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How Did Medicine Go So Wrong?

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Transcript

Thank you all for coming out this evening. I’m very, very pleased to be here. I’m grateful for that very kind introduction. I’m going to talk about a subject that in some ways difficult for bioethics, my home discipline, to wrestle with. Bioethics itself, in my view, has never really grappled with the Holocaust. So I’m going to try and explain what I mean by that, why I think that’s so. It becomes very important in current debates to examine this question because, in bioethical debates today, the Holocaust, the experience of medicine and what it did in Germany, pre-World War II and during World War II, is constantly invoked in public policy arguments and public policy debates. And I’ll give you some examples of that tonight.

I think many of the people who invoke analogies, what I’ll call the Nazi analogy in bioethics, do so inappropriately. It’s hard for bioethicists to sort that out or to say when it might be appropriate and when it might not. Because bioethics doesn’t have a good grasp itself on what took place with respect to euthanasia, eugenics and, what I’ll talk about mainly tonight, medical experimentation. There are some interesting reasons why that’s so and I’ll try and explain why that’s so. But it shouldn’t be so any more. Hopefully, by the time I’m done tonight, we’ll both understand why, if you will, the Holocaust has been neglected and why it’s important to understand even some of the most difficult questions, which I am going to go into tonight, which are some of the ethical arguments that German doctors and scientists gave for euthanasia, eugenics and, mainly what I’ll concentrate on tonight, human experimentation.

Part of the reason it’s difficult for bioethics to grapple with the Holocaust is that you have to come face to face with the question what about ethical arguments in defense of horrible crimes, terrible tortures and mass human indignity? To put it simply, if you can justify the Holocaust on ethics terms, which people tried to do, then what couldn’t you justify and what’s the point of doing ethics? That’s a hard question if you’re making a living doing bioethics. So I think that’s been part of the problem and I think, nonetheless, it’s important to take this head on and try and look at it. And if the Museum was brave enough and smart enough to organize this exhibit then, in a way, I feel I have to go back and talk about what bioethics needs to do to wrestle with history as well.

I said that bioethics has never really paid much attention to the Holocaust. That might sound odd to some of you who have looked at bioethics literature, maybe took a course in bioethics. I one sense, every bioethics course starts with the Nuremberg Code. It always begins with the document produced at the end of World War II in 1947, which was basically the opinion, if you will, or the verdict at the so-called Doctors Trial. At the end of the war, the first group put on trial were physicians and public health people who had been involved with various crimes in the camps, usually around medical experimentation. And the Nuremberg Code was the verdict rendered in response to the trial of these individuals. There were I think 22 people put on trial. Interestingly enough, and some of you in the room may know this, anybody who’s had a bioethics course should know this, the core moral precept that drives the Nuremberg Code and subsequently drives most of American bioethics is the first principle of the Nuremberg Code. Anybody tell me what that is, just for…I should pass out…make you put your heads down on your desk and raise your hand to see if you can answer this question. Informed consent. The informed consent of the subject is absolutely essential. By the time you’re going to leave here tonight, you’re going to know what that’s the first principle of the Nuremberg Code. If you begin with the Nuremberg Code and say the informed consent of the subject is absolutely essential, you might say that’s self-evident. Of course, we have to get informed consent from people before we put them in experiments. Ironically, bioethics literature, bioethics courses do not spend much time explaining the Nuremberg Code. They begin there but they don’t tell you why it came to be.

And similarly, the invocation of what I’m going to refer to tonight in shorthand as the Nazi analogy, if we do this we’re acting like Nazis; if we do this, we’re going down the road that the Nazis went down. Despite the relative lack of attention, what happened in Germany is omnipresent in bioethics. So my first contention is there’s not much attention to history, even though people will often say bioethics begin in the ashes of the concentration camps, something that I think is partially true, but not really true. There’s not much attention in the books of bioethics, in the anthologies and readers to the Holocaust. If you look at them, they have the Nuremberg Code, but not much else. There’s not much said. Relatively few books and articles in bioethics on topics about Nazi medicine and science, a little bit more these days on eugenics but, in general, not lots of writing in the area. Relatively few conferences have been held on questions around what took place with medicine and science from say 1920 to 1947. What were people thinking; what were they up to? How did the leading country of its day in terms of medicine and science wind up having a anthropologically trained physician meet every train that showed up at a concentration camp? How did that come to be? And relatively few scholarly experts around on that particular historical period, if you will, the bioethical underpinnings of Nazi medicine and science.

