HAVING AN ETHICS CODE DIDN'T STOP NAZI DOCTORS FROM COMMITTING WAR CRIMES

Having an Ethics Code Didn't Stop Nazi Doctors From Committing War Crimes

From sterilization of hundreds of thousands of people to medical experiments and killing of people with special needs: Israeli Prof. Shmuel Reis tells Haaretz how this grim chapter of history should be taught at medical schools everywhere

May 06th, 15PM May 06th, 15PM

On November 8, a month after Hamas' massacre in the south, the medical journal The Lancet published an unusual article: "The Lancet Commission on medicine, Nazism, and the Holocaust: historical evidence, implications for today, teaching for tomorrow."

The piece, written by 20 researchers, physicians and ethicists, calls for the history of the Nazis' medical crimes to be studied by everyone seeking to become a health professional.

"The crimes committed by the Nazi regime, often with the collusion and help of the medical field, constitute the best documented case of medicine's involvement in large-scale human rights violations," the report's abstract states.

The Nazis' medical crimes are comprised of five main issues: The sterilization of hundreds of thousands of people, the killing of people with special needs and members of certain communities, medical experiments, participation in the Holocaust, and the exclusion of Jewish physicians.

"The Lancet Commission on medicine, Nazism, and the Holocaust … documents in detail a series of disturbing historical facts, including that German (and Austrian) physicians joined the Nazi Party in greater numbers than any other profession, were complicit in the dismissal and persecution of their Jewish and politically dissident colleagues, and eagerly took over their positions. The victims were forced into exile or risked imprisonment and death."

One might wonder why a British medical journal, one of the world's two most prestigious in the field, waited almost 80 years after the end of Word War II to address the Nazi doctors' crimes.

Either way, in January 2021, The Lancet's veteran editor in chief, Prof. Richard Horton, announced the establishment of a task force to address the study of medicine, Nazism and the Holocaust.

The aim was to sum up the historical literature and consider the implications, with the emphasis on teaching. Horton's announcement came on January 27 that year, International Holocaust Remembrance Day.

Medicine in the service of crime

The Nazis' medical crimes are comprised of five main issues, says Prof. Shmuel Reis, one of the authors of the Lancet article, a family doctor and an associate professor at the Hebrew University of Jerusalem.

The five issues are the sterilization of hundreds of thousands of people, the killing of people with special needs and members of certain communities, medical experiments, participation in the Holocaust, and the exclusion of Jewish physicians.

Already in 1933, the year the Nazis came to power, "the Jewish doctors were thrown out of the public service, along with the expulsion of all the Jews from the trade unions and the universities. By 1938, Jews were banned from medicine altogether. After this, many Jewish physicians fled Germany or committed suicide," Reis says.

"Although the Jews' expulsion was implemented via legislation, the Germans in the profession cooperated wholeheartedly – and not just a few hundred German doctors who were careerists or psychopaths. The entire medical and scientific establishment was complicit in the Nazis' medical crimes, and not by coercion. More than half of the German doctors chose to join the Nazi Party as members, even though those who didn't join weren't punished."

'Medical professionals collaborated with a murderous ideology. It's important to examine how our profession, which engages in healing, became a profession that engages in killing.'

Moreover, Reis notes, "7 percent of German physicians joined the SS, which was truly to dip your hands in blood, whereas in other white-collar professions the rate of joining the Nazi Party was under 1 percent. The medical profession found a home in Nazism."

Among the medics in 1967

Reis does research in a number of fields, but the Holocaust is of special interest to him. He was born in Germany in 1948 to Holocaust survivors. The family immigrated to Israel when he was 1 and settled in Tel Aviv, where he grew up.

"The Holocaust hovered in the house like a ghost," he says. At 18, he moved to Moshav Yodfat in the Lower Galilee, did his military service, and later settled in the hamlet of Atzmon in the Galilee, where he still lives.

His decision to study medicine was very much influenced by the 1967 Six-Day War. "In the battle of Umm Qatef I was in the squad that evacuated casualties," he says, referring to the decisive battle in Egypt's Sinai Peninsula at the start of the war.

"In the evening of the battle we evacuated casualties to the rear, and I remember sitting with the medics, like a shelter in the middle of the chaos, death, suffering and violence. It was the only sane space, and I remember to this day the impact it had on me."

Reis studied medicine in Paris and then at the Faculty of Medicine at the Technion, Israel's MIT. In the Galilee, he helped establish a rural health center, and alongside his work as a doctor, he taught and did research; his first subject was lower back pain. He later delved into the subject of medicine during the Holocaust.

In 2005, he earned a master's degree in education for the health professions from Maastricht University in the Netherlands. He's now an associate professor in the Department of Digital Medical Technologies at the Holon Institute of Technology and a member of the Center for Medical Education at Hebrew University.

Research on medicine, Nazism and the Holocaust is crucial for him, he says; he strives to find the best way to get the subject into curricula for the health professions.

