Lectures on Inhumanity: Teaching Medical Ethics in German Medical Schools Under Nazism.
In a recently published article, Barron Lerner and Arthur Caplan reflect on the role of history in the teaching of bioethics (1). They make the case for figuratively putting those studying and practicing bioethics in the shoes of prior researchers or clinicians to better understand how past ethical decisions in medicine and research were made and what circumstances affected these choices. The argument behind this reasoning is to resist the allure of presuming oneself to be more moral and enlightened than physicians and researchers in the bad old days. We share this position, agreeing that it is important to review the ethos and values of the relevant time to better appreciate history and hopefully prevent future ethical transgressions. Here, we extend this argument by historicizing the teaching of medical ethics itself, providing insight into ethics instruction at German medical schools during the Nazi period. In the course of the Nuremberg medical trial in 1946 and 1947, it became evident that physicians who had participated in medical crimes not only felt no remorse or guilt but continued to espouse the moral correctness of their conduct (2). Although some perpetrators may have conveyed the impression of moral innocence chiefly as part of their legal defense strategies, moral reasoning was not alien to Nazi medical officials or physicians (37). Since the Nazi movement had come to power in 1933, utilitarian and eugenic thinking had formed the basis of a new medical ethics (812). In this article, we demonstrate that Nazi-influenced medical ethics became an integral part of the curriculum at all German medical schools between 1939 and 1945. We outline the main aspects of Nazi medical ethics that were taught with the aid of the standard medical ethics textbook of the time (13), written by Rudolf Ramm, who has been named the eminent Nazi medical ethicist (14, 15). Our findings suggest that medical ethics itself can be corrupted and that a political and public realm of reason and humanity may be more vital in preventing immoral medical conduct than formal instruction in medical ethics. Teaching Medical Ethics in Germany Before 1933 At the beginning of the 20th century, medical ethics did not exist as a formal teaching subject in German medical schools. In the German medical community, as in other Western countries at that time, ethical thinking was expressed primarily in medical literature and codes of conduct rather than didactic teaching (1618). Traditionally, ethical debates had mostly revolved around professional etiquettethat is, ensuring conduct that would enhance the reputation of the medical profession (16). Requiring fair conduct among physicians was deemed more important than formulating ethical obligations toward patients, a phenomenon not limited to the German medical profession (18, 19). The lack of concern about patient-oriented ethics displayed by the medical profession contrasted with critical public discussion of human experimentation that was stirred by several reports of unethical clinical research between 1900 and 1930 (20). In 1931, the German Ministry of the Interior issued guidelines for new therapy and human experimentation that set out such standards as informed consent and protection of vulnerable groups. These regulations were remarkably advanced compared with international standards at that time. Of note, they were issued not by the medical profession but by government authorities (21). In the wake of Germany's defeat in World War I, fueled by economic hardship and hyperinflation, crude utilitarian and eugenic thinking intensified in the medical community, and engagement for an individual-based ethics remained weak. Some even proposed killing disabled or incurably sick persons to free the society from financial burden (22, 23). Two years before Adolf Hitler came to power, the renowned medical historian Henry Sigerist noticed a widespread rejection of individualism in German health policy (24). However, the growing influence of the eugenic movement did not receive political support for actions such as forced sterilization until the end of the Weimar Republic in 1933. Nazi Efforts to Introduce Ethics Into the Medical Curriculum After Hitler's rise to power, it became possible for the Nazis to act on their racist and eugenic concepts. The 1933 Law for the Prevention of Hereditarily Diseased Offspring legitimatized forced sterilization. Physicians were obliged to report patients with alleged categories of hereditary diseases to public health departments so that they could be forcibly sterilized (25). Medical ethicists published articles voicing their support for the new law and justified it as inevitable for the sake of the community (26). From the viewpoint of the Nazi authorities, a teaching program for medical students to substantiate and legitimatize the Nazi health policy was needed but still lacking. Even under the dictatorship, German