Take the following case. You are in a city in which the plague is raging. You, as a doctor, have a drug that you could use to combat the plague. However, you must test it on somebody. The commander, or let us say the mayor of the city, comes to you and

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• Take the following case. You are in a city in
  which the plague is raging. You, as a doctor,
  have a drug that you could use to combat the
  plague. However, you must test it on somebody.
  The commander, or let us say the mayor of the
  city, comes to you and says, Here is a criminal
  condemned to death. Save us by carrying out the
  experiment on this man. Would you refuse to do
  so, or would you do it?

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The Medical Ethos, Nazi Medicine, and the
Nuremberg Code

• Brian Callender, M.D.

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Objective

• Progression of ideas and theories into policies
  and then into practice can result in grave
  consequences for medicine and humankind

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The Medical Ethos

• Composed of interlocking set of views about the
  patient, the physician, and the medical
  enterprise
• Historical core values of medicine compassion,
  healing, relief of suffering
• Physicians role centered on healing and
  alleviation
• Special worth endowed upon the sick
• Medicine is compassionate and apolitical

5
The Medical Ethos

• Long held view that the ethos was immutable and
  that its values were stable despite individual
  and cultural variation
• Immune to social, political, and economic
  pressures

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Hippocratic Oath

• Primum non nocere first, do no harm
• Focus on the individuals suffering
• Responsibilities of physician are not stratified
  on the basis of a hierarchy of worth or on social
  priorities of the state

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Social Darwinism

• 1859, Charles Darwins Origin of Species
  published
• Application of principles of natural selection to
  human populations
• Improvement of population through selective
  cultivation

8
Social Darwinism

• Social Darwinists stressed that the integrity
  of populations was threatened because medicine
  began to destroy the natural struggle for
  existence
• Shift in social balance
• The poor, misfits, and the genetically feeble
  were overwhelming the talented, able, and
  genetically strong

9
Eugenics

• 1883, Francis Galton
• Eugenics the good birth
• Aimed at enhancing the quality of populations by
  modification of natural selection through
  selective breeding
• Programs in the United States, Britain, and
  Germany

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Racial Hygiene

• 1894, Alfred Ploetz
• If the fit were to be primary survivors,
  counter-selective forces should be avoided,
  including medical care for the weak, because this
  promoted reproduction among them
• Hierarchy of human worth
• subhuman, life without value, useless
  eaters, useless life, ballast

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Racial Hygiene

• Movement included physicians, industrialists,
  academics, politicians
• Expanded rapidly
• Became a respectable part of German biomedical
  science

12
Consequences

• Concerted shift from the development and care of
  the individual to the welfare of society as a
  whole
• Physicians were encouraged to move from doctoring
  the individual to doctoring the nation

13
United States

• Sterilization laws in the U.S.
• Resulted in the involuntary sterilization of
  60,000 persons
• Upheld by the Supreme Court in Buck v. Bell, 1924
• It is better for all the world, if instead of
  waiting to execute degenerate offspring for
  crime, or to let them starve for their
  imbecility, society can prevent those who are
  manifestly unfit from continuing their kind
  Justice Oliver Wendell Holmes
• Three generations of imbeciles are enough
• Racial segregation

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How Could this Happen? Historical Context

• Complicity of the German biomedical enterprise
  needs to be examined in historical context
• Expanding role of science to solve problems
• Industrialization and urbanization
• Poverty, crime, spread of infectious disease (TB,
  syphilis, etc), expanding rise in mental illness
• Social, economic, political upheaval of post-WWI
  Germany, including the loss of millions of young,
  fit Germans during the war.

