Keywords

2.1 Introduction

Even though the physician’s course is steep and difficult, if he is guided by a constantly urging conscience, and proceeds in faithful duty, he will be accompanied by a joy of responsibility and a sense of readiness to make sacrifices. Only the idealist has these qualities at this disposal (Ramm 2019).Footnote 1

This passage is from the preface to a medical textbook, Medical Jurisprudence and Rules of the Medical Profession (Ramm 2019). A medical professional can certainly identify with these words which, in essence, are what the practice of medicine is about. Medical students select their profession usually because they perceive medicine as a “faithful duty” to do good with inherent awareness, or “urging conscience” that the path will be “steep and difficult” requiring “sacrifices” to be made. Medicine is indeed an occupation that places huge demands on its members who are constantly obliged to question their actions, responsibilities, and their ethics, in other words to be somewhat “idealists.” Reading this paragraph out of context one would accept it as words of guidance for regular medical students, but taken in context, the paragraph attains an entirely different significance. The words are in fact incredible, because they were written in a German medical ethics manual (Arztliche Rechts–Und-Standeskunde) in 1943, at the peak of the Nazi Regime, by a zealous Nazi family physician and educator, Dr. Rudolf Ramm (Bruns 2014a, b).

This is a period in history where all forms of accepted humanitarianism and dignity were convoluted and warped. The Holocaust, the murder of six million Jews and other minorities, was one of the darkest times in humanity, and certainly the darkest in medical history, during which physicians who had sworn to heal and to help, instead, killed and maimed. Yet during this very period, an ethics textbook was issued that medical students were obligated to use and study (Bruns and Chelouche 2017). Ramm, the author, has been deemed “the man in charge of supervising German medical education” (Proctor 1988, 174) and a course, with the same name as the book, was commissioned as required learning at every medical school in Nazi Germany (Bruns and Chelouche 2017).

This may be surprising, or disquieting, due to the widespread notion that the Nazi physicians abandoned or ignored all forms of accepted ethical behavior in their “pseudoscientific” medical research. We know now that this was not “pseudoscience” at all, but rather unrestrained science that intersected with racial policy (Weindling 2017). In the last decades much has been published on the criminal and barbaric actions of the Nazi doctors, especially in the domain of medical research (Annas George and Grodin Michael 1992; Weindling 2017; Roelcke et al. 2014) but little has been said of their motivations (Grodin 2010; Weiss 2005) or their ethics (Bruns 2014a, b). It has been very complex to address the Nazi physicians in the context of morality or ethics (Caplan 2010). For decades after the Holocaust it was easier, and less discomforting, for the medical world to distance itself from this past and dismiss Nazi doctors as having renounced or abandoned all forms of traditional medical ethics (Roelcke et al. 2014). It was comfortable to continue the belief that those Nazi physicians who had engaged in immoral and unethical acts could not have been motivated by any form of ethical stance (Miller and Gallin 2019; Caplan 2010). However, the historical truth is that medical ethics were not ignored, nor were they abandoned. The uncomfortable reality is that the physicians who executed these crimes were of the conviction that their actions were morally and scientifically right (Caplan 2010). These were not incompetent, insane physicians from the fringes of the profession. Many were distinguished, experienced professionals from mainstream German medicine, which was considered to be the most progressive of the time (Aly et al. 1994; Weiss 2005). The German physicians were not coerced to join the Nazi Party, but did so on their own initiative and in greater numbers than any other free profession (Kater 1989). Among them were university professors and experienced physicians who, like Rudolf Ramm, took it upon themselves to inculcate future generations of physicians precisely due to the fact that they believed that what they were practicing and preaching was ethically and morally right (Bruns and Chelouche 2017). In Ramm’s words: “So this book should be a companion and a guide to the student of medicine and to the young physician for his established goal and an adviser to the young person in his choice of profession” (Ramm 2019, x).

Ethical teaching does not take place in a vacuum; rather, it takes on its relevance to the culture and society of the time and has to be sustained by the values of the larger community (Weikhart 2009). Nazi Germany was no different. Ramm, well aware of this, expounds, “Culture, race and spirit of the times affect a physician’s values and manner of engaging with previous problems, according to the standards of the time” (Ramm 2019, 75). In the “spirit of the times,” Nazi ideologues, including Ramm, asked the German people to develop biological attitudes and feelings as part of their racial character in order to form an “ethnic conscience.” The past racially indifferent, bourgeois-Christian morality, deemed responsible for the weakening of the national organism, was to be replaced by a racially appropriate biological humanism (Bialas 2013). This biological political thinking, permeated with ethical reasonings and underpinnings, was perceived by the Nazi leaders and the medical profession as “applied biology” (Proctor 1988; Weikhart 2009). For the very reason that the Nazi policies were so biological in their nature were they so appealing to the medical profession, creating a dangerous symbiotic relationship between Nazism and medicine that eventually served to radicalize them both (Weiss 2010).

It must be emphasized that the participation of the medical profession did not take on a “slippery slope” path as is commonly assumed (Hanauske-Abel 1996). Rather deliberate and careful steps, such as the publication and obligatory study of Ramm’s ethics manual, were taken to ensure medicine’s leading participation in the maleficent eugenic programs in the Nazi state. These physicians were not moral monsters to start out with, even if some of their subsequent actions were evil personified (Weiss 2010, 11). The reasons that they made their choices are varied, but it can be stated with certainty that they were certainly not “pawns” but rather “pioneers” in their contribution to racial hygiene. This contribution led to subsequent heinous consequences, for example transforming scientific orthodoxy in Germany to become supportive of totalitarian politics. Proctor (1988, 38). The challenging task ahead is to reflect and understand how and why this occurred, and not just to criticize and distance ourselves from this history by assuming that we in the present, and maybe the future, are morally enlightened or invulnerable to unethical behavior (Lerner and Caplan 2016). As evidenced by the widespread current international debates on whether to eliminate memorials to various historical figures, this is not a simple task. Studying Ramm’s book enables embarking on this mission because it provides additional insight into the ethical motivations behind the actions of the Nazi physicians. The various medical crimes perpetrated under National Socialism have been well documented in the literature over the past decades, but in this chapter, I will approach these issues through the lens of the material that was published to teach ethics and professionalism to medical students in Nazi Germany. The textbook, considered to be an extremely influential document, and quoted as “Germany’s leading textbook on legal and ethical aspects of the profession,” Proctor (1988) demonstrates what value system they were expected to aspire to in their medical practice, and, in retrospection of the medical atrocities, enables us to somehow understand how and why they did what they did. The original manuscript has now been translated into English, and though the language used is the translation of the old-fashioned German style and is somewhat cumbersome, I have chosen to provide the exact text (cited in italics) to enlighten the readers since this adds a new dimension to the narrative. Many of the chosen passages are self-explanatory, but I have included historical context where needed. If the young students and physicians faced any dilemmas on the morality and ethics behind what was expected of them, Ramm’s troubling text enlightened and guided them in providing the solutions.

