17.1 Introduction

Defining what it is that physicians ought to do is a question that philosophers and practitioners have long grappled with. Finding a consensus regarding the exact purpose and specific goals of medicine has proven difficult. Is the primary goal of the physician to heal the sick and cure illness, to prevent future disease or premature death, to provide care directed by the wishes of the patient or third-party providers or to serve the best interest of society? Should physicians be categorized as scientists, artists, businesspeople, advocates, administrators, public servants, or some combination of these? What can and should be done when a conflict arises between goals and purposes (Pellegrino 2001)? The answers to these questions, among others, shape the foundations of our healthcare system; thus, it is understandable that they provoke debate.

There are two main perspectives concerning the goals of medicine. The first is the teleological approach, in which medicine is viewed as a practice with intrinsic goals, such as relieving suffering or treating illness. The roots of this approach are philosophical in nature and incorporate traditional views about actions, practices, and virtues. All actions and practices must be goal oriented. In this case the goal would be defined as the aim of medicine: namely restoring and maintaining health (Schramme 2015). Medicine is based on the human experience of sickness and healing. It is not socially constructed (Pellegrino 2001). Although it is possible that the purpose of medicine may change depending on the needs of society, the teleological approach necessitates that the goal would still need to remain aligned with the ultimate aim of medicine, which is the health of the patient (Schramme 2015).

The second technique used for defining the goals of medicine is the consensual approach. Published in a report by the Hastings Center in 1996, the purpose of this philosophy is to achieve international agreement regarding the goals of medicine by allowing for historical and social change (Schramme 2015). Daniel Callahan, the Co-Founder of the Hastings Center, lamented that contemporary medicine does not appear interested in any type of systemic inquiry as to the goals of medicine. He questioned:

Is it no less important to ask whether medicine should have the same goals now as in the Hippocratic era, or in the 19th century? The litany is familiar: our century has seen an enormous increase in average life expectancy, the conquest of most infectious diseases, a huge increase in the cost of health care, the possibility of using genetic medicine to enhance human traits and a public demand for medical care that escalates just as steadily as its costs. (Callahan 1999, 103)

The consensual approach is an attempt to acknowledge that while there may be certain virtues or goods inherent to the practice of medicine, the social and historical environment in which medicine is practiced must also be taken into consideration when goals are determined. This includes scientific and technological advances that have altered the medical profession.

While these two approaches may differ in their methodologies, their outcomes are similar. Both the teleological and the consensual approaches advocate preventing sickness and disease and/or relieving the pain and suffering caused by them and promoting health and wellness. Specific questions as to exactly what constitutes “health” or “disease” and whether the role of medicine should include enhancement as well as curing continue to abound. It is clear there are many challenges associated with the philosophical nature of defining the goals and purpose of medicine and the implications of these issues are far-reaching (MacDougall 2020). However, regardless of any other questions that may arise, the well-being of the individual remains the priority of medicine.

For the purpose of this book and, more specifically, this final chapter focused on the goals of medicine in a post-Holocaust society, why is it important to examine the goals of medicine? If we can agree that the care and well-being of the individual is a priority within the medical profession, then the complete and utter disregard for the individual in Nazi medicine becomes even more stark by comparison. If we know that preventing sickness and disease and/or relieving the pain and suffering caused by them and promoting health and wellness are widely accepted goals of medicine, then the labeling, persecution, forced sterilization and experimentation and eventual mass murder perpetrated by Nazi doctors becomes almost unfathomable. In his article, “Goals of Medicine,” Thomas Schramme stated that any “reference to the alleged goals of medicine can often be found in contexts where certain contested ways of using medical means are being discussed” (2020, 5). In the case of the Holocaust, we are trying to understand how the goals of medicine could shift so drastically as to allow healers to transform into killers. To do so, we must recognize how the social, political, and medical atrocities of the Holocaust are important, not simply as history, but because they can inform how we can and should act today to ensure that the goals of medicine in a post-Holocaust society remain true to their Hippocratic pledge to, “First, do no harm.”

17.2 The Medical Profession in Nazi Germany

“The individual personality cannot be the final goal of ethics. […] The people (Volk) as an organism is the goal of our ethics […]” – Professor Dr. Fritz Lenz, Holder of the First Chair of Racial Hygiene in Germany (Bruns 2014, 215).

