Bioethics and the Holocaust

Front matter

The International Library of Bioethics 96

Stacy Gallin lraBedzow EFditors

Bioethics and the Holocaust

Foreword

The publication of Bioethics and the Holocaust: A Comprehensive Study in How the Holocaust Continues to Shape the Ethics of Health, Medicine and Human Rights represents the end of an era and the beginning of the next. For many decades, the dominant theme of scholarship in this field was whether scholars could overcome deeply ingrained resistance to the acknowledgement of the role medicine and science played in fueling the rise of Nazism. That matter is settled. One of the proudest moments of my life was securing the first formal apology from the German Medical Association for the crimes of the Holocaust. These sorts of official apologies mean denial is much harder to achieve.

A related issue has been whether bioethics can ever come to grips with its own long history of ignoring the Holocaust in its scholarship, teaching, and textbooks. While some disagree, I believe that bioethics did not really connect to the grim history of German medicine, science, and ethics until well into the 1990s. It is sometimes said bioethics was born out of the ashes of the Holocaust. We know that is not true. There is a much larger story to tell, which this book seeks to uncover. Many horrible experiments abusing and killing vulnerable populations went on in America and other nations while war was being fought against the Nazis and long after the issuance of the first judgements at Nuremburg by the war crimes tribunal in 1946. And in terms of scholarship of the sort represented in this book, it was not until the 1980s and 1990s that serious work was undertaken with either enthusiasm or in any real volume. In fact, it could be argued that the true engagement of bioethics with the Holocaust did not occur until the publication of my book, When Medicine Went Mad that appeared in 1992!

While my book set the mark for recognition and engagement, this book serves as the catalyst for the new era of incorporation of the lessons of the Holocaust into bioethics, medical, and public health profession education. The topics presented in this book, ranging from analyses of Nazi medical ethics to the role of doctors in specialty areas such as psychiatry to the bearing of the Holocaust on contemporary debates such as assisted suicide and human rights controversies, show that the battle over whether to deny the importance of incorporating the Holocaust into the field of bioethics is over. The importance of studying the Holocaust is clear. Rather than vi Foreword just haggle over the morality of using information from long ago Nazi medical experiments or whether only incompetent doctors were leaders in Nazi medicine (that is now known to be far from true), we must now wrestle with the challenge of how to incorporate the moral legacy of Nazi medicine and science into contemporary bioethical debate.

One key factor that permitted virulent Nazism to incorporate German social Darwinism from the 1910s and 1920s was racism. The subjects of the concentration camp and anatomical studies were dehumanized, viewed as less than human and deserving of no respect due to their religion, ethnicity, gender-orientation, political views, or status as prisoners according to Nazi race theory. Author after author in the chapters collected here notes how Nazi racial views distorted the ethics of doctors so that they did not feel they were violating the interests or rights of “human” beings.

It is important to try and connect the racism of German science and medicine that led to Rassenhygiene and the politicians who sought to utilize applied biology to the Holocaust. How does the long, dismal history of racism in American medicine and science and for that matter, society, continue to shape the practice of medicine and science today as well as our racially divisive politics? While this book does not answer these questions directly because it is beyond its scope, nevertheless some answers can be found in these pages and the book opens the door for these discussions to occur in medical and health care education. But much more work remains to be done to link the impact of slavery, the hatred of immigrants, the exploitation of indentured workers, Jim Crow, segregation (formal and informal), and the ridiculous battles over teaching critical race theory or simply how our long history of racially informed assumptions about groups shapes how we think about clinical care, access to care, trust, and autonomy in medicine now. Racism has long infected every aspect of life in America and medicine is no exception. All one must do is look at who is underinsured and uninsured, who lacks ready access to providers, and who gets rapid access to care in emergencies and the point is very clear. But it also clear that racist views drawn from science and medicine have shaped American politics and policy and those interactions merit more analysis and debate.