That Nazi analogy I mention, this is just a sample. I found people talking about, or making reference to, a contemporary issue and saying, that’s what the Nazis did or that’s exactly analogous to what took place in Nazi Germany. When Jesse Gelsinger died in a gene therapy experiment at Penn and Ellen Roche died in a challenge experiment, so-called, at Johns Hopkins, a physiological experiment trying to elicit asthma symptoms, some critics of human experimentation in America said those experiments are exactly what would have taken place in Germany. The “monster study” is a study that took place in the 20s at the University of Iowa. A scientist was trying to induce stuttering in orphans to see if you could understand what caused stuttering. Whether that study was right or wrong, there were many analogies in the debate about that study to what took place in concentration camps. “Acres of skin” refers to prison experiments done in the Philadelphia area to develop a drug that some of you probably have used, Retin-A, and there was a book out called Acres of Skin, which, in fact, drew an exact analogy from the prison experiments in the 60s in the Holmesberg prison to what took place in the concentration camps.

Some years ago I got involved in a dispute that all of you know about, you just didn’t know I started it, about whether or not you should use data from Nazi medical experiments involving hypothermia. That was when I was in Minnesota, which is an excellent place to study hypothermia. And one of my colleagues was interested in that question, could he cite the Nazi data, and we started to discuss it. We wrote about it, we had a conference on it. It was actually what led me to be here in 1994 talking about it some more. But in 1990 we explored that question. Many, many people were invoking all kinds of analogies to the Nazis, about [Robert] Pozos, the scientist who wanted to, was interested in temperature exposure and freezing cold and its physiological effects on people. Embryo research, embryonic stem cell research, lots of Nazi metaphors here, killing the innocent, a holocaust of the embryos, those sorts of references. Any of you who watched the Schiavo case, which I’m going to come back to, over the past month, will know that there were lots of Nazi references invoked there about euthanasia. And Jack Kevorkian, it’s hard to travel far around old Jack without hearing about Nazis from somebody. Even animal experimentation is sometimes analogized. Defenders of animal rights will say there is a mass murder of animals today, much as there was the Holocaust victims lo these 6 decades ago. And obviously abortion debates are full of Nazi references, Nazi analogies to what went on there.

I just went through some Schiavo stuff from the past couple of weeks. This is a statement from the traditional values coalition about the Schiavo case. “The philosophy of the Nazi doctors lives on in the minds of federal judges, our federal judges, as well as Michael Schiavo, the husband, and his new-age attorney, George Filos.” I don’t know what the new-age crack is, but there’s a claim that your judges are like Nazis if they let Terry Schiavo die. Radio talk show host, Michael Savage, who I hope none of you ever listen to, but I do occasionally, just for irritation factor. He made an analogy in this case, comparing the doctors who pulled the feeding tube from Terry Schiavo to Dr. Mengele, and to democrats, too, I might add. But there’s another one of the examples where the analogy popped up in recent discussion. There’s Patrick Buchanan talking about Terry Schiavo, arguing that her dehydration death, starvation, involuntary murder is exactly what took place at Auschwitz, and to say Patrick Buchanan can’t seem to get past anybody who’s not a Catholic who’s killed in Auschwitz. All of his analogies go that way. But there’s another one of them. And he’s arguing that our elites today, who would defend the removal of a feeding tube, are just like Weimar and Nazi Germany in the 20s and 30s. So there are plenty of these. I’m not going to bore you with more.