2.2 The Development of the Course

At the start of the twentieth century, medical ethics did not exist as a formal teaching subject in medical schools. In many Western countries at that time, medical ethical philosophy was expressed primarily in medical literature and codes of conduct rather than didactic teaching (Jonsen 2000). In the wake of Germany’s defeat in the First World War, fueled by the economic hardship and hyperinflation, crude utilitarian and eugenic thinking intensified in the medical community (Weikhart 2009). The central tenet in the Nazi system was eliminative Racial Hygiene, their view of eugenics, and these philosophies were to be transformed into pragmatic medicalized programs to which the commitment of the medical profession was essential (Proctor 1988; Weiss 2010). Medical students were seen as predestined for the future implementation of Nazi healthcare policy and race ideology because they, in contrast to the older doctors, had grown up and been socialized within the Nazi system (Bruns 2014a, b). A teaching program for medical students to substantiate and legitimize Nazi health policy was lacking. To realize these goals, the Nazis revised the medical curriculum and, in April 1939, introduced newly designed courses in racial hygiene, heredity, population policies, military medicine and the history of medicine (Bruns and Chelouche 2017). Another new subject and corresponding textbook, Medical Jurisprudence and Rules of the Medical Profession, became obligatory for students as well.Footnote 2 This was the first time that students would be required to formally study physicians’ moral and legal obligations to their patients, as well as to their profession and the state. Nazi medical officials established a lecturer for this new subject at all 28 medical schools in the German Reich. With the introduction of this new course, ironically Nazi Germany became the first country in the world to hold mandatory ethics classes in medical schools (Bruns and Chelouche 2017).

2.3 Hierarchy in the Medical Profession: Physicians as Health-Leaders

The revised curriculum provided the method of creating a new type of physician in Nazi Germany, where the whole medical profession was unified into a single political entity subordinated to the National Socialist Physicians’ League, which was hierarchically organized according to the Führer, or leadership, principle (Proctor 1988, 72). This Führer principle emphasized that health care was now to be replaced by health leadership, and the physicians were to become these leaders. Germany was characterized by a ubiquitous sense of hierarchy and obedience, and it was these features, particularly inherent to the medical profession, that were to ensure the future of medicine in Nazi Germany. Ramm explains, “The victory of the National Socialist revolution also meant for the medical community the breakthrough of a new attitude of mind… From this day forward, important regulations concerning the profession were no longer to be made by majority decision but rather by the leadership principle” (Ramm 2019, 41).

As mentioned above, around fifty percent of the physicians in Germany joined the Nazi Party most of whom were young physicians (Kater 1989). Every lecturer in the ethics course was an “old fighter,” i.e., a long-standing Nazi Party member (Bruns and Chelouche 2017), but belonging to a political party does not necessarily ensure immoral action. There was something very appealing for young students or physicians in the demonical blend of Nazi philosophy and medicine, both of which embodied hierarchal values and offered enormous power and prestige (Fernandes Ashley and Diann 2019). These young future physicians could easily identify with the promise of power and omnipotence that would enable them to take the lead, as the top echelons of the community, in solving the problems of post-World War One Germany. Ramm reiterates, “Only the physician of our time who is a true National Socialist will be a pillar of Volk community and a cooperative creator of the German future, which means a Volk comrade, who not only outwardly, but also in his inner heart, makes the biological laws the unique principles guiding his life and behavior, and as a tireless pioneer and preacher, convinces his Volk of the correctness and real truth of these laws. Only with this attitude is he to be an intellectual and moral leader of his Volk” (Ramm 2019, 76). This medicalized attraction to power typifies the Nazification of medicine during this period (Grodin 2010).

2.4 Obedience to Authority—The “Banality of Evil”

In our efforts to try to comprehend the motives for the actions of the Nazi physicians, we come across an expression coined by Hannah Arendt: “banality of evil,” which she used to describe the notion that Adolf Eichmann was not a monster, even though his deeds were indeed monstrous. Rather, the “banality”, or ordinariness, of his personality kept him from questioning Nazi orders (Arendt 1994).Footnote 3 Subsequent research has proven that under certain circumstances most individuals will conform to a majority and obey an authority even if this entails committing acts that are extraordinarily evil (Waller 2007). This has been used as one explanation for physician collaboration (Friedlander 1995), but we learn from Ramm that physicians were taught not just to thoughtlessly obey orders but were indeed expected to be held responsible for their own decisions: “A Compulsion to treat does not exist for the physician” (Ramm 2019, 101). He contextualizes this for the medical profession, and firmly displays his ethical stance that a physician cannot be expected to perform his duty under “impossible” circumstances, and that not every emergency needs to be treated as such. “The physician, being the one responsible for his reputation and his place in the Volk community, is to be allowed to decide for himself to whom and when he allots his help.” He continues, “It is just natural that each physician should determine for himself his own professional obligations in certain respects out of his own drive” (Ramm 2019, 103). He adamantly maintains that in the apparent conflict between the medical community and the legal system, the physician should always be the one to decide. It is thus only logical to conclude from Ramm’s text that physicians in Nazi Germany were taught that they would be expected to use their own personal judgement in exercising their professional duty and that there was no obligation to comply to a higher authority. This is just another example of the huge void between moral teaching and medical practice in Nazi Germany. Unfortunately, only a minute percentage of the Nazi physicians did indeed refuse to collaborate or to obey, and they suffered no dire consequences from this refusal (Friedlander 1995). Even in a culture like Nazi Germany, where obedience to authority was inherent, there was an option for conscientious refusal. They were not all idealists, although some like Ramm definitely were, but most were ordinary people (Browning 1998), who despite their medical training, abused their professional status in participation of murder. Obedience or “just following orders” was a subsequent defense mechanism and not a real motive for action. The Nazi medical students were taught that they their duty was to determine responsibly their choices of action in their practice of medicine. Nazi physicians knew that they had a choice.

