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The Death of Hippocrates: The “Logic” of Nazi Medicine

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SARA BLOOMFIELD: In thinking about your visits to the Museum, and we should say that you visited right before the exhibition opened, and then you came back and saw the exhibition again. You wrote a review of the exhibition. You got me thinking. And there are kind of four big areas that I would like us maybe to even just touch upon tonight, and they're, some of them they're interrelated. But I'm gonna share them with our audience. First is obviously your reactions to the exhibition itself. Something as a little bit about the history of German medicine and eugenics, something you taught us a great deal about. And then how that all evolved logically, to use a word I think I'm quoting from your review, into Naz-, what we call Nazi medicine, and that logic of Nazi medicine itself. And then finally, what do we learn from this history? How is it that we as a society think of ourselves as we look back upon this other society. So that's the overview for the, for the lesson tonight. But I want to start with your review. You wrote a review for The New Republic. It came out in the September 13th issue. And if you don't mind I want to quote for the audience something you wrote in that review. You wrote, "it is precisely because deadly medicine allows the story of its subject to unfold without editorializing that I found myself so taken aback and disturbed by my response to it. Like most physicians of my generation, I knew a great deal about the nefarious activities of the Nazi doctors and considered their behavior an aberration to be condemned. Not explainable in the ordinary terms of professional behavior and requiring a combination of socially infectious mass mental pathology and distorted nationalism to make sense of. It had always seemed obvious to me, and to the several colleagues with whom I had discussed it over the years, that none of us would ever have fallen prey to such delusions as the justification of euthanasia and then genocide. Now Deadly Medicine has made me doubt the certainty of those convictions." I read that and I said, wow. So would you comment on your reactions to the exhibition.

SHERWIN NULAND: Well, you know Sara, I'm a great believer in free association. And it served me well in the operating room. It certainly has served me well in now ten years of writing. And although I came to this exhibit with the thought, what am I going to learn from it, I know most of this material. I also came to it with the thought of, it's quite possible I might be surprised, and what surprised me grew out of the way Susan Bachrach, all of you have constructed it in such a way that one is not led to a conclusion, one is simply shown the facts. And as I went from one board to another watching the descriptions of the evolution of this process, it was specifically that word, "evolution," that came to form my thoughts. In other words, what you were essentially describing in the exhibit is the end of a very long historical process that seemed to make a great deal of scientific sense when it began, and yet led to something that would have been unimaginable even halfway through that process. And here is specifically what I mean. As everyone here must remember the 19th Century was the century when science was going to be the answer to everything. New inventions were coming into being. Inventors, applied scientists, scientists were becoming very prominent in the public eye. Always there was the notion that what can be bad about this? We're finding out about nature. We're finding out how to control nature. In the 20th Century, when it comes, we will be free of so much of the burden that nature puts upon us as human beings. Of course all of that was blasted to pieces by World War I when some of the most eminent scientist were involved in creating various kinds of explosives or ordinance or whatever it might be. But through the 19th Century everything seemed to be scientifically on an upward scale. And yet there were, as the exhibit clearly shows extrapolating back from the exhibit, already the seeds of what would come in the middle of the 20th Century. Because of the emphasis on science for good most scientists believed in their own virtue. Of course physicians always believe in their own virtue. One of the four principles of bioethics is beneficence and one of the others is non-maleficence, and we talk about justice. We talk about autonomy and we are the avatars of that. We are the people who are beneficent so we could never be maleficent. And yet it turns out that without meaning to be, we have been. And we have been when we become so profoundly soaked up in our goodness, in our certainty that science is the answer that we are led astray before we realize the directions in which science is moving. Of course there's this other thing about science, it is so objective, it so distant, it has, we are so distanced from our observations and our conclusions. And it turns out that that's not so. As early as the 19th Century people were commenting on the fact that science is a creature of its time, and no scientist ever objectively looks at her or his data. Well the 19th Century, his data. Right. We can't be anachronistic. Well what was happening in fact is that the leading scientific country in the world, and not just the leading scientific country of the world, but the country that everybody looked to, to bring the scientific enterprise to perfection was being infected by seeming philosophical and then seeming scientific notions from other countries. And by this I mean the idea of eugenics. Here's eugenics, we break the word into two. "Eu," "genics." Good genes, good breeding. Whatever words invented in the middle 1860s by Francis Galton, who was a scientist, a bit of a philosopher. And he used it originally because he was breeding animals and he wanted to teach people the proper way to do that. You make the breed better. You improve the breed. And it seemed not only harmless but it seemed important. So here we are steeped in science but we are also steeped, as we have always been, in a kind of nationalism, where the leading countries in science in the world, and of course Germany was by far the leader, have each convinced themselves that there is something about their society that makes it unique. So we are beginning to see the evolution of what later came to be called Social Darwinism: the idea that societies evolve just like people evolve. And if a society is very successful like American society of English society or German society, that must mean that it has within it characteristics that are head and shoulders over the characteristics of other countries that are not succeeding in this milieu. So you get this philosophy. You get the idea that if something seems scientifically based it must be true. And you transfer that idea from England where it got its original power to a country like Germany where the notion of uniqueness has been bred into a quality that is beyond what it is in most other countries. This goes back to the Middle Ages, the concept of Volk, this tribal thing where there is something in our blood that makes us unique and different. So we have this philosophy that is essentially learned from other countries that it is possible for one group, one nation, one culture to be superior to all others, that it can be scientifically based because understanding of genetics is coming to be. And since there is so much emphasis on science everything is thought to be biologically determined, genetically determined. And eventually in the 1920s and of course in the early 1930s this becomes hijacked. This philosophy, which seems so benign and so correct is hijacked by a group of monsters who use it to promote an agenda that would have stunned Galton, who made up the word in 1866, would have stunned the people who went to the first World Eugenics Conference in 1912. And we are left with the Holocaust.