15
Medicine and Dictatorship

• Science under dictatorship becomes subordinate
  to the guiding philosophy of the dictatorship -
  Leo Alexander, M.D.
• Rational utility replaces moral, ethical, and
  religious values
• Medical science becomes an instrument of
  political power
• Planning, initiation, administration, and
  operation of state policies and programs

16
Nazi Medicine

• National state must see to it that only the
  healthy beget children by modern medical
  needs. Adolf Hitler, Mein Kampf
• Hitler asked that the German medical profession
  move into the forefront of the race question
• Racial hygiene was to be the task of the German
  physician

17
Nazi Public Health

• Nazi director of public health, Dr. Arthur Guett,
  in The Structure of Public Health in the Third
  Reich, 1935
• It is the supreme duty of a national state to
  grant life and livelihood only to the healthy and
  hereditarily sound portion of the people in order
  to secure the maintenance of a hereditarily sound
  and racially pure folk for all eternity. The life
  of the individual has meaning only in light of
  that ultimate aim, that is, in the light of his
  meaning to his family and to his national state

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The German Medical Establishment

• Accepted, supported, and were instrumental in the
  application of racial hygiene policies
• Physicians adjusted to and accepted a new
  hierarchy of human worth that devalued the
  infirmed, the disabled, the genetically blighted
• Embraced belief that to heal the nation was
  incomparably more important than curing
  individuals
• Racial hygiene accepted as massive public health
  measure as dictated by the state

19
Physicians in the Nazi Party

• 6 of physicians belonged to the National
  Socialist party prior to Hitlers coming to power
• By late 1933, almost half of all physicians
  belonged to the Nazi Party
• 26 belonged to the SA
• 7 belonged to the SS

20
Nazi Medicine

• Turned away from the sick and useless and
  focused on a healthy state
• Campaign of propaganda and dehumanization
• Focused on disease prevention and education
• Powerful and effective public health programs
• Anti-smoking
• Cancer prevention
• Nutrition
• Exercise

21
Implementation

• Rise of Nazi power
• Political and judicial will of the state
• Willing medical establishment
• Policies
• Nuremberg laws
• Sterilization laws
• Euthanasia

22
The Nuremberg Laws

• Excluded Jews from citizenship and prevented
  marriage or sexual relations between Jews and
  non-Jews
• Marital health laws required couples to submit to
  medical examination prior to marriage to prevent
  racial pollution

23
Sterilization Laws

• 1933 Sterilization Law Law for the Prevention of
  Hereditarily Diseased Descendants
• Allowed involuntary sterilization of anyone
  suffering from disease thought to be genetically
  determined
• Feeble-mindedness, manic-depression,
  schizophrenia, malformation, deafness, blindness,
  epilepsy, alcoholism

24
Sterilization Laws

• Hereditary health courts (1 lawyer, 2 physicians)
• Physicians required to
• Undergo training in genetic pathology
• Register every case of genetic illness known to
  them
• Fill sterilization quotas (50,000 annually)

25
Sterilization Consequences

• Up to 400,000 (more than 1 of population)
  sterilized

26
Euthanasia

• September 1939
• Physicians to grant mercy death to patients
  judged incurably sick by medical examination

27
Euthanasia

• All state institutions required to report on all
  patients who had been ill more than 5 years and
  who were unable to work
• Filled out questionnaires giving name, race,
  nationality, marital status
• Decision regarding who is euthanized was based on
  these questionnaires
• Euthanasia became part of normal hospital routine

28
Nazi Human Experimentation

• Two types of experiments/motivations
• 1. Scientific pursuits designed to yield
  information applicable to military and political
  goals
• 2. Advance personal goals/agendas
• Political
• Academic

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The Nuremberg Doctors Trial

• United States of America v. Karl Brandt et al
• Oct 1946 - July 1947
• 23 defendants (20 physicians, 3 assistants)
• The defendants in this case are charged with
  murders, tortures, and other atrocities committed
  in the name of medical science.

