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Ethics Talk: Teaching the Holocaust

Learning Objectives
1. Identify key ethical values or principles at stake, as described in the program
2. Distinguish among factors of ethical, clinical, legal, social, and cultural significance
3. Articulate how central themes of clinical and ethical relevance in the program can influence health care practice
4. Explain at least one way in which micro-level clinical ethics questions intersect with broader macro-level policy questions in health care
0.5 Credit CME

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The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

0.5 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

0.5 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and

0.5 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Audio Transcript

Tim Hoff (Host): Welcome to Ethics Talk, the American Medical Association Journal of Ethics podcast on ethics and health and healthcare. I'm your host, Tim Hoff.

A national survey of US college students conducted in 2020 found that those who received education about the Holocaust in high school demonstrated not only more historical knowledge but more empathy, deeper critical thinking skills, and tolerance of a broader range of viewpoints. Testimony from Holocaust survivors helped bolster students' abilities to connect the Holocaust to modern day problems and to understand the importance of speaking up against stereotyping, bullying, and intimidation. The results of this survey suggests that Holocaust education in high school benefit students even after they graduate. What we learn from Holocaust education applies beyond historical recounting. What this survey shows according to Anti-Defamation League CEO Jonathon Greenblatt is the value of Holocaust education “not just as an important history lesson, but also in equipping students with the tools to identify bias and confront it when necessary.”

Many people would likely imagine Holocaust content might be integrated into social studies or history courses, as it well should. The roles of health professionals in supporting and advancing Nazi eugenics and murder campaigns demand more, however. The ongoing legacy of the Holocaust in contemporary society and in contemporary health care means that health professions, clinicians, and students need robust Holocaust education too. With us today to explore the importance of Holocaust education for health profession students and the pedagogy of teaching this challenging history is Dr Matthew Wynia.

Dr Wynia is Professor of Medicine and Public Health at the University of Colorado School of Medicine in Aurora, and he is the Director of University of Colorado Center for Bioethics and Humanities. He is also one of the guest editors for our January issue.

Dr Wynia, thank you so much for joining us.

Dr Matthew Wynia: It's my pleasure to be here, thank you.

Hoff: Most people likely first learn of the Holocaust in history or social studies courses and wouldn't think that it would be part of health profession school curricula, but in your articles for this month's theme issue you argue that the Holocaust is specifically relevant to clinicians and students. Why is that?

Wynia: So I've made the argument a number of times now that it's maybe impossible to understand contemporary medical ethics or health sciences ethics even without knowing something about this history. And you're absolutely right that most people learn about the Holocaust in social studies history courses. And those courses are incredibly valuable but they often omit the really unique roles that health sciences professionals played in the development of the Holocaust. So often the Holocaust history will be taught only around the war, for example, and will ignore the fact that medical personnel were involved in programs to forcibly sterilize people who were perceived to have disabilities – often those disabilities by the way were more socially constructed than medical – so there would be things like people who had been caught as truants multiple times or had a child or two out of wedlock or were convicted of petty crimes. And those people were thought to be genetically inferior, and therefore, they would be forcibly sterilized. Those kinds of programs for forcible sterilization evolved quite rapidly and well before the war into programs to actually murder babies who were born who were severely disabled - and not Jewish babies - just German babies of all sorts who were born severely disabled.

And that was actually the first mass-murder program of the Nazis was this eugenics based program carried out entirely by doctors and nurses and others in the health sciences oriented around perceptions of both racial inferiority but really also around disabilities and the possibility that disabilities they thought would be genetically carried through from generation to generation.

Those programs ended up eventually informing in very tangible ways the development of the programs for the mass-murder of Jewish people, the Roma and Sinti people of Europe – the so called gypsies - and others. The specific unique and very important roles of health professionals in both the ideology of what would become the Holocaust and also in the technology, in the specific crematory technologies that were eventually used in the extermination camps of E astern Europe. Those crematory ovens were first designed to be used in these murder programs for the disabled people of Germany. So those connections are just incredibly important for health professionals to be aware of and to understand because they continue to inform the ways that we think about medical ethics today often in implicit ways and sometimes in very explicit ways.

Hoff: What are some of the most common misconceptions that students have or what are some of the truths that perhaps they're aware of with which they struggle the most in your classes?