2.5 The Physician as Caretaker of the Race

In addition to becoming health leaders, physicians were to take on the role of “genetic doctors” leading the country into a future where the genetic health of society was the central idea around which the community revolved. The transformation that was expected of them was to embrace and internalize the Nazi philosophical viewpoint “which consists, not only as before, in the healing of physical and emotional wounds, consoling his fellow man during misfortune and in the administering of relief at the end of life, but additionally gives this mission priority over his duty to the individual” (Ramm 2019, 76). This change in the direction of physicians’ duty was rationalized: “Even though the ultimate responsibility of the physician goes to the healing of the patients and the perpetuation of life, this responsibility has experienced an essential expansion through coming to grips with biological thinking in the National Socialist state. For our Volk there existed the same danger of decline that led to the present death of the older volkish cultures. Extensive mixing with other mostly minority races, shocking decline in the birthrate, above all among the high class of the Volk, and an unrestrained increase in the lower classes of our population were the alarming signs of the beginning of degeneration and, with that, racial collapse” (Ramm 2019, 117). Race was to become a medical diagnosis, and physicians were the ones who were to administer this racial cure. Medical care was to be shifted away from the individual patient and geared toward the general welfare of the Aryan race, the Volk. Universally accepted medical ethics were to be replaced by a collective ethic of ensuring moral obligation only towards members of the Volk and excluding those of lesser genetic or racial value from the realms of morality (Bruns and Chelouche 2017). Ramm goes into minute detail on the role of doctors as medicalized political leaders and places a great deal of emphasis on the importance of becoming the “physician to the nation”: “As representative and reporter of the National Socialist idea he [the physician] should as a moral duty represent the elements of the party and state to Volk comrades, and should work for their fulfillment” (Ramm 2019, 88).

Immediately after the Nazi takeover, in 1933, a new medical system emerged, whereby all existing medical associations were annihilated and a new Nazi Physicians’ League, subordinated to the Nazi Party was created (Kater 1989; Proctor 1988). This step marks a crucial stepping stone in the “Faustian bargain” (Weiss 2010) between medicine and the Nazi government as the medical profession was not just overtaken by the Nazi political authorities, but rather played an active and premeditated role in the formation of subsequent highly coordinated, medicalized Nazi schemes of forced sterilization and murder. In 1936, the Reich Physicians’ Chamber was established to control private and public medicine with the legal enforcement of the “Reich Physicians Ordinance,” quoted to be the “Magna Carta” of the German Medical Association (Haedenkamp 1938a, b). This important document constituted a formal ethical guideline to medical practice in Nazi Germany, providing “German doctors at last with what they have badly wanted for a long time: a complete code of all those ethical conventions upon which their professional integrity is founded. Many of these closely concern everyday problems of their professional life” (Haedenkamp 1938a, b). Ramm emphasized the importance of the Ordinance by quoting the first paragraph: “The physician is called to the service of the health of the individual person and the entire Volk. He fulfills a publicly regulated responsibility through this law” (Ramm 2019, 86). In order to pursue this elevated status and revered calling he writes, “The personality of the physician must be of a firmly National Socialist philosophical nature and reach a high degree of completeness which arise out of three roots: his nature as a human, his education, and his calling.” According to Ramm “human” is defined as what the Nazis determined as healthy and Aryan: “The physician must be fully adequate, well-formed and harmoniously proportioned in body, clear and sharp intellectually, and deep, strong and kind in his soul. He must combine healthy judgment with composed and stable behavior and must be resolute in his dealing with Volk comrades” (Ramm 2019, 87). So we have here the juxtaposition of the physician as a healthy, honorable, moral human being who is responsible for his own wellbeing and also for the health and treatment of the deserving Aryan ill, but more importantly, whose foremost loyalty is now to the state and not to his individual patients.

