daniel wikler and jeremiah barondess -...

Daniel Wikler and Jeremiah Barondess

Bioethics and Anti-Bioethics in Light of NaziMedicine: What Must We Remember?

abstract. Only recently have historians explored in depth the role of the medicalprofession in Nazi Germany. Several recent works reveal that physicians joinedthe Nazi party in disproportionate numbers and lent both their efforts and theirauthority to Nazi eugenic and racist programs. While the crimes of the physicianMengele and a few others are well known, recent research points to a muchbroader involvement by the profession, even in its everyday clinical work. Anal-ogous activities existed in the German legal and industrial communities; disruptionof the medical ethic thus sprang from the broader social contexts of Nazi Germany.The new United States Holocaust Memorial Museum, now opening on the Mallin Washington, D.C, will have an opportunity to educate the public about boththe great crimes at Auschwitz and other camps, and the gradual but thoroughdegradation of ethics in the German medical profession. From this presentation,contemporary bioethics can ponder the proper use of the Nazi analogy in bioethicaldebate.

INTRODUCTION

OVER THE HALF CENTURY since the fall of the Third Reich,our interest in the Holocaust, its antecedents, and its sequelaecontinues unabated. Despite its obvious importance for bioethics,

however, the role of German doctors during the Nazi era received relativelylittle attention after the conclusion of the Nuremberg trials.1 Now theseterrible events are receiving the attention they deserve.

In the last half-dozen years, a number of detailed, provocative publi-cations have appeared on the role physicians played in the Nazi horrors.2In addition, the Berlin Ã„rztekammer (Chamber of Physicians) commis-sioned an exhibit, "The Value of the Human Being: Medicine in Germany1918-1945," which has traveled to the United States and is scheduled to

Kennedy Institute of Ethics journal Vol. 3, No. 1, 39-55 Â© 1993 by The Johns Hopkins University Press

KENNEDY INSTITUTE OF ETHICS JOURNAL Â· MARCH 1993

be shown in Japan. For Americans, the most dramatic example of thisrecent interest will be the new United States Holocaust Memorial Museum,scheduled to open in April 1993 on the Mall in Washington, D.C. TheMemorial Museum will present to millions of visitors vivid evidence ofmedicine's integral role in the horrors of that period; its exhibits anddocumentation will stimulate reflection and debate on how Nazi medicinebears on our own ethics, practices, and institutions.

The Memorial Museum was developed at the instigation of the UnitedStates Holocaust Memorial Council, which was created by a unanimousAct of Congress in 1980. The Council consists of 55 members of variousfaiths and backgrounds appointed by the President, as well as five UnitedStates Senators and five members of the House of Representatives, withex-officio representation of several cabinet members. In its considerationof the medical aspects of the Holocaust and its era, the Council appointedan interfaith Medical Advisory Committee to propose an appropriate setof activities for the Museum. One of this paper's authors (Barondess)chairs that committee, and the other author (Wikler) serves on it. Thecommittee has submitted its principal recommendations and will remainin existence to assist the Museum in its ongoing historical and educationalmission.

The Medical Advisory Committee's work proved to be a challenge.While the main events in Nazi medicine have been thoroughly chronicled,there is little agreement on their explanation and meaning. Moreover, wemust learn how to discern and apply the lessons of this history in aresponsible way. In the literature of bioethics, references to the Nazi periodhave become a standard method of argumentation. In particular, whenbioethicists warn of a slippery slope, the Third Reich lies at its bottom.Despite the obvious importance of the Nazi analogy, this argument hasbecome something of a loose cannon, intended as an unanswerable cautionagainst particular clinical measures and even used to forestall entire linesof research. Ironically, this weapon has recently been used against bioethicsitself, as we discuss below. In this article, we provide personal perspectiveson the interpretation of that era.

HALLMARKS OF NAZI MEDICINE

For the educated public, the term "Nazi Doctor" undoubtedly bringsto mind Josef Mengele and his partners in crime. At Auschwitz and else-where, thousands of unconsenting subjects were subjected to scientific orpseudo-scientific investigations and experiments which routinely led to

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WIKLER & BARONDESS Â· BIOETHICS & NAZI MEDICINE

suffering and death. The scale and inhumanity of these abuses shockedthe world and led directly, via the Nuremberg Code (Annas and Grodin1992), to today's elaborate regulation and review of medical researchinvolving human subjects.