But there are lots of these references to what the Nazis did, morally making them equivalent to what we do. Some of you may have heard Leon Kass when he was here, and he said eugenic vision and practice are gaining strength, he means in the US, all the more so because they grow out of sight behind the fig leaf of the doctrine of free choice. “We are largely unaware that we have a society already embraced the eugenic principle defective shall not be born.” He’s quoting from a 30s eugenics tract that’s very famous, and you’ll see it in the exhibit, in fact, if you go there, about what we should do to protect the genetic health of the German Volk. That analogy is deliberate. There’s another quote from Leon about prenatal testing. Practitioners of prenatal diagnosis already screen for a long list of genetic diseases. Possession of any one of these defects they believe renders a prospective child unworthy of life. That’s Leon playing off the “life not worthy of living” analogy that popped up in a lot of the pre-Nazi literature in medicine and science in the 30s. “Persons who happen still to be born with these conditions, disabilities, having somehow escaped the spreading net of detection and eugenic abortion, are increasingly regarded as the state’s, as inferior human beings who should not have been born.” So Leon is making analogies of the Nazi analogy sort between prenatal testing today and what took place with respect to race hygiene in Germany in the 20s, 30s and 40s. Are these analogies accurate? Eugenics and prenatal genetic testing, euthanasia, or analogies to say the death of Jessie Gelsinger or the Iowa stuttering experiments or the Holmesberg prison experiments in the form of medical experimentation. Are women who have amniocentesis really on the same road as Leon says, as German race hygiene theorists? Because that’s what prenatal testing is. I doubt it. The exhibit in some ways, if you pay attention, will show you why.

Core to what the Nazis were up to, at least with respect to euthanasia and eugenics, morally by their moral lights, was racism. The threat that the deviant races posed to the genetic health of the Reich, which is not a reason that anybody gives today for getting amniocentesis -- the genetic deviance of anybody posing a threat to the public health of the United States. Coercion, that is involuntary bans on marriage, on immigration and ultimately forced killing. That’s not the path that someone is on when they go I would suggest to have a prenatal test or that is not the path I would suggest that led anybody to pull a feeding tube from Terry Schiavo. And cost to the state. If you look to the debates about Terry Schiavo, one thing you could become pretty clear about is that it was a fight about what did Terry Schiavo want. If you take a trip through the exhibit, you can’t go there for too long without being very clear that nobody cared what anybody in the camps or in the T4 extermination programs wanted. There was no interest. They were coerced involuntarily to either be sterilized, restricted in who they could marry, and later, killed.

Those analogies are deeply disturbing when people make them because they’re not paying serious attention to what motivated German moral arguments. That’s why I’m going to tell you tonight in greater depth about the area of human experimentation. But even with respect to eugenics and euthanasia, my contention is the statements I just gave you invoking the Nazi analogy and bioethics are flawed. They’re making mistaken analogies between today, whatever you think about prenatal testing or whatever you think about Terry Schiavo, to say that what’s going on is analogous to, leading to, headed toward, somewhat similar to what was going on in Germany in 1930 is wrong, in my view.

Well, I’m going to spend the rest of tonight talking about the medical experiments. I’ve been working on this for a long time, thinking about it for a long time and I think it’s an area that is hard, grim, but it’s something I think, as I said, that bioethics has to take a look at.

Why wouldn’t people pay attention to the medical experiments and what the scientists and doctors involved with them thought they were doing, not in terms of the science, but in terms of the ethics? What would lead somebody to say, you know, today I’m going to wake up and go freeze somebody to death in a vat, or blow out their brains in a decompression chamber? Curiosity? Morally indifferent? It’s tough for medical science to accept the role of premier people in the biomedical establishment in experiments. One reason we don’t pay attention is it’s hard to actually say that leading scientists could be involved in what are awful, terrible, lethal experiments in the camps. The Germans denied this. We denied it, too. And it’s tough and in one sense to accept it. Dr. Mengele has become the person that we know and are familiar with as being a medical experimenter because he is a fringe scientist. It’s harder to look and see that mainstream people who held esteemed positions in Germany were actively involved in the experiments or supported them or analyzed the data. It’s tough for ethics and bioethics to accept the fact that the people who did these things had ethical reasons for doing them, and you’ll hear about that in a second. And it’s tough for ethics to justify looking at ethical justifications for barbaric experiments because, as I said earlier, well what’s the point of doing bioethics if you can justify these experiments on ethics grounds. So that’s some of the reason that it’s tough to look at an area like medical experimentation in Germany during the war and say what were they thinking about? What rationales, what moral position did they hold? It’s easier to say that kooks and crackpots and nuts were involved in doing this than it is to say that mainstream scientists were involved in doing this. And there were some kooks and crackpots and nuts who got involved in medical experimentation. That is, you’ll see in a minute, there were plenty of legitimate scientists and plenty of people at leading institutions who also got involved in barbaric medical experimentation.