2.6 Hippocrates in Nazi Medicine

It may seem indisputable that the words “Hippocrates” and “Nazi” are mutually exclusive, however this chapter proves how factually inaccurate this perception is. Medical historians have demonstrated that the Hippocratic Oath was not ignored in Nazi Germany, but was transformed into a nationalist, racial and collective ethic (Rutten 1996). Some Nazi physicians officially avoided disputing the validity of the Oath, others attributed no particular significance to the Oath, and another group saw their allegiance as belonging to the State in coherence with the Racial Hygiene paradigm of collective ethics (Bruns 2014a, b; Rutten 1996). Ramm imparted his rather progressive view of the “calling” of the medical profession as encompassing both art and science. He attributed the “art of healing” to Hippocratic philosophy, which he deemed eternally essential for the future physician. The Hippocratic Oath itself was an explicit, but not all inclusive, part of the medical students’ education: “It is clear to each person entrusted with the essence of the physician’s profession that a professional Ordinance cannot deal exhaustively with all medical professional duties, and that there are certainly pure moral demands which can be taken to be striving for the medical ideal, which are perpetual, like those already laid down in the Hippocratic Oath, and which thereby have created estimable medical ethics up to the present time. The deeper this unwritten law becomes incorporated in to the soul of the physician, the more encompassing it comes to be expressed in his actions, the more pronounced becomes the bearer of such a professional conception, the more he will be an effectively good physician, as a representative of the ideal that we recognize in the concept of ‘The Conception of Medicine’” (Ramm 2019, 86). It is evident from this passage that the ethical principles of the Oath were considered meritorious and valid for the moral compass of the Nazi physician, and students were explicitly conditioned not to ignore it. There were, however, additional factors to consider: “In addition to these [laws and regulations] there are even higher moral viewpoints completing the obligations of the physician, which arise in the concept ‘Medical Ethics’” (Ramm 2019, 86). According to the Nazi perspective, the new medical ethics encompassed the moral duties of the physician, not contradicting Hippocratic values but rather complementing them. Ramm explains what he means by the moral duties: “Out of tradition, each profession and each occupation cultivate a special professional honor and demand from its members a definite moral attitude in its individual Volk-comrades in regards to the Volk community” (Ramm 2019, 86). This Hippocratic ethic and art of caring was to be applied only to certain sectors of the community who were deserving of a good “trusting relationship” between them and their physicians. This trusting relationship demanded that the treating physician inform the patient if any danger was involved in the treatment, but this was enacted according to the coercive and paternalistic ethic: “While the physician is also obligated to explain to the patient about the necessity and possible consequences of an operation and make its performance in general dependent on his agreement, there are often cases in which the patient is obligated to endure the intervention if he wants to run no danger of losing his social security to which he is otherwise entitled” (Ramm 2019, 108). He does not specifically use the term “primum non nocere” but addresses the ethics of doing no harm and medical confidentiality in the liability context of negligence: “In the relationship of the physician to his patients the liability of the physician plays no small role. Most legal proceedings against physicians are not because of a violation of the duty to explain or because of professional secrecy, but rather are carried out because of an unsatisfactory therapy brought about by presumably incorrect diagnosis which led to damages to the patient” (Ramm 2019, 108). In accordance with the beneficence principle of the Oath, Ramm teaches physicians to treat the patient according to his best ability: “A physician should not use any therapeutic technique that he himself has not mastered” and that a physician should always use the “best means of healing” at his disposal (Ramm 2019, 109). He writes that the highest duty of the Nazi physician is to be vigilant with the use of “highly potent medical modalities and poisons” and to ensure that the doses of these medications are not too “strong” (Ramm 2019, 91). This is once again cruelly ironic because contemporaneous with the compilation of this manual, Nazi physicians involved in the “euthanasia” program, some of whom were lecturers in the ethics course, were at the peak of doing precisely this: poisoning their patients (Aly et al. 1994).

2.7 Bad Genes

By the third decade of the twentieth century, eugenics, the belief in science as a tool to reform and advance society, was widely accepted and became a popular international social and scientific movement (Weiss 2010). In Germany, the eugenic movement was led by physicians who enjoyed extraordinary prestige, which reinforced their view of themselves as the one professional group possessing the expertise to safeguard the health and the welfare of the nation (Weiss 2010). The meaning and uses of eugenics were not the same in every country and were interpreted differently in different cultures. Among the strongest intellectual and institutional ties within the international eugenics community were the ones between mainline American and German practitioners (Weiss 2010; Black 2003). In early twentieth-century Germany, eugenics was based largely on Darwinian inegalitarianism that contributed to the devaluing of the “inferior” in society. This emphasis on biological inequality and evolutionary ethics stimulated physicians to categorize people as “superior” or “inferior.” In answer to the question of who were inferior, a German physician provided this crude reply: “The sick, the weak, the dumb, the stupid, the alcoholic, the bum, the criminal; all these are inferior compared to the healthy, the strong, the intelligent, the clever, the sober and the pure” (Weikhart 2009). After the tremendous defeat in the First World War, a huge shift occurred in the minds of the German eugenicists, the majority of whom were physicians who saw themselves as being responsible for restoring the devastated nation (Weiss 2010). During this period, the German government took a great interest in eugenics and human heredity, which were conceived of as scientific tools needed to construct a welfare state. It was understood that healthy people of good genetic stock, the “superior,” were valuable resources to society, and much effort was put into various programs to promote eugenic ideas within the country (Weiss 2010). This development went hand in hand with a process of weakening humanist ethics centered on the individual, as physicians now propagated nationalist selective ethics defined on the basis of medical and racial criteria of inclusion and exclusion (Bruns and Chelouche 2017). It was argued that the sick, disabled or those with “bad genes” posed a huge burden to the state, and discussions began to take form on the value of human life from a medical and an economic point of view (Weikhart 2009). But most German eugenicists generally did not believe that their country was ripe for practical measures yet, even though the scientific literature was saturated with harsh terms such as “useless eaters” and “those unworthy of living” (Binding 2012, originally 1920). So, we see that eugenics, or the synonymous German term racial hygiene, was in fact not a Nazi conceived notion, but an accepted science that existed in the world long before the Nazis conceived of their murderous programs. It is important to understand, and not to underestimate, that the turning point came only with the Nazi takeover in 1933. Only after the Nazi’s rise to power with the view that everything sick, alien and disturbing were to be cleansed from society (Aly et al. 1994, 15), was it possible to act on these egregious concepts, with Nazi Germany becoming the only country in which the eugenic medicalized programs were to play out to the extreme. With the Nazis in charge, the “useless individuals” and those with “bad genes” would pay the price for these policies with their lives (Muller-Hill 1998).

The Nazi medical conception of the morality behind this rhetoric of inclusion and exclusion can be better understood from Ramm’s passages. He provides us with ample material on the importance of equitable care for patients, just not all patients: “In the help of the sick, the physician is not allowed to make any distinction between high and low, poor and rich. Each genetically healthy person must possess the same value for him whether he takes advantage of his help for money or demands it as God’s wages” (Ramm 2019, 89). The significance of this was that only people belonging to a certain genetic group, or race, were considered as being worthy of receiving medical care and ethical consideration. It was morally right to treat only certain groups within society for the greater good, and equally morally right to exclude other groups as not deserving of the same attitude or treatment due to their perceived hereditary worth. “As old as the science of healing itself is the responsibility of the physician to stand by the sick and weak person during his physical and psychological suffering and to help strengthen him. Equally as important from the standpoint of the Volk, is the pure preservation of blood through prevention of bastardization by bad qualities or foreign racial elements, as well as the responsibility for the protection of the genetic wealth, the preservation and improvement of the genetic predispositions and the complete eradication of the mass of bad genes” (Ramm 2019, 89). This resonates as Nazi propaganda but is actually the basic principle that lies behind the ethical teaching of every medical student in Nazi Germany. The duty of the Nazi doctor was now expanded. In addition to his duty to care for his “genetically well” patients, he was ethically obliged to care for the “preservation of the blood” of his nation by dehumanizing those who were considered to be a danger to the genetic health of society, and as such were now deemed morally eligible for “eradication”. This process of negative eugenics, validated by the internalization of the dehumanization of certain patients who were perceived of as being unworthy human beings, allowed for physicians to justify actions that would be otherwise considered as immoral.