Less well-known, even to bioethicists, is the central role played byphysicians in the camp's overall extermination process. Robert J. Lifton,who has studied the psychology of the physicians involved, observes that

In Auschwitz, Nazi doctors presided over the murder of most of the one millionvictims of that camp. Doctors performed selections. . . . Doctors supervisedthe killing in the gas chambers and decided when the victims were dead. Doctorsconducted a murderous epidemiology, sending to the gas chamber groups ofpeople with contagious diseases. . . . Doctors ordered and supervised, and attimes carried out, direct killing of debilitated patients on the medical blocksby means of phenol injections into the bloodstream or the heart. . . . Doctorsconsulted actively on how best to keep selections running smoothly; on howmany people to permit to remain alive to fill the slave labor requirements ofthe I. G. Farben enterprise at Auschwitz; and how to burn the enormousnumbers of bodies that strained the facilities of the crematoria ... As onesurvivor . . . put the matter, "Auschwitz was like a medical operation," and"the killing program was led by doctors from beginning to end." (1986, p. 18)Of course, the involvement of physicians did not stop there. The mass

killings of Jews and others during the war years were preceded by a hugeprogram of exterminating the disabled. "Aktion T-4," so-called becauseof the Berlin address (Tiergartenstrasse 4) of its headquarters, involved anational sorting of Germans of all faiths into the categories of the fit andthe unfit, of the productive and the "useless eaters." A parallel programextended to children. More than 200,000 of those identified as defectivewere collected in institutions that had once provided care, and murdered(Gallagher 1990). The very term "euthanasia," inappropriately and cyn-ically chosen by the Nazi regime in keeping with its cover story, wasstained forever.

These unspeakable acts of crime and betrayal, supervised at all timesby physicians sworn to act in the interests of the sick, helped to preparethe way for the events known as the Holocaust. T-4 and the other programsprovided a rehearsal of the organization and technology of mass murder;they provided a means for testing the limitsÂ—nonexistent, as it turnedoutÂ—to which the state could go in pursuit of its agenda; and they con-tributed to the desensitization to extermination on behalf of the state.

The actions of the physicians involved in these acts of barbarism will,[ 4i ]


and should, occupy center stage in any presentation of the terrible storyof Nazi medicine. The "euthanasia" program itself is a medical crimeunparalleled in history and would have justified the use of the Nazi analogyin bioethics even if the Holocaust had never happened. The experimen-tation program at Auschwitz took fewer victims, but exceeded AktionT-4 in its cruelty. The surprisingly important role played by physicianswho participated in the central event of the Holocaust, the killings ofhuman beings by the millions, casts a permanent shadow on physicianswho lend their skills to the state for dubious purposes.

If we are to learn from the awful experiences of the Nazi era in medicine,however, these actions must not stand alone under the historical spotlight.It is equally important to understand what events both inside and outsideGerman medicine up to the 1930s led to these acts, and also to look veryclosely at the behavior of the ordinary doctors of the period. Indeed, anargument can be made that the latter, less spectacular history is actuallymore significant in its implications for bioethics than the record of massmurder. While the "euthanasia" program and the Holocaust itself tookthe most victims, they employed relatively few doctors. The Nurembergtrials brought only a handful to justice; Andrew Ivy, who helped to preparethe prosecution's case, put the total number of criminal physicians at about70 (Kater 1989). This is certainly too low, but the correct figure is probably"only" a few hundred (Kater 1989).

A regime that produces this number of murderers and torturers fromthe ranks of the premier helping profession necessitates close scrutiny. Tothe degree that we fix our attention on the very worst offenders, however,we risk the error of explaining the crimes by focusing on what makesthese individuals different from their fellow physicians rather than on whatthey had in common. Inevitably, we invoke the language of psychopa-thology; since their actions are literally beyond human ken, we must treatthem as monsters. Our quest for understanding and interpretation thenreduces to the kind of questions we ask about our own ax-murderers andserial killers, affording us limited insight into the society in which theylived, not to mention our own. Exclusive attention to the few thoroughlyrotten apples even suggests, by implication, that the barrel as a whole wasgenerally healthy, and that little can be learned from studying the others.But it is only through such an examination that we can begin to compre-hend the more subtle aspects of moral degradation of the field as a whole,along with the ideological climate of opinion which fostered moral descent.

As Kater (1989) has emphasized, the "rotten apples" story was defended

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with vehemence by the postwar hierarchy of German medicine. Thoughsome of the identifiable offenders retained their positions and went on toflourishing careers,3 German medicine as a whole has since the war dis-tanced itself from the most notorious practices. "Defenders of the WestGerman medical establishment," according to Kater (1989, p. 222), "rea-son to this day that since the premier medical criminals have been caughtand sentenced, all the uncomfortable questions that might have lingeredhave been answered and therefore things are back to business as usual."If larger numbers of German physicians, even the majority, betrayed insome measure their duties as physicians, we must reach different conclu-sions.