Wynia: That's such a great question because this is difficult history period. Everyone struggles to wrap their minds around how human beings could come to do these kinds of things to each other. I think in the United States today, maybe the most difficult thing for us to wrap our heads around is the role that US scientific racism and eugenic programs, anti-miscegenation laws, our own forcible sterilization laws in the US were the models that the Germans used when the Nazis came to power for their own forcible sterilization laws. Our anti-immigration laws around the turn of the century into the 1920's and the 30's were very much the model for the Germans. For Americans who … we like to think of ourselves as having been on the right side of this war and we were, but we also - and in particular our scientific community - we were also part of an international movement that in the end lead to these heinous crimes against humanity that were carried out in the name of medical science. Even the Holocaust itself was seen as a racial cleansing exercise which was to achieve a perfect race, to achieve a perfect society through applying what they thought of as medical science and public health science to politics and to society. That is a historical fact that is just really difficult for most of us to come to grips with.

Hoff: Do you find that most of your students coming into your courses are aware of that connection between American eugenics policy influencing German policy or is that something that they learn?

Wynia: I think it is changing. I think this is changing rather quickly right now. Ten years ago, absolutely. I think 20 years ago when the US Holocaust Memorial Museum first put together their special exhibit on this called “Deadly Medicine: Creating the Master Race,” at that time this history was largely unknown and unexplored, even though, if you go back to the Nuremberg trial transcripts this was actually very clear in the transcripts, but it was hard to get people to think about it in subsequent decades. It really wasn't until the “Deadly Medicine” exhibit that I think many people became more aware of this medical aspect of Holocaust history.

And now of course with the kinds of racial reckoning that we're seeing in our country as a whole, I think we are seeing more and more students come in with an understanding that what we sometimes call systemic racism or structural racism, that these are embedded in US policies and laws and ways of thinking and the connection it has become easier to see for a lot of people as they come to acknowledge this very dark aspect of American history. The idea that that dark aspect of American history might have a direct application and an influence on the way Germans thought and on the way of Nazis, their ideology of racial cleansing, has become easier for people to recognize.

When I first started giving talks about this, I used to take a little booklet that I have from 1923 I believe, it's an AMA booklet that the AMA put out to all the medical societies around the country saying if you want to have an AMA specialist come and speak to your medical society, here are the topics that our board of trustees and our experts will come and speak on. I would say a quarter of the talks that are in that booklet are about racial hygiene and eugenics, so race hygiene and eugenics was big in the US before it become an important part of the German, you know, Nazi ideology.

Hoff: Holocaust denialism is obviously not a new problem, but it seems particularly relevant now as anti-Semitism surges nationally and internationally and as white supremacists views seemed to be expressed more unabashedly and with more impunity in many places and online. And you touched on this a bit that your students seemed inclined to make the connections between current events and historical events in your classes, but how do these concerns emerged more specifically when you teach these subjects?

Wynia: One of the ways in which this arises is the fact that we just don't have as any survivors around now as we used to – it has been for 50 years, 70 years. One of the primary mechanisms for teaching students about this history has been to have someone who was actually there come into a classroom and talk. In another ten years it's very likely we won't have any survivors remaining, right now the only survivors who were around were children at the time of the Holocaust. That has really driven I think both sometimes the possibility of talking about these things in ways that people were not talking about them before so the kind of unabashed as you put it, anti-Semitism, some of that is probably fostered by the idea that it's harder to teach this when you don't have survivors around. But it has also driven a push to make sure that this history is embedded in the curriculum so that it is not lost, so that it doesn't get muted, and come to be seen as irrelevant to contemporary medical ethics and medical science training.

Hoff: Just out of curiosity, do you bring in survivors to your courses?

Wynia: We have, but as I have said we're running out of them. We lost Eva Kor last year. She was a remarkable survivor, the subject of a documentary called “Forgiving [Dr] Mengele.” She was one of the Mengele twins and ran a Holocaust museum in Indiana just south of where AMA headquarters is in Chicago. Eva was a national and international treasure, and she's gone. This is going to become harder and harder. I think that things like the Shoah Project which has recordings are of course very valuable. But I think it's also really important for us to find ways to make connections between this history and the implicit ways in which it influences our contemporary ways of thinking in bioethics.

