Critical lessons can be gleaned by examining 2 of the most salient relationships between racism and medicine during the Holocaust: (1) connections between racism and dehumanization that have immediate, lethal, deleterious, longer-term consequences and (2) intersections of racism and other forms of hatred and bigotry, including discrimination against people with disabilities; lesbian, gay, bisexual, transgender, and queer people; and social and religious minorities. When considered in the US context, these lessons amplify need for reflection about the history of eugenics and human experimentation and about the persistence of racism and ableism in health care.
Racism, Medicine, and Dehumanization During the Third Reich
The murder of 6 million Jews and millions of other people in Nazi Germany was made possible by dehumanization on a pervasive and catastrophic scale. In her classic book, The Origins of Totalitarianism, Hannah Arendt analyzes historical conditions that gave rise to Nazism, arguing that an overriding impulse of Nazi ideology was to deprive its victims initially of their juridical and civil rights and next of their existential rights, ultimately denying perceived enemies of “the right to have rights.”1 This process turned social and human beings into “bare life,” naked and exposed to the regime's brutalities.2,3 Nazi Germany, of course, was not the first dehumanizing regime. Archives of colonialism, slavery, and war abound with examples of dominant powers using religious, moral, and scientific rationales and stereotypes to disparage and treat minorities as subhuman. Yet, during the Holocaust, health professionals and the awful ideologies they operationalized played an outsize role in dehumanizing and depraved medical practices.4
Health professionals' complicity in the Third Reich has garnered significant scholarly attention and served as a negative example that can be—and has been—used in the development of bioethics and health justice.5Quiz Ref ID One defining aspect of medicine during the Holocaust was its exhaustive infiltration and distortion by racism and racist ideologies. During the Third Reich, dehumanization was on grotesque display in ubiquitous portrayals of Jews as parasites and vermin that required extirpation from the body politic.6 Animalization worked in tandem with anti-Semitic presumptions that Jews were genetically inferior, incapable of full human essence. Family trees produced by Nazi geneticists often were accompanied by sinister and macabre representations of Jewish physiognomy and Jewish-Aryan intermixing.7 This kind of dehumanization fueled passage of anti-Jewish laws starting in 1933—notably, the Nuremberg Laws of 1935 that stripped German Jews of citizenship and outlawed unions between Jews and those of “Aryan” blood.4
Nazi dehumanization pivoted around medicine and science. Nazi scientists devoted their careers to measuring Jews' physiology and mapping their heredity, producing studies that displayed and intensified underlying racist biases. Quiz Ref IDFor example, Otmar von Verschuer, the director of the Division of Human Heredity at the Kaiser Wilhelm Institute for Anthropology, conducted research on twins in a quest to determine the heritability of conditions such as criminality, schizophrenia, and epilepsy.4 To confirm Jews' inherent defectiveness, he presented distorted results of these experiments in a professional journal and incorporated them into training for state physicians at the Kaiser Wilhelm Institute.8 Verschuer's eugenic studies were taken to the harrowing extremes of maiming and murder at Auschwitz by his student, Josef Mengele, who conducted lethal experiments on Jewish and Roma (Gypsy) twins, most of whom were children, to study heterochromia and to test how different “races” withstood infectious disease.9
Long Arm of Dehumanization
Nazi Germany. The horrors of Mengele's experiments at Auschwitz are a focal point for understanding how medicine and racism converged in Nazi Germany. Nazi clinicians enacted dehumanization on a wide scale during the entire Third Reich, infusing racist theories of genetic inferiority and superiority into daily health practices. As laws were promulgated to restrict Jews from social and political life in Germany, Nazi physicians were founding clinics where thousands of people with disabilities would be sterilized. The 1933 Law for the Prevention of Hereditarily Diseased Offspring authorized genetic health courts to sterilize women, children, and men “afflicted” with ostensibly inherited conditions, such as “feeble-mindedness,” schizophrenia, epilepsy, and alcoholism.10 Over the next decade, an estimated 400 000 people were sterilized under this law.4 Strikingly, sterilization led to euthanasia, performed initially in clinics—on children and later on adults—and ultimately on millions corralled into gas and kill chambers.9
Medicalized dehumanization evolved in large part out of disdain for people with disabilities and was interlinked with and fueled by anti-Semitism and racism. As such, Nazi logic was applied to a range of groups and intersecting identities, always denigrating those who fell outside the bounds of so-called Aryan purity. Quiz Ref IDJewish women “experienced dehumanization in distinct ways from men that specifically targeted their bodily integrity.”11 Women were vilified as breeders of undesirables, as threats to Aryanism.11 Gay men, and to a lesser degree lesbian women, were treated as vectors of sexual depravity, criminality, and illness; they were persecuted by law, unwittingly subjected to psychiatric experimentation, and assigned to brutalizing hard labor.12 Medicalized dehumanization also affected the Roma (Gypsies), Jehovah's witnesses, and political dissidents seen as traitors.9