My friend, Robert J. Lifton, wrote a book some years ago, I think 1986, called The Nazi Doctors. And I read that book and it influenced me a great deal because he was trying to wrestle with the question, how did people live with themselves, either sorting people out for the purposes of euthanasia or in justifying what they were doing in terms of causing great suffering and death to people in experiments. And he came up with a theory which he called “doubling.” Some of you may remember that view that what people did they almost split their personalities. They would go to work one kind of person, come home a different kind of person. And they literally became sort of two people inside the same body. That may be a coping thing, but I’ve come to think that the Lifton book is a little bit dangerous because what it does is it excuses us from having to look at what the Nazi doctors said about their ethics. I mean, maybe they did double their personalities, I don’t know. But if you take it as a split personality phenomena, you’re giving ethical exculpation because you don’t take seriously some of the arguments that these scientists and doctors in the camps involved in the Nazi experiments in the concentration camps made.

So I think we’re going to have to get past the Lifton type of psychoanalysis explanation if we’re really going to take seriously the ethics, as hard as that may be, of what the Nazi doctors and scientists had to say. The other reason it’s hard for bioethics to take a look and the reason the analogy is all over the place in current bioethics debates is that analogies to the Nazis are a show stopper. Someone says well, as Leon did here a couple of weeks ago or as other people do in other contexts, you do that kind of thing, you’re just like a Nazi or you’re going to reinvent the Nazis, you’re going to lead us back to a Nazi regime. Most bioethicists hear that and just go silent. They don’t want to tangle with the question of, well is that right, is that proper? The Nazi analogy tends to shut down debates. It’s kind of the nuclear weapon of bioethics arguments and so there’s a tendency to just run when it’s displayed.

Bioethics has another problem. It’s new and it’s been trying to wend its way into the heart of medicine. Remember, bioethics as a phenomena, as a discipline really arose in the 60s. One way to ingratiate yourself to your new friends in medicine, trying to tell them they need ethics, is not to go around saying that a lot of the things that they do might have analogies to what Nazis did. This is not the fastest way to gain fame and repute among American doctors is to try and ask what’s the same, what’s different between Germany medicine in the 30s and American medicine in the 60s. Racism, which is at the core, I believe, of a lot of what the Nazis were up to, is awkward to raise in the American context. We don’t like to admit to it. We try to shuffle it away, but it’s there, but it’s hard to look at. Bioethics doesn’t, it’s awkward for bioethics to remind people about that. It’s easier to say that nuts were involved in all of these activities than mainstream medical men, so bioethics, again, not wanting to irritate its partners in trying to promote medical ethics and bioethics, is prone to say well it must have been nutty people. And it’s easier to marginalize evil, true evil. Professionals don’t do these things.

So I’m saying in part that bioethics did suffer sort of co-optation. In order to get itself going in America in the 60s, it kind of had to ignore the history where ordinary doctors played key roles in the rise of Nazism, where competent and well-established and esteemed medical and scientific people played major roles in what took place in the Nazi Holocaust. It was uncomfortable to say that and I think that’s why those books are so weird, starting with the Nuremberg Code, but nothing before. Very little history, just sort of looking at the answer, if you will.

Mengele is the guy I wanted to mention just as the poster child of Nazi medicine and science and he was a nut. There is no doubt that no one took him seriously. He did barbaric and horrible experiments, mutilated children, just did awful things. No one read his reports. Nobody cared about his data. Nobody paid any attention to him. But he became the sort of poster child of Nazi medicine and science, not just because he had done terrible things, but because he became a convenient scapegoat for other people who had done equally terrible things, but weren’t as nutty and as fringy as this character.

Let me remind you about what the medical experiments are that took place in the camps. That’s what I’m really honing in now for tonight. There were 26 different categories of research, a number of them involved civilians who came into the camps to do studies. People tested different killing agents when they were trying to perfect the Nazi killing machine. You had to figure out what gases and agents to use, so those things were tested in the camps. Many modes of sterilization were tested there. Lots of studies done on stress and its effect on menstruation or ovulation, another way to try and control reproduction of undesirable peoples like Jews. Electro-convulsive shock therapy was tested there and many, many twin studies went on, which I’m sure you’ve heard about a little bit, and that’s where Mengele made some of his reputation. Karl Brandt was a very respected physician who was in charge of the entire public health in Germany. He pops up in the exhibit, if you go look at it.

