groups and populations as threatening the health of the German state permitted, and in the view of those on trial demanded, the involvement of medicine in mass genocide, sterilization, and lethal experimentation. The biomedical paradigm provided the theoretical basis for allowing those sworn to the Hippocratic principle of nonmaleficence to kill in the name of the state.
The Neglect of the Holocaust and Nazism in Bioethics
Why has the field of bioethics not attended more closely to the Holocaust and the role played by German medicine and science in the Holocaust? Why have the moral arguments bluntly presented by the Nazis received so little attention? These are questions that do not permit simple answers.
The crimes of doctors and biomedical scientists revealed at the Nuremberg trials were overwhelming in their cruelty. Physicians and scientists supervised and, in some cases, actively participated in the genocide of millions, directly engaged in the torture of thousands, and provided the scientific underpinning for genocide. Hundreds of thousands of psychiatric patients and senile elderly persons were killed under the direct supervision of physicians and nurses. Numerous scientists and physicians, some of whom headed internationally renowned research centers and hospitals, engaged in cruel and sometimes lethal experiments on nonconsenting inmates of concentration camps.
Ironically, the scale of immorality is one of the reasons that the moral reasoning of health care professionals and biomedical scientists during the Nazi era has received little attention from contemporary bioethics scholars. It is clear that what Nazi doctors, biologists, and public health officials did was immoral. The indisputable occurrence of wrongdoing suggests that there is little for the ethicist to say except to join with others in condemnation of what happened.
But condemnation is not sufficient. After all, many of those who committed crimes did so firm in their belief in the moral rectitude of their actions. While bioethics cannot be held accountable for every horrible act that a physician chooses to explain by using moral terms, those who teach bioethics in the hope that it can affect conduct or character must come to terms with the fact that biomedicine’s role in the Holocaust was frequently defended on moral grounds.
Guilt by association has also played a role in making some bioethicists shy away from closely examining what medicine and science did during the Nazi era. Many doctors and scientists who were contemporaries of those put on trial at Nuremberg denied any connection between their own work or professional identities and that of those in the dock. Contemporary doctors and scientists are, understandably, even quicker to deny any connection between what Nazi doctors or scientists did and their own activities or conduct. Many scholars and health care professionals, in condemning the crimes committed in the name of medicine and the biomedical sciences during the Holocaust, insist that all those who perpetrated those crimes were aberrant, deviant, atypical representatives of the health and scientific professions. Placing these acts and those who did them on the fringe of biomedicine keeps a needed distance between then and now.
To suggest that the men and women currently engaged in research on the human genome or in transplanting fetal tissue obtained from elective abortions or stem cell research are immoral monsters on a par with a Josef Mengele or a Karl Brandt is to miss the crucial point that the Nazis carried out genocide for moral reasons and from a biological worldview that has little connection with the values that motivate contemporary biomedical physicians and scientists. Abortion may or may not be a morally defensible act, but it is a different act from injecting a Jewish baby with gasoline to preserve the racial purity of the Reich.10 Scholars in bioethics may have avoided any analysis of Nazi medicine simply because they feared the wrath of those who felt belittled, insulted, or falsely accused by any connection being drawn between their behavior and that of Nazi doctors, nurses, and scientists.
Yet, by saying little, and thereby allowing all Nazi scientists and doctors to be transformed into madmen or monsters, bioethicists ignore the fact that the Germany of the first half of this century was one of the most "civilized," technologically advanced, and scientifically sophisticated societies on the face of the globe. In pre-World War II medicine and biology, Germany could easily hold its own with any other scientifically literate society of that time. Indeed, the crimes carried out by doctors and scientists during the tenure of the Third Reich are all the more staggering in their impact and are all the more difficult to interpret, precisely because Germany was such a technologically and scientifically advanced society.
The Holocaust is the exemplar of evil in the past century. The medical crimes of that time stand as the clearest examples available of moral wrongdoing in biomedical science. Bioethics may have been silent precisely because there seems to be nothing to say about an unparalleled biomedical immorality, but silence leads to omission. By saying little about the most horrific crimes ever carried out in the name of biomedicine and the moral views that permitted these crimes to be committed, bioethics contributes to the most dangerous myth of all—that those engaged in evil cannot be motivated by ethical beliefs. The challenge to bioethics and indeed to all of ethics is to subject the beliefs that led to such horror to close critical scrutiny.
