The Role of Eugenics in Research Misconduct

Introduction

Revisiting history provides a mechanism for medicine to explore the roles racial prejudice, ambition, and indifference played in the Holocaust. Some of the most difficult moral lessons to teach are those we have never learned or those we have ignored from the past. The unanticipated, organized role of physicians and their subsequent radicalization under National Socialism resulted in both medical and research misconduct. This left a legacy which continues to reverberate even though it has been more than sixty years since the Doctors’ Trial was held in the occupation zone of Nuremberg, Germany (United States of America v. Karl Brandt, et al.). The Doctors’ Trial (December 9, 1946 – August 20, 1947) was the first of twelve trials for war crimes which occurred during World War II. ¹ Specifically, these defendants were charged with, among other things, the performance of medical experiments on civilians and prisoners of war without the subjects’ consent in spite of pre-World War II German guidelines prohibiting such activity.² This unethical research and deliberate medical genocide occurred in hospitals, nursing homes, “asylums” and concentration camps.³ The medicalization of Rassenhygiene (racial hygiene) was a pre-condition for the Holocaust and racial purification was considered a step to “heal” society through “killing.”⁴

As new moral tensions arise in modern research, it is time to scrutinize how the German medical system became corrupted by ideology and misplaced utilitarian ethics. Were the cataclysmic events of the Holocaust specifically German, or could they occur in other societies? A partial explanation can be elucidated by exploring how Germany’s embrace of eugenics overlapped with its economic collapse. These events were historical precursors to medicine’s subsequent misconduct.

Historical Antecedents

In 1867, Germany became a state and by the 1880s, Chancellor Otto von Bismarck (1815–1898) introduced its first social insurance programs. His old-age pensions, accident insurance, medical care access, and unemployment insurance became a model for other countries and were the social-contract basis of the modern German state.⁵

Germany’s renowned academic reputation was based on its long-standing tradition of scientific research. Beginning in 1901, German scientists received numerous Nobel Prizes in Chemistry, Physics, and Medicine, and her emphasis on science required a research-based thesis for an M.D. degree. Furthermore, Germany (1931) developed guidelines for human experimentation in response to pediatric deaths from contaminated BCG vaccine research. ⁶

So how did Germany’s medical system become debased by the Third Reich? In spite of Germany’s visionary social and academic policies, physicians abandoned the sanctity of the Hippocratic Oath and willingly participated in genocidal activities. Forty-five percent of German physicians were members of the national Socialist Physicians’ League ⁴ and served as leaders in implementing Hitler’s policies.

Eugenics

In 1905, Ernst Rüdin, MD, (1874–1952), a Swiss psychiatrist, co-founded with his physician brother-in-law Alfred Ploetz (1860–1940) the ‘Society for Racial Hygiene,’⁷ which emphasized the hereditary nature of illness.

In 1921, Erwin Baur, Eugen Fischer and Fritz Lenz first published Human Heredity Teaching and Racial Hygiene. By 1932, formal courses on racial hygiene were incorporated into medical school curricula⁷ creating a professional socialization process and established discipline for physicians. Physicians were expected to know this anthropology as part of their medical training but did not have the normative skills to question its validity.

In addition, Alfred Hoche, a neuropathologist, and Karl Binding, a former president of Germany’s highest court, published a pamphlet, The Sanctioning of the Destruction of Life Unworthy of Living (1922), which radicalized eugenic ideas by contradicting moral, legal and medical prohibitions against killing using economic and medical arguments to substantiate their claims.⁸ Hoche and Binding were “shocked” by the tremendous amount of care provided to “completely worthless creatures” when so many healthy men had died in World War I. Their writings served to support a more “efficient” process than natural selection.

An inflection point in the German historical timeline occurred between 1924–1928 when public health improved in Germany as governmental policies provided expanded health care to all citizens. Physicians received payment from the state’s insurance program as employees of the government and as custodians of public health.⁹ This resulted in an unintended deterioration in the physician-patient relationship as social policies preferentially emphasized the nation’s public health. By 1929, physician loyalties underwent even further change as A) the world economic crisis diminished the amount of available state monies for social expenditures; B) competition for jobs increased; and C) health care became subject to cost-benefit analyses.¹⁰ As six million people became unemployed during the late Weimar period, there were additional pressures to trim the government’s budget.⁹ When German society began to experience further limitations in its financial revenues, the physician leaders in the eugenics movement argued against the unrestrained use of resources on “inferior” citizens. This collaboration between the medical and public health systems provided an infrastructure for government alignment of eugenics philosophy and subsequent control of physician behavior. Physicians began to shift their fiduciary responsibility and allegiances toward the public health of the body of society (the Volk) and away from individual patient needs. ⁹ Eugenics offered a de facto biomedical solution for societal problems and became a “morally respectable,” utilitarian-based justification for subsequent sterilization and euthanasia policies. Ironically, the international reputation of eugenics was already declining in the 1930s as Rüdin and his colleagues used eugenics as a scientific justification for their “applied biology”-racial policies. A comparative analysis of country specific eugenic movements is described by Adams. ⁹