SARA BLOOMFIELD: I want just to go back to something you said and I believe I remember this when you first came to the Museum going back to this 19th Century and the history of medicine, and correct me if I'm wrong. I thought you said something like, if you know the history of German medicine you can see how this evolved logically. And I vaguely remember you saying something that Germany unlike countries, for example France and elsewhere, had such a strong emphasis on research. And there was almost a detachment from the patient. Am I correct?

SHERWIN NULAND: That's certainly true. Well let me go back before the German period. One of the most fascinating things to me about the history of medicine is the way it moves from country to country. When you look at the history of medicine in the 16th, 17th Century, even into the 18th Century a lot of it is Italian. A lot of the work is being done in Italian universities. Padua, Bologna, most specifically. Some of it is being done in Leiden in Holland. But it's, it's really an Italian kind of a thing. In fact, the early anatomists were essentially working with the great artists. You find the leading anatomists at the University of Padua for example were very close to the Titians and the Michelangelos and the Leonardos because they were interested in structure and in movement. So there's an aesthetic that arises out of the late Renaissance. But that wasn't enough as medicine progressed and one had to study not just the notion of structure, but the notion of disease as well. So it starts moving to France because as the French of the early 19th Century used to say, the French physicians used to say we are sensualist. We are interested in things of the senses. So what they do is essentially develop the physical examination. An Italian anatomist named Morgagni in 1771 wrote a book in which he pointed out for the very first time that if a patient comes to you with a headache, if he comes to you with nausea and vomiting, if he comes to you with jaundice, it means that something has gone wrong in a specific organ of the body. He wrote this wonderful book called The Seats and Causes of Disease. And he referred to symptoms in this fascinating way. He called them the cries of the suffering organs. Prior to that, people thought you got sick because of your black bile, yellow bile, phlegm, blood was all out of whack, or there was a miasma, sort of cloudy thing over your city, you know, this, this kind of stuff. But he pointed out, no, no, no, no. If you open the bodies of patients that you've been taking care of, you're going to find pathology in those bodies. Pathological things that have caused the symptoms that you have seen. So he writes this wonderful book and everybody starts reading the book. Here we are in the late 1870s and, the late 18th Century, and the French come along and they say, well that's fine, to do this at autopsy, but it's a day late. What we need to do is to figure out what's going on in that body before the people die. So they got very interested first in feeling the body, in putting their ear onto the chest for example, listening to sounds. They got particularly interested in sounds, so much so that one day a five foot, three inch Frenchman named Rene Theophile Hyacinthe Laënnec was walking home from a hospital where he, being a shy little fellow had been embarrassed to put his chest of a beautiful, young patient, and it came to him in a flash. He invented the stethoscope so he wouldn't have to put his ear on this chest. It was a long, it was a long tube called liberton. It was a "liberton" [ph]. What I'm getting at is it was this sensualism, this need to use their senses that developed what we think of as the modern physical examination. But then there came a time where that wasn't enough. Because people were finding out things about physics and they were finding out things about chemistry, and what was needed was laboratory science. What was needed was the meticulous mind of a scientist. And if there is anything characteristic of the German mind of the 19th Century it was that care, that meticulousness, and something else. One of the rallying cries of the Revolutions of 1848 was "Lehrfreiheit" and "Lernfreiheit." "Freedom of learning and freedom of teaching." I did it backwards. What we call academic freedom. The German universities were the center of real academic freedom. Students could move from one university to the other. Professors were named on the basis of ability. And so here, unlike in France and in England where you had to know somebody to become a professor, in Germany everything was wide open and free. So naturally, the quality of the highest ranking people became superb. The first real laboratory in a medical school was in 1823, it was in Germany. And by 1850 it was recognizable that new medicine, the medicine of studying the blood, studying secretions of the body, trying to find out how the liver worked, all of this had moved from France to Germany. And I'm not talking only about the great universities as it had been in Italy and it had been in France. Every little university throughout Germany, whether it was Heidelberg or Goettingen, or whether it was something big like Vienna, which isn't strictly speaking in Germany, but is German speaking. Berlin. There were laboratories to study and complete freedom of study. The German contributions between 1850 and World War I to medical science are extraordinary. It was a golden period. It was the time when the real physiology of the body came to be understood. And of course this was known by young doctors from all over the world. Between 1870 and 1914 some 15,000 Americans came to study in German-speaking schools. And when I say study I don't mean they came for two weeks to look. I'm talking about either going to medical school there, which was not all that common, or spending six months, a year, two years working in the laboratories of the great German scientists. Every medical school in the United States is based on the original Johns Hopkins Medical School which opened in 1893. A rich man, Quaker merchant named Johns Hopkins left seven million dollars, leaves three and a half for the university, three and a half for the hospital. And when they got their first faculty, who did they get? Seven young men, five of whom had spent large amounts of time in Germany, and one of whom had visited. So it was six out of the seven had spent significant amounts of time in Germany, and the entire system was based on the German method of science. William Osler, who was the Professor of Medicine, used to say the whole school was Verdeutsched . So what I'm describing is a country whose science went unquestioned. A country whose scientists spoke like oracles and prophets. A country where medical scientists were members of the community who were known everywhere, throughout the community and throughout the country. This nation that I'm describing becomes fascinated with studying the notion of improving the breed, at the same time that they are carrying with them this long history of racial superiority, the Volk, going back to the Middle Ages, the purity of our blood, which was so important to German society. They never questioned, at the beginning, whether the ideas of eugenics are correct or not, because some of their finest scientists are working on it. Obviously some of the finest scientists in the United States are working on it, particularly in England some of the finest scientists are working on it. But when it gets to the Germans it becomes part of the philosophy, the psychology of the country, and of course it is backed by science. And this is the real reason that I wrote in that essay in the New Republic, oh my God, if I had been a Lutheran or a Catholic physician in Germany in the mid-, late 1920s and right into the, I think the mid-1930s, I would have hailed the idea of eugenics. I would have hailed the idea of what in the 20s in Germany became known as race hygiene, rassenhygiene, if I'm pronouncing it correctly. It just seemed logical. It seemed to grow out of science. It seemed to grow out of the superiority of German science. And it certainly grew out of the culture in which these people were brought up before they went to medical school. It was simply a logical extension of everything they believed about themselves, everything they believed about their country. We're not talking about bad people yet.