The perversion of the ethos of medicine was not the only failure of keysocial structures under the Nazis. The very fact of the Holocaust reflectedanalogous, supportive and facilitating roles played by the German legal,banking and industrial communities. The Holocaust reflected the nationalculture from which it emerged. At the same time, the demonstrated frailtyof the medical ethic in Nazi Germany is especially shocking; that the moralunderpinnings of the chief science-based helping profession should haveproven so porous and so easily swept away, demands efforts to comprehendwhat happened.

NAZISM AS BIOMEDICAL POLITICS: THE IDEOLOGICAL SETTING

Eugenic thinking was at its zenith at the time of Hitler's rise to power.The prospect of bettering humankind by improving its genetic endowmentappealed to thinkers across the political spectrum, including many hu-manitarians. The office of one of the authors of this article lies literallyin the shadow of Van Hise Hall, named for an honored leader of theWisconsin Progressives and president of the state universityÂ—who calledpublicly for sterilization of the mentally handicapped.

It is a commonplace that in Nazi Germany eugenics ran amok, dis-crediting its program for the indefinite future. The recent spate of scholarlypublications on Nazi medicine and politics, however, has shown thateugenic thinking in Germany had far greater implications. It provided alens through which the Nazi program, not just regarding the sick and thedisabled but in its entire ambition, could be portrayed as a healing mission.The centrality of medicine to the Nazi era follows as a matter of course.

Twentieth-century eugenics was not essentially racist, though after 1933German eugenics took on a uniform racist coloring. In either form, how-ever, it was susceptible to a world-view in which the basic unit of biology

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was something larger than the individual. Whether that unit, the "patient,"was the race, the nation, or mankind as a whole, the "defective" individualwould be viewed as a diseased part, harming the larger organism throughits contributions to the latter's gene pool and impairing its functioning byits inability to contribute usefully to the work done by others.

The Nazis made eugenics an official state ideology, but, as MÃ¼ller-Hill(1988), Proctor (1988), and others have shown, the ground had been well-plowed before 1933. As Proctor (p. 38) observes, "One often hears thatNational Socialists distorted science . . . but ... it was largely medicalscientists who invented racial hygiene in the first place. Many of the leadinginstitutes and courses on Rassenhygiene and Rassenkunde were establishedat German universities long before the Nazi rise to power. And by 1932it is fair to say that racial hygiene had become a scientific orthodoxy inthe German medical community."

The Nazis were thus able to draw on medical support for its majorprograms. The Aktion T-4 killing initiative was preceded by a huge effortto sterilize the hereditarily "deficient," claiming over 400,000 individuals(Kater 1989; Gallagher 1990). This program occurred during peacetimeand was hardly a secret. The affinity between racism and medicine wasso great that the infamous Nuremberg Laws of 1935Â—the "Law for theProtection of German Blood and German Honor" (MÃ¼ller-Hill 1988) Â—were, according to Proctor (1988, p. 141), "generally considered publichealth measures," with miscegenation deemed a public health hazard inmedical journals and regulations governing sexual relations between Jewsand Gentiles listed as German health legislation in the Sammlung DeutscherGesundheitsgesetze.

The disease metaphor, which to the Germans of the period was not seenmerely as a metaphor, reached extravagant heights in the propaganda ofthe period. Kater (1989, pp. 178f) quotes numerous references to Jews as"bugs, tapeworms, and bacilli." Eventually, the regime fastened onto atrio of images: "the Jew as disease, the German people as patient, andNational Socialism (qua Hitler) as physician," with Hitler portrayed inposters and in speeches as the doctor who rescues the German volk (Kater1989). In Gallagher's (1990, p. 191) words: "the Nazi administration wasas close as the world has come to being a medical state: a governmentrun in accordance with 'doctor's orders.' "

These messages reached every German, through the state's monopolyof the media. To the nation's physicians, however, they were more thanimages. Whether articulated through medical school lectures, in profes-

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sional meetings, or in physicians' journals, the attempt to "medicalize orbiologize various forms of social, sexual, political, or racial deviance"(Proctor 1988; Eley 1991) were closer to marching orders. If these cuesfailed to inspire most doctors to commit murder themselves, they did helpto legitimate a range of unethical practices, petty in comparison to Ausch-witz but inexcusable by ordinary standards, which the climate of the timesdoes not exonerate.

ORDINARY MEDICINE IN THE THIRD REICH

The sad and terrible fact is that physicians, as a group, were enthusiasticsupporters of and participants in Nazism. Almost half were members ofthe Nazi party, a much higher percentage than any other profession (Kater1989; Proctor 1988; Gallagher 1990); two-thirds were Nazi-affiliated insome way (Kater 1989). Physicians were seven times more likely to jointhe SS than were other German males (Proctor 1988). The Nazi Party'senthusiasm for the medical model of politics paid physicians great homage,and the doctors returned the favor.