2.8 Antisemitism in the Medical Profession

Antisemitism was an inherent feature of Nazi medical ideology. One of the first steps taken in the newly formed Nazi regime was the removal of Jews from medical practice, both academic and clinical. (Kater 1989; Proctor 1988). In reading the textbook we realize the extent to which the Nazi physicians internalized and embraced antisemitism as inherent to, and acceptable with, medical and ethical norms. Ramm praises the new antisemitic directives: “One of the first measures of the National Socialist Physicians leadership was the cleansing of the profession of politically unreliable and racially foreign elements, so long as the medical benefit for the Volk population was not endangered” (Ramm 2019, 42). “Cleansing the profession” refers to the expulsion of the Jewish physicians from medicine in 1938, whose licenses were revoked and who were no longer considered doctors, but rather healers permitted to treat only fellow Jews (Kater 1989). “One can however today already grasp the blessings which are important to life and to our Volk in the offices of the states that have emerged after the forceful expulsion of the Jews from the profession” (Ramm 2019, 42). He rationalizes the self-righteous persecution and marginalization of Jewish physicians: “It was the Jew who forced some German doctors into a crass materialistic employment of professionally unworthy methods of competition; the Jew who endangered the German Volk, and the one who through extension of his souls-poisoning ideas, enabled the destruction of germinating life while generating the impression, through his methods of advertising in wide circles of the population, that he was indispensable as a medical researcher and medical practitioner…Today no full-blooded German would allow himself to be treated by a Jewish doctor” (Ramm 2019, 42). Although these passages read as blatant racist propaganda, they are in essence what was deemed morally right to teach medical students in Nazi Germany.

Jewish medical students also were affected by the wave of overt brutal antisemitism. During the Weimar years a numerus clausus was established limiting the percentage of Jewish students, with the real objective of total exclusion of Jews from higher education and university life. Jewish medical students were excluded, provoked and discriminated against by the German professors (Weyers 1998). Many of the students in Ramm’s, and his colleagues’, classes would have been taught by these Jewish professors who now, under the Nazi regime, were expelled and forbidden not only to teach, but to practice as well.

Another facet of antisemitism in the medical profession, in line with the political discourse, was the perception of the Jews as contaminating the nation (Muller-Hill 1998). For professionals who deal with issues pertaining to contamination as a regular part of medical practice, this concept was particularly salient to the German doctors (Haque et al. 2012). In an attempt to give the Nazi race philosophy the appearance of true science, research was performed to prove that Jews, and other minorities, were more affected by certain diseases and had a genetic predisposition to criminality. (Weyers 1998; Weiss 2005). In accordance with the ethical notion of care for the genetic health of the nation, Jews and other minorities who were perceived as contaminating the genetic pool of the German citizens were not eligible or deserving of regular medical care. This perceived danger of “blood mixing” was realized by the passing of the 1935 Nuremberg Laws, thus putting policy into practice. These laws included the Reich Citizenship Law, determining that only “pure blooded Germans” would be given political rights; the Law for the Protection of German Blood and German Honor, prohibiting marriage or sexual relations between non-Jews and Jews; and the Law for the Protection of the Genetic Health of the German People, also known as the Marriage Health Law, requiring couples to submit to “genetic” medical examinations before marriage. These laws, conceived, compiled, and implemented by physicians were regarded as public health laws (Proctor 1988). Ramm elaborated on them with words of immense pride and praise: “[The Nuremberg Laws] were energetically pursued and are the milestones on the way towards re-winning racial unity and the promoting of the genetic health of the German people. They serve to improve the health and the higher development of the genotype of our Volk through extermination and selection” (Ramm 2019, 118).