medical faculties had proved to be slow to change; thus, the Nazification of the medical curriculum proceeded only gradually. Furthermore, the addition of new subjects to the already saturated curriculum ran contrary to the Nazis' goal to shorten the duration of study to encourage early marriage and procreation among physicians (13). After several years of preparation, the revised medical curriculum was implemented in 1939 (in contrast, a new curriculum for law students had been established by Nazi officials in 1935). The revised medical curriculum included newly designed lectures in racial hygiene, the science of heredity, population policy, military medicine, and the history of medicine (27). These subjects seemed particularly suitable for promoting Nazi ideology to medical students (28), as did another new set of lectures that became obligatory for students: Medical Law and Professional Studies (MLPS). Medical Law and Professional Studies In the 1930s, the terms medical ethics and bioethics were less common in discourse on medical morality than they are today (29). The reputation and etiquette of the medical profession itself were of greater interest than ethical issues pertaining to clinical medicine. The subject of MLPS, which was included in the new medical curriculum of 1939, focused for the first time on physicians' moral and legal obligations to their patients as well as to their profession and the state. From then on, students were required to attend a set of 14 MLPS lectures during the 10th and final semester of medical studies (13). Course catalogs from the end of 1939 show that 13 of the 28 medical faculties in the Greater German Reich (which included Austria and Danzig at that time) had held lectures in MLPS (30). By the winter semester of 19421943 and in 19431944, 25 of 28 faculties included MLPS training (30). These semesters mark the climax of the wartime institutionalization of medical ethics in German medical schools. By the winter semester of 19441945, the last regular semester at German universities before the end of the war and the Nazi regime, the number of schools that included MLPS lectures had decreased to 22 (30). This was probably due to the war and its disastrous effect on universities' structural and personnel resources. However, between 1939 and 1945, all of the 28 German medical faculties provided mandatory lectures on MLPS, at least temporarily. The MLPS lectures were intended to provide medical students with an understanding of both the written and unwritten laws of the medical profession and of doctors' ethics (13). The revised curriculum that included MLPS was intended to explicitly create a new type of physician (27). This physician would be trained to internalize and then implement the Nazi biomedical vision of a homogeneous and powerful people (Volk) in his daily work. This radical break from the traditional forms of medical morality was a key element of the MLPS lectures. It involved shifting the focus of ethical concern and medical care away from the individual patient and toward the general welfare of society or the people (31). Nazi Party Members as Ethics Lecturers The Reich Physicians' Leader Leonardo Conti and the Ministry of Science and Education sought to appoint only long-standing members of the Nazi Party as lecturers for MLPS. Most of these physicians were not affiliated with a university but had worked as local Nazi health functionaries (32). Conti, a general practitioner himself and a member of the Nazi Party since 1927 (33), selected mostly elderly general practitioners who desired academic honor as a reward for their longtime party loyalty (34). This choice was driven by the Nazis' belief that general practitioners, who were deemed more in touch with the people than university professors, had a kind of natural and holistic attitude toward medical ethics that was unspoiled by academic scholarship and closer to the crude worldview of the Nazis (35). In the winter semester of 19441945, half of all MLPS lectures at German medical schools were delivered by these physicians (30). Archival data reveal that all of them were early members of the Nazi Party (36). Most had signed up before 1933 and could therefore claim the Nazi status of old fighter, meaning that they had joined the party before Hitler's rise to power and before Nazi Party membership became popular for career advancement. Eugen Sthle, a physician and medical functionary who taught MLPS in Tbingen from 1941 to 1945, is an example of one who delivered medical ethics lectures during the Nazi period. Sthle, who joined the Nazi Party as early as 1927, was actively involved in the euthanasia program that started in 1939 (37). In this campaign, disabled children and adults were murdered by their physicians and nurses because they were deemed to be incurably ill, troublesome, or too costly or to belong to the wrong racial group. Sthle not only lectured on medical ethics but also directed this euthanasia program in southwestern Germany. Under his gui