Footnotes
This paper was presented at the dedication of the Robert L. Sadoff Library of Forensic Psychiatry and Legal Medicine at the College of Physicians of Philadelphia on May 22, 2004.
Other papers presented at that ceremony were published in the last issue of the Journal: Volume 33, Number 2, 2005.
References
Steinfels P: Biomedical ethics and the shadow of nazism: a conference on the proper use of nazi analogy in the ethical debate. The Hastings Center Report 16:1–19, 1986
Berger RL: Nazi science: the Dachau hypothermia experiments. N Engl J Med 322:1435–40, 1990
Lifton RJ: The Nazi Doctors: Medical Killing and the Psychology of Genocide. New York: Basic Books, 1986
Browning C: Ordinary Men: Reserve Police Battalion 101 and the Final Solution in Poland. New York: Harper Collins, 1992
Caplan AL: Medicine’s shameful past. Lancet 363:1741–2, 2004
Kater MH: Doctors Under Hitler. Chapel Hill, NC: University of North Carolina Press, 1989
Proctor RN: Racial Hygiene. Cambridge, MA: Harvard University Press, 1992
Caplan AL: When Medicine Went Mad: Bioethics and the Holocaust. Totowa, NJ: Humana Press, 1992
Trials of War Criminals Before the Nuremberg Military Tribunals: The Medical Case (vols. 1, 2). Washington, DC: U.S. Government Printing Office, 1948
Michalczyk JJ, ed: Medicine, Ethics, and the Third Reich: Historical and Contemporary Issues. Kansas City, MO: Sheed & Ward, 1994(Arthur L. Caplan, PhD)
Abstract
While the Holocaust is often placed at the genesis of bioethics, this relatively young field has not yet seriously explored the conduct of German scientists and physicians involved in the human subjects experiments of the Holocaust. We comfort ourselves with the beliefs that the individuals involved in the events of the Holocaust were mad or evil and unlike other scientists and physicians. Yet the evidence is that these professionals were educated and capable members of a technologically sophisticated society who believed they were somehow behaving morally within the context of their social-political situation. The first defendants at Nuremberg were physicians and public health officials. An examination of the trial transcripts provides data about what motivated these medical scientists to engage in human experimentation and mass murder and the extent to which ethics rationales were given for unparalleled moral wrong-doing in biomedicine. Bioethics must still address these beliefs and subject them to close scrutiny.
Why has it been so difficult for bioethics to deal with the Holocaust in general and the horrific experiments conducted in the concentration camps by German scientists and physicians in particular? It is not for want of invoking the analogy to Nazi behavior in current bioethical disputes.1 One does not have to look hard to find numerous references to the Holocaust in contemporary debates about abortion, stem cell research, fetal tissue research, animal experimentation, assisted suicide, the termination of hydration and nutrition for those in vegetative states, human experimentation, and many more contemporary topics. Yet, if one skims through the major anthologies and textbooks of the field of bioethics, the Holocaust and the brutal camp experiments merit hardly a mention.
Most histories of medical ethics locate the origins of bioethics in the ashes of the camps. The Nuremberg Code is frequently held up as the "constitution" of human subjects research. But very little is said about the actual experiments that generated this document. And even less, really nothing at all, is said about the ethical dilemmas the Nazi research raises. Why is this so?
One obvious reason is that the events of the Holocaust are so horrid that they speak for themselves. What more is there to say about mass murder and barbaric experimentation except that it was wrong?
Another reason is that many scholars have dismissed the research done in the camps as worthless and those involved in conducting it as lunatics and crackpots. What point is there in discussing research that is nothing more than torture disguised as science?2
Yet another reason for the absence of moral commentary is that there has been a tradition of trying to offer psychological explanations for the behavior of those involved in the killing so that moral explanations seem unnecessary. Those who went to work at the gas chambers and dissection rooms did so through adaptations of personality and character that make it difficult to hold them morally accountable for their conduct.3,4
Perhaps the most important reason for the absence of commentary on the ethics of the Holocaust and the ethics of the research done in the camps is that such questions open a door that few bioethicists want to traverse. If justifications can be given for why someone deemed mass murder appropriate in the name of public health or thought that it was right to freeze hapless men and women to death, or decompress them, or infect them with lethal doses of typhus, then to put the question plainly—what good is ethics?