SARA BLOOMFIELD: Right. So, but eugenics had a different outcome, as we know, in Germany than it did in the other countries, America, England, Scandinavia. Is it, do you think it's because of these, what you've cited, World War I, the blood and soil, the nationalism? I've wondered also, is it the sense of the, a society with an emphasis on the totality of the society as opposed to the individual? Is that part of it? The health of the nation as opposed to the health of the individuals who make up the nation. Hitler is the doctor of the people.

SHERWIN NULAND: [21:38] Yeah. America is based on individual liberty. It's a very different concept than the general European concept, but I think the tradition in Germany has always had to do with that notion of Volk, of people. We are a tribe and we are distinct. Now some German scientists thought it was ludicrous. The great Rudolph Veerhau [ph], who was the greatest German medical scientist of the late 19th Century at one point just to prove that none of it made sense, did a study of six million, seven hundred thousand school children and proved that there is very little probability of a Volk, because he showed that something like only forty percent fit in any way the blond hair, blue eyed thing. And the worst part of it was that eleven percent of Jews fit it perfectly. Hitler wasn't very happy with that when he came along several generations later.

SARA BLOOMFIELD: He himself didn't...

SHERWIN NULAND: But Veerhau was a social activist and a liberal. As a matter of fact he was the founder of a radical German party, and even as the greatest pathologist and maybe the greatest physician of Europe, was a member of Reichstag as well. So there were voices opposing this. But one of the reasons there were voices opposing it was that there was something very powerful to oppose, namely, the mood of the country. And you shouldn't think that the mood of Germany was all that different qualitatively, quantitatively it was, but it wasn't all that different qualitatively from the mood in England and the United States. One of the little stories I tell in that essay of course is, as recently as 1927 there was a well known Supreme Court case in which a young woman, whose name was Carrie Buck, who was retarded, whose mother had been retarded, was sterilized because twenty seven American states had eugenics laws. They had sterilization laws. And they could take retarded people and sterilize them if they wanted to. And the Constitutionality of that law in the State of Virginia was challenged, it went to the Supreme Court. And the Supreme Court upheld this sterilization law, this eugenics law. And what's most interesting to me is not that, just that the Supreme Court upheld it, but that the vote was eight to one. In other words, we all believed the same thing. Now granted, one might say American science was Verdeutsched, which it was, but this was the country where individual liberty means so much, and yet we went along with it. And if I'm not mistaken, I'm sure there are people who know whether I'm right in saying this. As recently as the early 1960s there was a eugenics in the home state of Zel Miller, Georgia. Yeah.

SARA BLOOMFIELD: I want to ask you something about this, about eugenics and how medicine ties to culture, which is really what we're talking about here in many ways. We know from the exhibit that it was somewhat of an international movement. But it seems to primarily have flourished, although a little bit in Japan, but in Western culture. Does this reflect differences between Western and Eastern medicine?

SHERWIN NULAND: Well I think it, I think it flourished in cultures that had a natural sense of superiority of their own cultures. We have that. The Scandinavians had that. And it did flourish in Denmark and Sweden. Less in Norway, but in Denmark and Sweden. And in Germany and as I say, it was a major factor in British thinking. And look at every one of those countries. There is a true sense of superiority everywhere. So when we think, I'm sure most of the audience, the ones who aren't doctors, those who are consumers of medicine, when we think of physicians and morality we think of the Hippocratic Oath. And one of my questions for you is did these German doctors in this exhibition take such an oath? Did they have ethics courses in their medical schools at the time? Did America have medical ethics courses?

Yeah. We're, we're in a bit of a time warp because the Hippocratic Oath is a very complex issue in itself and there's actually of course nothing in the Hippocratic Oath that would stand in the way of someone being a follower of eugenics. And there really is, in spite of all the ethical writings in the Hippocratic corpus, which is something like eighty books, there is nothing that would stop that either. But the fact is the ethics were not taught in medical schools. The teaching of ethics in medical schools is the product of the middle 1960's when bioethics came to be. There was really no bioethics movement at all, and so we mustn't think that it was naturally an outgrowth of that kind of thinking. Especially in German medical schools people went to learn science. Science was the high priestess of everything, and as you indicated quoting me correctly, therapy in the 19th Century was not what people went for, went to Germany for, except surgery. But as far as medical therapy, in the first place there was not a lot, and the real emphasis was in diagnosis, pathology, things of that nature. They were interested in correlating what goes on biochemically in the body, and atomically in the body, pathologically in the body, with what they see on the physical examination. Therapeutics was not a highly defined art until well into the, into the 20th Century.