As previously established, the role of physicians in society can take on many forms, but they all must remain consistent with the mission of medicine, succinctly expressed by the maxim, “Cure sometimes, relieve often, and comfort always.” However, medicine under the Third Reich bore very little resemblance to this notion. As a consequence of the Doctors’ Trial at Nuremberg and the resulting Nuremberg Code, many people are aware of the medical experiments performed by physicians during the Holocaust. However, the abrogation of ethics was not relegated to this one area. The medical profession was actively involved in every aspect of the systematic labeling, persecution, forced eugenic sterilization, and eventual mass murder of millions of people deemed “unfit” in the only example of medically sanctioned genocide in history (Caplan 2010). The role of physicians during the Holocaust included, but was not limited to:

  • Providing scientific justification for public policy measures

  • Enforcing public policies through hereditary health courts

  • Deciding which children would live or die based on nothing but questionnaires

  • Injecting lethal doses of medication into disabled children and adults

  • Falsifying death certificates

  • Selecting who would be sent to an immediate death and who would be forced into labor on the ramps of the concentration camps

  • Operating the gas chambers that killed millions of innocent victims (Proctor 1988; Lifton 1986)

Contrary to popular belief, physicians were not forced into these behaviors. Their participation was voluntary. The function of National Socialism in the process was not one of coercion, but rather of cooperation and empowerment (Proctor 1988). There were distinct changes in the moral ethos of the profession that allowed the primary task of the physician to transition from the care and well-being of the individual to the care and well-being of the nation of Germany. This paradigm shift, undertaken in the name of scientific and societal progress, became the foundation on which Nazi medicine was built. A variety of methods were implemented to provide the scientific and medical justification for Nazi political ideology, creating a powerful system that exploited and persecuted anyone considered to be an outsider.

17.2.1 Labeling and Othering

Placing people into social categories is an automatic act that begins in infancy. The process can help aid human development by allowing an individual to quickly assign unfamiliar people to groups to navigate the complexities of the social world we live in (Liberman et al. 2017). However, the process can also lead to stereotyping, discrimination, and dehumanization. While the process of “othering” may be an innate part of human development, its implications extend to the broader community as well. Sigmund Freud posited that one would naturally treat a neighbor differently than a stranger due to the feeling of connection that comes with being part of the same group. The idea of belonging to a shared community creates a moral obligation to care for one another. Those outside the shared community are not entitled to the same protections (Koonz 2003).

When attempting to understand how those who took an oath to care and heal could abandon their moral commitments, it is helpful to refer to a term Claudia Koonz refers to as the “Nazi conscience,” which she describes as “a secular ethos that extended reciprocity only to members of the Aryan community, as defined by what racial scientists believed to be the most advanced biological knowledge of the day” (2003, 6). In the quest for societal progress, the people entrusted with creating these classifications and determining who belongs to the community of belonging and protection were the scientists and doctors. Science provided the justification for the creation of a hierarchy of human life in which certain people were seen as being racially, ethnically, or culturally inferior based on biological traits. Creating a rationale for labeling and othering was the first step in the transformation of physicians’ moral ethos because it allowed them to alter the makeup of the community for whom they were responsible to care. It also paved the way for societal acceptance of the ostracization and exclusion of entire categories of people who were no longer considered part of the shared community.

Although the Holocaust is the only example of medically sanctioned genocide, the rationale behind scientific racism and discrimination goes back much further. Historically and philosophically, it is important to understand how the concepts of reason and progress were used to marginalize groups of people during the Enlightenment. The division of reason and unreason can be seen as the precursor to the eventual distinction between the mentally fit and the mentally unfit. Those considered to be unreasonable were seen as a threat to society, leading to the introduction of asylums to segregate them from the general population for the good of the community (Proctor 1988). This would allow the reasonable to thrive which would in turn lead to societal progress.

By the end of the eighteenth century, Enlightenment ideas about the power of reason, progress and science had usurped religion as the primary method for explaining social phenomena. Race, in particular, was identified as the driving force behind many of the major power shifts in world history. Arthur de Gobineau’s “Essay on the Inequality of the Human Race” (1853–1855) argued that the history of the world could best be defined as a racial struggle and, perhaps more importantly, this racial history should be categorized as science. While the concept of racial prejudice was not invented by Gobineau, his work provided a rationale for ethnic and racial discrimination that was biological, rather than religious (Proctor 1988). The popularity and acceptance of Gobineau’s theory demonstrates an important paradigm shift in which science replaced religion as the major explanatory force behind human nature.

As more people looked to science to provide biological explanations for human behavior, actions, and differences among members of humankind, the power of science to determine “the origin of human character and institutions” (Proctor 1988, 12–13) increased and it became “an important part of ideological argumentation and a means of social control” (Proctor 1988, 13). By the middle of the nineteenth century, science was seen as the answer to all of society’s problems. While Gobineau’s scientific racism was explanatory and theoretical in nature, once the idea grew and expanded it became part of a political ideology meant to support a power dynamic in which Anglo-Saxons remained the dominant culture (Proctor 1988).

By the first half of the twentieth century, Francis Galton’s theory of eugenics rose to international popularity, formally codifying the idea that all human behavior- positive or negative- was attributable to biology. Prior to the 1930s, all German citizens belonged to the same shared community and were entitled to the same protections. Eugenic theory broadened the spectrum of who could be excluded from this community, resulting in an increase in discriminatory policies focused on those with disabilities and restrictions on immigration (Robertson et al. 2019). Public policies such as the 1935 Nuremberg Laws were a blatant attempt to change the definition of who was to be considered a German citizen, and thus what rights were to be granted to whom. By 1939, there was a clear distinction between Aryans and non-Aryans, between those who were productive members of the Volk and those who were deemed “unfit.” These definitions were not arbitrary. They were created based on a combination of scientific theory and Nazi ideology (Koonz 2003). They were accepted by the public because of the leadership and endorsement of the medical community.