Debunking the Myths of Incompetence, Madness, and Coercion
It is comforting to believe that health care professionals from a country that was the world leader in medicine at the time, who had pledged an oath to "do no harm" could not kill babies or conduct brutal, often lethal, experiments on starving inmates in concentration camps. It is comforting to believe that it is not possible to defend involuntary euthanasia, forced sterilization, and genocide in moral terms. It is comforting to believe that anyone who espouses racist, eugenic ideas cannot be a competent, introspective physician or scientist. Such beliefs are especially comforting to those who have to grapple with the moral legacy of Nazi science. Nazi medical crimes demonstrate that each of these beliefs is false.5
It is commonly believed that only madmen, charlatans, and incompetents among doctors, scientists, public health officials, and nurses could possibly have associated with those who ran the Nazi party. Among those who did their "research" in Auschwitz, Dachau, and other camps, some had obvious psychological problems, were lesser scientific lights or both.3 But there were also well-trained, reputable, and competent physicians and scientists who were also ardent Nazis. Some conducted experiments in the camps. Others decided who ought to be put to death. Human experimentation in the camps was not conducted only by those who were mentally unstable or on the periphery of science. Support for genocide was not confined to the fringe of German medicine and science. Not all who engaged in experimentation or murder were inept.5–8
Placing all the physicians, health professionals, and scientists who took part in the crimes of the Holocaust on the periphery of medicine and science allows another myth to flourish—that medicine and science went "mad" when Hitler took control of Germany and that competent and responsible physicians and scientists could not willingly have had anything to do with Nazism. However, the actions as well as the beliefs of German physicians and scientists under Nazism stand in glaring contrast to this myth.6,7
Once identified, the myths of incompetency and madness make absolutely no sense. How could flakes, crackpots, and incompetents have been the only ones supporting Nazism? Could the Nazis have had any chance of carrying out genocide on such a staggering, monumental scale against victims scattered over half the globe without the zealous help of competent biomedical and scientific authorities? The technical and logistical problems of collecting, transporting, exploiting, murdering, scavenging, and disposing of the bodies of millions from dozens of nations required competence and skill, not ineptitude and madness.
The Holocaust differs from other instances of genocide in that it involved the active participation of medicine and science. The Nazis turned to biomedicine specifically for help in carrying out genocide after their early experience using specially trained troops to murder in Poland and the Soviet Union proved impractical.4
Another myth that has flourished in the absence of a serious analysis of the moral rationales proffered by those in German biomedicine who participated in the Holocaust is that those who participated were coerced. Many doctors, nurses, and scientists in Germany and other nations have consoled themselves about the complicity of German medicine and science in genocide with the fable that, once the Nazi regime seized power, the cooperation of the biomedical and scientific establishments was only secured by force.3,6,7 Even then, as this myth has it, cooperation among doctors, scientists, and public health officials with Nazism was grudging.
The myths of incompetence, madness, and coercion have obscured the truth about the behavior of biomedicine under Nazism. Most of those who participated did so because they believed it was the right thing to do. This helps to explain the relative silence in the field of bioethics about both the conduct and justifications of those in biomedicine who were so intimately involved with the Nazi state.
Why Does Bioethics Have So Little to Say About the Holocaust?
If one dates the field of bioethics from the creation of the first bioethics institutes and university programs in the United States in the mid-1960s, then the field is roughly 40 years old. Incredibly, no book-length bioethics study exists that examines the actions, policies, abuses, crimes, or rationales of German doctors and biomedical scientists.
There has been almost no discussion of the roles played by medicine and science during the Nazi era in the bioethics literature. Rather than see Nazi biomedicine as morally bad, the field of bioethics has generally accepted the myths that Nazi biomedicine was inept, mad, or coerced.
