Apologising for Nazi medicine: a constructive starting point

At long last: in May 2012 the German Medical Association (GMA) has apologised for medical atrocities under National Socialism (appendix). Although overdue, the apology is necessary and highly commendable, not least as survivors of medical atrocities and persecution are still living.

German medicine between 1933 and 1945 saw a colossal breach of the ethics of patient care: doctors initiated and implemented an estimated 350,000 coerced sterilisations and 260,000 killings of mentally ill and disabled patients, and an unknown number of coerced human experiments, taking well over a thousand research subjects to the point of death. Doctors conducted selections for slave labour or death at Auschwitz, and took part in the development and use of killing methods, as poison gas, fatal injections, starvation diets and electrocution. Tens of thousands of bodies of the executed were delivered to German medical institutes, so that teaching and research in some departments routinely used bodies of Nazi victims until at least 1990 and in some cases for longer.

This year’s German Medical Assembly has opened a new chapter in the German medical profession’s engagement with the Nazi past. What has already become known as the “Nürnberg Declaration 2012” goes beyond all declarations to date regarding medicine during National Socialism. It expresses understanding of how physicians took a major role in atrocities under National Socialism, as well as a long overdue official apology. Its full significance will become apparent with further disclosures following the clear words of the German profession. For an apology needs to be informed by full disclosure of evidence for which the apology is being rendered.

It has taken 33 years for the German Medical Association to hold its annual assembly in Nürnberg since it last met there, in a city which is historically associated both with Nazism and especially with Nazi medicine. It was here that the in 1935 the Nürnberg Racial Laws were proclaimed, here that the Nazi Party rallies were held, and at the Doctors Trial of 1946/47 the grim details of crimes against humanity were laid bare. Whether one is a vistor to Nürnberg or a resident, no one can escape its history.

Although the process of coming to terms with the past, has not always been easy, the city of Nuremberg has found various ways of engaging with its Nazi past as with museums and a human rights award. The Nürnberg Group of the IPPNW (International Physicians for the Prevention of Nuclear War) organised the international congresses on “Medicine and Conscience” from 1996 on questions of the history and ethics of medicine. The group initiated the change of name for the street where the Nürnberg Hospital is located: this renaming commorates Prof. Ernst Nathan – the director of the dermatological clinic, who in 1933 lost his position and in 1938 lost his right to practice medicine. Together with some medical historians the IPPNW group drafted the petition that was the verbatim text for the Nürnberg Declaration which the GMA assembly passed.

The situation was long one of denial and disassociation from medical crimes. In the late 1940s the West German Medical Association (forerunner of the German Medical Association) shifted responsibility to a small group of 350 criminal doctors, while contending that mainstream medicine under Nazism proceeded conscientiously and ethically in its duty to patients.

The 2012 apology marks a crucial change in the recognition of abuses that involved the profession and its organisations. Measures should be engaged on arising from the Declaration and ensuing responsibilities. What has to be recognised is that coercive medical measures under Nazism were not initiated by fanatics or pseudo-scientists, but they were implemented by scientifically informed physicians as part of efforts to reform systems of health care and public health, and to develop medical research on an experimental basis. Their actions had devastating consequences for patients and their families, and beyond this for psychiatric patients and ethnic groups like Roma. Yet, what is perplexing and disturbing is that it has taken the German medical profession so long to accept this evidence.

For not only did the German profession have the evidence cited in publications of Mitscherlich and his assistant Mielke, and of Platen-Hallermund (works later republished in 1960 and 1997 respectively), but also a mounting body of work by historians of medicine, reconstructing the institutions and systems of Nazi medicine, and identifying victims. Moreover, the GMA was confronted by dignified statement of the medical historian Richard Toellner at its Berlin meeting in 1989 stating the position of institutionalised abuse by the mainstream of the profession. Yet the profession remained headstrong in ignoring the evidence.