2.9 Selection and Sterilization

Ramm continues his praise for the racial hygiene laws by including long passages on the 1933 Sterilization Law, or the Law for the Prevention of the Genetically Ill Offspring. A great deal has been published on this law (Muller-Hill 1998; Proctor 1988) but reading it from the textbook undoubtably sheds new light on how this was to be dealt with from an ethical perspective. The Nazis argued that existing principles of healthcare and social welfare encouraged the reproduction of people with little value who would soon out-number the nation’s valuable citizens. To maintain the health of the nation, it was mandatory that the reproduction of certain citizens be restricted. In order to put this policy into practice, a compulsory sterilization program was legalized on eugenic grounds (Muller-Hill 1998; Proctor 1988). With unambiguous support of the Sterilization Law, Ramm proclaims: “Sterilization can be forcefully carried out in some cases of refusal, but can be avoided through prolonged placement of the genetically ill person in a closed institution, if the family can bear the resulting cost. In so far as the house physician can bear the influence of the decision on the involved family, he should set the plans in place for the operation” (Ramm 2019, 125). The Nazi physicians did indeed “set the plans in place,” and this program of legal compulsory mass sterilization of the ill and the disabled was to transform the German medical profession (Muller-Hill 1998). This was not intended to be a racial law, and it was not geared specifically against the Jews. Rather, it aimed to eliminate an entire generation of what were considered to be genetic defectives. Eugenicists in Germany and other countries prior to the Second World War had viewed compulsory sterilization for certain categories of people as a means of improving the state of the nations, and indeed in many countries thousands of people were sterilized against their will or without their knowledge (Black 2003). Germany was largely influenced by these countries, especially the United States, but the rise of the Nazi dictatorial regime, which conferred race and heredity as a cornerstone of its ideology, partnered ideally with the eugenics movement, and the practical implementations of this sterilization program were far more extreme than in other counties (Weiss 2010; Proctor 1988). We read how the Nazi medical student was taught that this highly immoral program was in fact considered ethical, as Ramm praises the basics of this law to his students: “The genetic health of the coming generation depends on his [the physician’s] conscientious application of the law” (Ramm 2019, 119). The “conscientious application” meant that in practice those deemed disabled or born with other conditions perceived of as hereditarily detrimental, were to be reported and forcibly sterilized by physicians, after special heredity court physician judges determined their suitability. These conditions included various forms of mental, physical and social impairments or disabilities such as mental illness, schizophrenia, manic depression, epilepsy, blindness and deafness and any form of physical deformity. Ramm expounds on this to his students: “In order to prevent any discomfort in the population as a consequence of this law and to be sure of an understanding acceptance in all Volk circles, it is the superior responsibility of the physician to put himself in a position where he can clarify and advise the Volk regarding the goal of this law” (Ramm 2019, 122). Students are told one of their duties as “genetic doctors” is to recognize the genetic sickness in the community or the institution and to impart to the family that their relative’s reproductive right has to be sacrificed for the greater good of the Volk community. In recognizing that under certain circumstances this might have been a very difficult idea to accept, both on the part of the family and the physician, the paternalistic function of the doctor is emphasized. There is no discussion about the need to obtain a person’s consent (a concept that was universally foreign to medicine in those days), but in recognizing that this may pose a moral hurdle, Ramm explains that the duty of the physician is to persuade the family, despite possible refusal or objection, that this medical procedure needs to be performed: “With the application of this law, we must, with great circumspection and special consideration to the feelings of the Volk, give clarification especially to the sense that the law is not demanding expiation for some guilt, but that the one affected has a tragic fate to thank for his genetic illness and that his elimination as a link in the chain of genetics represents a sacrifice in the interests of the Volk community” (Ramm 2019, 122). In accordance with the Nazi notion that the citizens had a “collective and personal duty to be healthy,” (Bruns 2014a, b) Ramm explains that a person, or a family, with a genetic condition has a “tragic fate” whose destiny lies in the hands of his caring physician whose duty is to “give psychological comfort to the genetically valued family and relieve them of their anxiety if they have a genetically ill member” (Ramm 2019, 122). In continuance with the Nazi demand for every German to be healthy, opposition to the sterilization procedure was perceived of as being immoral, or as Ramm writes, to be “false humanity”: “….the choices of cases must take place with great conscientiousness, with simultaneous consideration of the highest principles of all the physician’s activities so as not to cause injury, keeping in mind the many secret and public opponents of this law, who under cover of false humanity, seek to sabotage our racial hygiene measures” (Ramm 2019, 124). Some medical students wrote their doctoral theses on sterilization cases, proclaiming the virtue of the law and even attempting to reconcile this practice with the Hippocratic Oath (Duello 2010). The number of German patients who were forcibly sterilized is estimated to be approximately 400,000 (Proctor 1988).

2.10 Positive Eugenics

Negative eugenics played out in the form of the Sterilization Law. Positive eugenics was also to be an integral part of Nazi medical practice. In studying the Marriage Law, students were instructed that their role was to oversee marriage by ensuring that only genetically fit couples were permitted to marry. The Law determined that prospective couples were required to receive certificates of genetic health from public health physicians (Proctor 1988). Ramm perceives this as one of the “most pleasant” duties and provides detailed discussion: “The prohibition of marriage between a genetically ill person and one healthy is intended, on the one hand to prevent the generation of a genetically ill offspring, and on the other, not bind people with a healthy capacity for reproduction to a genetically ill partner.” Ramm explains how the physician should approach this issue: “For the physician, the completion of the clearance for marriage certificate does not exhaust his acts as caretaker of the Volk. Being knowledgeable on the genetic predispositions of the family entrusted to him, and given his knowledge and experience on the occasion of every consultation and each visit, during which questions of marriage and reproduction are brought up, he is to advise and clarify, and where he sees danger, effect limitation and hindrance. By the close contact with which he cultivates his charges, and by which he is in the position to practice great influence, there exists for him the high duty to recommend to one or the other Volk comrade, that they only go into a marriage in which there is to be expected no genetic damage to the offspring, but additionally and above all, there is also to be hoped an increase in the genetic value through the joining together of high valued marriage partners” (Ramm 2019, 127). With this self-explanatory rhetoric, Ramm elucidates another way in which the trusting relationship, essential to medical practice, between physician and patient is to be exploited.

2.11 The Ethics of Medical Gender Policies

The Nazi conception of women, as reproductive rather than political beings, was enshrined in legal doctrine (Proctor 1988; Bock 2004). Many laws and regulations, some mentioned above, were passed to ensure that the biological reproductive function of fit Aryan women was preserved, and they were encouraged to have as many healthy offspring as possible, with contraception being forbidden (Proctor 1988). In his text, Ramm stresses the importance of maternal health, care for pregnant women, post-natal care and the essential role that physicians should play in “preventative medicine for mother and child” as integral to the care for the German nation. “The female sex is the bearer of the coming generation of our Volk and has therefore a justified right to be acknowledged by everyone in respect to its high responsibilities and achievements, especially by the physician” (Ramm 2019, 90). These passages, out of context, would be accepted in today’s world, but when read in context, another light is shed on the sexist Nazi conception of reproductive health and women’s rights, which was embraced fully by the medical profession. The students were taught that one of the physician’s duties in the racial state was to “induce the genetically healthy high valued family to have as many children as possible and tell the less valuable family, or family with endangering biology, that they, in the interests of the maintenance of the racial worth of our Volk, must remain child-poor or childless” (Ramm 2019, 130). Medical advice was provided to fight infertility, and scientific research was carried out on fertility, including notoriously brutal human experiments (Weindling 2017). Ramm does not explicitly address human experimentation in his text.