And a person that I find very troubling and interesting and disturbing and difficult to deal with, Gerhard Rose. Gerhard Rose was the head of Koch Institute of Tropical Medicine. In its time and in his day, he was the world’s leading authority on tropical infectious diseases and typhoid and typhus. Gerhard Rose was on trial. He was one of the people in the dock before. He had nothing to do with Mengele. But he becomes a very interesting figure in trying to figure out what was Gerhard Rose thinking when he ran lethal typhus and typhoid experiments that killed hundreds of people in the camps? What was on his mind, what did he think about? We’ll come back to him a little bit later.

You’ve probably heard about decompression, trying to see what the effects were on the human brain and body. Hypothermia, the freezing experiments. Wounds, wounding people and trying to heal them, burning them. Desalinizing sea water to see if you could find a way to let people drink who fell into the North Sea or other places. These were all done under military sponsorship. These studies, you’ll pardon my using this term tonight, were, if you will, good science. And I don’t mean ethically good, what I mean is they were done by competent people, using the best methods possible to produce results that were published, analyzed and utilized. Sometimes I’m asked, should we use data from the Nazi medical experiments, and I actually chased that question back in 1990. The answer is, well you can use it or not as you wish, but it has been used. If you’ve ever put on a life vest, you’ve used the Nazi data. The finding from this study was that the way to keep a person alive if they went into cold water was to keep their brainstem out of the cold water. That cushion turned out to be the most effective way to keep people alive longer by keeping their head out of the water. The design comes from this camp experiment. Every country in the world used it, the British, the Canadians, the then Soviets, we did. Everybody used it in military application and, in fact, it’s become the design feature that is physiologically sound that guides our life preservers today. It was all perfected in this series of experiments in the camps. Skin grafting. Some of you know this, people with sometimes show you their arms, survivors, what happened. These are all done to learn how to treat wounds and burns.

Caliber of the science. Well, oftentimes people will say nothing that came out of the camp studies was any good, it was all done by crackpots. Obviously I don’t believe that. Some of it was, a lot of it wasn’t. There’s real science done in the camps and there’s some bad science done there. The bad science has some interesting features. I’m not going to show you my sort of working through some of this, but there are some aspects that tell you right away when something is, quote, unquote, nutty science of the Mengele type. The subjects are always sick and debilitated and nobody cares. The researchers have no credentials and no real track record as scholars. They haven’t published in the area that they’re fooling around with. And they’re not particularly selective about their subjects. They take anybody and do what they want with them and kill them in their studies and that’s it. In what I’m calling the real science, it had the military application, there’s always military sponsorship. The hypothermia, decompression, wound studies and desalination are all sponsored by the Luftwaffe or the Wehrmacht. That’s who’s underwriting them. They pick the scientist, they bring him in. Often they’re in the military already. They’re very selective about subjects. One of the ways it’s fascinating to see how racism permeates Nazi science is if you really cared about the results of your studies, you tried as hard as you could to get Aryan people as your subjects. So you can find that in the freezing studies, a lot of the people used were political prisoners or Dutch doctors who were resistors. You didn’t want to make analogies from racial inferiors. So Mengele could do experiments on whoever the hell he wanted. If you really cared about your results, you tried to get closer in your subject selection pool to people who were like Germans, according to Nazi race hygiene theory. You had first tier researchers involved as well and so that’s what’s going on. There’s always a kind of gap in who the subjects are, how they’re utilized, who’s doing it and who’s sponsoring it. And I didn’t put it up here but a lot of the work that we just looked at from the military side gets published and presented at medical meetings. By the way, some of it appearing in the United States in German medical journals which we subscribed to throughout the war. That is to say, some of the Nazi data showed up on our medical shelves because we continued to get in the major libraries the German medical journals throughout that time, even though they were camp experiments, not reported quite as such, but they’re in there. So, again, some of this stuff has crept into our science and medical knowledge as well.

