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 Lancet Commission on medicine, Nazism, and the Holocaust, which we are a part of, 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.
German health professionals were also involved in forced sterilizations of between 310,000 and 350,000 victims 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 mass murder of psychiatric patients helped prepare the extermination of 1.7 million Jews in German-occupied Poland when perpetrators, including health personnel, were transferred to the three extermination camps of so-called Operation Reinhardt from 1941 to 1943. Also, tens of thousands of individuals were subjected to forced medical research, resulting in great suffering, maiming, and death. Victims’ human remains were used for research and teaching, with specimens sometimes kept for research long after the end of the war.
Implications for Today
Implications from this history are relevant for every field of medicine and healthcare. The central insight is that while medicine holds immense potential to benefit humanity, it can, under certain circumstances, cause great harm. The role of healthcare professionals, medical institutions, and biomedical sciences in justifying, preparing, and executing some of the most egregious atrocities in history — albeit contingent on the specific conditions of Nazi Germany — highlights the potential dangers inherent to modern, scientific medicine as it emerged in the 19th century.
The moral agency of health professionals became distorted through opportunities and temptations offered by the Nazi regime. Recognizing this potential within medicine and its practitioners through interactions with states, employers, or other authorities, is important to understand one’s own agency.
In this context, preventive steps must be taken to counteract an ever-present risk of medical injustices or infringements of fundamental human rights. Our report discusses some of the specific risks linked to such factors as opportunities to abuse medical power, the tendency to objectify patients and research participants, dilemmas about split loyalties, and temptations to abandon basic values for ideological and opportunistic reasons.
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.
Therefore, professional ethics in healthcare constantly need to be critically assessed and reaffirmed to ensure they stay aligned with core values specific to medicine, and to avoid becoming exclusionary and inhumane. Further, this history demonstrates that courage, resistance, and resilience are necessary to prevent and counteract potential abuses of trust, power, and authority in healthcare, and that this is not only necessary, but indeed possible. Health professional practice and the pursuit of scientific knowledge should occur within a framework that prioritizes individuals’ human rights.
Finally, health professionals have particular responsibilities in fighting against discrimination. They have distinct credibility to challenge false scientific claims made by antisemites, racists, sexists, and other bigots, and they are in key positions to prevent, detect, document, or remedy human rights violations.
This is true not only in the practice of healthcare, but also in education and research settings. Health professionals know there is no factual basis for claims that human beings are fundamentally different or of different value; rather, we all share the same human rights, we all own dignity, and we all deserve respect.
Education for Tomorrow
We identified three foundational medical education constructs appropriate for our educational agenda:
- Competency-based medical education;
- The informative-formative-transformative paradigm; and
- Professional identity formation.
Specifically, we developed the new paradigm of history-informed professional identity formation for health professional education. It is defined as: “the shaping of professional identity through learning about, and reflecting on, historical episodes in which medical values and priorities were challenged.” At its core is “critical reflection about what professional values and priorities should be … to never unquestioningly accept existing professional structures and culture (or proposed changes to them), but rather to critically scrutinize them, explore their origins, assess the alignment between one’s personal values and those of the profession, and examine both for areas of weakness.”
In the report and its appendix, we describe ways to apply this educational paradigm. Aspiring educators in the field are guided step by step to create syllabi, pedagogies, assessment, and faculty development, with examples of educational interventions and advice for effective teaching and the gradual building of a comprehensive curriculum.
Finally, education-focused recommendations include the implementation of history instruction to emphasize the unique opportunities and responsibilities of health professionals in the elimination of discrimination; the creation of experiential learning opportunities, including visits to historical sites or museums; historical case studies that represent “real-life” approaches to learning; and examples of reflective exercises to consolidate informative and formative learning to facilitate transformative learning.
Herwig Czech, PhD, is a professor of the history of medicine at the Medical University of Vienna in Austria. Sabine Hildebrandt, MD, is an anatomy educator and researcher on history and ethics of anatomy at Harvard Medical School in Boston. Shmuel Reis, MD, MHPE, is a family physician in Northern Israel and faculty in the Holon Institute of Technology. He is the former academic head of the Center for Medical Education in the Faculty of Medicine in Jerusalem, and former head of the School for Competencies Education in Residency of the Israeli Medical Association.