The contribution of German doctors to Nazi policies, however, wentbeyond personal conviction and support of Party power. Many of theprincipal Nazi initiatives and programs, ranging from eugenics to anti-Semitism, drew on contributions in ways large and small from thousandsof doctors.

German doctors participated in the persecution of the Jews with littlecomplaint. Their first victims were fellow physicians of Jewish ancestry.Gallagher (1990) reports that

... on what was called "Boycott Day" in Berlin on April 1, 1933, membersof the German Physicians' League in the early hours of the morning broke intothe apartments and homes of Jewish and socialist doctors. They were draggedfrom the beds, beaten, and then hauled off to an area near the Berlin Lehrter.There, stripped of their clothes, they were forced to run laps about the trackas they were subjected to hazing, pistol shots, and beatings with sticks. Manyof them were then taken to the cellars of the Hedemannstrasse jail, where theywere tortured further before being released, (p. 190; see also Kater 1989, p.184)

As the decade progressed, Jewish physicians were, in stages, removed frompositions of responsibility, forbidden to treat non-Jewish patients, andthen evicted from the profession altogether. Not only was there hardlyany protest; these acts were planned and carried out by the leaders of the

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profession themselves (Kater 1989; Proctor 1988). Nor did the rank andfile show any hesitancy in seizing the opportunities left open by the removalof their Jewish competition. Some physicians grew impatient and in 1935complained to the government of an inability to attract patients from theirJewish colleagues; they were obliged by exhortations to German patientsto find non-Jewish doctors (Kater 1989, p. 189). The eventual murder ofthe Jewish physicians drew no more protest from their colleagues thandid the fate of the German Jews from their fellow citizens generally.

The eugenic obsession of the regime involved and implicated ordinaryphysicians in many ways. The Nazis' plan for the master race was of suchgrandiosity that it required a highly detailed map of the (supposedly)genetic endowment of virtually every German capable of reproduction.This information could only be gleaned by physicians.

The regime's physician advisers sought to direct the propagation ofdesirable genes by intervening in marriage decisions and by eliminatingthe sources of allegedly inferior genetic material. Even in the 1920s, theGerman government, with physician approval, offered advice on "racialhygiene" to prospective marriage partners (Proctor 1988). After the Nu-remberg laws, this "counseling" became mandatory, and physicians weregiven the job of administering detailed medical examinations and, forthose who passed, a marital health certificate certifying genetic health(Proctor 1988). Though resources limited the application of this require-ment, it and other eugenic and racial legislation necessitated an increasein the number of medical personnel, the exclusion of Jews notwithstanding(Proctor 1988).

Physician involvement in Nazi eugenic goals took a more sinister turnin connection with reporting requirements for signs of hereditary defects.Every German doctor was required by the state to identify those patientswho, in the view of Nazi medical scientists, threatened the genetic purityof the German people: the feeble-minded, the schizophrenic, the epileptic,the alcoholic, and many others. In the early years, these data were usedin judging who should be subjected to forced sterilization. The reportsfrom the country's doctors were collected and passed upon by genetichealth courts consisting of one lawyer and two physicians. Carrying outtheir verdicts was no small task; as Proctor (1988, p. 109) notes, "Thesterilization of 400,000 people required an enormous effort from Ger-many's medical profession. Doctors competed to fulfil sterilization quotas;sterilization research and engineering rapidly became one of the largestmedical industries." All this "transformed the German medical profession

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. . . every doctor had to become a genetic doctor. . . . Every doctor inGermany was required to undergo training in genetic pathology and tobecome proficient in the analysis of racial traits" (Proctor 1988, p. 109).

As the decade progressed, murder replaced sterilization as the fate ofthose marked as deficient, especially if their physicians had reported themas unable to work. Nevertheless, the stream of information from doctorsacross Germany continued unabated. Gallagher concludes that

. . . all of the physicians of Germany were participants in the sense that theywere aware of the program's existence. . . . Selection was made on the basisof [their reports], and patients selected would be transferred to the killinginstitutions. No doctor could have been unaware of the depletion of the hospitalwards or the disappearance of his patients. The doctors stood silent as theirchronic patients received medical referrals to other doctors who would killthem. (1990, pp. 62-63; emphasis in original)

By 1941, whole categories of patients in hospitalsÂ—Jews and criminalsin addition to the chronically illÂ—were taken to other hospitals and killed(Proctor 1988; Gallagher 1990). According to MÃ¼ller-Hill (1988, p. 41),investigations reveal that physicians earned from 5 to 10 pfennings permonth for reviewing these referrals. "Each decision, which meant life ordeath for a human being, cost about as much as one cigarette."