By subscribing to these myths, bioethics has been able to avoid a painful confrontation with the fact that many of those who committed the crimes of the Holocaust were competent physicians and scientists who acted from strong moral convictions. Not one of the doctors or public health officials on trial at Nuremberg pleaded for mercy on the grounds of insanity. A few claimed they were merely following legitimate orders, but almost no one alleged coercion.9
When called to account at Nuremburg and other trials for their actions, Nazi doctors, scientists, and public health officials were surprisingly forthright about their reasons for their conduct. The same cannot be said for the ethical evaluations offered in Germany and in the Western World for their crimes.
The puzzle of how it came to be that physicians and scientists who committed so many crimes and caused so much suffering and death did so in the belief that they were morally right cries out for analysis, discussion, and debate. But it is tremendously painful for those in bioethics to have to undertake such an analysis.
It is often presumed, if only tacitly, by those who teach bioethics that those who know what is ethical will not behave in immoral ways. What is the point of having bioethics, of teaching courses on ethics to medical, nursing and public health students, if the vilest and most horrendous of deeds and policies can be justified by moral reasons? Bioethics has been speechless in the face of the crimes of Nazi doctors and biomedical scientists precisely because so many of these doctors and scientists believed they were doing what was morally right to do.
Experimentation in the Camps
There were at least 26 different types of experiments conducted for the explicit purpose of research in concentration camps or using concentration camp inmates in Germany, Poland, and France during the Nazi era.8 Among the studies in which human beings were used in research were: the analysis of high-altitude decompression on the human body; attempts to make sea water drinkable; the efficacy of sulfanilamide for treating gunshot wounds; the feasibility of bone, muscle, and joint transplantations; the ability to treat burns caused by incendiary bombs; the efficacy of polygal for treating trauma-related bleeding; the efficacy of high-dose radiation in causing sterility; the efficacy of phenol (gasoline) injections as a euthanasia agent; the efficacy of electroshock therapy; the symptoms and course of noma (starvation-caused cutaneous gangrene); the postmortem examination of skeletons and brains to assess the effects of starvation; the efficacy of surgical techniques for sterilizing women; and the impact of stress and starvation on ovulation, menstruation, and cancerous growths in the female reproductive organs. A variety of other studies were carried out on twins, dwarves, and those with congenital defects. Some camp inmates were used as subjects to train medical students in surgery. Jewish physicians in one camp surreptitiously recorded observations about the impact of starvation on the body.
The question of whether any of these activities carried out in the name of medical or scientific research on nonconsenting, coerced human beings deserves the label of "research" or "experimentation" is controversial.2 When the description of research is broadened further to include the intentional killing of human beings to establish what methods are most efficient, references to "research" and "experimentation" begin to seem completely strained. Injecting a half-starved young girl with phenol to see how quickly she will die or trying out various forms of phosgene gas on camp inmates in the hope of finding cheap, clean, and efficient modes of killing, so the state can effectively conduct genocide is not the sort of activity associated with the term "research."
But murder and genocide are not the same as intentionally causing someone to suffer and die to fulfill a scientific goal. Killing for scientific purposes, while certainly as evil as murder in the service of racial hygiene, is, nonetheless, morally different. The crimes that were at the core of Nazi medical experiments involves not only torture and murder but also the exploitation of human beings to serve the goals of science. To describe what happened in language other than that of human experimentation blurs the nature of the wrongdoing. The evil inherent in Nazi medical experimentation was not simply that people suffered and died but that they were exploited for science and medicine as they died.
A summary report prepared for the American military about the hypothermia experiments has been cited in the peer-reviewed literature of medicine more than two dozen times since the end of World War II. Not only were the data examined and referenced, they were applied. British air-sea rescue experts used the Nazi data to modify rescue techniques for those exposed to cold water.8 The force of the question, should the data be used, is diminished not only because there are reasons to doubt the reliability and exclusivity of the data but because the question has already been answered—Nazi data have been used by many scientists from many nations.
There is another moral issue that does not hinge on the answer to the question of whether the research was well-designed or the findings of enduring scientific value. How did physicians and scientists convince themselves that murderous experimentation was morally justified?