Science had provided an explanation for the cause of society’s ills; it was now the job of the medical community to take the appropriate action to prevent further degeneration of the state and ensure its strength and vitality for years to come.

17.2.2 Medicalization and Dehumanization

As defined by Peter Breggin, medicalization in Nazi Germany referred to “the application of medical ‘diagnosis’ to psychological, social, spiritual, and political problems. The use of diagnoses establishes a hierarchy of superior (allegedly normal) and inferior (allegedly mentally ill) people. It ‘medicalizes’ human conflict, permitting ‘treatment’ of the victims. This fit Nazi ideology and paved the way for ‘selections’ in extermination centers” (1993, 143). Using this type of biomedical model to explain behavioral or psychological variations aligns with eugenic theory because it assumes that there is an inherited, genetic basis to abnormal behavior which predisposes a person to being biologically inferior. Further, medicalization advocates for the use of healthcare practitioners using biomedical means as the primary methodology for dealing with these problems (Breggin 1993).

Medicine was given a prominent role in Nazi Germany and the power and privilege that accompany this position in society. Adolf Hitler gave a speech to the National Socialist Physicians’ League in which he stated, “You, you National Socialist doctors, I cannot do without you for a single day, not a single hour. If not for you, if you fail me, then all is lost. For what good are our struggles, if the health of our people is in danger?” (Proctor 1988, 64) Physicians in Nazi Germany were tasked with finding and implementing a medical cure for society’s ailments, based on the definition of eugenics: “the science which deals with all influences that improve the inborn qualities of a race; also with those that develop them to the utmost advantage” (Galton 1904, 1). Thus, the role of the physician in Nazi Germany was to label and medicalize the inferior and unfit and then rid the nation of this biological scourge.

Physicians defined the category of “unfit” in a way that aligned with eugenic theory while also benefitting Nazi ideology. Following in the footsteps of Enlightenment philosophers, anyone deemed “mentally unfit” was segregated from the community for the good of society. However, Nazi medicine differed from Enlightenment philosophy in its treatment protocols. Many of these people were forcibly sterilized or killed- not because it was in the best interest of the individual, but because they could not contribute to society and were a biological threat to the health and future of the Volk. They were removed from the community of belonging by physicians, and their freedoms, rights, and liberties, including the right to life, were taken from them. The same fate would befall the Jews who were forced into ghettos to segregate them from their Aryan counterparts and ensure that they would not infect the Volk before ultimately being sent to their deaths in concentration camps (Proctor 1988).

When combined with Nazi ideology, eugenics morphed into Rassenhygiene (Racial Hygiene)—a theory that linked the biological concept of race with the German notion of hygiene as a way to control the spread of disease. Racial Hygiene Theory became a call to action aimed at cleansing the nation of Germany of a deadly inherited disease. This social reform movement advocated for public health measures to rid Germany of its inferior genetic stock and purify the nation. The scientific and medical terminology created an aura of trust that further broadened the purview of medicalization to include social issues such as crime, poverty, alcoholism, and other problems that would now be treated with biomedical means (Proctor 1988).

Caring for society became the ultimate goal. An individual’s value was measured by his or her ability to contribute to society. Thus, those who could not contribute to society due to a perceived biological inferiority were seen as expendable and not worthy of the same level of care. The term Lebensunwertes Leben (life unworthy of life) was coined by two German scholars, jurist Karl Binding and psychiatrist Alfred Hoche, and came to encompass the category of people considered unfit in Nazi Germany. Included in this group were (among others): those suffering from congenital mental or physical illness, prisoners, degenerates, political dissidents, schizophrenics, epileptics, homosexuals, those suffering from muscular dystrophy or cerebral palsy, the Roma, the deaf and the blind, and Jews (United States Holocaust Memorial Museum 2019; Kershaw 2001; Snyder and Mitchell 2006; Proctor 1988). People belonging to these groups were viewed as biologically inferior to pure German citizens. Stripped of their status as members of the community of human belonging by science and medicine, physicians had no moral obligation to care for them as they would typically care for their patients.