SARA BLOOMFIELD: So is there a difference between medical ethics and bioethics? And did this, did any of this evolve out of the Nazi era?

SHERWIN NULAND: Well, bioethics refers to the ethics of anything that is living. For example, in our bioethics unit at Yale the Forestry School was involved. The Divinity School is involved. Everybody that deals in any way with living things is involved. Medical ethics specifically has to do with medicine, and it's traditional to go back to the Hippocratics, whose medical ethics had to do with one's specific responsibility to individual patients. But it's out of the movement of the 1960s that medical ethics first came to be, the self expression, self determination really, movement, resulted in the realization that this extraordinary amount of power that doctors have over patients' lives is so unbalanced that decisions are made for reasons that are only clinical and scientific reasons. And many of these decisions have a moral component. They have a spiritual component. They have a familial component. And so more and more there was a demand for the idea that it's my body, doctor. Your obligation is to describe for me what choices I have and help me make a choice, but the ultimate choice is mine. That evolved, as I say specifically in the late 1960s, and the history of bioethics is replete with some of the early cases, almost all of which involve situations in which a doctor is thought to have made decisions, whether correct or incorrect, about the course that a patient would follow.

SARA BLOOMFIELD: Now one of the clear cut legacies of this period was the change in the requirement for medical experimentation and the voluntary consent of the subject. But I'm curious about other legacies. One of the things that I thought was interesting and a lot of the doctors that we met with that reacted to this exhibit, it came out that you know it's easy to throw out Nazi doctors, and it becomes kind of a conversation stopper. And I wondered if the Nazi era has prevented certain kinds of thinking and ways of discussing genetic research today because it was such a gross perversion. I've wondered had it any stultifying effect on the field.

SHERWIN NULAND: I think it's a little hard to know the answer to that. I'd like to say that we have a much greater awareness of the dangers of the kinds of things we were doing. I think it was the Nuremberg trials, which obviously grew out of the Nazi era, that had such a profound effect on American science, because of course one of the defense's arguments were, look at what some of the things that you do in your scientific studies, the famous Tuskegee experiments in following the course of syphilis where these young black men were not told what was going on, were not treated, but they were simply being followed. There were a number of experimental studies done at mental hospitals, one in New York State at Willowbrook, once again patients not knowing what was going on. Out of the Nuremberg trials grew to a large extent the notion of informed consent because some of the American doctors had the same response to the Nuremberg trials as I had to the exhibit, oh my God. I could so easily have been doing this, or oh my God I am doing this. How well I remember having graduated from medical school in the late 1950s the kinds of experiments that we did with patients, not only without informed consent, but even we didn't know the consequences of what we were doing, or procedures that were allowed to be done unsupervised by very junior people, which would result, not often, but sometimes in death. And then you'd go to a mortality and a morbidity conference and you'd speak very wisely about you know where you had gone wrong. But it had never occurred to anybody in the 1950s to tell the patient every possibility that might occur, and that all grew out of this self awareness that the angry kids in the late 60.s gave us. They gave us some tough stuff but they gave us some great stuff. They gave us that, they gave us, they gave a lot of impetus to the Civil Rights Movement, to the Women's Liberation Movement, to the Gay Liberation Movement. But from the point of view of medicine the greatest thing that happened was the awareness of our behavior, which was far more, far less ethical than we had thought it was.

SARA BLOOMFIELD: And I just want to remind you to be writing your questions. We'll pick them up shortly and I'll give you some warning. I want to just jump in. You talked about the challenges to your profession and how external events and your own advances are forcing you to think very hard about what you do. And I'm sure you read the article in the Sunday Times Magazine a few weeks ago. I don't know if you read this. It was an article entitled, "The Genome in Black and White and Gray". Did you ...?

SHERWIN NULAND: No. I didn't.

SARA BLOOMFIELD: Okay. Well, I have something interesting for you here. It was written by Robin Marantz Henig, and she was talking about where genetic research is today, and she said that it might even change the way we think about the notion of race, and even implied that it could provide a scientific basis for difference in races, pretty, pretty important stuff. But in writing her piece, she referred to visiting the deadly medicine exhibition and I want to read for you and for the audience a section she wrote and then I want to ask you a question about this. Here's what she wrote. She wrote, with rulers, calipers, charts of eye shapes, and elaborate reconstructions of family trees, eugenicists of the 1920s and 30s took great care to describe physical characteristics of different racial groups. They photographed subjects, measured their noses and mouths, made plaster casts of their faces, and documented variations on facial features and head proportions. Is it possible that the difference between then and now is that the tools have changed? That instead of using calipers and scales scientists now use DNA sequencing machines. Connecting contemporary genomic studies to the Holocaust is too glib, but the exhibit is a sobering reminder of how easy it would be to travel down that path. Now here's my question for you. She then went on to quote Francis Collins, the head of the National Genome Research Institute who said in answer to that question, which she posed to him, he answered it this way. I think our best protection against that, because this is gonna be done by somebody, is to have it done by the best and the brightest and hopefully most well attuned to the risk of abuse. Well some might say we, our exhibition down the hall talks about the best and the brightest. So I'm curious about your thoughts about her comment, and particularly Mr. Collins's response.