2.11.1 Abortion

What he does address is abortion: “There is a moral duty for every physician to strengthen the desire to have children and thereby guarantee the future of the Volk. As a logical consequence of this, it must be taken to be self-evident that he cannot carry out or recommend, without an extreme degree of justification, any means which leads to contraception, and further that he is permitted to perform an abortion and sterilization only in a legally determined capacity. Thus, it is one of the most noble responsibilities of the physician to protect a germinating life and to carefully guard over it to see that it is not destroyed” (Ramm 2019, 94). This passage is included in the section on the Criminal Law Code because abortion was legally forbidden for a healthy German woman, and for the performing physician, unless the life of the mother was in danger (Proctor 1988; Bock 2004). “There is an iron law of this code of honor that the German physician agrees to perform an abortion only if there is a danger to the life of the pregnant woman. Therefore, let this be a warning to each physician that anyone who does not keep to this prescribed way will have his license revoked by the Reich Physicians’ Leader, even if there are mitigating circumstances for the perpetrator. Whoever weakens the Volk community through abortion of a fetus is to be placed on the same plane as a traitor to the country and Volk” (Ramm 2019, 92). Surprisingly, he does not include the Nazi stance on permitting, or even demanding, abortion for eugenic and racial reasons, which was included as an amendment to the original Sterilization Law, allowing abortions for those already slated to be sterilized (Chelouche 2007).

2.12 Confidentiality

The Reich Chamber Ordinance underlined the importance of confidentiality (Haedenkamp 1938a, b), and Ramm echoes this in what he calls the “duty of silence” as a basic tenet to the trusting relationship between physicians and patients. “The Professional Ordinance puts a very heavy emphasis of protecting the physicians’ duty of silence, which is understood to be the protection of each secret that has been entrusted or accessible to him as a physician… This duty of silence is to be adhered to not only during the life of the patient, but even after his death” (Ramm 2019, 91). However, there were exceptions to this rule, and in cases of certain “behaviors” or genetic illnesses endangering society, the physicians’ higher duty was to report these cases (Proctor 1988). A physician in Nazi Germany could be punished for abusing the doctor-patient confidentiality in treating certain patients, but with regard to genetically-inferior patients the physician was obligated to report on their conditions and to ignore or disregard these patients’ rights to confidentiality. This approach can be understood in the discussion on the Sterilization Law. “If, however a sickness, behavior or genetic trait conceals the individual danger to the Volk community, then there is a higher viewpoint which transcends the duty of silence, leading to the duty to report and thereby serve to protect the community. We are thinking here of notifying the health authorities of overwhelming sicknesses and the reporting of genetic illness for the purpose of sterilization” (Ramm 2019, 92). This is just another example of the disparity of the values and ethics that were integral to the Nazi medical profession.

2.13 “Euthanasia”—The Connection to the Final Solution

Ramm poses the question: “Is the ethical duty of the physician to give, through some intervention or means, release from incurable suffering?” (Ramm 2019, 94).

The term “euthanasia” literally means “good death,” and is most commonly understood today as the bringing about of a merciful death for the terminally, irreversibly ill who are suffering and are in pain. There are two main reasons why it is imperative to include euthanasia in the discourse on Nazi medicine. The first reason is that in Nazi Germany “euthanasia” was demonically used as a euphemism for a devastating state-sponsored medicalized program of the murder of disabled patients by their physicians and nurses (Muller-Hill 1998). “Mercy killing” had been the subject of discussion in the medical ethics field for many years preceding the Nazi takeover. As early as 1920, two eminent German scholars, jurist Karl Binding and psychiatrist Alfred Hoche, proposed the most radical solution to the problem posed by the institutionalized disabled in Germany in their polemical work entitled “Authorization for the Destruction of Life Unworthy of Life” (Binding 2012, originally 1920). Drawing on eugenics, they introduced the idea of “life unworthy of life” and called for the legalization of “mercy killing” for the “mentally or intellectually dead”, who were perceived as being a social and economic burden on society. Although implementation of this radical solution was not possible during the period of the democratic Weimar Republic, the book launched a lively debate in scientific circles. As war approached in 1939, the Nazi regime moved to adopt more radical methods of exclusion, and practices that would have been impossible in peacetime became possible during wartime. Coinciding with the outbreak of the war, a “euthanasia” program commenced with the murder of disabled children in around thirty specially established “children’s wards” in various state hospitals throughout the country, where specifically selected physicians and nurses killed pediatric patients by starvation or overdoses of sedative drugs. These killings continued throughout the war, and it is estimated that at least 5000 children were victims of this malevolent medical program. Subsequently, the Nazi government broadened the killing process to include adults in what is known as Operation T4 (Robertson et al. 2019). Instead of protesting against this immoral medicalized murderous program, the physicians, who were well aware of the unethical aspect of this program and fearing possible prosecution, asked for a law to legalize it (Aly et al. 1994; Muller-Hill 1998). They never received the requested legislation, but instead relied on a document, personally signed by Hitler, authorizing physician compliance in murdering their patients under the guise of mercy killing (Muller-Hill 1998). As Hermann Pfannmüller, one of the “euthanasia” centers’ head physicians, rationalized, “At this point, I for one, consider it appropriate to openly and expressly point out the necessity that, when treating the life unworthy of life, we physicians take the final appropriate action of eradication” (Hohendorf 2016).

Physicians determined and reported which patients would be killed; they aided in establishing six killing centers to implement this task; they experimented on the best method to kill patients, deciding on gas as the killing agent in specifically built gas chambers; they supervised the transports of patients from the various institutions in the Reich to these killing centers, where other physicians decided, on the basis of records alone whether the person would be killed; they operated the gassing process personally, and then determined and pronounced the deaths of these patients; they performed autopsies and other experiments on various body parts of the victims; and finally they sent fake death certificates and ashes to the victims’ relatives. In August 1941, Hitler ordered these killings to be halted due to pressure mainly from the Church, but despite this, the medical staff continued to murder their patients with fatal doses of medication or starvation up until the end of the war (Hohendorf 2016; Robertson et al. 2019).