No longer seen as “individuals,” the unfit were dehumanized. They were “diseases” that needed to be “cured,” for the good of the Volk, and it was the responsibility of physicians to undertake this endeavor. Fritz Klein, a physician in Nazi Germany, declared, “Of course I am a doctor and I want to preserve life. And out of respect for human life, I would remove a gangrenous appendix from a diseased body. The Jew is a gangrenous appendix in the body of mankind” (Lifton 1986, 29). The paradigm shift was complete: the role of the physician was solely to promote the health of the state. Whatever practices supported this objective fell within the purview of the physician, and he was empowered to use whatever means necessary to prevent any threats to achieving this goal. Doctors became involved in every aspect of the persecution and mass murder of millions of people, lending a pretense of trustworthiness to the process. Behaviors that would not otherwise have been legally or ethically acceptable, such as forced sterilization and experimentation, were organized and performed by physicians (Breggin 1993; Colaianni 2012). Diminishing the inherent dignity of the individual person by enacting a system of classification in which people were valued based on their worth to society was a key factor in the process of dehumanization. This allowed physicians to ignore the traditional medical goals of promoting health and well-being and preventing sickness and disease in the individual.

17.2.3 Politicization, Utilitarianism and Caring for the Volk

As we have seen, the role of physicians in Nazi Germany included labeling, othering, medicalizing, dehumanizing, persecuting, and murdering. The sum of these actions was medically sanctioned genocide, a unique occurrence throughout history. This begs the question: what was it about this particular situation that led physicians to willingly accept the unification of medicine and politics as the primary objective of the profession? As Michael Grodin argued, “Joining a political party is one thing; using its ideology to justify the torture and extermination of an entire people is another” (2010, 51). Yet the medical profession played a central role in establishing the Volk as the chief object to be cared for and nurtured. Doctors validated the idea that it was the health of the Volk that must be protected at all costs, and that any and all threats to the Volk must be eliminated (Breggin 1993). This concept—that society was paramount and must be cared for at all costs regardless of what that meant for the individual—represented a confluence of political ideology, scientific theory and medical implementation that resulted in the mass murder of millions deemed unfit.

The political ideals of the Nazi party were to systematically identify, socially isolate and legally persecute the unfit. At the same time, science and medicine were using genetics to better society. The Nazi vision was to use science and medicine to gain total control of the biological process and ultimately ensure the health and strength of the German nation. Incorporating eugenics and race hygiene into National Socialism provided the justification necessary to gain the trust and acceptance of the public. Laws and policies were portrayed as public health measures intended to protect and improve the Volk.

Physicians were empowered to take whatever means necessary to protect the Volk. Their actions could be defended “on the grounds that the Jew, the homosexual, the congenitally handicapped, and the Slav posed a threat, a biological threat, a genetic threat, to the existence of the future of the Reich” (Caplan 2010, 90). Once identified, threats were to be eliminated. There was no need for lengthy explanations or debates. It was science—value free, objective, and neutral. A physician need not explain his rationale for removing one’s burst appendix (Caplan 2010). Similarly, one did not have to provide a defense for removing a biological threat to the Volk.

This justification was offered at the Doctors’ Trial at Nuremberg when physicians were held accountable for their actions as part of an American military tribunal. The neutrality intrinsic to science and medicine was cited as part of the defense: “[I]f the experiment is ordered by the state, this moral responsibility of experimenter toward the experimental subject relates to the way in which the experiment is performed, not the experiment itself” (Nuremberg Trial Transcripts 1946–1947 in Caplan 2010, 88). Using this argument, the physician’s skillset qualified him to perform the actions; however, he did not have the appropriate knowledge regarding moral virtue to determine the ethical validity of the actions themselves. As such, he should not be held accountable for his actions (Caplan 2010). Science and medicine, by definition, must remain objective and impartial.

Diffusion of responsibility was another method used to distance physicians from moral accountability. In concentration camps, such as Auschwitz-Birkenau, responsibilities were often divided up amongst a group of medical personnel. This allowed the individual physician to believe that he was not directly responsible for the atrocities that were taking place (Lifton 1986). Believing that he was a member of a special group entrusted with protecting the Volk provided a rationalization for the physician’s actions. This is what Nazi doctors did. Their responsibility was, first and foremost, to care for society using whatever means necessary to rid the state of its diseased and inferior elements.

However, many physicians did not need any coping mechanisms at all to deal with the medicalized persecution and killing. One of the distinguishing characteristics of being a physician is what Alessandra Colaianni calls the License to Sin (2012, 436–437). From early on in their training, medical students are given permission, and even encouraged, to partake in activities that would be considered unethical, immoral, and illegal if performed by non-medical personnel. This is done in the name of science. Physicians are granted permission to perform acts that, in other settings, would be unacceptable at best and criminal at worst. Under the Third Reich, the License to Sin was even more pronounced. Hitler signed an order in October 1939 (backdated to September 1, 1939, to coincide with the start of the war) that stated, “charged with the responsibility of enlarging the authority of certain physicians to be designated by name in such a manner that persons who, according to human judgment, are incurable can, upon a most careful diagnosis of their condition of sickness, be accorded a mercy death” (Robertson 2019, 25). This was one of the few orders ever put down in writing by Hitler and provided for the establishment of an organized system for the identification, labeling, segregation, and potential murder of the unfit. Hitler’s order was a literal License to Sin that, while never explicitly forcing physicians to do anything against their will, provided them with the power, justification, and defense to choose who would live and who would die. The politicization of medicine allowed those dedicated to healing to kill in the name of the state.