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Human Experimentation

• High-altitude Experiments
• individuals subjected to low-pressures to
  simulate atmospheric conditions at high altitudes
  (up to 68-thousand feet)
• test the limits of human endurance at extremely
  high altitudes with and without oxygen

31
Human Experimentation

• Freezing Experiments
• victims placed in tank of ice water or kept naked
  outdoors
• investigated how to treat people who had been
  chilled or frozen by testing different methods of
  re-warming

32
Human Experimentation

• Malaria Experiments
• victims infected by mosquitoes or injected with
  extract of mucous glands of mosquitoes
• Mustard Gas Experiments
• wounds deliberately inflicted on victims and then
  infected with poisonous gas in search of
  effective treatment for burns caused by mustard
  gas
• Sulfanilamide Experiments
• wounds infected with streptococcus, gas gangrene,
  and tetanus, then wood shavings and ground glass
  forced into wounds to test if sulfa drugs could
  improve survival

33
Human Experimentation

• Bone, Muscle, Nerve Regeneration, and Bone
  Transplantation Experiments
• section of bones, muscles, and nerves (including
  whole limbs) removed from victims and
  transplanted to other victims
• Sea Water Experiments
• victims ingested salt water
• purpose was to develop method of making sea water
  drinkable through desalination

34
Human Experimentation

• Epidemic Jaundice Experiments
• subjects injected with epidemic jaundice
  (hepatitis)
• Sterilization Experiments
• victims sterilized by x-ray, surgery, and drugs
• goal was to develop cheap and quick sterilization
  methods (surgical sterilization was too expensive
  and slow)
• Spotted Fever (typhus) Experiments
• victims injected with typhus to test various
  vaccines

35
Human Experimentation

• Poison Experiments
• victims deliberately poisoned to time how fast
  death occurred and determine how much pain and
  agony various poisons caused
• Incendiary Bomb Experiments
• victims burned with phosphorous to then determine
  the utility of ointments and liquid therapies
• Jewish Skeleton Collection
• 112 Jews were murdered to complete a skeleton
  collection for the Reich University at
  Strasbourg, France

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Recurrent Themes of Nazi Medicine

• Devaluation and dehumanization of certain
  segments of society
• Medicalizing of social and political problems
• Consequences of refusal
• Bureaucratization of medical role
• Lack of concern for medical ethics and human
  rights
• Relationship between science and ideology

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The Nuremberg Trial Closing Statements

• Final statements of defendants devotion to the
  communitythe service of my beloved
  Fatherland.to overcome tremendous losses among
  the ranks of our comradesgood of mankindserve
  the good of humankindendeavor of mankind and was
  morally as well as medically justifiedI never
  failed in my duty to mankind

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The Nuremberg Trial Verdict

• 16 were found guilty
• 7 received the death penalty by hanging
• 5 life in prison
• 7 were acquitted
• Courts judgment included The Nuremberg Code
• Consists of 10 basic principles to govern medical
  experimentation

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The Nuremberg Code

• 1. Voluntary consent is absolutely essential
• 2. Experiment should yield useful results,
  unobtainable by other methods
• 3. Based on animal experimentation
• 4. Avoidance of unnecessary physical or mental
  suffering and injury
• 5. Death or disabling injury should not be
  expected outcomes

40
The Nuremberg Code

• 6. Degree of risk should not exceed expected
  importance
• 7. Protection against injury, disability, death
• 8. Scientifically qualified persons
• 9. Subject may withdraw from experiment
• 10. Discontinuation if experiment is likely to
  result in injury, disability, or death

41
The Nuremberg Codes Legacy

• Refocused the medical ethos on the primacy of the
  patient as an individual
• Serves as blueprint for todays principles that
  ensure the rights of subjects in medical research
• World Medical Association Declaration of
  Helsinki, 1964 Ethical Principles for Medical
  Research Involving Human Subjects

42
The United States

• Code applies to them and not us
• ..good code for barbarians but an unnecessary
  code for ordinary physicians..