No one understood the need for justification more clearly than the doctors and scientists put on trial for their crimes after the conclusion of the war. The defendants admitted that dangerous and even lethal experiments had been conducted on nonconsenting persons in prisons and other institutions. Some protested attempts by the prosecution, in its effort to highlight the barbarity of what they had done, to demean or disparage the caliber of their research. No one apologized for taking a role in various experiments conducted in the camps. Instead, those put on trial attempted to explain and justify what they had done, often couching their defense in explicitly moral terms.
The Ethics of Evil
Probably the most succinct précis of the moral arguments brought forward by physicians, public health officials, and scientists in defense of their participation both in experimentation in the concentration camps and in the "final solution" can be found in the transcripts of the Nuremberg trials. The first group of individuals to be put on trial by the allies were physicians and public health officials. The role they had played in conducting or tolerating cruel and often lethal experiments in the camps dominated the trials.8 As it happens, the same arguments that were brought forward in defense of the camp experiments were also used to justify participation in mass murder and attempts at the forced sterilization of camp inmates. 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 hypothermia and phosgene gas experiments, but also for the involvement of biomedicine in the broad sweep of what the prosecution termed "crimes against humanity."
One of the most common moral rationales given at the trials was that no wrong had been done, because those who were subjects had volunteered. Prisoners might be freed, some defendants argued, if they survived the experiments. The prospects of release and pardon were mentioned very frequently during the trial, since they were the basis for the claim that people participated voluntarily in the experiments.9 On this line of thinking, experimentation was justified, because it might actually have benefitted the subjects.
The major flaw in this moral rationale is simply that it was false. A British newspaper, the London Sunday Observer, in 1989, found a man who had survived the hypothermia experiments that involved prolonged submersion in tanks of freezing water. He had been sent to Dachau because of his political beliefs.
He said that the researchers told him that if he survived the hypothermia experiments and then the decompression experiments, he might be freed. He was not. He said no prisoners were. However, he was given a medal by the Reich on the recommendation of the experimenters. The medal was given in recognition of the contributions he had made to medical science!
Another of the key rationales on the part of those put on trial was that only people who were doomed to die were used for biomedical purposes.9 Time and again, the doctors who froze screaming subjects to death or watched their brains explode as the result of rapid decompression stated that only prisoners condemned to death were used. It seemed morally defensible to physicians and scientists to learn from what they saw as the inevitable deaths of camp inmates.
A third ethical rationale for performing brutal experiments on innocent subjects was that participation in lethal research offered expiation to the subjects. By being injected, frozen, or transplanted, subjects could cleanse themselves of their crimes. Suffering prior to death as a way to atone for sin seemed to be a morally acceptable rationale for causing misery in those who were guilty of crimes.
The problem with this ethical defense is that those who were experimented on or made to suffer by German physicians and scientists were never guilty of any crime other than that of belonging to a despised ethnic or racial minority or for holding unacceptable political views. Even if those who were experimented on or killed had been guilty of some serious crime, would it have been moral to use medical experimentation or the risk of death as a form of punishment or expiation? It is hard to see how these goals square with the goals of medicine or health care. It is impossible to see how such a position is persuasive with respect to incompetent persons and children.
A fourth moral rationale, one that is especially astounding, even by the standards of self-delusion in evidence throughout the trial proceedings, was that scientists and physicians had to act in a value-neutral manner. They maintained that scientists and doctors are not responsible for—and have no expertise about—values and thus could not be held accountable for their actions. "...[I]f the experiment is ordered by the state, this moral responsibility of experimenter toward the experimental subject relates to the way in which the experiment is performed, not the experiment itself" (Ref. 9, p 542).
Some researchers only thought themselves responsible for the proper design and conduct of their research. They felt no moral responsibility for what had occurred in the camps because they did not have any expertise concerning moral matters. They claimed to have left decisions about these matters to others. In other words, they argued that scientists, to be scientists, could not take normative positions about their science.
The fifth moral justification for what had happened presented by many of the defendants was that they had done what they did for the defense and security of their country. All actions were taken to preserve the Reich during "total" war.
