Medicine After the Holocaust (contd)At the Nuremberg Doctors’ Trial known

as The Case Against the Nazi Physicians, only 23 defendants were charged with “murders, tortures, and other atrocities committed in the name of medical science.” In reality, there were thousands of physician perpetrators and accomplices, the overwhelming majority of whom escaped justice. Indeed, many were restored to positions of prominence and respect among the German medical community.

Medicine After the Holocaust (contd)Fritz Lenz was reappointed professor

of human genetics at the University of Göttingen (after his Munich chair for racial hygiene was dissolved) in 1946 and published into the 1970s.

Otmar Freiherr von Verschuer, continued as professor of human genetics at the University of Münster.

Eugen Fischer retired in 1942 but continued after the war to edit various scholarly journals and to lecture on anthropology and other topics.

Medicine After the Holocaust (contd)Ludwig Clauss, editor of the Nordic-

supremacist journals Die Sonne, Odal, and Rasse, emigrated to Saudi Arabia in order to live, as he told his friend Hans F. K. Günther, “as a bedouin among the bedouins” in the freedom of the desert.

Günther himself continued to write on racial topics; his 1959 Begabungschwund in Europa lamented a host of “counterselective forces” eroding the health of the white races of Europe.

Medicine After the Holocaust (contd)Organized German medicine, often

infiltrated with former Nazi doctors, collaborated to cover up the past. In 1946, the West German Physicians’ Chambers asked Alexander Mitscherlich, a young lecturer in psychiatry, and Fred Mielke, a medical student, to report on the Nuremberg Doctors’ Trial. Ten thousand copies of their book, Doctors of Infamy, were printed and sent to the West German Physicians’ Chambers. The book was not reviewed in any medical journal and the fate of the ten thousand copies is unclear.

Medicine After the Holocaust (contd)Four of the Nazi defendants at the

Nuremberg Medical Trials were at some point employed by the U. S. Military. Defendants Becker-Freysing, Ruff, and Shaefer were employed by the Army Air Force up until they were arrested and taken to the Nuremberg prison to stand trial for war crimes and crimes against humanity. Defendant Kurt Blome, who in 1943 had been ordered by SS Chief Himmler to conduct plague vaccine experiments on concentration camp victims, was contracted to work for the U.S. Army Chemical Corps on August 21, 1951.

Medicine After the Holocaust (contd)“Houston, we have a problem.”Wernher von Braun, who according to

a NASA website, was “without doubt, the greatest rocket scientist in history.”

Wernher von Braun worked for the Nazis at Peenemünde from 1937-1945 and developed and realized 6,000 V-2 missiles, of which 3,000 were launched against Europe, especially London, in the last year of World War II.

Medicine After the Holocaust (contd)Indictment is framed in four counts:

The Common Design or Conspiracy to commit war crimes and crimes against humanity.

War Crimes and Crimes Against Humanity in reference to “civilians and members of the armed forces [of nations] then at war with the German Reich…in the exercise of belligerent control.”

War Crimes and Crimes Against Humanity in reference to “German civilians and nationals of other countries.”

Membership in a Criminal Organization, the SS.

Medicine After the Holocaust (contd)Counts two and three allege, in

substance, that between September 1939 and April 1945 all of the defendants “were principals in, accessories to, ordered, abetted, took a consenting part in, and were connected with plans and enterprises involving medical experiments without the subjects’ consent…in the course of which experiments the defendants committed murders, brutalities, cruelties, tortures, atrocities, and other inhuman acts.”

Medicine After the Holocaust (contd)The 10 point “Nuremberg Code”

resulted from this trial.“The great weight of the evidence

before us is to the effect that certain types of medical experiments on human beings, when kept within reasonably well-defined bounds, conform to the ethics of the medical profession generally. The protagonists of the practice of human experimentation justify their views on the basis that such experiments yield results for the good of society that are unprocurable by any other means of study. All agree, however,

Medicine After the Holocaust (contd)

that certain basic principles must be observed in order

to satisfy moral, ethical and legal concepts:

(Point 1) The voluntary consent of the human subject is

absolutely essential. This means that the person involved

should have legalcapacity to give consent; should be so

situated as to beable to exercise free power of choice,

without theintervention of any element of force,

fraud, deceit,duress, over-reaching, or other ulterior

form ofconstraint or coercion; and should have

sufficient

Medicine After the Holocaust (contd)

knowledge and comprehension of the elements of the subject matter involved as to enable him to make an understanding and enlightened decision. This latter element requires that before the acceptance of an affirmative decision by the experimental subject there should be made known to him the nature, duration, and purpose of the experiment; the method and means by which it is to be conducted; all inconveniences and hazards reasonably to be expected; and the effects upon his health or person which may possibly come from his

Medicine After the Holocaust (contd)

participation in the experiment.The duty and responsibility for

ascertaining the quality of the consent rests upon each individual who initiates, directs, or engages in the experiment. It is a personal duty and responsibility which may not be delegated to another with impunity.”