Not all of the service provided by physicians to the regime led directlyto death, but in many ways the doctor betrayed an appalling lack of moralinsight and integrity. The hallowed principle of medical confidentialityeroded rapidly in the face of the reporting requirements (Kater 1989).According to Lifton (1986, p. 43), physicians played a central role inHimmler's Lebensborn ("spring of life") breeding program, which movedbeyond encouragement of SS men in procreation to kidnapping of "Aryan"children in occupied territories. Kidnapped children who did not makethe grade were referred by participating physicians for sterilization ordeath. Physicians were similarly entrusted with the task of examining thewomen to whom SS men proposed marriage (Proctor 1988). Applicationof the Nuremberg racial laws required expertise in judging Jewish ancestry,since evasions and conversions may have obscured an individual's origins;medical journals provided detailed instructions for detecting Jewishnessthrough medical exams (Proctor 1988). The Reich even provided doctorswith a kit of measuring instruments for facial features which could beused to detect the expression of non-Aryan genes; physicians administeredthe examinations to patients anxious to establish their racial bona fides.4

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In historical perspective, what is striking about medical misbehaviorunder the Nazis is how mundane and normal it became. As Eley (1991,p. 502) has observed, " 'Normalizing' Nazism in this sense is not to sup-press its evil, so much as to find the evil in the center of the norm. TheThird Reich's 'normality,' what in an earlier context was called the 'ba-nality of evil,' was precisely its danger." For in general, German physicianswere not forced to commit these acts. As Proctor (1988, p. 193) observed,"Doctors were never ordered to murder psychiatric patients and handi-capped children. They were empowered to do so, and fulfilled their taskwithout protest, often on their own initiative." The same is true of nearlyall the other acts of commission and omission.5

Postwar self-justification of German physicians centered on the familiartheme that only a few high-ranking officials knew of the criminal abuses,along with the relatively small number of physicians who actually carriedthem out. For the medical crimes, at least, these claims are particularlydubious. As Gallagher (1990, p. 70) has noted of the murder of the mentallyhandicapped, "The fact that they exempted veterans in deference to publicopinion indicates they expected the program to become public knowledge,as, in fact, it did." The physicians guilty of the very worst abuses wereoften the most prominent in their fields (Gallagher 1990; Kater 1989).The widespread knowledge of these abuses among physicians, togetherwith the Party affiliation of most physicians and the voluntariness, eveneagerness, which marked their participation in the Nazi programs, pointsto a thorough, historically unique degradation of medical ethics. The lossof moral compass points meant that the lesser evils paled in significancecompared with the great crimes; but also, as the Swiss historian Fischer-Homberger has pointed out,6 the latter eventually seemed less monstrousthe more that ordinary medical norms drifted in their direction.

THE CONTEMPORARY RELEVANCE OF NAZI BIOETHICS

If we can avoid repeating the wrongs of the past only if we rememberthem, what precisely are we to remember and thus avoid? Nearly allhistorians of Nazi medicine agree that the worst atrocities committed bydoctors were an outgrowth of earlier developments. Simply resolving notto repeat the crimes would be pointless if they become inevitable once theroot causes, such as ideological or institutional trends, are put in motion.The descent into moral degradation must be blocked at the top of theslippery slope.

Our task is thus to diagnose the moral disease. But there are many more

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explanations for Nazi medical misbehavior than there are historians ex-amining it. Was the root cause the conception of medicine as a purely"scientific" world without values (MÃ¼ller-Hill 1988; Kater 1989)? Thefrustration of not being able to ameliorate hereditary chronic disabilities(Gallagher 1990)? Emphasis of nature over nurture in explaining socialproblems (Proctor 1988)? The specific legacy of racism? The eugenic ideal?The continued uncertainty over what led Germany astray leaves contem-porary observers free to interpret the bearing of the German experienceon our own era through the lens of their distinctive outlook and interests.Although abortion was virtually banned in the Third Reich, the Right toLife movement compares the millions of abortions each year to the massmurders of the Holocaust. The American Medical Association's executivevice-president sounded a familiar AMA theme in commenting on the BerlinÃ„rztekammefs exhibit, which the AMA co-sponsored: "The great concernof American physicians is the Government increasingly interfering withthe doctor-patient relationship"7 (Leary 1992).

Whether one agrees or disagrees with these interpretations, however, itis plain that the Nazi medical experience looms large over the centralbioethical uncertainties of our time:

Â• As the United States inches toward a "right to die," are we flirtingwith disaster? A key question is an historical one: does the Nazi era showthat desensitizing doctors to causing deaths is a calamitous move? Or thatthe problem was the conception of "euthanasia" as a prerogative of thestate rather than a right of the individual?