The fact that we are so concerned today about racism is in part an outgrowth of the horrors of the Holocaust. There's a quite strong argument that can be made that one of the reasons for the civil rights movement happening at the time that it did in the 1950s and the 60s was because there were a very large number of people who came back from the war as veterans and said, “wait a minute, I was in Europe fighting against a racist regime, and now here I am at home and seeing racist regimes in my own back yard.” And so, many of the early civil rights leaders were people who had been involved in fighting the Nazis, and they come home and said this is unacceptable in the United States. So, there's a very strong connection here both on the sort of negative side that we were involved in the development of the ideologies that drove the Holocaust. We also were involved in the response to those ideologies that drove the civil rights movement.

Hoff: Analogies to the Holocaust, as you just mentioned, have been drawn since, essentially, the Holocaust, and perhaps most recently they're being drawn to the detention camps being operated on the US-Mexico border. Do students in your classes articulate these analogies comfortably or do they tend to want to keep a more comfortable historical distance between the roles of clinicians in camps then in Germany in the 1940s and now as if there's some sort of substantial difference?

Wynia: Well, so that's such a good illustration, I think, of one of the major challenges of teaching and talking about this history because if you follow the debates about whether it is appropriate to call detention camps on the border concentration camps, you would notice that there were, uh, the Jewish community was on both sides of that. And there's legitimate reasons to be on both sides of it, right?

On one hand they're not the same. These are not extermination camps. And there is a sort of argument that what the Nazis did was so heinous, so outside the pale of civilized anything, that it should be sort of set aside and seen as unique - because it is unique, it is uniquely horrible and horrifying. And at the same time if you want to learn from that history you have to be able to recognize echos of that history in contemporary events. Even if you don't see the same types of things, you have to be able recognize in order to learn. You have to be able to recognize the resonance that we sometimes see in things that happen today. That's a continuous challenge, recognizing the uniqueness of the horrors of the Holocaust while also being able to learn from those by virtue of seeing the comparisons to today. I don't have a perfect answer for that. It's an explicit thing that we talk about at multiple points in time when we're teaching about this because I think people need to be able to understand both what the Nazis did was uniquely heinous and it was a reflection of some underlying tensions that continue to cause ethical dilemmas in medical practice, and in public health, and in policy, in immigration policy. These things don't go away just because the Nazis took them to such an extreme. And in fact, the reality that the Nazis took them to such an extreme should be a way for us to study those issues and shed light on contemporary dilemmas.

Hoff: What are some of the most helpful pedagogical strategies that you use to defuse tension or draw productively on conflict in class? When you challenge students to consider how prior clinicians were complicit in atrocities, it might be their inclination to perhaps clam up or not want to engage with that comparison, but how do you draw that discussion out and how do you ask them press the bounds of their comfort zone while still being open to discussion?

Wynia: I think I mentioned already, I do not have the perfect answer for this. It's a very difficult subject to teach and just to have a conversation about it is emotionally wrenching. So what we do - and again if there are other people who have suggestions on this please send me notes because I would love to hear more about this - what we do is we acknowledge repeatedly how difficult this is to talk about. We acknowledge that we're asking people to push beyond a normal comfort zone. It's very easy to think that the US were heroes in this war and that everything we do today is exactly antithetical to what the Nazis did and yet even if you believe all of that what we end up talking about in the class is… you know, 50% of German doctors were voluntarily became members of the Nazi party. They were not required to be members. They choose to become members of the Nazi party. Some of the reasons for - and that by the way, twice as many proportionately as many of the other professions like engineers, and teachers, and lawyers, and so on - so, doctors were disproportionately likely to buy-in to this sort of biological paradigm of creating a master race and using medical science to do that. So, how did that hubris overcome not a backwards nation, the Germans in the 1930s were at the forefront internationally in medical sciences and public health. If you wanted to become an internationally renowned physician in 1935 or 1930 you went to go get your training in Germany. The German model of medical education is what Flexner went to study when he wanted to find the best model of medical education in the world in 1910. If you look at the period, the ten years before the outbreak of World War II, Germany and the Austro-German Empire had won half of the Nobel Prizes in medicine and medical science leading up to World War II.

