Fifty-nine years ago, Dr Leo Alexander published his now famous report on medicine under the Nazis. In his report he describes the two major crimes of German physicians. The participation of physicians in euthanasia and genocide and the horrible experiments performed on concentration camp prisoners in the name of science. In response to this gross violation of human rights by physicians, the Nuremberg military tribunal, which investigated and prosecuted the perpetrators of the Nazi war crimes, established ten principles of ethical conduct in medical research in 1949. Foremost among them was the need for voluntary consent of the human subject and that the experiment be conducted to avoid all unnecessary physical and mental suffering. Notwithstanding all these important efforts and impressive achievements in understanding the ethical failings of Nazi physicians, the bioethical community has almost completely ignored the moral challenges facing the victims of the atrocities. These dilemmas and their responses have continued relevance for modern medicine.
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Fifty-nine years ago, Dr Leo Alexander published his now famous report on medicine under the Nazis.1 In his report he describes the two major crimes of German physicians. The participation of physicians in euthanasia and genocide and the horrible experiments performed on concentration camp prisoners in the name of science. In response to this gross violation of human rights by physicians, the Nuremberg military tribunal, which investigated and prosecuted the perpetrators of the Nazi war crimes, established ten principles of ethical conduct in medical research in 1949. Foremost among them was the need for voluntary consent of the human subject and that the experiment be conducted to avoid all unnecessary physical and mental suffering. Building on this document, the World Medical Association ratified the Declaration of Helsinki in 1964, which protected the rights of subjects in medical research. The ethical principle of “voluntary consent” was extended to clinical care and autonomy became the guiding principle of modern medical practice.
THE ETHICAL RESPONSE
The protection of research subjects and the paradigm shift from paternalism to autonomy are probably the main ethical responses to the horrors of Nazi medicine. While autonomy and beneficence have been firmly established in the culture of modern Western medicine, there continues to be gross violations of these principles in dictatorships and in wartime, even in liberal democracies. The involvement of some Iraqi physicians in the crimes of Saddam Hussein and of Chinese and Western physicians in the harvesting of organs from condemned prisoners highlight the continued participation of physicians in heinous medical practices. These observations should be of concern to those who maintain that conscience has no role to play in medicine. An individual physician’s ethical principles is sometimes the only bulwark against participation in immoral medical practice
Likewise, the principles of ethical research have been accepted by almost all investigators; however, in practice there continues to be gross violations of these recommendations. The infamous Tuskegee syphilis study continued into the 1970s and the Willowbrook hepatitis study was performed in the 1960s. Even after the Nuremberg and Helsinki codes were adopted, Paul Ramsey had to teach the medical community the inviolability of the individual even at the expense of the pursuit of scientific advancement.2 This message needs to be consistently reinforced. Ramsey himself felt that in the early days of cardiac transplantation insufficient attention was paid to obtaining adequate consent from the patients and the risks to the recipients were downplayed in the name of potential spectacular achievement.2 One could argue that similar ethical concerns have plagued attempts at human gene therapy.
Interestingly, Alexander himself did not view respect for autonomy and the protection of research subjects as the fundamental lesson of Nazi medicine. In his own words:
“Whatever proportions these crimes finally assumed, it became evident to all who investigated them that they had started from small beginnings. The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans. But it is important to realize that the infinitely small wedged-in lever from which this entire trend of mind received its impetus was the attitude toward the non-rehabilitable sick”.1
He goes on to make a case for more funding for the handicapped and chronically ill in the United States.
Alexander also points out that only one country, the Netherlands, resisted the Nazi’s murderous treatment of the handicapped; but, interestingly, the Netherlands is now at the forefront of the euthanasia movement, extending it even to severely handicapped newborns.
There has also been much debate in the ethical literature on the morality of using the Nazi experimental data and testimony from the survivors of the research have been meticulously collected.