Medicine After the Holocaust (contd)George Annas and others argue that

“modern bioethics was born at the Nuremberg Doctors’ Trial” and goes on to say, “Historians are correct to see American bioethics in the late 1960s and early 1970s as fundamentally a reaction to powerful new medical technologies in the hands of medical paternalists who disregarded the wishes of their patients…the major strategy to combat this unaccountable power was to empower patients with the doctrine of informed consent (sometimes called autonomy, and put under the broader rubric of

Medicine After the Holocaust (contd)

respect for persons)…The first response of the American judges to the horror of the Nazi doctors was to articulate, in the first precept of the Nuremberg Code, the doctrine of informed consent.20 The modern doctrine of informed consent was not born of either U.S. health law in 1972 or American bioethics shortly thereafter, but at Nuremberg in 1947.”

Medicine After the Holocaust (contd)For others, Nuremberg is seen as an

important event, but one that had no immediate impact on medical ethics. One of the main reasons for this has been an active program to bury the Nazi doctor past and distance American medicine and American bioethics from Nazi medicine for fear it would be somehow tarnished by it.

Similarly, the World Medical Association, founded in 1946 just as the Doctors’ Trial was getting underway, drafted its Helsinki Declaration on human research,

Medicine After the Holocaust (contd)

which many saw as a way to “save” medical research from becoming dominated by the “overly rigid” Nuremberg Code…overly rigid because of what psychiatrist Jay Katz consistently highlighted and praised about it, its “uncompromising language to protect the inviolability of subjects of research.”…the Nuremberg judges sought to put the interests of individual humans over the interests of society in medical progress.

Medicine After the Holocaust (contd)Under the Helsinki Declaration, first

adopted in 1964, the rigid requirement of Nuremberg for respect for persons is softened, and the requirement of informed consent is differentiated between therapeutic and non-therapeutic clinical research.

One possible explanation is that the World Medical Association itself had been compromised by its own Nazi legacy since its leadership included physicians with direct links to the organizations responsible for the horrors which brought about the enunciation of the Nuremberg code.

Medicine After the Holocaust (contd)The president of the WMA for1973-4

was Dr Ernst Fromm (b 1917), of Hamburg, who had been a member of the SA (Nazi stormtroops) and SS.

In 1992 the World Medical Association appointed as president elect for 1993-4 Professor Dr Hans Joachim Sewering (b 1916), of Dachau. During the Hitler period Sewering was a member of the Nazi party and the SS and worked to the killing centre at Eglfing-Haar.

Dr. Severing was forced to step aside in January 1993 when his past was revealed outside Germany.

Medicine After the Holocaust (contd)While the Nuremberg Code and the

Declaration of Helsinki were widely known, no legal authority applied either to research in the United States.

In 1966 it became clear that American research was not always following the principles of either document. Henry Beecher, an anesthesiologist at Harvard Medical School, published an article in the New England Journal of Medicine that detailed 22 examples of unethical research in the United States.

Medicine After the Holocaust (contd)In 1972, nearly 30 years after

Germany lost the war, a newspaper account of the Tuskegee study exploded into the public consciousness, although it had never been secret and articles based on it were published.

The project, undertaken by the USPHS with government and philanthropic funds, began in 1932 (one year before Hitler came to power) by enrolling about 600 black men, mainly poor sharecroppers.

About two-thirds of the men were already infected with syphilis; the other third was to serve as a control group.

Medicine After the Holocaust (contd)The men were not told of the nature of

the study, that they had syphilis, or anything about the disease.

Local physicians were told not to treat them.

After the war, penicillin became widely available as a safe, inexpensive, and effective treatment for most cases of syphilis. The USPHS considered whether to terminate the study and provide penicillin, but decided instead to continue the observational study as, in light of the new treatments, it would be the last chance to obtain this kind of data.

Medicine After the Holocaust (contd)After the July 1972 newspaper article,

the Tuskegee study was reviewed within the government and, several months later, terminated.

By that time, 28 of the men had died from syphilis and another roughly 100 from conditions that could be complications of syphilis.

The revelations about Tuskegee and other scandals, led to substantial congressional interest, notably through hearings chaired by Senator Kennedy.

As a result in 1974, Congress passed the National Research Act.

Medicine After the Holocaust (contd)One result of the National Research

Act was the formation of the purely advisory National Commission for Protection of Human Subjects of Biomedical Research and Behavioral Research.

In 1979, the commission published the so-called Belmont Report, officially titled "Ethical Principles and Guidelines for the Protection of Human Subjects of Research.”

Medicine After the Holocaust (contd)The Belmont Report begins with an

opening paragraph about the Nuremberg Code, but then quickly asserts that it is “often inadequate to cover complex situations,” like research on children and the mentally disabled.

