A momentous article, "Medical Science Under Dictatorship," by Dr. Leo Alexander, the Chief U.S. Medical Consultant at the Nuremberg War Crimes Trials, first printed in the July 14, 1949 issue of The New England Journal of Medicine, has been reprinted as a monograph, and it could not have been reprinted at a more opportune moment. Today, the concept of managed care, cost containment, and rationing threatens to eradicate the ethics of Hippocrates in medical practice, with the physician less beholden to his individual patient than to the managed care entity which employs him or pays his salary. In fact, many leaders of organized medicine (i.e., the medical politicians) are even questioning whether the ethics of medical care in the tradition of Hippocrates (and putting patients first) are a relic of the past.
And now you ask, "What does Nazi medicine have to do with managed care today?" For one thing, Dr. Alexander not only examined "the process by which the German medical profession became a willing and unquestioning collaborator with the Nazis," but also noted the early changes in medical attitudes that predisposed German physicians to first collect data on their patients as to conduct what today we call "cost-effective analysis," and then use the latter information as a vehicle to commit (passive then active) euthanasia, forced sterilizations, ghastly experimentations, and even medical genocide under the auspices of the totalitarianism of National Socialism.(1)
In "Medical Science Under Dictatorship," Dr. Alexander, a distinguished American psychiatrist, warns us, "from small beginnings" the values of an entire society may be subverted and led to the horrors of (active) euthanasia, gruesome and unscientific medical experimentation, and ultimately, death in government clinics, and later --- in concentration camps.
As I wrote in, "The Perversion of Science and Medicine" (Medical Sentinel, Spring and Summer 1997) medical science under collectivist and totalitarian regimes --- whether of the National Socialist variety (i.e., Nazi Germany), or communist persuasion as in the former Soviet Union --- the results have been as perverse as they have been disastrous.(2) Could it happen "here?" I will review this article at some length to explore at least one possible answer.
The Perversion of Medical Science in Nazi Germany
"Medical sciences in Nazi Germany," Dr. Alexander writes, "collaborated with this Hegelian trend ["rational utility"] particularly in the following enterprises: the mass extermination of the chronically sick in the interest of saving 'useless' expenses to the community as a whole; the mass extermination of those considered socially disturbing or racially and ideologically unwanted; the individual, inconspicuous extermination of those considered disloyal with the ruling group; and the ruthless use of 'human experimental material' for medico-military research."(3)
We learn that well before the Nazis came to power in Germany, the Weimar government (i.e., although named a "Republic" was truly a "progressive" social democracy) propaganda had already paved the way for the adoption of a utilitarian, Hegelian point of view, with sterilization and euthanasia of persons with chronic mental illnesses being discussed by Bavarian psychiatrists as early as 1931 and extermination of the physically or socially unfit openly accepted and discussed in official German medical journals by 1936.(4)
In the German public schools, this ideology was also inculcated in the impressionable and fertile minds of the children. For instance, the German public school textbook of mathematics had problems such as: "How many new housing units could be built and how many marriage-allowance loans could be given to newly wedded couples for the amount of money it costs the state to care for 'the crippled, the criminal, and the insane?' "(4)
Hitler issued the first direct order for euthanasia in Germany on September 1, 1939, as his Panzers moved on the Blitzkrieg of Poland. Organizations with humanitarian-sounding names were immediately set up to execute "health" programs, again, under deceptively, euphemistic terms. For example, questionnaires collected by a "Realm's Work Committee of Institutions for Cure and Care" gathered and reported information on patients who had been ill five years or more and who were unable to work. "On the basis of name, race, marital status, nationality, next of kin, whether regularly visited and by whom, who bore financial responsibility, and so forth," decisions were made at key universities about which patients should be killed by psychiatrists who had themselves never seen the patients.(5) Likewise, the "Realm's Committee for Scientific Approach to Severe Illness Due to Heredity and Constitution" was exclusively devoted to the killing of children with congenital anomalies or chronic illnesses. In all, 275,000 people were put to death in these killing centers before the Nazi Holocaust. This early extermination centers for the German people became the hub of the much larger centers to come later in the east where the plan was to kill all Jews and enemies of the German state.(6)
The exterminations included the mentally impaired, schizophrenics, epileptics, patients with infantile paralysis, Parkinson's Disease, multiple sclerosis, brain tumors, etc. Mass killings were carried out initially with carbon monoxide gas, later with "cyclon B," which was found to be the most effective. In practice, all those abject souls, whom their collaborating physicians thought unable to work and considered non-rehabilitable, were killed.(7) Dr. Alexander recalls a first hand conversation with Dr. Hallervorden, a famous German neuropathologist who had obtained 500 brains from the killing centers: There was wonderful material among those brains...I accepted those brains of course. Where they came from and how they came to me was really none of my business...These were selected from the various wards of the institutions...Most institutions did not have enough physicians, and what physicians there were were either too busy or did not care, and they delegated the selection to the nurses and attendants. Whoever looked sick or was otherwise a problem was put on a list and was transported to the killing center. The worst thing about this business was that it produced a certain brutalization of the nursing personnel. They got to simply picking out those whom they did not like, and the doctors had so many patients that they did not even know them, and put their names on the list.(8)
Patients were killed in such large numbers that autopsies of the bodies were not feasible; only the brains which were always fixed and suspended in formalin were sent to Dr. Hallervorden, according to his instructions. The first political killings were done by psychiatrists under the guise of mental illness. In this fashion, members of racial minorities and political prisoners or captured prisoners from occupied territories were diagnosed "inveterate German haters," as was the case with many members of the Czech underground and dispatched to the killing centers.(9)
Those selected for death for political or racial reasons were used in medical experiments as human subjects. In fact, medical experiments became so acceptable and commonplace that from 1942 on, they were carried out in concentration camps and openly presented at medical meetings. This research program eventually led to "terminal human experiments," a term introduced to designate those who at the conclusion of the experiment were put to death in the name of science. For this science of annihilation Dr. Alexander proposed the term "ktenology," the science of killing.