German Regulations and Sterilization Research

The Nazification of medical values⁶ increased when six months after Hitler became the Chancellor of Germany, the “Law for the Prevention of Progeny of Hereditary Diseases (Gesetz zur Verhütung erbkranken Nachwuchs)” (July 14, 1933, co-written by Ernst Rüdin), was passed. [Of interest, U.S. sterilization policies (1907) served as a basis for German law. By the 1920s and 1930s, the “eugenic policy of sterilizing certain mental patients was implemented in a variety of other countries, including Belgium, Brazil, Canada, Japan, and Sweden.^{9, 11}

Eugenics is the study of the agencies under social control, that improve or impair the racial qualities of future generations either physically or mentally.

-Sir Francis Galton

This legislation permitted the forced, involuntary sterilization of “genetically inferior” German citizens who suffered from blindness, hereditary deafness, schizophrenia, epilepsy, manic depression, alcoholism, Huntington’s chorea and “feeblemindedness” and allowed for further consolidation of social and medical policies.¹² The Reich Committee required physicians and midwives to register their patients with any of the above disorders and an “independent” Genetic Health Court determined whether forcible sterilization could occur. The patient was not required to be present during this deliberation process. Within four years, 300,000 patients were sterilized, often requiring the use of police force. Many physicians justified the involuntary sterilizations because they thought the sterilization policies served the long-term interests of society. ¹³ Ultimately more than 1% of the entire German population was sterilized. ¹⁴

Euthanasia

It soon became apparent, however, that eugenic sterilization processes were not enough to rid German society of “unworthy” citizens who were born prior to the 1933 sterilization laws. The next stage in this moral crisis began in the spring and summer months of 1939. An entire infrastructure for “mercy killings” was created under the auspices of Philipp Bouhler (1899–1945) [the director of Hitler’s private chancellery] and Karl Brandt (1904–1945) [Hitler’s attending physician], mandating reporting of all infants and children under the age of three with severe mental or physical disabilities. These children were admitted to specialized clinics whereby systematic pediatric euthanasia was promulgated (1939–1945). Adolf Hitler signed a secret authorization to protect participating physicians. If any legal actions were taken against a physician, the cases would be thrown out of court. Specialized staff murdered the children via lethal overdoses or through starvation until the last days of World War II.¹⁵ Although participation in sterilizations or killings was “voluntary”, individual resistance was rare.¹⁴ Because there were minimal reactions against the killing of children, the scope of the program soon expanded to juveniles and by 1940, the adult euthanasia program, T4, began in earnest (1940–1945). The detainee euthanasia program, known as Action 14f13, (bureaucratic code word for euthanasia), occurred from April 1941 to December 1944 ¹⁶ in the concentration camps. It is important to realize that not only did the pediatric euthanasia program predate the more systematic genocide by two years,⁸ it served as a rehearsal for Nazi genocidal policies which were activated after the infamous Wannsee conference (1942).

This massive scale of death and dehumanization desensitized the perpetrators, many of whom felt they did nothing wrong. The Hippocratic Oath bled into indifference as individuals ceased to exist. As Micozzi states, “in a system in which so many were routinely condemned to die, the temptation proved strong to use human subjects in medical experimentation prior to their tragic and terrible deaths.” ¹⁰

Research Misconduct

Prior to World War II, German guidelines prohibited research where consent had not been given. After 1933, these guidelines were ignored. ⁶ The German government funded the “academic” research studies on euthanasia populations, especially for physicians who wanted to advance their careers and who also supported Nazi policies. Julius Hallervorden, from The Kaiser Wilhelm Institute, conducted multiple research projects based on these programs. During his interrogation in 1945 Hallervorden said, “if you are going to kill all these people, at least take the brains…there was wonderful material among these brains.” ^{14, 15, 17} Investigators had an endless supply of subjects and requested clinical specimens specific to their research interests even in advance of the subjects’ deaths. This also allowed the collection of clinical information as children selected for “treatment” were observed for a period of time prior to their execution. Once the children were murdered, the organs were collected under the veils of secrecy and the cause of their death was falsified.¹⁸ Another researcher, Hans Nachtsheim, thought it “was ethically permissible to experiment on persons who were going in any case to be killed.” ⁶