Germany was engaged in war at that time. Millions of soldiers had to give up their lives because they were called upon to fight by the state. The state employed the civilian population for work according to state requirements. The state ordered employment in chemical factories which was detrimental to health... . In the same way, the state ordered the medical men to make experiments with new weapons against dangerous diseases (Ref. 9, p 566).
The defendants maintained that total war, war in which the survival of the nation hangs in the balance, justifies exceptions to ordinary morality. Allied prosecutors had much to ponder in thinking about this defense in light of the fire-bombing of Dresden and Tokyo and the dropping of nuclear bombs on Hiroshima and Nagasaki.
The last rationale is the one that appears to carry the most weight among all the moral defenses offered. Many who conducted lethal experiments argued that it was reasonable to sacrifice the interests of the few to benefit the majority.
The most distinguished of the scientists who was put on trial, Gerhard Rose, the head of the Koch Institute of Tropical Medicine in Berlin, said that he initially opposed performing potentially lethal experiments to create a vaccine for typhus on camp inmates. But he came to believe that it made no sense not to risk the lives of 100 or 200 men in pursuit of a vaccine, when 1000 men a day were dying of typhus on the Eastern front. What, he asked, were the deaths of 100 men compared with the possible benefit of getting a prophylactic vaccine capable of saving tens of thousands? Rose, because he admitted that he had anguished about his own moral duty when asked by the Wehrmacht to perform the typhus experiments in a concentration camp, raises the most difficult and most plausible moral argument in defense of lethal experimentation.
The prosecution encountered some difficulty with Rose’s argument. The defense team for Rose noted that the Allies themselves justified the compulsory drafting of men for military service throughout the war, knowing many would certainly die, on the grounds that the sacrifice of the few to save the many was morally just. Moreover, they also pointed out, throughout history medical researchers in Western countries have used versions of utilitarianism to justify dangerous experiments on prisoners and institutionalized persons.
Justifying the sacrifice of the few to benefit the majority is a position that must be taken seriously as a moral argument. In the context of the Nazi regime it is fair to point out that the sacrifice is not borne equally by all, as is true of a compulsory draft that allows no exceptions. It is also true that many would argue that no degree of benefit should permit intrusions into certain fundamental rights.
Crude utilitarianism is a position that sometimes rears its head in contemporary bioethics debates. For example, some argue that we ought not to spend scarce social resources on certain groups within our society, such as the elderly, so that other groups, such as children, may have greater benefits. Those who want to invoke the Nazi analogy may be able to show that this form of crude utilitarian thinking does motivate some of the policies or actions taken by contemporary biomedical scientists and health care professionals, but they should do so with great caution.
In closely reviewing the statements that accompany the six major moral rationales for murder, torture, and mutilation conducted in the camps—freedom was a possible benefit, only the condemned were used, expiation was a possible benefit, a lack of moral expertise, the need to preserve the state in conditions of total war, and the morality of sacrificing a few to benefit many—it becomes clear that the conduct of those who worked in the concentration camps was sometimes guided by moral rationales. It is also clear that all of these moral arguments were nested within a biomedical interpretation of the danger facing Germany.
Physicians could justify their actions, whether direct involvement with euthanasia and lethal experiments, or, merely support for Hitler and the Reich, on the grounds that the Jew, the homosexual, the congenitally handicapped, and the Slav posed a threat, a biological threat, a genetic threat, to the existence and future of the Reich. The appropriate response to such a threat was to eliminate it, just as a physician must eliminate a burst appendix by means of surgery or a dangerous bacterium by using penicillin.5
Viewing specific ethnic groups and populations as threatening the health of the German state permitted, and in the view of those on trial demanded, the involvement of medicine in mass genocide, sterilization, and lethal experimentation. The biomedical paradigm provided the theoretical basis for allowing those sworn to the Hippocratic principle of nonmaleficence to kill in the name of the state.
The Neglect of the Holocaust and Nazism in Bioethics
Why has the field of bioethics not attended more closely to the Holocaust and the role played by German medicine and science in the Holocaust? Why have the moral arguments bluntly presented by the Nazis received so little attention? These are questions that do not permit simple answers.