Research included not only mass killings but also investigations of projects for mass sterilizations. A professor at Auschwitz concentration camp even claimed to have developed a method by which he could sterilize 1000 women in one day. For conquered populations, for example, large doses of radiation were utilized for sterilization (castration). In the case of this research, the testicles of the victims were removed for histologic examination. Dr. Alexander himself examined four castrated survivors of this ghastly experiment. Sterilizations, however, were eventually given up for being "impractical."
"Ktenology" also led to new methods of execution for individual members of the ruling elite, including the SS itself, when they were suspected of disloyalty; for them, the method of choice was the injection of phenol or gasoline intravenously. At the Dachau concentration camp, Dr. Sigmund Rascher developed the highly effective standard cyanide capsules which could be bitten through, either deliberately (i.e., suicide) or accidentally, if mixed with certain foods (i.e., homicide).
Pus was injected intramuscularly to induce septicemia. At the Dachau camp, for example, the subjects of these grisly experiments were almost exclusively Polish Catholic priests, but because this method frequently caused abscesses rather than septicemia and death, it was discarded.10 For the medical execution of prisoners and members of the SS and other branches of the German high command, the phenol injection remained the method of choice.
In subverting medical science into an instrument of political power for the Nazi regime, SS Chief Heinrich Himmler (1900-1945) demanded and received the cooperation of German physicians, and the science of killing or "ktenology," as coined by Dr. Alexander, took a stride forward.
When Himmler learned that the major cause of death in the battlefield was hemorrhage, he instructed Dr. Sigmund Rascher to search for a blood coagulant that might be given to his men prior to action. Experiments were performed in which Dachau concentration camp prisoners, (i.e., Russian soldiers), were shot through the spleen, and their freshly amputated limbs timed for bleeding.(11) Live dissections or vivisections were also performed in medical experiments. In one of these experiments, the subjects were dissected underwater while their hearts were still beating! It was in this fashion that Nazi doctors demonstrated air embolisms in the blood vessels and other organs.
German researchers were also interested in the death of naval military personnel who died in the cold waters of the North Sea. Dr. Rascher therefore duplicated these conditions at Dachau concentration camp and used about 300 prisoners in experiments on shock from prolonged cold water immersion.(12)
Other experiments tested various vaccines and drugs at both Buchenwald and Natzweiler concentration camps. Pre-vaccinated persons and non-vaccinated controls were injected with live typhus rickettsia, and the death rates of the two series compared. When the experiment failed and there were no deaths because the typhus strain they used became avirulent for man, the scientists were disappointed. Instead of seizing upon this opportunity to develop a live attenuated vaccine, the experimenters, including the chief consultant, Professor Gerhard Rose, neglected this fact and became annoyed at the fact the controls did not die either; without realizing the implications of these results, they discarded this avirulent strain and continued testing ineffective dead vaccines. As Dr. Alexander points out, this incident shows that under these conditions, in which science is subordinated to the state, unconscious motivation, ideologies, and attitudes influenced adversely the scientists awareness of the phenomena they were investigating.(13)
At the suggestion of Heinrich Himmler, Professor Dr. Karl Gebhardt amputated limbs of live prisoners at Ravensbrueck concentration camp, and wrapped in sterile moist dressings took them via automobile to the SS hospital at Hohenlychen, where Professor Gebhardt had attempted unsuccessfully to transplant them to German soldiers. The prisoners whose limbs had been amputated were usually killed by lethal injection.