SHERWIN NULAND: Well I think we're back to the age of biologic determinism. Aren't we? Scarcely a month passes by where some scientist at Stanford or Cal Tech or wherever it may be doesn't tell us that he has discovered the gene for bad behavior in the third grade, and he can even tell you where on the chromosome that gene is. And I find myself terrified by that kind of thinking. In the first place it's obviously very, very preliminary, and nowadays we have extraordinarily rapid communication. Telephone lines, emails, reporters call you in your laboratory, and it's very flattering. Many people here have probably been called by a reporter. You know what it's like. You just really want to spill the beans and say great things. And then you look at the paper the next day and see if they quoted you correctly. Scientists aren't different than anybody else. We are finding things in newspapers that shouldn't be there for two or three years because there isn't enough research done. One of the great problems, there are some real scientists in this audience tonight and I think they'll agree with me that one of the great problems with medical science is that if you wait five years it turns out to be on the other side of the fence, especially in medicine. When you're as ancient as I am you have lived through these pendulum swings back and forth. Most of the lay public is not trained scientifically, has never done bench research and doesn't understand that when a scientist tells you he has found the gene for tongue tiedness, he may not be right. So the world is beginning to be soaked up in this whole notion again. As I say if biologic, specifically genetic determinism, and we are almost, we haven't quite gotten back to Social Darwinism yet, but there's enormous danger in this kind of thing as any gay man who has heard about the gay gene will tell you. We have no idea if any of these formulations are correct or incorrect, but they harken into something within us that likes to think that we are molded in a particular way, and this is the way we are. We, many of us of course believe in free will. We talk about free will, but there's something very satisfying in the minds of many people in believing that things are determined. And this is an enormous danger and it gets extrapolated to notions of genetic engineering and what we can do with genetic engineering. We used to talk about improving the breed. Well now we have this wonderful word enhancement in which we are not talking about improving the breed but improving individuals. And there are numerous books and numerous people who call themselves futurists, some of them who are very highly qualified scientifically, who talk about what they call meta-man, the man of the future, where you can order up the color of your child's eyes, and your child's nose and if he'll be tall enough to play basketball for Duke, and also not just your child, but they're gonna convert the very germ plasm, the very heredity of your line so that this will persist. Now these people are very serious. And they're very high minded. They, they are not in their own minds dangerous. But doesn't this smell the same way as that?

SARA BLOOMFIELD: So, and let me ask you to ask the staff, we'll come through the aisles now to pick up your cards if you pass them to the end. But let me ask you Dr. Nuland about that very question, so how do we as a society protect ourselves from being, I don't want to be glib as, as The New York Times article said we'll be like Nazis, but is it just a matter of having free speech and debate and programs like tonight. I mean as average citizens it's hard for us to understand these issues. You said it yourself. And do even the, how do we gauge this public debate that's going on today around us all the time. What do we do to protect ourselves from our impulses and from all these advancements, in quotes?

SHERWIN NULAND: Well, Sara, one of the bad heritages of the late 60.s, I think it's worst heritage, is the cult of Narcissism. I don't know of a time in history when as individuals and as societies we have been more self-centered. We're, not only self-centered but we're foolish about our self-centeredness. We don't think at all of the implications that some of the new information will have if it is put into applications. I make the analogy in our society - Do you remember years ago when a kid was really smart they would skip him a grade? Probably a whole bunch of people in this room. The old people have been skipped. So you find yourself in fourth grade instead of third grade and you're not mature enough to be in fourth grade. The University of Chicago had this wonderful system, if you got to be fourteen you're smart enough, they'd put you in college and I have met a few of the results of that. Well now they do it just the opposite. Now, f you're really smart and you're not mature enough to be in third grade they keep you back no mater how smart you are. And we've been doing this for about a generation, and the results of that are much better. I think of our society as being just too smart. And too immature in its smartness. We are soaked with the brilliance of science. We are soaked with more scientists than have ever existed in the history of the world, producing extraordinary amounts of data, information, that we can't deal with. I think we ought to leave ourselves back. I, I think that we have finally come to a time in the history in science and the history of the world where we can no longer leave the applications of the discoveries to the scientists themselves. And sometimes I'm even wondering, I'm looking out at a couple of very serious minded people in this audience, and I'm even wondering if we should, not that everybody isn't serious minded - I'm even wondering if we should try perhaps to influence the direction in which some kinds of basic research are done. We're doing it with human cloning. Nobody seems to want human cloning and we're getting in the way of research of human cloning. I think we need a kind of a moratorium. I think we need to sit back. There's a, in the Hippocrates corpus, in this series of eighty Hippocratic books there's one called Precepts. And in the book of Precepts, which is really instructions for how to bring up young men in medicine, teach them how to be doctors, it points out the leavening value and the moral value of time. Sit back and watch it. Look at it. You don't have to use it just because you have it. I think we've come to that. It's the anathema to any scientist. It's an anathema to the way the scientific enterprise has always worked, but then again the scientific enterprise has finally gotten us into areas that it's never brought us to before. It's bringing us to the verge of meta-man. It's bringing us to the verge of designer man. It's bringing us to the verge of playing around with our germ plasm and our heredity with complications and implications that no one has yet dreamed of because they're unimaginable. You know what I was doing last week, I flew over to Cambridge and I spent two solid days sitting across a pub table drinking beer with a scientist from Cambridge who was convinced that he can make us live for thousands of years. Thousands. Five, ten, fifteen. You decide when you want to die and you die. And if, if you follow the science, all of the science makes perfect sense. We can't do it yet because we don't know enough about, well stem cell engineering is involved in it, and other things involved and we can't do it yet. But it never occurs to this fellow that this is really nuts. So I think we're too brilliant for our own good. I think this is the time for the thinking and the moratorium. And this is the time to be self aware of our extraordinary Narcissism.