Â• Should the Nazi record make us wary of the enhanced scope of geneticscreening and genetic engineering expected to result from advances inmolecular biology and the human genome project? Does a eugenic impulselie at the heart of these programsÂ—and need we fear that if we avoid theracism and quackery of Nazi eugenics and limit our interventions to en-hancing the choices of prospective parents?

Â• Is community welfare an illegitimate consideration in weighing patientbenefit against cost? Must the specter of Aktion T-4 dissuade us fromencouraging the public to consider the interests of the next generation asthey incur huge medical expenses during the last months of life?

Contemplation of the Nazi era in medicine has immediate practicalutility. Its bearing on the issues of euthanasia, the uses of genetic infor-mation, and on cost-containment is so direct and important that these

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debates must be carried out in the context of a continuing and searchingattempt to interpret and explain the historical record of the Third Reich.Universities, and in particular their medical schools, should have accessto teaching materials for their students, to enable them to make sense ofthe constant references to these Nazi practices in the bioethical debates.The public, moreover, needs familiarity with the German record so thatit can learn what to ask of its physicians, its lawmakers, and even itsphilosophersÂ—and what not to ask. Here the degradation of ordinarymedical practice is of even greater significance than the atrocities at Ausch-witz.

Exhibits and other forms of education about Nazi medicine could alsouse the occasion to make Americans aware of our own history, both goodand bad. Relatively few know the troubling story of American eugenics,including a vigorous program of involuntary sterilization, from which theNazi theoreticians learned a great deal. The record of occasional abuse ofhuman subjects of medical experimentation is largely unknown; in thecase of the Tuskegee syphilis study, our past sins also had a racist coloring.The public should also have a greater familiarity with the elaborate safe-guards that have since been put in place, such as the laws and regulationsforbidding involuntary bodily intrusions, and the Institutional ReviewBoards which must approve medical research protocols. Presentation ofthese protections in the light of the Nazi record would provide an effectivereminder of why they were enacted and why their continued functioningis important to every citizen.

A DANGEROUS SUBJECT?

Nowhere has the discussion of bioethics in light of the Nazi era rousedsuch strong feelings as in Germany and Austria, the lands of the NaziReich. The passion of these arguments is of course understandable. In thepast three years, however, the course of the debate has taken a surprisingturn: numerous participants have decided that the lesson of the Naziexperience for bioethics is that bioethics should not be discussed at all.Bioethics, in their view, is itself a slippery slope.

The story of this controversy, which been recounted in many Germanpublications and in the English-speaking press as well (SchÃ¶ne-Seifert andRippe 1991; Singer 1991), dates back to the summer of 1989. The Aus-tralian philosopher Peter Singer, co-editor of the British journal Bioethicsand a figure of considerable reputation in Anglophone moral philosophy,was invited to give a lecture at a conference called "Bioengineering, Ethics,

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and Mental Retardation," to be held in Marburg, Germany; he also ac-cepted an invitation to give a public lecture at the University of Dortmund.Singer (1987) had defended in his book Practical Ethics, the prerogativeof parents of seriously defective newborns, such as anencephalics, to decidewhether their offspring should live or die.8 A coalition of anti-biotech-nology and disability-rights groups labeled Singer as an advocate of policiesthat would rekindle the Nazi's "euthanasia" program of the handicapped,and warned that if he were allowed to appear they would disrupt theproceedings (SchÃ¶ne-Seifert and Rippe 1991). Singer received a letter re-scinding his invitation to speak at Marburg. The letter distinguished be-tween discussions "behind closed doors with critical scientists who wantto convince you that your attitude infringes human rights" and promotionof Singer's views "in public" (Singer 1991).

This challenge quickly developed into a movement, one aimed at pre-venting Singer or others thought to be like him from giving any lecturesat all. Entire conferences were shut down because of threats, protests anddisruption. An invited address by Singer was shouted down with the chant,"Singer Raus!" ("Singer Out") and Singer was manhandled at the speaker'spodium (Singer 1991). (Singer, three of whose grandparents were murderedin the Holocaust, recalled the "Juden Raus" slogan of sixty years ago.)

Soon the target extended beyond public occasions; university courseswere cancelled and academic careers threatened because of the associationwith these "dangerous" ideas. Moreover, the target widened: where onceonly Peter Singer's views on euthanasia for defective newborns was thetarget, now all of bioethics, and even the whole of Anglo-American phi-losophy, came under attack. Bioethics was condemned as a "public re-lations department of the new biotechnologies" (SchÃ¶ne-Seifert and Rippe1991),9 a kind of stalking-horse for the medical-industrial complex. Thecampaign soon caught the press's attention. Der Spiegel, the newsmaga-zine, published a long article by one of the protesters, Franz Christoph(1989), accompanied by photographs depicting the Nazi horrors; it re-fused, however, to publish a reply by Singer, the object of the attacks(Singer 1991).