THE VICTIMS’ RESPONSE
Notwithstanding all these important efforts and impressive achievements in understanding the ethical failings of Nazi physicians, the bioethical community has almost completely ignored the moral challenges facing the victims of the atrocities. These dilemmas and their responses have continued relevance for modern medicine. A number of reasons exist for this startlingly omission. There existed in traditional Holocaust scholarship a regrettable trend to concentrate on the story of the murderers as opposed to the narrative of the victims. Much of the moral responses display spiritual strength, which has been overshadowed in Holocaust scholarship by stories of active resistance, such as the heroism of the Warsaw ghetto fighters or the bands of partisans. In addition, much of the moral literature is found in queries addressed to prominent Rabbis, which they answer in highly technical Hebrew relying heavily on Talmudic sources. These responsa mostly relying on the methodology of casuistry attempt to answer modern queries by comparing contemporary ethical dilemmas to precedent cases previously decided by respected authorities. They are an invaluable resource in the study of Jewish life and of ethical attitudes. In the traditional response literature, the ultimate source of morality is the halakhah (Jewish law) whose origin is based on divine revelation and whose basic tenants were recorded in the Talmud approximately 2000 years ago. The most comprehensive of these Holocaust era responsa were written by Rabbi Ephraim Oshry—a young scholar in German-occupied Lithuania.3 After the Jews in his hometown of Kovno (Kaunas) were herded into a ghetto, the Nazis placed him in charge of a warehouse of Jewish books that were being stored for a planned exhibit on “artifacts of the extinct Jewish race” and Rabbi Oshry used these resources to write his responsa. He wrote his response on remnants of cement sacks he had to carry on forced marches and hid them in buried cans that he retrieved after the war. Among the questions addressed to Rabbi Oshry was the following.
An order was given in the Kovno ghetto that all pregnant women were to be shot. A Nazi guard noticed a pregnant Jewish woman walking in the street and shot her dead. She was quickly brought to the hospital and the doctors determined that the baby could be saved if an immediate caesarean section was performed. The question was brought to Rabbi Oshry because Jewish law prohibits the desecration of a human corpse and therefore the operation should be prohibited. Rabbi Oshry ruled that “when saving a life is involved we are not concerned with desecration of the dead” and besides would not the murdered women welcome desecration of her corpse to save her child’s life. But he also ruled that one is not allowed to remove a gold filling from a corpse because it would be a desecration of the body. Other questions addressed to Rabbi Oshry was whether a father can take his dead neighbour’s property in order to feed his starving children (yes) and whether a parent can commit suicide rather than watch his children be murdered (no).
Rabbi Tzvi Hirsch Meisels, another European Rabbi from the Holocaust era, was asked the following question when 1400 hundred boys were rounded up at Auschwitz to be gassed the next day.4 The father of one of the boys asked Rabbi Meisels whether he can purchase the release of his only son but then the Nazis will take another in his place. When the Rabbi heard the question “the thought of rendering a decision on this matter of life and death caused me to tremble” and he hesitated in answering the question. The petitioner understood from the Rabbi’s hesitation in answering the question that it was not allowed and commented: “If it were permissible without any doubts certainly you would tell me so. To this means that according to the halacha (Jewish law) it is forbidden to me. I accept this with love and joy, and I shall not do anything to redeem him, because that is what the Torah commanded.” The response of this simple father to the pain and suffering he experienced was an unwavering commitment to Jewish law and heritage.
In the face of unimaginable horrors and an enemy that had no regard for human suffering, traditional Jews persisted in maintaining a theology that placed the highest premium on human life and a complete aversion to the wilful taking of innocent life. As opposed to their murderers, the Rabbis recognised an element of a universal natural morality as reflected in their hesitancy to permit cannibalism even when human survival was at stake. The Rabbis also demonstrate in answering the queries addressed to them a profound sensitivity to the suffering of the petitioners and their answers do not simply address legal principles but respond to the particular human situation.
What is the relevance of these responsa to modern medical ethics? First, they can contribute to the discourse on modern dilemmas in medical ethics. For example, modern scholars have used some of these responsa to develop an approach to social justice and the allocation of scarce resources.5 Daniel Callahan has argued for the benefit of an extensive exposure “to the accumulated wisdom and knowledge that are the fruit of long established religious traditions. I do not have to be Jewish to find it profitable and illuminating to see how the great rabbinical teachers have tried to understand moral problems over the centuries.”6 Reading these responses, we can gain an appreciation on the high value that Judaism places on the sanctity of life and an understanding of how this particular legal system balances respect for tradition with compassion.
Second, study of these responsa can help us develop empathy for the victims and an appreciation of the moral heroism they demonstrated and the power of faith in the modern world. This understanding is of particular importance as the medical community has only begun to realise the impact of these experiences on the geriatric survivors of the Holocaust.
Third, and most importantly, they should remind us that moral dilemmas of this nature still tragically exist in the world particularly in regions where evil reigns and human life is of no moral value. Women in Darfur and victims of suicide bombers in the Middle East on a daily basis face similar ethical dilemmas mostly hidden from the world’s eyes and ears. The voices of the victims as heard in these responsa call on us as physicians and ethical human beings to fight these epidemics of human injustice.
Competing interests: None.