Dr. August Hirt, professor of anatomy at the University of Strassburg, for his part, became interested in establishing a collection of skeletons of Jews for the disposal of science, expecting that with the extermination policies of the Third Reich, they would soon become scarce.
The Slippery Slope
Dr. Alexander suggested that an important feature of these macabre medical experiments not only represented a ruthless and distorted pursuit of scientific goals but also elucidated sinister motivations with practical ulterior motives arising out of the requirements of serving under a totalitarian state. Within the Nazi hierarchy, there was fear, suspicion, rivalry, intrigue, and an internecine struggle within their ranks which the Germans euphemistically termed "self-selection of leaders." For example, Dr. Gebhardt performed these grisly experiments to clear himself of the suspicion he had contributed to the death of SS General Reinhard Heydrich, "The Hangman," either because of his own medical negligence or, deliberately, by failing to treat his wound with the advent of the new sulfonamide antibiotics. After Heydrich (who had been ambushed by Czech partisans) died from gas gangrene, Himmler told Dr. Gebhardt the only way he could clear himself from the possible repercussions of Heydrich's death and prove it was "fate determined" was by carrying out a "large-scale experiment" on prisoners that would prove or disprove the effectiveness of sulfonamides on the treatment of gas gangrene.(14)
Dr. Sigmund Rascher, the notorious vivisectionist of Dachau concentration camp, became the willing tool of Himmler's research interest after he was forbidden to use the facilities of the Pathological Institute of the University of Munich because of suspicion of communist sympathy. Dr. Rascher was then ready to go and do anything to prove otherwise and to regain the acceptance and trust of the Nazi Party and the SS.
What these examples illustrate is an age-old method used by inimical elements, in this case the SS, of consciously and methodically making suspects of disloyalty clear themselves by participating in a crime that will definitely and irrevocably link them to the organization. The SS called this process of reinforcement of group cohesion "Blutkitt" (blood cement). It is important to note that Dr. Alexander opined that ideologically conditioned crimes against humanity may be motivated not just by perversity, but by cowardice and fear, especially fear of punishment or of ostracism by the group.(14) Moreover, the earliest changes in the German medical attitude, the slippery slope, so to speak, began as a subtle shift in emphasis in the basic attitudes of the physicians toward euthanasia, namely, that there was such a thing as "a life not worth living" (lebensunwertes leben). He wrote:
This attitude in its early stages concerned itself with the severely and chronically sick. Gradually the sphere of those to be included in the category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans. But it is important to realize that the infinitely small wedge-in lever from which this entire trend of mind received its impetus was the attitude toward the non-rehabilitable sick.15 This subtle change in attitude was most pronounced in psychiatry and most significant in the recent medical trend toward regarding prevention as more important than cure.(15)
An irony of history is that during the Nazi occupation, Dutch physicians refused to follow the same path as German physicians, realizing that taking the first step toward government-directed "rehabilitation" would lead inexorably to euthanasia. When Seiss-Inquart, Reich Commissar for Occupied Netherlands Territories wanted to subvert them, Dutch physicians declined to participate in euthanasia and forced sterilizations. This was possible because the first step, when they were directed to use their efforts on the rehabilitation of the sick for useful labor and abolish the ethics of patient confidentiality, Dutch physicians recognized this as a perversion of Hippocratic medicine and absolutely and irrevocably rejected it. When Seiss-Inquart threatened them with revocation of their licenses, Dutch practitioners surrendered their licenses and continued to see their own patients privately and in secret.
Although, a hundred Dutch physicians were arrested and sent to concentration camps, the Dutch medical profession valiantly remained united and adamant in their resolve not to be subjugated. They had acted with foresight unanimously resisting the first step and won out in the end. The German medical profession could have done likewise if they had avoided the first step. We must realize, however, Dutch physicians did not feel they were part of a new movement originating from within, but that it was being imposed on them by an occupying, foreign aggressor. Today, the majority of Dutch physicians, practicing in another socialized medical milieu, participate voluntarily in euthanasia in the Netherlands, the only country in which it is openly sanctioned by the state. Dr. Alexander admonished us: "It is the first seemingly innocent step away from principle that frequently decides a life of crime. Corrosion begins in microscopic proportions."(16)
Ethical Implications for Today
The Medieval period of medical history contributed to the Hippocratic concept that medicine and nursing were not based solely on the rationale of the feasibility of cure, but rather caring. In choosing medicine as a calling, physicians and nurses have been motivated by compassion and the need for alleviating suffering. And, prior to the advent of scientific medicine, the physician's main function was to give comfort and hope to the patient and to relieve the family of responsibility for the outcome of his illness, while providing moral support. Along with scientific medicine, there has been, unfortunately, a maleficent, rationalistic point of view that has insidiously crept into the motivation of medical effort, supplanting the old Hippocratic/medieval point of view for a new socialist utilitarian one. Thus, Dr. Alexander believed that in emergency situations triaging may be necessary, but otherwise, doctors must be aware that such attitudes are not assimilated into the everyday practice of medicine because, once such consideration enters into the decision-making process, the next logical step is, "Is it worthwhile to do this or that for this type of patient?" This is particularly important with the advent of managed care rationing in which the government is motivated toward "the proper allocation of scarce and finite resources" and the health care mega-corporations, acting as agents of the government (and using unwary doctors as vehicles wittingly or unwittingly) in dispensing rationed care, are more interested in making profits for their privately-held coffers than in the quality of care of individual patients.