SARA BLOOMFIELD: But where, this is wonderful and it seems very idealistic to me, I mean the likelihood of a moratorium...

SHERWIN NULAND: and quite impractical.

SARA BLOOMFIELD: Yes, yes. So bringing you back to planet earth and reality, one of the things that occurs to me as you say this is what are the institutions in society that help us frame these debates, think about these issues? This Museum is devoted to talking about the failure of institutions. But I think about medicine and science now. We have a free press, that, that brings us all these issues. Somewhat maybe confusing us more as you've implied, but certainly making a big public debate about them. The government is involved as we know. Religious bodies are involved. I mean how, is there a dynamic of all these institutions working together that might slow down or refine the debate? It doesn't seem like it's happening or possible to me.

SHERWIN NULAND: Well one of the problems right now of course is that the people who want to slow science down are the ultra-conservatives in our society who don't know anything about science. And this is always the danger, that if you don't put the brakes on something yourself, the brakes will be put on by people who have no conception of what they're doing, or the implications of what they're doing. The mere fact, some years ago I heard a talk by Aba Eben and he said that he would be willing to take questions. And at the end of it someone asked him a question of the magnitude of the one you've just asked me, and the magnitude of difficulty of the one you've just asked me. He said well I agreed to take questions, I didn't say I agreed to answer questions. I, I don't know. I think it begins with awareness. I think it begins with awareness of the kinds of things that we're talking about now. I think it begins with awareness of the sorts of things that you provide for us in your exhibit. I think it begins with school children. I think it begins with teachers. I think it begins with clergy. I think it begins with the legal profession. But mostly I think it begins with trying to turn our society back to a thinking society, to a non-accelerating society that sits down on a stool and promptly runs off in three directions at once. This is what we're doing. We're just moving too fast. And we are not yet morally or socially equipped to move as fast as the acceleration is taking us.

SARA BLOOMFIELD: You obviously won't be running for President. Now we have a few, some questions from the audience, and we have a lot of them here. So I'm not sure we're going to get to all of them tonight. But let me share with you a few. I recall within the last decade that there has been some controversy about the use of the results of the Nazi doctor experiments, particularly those involving hypothermia. These are experiments that have yielded valuable information even though they should not ethically have been done. What are your thoughts on this controversy?

SHERWIN NULAND: Well I'd like to focus on a part of that question and it's a very pertinent question. I'd like to focus on a part of that question that I haven't seen addressed. As I've watched scientists, and like every physician who trained I spent several years in a laboratory getting really close to basic scientists. As I watched them I've recognized what everybody probably knows theoretically but not many people know practically, that in order to do good science you have to be the most honest person in the world. Everything must be as detached as you possibly can be, recognizing that there's no such thing as detachment. So because there's no such thing as real detachment or real objectivity, one must be as objective and detached as one consciously can be to make up for what you're missing. What is involved in this is a kind of ethical principia. The way you used human subjects, the observations you make on human subjects and the way you interpret those observations. It seems to me that experiments done the way the Nazis did them, were not done in this way and therefore all of the talk about how much valuable information is available form them is just so much talk. That if those studies were looked at very carefully you would find that the observations, the results, the conclusions, are so tinged by bias and by, by experimental protocols that are poorly designed that they would be useless. So it isn't just on moral grounds, but my thought is that immoral research results in erroneous results too.

SARA BLOOMFIELD: Another specific, very, more technical question. Did early 20th Century German medical scientists have the idea of case versus control studies, and was there any awareness of researcher bias in the results?

SHERWIN NULAND: Well you're using mid-20th Century terms. Sure there have been controls in science ever since 1775 when Robert Lynn [ph] decided he wanted to cure scurvy so he took a bunch of seamen and he gave some of them, oh I don't know what it was, garlic juice, and some of them water, and some of them lemons and limes, and he found out that the ones with the lemons and limes did better. There have been, always been loose controls. But I don't think that until we get into the post World War II period that we have the kind of stringent and rigid controls that we have today. The double blind study for example is a, really a new thing. It has come up within my time in medicine.

SARA BLOOMFIELD: This question is, and I want to add something of my own to it, it says doctors as a profession were well represented as Nazi Party members,. What is it in Nazi ideology that held such a high attraction for doctors? And I actually want to add to that question a little bit about motivation. Motivation is a question we talk about a lot at the Museum. And surprising research has shown that many of the killers were not necessarily motivated by a vicious antisemitic ideology. Sometimes it was a very mundane reason like career advancement, peer approval, greed. And so I'm curious about what you're thinking about doctors and Nazis and human motivation...

