Ethical Considerations in Using the Pernkopf Atlas in Otolaryngology Education Ethics in Practice: Point‐Counterpoint

Case Presentation

A junior otolaryngologist prepared grand rounds slides on infratemporal fossa anatomy. To depict complex surgical relationships, the resident selected several highly detailed images from a legacy didactics repository created by a now‑retired faculty member. The repository did not explicitly identify image provenance beyond standard citations to the originating Atlas and the internal presentation title.

During the presentation, a faculty member recognized the illustrations as originating from the Pernkopf Atlas of Anatomy. Subsequently, the faculty member expressed concern that the Atlas' images may have come from executed prisoners under the Nazi regime and raised questions about whether the images should have been used without explicit disclosure of that history.

This ethical dilemma prompts reflection on obligations to acknowledge unethical provenance, the risk of normalizing unethically derived knowledge, the availability of ethically obtained alternatives of comparable educational value, and the balance between remembrance, harm prevention, and scholarly integrity in modern otolaryngology education.

Ethical Question

Is it ethically permissible for educators and trainees to use images from the Pernkopf Atlas in contemporary otolaryngology anatomy teaching, and if so, under what conditions of disclosure, contextualization, and limitation?

Point: Rationale for Continued Use With Transparent Disclosure

Eduard Pernkopf served as Dean of Medical Faculty and Head of Anatomy at the University of Vienna beginning in 1938. Known for his perfectionism and “ingenious” skill in dissection and anatomy, his four‐volume Topographische Anatomie des Menschen (The Atlas of Topographical Human Anatomy) has been recognized as the “best anatomy Atlas of all time.” ¹ This Atlas was among the first to use a four‐color separation technique, preserving the detail and precision of the original watercolor paintings in mass‐produced prints. The Atlas has been used across generations of medical training, and its images continue to appear in the scientific field due to its unmatched detail in showing complex anatomical relationships, particularly of the head and neck. ¹ , ² , ³ , ⁴

It was not until decades following the publishing of the Atlas that Pernkopf's contribution and loyalty to the Nazi Party became known. In 1988, Dr. David Williams' article titled “The History of Eduard Pernkopf's Topographische Anatomie des Menschen” exposed Pernkopf's activities during World War II and sparked an investigation into the source of the bodies used. ² , ³ In 1995, investigations into the Pernkopf Atlas by Dr. Edzard Ernst concluded that Pernkopf contributed to acts of “race hygiene” at the University of Vienna. It was because of this that the American Medical Association withdrew it from their collection in 1996. ⁵

Since the discovery of Pernkopf's affiliations and actions, there has been strong agreement that the creation of the Pernkopf Atlas is unethical and that the immoral actions of Pernkopf and his team are condemned by many in the medical community. The controversy presents a dilemma whether the continued utilization of the Atlas in the medical field is beneficial, ethical, and necessary within modern frameworks.

With advances in technology and artificial intelligence (AI), it has become nearly impossible to eradicate Pernkopf‐derived images and information from access. Generative AI platforms are among the most popularly used AI subtypes and are designed to be trained and expanded based on input data. Information from publicly available sources, consumer responses, and individual input can be used to “train” generative AI to create algorithms for producing images, videos, and texts. Given its long‐standing presence in medical education, information derived from the Pernkopf Atlas is most certainly included in AI‐generated material. In addition, it is difficult to determine if information can be “unlearned “from AI‐generated material effectively.

Even before AI, the use of the Pernkopf Atlas is argued to have inspired newer anatomy Atlases, rendering its existence both untraceable and possibly immortal. An argument exists that rather than eradicating all content of the Atlas, efforts should be aimed toward acknowledgment of the Pernkopf Atlas, aiming efforts toward acknowledgment of its origin and placing emphasis on the ethical teachings that arose from it as more beneficial to our field as a whole. Perhaps the most important argument for the Atlas' continued use is to serve as a reminder of the historical context of its origin, and to create a precedent for the importance of medical ethics in the use of human subjects. Removing the existence of Pernkopf's work from the medical field entirely creates the risk of erasing the historical and ethical lessons learned from this historical period. The noted bioethicist Dr. Arthur Caplan argues that the incorporation of unethically obtained information into scientific knowledge is inevitable, and that the use of this information “should be regarded as ethically and epistemically problematic when the immorality of that information's source or means of acquisition is subsumed, rendered invisible, by the general legitimacy of that broader body of knowledge.” ⁶ This perspective suggests that providers not only accept the presence of the Pernkopf Atlas as a long‐lasting contribution to scientific knowledge but also to approach its use through transparency and ethical reflectiveness. The disclosure of the Atlas' history to patients, students, and trainees can provide a voice to those who suffered and were exploited. Otolaryngologists should continue honoring these victims through professing humanity as a clear duty of the profession. It is an imperative that the historical implications are transparent to all who use or benefit from the Atlas' illustrations.

The use of this Atlas is a clear example of the complexity of medical ethics and how biases, politics, and ambition can shape decision‐making in the scientific field. Understanding the history of this Atlas transforms abstract concepts of autonomy, beneficence, nonmaleficence, and justice into tangible reality, and reminds us that these ethical frameworks were created in response to real‐life moments of human suffering rather than theoretical ideals. Medical educators and learners must understand both the negative and positive implications of the Atlas' history, which can serve as a guide for approaching complex situations in medicine. As a catalyst for discussion and reflection, the use of the Atlas provides an opportunity to share its history and emphasize the importance of the ethical care of patients and human subjects.