One other area requiring more inquiry is the role played by the shift during pandemics to public health ethics. While critics of mandates and quarantines often draw crude analogies to both Nazism and communist repression, the reality of how to manage community needs in a culture that adores autonomy in its medical care and its public behavior remains unresolved. German medicine, again as many contributors here note, took the people or the “Volk” as their patients. How can public health learn from that experience as it tries to grapple with pandemics and poverty?

Foreword Vii

So, celebrate the achievements of those whose work is represented here. It forms the foundation for the next few decades of continued learning about medicine, science, and the Holocaust.

Arthur L. Caplan, Ph.D.

Mitty Professor and Director Division of Medical Ethics NYU Langone Medical Center New York, USA

Preface

The Maimonides Institute for Medicine, Ethics and the Holocaust was founded on the premise that the only way to truly preserve the legacy of those who perished or whose lives were changed irrevocably at the hands of Nazi medicine is to use the lessons of the past to inform how we can and should act today; to foster a personal and professional ethos that values the protection of human rights and the central principles of ethics first and foremost; and to empower the next generation to understand the necessity of standing up and speaking out whenever injustice is present.

One of our primary goals was to create unique educational offerings that would use the Holocaust as the historical framework for exploring the ramifications of placing scientific and societal progress over the promotion of individual welfare and human dignity. These materials would provide a mechanism for encouraging people to recognize the systemic issues within healthcare and society that continue to create a hierarchy of human life and empower them to explore their role as active agents of social change who will advocate for equality and social justice in health care.

The Holocaust is often taught solely as part of history specific to a particular group of people: Jewish or German, political or military. However, its lessons transcend these types of traditional boundaries. Holocaust education can and should be universally relevant and serve to promote justice and tolerance, equality, and human dignity for all people. The purpose of this book is to make it easier to achieve this type of inclusive and meaningful Holocaust education by providing a primary text that outlines many of the major areas of medicine, ethics, and the Holocaust as an academic discipline. Though it would be impossible to cover every aspect of the field, it is our hope that this book will serve as a tool for those who want to teach and learn about the contemporary relevance of the topic. We have organized the book to make it easy to use in a university or post-graduate setting based on the number of weeks in a semester, and even piloted it with a group of students enrolled at a medical school in the United States.

As editors, we want to acknowledge the wide range of views regarding contemporary issues presented by the contributing authors. While these perspectives do not necessarily represent our personal beliefs, we feel it is important to show the x Preface broad spectrum of opinions surrounding the use of the Holocaust in current bioethical debate. This speaks to the relevance of the Holocaust and the ways in which it continues to shape the ethics of health, medicine and human rights. In keeping with the theme of this book, we believe that our role as editors is not to attempt to persuade the audience to agree with our position on some of the more contentious issues by only offering a one-sided view. Rather, we have included internationally recognized scholars who can provide a balanced academic approach that will motivate the reader to form his or her own opinion.

While this idea for this book was conceived long before COVID-19, this global pandemic has called into question our core ethical values, resulting in proposed modifications to basic moral principles at varying levels within healthcare politics, public policy, the media, and society as a whole. Systematic inequalities that emphasize the hierarchy of human life—long present in society—have come to the forefront of debate. At the same time, we are experiencing a troubling rise in racial, ethnic, and religious hate crimes as well as a lack of knowledge regarding the Holocaust. At this defining point in human history, we face an unprecedented challenge. We must be able to use the lessons of the past—those from another defining moment in human history—to inform our actions, shape our present, and create a better future.

Stacy Gallin, DMH

Founding Director, Maimonides Institute for Medicine, Ethics and the Holocaust (MIMEH), Co-Director, Department of Bioethics and the Holocaust of the International Chair of Bioethics (ICB)

Marlboro, USA

Ira Bedzow, Ph.D.