Dr. Alexander asked, "If only those whose treatment is worthwhile in terms of prognosis are to be treated, what about the other ones? The doubtful patients are the ones whose recovery appears unlikely, but frequently if treated energetically, they surprise the best prognosticators."(17) Under collectivist or totalitarian regimes, the ruling elites take a utilitarian and pragmatic approach (e.g., "what is useful is good" and "is being done for the best of the people as a whole, rather than for the benefit of an individual patient"), and ethics and principles are abandoned because "the end justifies the means." The killing and ghastly medical experiments performed in the concentration camps do not act on human compassion or ethics, but on the pursuit of efficiency and the "rational allocation of resources." And here again Dr. Alexander notes: To be sure, American physicians are still far from the point of thinking of killing centers, but they have arrived at a danger point in thinking, at which likelihood of full rehabilitation is considered a factor that should determine the amount of time, effort and cost to be devoted to a particular type of patient on the part of the social body upon which the decision rests. At this point, Americans should remember that the enormity of a euthanasia movement is present in their own midst.(18)
Thus, as far back as 1949, Dr. Alexander admonished American medicine to realize where it stands in its fundamental premises: There can be no doubt that in a subtle way the Hegelian premise of 'what is useful is right' has infected society, including the medical portion. Physicians must return to the older premises, which were the emotional foundation and driving force of an amazingly successful quest to increase the powers of healing....(19)
Today, unfortunately, ignoring this admonition, idealism seems to have given way to pragmatism in the medical leadership. Principle has given way to expediency.
Finally, Dr. Alexander agreed with the historian Arnold Toynbee (1889-1975) that what occurred in Germany may have been the inexorable historic progression that the Greek historians have described as the law of the fall of civilizations; that there is a logical sequence in civilization: [F]rom surfeit to disdainful arrogance to disaster, the surfeit being increased scientific and practical accomplishments, which, however, brought about an inclination to throw away the old motivations and values by disdainful arrogant pride in practical efficiency. Moral and physical disaster is the inevitable consequence.(19)
I recommend every physician obtain a copy of this monograph, read it, and choose his course. It is within our power to choose the path we take. Will physicians stand by the principles and Oath of Hippocrates or will we, "disdainfully arrogant" and expediently, collaborate with those who seek to annihilate the ethics of the profession in their nefarious quest for the dual iniquities of economic gain and political power?
1. Alexander L. Medical science under dictatorship. N Engl J Med 1949;July 14. Reprinted by Bibliographic Press, Flushing, New York, 1996, p.3.
2. Faria MA Jr. The perversion of science and medicine. Part II: Soviet science and gun control. Medical Sentinel 1997;2(2):49.
3. Alexander, op. cit., p.4.
4. Ibid., p.5.
5. Ibid., p.6.
6. Ibid., p.8.
7. Ibid., p.9.
8. Ibid., p.10.
9. Ibid., p.11.
10. Ibid., p.15.
11. Ibid., p.17.
12. Ibid., p.18.
13. Ibid., p.19.
14. Ibid., p.22.
15. Ibid., p.23.
16. Ibid., p.25.
17. Ibid., p.28.
18. Ibid., p.29.
19. Ibid., p.30.
Dr. Faria is a consultant neurosurgeon, Adjunct Professor of Medical History (1993-1996) at Mercer University School of Medicine, and author of Vandals at the Gates of Medicine (Macon, Georgia, Hacienda Publishing, Inc., 1995) and Medical Warrior: Fighting Corporate Socialized Medicine (Macon, Georgia, Hacienda Publishing, Inc., 1997). He serves as Editor-in-Chief of the Medical Sentinel, the official journal of the Association of American Physicians and Surgeons (AAPS).
Originally published in the Medical Sentinel 1998;3(3):79-83. Copyright © 1998 Association of American Physicians and Surgeons (AAPS).