17.3 Medicine in a Post-Holocaust Society

During the Holocaust, the traditional goals of medicine were altered to serve the best interests of National Socialism. Conventional medical ethics was subverted in favor of a professional ethos that ministered to the healthy instead of the sick, the strong instead of the weak, the productive rather than the vulnerable. Medicine during the Holocaust represented the complete abandonment of Hippocratic ethics and the doctor-patient relationship. International outrage surrounded the crimes against humanity perpetrated by those in the medical community. Chief Prosecutor, Brigadier General Telford Taylor in his opening statements at the Doctors’ Trial charged the defendants with “murders, tortures, and other atrocities committed in the name of medical science” (Gallin and Bedzow 2020, 8). However, although the Trial resulted in 16 of the 23 physicians being convicted of war crimes and crimes against humanity as well as the publication of the Nuremberg Code, unethical behavior committed in the name of scientific progress continues to abound (Gallin and Bedzow 2020). As the events of the Holocaust continue to fade into memory and the ability to hear first-hand accounts from survivors lessens with each passing year, it becomes increasingly important to explore and understand how the Holocaust continues to shape the ethics of health, medicine, and human rights.

17.3.1 Lessons from the Holocaust

Using the Holocaust as the historical framework for exploring the ramifications of placing scientific and societal progress ahead of the promotion of individual welfare and human dignity is essential to ensure that the lessons of the Holocaust remain relevant for current and future generations. While the Holocaust can serve as an invaluable educational tool, it must be invoked with caution so as not to overuse the Nazi analogy. There are certain unique attributes of the Holocaust that should be recognized as such. Referencing the Holocaust when discussing current debates in bioethics can seem like an unjust comparison. However, to ignore the motivations and rationales of Nazi medicine when analyzing current issues is to turn a blind eye toward a period of time that many people, particularly those in the medical field, may prefer to forget, despite the necessity of examining these critical perspectives and their implications for modern society (Robertson et al. 2019). After all, “If the Holocaust is like nothing else, it is relevant to nothing else” (Neuhaus 1992, 214). As we have seen throughout the course of this book, the lessons of the Holocaust remain increasingly relevant to the fields of medicine, healthcare, public policy, and human rights—to name just a few. It is incumbent upon us to preserve the legacy of those who perished or whose lives were changed irrevocably by Nazi medicine to use these lessons to shape a post-Holocaust society that reflects upon the past to protect current and future generations.

Conversely, balancing the use of the Holocaust for educational purposes with the need to respect the enormity of the event should not be overlooked. When invoking the Holocaust in any situation, it is important to understand the reason for doing so. In trying to determine what the role of medicine is and what it should be, examining the ways in which the foundations of medicine were corrupted in Nazi Germany can provide valuable lessons for today. Studying the changing moral ethos of the medical profession in the Third Reich and how it led to policy decisions is instructive as its ramifications continue to reverberate internationally. The people have changed, the political ideologies are different, the motives are not the same, but the ideas underlying Nazi medicine and its rise to power are still pertinent to our discussions about the role of medicine and the rights of individuals to be treated freely and equally in society. As Richard John Neuhaus argued.

Of course then is not now, and there is not here, and they are not us…Since those who do it may continue to be in charge, since there may never be the equivalent of the Nuremberg trials, it will be called not Holocaust but Progress. We need never fear the charge of crimes against humanity so long as we hold the power to define who does and who does not belong to “humanity.” (1992, 217)

The best way to protect medicine and the people it professes to serve now and in the future is to continuously reassess the core values of the profession and its role in society, always keeping in mind the lessons of the past.

17.3.2 Medicine: Its Power and Privilege

The medical profession has long been granted a special role in society. After the creation of the Code of the Medical Ethics of the American Medical Association (AMA) in 1847, “the social status of physicians was eventually raised to near-stratospheric heights, based in part on this explicit social contract that demanded altruism, civic-mindedness, devotion to scientific ideals, and a promise of competence and quality assurance through self-regulation” (Wynia 2008, 568). In the early part of the twentieth century, Germany’s medical and academic centers were renowned for being the best in the world, and physicians were treated with the commensurate levels of respect and prestige. Part of Hitler’s strategy was to bestow even more power and privilege upon doctors in the Third Reich, as evidenced by the importance of medicine in Nazi ideology and propaganda. Their ability to determine who shall live and who shall die, and to then execute such decisions, is the supreme example of their influence and authority.

Physicians continue to occupy a place of power and privilege in society. While the motivations behind such choices are different, decisions about who shall live and who shall die remain in the hands of the medical profession. Beginning of life care and end of life care are two major areas that face these challenges on a constant basis. Returning to the earlier notion of shared communities, physicians are still being tasked with determining who is part of these communities of belonging and protection and what types of care they are morally entitled to. These decisions result in a system of classification in which some lives are worth more than others based on definitions of personhood or quality of life. Choices regarding treatment or allocation of resources are affected by these determinations.