Emory University School of Law Atlanta, USA

Contents

Michael Berenbaum

2 Teaching Medical Ethics in Nazi Germany: Debunking

Tessa Chelouche

Chapter 1 A) The Question of Relevance geit Michael Berenbaum

1.1 Would That the Holocaust Was Irrelevant

A personal word: many years ago, when we were first developing the United States Holocaust Memorial Museum, we struggled with the issue of how to end the permanent exhibit. We had come up with an appropriate beginning that would serve the function of taking visitors off the National Mall, taking them back what was then fifty years in time, moving them a continent away and introducing them to a European event that we knew they would be seeing primarily through American eyes. Responding ever so subtly to the question of what this event has to do with the American experience, we decided to begin at the end of the Holocaust with the American troops entering the concentration camps, encountering its survivors as well as its evil. It worked because we could conclude this transitional beginning by asking the question those troops who entered the camps asked: how this could have happened?

The rest of the Museum was a response to that question.

But how was the Museum to end?

What transition could we make between the capital of the United States and the world of the Shoah—what survivors and scholars of the Holocaust had named “I universe concentrationaire, the planet of Auschwitz,’ what Elie Wiesel, who was deeply committed to maintaining, “that world is not our world... the Holocaust was a world apart,” often called the “Kingdom of Night?”.

I knew the ideal ending. We could simply say, “This is how twentieth century humanity behaved toward one another. We, however, do not behave this way, nor should we.” Unfortunately, that is not something we could say; it would neither be credible to our visitors nor to ourselves. Thus, we ended by presenting a lightly narrated film of survivors telling their stories—fragments of memory—to serve as

M. Berenbaum (BX) Los Angeles, USA e-mail: michael @berenbaumgroup.com

© The Author(s) 2022 1 S. Gallin and I. Bedzow (eds.), Bioethics and the Holocaust, The International Library of Bioethics 96, https://doi.org/10.1007/978-3-031-01987-6_1 a bridge between that world and our world. As survivors, they have lived in both, and they had made the transition between the two worlds. We had little interest in showing the transition that the perpetrators made from being staff at Auschwitz or from the killing fields of Ponar to living ordinary lives as post-war citizens of Germany, Austria and other perpetrator countries- even in the United States.

My dream today remains the same as it was then: that someday the Holocaust will become irrelevant and the people of that era could look back upon it as an aberration and a warning, a lesson in how individuals, societies and governments should not behave, the negative example par excellence. We could also learn from the all-too-few who lived through the Holocaust but, nevertheless, present a positive model of human behavior. My hope is that someday we can utter the words “Never Again” neither as a cliché nor with shame, but with a sense of achievement in a world transformed.

I am not alone in these sentiments. Speaking at the commemoration of the 75th anniversary of the liberation of Auschwitz at Yad Vashem, the President of Germany, Frank Walter Steinmeier, said:

I wish I could say that our remembrance has made us immune to evil.

But...the spirits of evil are emerging in a new guise, presenting their anti-Semitic, racist, authoritarian thinking as an answer for the future, a new solution to the problems of our age. I wish I could say that we [Germans] have learnt from history once and for all.

But I cannot say that when hatred is spreading.

Of course, our age is a different age. The words are not the same. The perpetrators are not the same. But it is the same evil.

And there remains only one answer: never again! Nie wieder!

As a religious but somewhat disbelieving Jew, the easiest affirmation that I make is that “this is a world that is not redeemed.” While the more pious, the more faithful, await the Messiah daily, I live in an unredeemed world, one in which the Holocaust still has abiding relevance. With the rise of antisemitism, racism, authoritarianism, and fascism in recent years, everyone in this field is challenged with the question, “What have we learned from the Holocaust?” In a polemical talk for the Tikvah (Hope) Foundation, Ruth Wisse, a Harvard Professor Emeritus of Yiddish, questioned the very necessity and utility of Holocaust education.

1.2 The Curse of Abiding Relevance

Still survivors and scholars of the Holocaust are routinely asked to comment on parallels between current events and the Holocaust. Non-sophisticated students often confuse analogies with equivalences as if comparing two events makes them identical. As we learned early on in our high school education, we must both compare and contrast; only when we do both can we understand the distinctiveness of each event. During the ongoing COVID-19 pandemic, survivors and scholars, myself included, were often asked what we can learn from the Holocaust that sheds light on the pandemic. Clearly the two events are dissimilar, but still there is something that can be learned.