Limitations of the Nuremberg Code.Quiz Ref ID After the war ended, the Nuremberg Doctors' Trial (1946-1947) held high-profile perpetrators such as Karl Brandt (Adolf Hitler's personal physician) accountable for the war crimes of human experimentation and genocide through mass euthanasia. Of the 23 defendants brought before the court, 20 were physicians; most were found guilty, including 7 who received death sentences and 9 sentenced to prison for terms ranging from 10 years to life.13 The trial served as the impetus for the drafting of the Nuremberg Code, a postwar blueprint of bioethical principles intended to guide human subjects research ethics.14,15 Although the drafting of the code was a pivotal moment in bioethics' history, its heavy emphasis on ghastly experimentation and euthanasia underplayed “the nonmilitary ideological and occupational motivations” of clinicians and scientists that permeated the discourse on racial hygiene in less dramatic yet insidious ways.16
Postwar human subjects research. The partial scope of the Nuremberg Code helps explain why coercive studies involving vulnerable human subjects proceeded unchecked in the United States even after World War II. Henry Beecher's game-changing 1966 article in the New England Journal of Medicine described the purpose, funding, and moral dubiousness of 22 ongoing “unethical or questionably ethical studies.”17 Yet neither awareness of the Nuremberg Code nor alarms raised by Beecher disrupted business as usual. The US Public Health Service Syphilis Study at Tuskegee, launched in 1932, tracked the course of untreated syphilis on Black men in rural Alabama while deceptively promising them free treatment.18 This blatantly racist study continued for 40 years until a reporter broke the story as front-page scandal in 1972. Similarly, physicians carried out hepatitis experiments on children with disabilities at the Willowbrook State School in Staten Island, New York.19 From 1955 to the early 1970s, a team of physicians intentionally infected minors with hepatitis to study the course of infection and evaluate the efficacy of gamma globulin injections to confer immunity. The perfunctory, vague consent forms that Willowbrook physicians asked parents to sign exemplified maleficence and coercion.19
Mandatory sterilization. Eugenic sterilization, which paved the way for the Final Solution in Nazi Germany, continued in the United States long after 1950. Quiz Ref IDBetween 1907 and 1937, 32 states and Puerto Rico authorized state health officials to sterilize those labeled defective and “unfit.”20 By the time these laws began to be repealed in the 1970s, more than 60 000 Americans had been sterilized.20 Akin to Germany's sterilization laws (informed by California legislation), US laws were couched in terms of protecting the nation from unwanted disability and defectiveness and identified putatively hereditary conditions as sufficient indicators for reproductive surgery.21
Although no US laws were aimed at specific racial or ethnic groups, racism was refracted through the prism of mental disability, such that African Americans were sterilized disproportionately in North Carolina—most notably in the final decade of that program (1958-1968), when Black women, many of them single mothers, made up approximately 60% of those sterilized even though Blacks were roughly 23% of the population.22 At the height of California's eugenics program—from 1920 to 1950—Latin men were 23% more likely than other men to be sterilized, and Latin women were 59% more likely than other women to be sterilized.23
COVID-19 and the Recalcitrance of Medicalized Dehumanization
It is worth dwelling on the juggernaut of dehumanization, which enabled US health professionals in diverse settings to treat particular populations as subjects undeserving of autonomy or rights. In the United States, deep-seated racism, xenophobia, and homophobia facilitated clinicians' perpetration of dehumanization in the 20th century in mental institutions, hospitals, prisons, and reformatories. But with the civil rights movements of the 1960s came questioning of authority and interrogation of medical paternalism, and the status quo began to fracture. By the 1970s, class-action lawsuits and congressional hearings held unscrupulous health professionals to account, and more robust bioethical policies, frameworks, and organizations emerged and solidified. In the United States, following the formulation and release of the Belmont Report in 1979,24 the Nuremberg Code became less a guide than a relic.
Despite such strides in the field of bioethics, dehumanization is still expressed in bigotry and cruelty against Jews,9 people with disabilities,10 gays and lesbians,12 and many with minoritized identities. Acknowledging the intersectional dimensions of discrimination and how biases amplify one another can shed light on contemporary incidents of medical malfeasance, such as the unauthorized sterilization of more than 140 women—the majority of them women of color—in 2 California women's prisons from 2006 to 2010.25 Many of these women were sterilized by a physician who opined that the money spent sterilizing inmates was negligible “compared to what you save in welfare paying for these unwanted children—as they procreated more.”25 From 1989 to 2014, people with mental illnesses in many states saw restrictions on their civil rights, especially related to marriage and parenting,26 underscoring the recalcitrance of eugenic stereotype of some as “unfit” to couple or parent.
The COVID-19 pandemic has laid bare not only the devastating racial health inequity that characterizes American society, but also the human costs of systemic racism, long-standing disinvestment in public health and infrastructure, and implicit racial bias in health care.27- 29 African Americans, Latin Americans, and Native Americans all have been infected and died of COVID-19 at disproportionately higher rates than Whites.29 In Michigan, one of the states hit hardest during the early months of the 2020 pandemic, African Americans, who make up 14% of the population, constituted 40% of the fatalities as of May 2020.30 The planning for health care rationing in intensive care units during projected COVID-19 hospitalization surges illustrates a persistent eugenic assumption that the lives of younger—presumably healthier—people are more worth saving than those of older people or people with disabilities or chronic illnesses.31 Uprooting racism, ableism, and other forms of discrimination in health care will require a commitment to systemic transformation and constant reminders that complacency about dehumanization is not ethically or clinically acceptable.32