Time and again we find ourselves dealing with the issue of defining the self in relation to its value to society. The constant mission to achieve societal progress through personal improvement exacerbates pre-existing distinctions and classifications. What is the starting point for a “good” individual, one who is “normal,” or “healthy,” or “fit? Who is determining this? Once this baseline is established, what are the gradations of physical improvement? How are they achieved through medical means and at what financial cost to the individual? How do personal improvements correlate with societal betterment? This process can reinforce stereotypes, further marginalize minoritized or vulnerable cultures and be used to justify the biological superiority of one group over another (Rose 2009). Physicians are at the heart of this never-ending cycle because they are not only the ones who create the standards for normalcy and the benchmarks for progress, they also develop and implement the mechanisms for achieving these goals.

We have also learned that medicine does not exist in a vacuum. The moral ethos of the profession can be manipulated by outside forces: economic, social, political, etc., that can influence decisions about who will be considered as part of the community of belonging. Political and social conditions affect the medical profession, and these circumstances, which are external to the field of medicine, are constantly changing. Though it may not be ideal, we must recognize this as a fact and cautiously guard against a professional ethics that is overly affected by outside influences (Bruns and Chelouche 2017).

17.3.3 Responsibility of Medicine to Society

Once we accept that medicine exists within a complex system, we must take into consideration the reciprocal relationship between medicine and society. We have established that medicine should be accountable to the individual first and foremost, but what responsibility does medicine have to society as a whole?

Dr. Andrew C. Ivy, medical scientific consultant for the American Medical Association at the Doctors’ Trial stated, “Had the medical profession taken a strong stand against the mass killing of sick Germans before the war it is conceivable that the entire idea and technique of death factories for genocide would not have materialized” (Mitscherlich and Mielke 1949, xi). The focus of the Doctors’ Trial was largely on the unethical medical experimentation and the crimes against humanity that took place in the concentration camps, yet Ivy goes back much further in his criticism of the medical community and their abrogation of responsibility. Using eugenic theory as the justification to kill the mentally and physically unfit was the precursor to the Holocaust. Ivy’s statement places the blame for the decline of moral responsibility and standards of medical practice on the prewar medical community. His comments make clear his belief this was not something that happened overnight. These were not decisions made by a handful of unprincipled representatives of the medical community. This was a failure of the profession to stand up and speak out early on when the foundations of the union between science and politics were being formed and when there was still time to use the power and privilege of the medical profession to put a stop to the atrocities that were to follow.

Hitler knew that to get the public to go along with his plans, the cooperation, endorsement, and leadership of the medical profession were essential. Though there are few examples in modern society of the type of enmeshed relationship between politics and medicine seen in Nazi Germany, the medical community still holds a great deal of influence not only in shaping the perceptions of the general public, but also in shaping public policy and health law. Specifically, regarding controversial issues such as physician-assisted suicide (PAS), there are some who believe that it is the role of the medical profession to actively take a stance as part of their ethical responsibilities. Because physicians are the primary participants involved in the act of physician-assisted suicide, the profession must take a public position on this debate. To choose not to do so relinquishes the moral accountability inherent in the profession (Sulmasy et al. 2018). If those who are most knowledgeable about the action being discussed do not take a stance, this leaves the door open for others who may not have the requisite information regarding the medical aspects of PAS to determine the fate of this contentious issue. In addition, if physicians are ultimately going to have to abide by whatever decision is made, then it would stand to assume that the physicians who make up the professional associations would want to voice their opinions on a topic that will have direct consequences for their practice (Sulmasy et al. 2018).

When exploring the role of medicine in society, another issue that must considered is that of advocacy. Recognizing that medicine does not exist in a vacuum necessitates understanding that the care of patients also takes place within a complex society. While a full examination of the need for advocacy in the medical profession is beyond the scope of this chapter, one cannot ignore the fact that an individual’s health and well-being is impacted by his or her ability and capacity to seek care which in turn is affected by social determinants of health. In “The essential role of physician as advocate: how and why we pass it on,” LeeAnne M. Luft suggests that a definition of physician advocacy must take into account both individual and societal factors: “Action by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise” (2017, e109–e110). Caring for the individual requires an understanding of the relationship between that individual and society and the way in which that relationship influences the individual’s health and well-being. While advocacy can be defined in many ways on many levels, in its most basic iteration, a physician has a responsibility to advocate for the best care of the patient. This cannot be done without, at the very least, identifying and acknowledging the aforementioned social, economic, educational, and political barriers to health. Taking steps to help the patient overcome these barriers is often the only way to achieve the goal of health and well-being for the individual.