Counterpoint: Rationale for Discontinuing Use and Preferring Ethical Alternatives

While the Pernkopf Atlas holds significance in both remembrance and as a precautionary ethical lesson, for both future and current physicians. An equally compelling argument is that its Utilization as a visual learning resource should be entirely banned. Its use as a tool in medical education has the risk of normalizing unethically obtained anatomical depictions. Rather than preventing future violations, its continued use could paradoxically dignify Pernkopf's work. Continued use of the Pernkopf Atlas may indicate the casual acceptance of what was a blatant abuse of human subjects and persons who had no agency and no ability to refuse participation, thus violating core ethical principles.

With advancements in technology and the creation of alternative anatomy resources, superior options to the Pernkopf Atlas are available in medical education, and its uniqueness diminishes with advanced AI‐generated images. Its popularity as an anatomical resource has been greatly reduced within several past generations of learners. For example, Coombs et al found in their study of opinions from first‐year medical students at Drexel University that 95% of respondents from the class of 2019 were unaware of the Atlas' existence prior to their participation in the study. ⁷ Interestingly, this study also noted that while 71% of participants found the Pernkopf Atlas more anatomically accurate when compared to Netter's Atlas of Human Anatomy, surveyed students still preferred Netter images as a more effective learning tool in their gross anatomy studies. ⁷ This highlights that even the most realistic and detailed drawings may not be the favored resource for gross anatomy education. Two‐dimensional images are limited compared to three‐dimensional images, which are more applicable to procedural medicine and surgery. Current capabilities of advanced technology render the Atlas' functionality for education significantly inferior. In addition, the justification for its use holds little value when being compared to an ethically sourced tool with comparable or enhanced accuracy.

Any data or resources obtained unethically should be questioned not only for the moral dilemma it creates but also for research integrity and validity. If a researcher fails to follow ethical codes, it raises concerns about adherence to scientific rigor and the accuracy of findings. One case in point is the research derived from the Nazi hypothermia experiments on prisoners, which were found to have inconsistencies and errors that made the findings scientifically invalid and recognized as “scientific fraud.” ⁸ It has also been reported that the Pernkopf Atlas also has anatomical inconsistencies and errors in some of its published images. ⁹ Additionally, authors have reported that some of the images convey rare anatomical variations rather than more standard representative anatomy. ⁹ These findings tarnish the Pernkopf Atlas' reputation of being a flawless anatomical reference and further support an improved argument for the use of enhanced anatomical technologies from both an ethical and scientific standpoint.

Lastly, we must consider the victims, our patients, and the individuals affected by the heinous acts of the Nazis when deciding whether the Atlas' continued use is ethically justifiable. In 2017, the Chief Judge of the Rabbinical Court of Massachusetts, Rabbi Joseph Polak, created the Vienna Protocol, which provided guidelines on the continued use of the Pernkopf Atlas and other scientific findings obtained during World War II. These guidelines were derived from elements of Jewish law, and in specific regard to the Pernkopf Atlas, Polak advised that Jewish law permits the use of the Atlas only when used with the purpose of saving the life of a human being. ¹⁰ The Vienna protocol also strictly requires that the use of the Atlas must be prefaced with its historical context and acknowledgment of its origin. ¹⁰ While this provides a framework that grants the Atlas an ethical purpose, the broadness risks ambiguity and leniency. Over time, disregard for the historical significance of the ethical issues inherent to the Atlas' development will fail to inform and warn those who utilize it. Lastly, while the Vienna protocol and Jewish law technically permit the use of the Pernkopf Atlas under certain circumstances, it does not necessarily reflect the possible moral harm of the individuals, the victims, and their families, or, more broadly, members of the Jewish community. Our credibility in the medical field relies heavily on our oath to respect human dignity, and our commitment to building a trustworthy and cooperative relationship with our patients. With this principle in mind, it can be argued that the continued use of the Atlas deserves deeper consideration beyond just legal and religious permissibility.

Practice Recommendations

Based on the arguments developed above and the importance of transparency and honesty with our patients, we recommend the following considerations:

• Require explicit provenance disclosure and historical context when referencing or reproducing images derived from ethically tainted sources; acknowledge victims respectfully.

• Prefer ethically sourced resources when they meet or exceed educational needs; justify exceptions narrowly.

• Adopt departmental guidance for teaching materials that includes review for provenance, availability of alternatives, and appropriateness for learner level.

• Engage trainees in structured ethical reflection (autonomy, beneficence, nonmaleficence, and justice) when controversial materials are presented.

• Archive policy: annotate prior presentations with provenance notes rather than silently removing educational content, to avoid erasure of critical history.

Author Contributions

Erin Kraus: formal analysis, investigation, writing—original draft, writing – review and editing; Linda Grace Solis: formal analysis, writing—review and editing; G. Richard Holt: conceptualization, formal analysis, writing—original draft, writing—review and editing.

Disclosures

Competing interests

The authors declare no conflicts of interest.

Funding source

No specific funding was received for this work.