Survivors, who spent years in hiding from an all too visible enemy, spoke of their experience with newly isolated and quarantining students and adults hiding from an invisible enemy-the virus. These students and adults wondered how survivors passed the time and dealt with the isolation and loneliness during the Holocaust, when they were without the use of the internet, email, television, telephone and Zoom, all of which have been readily available to this generation. The conversations were interesting, the engagement lively as one generation began to understand the other.

In the last months of 2020 and most especially after the infamy of January 6, 2021, many of us have been asked if we are living in 1931, 1933, or 1938. We are living in 2022, and the challenges of this age are unique to the tools of this age. The internet and social networks, multiple and often conflicting sources of news and information have led to disagreements about basic facts and even whether there is any type of objective truth. We face problems specific to this moment in time: the health crisis, the economic crisis, the social justice crisis, the leadership crisis and the climate crisis.

After the storming of the Capitol on January 6, 2021, analogies were made to the Reichstag Fire of February 1933 or Kristallnacht, the November 1938 Reich pogroms. Most people understand that the analogies are inexact; history does not quite repeat itself, not directly, but the past has echoes in the present and the Holocaust has by now assumed its place at the “Negative Absolute” (Berenbaum 2003, 46) of our age.

In a world of relativism, where facticity is challenged and truth often abandoned, the Holocaust has come to serve as a pivotal point of reference. We do not know what is good and what is bad, what is truth or fiction, but we do know that the Holocaust was evil, absolute evil, even the “gold standard” of evil. It is therefore the “go to event” when people want to call attention to a violation of human dignity or human rights, to mass murder, inhumanity, persecution, discrimination, racism, and genocide. It is for this reason that some want to deny the event, to purge that evil, while others, who seek to mimic it or repeat it, invoke its symbols, and provoke by using its iconography. And in times of crises, we hear echoes of the Holocaust again and again as fear, as a warning, and sometimes, sadly even as aspiration.

1.3 Science in the Service of Ideology, In the Service of Politics

Readers of this book certainly know that the judges at the Doctors’ Trial at Nuremberg established ten principles—perhaps Ten Commandments—which have served as a cornerstone of contemporary medical ethics. Among them are the right of the patient to be informed of their treatment and to consent to it, and the right of the patient to end treatment. These ten principles have been critical also in considering the ethics of human experimentation. So much has been learned from the Holocaust in the sphere of medicine—much, but not enough.

During the COVID-19 pandemic, we have seen the politicization of medical information, the falsification of medical data to advance a political agenda to the exclusion and even derision of scientific knowledge, the promotion of false information to satisfy the whims of political leaders, national and local. We have witnessed and been victimized by restrictions on publicizing information that could save human lives, as well as inform physicians in an ongoing medical emergency about best practices and what practices to avoid. We have seen the promulgation of needless optimism when realism and cautious restraint were necessary to protect human life. We have heard self-serving lies when truth would have been an important warning.

We have seen medical personnel affiliated with some of the great universities of the United States advance theories and policy recommendations contradicting the best medical advice available, subordinating themselves, their reputations, and exploiting their credentials to a political leader they supported. For example, Dr. Scott Atlas, a senior fellow at the Hoover Institution, a conservative think tank at Stanford University did not have a specialty in either infectious diseases or public health. Instead, his focus is on healthcare policy with a background in neuroradiology, which is the reading of X-rays, CT scans, and MRIs. He was given his position as a Special Coronavirus Adviser to President Trump not based on his medical qualifications but because he attacked those who challenged the President and offered without any known expertise in this area advice against lockdowns and masking (Romo 2020). Seemingly, this type of behavior, which is antithetical to the foundations of medicine, was without consequences in the medical community including discipline by medical boards or withdrawing of university affiliation or firings. At the same time, experts with the knowledge and skills to save human lives have been silenced. And others, responsible physicians such as Anthony Fauci and Deborah Birx, had to walk a tightrope, avoiding lies, saying just enough to inform the public but withholding unessential criticism and toning down their views in order to retain their jobs or not be sidelined. They knew that should that occur their successors would only be more ineffective and probably less honorable (Collins 2021).

