Foundational documents of modern biomedical ethics, such as the Nuremberg Code, the World Medical Association's declarations of Geneva and Helsinki, and the Belmont Report, trace their origins to health care professionals' complicity in the Holocaust. Rituals of contemporary medical education, such as white coat ceremonies and oath swearing at graduations, are practices that express professional resolve to never again be complicit in genocide or human exploitation. This article considers a historical approach to teaching the Holocaust's contemporary ethical implications for clinicians and their practices.
History in Ethics Education
History can awaken students' imaginations to the past so that they can study its implications for the future. As one bioethicist and historian team suggested:
Good history transports those studying and practicing bioethics to an earlier time, figuratively putting them in the shoes of their predecessors and teaching them how these past individuals rationalized … choices that now seem clearly ethically dubious. Learning how societal values, scientific zeal, ideological beliefs, and the desire for personal achievement influenced these persons reveals how similar factors can and often still remain in play, even in our supposedly more “enlightened” era.1
It is in this spirit that I routinely discuss health care professionals' roles in the Holocaust in my bioethics courses. It is important that future health care professionals recognize that in the 1930s and 1940s, their German counterparts believed they had an ethical duty to collaborate in killing children with disabilities, gay people, Roma, and—most notoriously—Jews. Quiz Ref IDMore to the pedagogical point, it is important for students to learn that, directly or indirectly, foundational documents of modern health care ethics—the Nuremberg Code, the World Medical Association's declarations of Helsinki and Geneva (a modern version of the Hippocratic Oath) and the Belmont Report—were written to prevent both researchers' abuse of the people serving as human subjects and the recurrence of medical complicity in genocide.
Earliest among these foundational documents was a code of research ethics issued by judges at the Nuremberg Doctors' Trial. Responding to revelations that German physicians subjected concentration camp inmates to experimentation, war crimes, and crimes against humanity, the court convicted 16 of the 23 accused health care professionals and Nazi administrators.2 Before sentencing, justices issued a code of 10 principles to which, they claimed, all morally responsible researchers subscribed.2,3 These came to be known as the Nuremberg Code.4 The trial and the code have been exemplars of accountability for later generations of research ethics reformers.
The 1948 Declaration of Geneva
In 1947, physicians in the allied military campaign to retake Europe from the Nazis founded the World Medical Association (WMA). The WMA's objective was to rebuild Europe's devastated health care institutions: bombed-out clinics, hospitals, laboratories, and schools. Although rumored during World War II, German health care professionals' roles in the Holocaust became fully known only after the Nuremberg Trials. Quiz Ref IDWhat also became known was that “Nazi medical ethics” was neither a misnomer nor an oxymoron, nor was it hyperbole.5,6 When Karl Brandt (1904-1948), a Nazi physician and member of Hitler's inner circle, was asked about his role in directing the Nazi Aktion T4 euthanasia initiative, a systematic program for killing children and others with disabilities, he replied:
We German physicians look upon the state as an individual to whom we owe prime obedience, and we therefore do not hesitate to destroy an aggregate of, for instance, a trillion cells in the form of a number of individual human beings if we believe they are harmful to the total organism—the state.7
When asked about traditional statements of medical ethics, such as the Hippocratic Oath, Brandt observed that, had Hippocrates been a German physician in the 1930s, he would have revised his oath.7 The WMA knew that Brandt and his Nazi colleagues accepted what their teacher Alfred Hoche (1865-1943) endorsed: euthanasie of people with mental disabilities was ethical because it alleviated the state's burden of supporting lebensunwertes leben (lives unworthy of living).8 Fully embraced, this racialized eugenic public health ethics, or rassenhygiene (racial hygiene),9,10 justified killing “individual human beings if we [German physicians] believe they are harmful to the total organism—the state.”7
Because the WMA's objective—to rebuild the health infrastructure of Europe—included occupied and postwar (West) Germany, German health care professionals' cooperation was essential. Quiz Ref IDThe WMA knew that effective denazification would require German health care professionals to recommit to traditional medical ethics. Accordingly, the WMA adopted a pragmatic approach: German health professional organizations' recognition would be conditional on their members' reaffirmation of traditional values of allopathic medicine. German clinicians had to publicly swear a modernized version of the Hippocratic Oath, the Declaration of Geneva. In its original 1948 formulation, the Declaration of Geneva stated:
I will consecrate my life to the service of humanity…. THE HEALTH OF MY PATIENT will be my first consideration…. I WILL NOT PERMIT considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient…. I will not use my medical knowledge contrary to the laws of humanity.11
Note the declaration's explicit rejection of Nazi medical ethics—which placed the welfare of the organic state above the individual patient's health—by its emphasis on clinicians' duties to humanity, and its emphatic rejection of the relevance of a patient's race, nationality, or social class to health care service delivery. The WMA regularly updates the wording of the oath, a version of which is regularly sworn by students throughout Canada and the United States.