This “euthanasia” program was being implemented while Ramm wrote his manual. He elucidates his viewpoint for his students: “One of the most noble responsibilities of the physician is to protect the life of the older and weaker people, even if they appear to have lost their mental capacity due to the severity of their illness, and to take them carefully into his protection so as to alleviate their pain and suffering according to his best ability up until the entry of releasing death.” (Ramm 2019, 94). He proceeds to point out that according to the law, mercy killing is forbidden, even if it entails the relief of suffering. He then continues with the use of the term “euthanasia” to describe the position that physicians were expected to adopt in the cases involving the disabled or genetically inferior patients: “The problem of Euthanasia extends however to people afflicted with intellectual and physical genetic illnesses, who can never develop normally and are always arrested at some low developmental level, especially in people in whom genetic traits produce later disintegration of their intellectual personality. This merely vegetative creature places a terrible burden on the Volk community to the extent that it drives down the living standards of the remaining family members, and requires a person to care for it during the remainder of its life” (Ramm 2019, 95). We can, once again, understand that the Nazi medical ethical perception of the value of life had contrasting positions. For the genetically fit dying Germans, compassionate care was to be provided until their final days, but the genetically disabled and infirm, who in most cases clearly were not suffering from terminal illnesses but were posing an economic burden on society, were “vegetative creatures” not worthy of living. “If a person is burdened by a terrible agony from an incurable suffering or if the intellect disintegrates from continuing derangement, then doubtless on the grounds of humanity, euthanasia would be appropriate to consider. It is the responsibility of the medical profession to be the forerunner in this consideration and the responsibility of the state to confer this on him as a force of law” (Ramm 2019, 95). As mentioned above this never became a force of law, but this did not prevent physicians, together with other medical staff, from murdering an estimated 300,000 adult patients under the guise of mercy killing (Hohendorf 2016).

The second reason for the importance of discourse on the “euthanasia” program was that it was in effect the opening act of the Nazi genocide, the Holocaust. Jewish disabled patients were murdered in the T4 killing centers just because they were Jewish, forming the earliest link between “euthanasia” and the Final Solution. In 1940, German concentration camps were growing in number and size, but did not yet possess the facilities to kill the rapidly growing number of inmates. To reduce the population, the SS therefore turned to the T4 personnel to utilize their killing capabilities. Thereafter, a new killing operation commenced, designated as “Special Treatment 14f13”, during which SS camp physicians selected disabled and Jewish inmates to be sent to T4 physicians who murdered them in the T4 centers’ gas chambers, proving yet another link in the chain between “euthanasia” and genocide. Subsequently in June 1941, the German army invaded the Soviet Union, embarking on mass executions of Jewish civilians, among whom were disabled hospitalized patients. When the civilian mass murders proved to be too public, a better method was searched for and concentration camp staff turned, once again, to the T4 personnel, among them many physicians, for their expertise on how to construct gas chambers and which gas to use, based on the use of gas chambers in the T4 centers (Friedlander 1995; Robertson et al. 2019).

This was simple murder in disguise and could have been implemented without the actual participation of trained medical staff. Physicians realized what they were doing as they witnessed the agony of their victims but nevertheless, continued to inflict killing as part of their medical work. These physicians were not compelled to comply with the directives. Even when the “euthanasia” program was officially halted in 1941, they consciously decided to continue the killings (Friedlander 1995). The physicians who participated in murdering their patients were mostly young physicians (Friedlander 1995), who had graduated in the early years of the war when Ramm’s textbook was used as an integral manual for their compulsory courses on medical ethics. Some of the lecturers in the ethics courses were actively involved in the “euthanasia” program while simultaneously delivering classes on medical ethics to their students (Bruns and Chelouche 2017). The entire medicalized killing enterprise that had started in January 1940, with the murder of the most helpless and vulnerable human beings, the institutionalized handicapped patients, had expanded in 1941 to include Jews and Roma (Gypsies), and had by 1945 cost the lives of at least 6 million men, women, and children (Friedlander 1995).

2.14 Conclusion

Reflecting on the ethic of medical practice in Nazi Germany through the lens of Ramm’s book illuminates the fact that medicine under the Nazis cannot be conceived as arising from an absence of morality. Nazi physicians did not abandon, nor did they ignore ethics. As with every ethical system, including our present one, the Nazi medical ethic was greatly influenced by the political and social culture of the time, and a twisted, corrupt Nazi version of medical ethics was created to rationalize and substantiate their health policies. The Nazification of the medical profession was a long and deliberate process and was accomplished with the assistance of the whole German medical profession, including distinguished physicians who, like Ramm, provided ethical justification for the unethical practice of medicine. We cannot dismiss the Nazi physicians without contemplating how they functioned. We cannot distance ourselves from this history by claiming that it is irrelevant. Even though it is largely unknown and untaught, every aspect of modern medical ethics has been, and continues to be, profoundly affected by the acts of the Nazi physicians during the Holocaust (Wynia et al. 2015). The reading of this important instructive manuscript, with the aim of trying to understand under what circumstances it was published and how it was used, serve us well in reminding us that ethics instruction does not ensure future virtuous medical practice. In addition, the existence of codes and directives and in this case, ethical textbooks, does not assure moral integrity. In fact, Ramm’s work shows us just how training and education can be used deleteriously. Medical professionals, and medical ethics teachers, would be wise to use this part of medical history to inform the modern medical ethics discussions, because internalizing this history can contribute to future physicians’ realization that they are not invulnerable to unethical or immoral conduct. It can serve to remind us that in certain circumstances, physicians can be at risk of repeating these behaviors, in some form, if we do not recognize our own capacity for moral transgressions (Waller 2007). Using the platform of studying medicine during the Holocaust, including reflection on Ramm’s textbook, can aid in educating students on their path to becoming future physicians where they will be called upon to reflect constantly on their ethical and moral views. This study can remind them to be vigilantly observant of external factors that may affect their decisions and can assist in emphasizing the importance of retaining their personal empathy (Horton 2019; Reis et al. 2019; Levine et al. 2019). Medical training is naturally hierarchal and tends to encourage a culture of subordination, especially in a culture like Nazi Germany, but our crucial role in education is to remind students that it is essential to realize their ability to differentiate right from wrong, even when they may be taught otherwise.