The commission identified respect for persons, beneficence, and justice as the most relevant principles and saw informed consent, assessment of risks and benefits, and selection of research subjects as each principle’s most important application.

Medicine After the Holocaust (contd)The newly renamed Department of

Health and Human Services (HHS) published regulations for human subjects research in January 1981.

Another commission, the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, advocated broader application of the HHS regulations.

In 1991, interagency negotiations resulted in 16 federal agencies adopting a form of the HHS regulations as their own regulations, regulations that became known as “The Common Rule.”

Medicine After the Holocaust (contd)The Common Rule is the main legal

regulation of human subjects research in the United States. It applies to:Research performed by almost all

agencies with any substantial research funding.

Research funded by those agencies. Research performed by an institution

that has given the federal government an assurance that all of its relevant research will conform to the Common Rule.

Research done with FDA authorization or with an intention to submit the results to the FDA.

Medicine After the Holocaust (contd)Apart from a few exclusions and

exemptions, any human subjects research done by a covered institution must follow the Common Rule.

Research must be approved through a process that involves an “Institutional Review Board,” universally referred to as an “IRB.”

In spite of all of its flaws, the Common Rule serves as a protection against much risky and inappropriate research.

As a result, human research subjects have largely been protected from direct risks to their safety.

Medicine After the Holocaust (contd)According to George Annas, “American

bioethics has had a major positive impact on the way medicine is currently practiced in the United States, especially in the areas of care of dying patients, including advance directives (living wills and health care proxies) and ethics committees as well as the establishment of rules governing medical research, including federal regulations to protect research subjects and institutional review boards (IRBs).”

Medicine After the Holocaust (contd)Annas goes on to say, “American

bioethics has probably exhausted what it can usefully accomplish in these limited spheres. In the only other major area it has worked in, the related fields of abortion, embryo research, and cloning, it has had no real impact in debates that have been dominated by religion.”

Medicine After the Holocaust (contd)However, we will reconsider the

“major positive impact (of secular bioethics) on the way medicine is currently practiced in the United States, especially the areas of care of dying patients, including advance directives (living wills and health care proxies) and ethics committees” and the impact of religion and tradition.

Rights (or autonomy), the language of the (unrestrained, Greek) enlightenment and duty, the language of the (constrained, Jewish) tradition, often clash in the arena of bioethics.

Medicine After the Holocaust (contd)In Million Dollar Baby, Frankie (Clint

Eastwood) is a gruff boxing trainer who coaches Maggie (Hillary Swank) to boxing fame. As Maggie nears boxing stardom, he watches her arch nemesis break her neck with an illegal maneuver in the boxing ring.

After her spine injury, Maggie is confined to bed with little ability for movement, and she clearly no longer wishes to live. Frankie is wracked with agony about assisting her in her wish to die and he visits his hard-boiled priest (Brian O’Byrne), with whom he has a tenuous relationship.

Sheldon Rubenfeld, M.D.Clinical Professor of Medicine

Baylor College of Medicine

Healing by Killing: Medicine in the Third Reich

Medicine After the Holocaust (contd)America in the 21st century is not Nazi

Germany in the 20th century and has several foundational elements that should prevent America from ever becoming like Nazi Germany:FederalismJudeo-Christian traditionA tradition of individualism

On the other hand, as Mark Twain has been quoted as saying, “History does not repeat itself but it does rhyme.”

Medicine After the Holocaust (contd)Neither religion nor any other

traditional institutions of Western civilization prevented the Holocaust.

Similarly, the Hippocratic Oath did not prevent the most egregious and well-documented violations of medical ethics ever.

The propagation and acceptance of myths about Nazi medicine has led to a deafening silence about the ethics of physicians during the Third Reich.

Medicine After the Holocaust (contd)Three Myths identified by Volker

Roelcke:1. Medical atrocities were committed by

a few fervent Nazi doctors and were the result of irrational ideologies imposed from above by Nazi politicians on apolitical physicians.

2. The programs of mass sterilizations and patient killings were the expression of an ideology that had little or nothing to do with contemporary state of the art medical reasoning and practice.

Medicine After the Holocaust (contd)Three Myths identified by Volker

Roelcke (contd):3. The activities of eugenically

motivated medical geneticists and medical scientists experimenting on humans in concentration camps had nothing to do with science, but were rather the expression of racial ideology or even individual perversion disguised as science and, therefore, better termed “pseudoscience.”

As we have seen, each of these myths is untrue but they have allowed bioethicists, academics, and physicians to ignore the implications of the behavior of Nazi medical personnel.

Medicine After the Holocaust (contd)The reason these myths have been

accepted is to avoid asking difficult questions because, according to Arthur Caplan, “such questions open a door that few bioethicists wish to enter. If moral 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 bioethics?”