So Germany was at the forefront of the world and their hubris that they could use medical science to create a master race is in part what drove all of this. We as learners today need to recognize that some number of the people in a classroom, probably the majority, if they had grown up in Germany in this time would have become Nazis. That's a very difficult - that means you have to put yourself in the mindset and then you have to think how would I avoid that? After acknowledging that, you have to say okay what could we as a community of health professionals do to avoid having this kind of thing happen again? Or something lesser? Because I don't think we are on the brink of becoming Nazis again. But how do we avoid lesser versions of these crimes? That's the really difficult question that we have to grapple with.

Hoff: As we wrap up, would you leave our listeners with what you think are the most important lessons of the legacy of the Holocaust that can help students and clinicians care well for patients and communities today. How do students translate your course into actions with their patients?

Wynia: We talk about three broad ethical tensions that are innate to becoming a doctor and to practicing the medical craft and art and science. These are things that are particularly well illustrated because the Nazis got them so wrong. But they are inherent tensions that will continue to arise moving forward.

The first is, the proper calibration of science and scientific skepticism. Eugenics was - in the US, it continued to be debated and deliberated. It was not bought by everyone. In Germany they went completely towards “everyone understands that eugenics is explanatory and can be used to create this master race and create a perfect society.” Whereas in the US that continued to be debated. So how do we continue to debate things that need to have continued debate within science while not becoming so skeptical that we don't accept things, let's say vaccine science or climate science? There are things that we need to be able to use public policy to address even as they are issues that remain under some level of contention. So that's an important balance for us. To recognize that skepticism about medical and scientific theories is important, and there is a role for using science and scientific theories for public policy. Look at the current COVID pandemic. And the debates over using masks and the push to get a vaccine. So all of these things are about calibrating the level of evidence that is required in order to make public policy decisions based on a scientific theory. And that's going to be an ongoing thing.

The second one we talk about is, balancing empathy for individual patients with the need to be able to move on from one patient and to the next even though patient number one was suffering terribly and has a really tragic thing going on. You, as a professional, you've got to be able to move on to the next patient, give that next patient your full and complete devotion and attention without empathy for the first patient continuing through to how you address the next patient. That's just the reality of medical practice. We do witness suffering, we do witness terrible things that happen to people. We have to be able to carry on in our jobs without becoming inured to human suffering. Clearly the Nazis became inured to the suffering of individuals in pursuit of sort of this grand vision of the community becoming perfected through killing a lot of individuals. So that balance of professional detachment – it's often called – and retaining your humanity and your empathy with every individual patient, I think is something that many people struggle with as they become professionals, as they become doctors and nurses and others.

And then the third is maybe the most obvious, but it's also often the most difficult which is the reality of medical practice and of nursing practice and certainly of public health practice, is that we are often balancing our responsibilities to individual patients, individuals, and our responsibilities to the community. And our responsibilities to our own families and our responsibilities to ourselves. Each of us as individuals have competing responsibilities, and the idea of dual loyalties or competing loyalties is something that all of us have to struggle with throughout our careers – how to create a professional life and a personal life that is balanced. Where you don't fall into the Nazi paradigm which was we only care about the community, we don't care about any given individual within the community. That is obviously taking that way to one extreme, but we also can't take it all the way to the other extreme and say, “I don't care about the community at all I only care about the one person sitting in front me.” Because in fact we do have a responsibilities to our communities and finding the balance there without falling astray is a continuing challenge for all of us in health and medicine.

Hoff: Dr Matthew Wynia is a Professor of Medicine and Public Health at the University of Colorado School of Medicine in Aurora, and he is the Director of University of Colorado Center for Bioethics and Humanities. Dr Wynia thank you so much for sharing your expertise on this topic.

Wynia: Thank you for having me, Tim.

Hoff: That's our episode for this month. Thank you to Dr Matthew Wynia for joining us. Music was by the Blue Dot Sessions. To read our January issue, “Legacies of the Holocaust in Health Care,” visit our site, JournalofEthics.org. Follow us on YouTube, Twitter and Facebook @journalofethics. And join us in February and March for a double issue on health equity in health care. Talk to you then.

Audio Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

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