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    Why we must teach medical students about the role of physicians during the Holocaust

    Medical education must include moral education, and understanding the complicity of the medical-scientific establishment during the Nazi regime can help foster empathy and combat antisemitism and racism today.

    Students and faculty from Oakland University William Beaumont School of Medicine spent a week in Poland in June to better understand the Holocaust. Here they are shown at the gate of the former Auschwitz 1 concentration camp.
    Students and faculty from Oakland University William Beaumont School of Medicine spent a week in Poland in June to better understand the Holocaust. Here they are shown at the gate of the former Auschwitz 1 concentration camp.
    Credit: Oakland University William Beaumont School of Medicine

    On January 27, 1945, Soviet soldiers liberated Auschwitz-Birkenau, the largest Nazi concentration and extermination camp and site of unspeakable horrors against the Jewish people and others demonized by the Nazi regime. As weeks and months passed, the extent of the atrocities carried out there and at many other camps throughout Germany, Poland, and other Nazi-occupied territories began to be unveiled.

    So, too, did the complicity not just of Nazi functionaries and soldiers, but of countless physicians, nurses, and other medical professionals who joined the Nazi regime in large numbers and provided the scientific justification for the “racial purification” that took place. Indeed, the pervasive complicity of physicians and the medical-scientific establishment in Nazi Germany is of decisive importance in the genesis of the Holocaust, the deliberate genocide of 6 million European Jews driven by antisemitism, and the mass murder of others persecuted by the Nazi regime. Even before the establishment of extermination camps in late 1941, gas chambers were used in psychiatric hospitals to exterminate more than 300,000 disabled children and adults. Gas chamber technology developed by physicians at hospitals was transferred to extermination camps for the industrialized murder there, with expertise from top “euthanasia” program medical officials who had been transferred to these camps for this purpose.

    The oft-assumed lack of guiding ethics at the time is among longstanding myths about the relationship between the Nazi regime and medicine. 

    Medical scientists obtained permission from Nazi officials to access prisoners in concentration camps for the study of scientific questions such as the physiological impact of high altitude, freezing temperatures, drinking seawater, vaccinations against typhus and infectious jaundice, and the development of sterilization techniques, thereby maiming and killing thousands of their “subjects” with extreme cruelty.

    The oft-assumed lack of guiding ethics at the time is among longstanding myths about the relationship between the Nazi regime and medicine. Indeed, medical ethics education had become a mandatory part of German medical curriculum between 1939 and 1945. However, it included teachings about the unequal worth of human beings, the authoritative role of the physician, the necessity of preserving a pure Aryan people, and the priority of the health of the “Volk,” or state, over the care of individual patients who were considered unworthy of such care.

    Bioethicist Arthur Caplan, MD, who has written about this unparalleled wrongdoing, observes: “The myths of incompetence, madness, and coercion have obscured the truth about the behavior of biomedicine under Nazism. Most of those who participated did so because they believed it was the right thing to do.” How, then, do we reconcile this truth with our own understanding of the role of health care professionals? Can we?

    When SS physician Fritz Klein was asked by prisoner-physician Ella Lingens-Reiner how he reconciled his actions in concentration camps with his ethical obligations as a physician, he answered, “Out of respect for human life, I would remove a purulent appendix from a diseased body. The Jews are the purulent appendix in the body of Europe.”

    Bioethicist Arthur Caplan, MD, who has written about this unparalleled wrongdoing, observes: “The myths of incompetence, madness, and coercion have obscured the truth about the behavior of biomedicine under Nazism. Most of those who participated did so because they believed it was the right thing to do.”

    There were, however, also stories of resistance and moral courage, both of imprisoned Jewish physicians and nurses in ghettos and concentration camps and non-Jews who took great risks to save their Jewish friends and neighbors (these men and women have been honored as “The Righteous Among the Nations” by the Yad Vashem memorial).

    Medical care is complex, and ethical quandaries are inevitable. Medical educators care about cultivating ethical vigilance in learners, about inspiring caring for the person who is the patient, free of bias and pejorative judgment. Discussions about concepts of character and values may provide a moral compass in becoming a health care professional. The history of medicine during Nazism and the Holocaust can support such critical reflection at all stages of the professional life cycle. It can help us recognize patterns to avoid or aspire to, and thus support us in the development of our own stories of ethically responsible health care.