For the American observer, sympathy for the anti-bioethics movementis difficult. As Singer himself observed, "There is ... a peculiar tone offanaticism . .. that goes beyond normal opposition to Nazism, and insteadbegins to seem like the very mentality that made Nazism possible." Theprotesters are careless in selecting targets (SchÃ¶ne-Seifert and Rippe 1991).Indeed, the anti-bioethics movement builds on a recent history of protests

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that are difficult to comprehend. Protesters blocked the gates of the MaxPlanck Institute for Breeding Research in Cologne to prevent the plantingof pink petunias, saying that the genetic alteration revived memoriesof Nazi racial experiments in concentration camps ("West German Scien-tists . . ." 1990). Benno MÃ¼ller-Hill, a pioneer researcher on Nazi medicalatrocities and also a geneticist, reports that his genetics department hasbeen firebombed twice in recent years, as has the department at Heidelberg(see Meyer 1989).

It is noteworthy that these acts have been committed only in German-speaking Europe. There has been little echo elsewhere on the Continent,and none in the United States.10 The lack of an academic commitment tofree speech and open inquiry in those countries is worrisome. Might onenot take comfort, however, from the fact that at least some people inGermany and Austria care so passionately about preventing a return ofNazi thinking? And might it not be dangerous for questions of euthanasiaand eugenics to be debated calmly and dispassionately on ground whichhad proven to be fertile soil for inhumanity? After all, the anti-bioethicsfuror in Germany and Austria followed closely on the recent publicationof the historical works documenting the Nazi medical atrocities; some ofthe writers were in the forefront of the protesters (SchÃ¶ne-Seifert and Rippe1991). Did they not best know whereof they spoke?

The answer might be "yes" if we accept the premise that the best, oreven the only, way to prevent the fall down the slippery slope is to preventthe issues from being debated at all. This premise will win few followershere; nor should it. The implication of the Nazi era for contemporarybioethics, with which we are here concerned, cannot be discussed if werefuse to discuss bioethics. And it is ludicrous to suppose that academicdiscussions of this sort will lead to a new Auschwitz.

But the German protesters' challenge raises, in our opinion, an importantissue, in view of our argument that the most important Nazi-era phenom-enon for contemporary bioethics was the moral degradation of ordinarymedicine. The German protesters do not want a public debate, they say,because despicable and dangerous views are made respectable merely bybeing debated; this occurs, they say, even if these views are fully rebutted.That is why their response is not to enter the debate but to prevent it. Asthe new history of Nazi medicine has shown, the misbehavior of theordinary German physician was possible in large part because abhorrentideas became commonplace and respectable. When German doctors lost

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their moral instincts, their ability to notice evil and to recoil from it, theirsins of omission and commission came easily.

Discussion of the meaning of Nazi medicine for contemporary bioethicswill therefore be a hazardous enterprise in German-speaking Europe. Asthe Nazis' opponent, the United States is in a less difficult position as itcontemplates these events. Nevertheless, we cannot be complacent. Asmentioned above, the Nazis acknowledged us as their teachers in institutingeugenic programs of forced sterilization. Our own misdeeds in humanexperimentation, though not at all comparable to Mengele's, are the oc-casion for humility. And the integrity of physicians' ethics is constantlyendangered. Recently, for example, Illinois passed a law (over the protestsof the AMA) requiring that two physicians be present when executionsby lethal injection are carried out (111. Rev. Stat. ch. 38, par. 119-5 (1992)).The law promises participating physicians anonymity and a cash payment.Germany is not the only country with ghosts in its medical closet (thoughit has by far the worst ones), or with present-day moral lapses. Continuingreflection on the events in Germany 1933-1945, and reinterpretation oftheir implications, will be necessary not only in resolving bioethical dis-putes, but as a precondition for bioethics itself.

We would like to thank Irving Ishado for research assistance.

NOTES

1. Michael Kater (1989) reports that a German chronicle of these events a fewyears after the war was effectively suppressed.

2. See, for example, Hugh G. Gallagher (1990), Michael H. Kater (1989), RobertJ. Lifton (1986), Benno MÃ¼ller-Hill (1988), and Robert Proctor (1988). Afurther volume, When Medicine Went Mad: Bioethics and the Holocaust,edited by Arthur L. Caplan (1992), provides a number of interpretive essays.

