Studying medicine, Nazism, and the Holocaust crucial to strengthening medical education and ethics, says new work

Efforts to strengthen contemporary health professionals' education and medical ethics should be informed by a robust understanding of medicine's role within the Nazi regime, according to a new report from the Lancet Commission on Medicine, Nazism, and the Holocaust: Historical Evidence, Implications for Today, Teaching for Tomorrow.

An education in how and why such atrocities were enabled can further empower generations of medical and health professionals to face moral and ethical medical dilemmas and their own biases, stand up to power, and protect vulnerable populations and patients.

The work—written by a diverse and international group of 20 scholars, physicians, and researchers with expertise in history, medical education, and bioethics—is the first Lancet Commission report focused on the history of medicine.

Through examples of discriminatory and inhumane medical policies and practices under the Nazi regime, the authors aim to inform approaches to contemporary issues in medicine and underscore the importance of centering human rights and dignity in medical professionals' conduct—this includes a willingness to stand up to wrongdoing whenever and wherever necessary.

"Nazi medical atrocities represent some of the most extreme and best-documented examples of medical involvement in human rights violations in history. While it is tempting to view the perpetrators as incomprehensible monsters, the evidence put forward by the Commission demonstrates how many health professionals were capable of committing ethical transgressions and even crimes against their patients under certain conditions and pressures. Health professionals—who often care for people at their most vulnerable—have a unique and important duty to develop and preserve a strong moral agency.

"By learning about medicine's role and health professionals' behavior under Nazism, they can further develop their own moral reasoning and stand up to abuses of power in the name of individual patient rights and the dignity of all human beings, regardless of race, ethnicity, religion, and other individual characteristics," said Commission Co-Chair Dr. Sabine Hildebrandt of Boston Children's Hospital and Harvard Medical School (U.S.).

The core values of ethics and health care are fragile and must be protected

The Nazi regime is not the only instance in history in which members of the medical community were involved in crimes against humanity. However, it is one of the most extreme, well-organized, and extensively documented examples of medicine's active participation in human rights violations—including anti-Semitism, racism, discrimination, mass atrocities, and genocide. As such, important implications can be drawn for today's health professionals' moral agency, especially under economic, political, or other types of pressure.

"A wide range of debates we see in medicine now—from who should receive care during a catastrophic event, to end-of-life care and new developments in genetics, to name just a few—indicate how medicine and science are linked with politics, personal beliefs, and socio-economic factors. Medical professionals and bio-scientific researchers have to be aware of these influences and their manifold implications for patients and study participants," said Commission Co-Chair Prof. Herwig Czech, Medical University of Vienna (Austria).

During the Nazi era, the medical community helped create, justify, and implement policies according to the Nazi doctrine and changed their understanding of medical ethics accordingly. Records indicate that physicians joined the Nazi Party and its affiliated organizations in higher proportions than any other profession, and Germany's medical and research institutions played instrumental roles in the regime.

Throughout the Commission's report are examples of how the Nazi "ethical code" was weaponized as a tool to value, prioritize, and advance people of German "Aryan" descent above all others in medical care and research, as well as rationalize eugenics, forced sterilization, the "euthanasia" patient murder program, and brutal human experiments.

Methods first developed and applied in the T4 patient murder program of 1939–41, during which 70,000 institutionalized patients were killed by gas, were later applied to the extermination camps in Poland, where victims were murdered upon arrival in gas chambers disguised as showers.

"It is often surprising how limited the knowledge about Nazi medical crimes in the medical community is today, perhaps apart from a vague notion of Josef Mengele's experiments in Auschwitz. Our report aims to change this. Although the examples we present are extreme, studying medicine under Nazism highlights the critical role of societal factors and of ethics in medical and scientific advancement. Today's health professionals operate in systems and structures that do not benefit all patients equally. While there is no simple path ahead, knowledge of historical extremes can make us better prepared to work through ever-evolving ethical dilemmas in medicine," added Prof. Czech.