So, now we’re down to the nitty gritty here. What did they say? What were they thinking? Aside from split personalities and eliminating sort of the fringe and kooky scientists, what did people say? I’ve given you here the ethical arguments that were actually used at the trial. I think people believed them and I think they’re powerful ethical arguments. I think that you could sleep at night, having decompressed or frozen or burned somebody and tried to treat them, if you thought morally you were doing the right thing. And my contention is that you wouldn’t sleep too well at night if you didn’t think you were doing the right thing. The first argument was that everybody in the experiments in the camps was going to die anyway. There was no point in worrying about what their fate was because they were all going to die. So if you learn something from people who are doomed to die, that was morally legitimate. You might say they were all terminally ill and it was sensible, many of the researchers felt, to learn from people who were doomed to die. They were prisoners, criminals, threats to the Reich. You can do what you want to prisoners.

Now, it happens to be the case that we sent an expert over, Andrew Ivy, to testify at the Doctors Trial and Andrew Ivy said, “that isn’t true. We would still avoid or not use prisoners without their consent in America.” He said this at the Nuremberg Trial. And the German prosecution team said “really, Dr. Ivy, where did you work in the 1930s.” And he said “I worked at the Statesville Prison outside of Chicago.” And he said “did you ever get consent from any of the prisoners,” and he said no. Nor did they at the Holmesberg Prison in those Philadelphia experiments. That’s because prisoners were considered expendable and, in fact, exactly the people that should be put into experiments. Take advantage of experiments in nature. Those of you who know something about the history of medicine know who Claude Bernard was, very famous physician, French physician, who basically invented the experimental method controlled trials that we use today. One of the things that Claude Bernard had argued strenuously for was there are situations where you can’t design an experiment, but what you need to do is take advantage of disasters that take place in nature. If there’s an earthquake and people have crush injuries, you study that. You wouldn’t crush them but, if it happens, then you study it. Many of the German scientists and physicians who knew Claude Bernard, who were well-educated people said the camps are experiments in nature. We didn’t organize them; we didn’t design them, but here they are and we’ll learn from them. So, if we want to study starvation, this is where we will learn about starvation.

Early release. Some of the prisoners were promised that if they’re in these studies and agreed to be in them, quote, unquote, they’d let them go. Nobody was ever let go, but I did meet a man years ago from Belgium, one of those political resistors, who showed me a medal that was given to him for surviving the hypothermia experiments. … Was the only person who ever got a medal for being a human subject and it honored him for his service to the Reich. He smiled and said it was a little involuntary but some people believed, who were the researchers, that, in fact, benefits would come to the subjects by being in the research. Many people said in war the rules of experimentation are void. We don’t do that. You can think about Iraq. You can think about bio-terrorism today. You can think about many areas where an analogy might be drawn to a particular argument with some force. The rules are off during war. You don’t get consent from anybody. And Gerhard Rose, who had the most important argument, the most sensitive argument, the scariest argument, the most difficult one to look at, what Gerhard Rose said was this, the Wehrmacht came to him and said on the Eastern Front 1942 we are losing five men for every one that the Red Army kills to typhus and typhoid. You must do experiments in these camps where people are going to die anyway to try and find a vaccine to either prevent this or cure this or we are going to lose this war. Gerhard Rose said no, I can’t do such experiments. Basically, they revisited him about four months later and said now it’s about eight men dying to diseases, infectious disease, to the toll taken on us by the Red Army and he said yes. Gerhard Rose basically argued that the benefits to the many by the sacrifice of a few justified the camp experiments. And that’s probably the strongest and toughest argument of all, of all the ones that were made by the Nazi scientists.

Now let me just recap here for a second. What I’ve tried to show you is, number (1) there was state-of-the-art science being done in the camps, not all of it, but some of it; (2) bioethics has never wrestled with these arguments at all because it starts with the Nuremberg Code and moves out; (3) these moral arguments have force; (4) most of them have nothing to do with the Nazi analogies that are invoked today about human experimentation. Some might, but most of them don’t. Rose, by the way, was one of the few people at the end of that trial who was not hung because people found some moral credit in what he tried to explain in terms of his actions. I always thought he’d make for a great play if I ever get some time. Going to try and turn him into a different kind of a dramatic story.

German ethical arguments made by the researchers are very powerful. They are still raised today. How many of you followed this recent decision to end a pesticide study in Florida which was going to pay people to monitor pesticide exposure in their kids. That is a classic experiment in nature. No one was going to give pesticides to the kids. They were just going to see what happened if you used pesticides in your house. That’s an experiment in nature just like Claude Bernard, just like the Nazis said the camps were. These arguments are discomfiting in that horrible abuses stand upon ethical justifications. With respect to my friend Bob Lifton, they may be doubling their personalities, my claim tonight is they also slept well at night because they believed that what they were doing was right. They offend us in that they justify barbarity and they link barbarity to the mainstream. There’s nobody more mainstream than Gerhard Rose. He’s the best that science and medicine has to offer of his day, worldwide.