SHERWIN NULAND: Now this is a very important historical question actually. The fact is, and I know many people here are aware of this, that there was no other profession that was so much wrapped into Nazi ideology as the medical profession. Not only individual doctors but the medical societies from the very beginning supported the Nazi movement officially. As many here probably know, the early work on euthanasia, if you want to call it that, on the execution of disabled people was really run by physicians. The actions that began in 1939 that came out of that little house in the Tiergartenstrasse was largely run by doctors. The early murders of disabled children could not have been carried out without the help of the pediatricians who brought them or arranged for them to go to the central areas. I think it begins with the long history of antisemitism in German speaking universities. It was always a major problem. I have a surgical hero and his name is Theodore Billroth. He's born in northern, actually in Rugen, which is an island north of Germany in the Baltic. And he ended his career, spent most of his career in Vienna as a professor of surgery, and he was the leading surgeon of Europe actually from about 1876 to 1893 when he died. And he wrote a book called Medical Education in the German universities and in it there is a diatribe directed against Jewish students who have come from Eastern Europe largely as a result of the Haskala, the Jewish Enlightenment that brought so many people into the Austro-Hungarian Empire, into Germany and Poland and so forth. And he says that they're totally ill-equipped to become doctors because they're so different from the Germans. And Bilrothen would have been shocked if you called him antisemite. He had Jewish trainees. He was a philosopher among other things and actually supported Jews in many ways and yet he was blind to academic antisemitism. And this tradition of people going to universities being steeped in the antisemitic tradition of the dueling societies for example, the beer halls, Jews were not part of this. It was part of the uniqueness, the falk, the uniqueness. So we've got that, and all doctors have gone through that careerism that you mention is a very important factor. Because something like twenty four percent of the physicians in Berlin, for example, in the early 30s were Jewish. It always happens that there's competition among physicians. In spite of the academic antisemitism some very significant posts in hospitals, and especially in science, medical science, were held by Jewish physicians. And so there was this tremendous opportunism, this pragmatic seeking out of those positions. So those were really the major factors, I think. It wasn't necessarily this virulent antisemitism that seized so many people. It was the fact that here was an opportunity and you grow up with the idea that these Jews don't belong in our universities anyway, and look what they've taken from this. I deserve this. I should have that. And it became formalized. It became formalized in the medical societies where Jews were just thrown out in the early 30s.

SARA BLOOMFIELD: Here's a question. Is genetic engineering different from eugenic? And I would just add to that, the Nazis didn't understand we have DNA now. We understand that as how we think about that. Does the discovery of DNA make something like eugenics or Nazi medicine impossible or more possible? I mean...

SHERWIN NULAND: Well - I think it puts a gloss over the possibility of the notion of improving the breed that makes it palatable. We used to, as I said a moment ago want to improve the breed. Now we want to improve ourselves as individuals. We are not enough aware of how close this slope is. This, we always use the term slippery slope. The difference between genetic engineering and the uses to which it may be put, there is always that danger and this is one of the many reasons that I say we better slow down folks. And we better start thinking about the implications of what we're doing and why we want to proceed in certain directions. I have thought, never, ever would the notion of eugenics come back. But now that I read some of the literature about genetic engineering and its possibilities I begin wondering.

SARA BLOOMFIELD: Ooh, I just got some very interesting. There's a lot of great questions. We're not gonna get to them all. Here's an interesting one. The Nazis sold some of their medical ideas based on saving money for society. Are we as Americans running ethical risks based on the economies of medicine and healthcare?

SHERWIN NULAND: Well, you're damned if you do, damned if you don't. We have finite resources. And one has to make choices. And sometimes those choices are wrong . That's the only way I know how to answer that question. One of the nice things about ethical questions in general is you never know, you never have the right answer. The trick is to find the answer that's least wrong.

SARA BLOOMFIELD: Here's a question that I'm also very interested in about Tay-Sachs disease, which is a disease that I think is prevalent in Ashkenazi Jews I believe. I think mostly eradicated now. But, so the question is, Tay Sachs disease and couples with recessive genes for the disease are urged not to marry or have children. Is this a good use of eugenics in humans?

SHERWIN NULAND: Well, we're using that word when actually what we're talking about is therapy and preventive medicine. And you can't take a word and smear every attempt to genetically influence the next generation. You can't smear those attempts with that word. The word's gotten a bad name we oughtta throw the word away. We ought not to think about it at all. Just take it out of our vocabulary. We ought to talk about what's therapeutic and what has to do with enhancement. Medicine has always had as its goal the treatment of disease and the betterment of individuals who are being crippled by disease. In the last twenty years medicine has discovered that one of its goals is to make people better than they are. Well I don't necessarily agree that that's a valid goal. The way couples can potentially have a child with Tay-Sachs are counseled is classical preventive medicine. You want to call it eugenics, you can call it eugenics. You can call it Santa Claus if you want, but essentially what we're talking about is preventing disease and everybody knows that the reason that we used to die at forty nine in 1900 and we now die at seventy eight or whatever it is, has far more to do with preventive medicine than it has to do with any treatment, except anti-biotics that we give anybody.

SARA BLOOMFIELD: Okay. A couple of big questions to close with, and you've alluded to some of this, but this is a very pointed question and we know we'd have some tonight. You mentioned that in Nazi Germany scientists were revered and thus their inhumane experiments were embraced without question. Would it be better for government to place ethical limits, ethical limits on research such as the current administration's stance on stem cells. Who should be the ultimate arbiter of medical ethics for society?

