Kathryn E. McGoldrick, MD, FCAI(Hon)
‘Into whatever houses I enter, I will go into them for the benefit of the sick and will abstain from every voluntary mischief and corruption.’
Although it is perhaps less true today than four or five decades ago, physicians are often perceived by the public—and possibly by doctors themselves!—as morally superior people. Physicians are required, by law as well as by societal expectation, to adhere to the highest ethical standards. When this goal is not achieved, public outrage is a justifiable response.
Having high expectations of myself and my physician colleagues, I have always been enraged and baffled by the close physician involvement in both the formulation and execution of Nazi racial doctrine and genocide during World War II. How could doctors have participated in such unspeakably cruel acts on a routine basis and still maintain a semblance of being members in good standing of a purportedly noble profession?
With the 1986 publication of his immensely important book, The Nazi Doctors: Medical Killing and the Psychology of Genocide, Robert Jay Lifton, MD, confronted painful questions that needed to be asked—and answered.1 As a distinguished professor of psychology at John Jay College of Criminal Justice and the Graduate Center of the City University of New York, Dr. Lifton had the commitment to spend more than seven years studying Nazi physicians. He traveled the globe, searching for and interviewing Nazi physicians and prisoners. The product of his efforts was illuminating and provocative.
It is essential to understand that physicians were directly engaged in all aspects of the Nazi killing programs, from the paperwork to the actual killing and the maiming of corpses. It is also important to appreciate that Germany was the sorry possessor of a long history of anti-Semitism, dating back to the Middle Ages when Jews were held responsible for causing the Black Death. Indeed, Martin Luther had castigated Jews as a “venomous” danger to German–Christian fellowship.
As discussed by Lifton, since Jews and non-Aryan races were viewed by the Nazis as a “disease,” the idea of “killing as a therapeutic imperative” became an extension of this warped concept. And the physician was perceived as a natural leader in this biocracy; he or she was perceived as a “cultivator of the genes” and “caretaker of the race.” Gradually, the German medical profession came to accept Nazi dogma, arguing that killing in instances of “life unworthy of Life” was not only “allowable” but also useful.
The Nazi “euthanasia” program started with the murder of children. Solely on the basis of a report of an anomaly or a serious illness, three medical experts determined whether the afflicted child was to be murdered. The killing was then performed by physicians, who resorted to medication, poison or starvation. A few months later, the program was expanded to include adults and was given the code name T4. Furthermore, it was official T4 policy that the killing actually be performed by a physician. After the murders, the physicians were charged with preparing false death certificates, ascribing the killings to medically credible causes.
The next step in the expansion of medicalized killing was Operation 14f13, begun in early 1941, whereby excess prisoners in concentration camps were killed on the arbitrary basis of race or physical incapacity. Operation 14f13 was the precursor to genocide because it was the vehicle by which killing in the fashion of T4 was introduced to the concentration camps.
The “Final Solution” to the Jewish question was to be Auschwitz, the extermination camp that eventually claimed the lives of 4 million people. Physicians were inextricably enmeshed in the program through which arriving men, women and children were selected either to live—and function as experimental subjects or slave laborers—or to die immediately.
The method of murder varied from death in the gas chambers to intravenous or even direct intracardiac injection of lethal drugs. People allowed to escape death upon arrival served as cheap experimental animals, yielding data on poison ingestion, artificially induced infections, intentionally inflicted burns and cold immersion. The Nazis’ “medicine” and “experiments” were, of course, neither; they were depraved and despicable, morally and ethically bankrupt acts. They used disease as another method of prosecuting war and of exterminating Jews and other untermenschen—those deemed racially or socially inferior.The Nazis’ experimentation with typhus, for example, killed some 1.5 million people in concentration camps.2
Operative Psychological Mechanisms
In his classic tome, Dr. Lifton wrote eloquently and tellingly of the psychological mechanisms used by German physicians during their socialization to Auschwitz. Gradually, the attitudes of the doctors shifted from revulsion to acceptance following the application of pressure and mentorship, and then the establishment of psychological distance.
The uncomfortable, eerie message is that virtually anybody can be socialized into becoming a killer. Perhaps all that is really necessary is for the individual in power to think of his or her victim as other than a person. After all, it is routine for physicians to eradicate a disease or a problem. It is quite another matter to intentionally kill a bona fide human being. Rationalization, semantic machinations and doubling, defined as “the division of the self into two functioning wholes, so that a part-self acts as an entire self,” became the operative mechanisms to explain shocking discordance of character.
Johanna (Hannah) Arendt introduced the concept, although controversial, of “the banality of evil” in her book titled Eichmann in Jerusalem: A Report on the Banality of Evil, which was first published in The New Yorker in 1963.3 She argued that the great evils of history in general, and the Holocaust in particular, were not carried out by sociopaths, but rather by ordinary people who accepted the premises of their state and participated in atrocious acts, thinking their behavior was normal.
When one normalizes the unthinkable, horrific acts become routine and are accepted. Arendt, therefore, posited a tendency of ordinary people to conform to mass opinion and acquiesce to performing unspeakable acts without critically evaluating the consequences of their actions or inaction.
Lest we excuse the evil of the Third Reich as a unique aberration in an otherwise immaculate record of physician compassion over the centuries, Dr. Lifton wrote in his foreword, “One need only look at the role of Soviet psychiatrists in diagnosing dissenters as mentally ill and incarcerating them in mental hospitals; of doctors in Chile … serving as torturers; of Japanese doctors performing medical experiments and performing vivisection on prisoners during the Second World War; of white South African doctors falsifying medical reports of blacks tortured or killed in prison” to see physicians wrongfully involved in the politics and implementation of deception, torture and murder.