17.4 Morality and Medicine After the Holocaust

Debate continues regarding the goals and purpose of medicine. However, in a post-Holocaust society, one aspect of medicine that must not be in question is the significance of using the Holocaust as a historical framework for building a moral ethos that will guide the profession now and in the future. Much of Holocaust education has focused on remembering those who died and ensuring that their stories continue to be told to preserve their legacy. This is, of course, a crucial task and one that should be undertaken with the utmost care. However, if we truly want to preserve the legacy of those whose lives were lost, we must not only remember the past, we must also use those lessons to protect the future. As Neuhaus stated, “The Holocaust began in depersonalizing the victims and ended in depersonalizing the perpetrators” (1992, 214). We cannot neglect the essential mission of identifying the process that enabled medically sanctioned genocide to occur so that we can safeguard history from repeating itself. Just as the victims have names and stories, so too do the perpetrators. They must be held accountable for their actions and the rationale given to morally justify their behaviors (Neuhaus 1992).

Physicians are given a special place in society because their profession is unlike any other. Their power stems from the godlike ability of the profession to preserve and take life. Patients literally entrust their lives to physicians, so to look back on the history of Nazi medicine and see the ways in which doctors blatantly abdicated their moral responsibility to patients, to human life, is alarming. Reading transcripts from the Doctors’ Trial in which physicians attempt to provide ethical justifications for their behaviors by citing science, medicine, utilitarianism, or the belief that they were “just following orders” calls into question the virtue of the profession. In a post-Holocaust society, how can the medicine redefine itself and regain the trust of those it pledges to serve?

17.4.1 Rehumanizing the Patient

During the Holocaust, we saw the disastrous effects of the process of dehumanization. When an individual is no longer viewed as a human being, but rather as an object without any inherent worth or value, it becomes easier to treat him or her using inhumane methods. The moral rationale for exterminating these groups becomes more acceptable (Breggin 1993; Miller and Gallin 2019). While modern medicine may not be experiencing the same type of blatant discrimination and dehumanization witnessed during Nazi Germany, economic and political pressures along with the rise of medical technology are creating an environment where the centrality of the human person is again at risk. There are debates about the economic cost of keeping alive the elderly or people with disabilities who require long term care and whether that money might be better spent somewhere else. Having the technology to prolong the length of someone’s life does not always preserve the quality of a life, and tissues, cells or organs that are kept alive by those machines may be able to help other people (O’Mathúna 2006). The factors being considered when making these decisions and the people in charge of drafting these policies may have goals that are not medical or humanistic in nature directing their choices. Thus, it is not so far-fetched to imagine that society could once again find itself with a healthcare system guided by political or economic forces attempting to do what is in the best interest of society, rather than the individual patient.

As a result, the primary task of medicine in a post-Holocaust society must be to rehumanize the profession. We are living in an unprecedented era of biomedicine in which we increasingly have the ability to alter aspects of the self (Schulman 2008). From personalized genomic medicine to germline genetic intervention, the quest for personal and societal betterment has only increased since the end of WWII as technology has drastically improved. As we continue down this pathway to perfection, we are faced with a challenge: what is the ethical responsibility of the medical profession in protecting the nucleus of humanity? As bioethicist Adam Schulman asked, “Among all the features of human nature susceptible to biotechnological enhancement, modification, or elimination, which ones are so essential to our humanity that they are rightly considered inviolable?” (2008, 16) In order to rehumanize medicine, we must first define what it means to be human.

Like the role of advocacy in medicine, a full examination of what it means to be human is outside the scope of this chapter. However, when attempting to locate the central aspect of humanity, the element that must be respected and protected at all costs, there is one feature that delineates humankind from other species: dignity. Prior to the rise of Social Darwinism, there was a consensus within society that all humans were entitled to certain basic rights based on the religious ideals of the sanctity, dignity, and value of human life. As science began to replace religion as the major explanatory theory of behavior, this view of the inherent dignity of the individual was replaced with the perspective that some lives were worth more than others based on their value to society. This became the foundation for Nazi doctors to persecute and kill those who were not seen as having the necessary value to exist in the Third Reich (O’Mathúna 2006). From an ideological perspective, the link between the inherent dignity of the individual and the rights that are granted as a result was a central characteristic that defined those categorized as part of the community of belonging and protection. Once certain people were stripped of their human dignity, there were also excluded from the community of belonging and protection and vulnerable to the dehumanizing practices of Nazi medicine.

For the purpose of this argument, we can define human dignity as the inherent value of the individual. To further parcel out this definition, “the term ‘inherent’ means ‘involved in the constitution or essential character of something,” “intrinsic,” “permanent or characteristic attribute of something’” (Adorno 2009, 229). In addition, “The idea expressed in this term, when it is accompanied by the adjective ‘human’ is that dignity is inseparable from the human condition. Thus, dignity is an unconditional worth that everyone has simply by virtue of being human.” (Adorno 2009, 229). This definition is the opposite of that used by Nazi doctors. It assumes that the value of a human being is based on their being human, not on the material or functional value he or she may have for society.