SHERWIN NULAND: In the Holocaust Museum I'm allowed to say, oy vey . You know, we talk about this, and I do it all the time, this disembodied thing we call society. When you use the word government I really get scared. And I get scared for a lot of reasons. I get scared because government intervenes, and so they decide they're gonna have a bioethics committee to advise the President. Well there are bioethics committees, and there are bioethics committees. One of the speakers on this in this series is one of the people that I admire most in the world, he's the Chair of the President's bioethics council. He's also the most conservative bio-ethicist, ethicist in the United States. Hand-picked because he is the most conservative bio-ethicist in the United States. Well, one would think ideally a benevolent government wouldn't do such a thing. Ideally, a benevolent government should have in its own interest what is best for its people. But what has happened when you use the word government is that obviously government involvement is politically motivated. Answers to a specific constituency. So I don't know where this answer is going to come from. Maybe we should go back to ancient Greece where all the citizens got together and they talked about things sitting in a stadium and the whole polis made its decision. Now we can't do that any more. I don't know the answer. We don't have any answer. We don't know how to influence the scientist, for example, to slow down for a little bit. The bio-ethicists have helped. They've changed the face of medicine. Certainly there are research committees. Human investigation committees. They probably don't go far enough. Maybe there should be an entire bio-ethics community that tries to get together, scientists obviously would be involved in this, to help guide decisions about the future of research and its applications. There are not that kinds of, kind of bio-ethics committee. The ones that I know of that deal with science have to do with things like human investigation. They have to do with allowing or disallowing certain kinds of research. They don't have to do with setting major philosophical directions for science as the medical bio-ethicists have done. Maybe that's what we need, an entirely new kind of person. An entirely new kind of group composed of representatives from the community just as the bio-medical ethicists do. Lawyers, government representatives, ministers, the entire cross-section of society. Just do something that's never been done before.

SARA BLOOMFIELD: And then figure out a way to translate it for the rest of us.

SHERWIN NULAND: Well, that's our fault. Yeah. Yeah. We talk in gibberish, don't we.

SARA BLOOMFIELD: Yeah. It is hard to understand these issues. And I've tried to read a lot about them since you came here and we opened this exhibit. And I'm, just know that I understand less than I thought I knew.

SHERWIN NULAND: You're not helped by the Science section on Tuesday in The New York Times. I find some of that stuff impenetrable. There's a fellow named Nicholas Wade. Wade is right, I can't wade through any of his stuff. There are some very gifted people. Natalie Angier is among them, but not, not many.

SARA BLOOMFIELD: I wish you had said that after The New York Times did the review of this exhibition. That is happening shortly. So - I want to close tonight with a question that I actually had on my mind as did a member of our audience. This person wrote, what advice would you give to young physicians based on the lesson of this exhibit. And my question is, what advice do you not only give for young physicians, but also what advice do you give for us as citizens facing these issues as we move forward?

SHERWIN NULAND: I'm gonna start with something that may not seem to apply to your question. When I wrote that book, How We Die, about ten years ago, I talked a lot on college campuses, medical school campuses, and one of the very earliest talks was at the University of Michigan, and I was talking about the need for certain kinds of behavior near the time of death, and compassion, and most importantly the need not to let us as we train you young doctors, leech the humanity out of you, as we do in our training programs. You know, our training programs I was saying at dinner tonight, are like Marine boot camp, and we get these idealistic kids and we clone them into being like us. They end up being just as tough as nails and not particularly interested in their old ideals. And a young man got up in the back and he said I'm a second year medical student, how am I supposed to resist this process? And I had never thought of that. All I did was pose the question. And something burst out of me that I always tell my children, which is, remember who you are. Remember what brought you to this profession in the first place. When you get a vacation, don't go to some small island in the Caribbean and chase boys or chase girls, whatever you want to chase, go home, talk to your mom, talk to your dad, if you're a person of faith talk to your minister. Get back into the sense of idealism. I would say the same thing to scientists. But I would say something more. I would talk about the self-awareness that seems to come out of seeing this exhibit, for example, that I think a lot of people who have come here have discovered themselves far more self-aware than they thought they were. We accelerate through training programs and research training programs and clinical medicine. And we take away their ability to speculate about themselves, to speculate about their own motives. To be perceptive about why they are doing things, why their colleagues are doing things, and once again that word, the implications of the kinds of research and clinical work that they just accept as this is the way it's done. I think we need a new paradigm of researcher and clinician. And the paradigm is one who simply follows the Golden Rule, which I will state, I think it was Rabbi Tarfun [ph] who put it this way, that which is hateful unto thyself do not to others. Which is a little different than the way the Golden Rule is expressed. You've got to, as a scientist, think about the human implications of the application of your work, and we've got to inculcate into young people what that's all about. Whether we want to call it ethics. And what's the difference between ethics and morality? Well morality is what you learned at your mother's knee. Ethics is a negotiated thing. Groups of people get together and they say this is ethical, that is ethical, this is the way we will behave. This is the way our group will behave. We've got to remember that as we professionalize people, we help them forget the basic morality that brought them to this place. And we make up for it by creating this thing we call ethics, this group of laws. The reason we have the bioethics movement was because we realized how unethical we were being, in many ways how immoral we were being. We wouldn't have needed the movement otherwise. Well the next step then, instead of group ethics becomes individual ethics, which is almost equal to morality, which we all start out with, and we must be aware of how the process of professionalization tends to take that away from us, so that we become just like everybody else.

SARA BLOOMFIELD: Well, that's an amazing note to end on. I think we all wish, that all doctors and scientists would have the humanism, empathy, and self-awareness that you have. Dr. Nuland has graciously agreed to stay and sign books if you'd like. I'm sure he'll answer additional questions. But I want to thank you very much on behalf of the Museum. I want to thank our audience. And remind you that if you fill out your evaluation form I'll give you four passes to the permanent exhibition. So please do so. Thank you for coming.

[applause]

Sara Bloomfield, Director of the US Holocaust Memorial Museum, interviewed Sherwin B. Nuland on October 28, 2004.

Sherwin B. Nuland is the best-selling author of How We Die and Lost in America: A Journey with My Father and Clinical Professor of Surgery at Yale University.