• Education
• eugenics
• euthanasia
• history of health ethics/bioethics
• torture and genocide

On a rainy day in Oświeçim, Poland, I stood next to the rusty railroad tracks leading into Auschwitz in the same place where Nazi doctors performed ‘selections’, sentencing millions of innocent people to death or imprisonment by pointing left or right. Although I had spent weeks studying the role of physicians in the Holocaust as part of the Fellowships at Auschwitz for the Study of Professional Ethics, I was incredulous. The value of physicians to the Nazi regime is clear: their support gave scientific legitimacy to the principles of eugenics on which the Nazis built their Rassenpolitik (racial policy) and rationalised murder under the logic of medical necessity. Indeed, without active physician participation, the Nazi regime could not have achieved its murderous aims so efficiently: physicians disguised the horrors by systematising them and cloaking them in misleading medical jargon. In so doing, they subverted their own professional values. How could so many who had sworn to do no harm have become such an integral part of murder and torture?

What is perhaps more disturbing is the fact that the Nazi regime was neither the first nor the last to facilitate the transformation of physicians into murderers. Physician involvement in torture and murder has been a stain on the profession throughout history.1 In just the last decade, American physicians have been accused of murder in the form of ‘mercy killing’ during the worst of Hurricane Katrina2 and torturing prisoners in Guantánamo Bay.3 If we include murder committed in the name of scientific advancement, the number of physician perpetrators increases still further.

In discussing this issue with medical peers, I have encountered two insufficient explanations. The first is that any physicians who murdered innocent people during the Holocaust were by definition psychopaths, and would have been monsters even if the Nazis had never attained power. I find this explanation unsatisfactory due to the sheer number of physicians who participated: by 1945, half of all German physicians had joined the Nazi party, 6% before Adolf Hitler gained power (by contrast, estimates of physician membership in the American Medical Association are far lower, approximately 20%). Furthermore, 7% of all physicians were members of the Schutzstaffel (SS), compared with less than 1% of the general population.4 While truly pathological examples exist (Drs Josef Mengele, Sigmund Rascher and Hermann Pfannmüller, among others), most doctors who participated in the Holocaust were regular people who believed that they were doing an unpleasant but morally correct and necessary job.4 In her famous analysis of Adolf Eichmann, who had been in charge of deporting Jews to death camps, Hannah Arendt coined the phrase ‘the banality of evil’ to describe the bureaucratic mentality with which Eichmann completed his deadly work. Eichmann, she argued, was not a monster but a conventional bureaucrat, motivated by career ambition rather than hatred for his victims.5 I view the physicians completing stacks of forms during the T4 ‘euthanasia’ programme, recommending life or death with simple strokes of ink, in a similar light.

The second explanation I have encountered is that even if the Nazi physicians were not monsters, they were forced to participate at risk of their own deaths; they did not have free will and therefore cannot be held accountable for the ‘choices’ they made. However, many studies have concluded that, ‘after almost 50 years of postwar proceedings, proof has not been provided in a single case that someone who refused to participate in killing operations was shot, incarcerated, or penalised in any way’.6 Furthermore, a few doctors did refuse to participate—and far from being killed for their actions, they were tolerated and even, in some cases, respected for their decisions.7 Physicians joined the Nazi party and the killing operations not at gunpoint, not by force, but of their own volition.

These physicians were normal, sane individuals who chose to commit murder—but why? In social psychology, situationism describes the idea that humans make choices based on the circumstances of their social environment rather than an understanding of right and wrong. The famous obedience experiments performed by Stanley Milgram in the 1960s showed that, when instructed to do so by a person they perceived to be an authority figure, normal people willingly inflict severe pain on fellow humans.8 These experiments demonstrated that under the right combination of pressures, anyone can commit morally heinous acts. If we accept a situationist perspective, then physicians who participated in the Holocaust did so, at least partly, because of the social circumstances in which they found themselves: a long history of European anti-Semitism, a new marriage of science and policy, and a Führer exhorting them to protect their race.

Situationism is not an abdication of personal responsibility: we are held morally accountable for things we do, even as a result of circumstances beyond our control. Philosophers Thomas Nagel and Bernard Williams call this concept ‘moral luck’.9 Although traditional Kantian ethics suggest that our moral judgement of a person should be influenced by inherent goodness or badness rather than uncontrollable circumstances, Nagel and Williams argue that in practice, we judge people who do immoral things as immoral, regardless of what role circumstances play. Nagel uses the thought experiment of two men who become equally intoxicated and drive home: a child runs out in front of the first man's car, and he strikes and kills the child. The second man is lucky: no child runs in front of his car, and he makes it home safely. Although the child running in front of the car was a product of circumstance (luck), we judge the first man as having committed a far worse crime than the second. (My use of this example is not to draw a direct parallel between the drunken driver and the Nazi physicians, but to illustrate concisely the concept of moral luck).

It is natural for us as physicians (and, in my case, as a future physician) to try to find some fundamental difference between ourselves and the Nazi doctors—to distance ourselves from the perpetrators of such heinous crimes. However, moral luck and situationism force us to consider that Nazi doctors were ordinary people operating under extraordinary conditions—and that we may have the same capacity for wrongdoing. We cannot say with certainty that, under the same circumstances, we would not have committed the same crimes. We cannot even assert that we will not do something similar in kind if our circumstances should change. Given that other physicians throughout history have made similar transformations under other circumstances, it bears asking whether there is something inherent in being a physician, or in medical culture, that promotes this transition. As one Holocaust scholar and physician has written, ‘medicine as a profession contains the rudiments of evil, and even some of the most humane acts of medicine are only small steps away from real evil’.10 This leads to an unsettling question: are there social pressures now that predispose physicians to unethical behaviour?

Through research and reflection, I have come to believe that specific moral vulnerabilities exist within the medical profession, which, when combined with enabling political circumstances, have in multiple instances facilitated the almost unfathomable transition from physician to murderer. All of the vulnerabilities I discuss are in some ways necessary parts of medical culture or of being a physician, but they occupy a vanishingly small space between being adaptive and dangerous. In the remainder of this paper I will define these vulnerabilities in contemporary medical culture, assess how they enabled physician participation in the Holocaust, and reflect on what I can do to avoid moral erosion in my own evolution from medical student to physician.