"Medical professionals collaborated with a murderous ideology. It's important to examine how our profession, which engages in healing, became a profession that engages in killing," Reis says.

"Everybody in this field needs to be aware of the role played by health professionals in the Holocaust, to learn the facts and carry that history as part of their identity. Our profession has a great deal of power, so it's important to be aware of the danger in abusing that power."

How do you explain the fact that doctors joined the Nazi Party and espoused the Nazi ideology without ethical dilemmas regarding their commitment to the Hippocratic Oath?

"According to some explanations, the German physicians didn't have an ethics code and didn't know the meaning of empathy. But that wasn't the case; the Germans simply had a different version. In fact, Germany was the first country to adopt an ethics code in medicine, years before the rise of the Nazis. When the Nazis came to power, the only change was that the ethics rules applied only to 'Aryans.'"

How did that change play out?

"The entire professional identity of physicians was reformulated and reshaped. They had medical schools according to the Nazi doctrine; the physician's identity was molded into a twisted professional persona. Some of the testimonies by doctors from that period show that they viewed the activities they were engaged in – such as treatment of the disabled – as a moral act stemming from empathy.

"This is an example of how it's possible to take all the values and reverse them. It also shows how values of morality and ethics can be fragile in a particular situation, which is why it's important to actively protect them."

The Lancet notes that health professionals in Nazi Germany took part in the forced sterilization of between 310,000 and 350,000 people with alleged genetic defects. "Between 1939 and 1945, at least 230,000 people with various mental, cognitive, and other disabilities were murdered in killing programs in Germany and the areas it had conquered under the euphemistic term 'euthanasia,'" the authors write.

Nazi doctors also played an active role in the mass murder of psychiatric patients and assisted in the preparations to annihilate 1.7 million Jews in occupied Poland as part of Operation Reinhard from 1941 to 1943. In these efforts, systematic murder was perpetrated at the Belzec, Sobibor and Treblinka death camps. All told, 3 million Polish Jews were killed in the Holocaust.

The Nazi doctors also engaged in brutal medical research on tens of thousands of people; the result of course was immense suffering, disfigurement and death. According to the report, "Victims' human remains were used for research and teaching, with specimens sometimes kept for research long after the end of the war."

History is rife with wars, oppression, genocide and the "cleansing" of various communities as policy, whether on an ethnic, political or other basis. Some of these events occurred after the Holocaust. Why is the Holocaust deemed fitting for the curricula of medical students in Japan, Indonesia or Kenya?

"Because it's the most extreme event, and above all the most documented event, a maximum expression of how fragile ethics and morality can be even in the case of health professionals. Or how deeply the banality of evil, as Hannah Arendt called it, can take root even in systems that are perceived as immune to moral perversion.

"The Germans' potential for evil or a lack of morality is no different from other nations, but German thoroughness and orderly documentation make the Nazis a test case that can be taught in depth. It wasn't only a case of preaching, ideology or principles. Method, infrastructure and bureaucracy created Nazi medicine and enabled physicians to do terrible things to Jews while displaying compassion and empathy for 'Aryans' without feeling the contradiction between the two.

"And even if the method and documentation were unique to the Nazis, the potential for the abuse of power doesn't exist only in Germans and Nazis. It exists in everyone. So this chapter of history must be part of the training of health professionals. They can't evade their social responsibility and the understanding that they have a special task. One element of acquiring medical skill and education is to be able to identify these places within ourselves too."

What special ethical dilemmas do health professionals face today?

"One very common situation is dual loyalty, a condition that can be seen with military doctors, for example. A doctor in uniform is obligated to his profession and the treatment of soldiers, but he's also obligated to the commanders and the mission. Sometimes the commander wants a soldier to return to battle, but the doctor isn't sure that this is right for the soldier, who's the patient.

"Another dilemma of dual loyalty, one very intense lately, relates to treating the enemy. After October 7, there was a great deal of anger at the hospitals in cases where murderers were going to be hospitalized.

"After this, a decision was made to open a field hospital specifically for terrorists. Before October 7, every terrorist who was involved in an attack and wounded was hospitalized and treated in a regular hospital, sometimes even a few meters from his victim."

And there are cases where the ethical dilemmas are totally trampled.

"In the Russian invasion that became the Russia-Ukraine war, the Russians committed every possible violation of the rules of medical care in wartime. They didn't treat enemy wounded or civilians in the territories they conquered. The Russian soldiers committed war crimes and the doctors said nothing and made no attempt to stop them.

"The Russians didn't grant immunity to medical facilities and medical personnel, as the Geneva Convention mandates. They bombed ambulances and medical facilities, and also killed medical personnel."

And Hamas, which is a terrorist organization and not a state, continues to commit what are known a "medical crimes."