Adopting a rehumanized paradigm can enhance the physician–patient relationship at the heart of medicine by reminding the doctor that each patient is an individual human being and should be treated as such. If caring for the individual person is considered to be the aim of medicine, then “no contingent factor—race, religion, economic status, disability, or actions of the past, present or future—can rob a person of the dignity she is owed” (Fernandes and Ecret 2019, 35). Each individual patient is a member of the physician’s community of belonging and protection simply because he or she is a human in need of care. The patient is a person—not to be referred to as a diagnosis or a case or a room number—and has the right to be treated with respect and dignity (Adorno 2009). This kind of professional ethos based on human dignity and equality can help prevent the type of abuse of power and moral corruption that took place during the Holocaust.

17.4.2 Rehumanizing the Physician

Michael Grodin stated, “Medicine as a profession contains the rudiments of evil, and some of the most humane acts of medicine are only small steps away from real evil” (2010, 58). Grodin then went on to give the example of amputating a gangrenous limb. Performed in a surgical setting by a licensed physician, this is an act of healing, but in another context it would be considered criminal and, arguably torturous. The distinctive aspects of the medical profession create an environment where medicalization and dehumanization are necessary tools that allow physicians to process the pain and suffering they deal with daily and sometimes must even afflict in order to heal or cure (Grodin 2010). Terminology such as “battling” or “beating” a disease carries this same mentality of attacking and harming. The moral vulnerabilities that allow physicians to engage in this kind of compartmentalization and utilize these coping mechanisms can be dangerous when combined with a political or economic agenda (Annas 2010; Colaianni 2012).

The ability to clinically detach from both the practice and the patients is another skill that must be mastered by physicians not only to successfully do their job but also to avoid burnout (Colaianni 2012). While empathy is a valuable component of medical practice, a physician must keep a level of clinical detachment that permits her to act in the patient’s best interest while also protecting her own well-being. Robert Jay Lifton refers to this as the “medical self,” which “enables one not only to be relatively inured to death but to function relatively efficiently in relation to the many-sided demands of work (2000, 427). Human emotion should be exhibited when dealing with the patient, but only in the proper amount and when necessary. Likewise, after the interaction with the patient ends, there is an appropriate time, place, and duration for emotion. Too little or too much can throw off the delicate balance of the medical self. The concept of hierarchy is essential to medicine as well, so while one may question the instructions or decisions of an ordering physician, controversial or dissenting opinions are not encouraged (Colaianni 2012).

A post-Holocaust medical morality must focus on rehumanization, not only as it applies to patients but physicians as well. To reiterate Ivy’s comments from the Doctors’ Trial, had the medical community taken a stand against the status quo of killing the sick, it is likely that the Holocaust would not have happened. However, at the time the culture of the medical profession in prewar Germany made this difficult to do. Scientific and moral justifications were offered for killing the unfit. Medical, academic, and military leaders were advocating for the essential nature of medicine in preserving and protecting the Volk. Yet, as Neuhaus warns, to overgeneralize the nature of what took place is dangerous (Neuhaus 1992). To reduce the Holocaust to policies and procedures implemented by nameless, faceless, evil bureaucrats who were just following orders dehumanizes one of the most important events in history, effectively ridding it of its relevance for humanity. The truth is much more nuanced: “It happened one hour at a time, an equivocation at a time, a lie at a time, a decision at a time, a decision evaded at a time” (Neuhaus 1992, 214). Therefore, we must study physician participation in the Holocaust—to understand the moral complexities involved in each step of the process that allowed healers to transform into killers.

Because of the distinct nature of the profession, creating a medical self that allows one to cope with the challenges peculiar to the field is necessary for the well-being of both the physician and his or her patients. The existence of a chain of command, following orders given by superiors and being able to clinically detach from difficult situations can be necessary. However, a rehumanized medical ethos must balance the medical self with a true self based on one’s own personal moral ethos. It must allow the physician to ask questions if something does not seem right, to respectfully disagree, to stand up and speak out against injustice or discrimination of any kind and in any form without fear of penalty or backlash. Only then will the health and well-being of both the individual and the physician be respected and protected.

17.5 Conclusion

It has been three quarters of a century since the world learned of the atrocities committed by physicians in the name of science at the Nuremberg Doctors’ Trial, yet the questions brought to light then still resonate now: What are the goals of medicine? What is the role of medicine in society? Who belongs to the community of belonging and protection? What will physicians do with the great power and privilege that comes with their profession? In a post-Holocaust world in which political, economic, and social forces are increasingly encroaching on moral decision-making within medicine, using the Holocaust as the historical framework to explore the relevance of these questions is essential for building a new paradigm that emphasizes rehumanization and human dignity. Each of us has a responsibility to reflect on the past to protect current and future generations and to ensure that “Never Again” is more than just a rallying cry.