43
Human Experimentation in the United States

• Tuskegee syphilis experiment
• Human radiation experiments
• Experiments where known effective treatments
  withheld
• Injection/implantation of infective agents and
  cancer cells

44
The Modern Medical Ethos

• Scale of Worth
• Primacy of the individual patient and justice and
  equity in medical care
• Science needs to have concern for its human
  implications
• Medical Hubris
• Power of excessive certainty, especially with
  respect to public policy
• Equity and fairness in delivery of health care

45
The Modern Medical Ethos

• Core values of medicine require protection,
  especially from informed, engaged, and concerned
  professionals dedicated to the practice of
  medicine

46
Should the Data be Used?

• Is the data accurate? Scientifically flawed?
  Skewed by political imperatives?
• Does its use imply complicity or acceptance?
• Does its use demean medicine?
• An intangible memorial to the victims?

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Modern Implications

• Human Genome Project
• Involvement of physicians in execution of
  convicted criminals
• Racial inequalities in access to healthcare
• End-of-life issues
• Stem Cell research
• Abortion
• Cloning
• Treatment of prisoners, including forced feeding

48
References

• Alexander, L. Medical Science Under Dictatorship.
  New England Journal of Medicine. 1949 241 39-47
• Annas, G. and M. Grodin, Eds. The Nazi Doctors
  and the Nuremberg Code Human Rights in Human
  Experimentation. New York Oxford University
  Press, 1992
• Barondess, J. Medicine Against Society Lessons
  from the Third Reich. JAMA. 1996 276(20)
  1657-1661
• Barondess, J. Care of the Medical Ethos
  Reflections on Social Darwinism, Racial Hygiene,
  and the Holocaust. Annals Internal Medicine.
  1998 129 891-898
• Baumslag, N. Murderous Medicine Nazi Doctors,
  Human Experimentation, and Typhus. Westport, CT
  Praeger, 2005

49
References

• Beecher, H.K. Ethics and Clinical Research. New
  England Journal of Medicine. 1966 274 1354-1360
• Bogod, D. The Nazi Hypothermia Experiments
  Forbidden Data? Anaesthesia. 2004 59 1155-1156
• Geiderman, J.M. Ethics Seminars Physician
  Complicity in the Holocaust Historical Review
  and Reflections on Emergency Medicine in the 21st
  Century, Parts I and Parts II. Academic Emergency
  Medicine. 2002 9(3) 223-240
• Goodman, J., A. McElligott and L. Marks, Eds.
  Useful Bodies Humans in the Service of Medical
  Science in the Twentieth Century. Baltimore
  Johns Hopkins University Press, 2003
• Grodin, M. and G. Annas. Legacies of Nuremberg
  Medical Ethics and Human Rights. JAMA. 1996
  276(20) 1682-1683

50
References

• Kater, M. Doctors Under Hitler. Chapel Hill
  University of North Carolina Press, 1989
• Katz, J. The Nuremberg Code and the Nuremberg
  Trial A Reappraisal. JAMA. 1996 276(20)
  1662-1666
• Lefor, A. Scientific Misconduct and Unethical
  Human Experimentation Historic Parallels and
  Moral Implications. Nutrition. 2005 21 878-882
• Lifton, R. The Nazi Doctors Medical Killing and
  the Psychology of Genocide. New York Basic, 1986
• Proctor, R. Racial Hygiene Medicine Under the
  Nazis. Cambridge Harvard University Press, 1988

51
References

• Proctor, R. Nazi Science and Nazi Medical Ethics
  Some Myths and Misconceptions. Perspectives in
  Biology and Medicine. 2000 43 335-346
• Seidelman, W. The Legacy of Academic Medicine
  and Human Exploitation in the Third Reich.
  Perspectives in Biology and Medicine. 2000 43
  325-334.
• Spitz, V. Doctors from Hell The Horrific Account
  of Nazi Experiments on Humans. Boulder, CO
  Sentient, 2005
• Shuster, E. Fifty Years Later The Significance
  of the Nuremberg Code. New England Journal of
  Medicine. 1997 337(20) 1436-1440