"Medical crimes were committed on October 7: wounding and killing medical staff as they were treating and assisting people; sabotaging parked ambulances, shooting and damaging ambulances that were on the road. Hospitals became facilities for terrorists, including the storage of weapons, and hostages were reported to have been murdered in the hospitals themselves.

"In Gaza and in Hamas, there are health professionals whose conduct appears to breach the profession's ethics codes. What part of this conduct originates in coercion and what part in voluntary cooperation? That's a something that should be studied.

"True, we're talking about a terrorist organization and not a state, and mostly about murderers and not medical staff bound to an ethics code. But in the end, under certain conditions, within each of us lies the potential to abuse power and behave immorally. This is something that health professionals need to engage with."

Ethics under pressure

The task force's main insight was that the medical profession is also capable of inflicting severe damage. The report explores the way doctors and medical institutions aided in some of the worst atrocities in human history. These things occurred in Nazi Germany, but they underscore the dangers inherent in modern medicine, the authors write.

They add: "The moral agency of health professionals became distorted through opportunities and temptations offered by the Nazi regime. … Learning about medicine, Nazism, and the Holocaust provides a unique possibility to explore the aims and limits of professional ethics, and how they change over time dependent on cultural, social, economic, and political factors, particularly when put under pressure."

So the task force drew up four recommendations. First, the subject of medicine, Nazism and the Holocaust should be a core course in training health professionals. Second, this training should examine present-day ethics against the backdrop of historical facts.

Third, an international body should be established to apply and monitor the implementation of the report's recommendations. Fourth, the victims of the Nazis' medical crimes should continue to be identified and commemorated, with the emphasis on institutions that were active during the Holocaust.

The Lancet is a highly influential journal, but not as influential as the World Health Organization, for example. How powerfully will the report resonate? Are institutions applying what the report recommends?

"The launch of the report in Berlin was intended to show its recognition by German and international organizations including the medical associations in the United States, Israel and Germany; the World Medical Association; the Max Planck Society, Germany's chief research organization; the Free University of Berlin, and others. All these entities lauded the report's findings and undertook to aid in disseminating and applying them.

"At both [launching] events, in Berlin and Vienna, video was shown of survivors of Josef Mengele's experiments on twins, and speeches were given on the Nazis' sterilization and killing programs. The World Medical Association and the medical associations of Germany, the United States and Israel have committed to implement the report's recommendations, but we need to see this really happen.

"The intention isn't to suffice with lectures but also for analysis and writing to deepen ethical research. ... In Germany, for example, we discovered significant teaching of the subject, including medical students' visits to death camps. Medical students from the United States are also starting to travel there."

What about Israeli medical schools?

"A course on the Holocaust and medicine is taught in five of Israel's six medical schools, but in most of them as an elective. Our challenge is to make it a core course. Of the 30 nursing schools, only two teach the subject, so we've launched a dialogue with the institutions. ... At Hebrew University, for example, we launched an online course three years ago, and about 1,500 students have taken it – though most of them aren't medical students."

Many Arab Israelis are studying to be health professionals. What's in a course like this for them?

"Many Arab students choose to take the course. It's not a war between the Holocaust and the Nakba. We respect the suffering of every nation. But the Holocaust included medical involvement on a scale unknown in any other event."

Tangled relations

Unlike other scientific journals, The Lancet is known for a willingness to tackle volatile issues outside the world of medicine. And Horton, the editor in chief, and Israel have clashed. During the 2014 Gaza war, the journal published a letter accusing Israel of committing a massacre and other war crimes in Gaza, signed by physicians from a number of countries. Horton was accused of antisemitism.

In 2017, in a conciliatory gesture, Horton visited Israel, and the journal devoted an entire issue to the country, called "Health in Israel." Ten articles were written by Israeli physicians and researchers including abstracts in Hebrew and Arabic.

Last August, The Lancet published an article by Israeli public health experts warning about the ramifications for the health system of the Netanyahu government's effort to weaken the judiciary.

On October 18, a week and a half after Hamas' attack, three Israeli physicians published an article in the Lancet, "An urgent call for the immediate release of Israeli hostages." It was signed by about 1,500 Israeli health professionals.

Four days later, the journal published a letter from a physician from Gaza, who asked, "Under what system of law and morality does Israel have the right to target health-care workers, civilians, and children, showing a tragic disregard for the humanity of Gazans? Under what system does Israel have the right to turn the already besieged Gaza Strip into a mass graveyard? If the massacre continues on its current path, we will be dangerously close to witnessing a large-scale genocide of civilians and patients. When have such illegal and immoral acts ever been justified?"

Reis says he told Horton "about my interest in the subject of medicine and the Holocaust. That didn't attract or interest him sufficiently at the time."

But something happened. "For a reason still not clear to me, Horton spent his summer vacation in 2019 reading books on the subject of the Holocaust and medicine. That spawned the understanding that the study and teaching of the lessons of the Holocaust in a medical context is something dramatic for medicine. And it led to the establishment of the task force."

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