To ask why the profession sought to bury the evidence (literally when it came to Nazi body parts) is to identify factors strong in German medicine, but also instructive for medicine in general. What has been at stake is professional honour and authority. Accepting the evidence of misconduct was deemed to dishonour the profession collectively, as well as denigrating senior figures in the profession. The presentation of evidence was deemed a breach of collegiality. Thus when a junior doctor, Hanauske-Abel published in The Lancet in 1986 on medicine and National Socialism, his evidence of a link to atomic weapons research was not empirically questioned, but he was dismissed for dishonouring the German medical profession. It was a question of evidence confronting senior status, indicating that a junior doctor should not question those in authority. Effectively, professional misconduct on a colossal scale was being covered up. This protecting mechanism meant senior figures from the wartime generation continued in office on into the 1950s and 60s, and then their deferential students took positions. If junior doctors ventured into the institute or hospital cellars to examine past records, they did so at considerable risk to their career. German laws on data protection and privacy backed up such suppression. It is considered illegal to publish names of murdered patients so institutional referrals can only be traced with difficulty, and families are hindered from finding out about relatives.

A situation thus arose of a professional leadership enforcing silence on issues of medical atrocities, and a dissident grass roots movement agitating to make evidence accessible. In the early 1990s the GMA refused to fund an edition of the Nuremberg Doctors Trial. The psychiatrist Klaus Dörner had the genial idea of appealing directly to physicians: commendably hundreds of individual physicians gave personal donations, making the publication of a superb teaching resource possible in 1999. A more recent interest of professional denial is that all references to Hans-Joachim Sewering, a past GMA president who died in 2010, having referred children to a euthanasia killing centre were only reluctantly disclosed in the GMA publication, Deutsches Årzteblatt.

Time and time again, the idea of the profession taking responsibility for past malpractice was met by denial and disassociation. This can be seen in a recent book sponsored by the GMA on medicine and National Socialism. A bibliographical guide edited by Professor Robert Jütte, the long-term historical advisor to the GMA, omits not only fundamental studies on Nazi medicine as by Alice Platen-Hallermund (one of the above-mentioned German medical delegation at the Nürnberg Doctors’ Trial) and Werner Leibbrand (a psychiatrist who testified at the Trial), but also the evidence-based research findings of critically engaged physicians from the 1980s. The situation has thus been one of evidence against authority. Essentially the GMA has fought a rearguard action for some 65 years so that the older generation and their acolytes could pass away with honour, by prioritising professional authority over that of research-based evidence.

The recognition makes the conduct of dissidents and overt resistance under National Socialism all the more commendable. There were doctors who sought to extract patients from institutions that became part of the system of medicalised murder. Some physicians withdrew from specialisms like psychiatry because patients were being maltreated. Alice Platen-Hallermund was shocked by such abuses; yet her pioneering account of psychiatry under National Socialism meant that she was reviled as professionally disloyal and uncollegial. Overall, the picture is one of a profession that saw National Socialism as an opportunity for expanding power, influence and status in driving forwards coercive systems of medicine. While until the 1990s the excuse was that Nazism suppressed research in favour of “pseudo-science”, what is now clear that medical research benefitted from vast resources under National Socialism. Effectively, the denial of medical crimes under National Socialism was to endorse medical science bereft of a patient oriented and consensual ethics. There was a legacy of the authoritarian pursuit of scientised medicine that could not be questioned from an ethical or evidential basis without a junior imperilling his or her career. Two models of authority – one evidential, and the other status-oriented – conflicted.

The apology resolving this conflict comes late – but not too late in terms of persons directly affected still being alive. This includes a handful of the expelled doctors, persons who were sterilised, and close family of victims of “euthanasia”. Given that children became a target group of the intensifying human experiments as the war progressed, victims still survive. They will be heartened to hear of this apology.

What is also clear is that in terms of care for victims of these atrocities, the medical systems have shown appalling neglect, amounting to a tacit endorsement of medical crimes. Victims of sterilisation demanded re-fertilisation and hormone therapy after the war, measures that were provided only when a victim could afford these. Compulsory sterilisation was officially not deemed a Nazi measure; this view began to change in the 1980s but an unreserved apology from the German state remains outstanding. Moreover, the medical profession has generally failed to provide recognition and support for victims.

What is chilling is that the politics of denial meant that authoritarian and inhumane structures in medicine could persist. The apology should be taken as a constructive starting point in ethical disclosure. The GMA should provide transparency as regards its own conduct and deliberations both to its membership and a wider a public. The German Foundation for Memory, Responsibility and the Future has to its immense credit (and possible discomfort) achieved this by inviting scrutiny by a team of historians. An apology should not mean drawing a line from the past. What is necessary is a constructive process of active engagement with past legacies. This can only be salutory for an ethically and evidence-based medicine, not only in Germany but for best practice in medicine more generally.