Paradoxically, animals received more research protections than German citizens under the Third Reich. On November 24, 1933, National Socialist Germany enacted the Reichstierschutzgesetz (Reich Animal Protection Act), for the protection of animals. In addition, on February 23, 1934, the Prussian Ministry of Commerce and Employment enacted the decree requiring education on animal protection laws at primary, secondary and college levels. ¹⁹

The medical experiments which occurred during the Nazi regime were purported to advance German medicine but the idealism which supported these efforts undermined the moral integrity of their institutions. Ordinary people opportunistically competed for research funding and were propelled into abhorrent behaviors. Their research ideas were not limited to military needs, but also included racially motivated research (e.g. twin experiments) and research which included death as an endpoint. If not for individual physicians and organized medicine, the sterilization programs and T4 program may not have occurred. ²⁰ The medical experiments of the Third Reich would have been prohibited. ²¹

The Nuremberg Code (1948) and the Declaration of Helsinki (1964) are international responses emphasizing the prerequisite importance of informed consent, appropriate scientific design, minimization of risk, and qualified research teams. [These same, albeit ignored, concepts were present in pre-WWII Germany.] These virtues were re-emphasized and reinforced in the Belmont Report (September 30, 1978) when beneficence, respect for persons and justice were described. The Belmont principles are reflected in current U.S. regulatory requirements surrounding research oversight and informed consent processes and are required knowledge for modern scientists. In addition, regulatory guidelines provide special protections for vulnerable populations including prisoners, women and children.²²

Present Day Implications

The challenges of maintaining medical and research ethics are ongoing. Dr. Henry K. Beecher’s (1904–1976) New England Journal of Medicine article reviewed continued violations of informed consent precepts when he described, for example, hepatitis experiments at Willowbrook (which paralleled Sachsenhausen-Oranienburg) and cancer cell injections in nursing home residents.²³ Up until then, many US scientists thought the Holocaust experiments were anomalous and did not apply to their work. The regulatory aftermath from Jesse Gelsinger’s (1981–1999) gene therapy death led to mandatory research ethics training by the OHRP and NIH.

These are just a few examples of how misconduct reveals psychological attitudes, including cognitive dissonance and dehumanization, which continue to persist in spite of regulations. Without self-awareness, investigators are still distracted by personal ambition, prejudice, judgment, efficiency, jealousy and denial. Even today, historical gaps remain in the number of individuals who underwent German experimentation. These final numbers remain unknown. A forensic analysis of academic publications and textbooks based on these activities remains incomplete.⁶ Only in August 2012 did the German Medical Association acknowledge and apologize for the role of medicine in the Holocaust. This apology has become known as Nuremberg 2012.²⁴

Health care research (e.g. nanotechnology, genetic transfer) requires continued moral inquiry and oversight. Genetic sequencing has the potential ability to be misused especially if social policies identify new populations unworthy of health care. The consequences of stem cell research remain unknown. Which safeguards should society consider?

Certainly regulatory oversight remains essential. Although many countries utilize Institutional Review Boards or Research Ethics Committees, they must be independent and dispassionate to be effective. Furthermore, institutional-based systems need to be in place to manage scientific review, conflicts of interest and research misconduct. Pro-active and integrity-based education and mentoring can provide substantial ethical foundations to protect the rights of individual patients against changing ideology. Scientific inquiry, in most cases, still needs to be subordinate to privacy, confidentiality and voluntary consent.

History shows us how the demonization of specific populations, medicalization of racial purification, radicalization of racial hygiene, and state-sponsored genocide provided the necessary crucible for the Holocaust.¹⁴

The world can only hope that societal prejudices will not masquerade as scientific proof. History no longer allows us to hide behind these precepts. Our current system provides checks and balances which were not present or enforced in the 1930s or 1940s, and it is unlikely that a systemic failure could reappear. ¹⁷ Bioethics and research ethics have become everyone’s responsibility. Whereas eugenicists overlooked the importance of diversity, collaborative partnerships and patient advocacy are becoming more common. An emphasis on subject autonomy and the oversight role of the IRBs provide additional protections. Our professions must continue to learn and teach from our mistakes, and listen to our consciences. Through these insights our virtuous behaviors can mitigate the most egregious harms.

Biography

Susan M. Miller, MD, MPH, is Professor of Clinical Family Medicine at the Institute of Academic Medicine, Houston Methodist Hospital Research Institute in Houston, Texas.

Contact: smmiller@houstonmethodist.org