Medicine After the Holocaust (contd)There has been extensive analysis and

successful application of the Nuremberg Code in the area of medical research, a relatively easy area to deal with.

The Nuremberg Code led to patient protection in medical research by maintaining the doctor-patient relationship and by empowering the patients with autonomy and the right to informed consent. And it worked.

Medicine After the Holocaust (contd)There has been less analysis of the

fundamental flaws in the doctor-patient relationship that led to eugenics, euthanasia and extermination.

While autonomy, informed consent and patient rights were successfully used to correct the imbalance of power in the doctor-patient relationship in medical research, this approach to the doctor-patient relationship in clinical medicine has been less successful.

Medicine After the Holocaust (contd)The transformation of the doctor-

patient relationship to the state-volk relationship was the fundamental flaw in the practice of medicine in the Third Reich. Once physicians and nurses accepted Hitler as the” doctor to the German people,” the Hippocratic Oath was refashioned in Hitler’s image. Hitler became the doctor, the German volk became the patient, and people with disabilities, Jews, homosexuals and others became the pathogens under the microscope that had to be eliminated.

Medicine After the Holocaust (contd)Once German physicians and nurses

could rationalize sterilizing and euthanizing their fellow German citizens, then they would have few qualms about murdering and experimenting upon lives not worth living. The distortion of the doctor-patient relationship was the gateway to murder.

Whereas the doctor-patient relationship has since been strengthened in the arena of medical research, it has been weakened in the larger arena of clinical medicine.

Medicine After the Holocaust (contd)According to George Annas, “As I have

already suggested, recognizing and nourishing this birth relationship (of bioethics and Nuremberg) will permit American bioethics to break free from its focus, if not obsession, with the doctor-patient relationship and medical technology and to cross our own border to become a global force for health and human rights—not as an imperialistic project, but to learn from and work with other cultures, countries, and activists.”

“Medicine is too important to be left to doctors.”

Medicine After the Holocaust (contd)David Rothman in Strangers at the

Bedside: A History of How Law and Bioethics Transformed Medical Decision Making: “Beginning in the mid-1960s, the practice of medicine underwent a most remarkable—and thoroughly controversial—transformation. Although the changes have altered almost every aspect of the relationship between doctor and patient—indeed, between medicine and society—the essence can be succinctly summarized: the discretion that the profession once enjoyed has been increasingly circumscribed, with an almost bewildering number of parties and procedures participating in medical decision making”

Medicine After the Holocaust (contd)One way of looking at changes in

medicine after the Holocaust is to analyze the transition of medical ethics to bioethics.

According to Arthur Caplan: “Medical ethics, whether of the early Greek physicians or of the nineteenth-century physicians and surgeons of Britain and the United States, consists of a code or professional conduct for doctors.”

Also, according to Arthur Caplan:

Medicine After the Holocaust (contd)

“Bioethics is far more than that. It is the study of ethical problems in the practice of medicine involving doctors, nurses, other health care professionals, managers, payers, patients, and researchers. Bioethics’ scope ranges beyond clinical medicine to include moral problems in the life sciences, research, and health economics. More to the point, bioethics involves multidisciplinary reflections on ethical problems, not simply the wisdom of the medical profession about how best to practice.”

Medicine After the Holocaust (contd)George Annas: “American bioethics

has had a major positive impact on the way medicine is currently practiced in the United States, especially in the areas of care of dying patients, including advance directives (living wills and health care proxies) and ethics committees as well as the establishment of rules governing medical research, including federal regulations to protect research subjects and institutional review boards (IRBs). American bioethics has probably exhausted what it can usefully accomplish in these limited spheres. In the

Medicine After the Holocaust (contd)

only other major area it has worked in, the related fields of abortion, embryo research, and cloning, it has had no real impact in debates that have been dominated by religion. Given this, I think it is fair to conclude that American bioethics is likely to have no real world future without a significant re-orientation of its focus and direction. I will suggest that the most useful reformulation involves recognition and engagement with two interrelated forces reshaping the world and simultaneously providing new frameworks for ethical analysis and

Medicine After the Holocaust (contd)

action—globalization and public health. Most relevant for American bioethics is that globalization brings with it a new focus on international human rights law and its aspirations as articulated in the Universal Declaration of Human Rights.”

Has “American bioethics…exhausted what it can usefully accomplish in these limited spheres” of the practice of medicine?

Has “American bioethics…exhausted what it can usefully accomplish in these limited spheres” of the practice of medicine?

Medicine After the Holocaust (contd)Has American bioethics been so

successful that it is ready to move on to “engagement with two interrelated forces reshaping the world and simultaneously providing new frameworks for ethical analysis and action—globalization and public health. Most relevant for American bioethics is that globalization brings with it a new focus on international human rights law and its aspirations as articulated in the Universal Declaration of Human Rights.”