The results have been that as of January 19, 2021, almost exactly one full year after the first case was confirmed in the United States, the nation surpassed 400,000 COVID-19 deaths (Crist 2021). Although accounting for only 3% of the world’s population, the U.S. had as of the inauguration of Joseph Biden as President of the United States almost 20% of the world’s COVID-19 cases, and the virus continued to surge throughout the country until the vaccine was widely distributed.

The scientific achievements of the vaccines, seemingly in remarkably record time, demonstrate what science can accomplish. The catastrophic handling of the pandemic by our leaders, empowered and legitimated by their medical enablers who subordinated their knowledge and talent to a manifestly political agenda—seemingly without professional consequences—demonstrates the perils of what can occur when medical personnel decide to be more faithful to politics, power, prestige, position, and fame than to medical knowledge and when that subservience directly contributes to the loss of life.

We have also witnessed the politicization of data collection. Some political leaders did not want to provide for adequate testing for fear the results would impose obligations to quarantine, to close bars and restaurants and businesses, even assembly lines at meat processing plants where a majority of workers got sick. Some also refused to release statistics for similar reasons or to support the perception—in the face of evidence—that the pandemic was under control. The former Governor of New York has been accused of requiring nursing homes to accept COVID-19-positive patients when New York’s hospitals were overflowing, and then, to hide data about deaths of nursing home residents to maintain credit for handling the virus properly (Cohrs 2021). This happened at state and local levels and not merely on the national scene. It occurred in the U.S: a democracy, not a totalitarian state.

We must realize that the subordination of scientific knowledge to the political agenda of the head of government—national, state and local—and his/her ideological enthusiasts was not restricted to Nazi doctors alone. It was also not restricted to medical personnel. This took place within a democracy with constitutional checks and balances and an independent judiciary. One can only imagine what could happen in authoritarian states or dictatorships where the consequences of opposing the dominant political position is imprisonment, exile and death, not just loss of position, prestige and political influence. The silence of international doctors who could have spoken up at the beginning of what was to become a global pandemic and their reluctance to share information in a timely fashion must be studied in the future.

These were observable violations of medical ethics. Over time we will come to understand that there were other significant violations as doctors and other medical personnel decided who shall live and who shall die, what priorities to give to treatment and who should be allowed to die by neglect. Others will write of the implications in new fields of genetics and the ability to attack certain diseases in vitro. The behavior of Nazi doctors should indicate that restraints need to be in place. Ethical norms need to be established, sustained, and defended-even in times of crisis.

Although the roll out of the vaccination program got off to a slower start than desired, there were a series of sustained, public, and serious debates as to who should get priority for receiving the vaccine and little dispute that the priorities are ethically valid, beginning with front line workers, then going to those in nursing homes and assisted living conditions, the elderly and those with underlying medical conditions before the general population. While these priorities have not been universally observed they make ethical sense and have properly enjoyed the support of the American public. We have also seen that minorities have been vaccinated less than others and among minorities, there is a greater suspicion as to the efficacy and safety of vaccines because of a greater distrust of government and of science (Recht et al. 2021).

Vaccine nationalism, now prevalent throughout the world, raises an interesting ethical dilemma since there has developed a gap between the wealthy nations and others. This is highly problematic because only global vaccination will lead to safety as borders are porous, and travel will spread contagion. The rabbinic sage Hillel admonished, “If I am not for myself who will be and when I am only for myself what am I? If not now, when?” This seems not only sound political advice, but the only policy that will starve the virus and return us to pre-pandemic normalcy.

1.4 Medicine in Extremis: Then and Now

As we have faced the greatest public health crisis of our time, what can we continue to learn from the Holocaust? Where is the relevance both to how we will judge our actions during the COVID-19 pandemic and prevent future social injustices related to health and medicine? To answer this question, let me turn to medicine in extremis. As I witnessed New Yorkers pausing at 7:00 PM each evening at the beginning of the pandemic and going out on their balconies to applaud for first responders, doctors and nurses, fire fighters and ambulance drivers, I thought momentarily of the doctors and nurses, pharmacists and other health care workers in the ghettos of German occupation, who, under increasingly dire conditions had to provide for their besieged Jewish populations.