In the aftermath of World War II, deliberations over medical ethics—including human rights-based medicine, health care, and voluntary consent in research—drew international attention. Starting in 1946, the Nuremberg Doctors' Trial led to the first international principles for ethical research on humans, later to be known as the Nuremberg Code. This formed the basis of many subsequent declarations and was an important factor in the development of modern bioethics.

Taking accountability for the past is a responsibility for future generations of medical professionals

As the report details, contrary to common misconceptions, medicine in Nazi Germany was not "pseudoscience." In fact, it worked on the basis of standards and practices of biomedical science developed in the late 19th and early 20th centuries. German scientists were part of broader international networks exploring and promoting eugenics and developing racist medical rationales.

In life and death, the bodies of Nazi victims were used for research and teaching, and specimens of their human remains were sometimes kept in scientific collections for decades after the war. The Pernkopf anatomy atlas (panel 13) is an example of how Nazi research has become part of the canon of medical knowledge.

Re-drawings of the Pernkopf images—some deriving from the bodies of victims of the Nazi regime—have been copied in many publications and atlases, often without reference to the original. Current understanding of aviation safety, hypothermia, and even the effects of tobacco and alcohol use on the body has also been informed by research in the Nazi era, but again, awareness of how the research was obtained is scarce.

"Accountability for and recognition that crimes were committed in the name of medicine in the Nazi era and during the Holocaust remains woefully inadequate. Medical students, researchers, and practicing health professionals should know where—and from whom—the foundations of medical knowledge come from. Victims of Nazism are owed that; they have a right to be honored and treated with dignity in life and death for coerced contributions to medicine as we know it today.

"The goal of our report is to provide additional resources and information for medical schools, research institutions, and medical associations worldwide to continue accountability efforts as part of their responsibility to past and future generations," said Commission Co-Chair Prof. Shmuel Pinchas Reis, of the Center for Medical Education at Hadassah/Hebrew University Faculty of Medicine (Israel).

Empowering students and medical professionals to be ethical agents of change

The Commission stresses that the pursuit of scientific knowledge and the delivery of medical and health care must occur within a framework that prioritizes human rights. As such, the authors put forward recommendations to ensure that medical education focuses on developing history-informed moral agency and resilience among medical professionals. Key recommendations include:

• Incorporate the study of medicine, Nazism, and the Holocaust in curricula for all medical students and health professionals, across the medical field and in continued medical education initiatives.
• Encourage students and medical professionals to develop a history-informed professional identity, including being able to recognize their own potential biases or conflicts of interest, challenge hierarchies, and equip them with the tools necessary to overcome them.
• Universities, psychiatric hospitals, and other medical institutions worldwide should actively identify and commemorate victims of Nazi medical crimes and initiate research to better understand their direct connections to human rights violations in the past. They should also look at their own past, identify and document patterns of medical abuse, and integrate this history in their curricula.

The report also tells the stories of Jewish and non-Jewish health professionals working and caring for their patients in extreme circumstances—such as in ghettos and concentration camps. Their personal testimony has become intrinsic to teaching and discussing the horrors of the Holocaust and other atrocities of the time. Recognizing these people and their efforts to provide human rights-based care where possible is instructive to health professionals today and in the future; it stands in sharp contrast to the dehumanizing practices of health professionals complicit with the Nazi regime and demonstrates that acts of moral courage are possible even in dire situations.

"Over the last few years, scientific research, medical, and health policies have been subject to great scrutiny. Our report sets out some of the most horrific distortions of medical practice and policies in history, and it is incumbent on all in the health and medical community to keep the memory of the events of the Nazi era from fading. We must study this history of the worst of humanity, to recognize and work against similar patterns in the present, with the goal of promoting the best.

"We must speak out against anti-Semitism, racism, and other forms of discrimination, uphold and advocate person-centered, human rights-based medicine, protect the vulnerable, serve the marginalized, and acknowledge the humanity and dignity of each and every patient," said Dr. Hildebrandt, in summarizing the insights of the Commission's work of the last three years.