Medical ethics education must be informed by a robust understanding of medicine’s role within the Nazi regime, according to a new report from The Lancet Commission on medicine, Nazism, and the Holocaust: historical evidence, implications for today, teaching for tomorrow.

This is the first Lancet Commission focused on the history of medicine. Through examples of discriminatory and inhumane medical policies and practices under the Nazi regime, the authors aim to inform approaches to contemporary issues in medicine and underscore the importance of centring human rights and dignity in medical professionals’ conduct, including a willingness to stand up to wrongdoing whenever and wherever necessary.  

“Nazi medical atrocities represent some of the most extreme and best-documented examples of medical involvement in human rights violations in history,” explains Commission Co-Chair Dr Sabine Hildebrandt of Boston Children’s Hospital and Harvard Medical School. “While it is tempting to view the perpetrators as incomprehensible monsters, the evidence put forward by the Commission demonstrates how many health professionals were capable of committing ethical transgressions and even crimes against their patients under certain conditions and pressures.”

Fragile core values

There is no doubt that doctors living under the Nazis participated in human rights violations—including antisemitism, racism, discrimination, mass atrocities, and genocide. As such, important implications can be drawn for today’s health professionals’ moral agency, especially under economic, political, or other types of pressure, says The Lancet.  

During the Nazi era, the medical community helped create, justify, and implement policies according to the Nazi doctrine and changed their understanding of medical ethics accordingly. Records indicate that physicians joined the Nazi Party and its affiliated organisations in higher proportions than any other profession, and Germany’s medical and research institutions played instrumental roles in the regime.

Throughout the Commission’s report are examples of how the Nazi “ethical code” was weaponised as a tool to value, prioritise, and advance people of German “Aryan” descent above all others in medical care and research, as well as rationalise eugenics, forced sterilisation, the “euthanasia” patient murder program, and brutal human experiments.

Methods first developed and applied in the T4 euthanasia program of 1939-41, during which 70,000 institutionalised patients were killed by gas, were later applied to the extermination camps in Poland, where victims were murdered upon arrival in gas chambers disguised as showers.

“It is often surprising how limited the knowledge about Nazi medical crimes in the medical community is today, perhaps apart from a vague notion of Josef Mengele’s experiments in Auschwitz. Our report aims to change this,” says Co-Chair Prof Herwig Czech, of the Medical University of Vienna. “Although the examples we present are extreme, studying medicine under Nazism highlights the critical role of societal factors and of ethics in medical and scientific advancement.”

In the aftermath of World War II, deliberations over medical ethics—including human rights-based medicine, health care, and voluntary consent in research—drew international attention. Starting in 1946, the Nuremberg Doctors’ Trial led to the first international principles for ethical research on humans, later to be known as the Nuremberg Code. This formed the basis of many subsequent declarations and was an important factor in the development of modern bioethics.

Accountability for the past

As the report details, contrary to common misconceptions, medicine in Nazi Germany was not “pseudoscience.” In fact, it worked on the basis of standards and practices of biomedical science developed in the late 19th and early 20th centuries. German scientists were part of broader international networks exploring and promoting eugenics and developing racist medical rationales.

In life and death, the bodies of Nazi victims were used for research and teaching, and specimens of their human remains were sometimes kept in scientific collections for decades after the war. The Pernkopf anatomy atlas is an example of how Nazi research has become part of the canon of medical knowledge. Re-drawings of the Pernkopf images—some deriving from the bodies of victims of the Nazi regime—have been copied in many publications and atlases, often without reference to the original.

Current understanding of aviation safety, hypothermia, and even the effects of tobacco and alcohol use on the body has also been informed by research in the Nazi era but, again, awareness of how the research was obtained is scarce.

“Accountability for and recognition that crimes were committed in the name of medicine in the Nazi era and during the Holocaust remains woefully inadequate,” says Commission Co-Chair Prof. Shmuel Pinchas Reis, of the Center for Medical Education at Hadassah/Hebrew University Faculty of Medicine, in Israel. “Medical students, researchers, and practicing health professionals should know where—and from whom—the foundations of medical knowledge come from. Victims of Nazism are owed that; they have a right to be honoured and treated with dignity in life and death for coerced contributions to medicine as we know it today.”

Recommendations

The Commission stresses that the pursuit of scientific knowledge and the delivery of medical and health care must occur within a framework that prioritises human rights. As such, the authors put forward recommendations to ensure that medical education focuses on developing history-informed moral agency and resilience among medical professionals. Key recommendations include: 

• Incorporate the study of medicine, Nazism, and the Holocaust in curricula for all medical students and health professionals, across the medical field and in continued medical education initiatives.
• Encourage students and medical professionals to develop a history-informed professional identity, including being able to recognise their own potential biases or conflicts of interest, challenge hierarchies, and equip them with the tools necessary to overcome them.
• Universities, psychiatric hospitals, and other medical institutions worldwide should actively identify and commemorate victims of Nazi medical crimes and initiate research to better understand their direct connections to human rights violations in the past. They should also look at their own past, identify and document patterns of medical abuse, and integrate this history in their curricula.