I had been working on two books at that point, writing a review of Mark Smith’s The Yiddish Historians and the Struggle for a Jewish History of the Holocaust, and assisting in editing the English language translation of a Ph.D. dissertation on the Doctors of the Warsaw Ghetto by Maria Ciesielska. The Yiddish writers of the Holocaust were committed to writing about how Jews lived and not about-or at least, not only about how Jews were murdered. Following their example, rather than write about Nazi doctors and Nazi medicine alone, in this chapter I have chosen to give a brief overview about what happened inside the ghetto as Jewish doctors tried to practice medicine in extremis and the parallels we can draw in contemporary society.

Germany invaded Poland on September 1, 1939, from the West; the Soviet Union invaded from the East on September 17; Poland was thus divided. In the weeks before the war, the Polish Army was mobilized and physicians who had been part of the Polish Army were called up into their military units. That left many Polish hospitals understaffed, presuming that the military would bear the brunt of the casualties, but as fighting became fierce and the attacks on the civilian population widespread, the civilian hospitals’ abilities to handle the wounded overran the hospitals’ capacities. During the initial stages of the invasion, doctors throughout Poland had to practice triage in choosing their patients. This was due to the fact that the German army did not merely attack military targets but attacked civilian targets and the general population as well. They, therefore, had to balance treating military personnel, who required medical treatment and were also needed by the Armed Forces to return to battle, along with civilian casualties. They too operated with limited resources and inadequate supplies. Ill prepared, they had to practice emergency medicine without certitude as to when they would benefit from resupply. Given an emergency situation of unknown duration, it was all-hands on deck for the foreseeable future, a sprint was required to keep pace in what turned out to be a marathon, enduring throughout the war years.

In areas under German occupation, Jews were immediate targets of persecution and placed in ghettos. In retrospect, the ghettos were a place to contain the Jews until the Final Solution to the Jewish Problem became the operative priority of the German government and the infrastructure was built for their annihilation- death camps complete with gas chambers and crematoria. As a general principle under German occupation, there was no interest on the part of the occupiers in the general health of the Jewish population. There was only self-interest in preventing epidemics that could endanger German personnel or reach beyond the ghetto walls and afflict the Aryan population, which would in turn jeopardize the health of German troops and civilians.

German assistance to the hospitals of the ghettos was motivated solely by a desire to contain epidemics, specifically typhus, and not by a desire to care for the wellbeing of the captive Jewish population. Health care providers were thus working under conditions of deliberate depravation where the very act of obtaining medical supplies was contrary to the basic interest of the occupiers. During the COVID-19 pandemic, the entire world was faced with an unprecedented demand for medical necessities (e.g. personal protective equipment, ventilators, hospital space) that far outweighed the available supply. This is vastly different than the situation in the ghettos under German occupation, where the ability to provide medical care was present, but a deliberate choice was made not to do so.

Clearly, there are differences between the medical crises of the German occupied ghettos and our current experience with COVID-19. The Nazis manufactured a medical crisis to suit their own political and racial ideology, using science and medicine as a justification. The death and destruction caused by this medical crisis was linked to the second World War. COVID-19 is a global pandemic that has ravaged the world population, (mostly) independent of politics or international hostilities. Yet, there is still much to learn from medicine in the Holocaust, and the behavior of physicians in extreme circumstances in particular that can impact our response to the challenges we currently face. Stories of physicians who remained dedicated to healing and saving lives in any way possible prove that ethics, virtues, values and hope can prevail. These tales of Jewish physicians and righteous Gentiles who risked their lives to save others inspire a positive view of medicine and bioethics in which the power of the profession is harnessed for good, even in increasingly desperate circumstances. The lessons of the Holocaust- how the power and privilege of medicine can be used in both positive and negative ways- have informed our current situation as we have struggled to meet the challenge of COVID-19 in the most ethical manner possible.