The Nazi Doctors is excruciatingly painful to read. Yet, because of its profound implications for the medical profession, I think this book should be required reading for all students and practitioners of medicine. While distancing is a mechanism that helps the physician to survive medical training and function as a competent physician, distancing gone awry results in tragedies of the kind so graphically documented in this volume. And doubling, of course, was the psychodynamic framework that eventually allowed the “doctor healer” to become the “doctor killer.”
These are somber thoughts. If we cannot confront and learn from our most egregious mistakes, we may be destined to repeat them. More frightening still is the fact that even detailed and deep knowledge of the world outside and inside ourselves has yet to spare us from what Joseph Conrad termed “the horror,” because interest in and skill with moral analysis will not guarantee moral actions. Recall that Hitler had at his side not only physicians, he also had members of the clergy and, alas, moral philosophers.
In a more contemporary vein, let us briefly reflect on the heinous crime of torture. Any participation by physicians in torture is difficult to understand, much less condone.
Sadly, at prisons in Abu Ghraib, Iraq, and Guantánamo Bay, Cuba, physicians have been implicated in such despicable activities as allowing interrogators to use medical records to develop interrogation approaches that would maximize anxiety and distress in individual prisoners, falsifying medical records and death certificates, and failing to provide basic medical care.4
A spokesman from the Pentagon, while declining to address specifics in the reported accounts, has suggested that doctors advising interrogators were not bound by ethical strictures because they were not treating patients but rather acting as behavioral scientists in the Iraqi and Cuban venues.5
Surely, even in the face of heavy command pressures, physicians are bound by ethical duties to their patients. Physicians are explicitly prohibited from participating in any kind of torture by the 1975 Declaration of Tokyo of the World Medical Association. We should follow the dictums of conscience and of international law and not countenance, much less participate in, torture. Such behavior offends human dignity and dehumanizes all parties.6
If the medical profession were to remain silent with regard to these issues, our silence could legitimize acts that violate the most fundamental tenets of the medical profession and make us complicit in the moral erosion that led to the disgraceful events at Abu Ghraib and Guantánamo Bay.
Today’s headlines and newscasts suggest that we have much to reflect on as we recall the cautionary lessons from 75 years ago when the unimaginable happened. Certainly, it would be egregiously wrong to remotely equate the behavior of American medical personnel at Abu Ghraib and Guantánamo with the apotheosis of medical evil displayed by Nazi doctors.
Nonetheless, we should shun the slippery slope that may seem superficially acceptable or justified during a time of war. Rather, let us learn from the most extreme examples of doctors’ vulnerability to being socialized to abusive environments and to engage in destructive, unethical and frankly reprehensible behavior.7 Santayana was wise in admonishing us to learn from the mistakes of the past, lest we be condemned to repeat them.
In Sinclair Lewis’ 1925 novel about the training of an early 20th-century physician, the young Martin Arrowsmith, who is just beginning to experience the ecstasy of the “drug of research,” is admonished by his mentor Max Gottlieb to develop the proper attitude of the scientist:
“Be sure that you do not let anything, not even your good kind heart, spoil your experiment …. You must pity, oh, so much, the generation after generation yet to come so that you can refuse to let yourself indulge in pity for the men you will see dying.”8
But is sensitivity to suffering truly an indulgence or an obstacle that the researcher or clinician must learn to deny or overcome? Or can it be a vital ethical guide to formulating responses to crucial questions? Can it serve as a moral compass?
I would submit that retaining this sensitivity would not allow us to view any person as an abstraction; rather, it should enable us to see and respect every individual as a unique, sentient creature with his or her special talents, weaknesses, memories, dreams, regrets, agonies and secrets. In the 12th century, Moshe ben Maimon (Maimonides) purportedly admonished in his oath, “May I never see in the patient anything but a fellow creature in pain.”
Nine centuries later, the wisdom of these words still shines as a beacon to guide our behavior.
Kathryn E. McGoldrick, MD, FCAI(Hon) is Professor and Chair of Anesthesiology, Emeritus, and Advisory Dean, Emeritus, at New York Medical College; and serves on the Accreditation Council for Graduate Medical Education (ACGME) and the Department of Institutional Accreditation, Clinical Learning Environment Review (CLER).
- Lifton RJ. The Nazi Doctors: Medical Killing and the Psychology of Genocide. New York, NY: Basic Books; 1986.
- Baumslag N. Murderous Medicine: Nazi Doctors, Human Experimentation, and Typhus. Westport, CT: Praeger; 2005.
- Arendt H. Eichmann in Jerusalem: A Report on the Banality of Evil. Revised ed. New York, NY: Viking Press; 1968.
- Miles SH. Abu Ghraib: its legacy for military medicine.Lancet. 2004;364:725-729.
- Lewis NA. Interrogators cite doctors’ aid at Guantánamo.The New York Times. June 24, 2005:A1.
- Annas GJ. Unspeakably cruel: torture, medical ethics, and the law.N Engl J Med. 2005;352:2127-2132.
- Lifton RJ. Doctors and torture.N Engl J Med. 2004;351:415-416.
- Lewis S.Arrowsmith. Franklin Center, PA: The Franklin Library; 1975:413-414.