So, now you’re in a position to understand something else, the ethical response. Why is principle one of the Nuremberg Code the informed consent of the subject is absolutely essential? It’s because it’s the answer to Gerhard Rose. You can’t sacrifice the few or the one to benefit the many in medical experimentation. You must let individual choice and autonomy trump the needs or the possible benefits to the community. It’s not an accident that it’s principle one. The judges knew that. What they were trying to say was here’s the counterweight to a powerful moral argument. It would be perhaps plausible to say we could benefit a lot of people by just killing 20 or 30 people in a trial, or blowing out the brains of some people in a decompression chamber. But you can’t because you must still respect individual rights to choose. Even prisoners and the terminally ill, which are down at principles 4 and 5 of the Nuremberg code, have this right. You can’t say just because someone is going to die anyway that you do what you want to them. You can’t say that just because someone is a prisoner, you can do what you want to them. That’s what the code was trying to respond to. War is not an excuse for the waiver of informed consent.

I was very proud to see in the past week those federal courts that some people think are like Nazis said that if you’re going to do anthrax vaccine experiments on the troops, you must get their informed consent. That’s the right principle. It doesn’t mean you can’t order them to do it, doesn’t mean you can’t say this is the right thing to do for your unit. You still need to get their permission. You shouldn’t force, coerce or use the argument that in war, even soldiers lose their rights. War is not an excuse, says the Nuremberg Code. You can’t understand what happened in Germany, much less understand what happened in bioethics, without laying out the moral arguments that these German scientists and doctors gave when they were in the camps. None of it hangs together. None of it makes any sense. But it’s been missing, if you will, from bioethics history. Because it’s been missing, it lets that Nazi analogy and metaphor in current bioethics discussions run amok because it’s not grounded to anything. So anybody can say anything is like the Nazis. Anybody can say anything that happens that they don’t like, reminds them of the slippery slope to Nazism. I’m here basically to say the Nazis had some pretty clear ideas about what their moral justifications were, believed in them, argued for them and knew what they were trying to prove.

Some people have said to me, did they really understand them, did they really believe them. I think they did. I think these were sophisticated people who had thought long and hard about why it was that they were going to report for duty to do these experiments. Remember, when Rose said no the first time, no one jailed him, no one threatened him, no one did anything. He just said no because he thought it wasn’t the right thing to do. Later he convinced himself it was the right thing to do. You can call that a personality split, you can call it some kind of denial, if you want. I call it the harsh reality that most people most of the time are not going to do things they think are immoral. They’re going to come up with ways to understand and justify what it is that they do. Worse, from a bioethics point of view, these arguments, people make them all the time. You could hear echoes of them in many contemporary debates about science and medicine. What we’ve tried to do, I hope, in bioethics, is to show that you can’t take any of those principles and let them run unbridled. Why is autonomy so strong in American bioethics? Why is it that we spend so much time talking about informed consent day and night? It isn’t just that Americans are an autonomy-driven people. It’s because it’s the antidote to a set of moral arguments that have lain dormant, unexamined and basically too hard for us to look at ever since the war ended.

I hope tonight I’ve tried to change that situation for you. I hope I’ve made you start to think that you have to treat in current debates the Nazi analogy with caution and care. It’s not that it couldn’t be right, but you want to know exactly what the basis is for the claim. Just throwing it around willy-nilly is completely irresponsible. It demeans the Holocaust. It demeans what happened in terms of the moral justifications that people gave. It’s hard to say sometimes that someone who froze someone to death or blew someone’s brains out or intentionally burned someone severely and then let them suffer did it because they thought it was right. I believe that’s true. I believe it’s bioethics’ job to look in there then, go face to face with the grimmest things that have happened in the name of medicine and science and show what moral principles would not allow that to happen. Thank you.

Arthur Caplan, Director, Center for Bioethics, University of Pennsylvania. Dr. Caplan explores how moral inquiry into this history can inform the field of bioethics today as it confronts controversial issues and practices.