The 1964 Declaration of Helsinki
Quiz Ref IDAlthough inspirational, like many firsts, the Nuremberg Code was far from perfect. The judges presiding at the Doctors' Trial stipulated that “voluntary consent of the human subject is absolutely essential”12 and made this the primary principle of human subjects research ethics. But some prospective research subjects lack capacity to consent, and, by overlooking the need for surrogate consent, the judges inadvertently prohibited testing interventions for sick children, unconscious patients, and other key groups. A second factor undermining the Nuremberg Code's scope of influence was the outbreak of the Cold War (1945-1990). As this conflict heated up, the code's restrictions on human subjects research came to be seen as impeding efforts to understand radiation exposure from weapons of mass destruction.13
A form of mass retrograde amnesia about professionals' roles in the Holocaust became convenient. In the United States, “Neither the horrors described at the Nuremberg Trial nor the ethical principles that emerged from it had a significant impact on the American research establishment.”13 Similarly, “the Nuremberg Code … was routinely ignored by researchers in Britain … who believed the guidelines … did not apply to them.”14 Recognizing a need for applicable research ethics, the WMA issued a new code in 1964, the Declaration of Helsinki, which expressly recognized that surrogate consent filled a need “in case of legal incapacity” and stipulated that “consent should … be procured from the legal guardian.”15 Updated continuously since its passage, the Declaration of Helsinki's supplemental declarations (eg, the declaration on health data banks issued in 2016) continue to remain foundational for international medical and research ethics.16
Beecher, Pappworth, and Buxtun
Quiz Ref IDMemories of the Holocaust tended to be overshadowed by Cold War concerns in the 1970s, but they had been seared into the minds of Jews everywhere and remained in the thoughts of a handful of World War II military clinicians, including the Harvard medical researcher Henry Beecher (1904-1976). Beecher's original interest in the Nuremberg trial was that of a Cold War warrior: gleaning information from the Nazi experiments. Eventually, however, Beecher came to realize that some of his own Cold War experiments were unethical. In what could be construed as an act of contrition, he blew the proverbial whistle on content published in leading clinical journals that violated the informed consent standard in the Nuremberg Code and the Declaration of Helsinki.17- 20
Beecher corresponded with a fellow World War II veteran, Maurice Pappworth (1910-1994), a British physician barred from appointments at London's teaching hospitals because, as he was once informed, such positions were reserved for gentlemen and “no Jew could ever be a gentleman.”21 In 1936, Pappworth passed the Royal College of Physicians (RCP) examination, an indicator of professional achievement normally followed about a decade later by election as a fellow to the college, but he was not elected until a few months before his death in 1994.21,22 Although this unprecedented 57-year delay was unjust, Pappworth made the most of it, and to our collective benefit: unburdened by the club morality of gentlemanly RCP fellows, Pappworth informed the British medical and popular press about unethical experiments on patients in the British National Health Service and elsewhere.21 In response to complaints from the British medical establishment, he replied: “Those who dirty the linen and not those who wash it should be criticised. Some do not wash dirty linen in public or private and the dirt is left to accumulate until it stinks.”23
Beecher's and Pappworth's whistleblowing catalyzed research ethics reforms in the United States and Britain. While working for the US Public Health Service (USPHS), Peter Buxtun (1937- ), a son of Holocaust refugees, discovered that an ongoing (1932-1972) study of untreated syphilis in African-American men deceived subjects into thinking that they were being treated for “bad blood,” a euphemism for syphilis, when in fact they were being studied for untreated syphilis.24 Buxtun sent USPHS officials a report comparing the role of deception in the USPHS Syphilis Study at Tuskegee to Nazi clinicians' atrocities condemned at Nuremberg.24 Years after the USPHS rejected Buxtun's report, Buxtun informed the Washington Star about the ongoing experiment.24 Scandal ended the study and led to a US Congressional investigation, culminating in the 1979 Belmont Report,25 which proposed the process—now encoded in the US Code of Federal Regulations—of institutional review board review, approval, and ongoing compliance monitoring of protocols involving human subjects that are federally funded.
The ethical principles proposed in the Belmont Report—beneficence (and nonmaleficence, later) and justice—are also found in the 1947 Nuremberg Code and the 1964 Declaration of Helsinki. Autonomy or respect for persons, however, was new.25 It transformed consent from a legal concept into a moral concept. Traditionally, if researchers asked their subjects to consent, it was to protect themselves against lawsuits arising from harm their subjects could suffer.27 The Belmont Report reconceptualized consent as a legally enforced moral concept that asserts subjects' rights and recognizes that, as persons, they deserve respect. The commission that authored the Belmont Report stated: “To show lack of respect for an autonomous agent is to repudiate that person's considered judgments, to deny an individual the freedom to act on those considered judgments, or to withhold information necessary to make a considered judgment, when there are no compelling reasons to do so.”25 This is precisely what the USPHS researchers had done to the African-American men in their study for 40 years. As medical historian Susan Lederer observed: “[I]nvestigators who staffed the study over four decades regarded their African American subjects neither as patients, nor as experimental subjects, but as cadavers, who had been identified while still alive”—that is, they treated them as nonpersons.26 Eighteen years after the publication of the Belmont Report, the President of the United States publicly apologized to victims of the Tuskegee study.27
As I explain to my students, the oaths they swear at white coat and graduation ceremonies28- 30 and the regulations with which they must comply when doing human subjects research originated in our responses to clinicians' roles in the Holocaust. The founders of the WMA, Beecher, Pappworth, and descendants of Holocaust victims and survivors like Buxtun drew on the Holocaust to identify and speak out against unethical experiments or research. Our students have no such memories, so it is up to us, their educators, to cultivate their professional formation and their awareness of complicity as a species of atrocity. Never forget. As Jorge (George) Santayana (1863-1952) observed: “Those who cannot remember the past are condemned to repeat it.”31