    Much of this history forms the roots for biomedical ethics and may inform responses to the challenges of contemporary ethical dilemmas in clinical practice, research, and public policy, including potential abuse of power, the influence of economic or political issues on medical work, competing loyalties, beginning and end of life issues, genomics and technology expansion, issues of diversity, equity, and inclusion, and societal issues of preserving human dignity.

    Learning the history of medicine during the Holocaust should become part of the toolkit used by health care professionals as a guide to ethical vigilance and must be included in medical education curricula.

    Medical education includes moral education. Fostering reflection on this history of the profession is relevant in relation to fighting overt antisemitism and racism. Knowing this history can be transformative and can help foster empathy and prevent dehumanization in medicine. There are, indeed, “moral determinants of health.” “Medicine is a moral enterprise,” as physician-ethicist Dr. Edmund Pellegrino wrote.

    It is essential to teach about this period in medicine’s past. The historical evidence of medicine’s complicity in the Holocaust should be in the “repertoire of knowledge” of emerging health care professionals. Health care professionals bring their medical expertise to their work, but they also bring their character, moral integrity, resilience, and their humanity. They must interact with and react to the society and political environment in which they exist.

    This specific history can inform how learners understand their profession and become health care professionals, a process that continues throughout their careers. It is a history of extremes, yet relevant in the here and now — and while it includes examples of resistance and resilience, it also involves collaboration, complicity, and abject crime. Studying and reflecting upon the historic details can foster morally resilient professional identity formation, which is a central goal of medical education. In 2021, the Lancet Commission on Medicine and the Holocaust was established on Holocaust Remembrance Day, January 27, to “propose educational approaches that promote ethical conduct, compassionate identity formation, and moral development.” We are honored to serve on this commission.

    According to David Skorton, MD, AAMC President and CEO, “When we say ‘Never Again’, it means fostering discussions about how to navigate ethical challenges in our field. It means incorporating arts and humanities, including the history of medicine and its role in the Holocaust, as a fundamental part of medical education.” Learning the history of medicine during the Holocaust should become part of the toolkit used by health care professionals as a guide to ethical vigilance and must be included in medical education curricula. Educational initiatives utilizing this history are expanding, with examples including a required seminar as part of Eastern Virginia Medical School’s diversity/equity/inclusion/cultural humility curriculum, and at Geisinger Commonwealth School of Medicine, University of Louisville School of Medicine, Oakland University School of Nursing, Oakland University Beaumont School of Medicine (which includes a study trip to Auschwitz), and the University of Toronto Faculty of Medicine. Educational opportunities also are being offered in graduate medical education — for example, recently for the Northwell Health internal medicine residency program — and in continuing medical education as well.

    Our call to action is precisely this: Integrate a required seminar or module on this history in all health professions education within ethics, professional identity formation, leadership, or humanism in medicine curriculum threads. Other options include the insertion of historical case studies from the various medical disciplines (e.g., throughout the 4-year medical education curriculum). A 2022 AAMC webinar and faculty guide for facilitating post-webinar reflection sessions using the medical humanities are available, and the Lancet Commission is planning to provide additional resources with the publication of its report, expected in 2023.

    A first-year medical student’s reflective writing during one of these sessions is illustrative of the impact of this history: “Realizing our connection with the past is crucial. … It is especially important not to dismiss the physicians who were compliant with the Holocaust as simply evil monsters. We all have the potential to do good or to do bad, and we have to be critically aware of this.”

    Teaching about and critically reflecting upon the legacy of medicine during the Holocaust and its striking contemporary relevance is not only a medical imperative but a moral one.

    Hedy Wald, PhD, is a medical educator at Alpert Medical School of Brown University and the daughter of an Auschwitz survivor whose entire family was murdered in the Holocaust. She teaches internationally about medicine during the Holocaust, including at Auschwitz, for medical students from the Witten-Herdecke Faculty of Medicine, Germany, and for Oakland University Beaumont School of Medicine medical students as part of a Holocaust and medicine course. Sabine Hildebrandt, MD, is a German-born anatomy educator who teaches students at Harvard Medical School and Harvard College about the ethics of anatomy and specifically the history of anatomy in Nazi Germany.

    Editor’s note: The opinions expressed by the authors do not necessarily reflect the opinions of the AAMC or its members.