The crimes of doctors and biomedical scientists revealed at the Nuremberg trials were overwhelming in their cruelty. Physicians and scientists supervised and, in some cases, actively participated in the genocide of millions, directly engaged in the torture of thousands, and provided the scientific underpinning for genocide. Hundreds of thousands of psychiatric patients and senile elderly persons were killed under the direct supervision of physicians and nurses. Numerous scientists and physicians, some of whom headed internationally renowned research centers and hospitals, engaged in cruel and sometimes lethal experiments on nonconsenting inmates of concentration camps.
Ironically, the scale of immorality is one of the reasons that the moral reasoning of health care professionals and biomedical scientists during the Nazi era has received little attention from contemporary bioethics scholars. It is clear that what Nazi doctors, biologists, and public health officials did was immoral. The indisputable occurrence of wrongdoing suggests that there is little for the ethicist to say except to join with others in condemnation of what happened.
But condemnation is not sufficient. After all, many of those who committed crimes did so firm in their belief in the moral rectitude of their actions. While bioethics cannot be held accountable for every horrible act that a physician chooses to explain by using moral terms, those who teach bioethics in the hope that it can affect conduct or character must come to terms with the fact that biomedicine’s role in the Holocaust was frequently defended on moral grounds.
Guilt by association has also played a role in making some bioethicists shy away from closely examining what medicine and science did during the Nazi era. Many doctors and scientists who were contemporaries of those put on trial at Nuremberg denied any connection between their own work or professional identities and that of those in the dock. Contemporary doctors and scientists are, understandably, even quicker to deny any connection between what Nazi doctors or scientists did and their own activities or conduct. Many scholars and health care professionals, in condemning the crimes committed in the name of medicine and the biomedical sciences during the Holocaust, insist that all those who perpetrated those crimes were aberrant, deviant, atypical representatives of the health and scientific professions. Placing these acts and those who did them on the fringe of biomedicine keeps a needed distance between then and now.
To suggest that the men and women currently engaged in research on the human genome or in transplanting fetal tissue obtained from elective abortions or stem cell research are immoral monsters on a par with a Josef Mengele or a Karl Brandt is to miss the crucial point that the Nazis carried out genocide for moral reasons and from a biological worldview that has little connection with the values that motivate contemporary biomedical physicians and scientists. Abortion may or may not be a morally defensible act, but it is a different act from injecting a Jewish baby with gasoline to preserve the racial purity of the Reich.10 Scholars in bioethics may have avoided any analysis of Nazi medicine simply because they feared the wrath of those who felt belittled, insulted, or falsely accused by any connection being drawn between their behavior and that of Nazi doctors, nurses, and scientists.
Yet, by saying little, and thereby allowing all Nazi scientists and doctors to be transformed into madmen or monsters, bioethicists ignore the fact that the Germany of the first half of this century was one of the most "civilized," technologically advanced, and scientifically sophisticated societies on the face of the globe. In pre-World War II medicine and biology, Germany could easily hold its own with any other scientifically literate society of that time. Indeed, the crimes carried out by doctors and scientists during the tenure of the Third Reich are all the more staggering in their impact and are all the more difficult to interpret, precisely because Germany was such a technologically and scientifically advanced society.
The Holocaust is the exemplar of evil in the past century. The medical crimes of that time stand as the clearest examples available of moral wrongdoing in biomedical science. Bioethics may have been silent precisely because there seems to be nothing to say about an unparalleled biomedical immorality, but silence leads to omission. By saying little about the most horrific crimes ever carried out in the name of biomedicine and the moral views that permitted these crimes to be committed, bioethics contributes to the most dangerous myth of all—that those engaged in evil cannot be motivated by ethical beliefs. The challenge to bioethics and indeed to all of ethics is to subject the beliefs that led to such horror to close critical scrutiny.
Footnotes
This paper was presented at the dedication of the Robert L. Sadoff Library of Forensic Psychiatry and Legal Medicine at the College of Physicians of Philadelphia on May 22, 2004.
Other papers presented at that ceremony were published in the last issue of the Journal: Volume 33, Number 2, 2005.
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