3. One of these leaders, Dr. Hans Sewering, was at the time of this writing nearthe zenith of his profession: president-elect of the World Medical Association.But Der Spiegel, the newsmagazine, had revealed that Sewering had joinednot only the Nazi Party but the SS, and it named a 14-year-old handicappedgirl, one Babette Froewis, who in 1943 had been sent on Sewering's ordersto a hospital killing center (Kater 1989). Raymond Scalettor, chairman ofthe board of the AMA, wrote to the WMA protesting Sewering's possible

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election, stating that "The personal activities of the WMA officers must inall respects reflect the highest ideals of medicine and adhere to the higheststandard of medical ethics." On January 7, the AMA asked that Seweringwithdraw his name. On January 24, he did so, blaming pressure from theWorld Jewish Congress.

Sewering had maintained that he had not anticipated the girl's fate whenhe assigned her to the Haar-Eglfing "healing clinic," and had insisted thatlocal church authorities had concurred in his action. The repudiation of thisclaim by four nuns and a hospital director, 50 years after the fact, precipitatedSewering's withdrawal. The Chamber of Physicians in Germany maintainedits support of Sewering's candidacy, blaming the World Jewish Congress fora campaign of defamation. This incident illustrates any number of themesof the present article.

4. A vivid portrayal of one such examination is in Joseph Losey's film, "Mr.Klein."

5. The mandatory reporting requirements were an exception, but the smallminority of physicians who maintained their moral commitments to handi-capped patients were for the most part able to evade the letter of the lawwithout harm to themselves.

6. Kater (1989) citing Esther Fischer-Homberger, Geschieht der Medizin, Berlin,1975.

7. Warren E. Leary (1992) suggests that the Nazi horrors stemmed in part fromthe state's role in ensuring access to care, even in Weimar Germany. Thissuggestion was rebutted in a letter published shortly thereafter (Landsberger1992).

8. This position is a standard, though not universal, view in the bioethics lit-erature in English. On other issues, ranging from aid to the poor to educationfor the disabled, Singer has favored redistribution from the fortunate to theunfortunate. In the United States, Singer is best known for his book AnimalLiberation (1975, second edition 1990) which was instrumental in launchingthe last decade's movement for humane treatment of animals.

9. Quoting and translating E. Klee, "Durch Zyankali erlÃ¶st": Sterbehilfe undEuthanasie heute. Frankfurt: M. Fischer, 1990, p. 81.

10. One of the conferences shut down by protesters in Germany was simplymoved to nearby Netherlands, where it proceeded without incident (Singer1991). At a recent Congress of the International Association of Bioethics,with delegates from 37 countries, Singer was elected president. However, hisassociate, Helga Kuhse, was shouted down at a talk in Bielefeld, Germany,the week before, and another speaker was spattered with green paint (personalcommunications).

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REFERENCES

Annas, George J., and Grodin, Michael A. 1992. The Nazi Doctors and theNuremberg Code: Human Rights in Human Experimentation. Oxford: Ox-ford University Press.

Caplan, Arthur L., ed. 1992. When Medicine Went Mad: Bioethics and the Holo-caust. Totowa, NJ: Humana Press.

Christoph, Franz. 1989. (K)ein Diskurs Ãœber 'lebensunwertes Leben.' Der Spiegel(5 June) no. 23.

Eley, Geoff. 1991. Dealing with the Past: Nazism and other Continuities. MichiganQuarterly Review 30: 488-505.

Gallagher, Hugh G. 1990. By Trust Betrayed. New York: Henry Holt.Kater, Michael H. 1989. Doctors Under Hitler. Chapel Hill: University of North

Carolina Press.

Landsberger, Henry A. 1992. Don't Tie Weimar Clinics to Nazi Horrors. NewYork Times (29 November): ElO.

Lifton, Robert J. 1986. The Nazi Doctors. New York: Basic Books.Meyer, Ernie. 1989. When Ethics Fall Prey to 'Thrill of Science.' Jerusalem Post

(12 May).MÃ¼ller-Hill, Benno. 1988. Murderous Science. Oxford: Oxford University Press.Proctor, Robert. 1988. Racial Hygiene. Cambridge: Harvard University Press.SchÃ¶ne-Seifert, Bettina, and Rippe, Klaus-Peter. 1991. Silencing the Singer-. Anti-

bioethics in Germany. Hastings Center Report 21 (6): 20-27.Singer, Peter. 1975. Animal Liberation. (2d ed. 1990). New York: Random House.______1991. On Being Silenced in Germany. New York Review of Books (15

August): 36-42.______1987. Practical Ethics. Oxford: Oxford University Press/Clarendon Press.West German Scientists Plant Genetically Altered Flowers. 1990. Reuters (14

May).

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