German medicine between 1933 and 1945 saw a colossal breach of the ethics of patient care: doctors initiated and implemented an estimated 350 000 coerced sterilisations, the killing of some 260 000 people with mental illness or disabilities, and an estimated 25 000 human experiments that led to the deaths of more than 2000 research subjects. Doctors selected individuals for slave labour or death at Auschwitz, and took part in the development and use of methods to kill people, such as by poison gas, fatal injections, starvation diets, and electrocution. Tens of thousands of bodies of the executed were delivered to German medical institutes for teaching and research, and in some departments bodies of Nazi victims were still used for these purposes until at least 1990, and in some cases for longer.
It has been 33 years since the German Medical Association last held its annual assembly in Nuremberg—in a city that is associated with both National Socialism and Nazi medicine. It was in this city that the Nuremberg Racial Laws were proclaimed in 1935, that the Nazi Party rallies were held, and that the Nuremberg Doctors' Trial was held in 1946—47 that laid bare physicians' crimes against humanity.
Although the process of coming to terms with the past has not always been easy, the city of Nuremberg has found various ways of engaging with its Nazi past. Since 1996, the Nuremberg Group of the International Physicians for the Prevention of Nuclear War (IPPNW) has organised international congresses on “Medicine and Conscience” to explore questions on the history and ethics of medicine. Together with three medical historians, the IPPNW group drafted the petition endorsed by 42 doctors and historians. The petition was the verbatim text for the Nuremberg Declaration 2012 which the German Medical Association's assembly passed (appendix).
The situation in Germany was long one of denial and disassociation from medical crimes. In the late 1940s, the West German Medical Association (the forerunner of the German Medical Association) shifted responsibility for Nazi medicine to a small group of 350 criminal doctors, while contending that mainstream medicine had proceeded conscientiously and ethically in its duty to patients. The 2012 apology marks a crucial change in the recognition of abuses that involved the profession and its organisations. What has to be recognised is that coercive medical measures under National Socialism were not initiated by fanatics or pseudo-scientists but were implemented by scientifically informed physicians as part of efforts to reform systems of health care and public health, and to develop medical research on an experimental basis. Under National Socialism, the medical profession expanded its power, influence, and status. What is so disturbing is that it has taken the German medical profession so long to accept the evidence of this past.
Evidence was documented in the immediate aftermath of the war by the physician Alexander Mitscherlich, with his assistant Fred Mielke, and by the psychiatrist Alice Platen-Hallermund, and then later by a mounting body of work by medical historians that reconstructed the institutions and systems of Nazi medicine and identified victims. In addition to this evidence, the German Medical Association was confronted by the dignified statement of the medical historian Richard Toellner at its Berlin meeting in 1989, when he outlined the position of institutionalised abuse by the mainstream of the profession. Yet the profession remained headstrong in ignoring this evidence.
To ask why the profession sought to bury the evidence (literally when it came to Nazi victims' body parts) is to identify factors that have had a powerful influence on German medicine. What has been at stake is professional honour and authority. Accepting the evidence of misconduct was deemed to dishonour the medical profession collectively, as well as to denigrate senior figures within the profession. The presentation of evidence was deemed a breach of collegiality. Thus when a junior doctor, Hartmut Hanauske-Abel, published work in The Lancet in 1986 on medicine and National Socialism, his evidence of a link to atomic weapons research was not empirically questioned but he was denounced for dishonouring the German medical profession. Effectively, professional misconduct on a colossal scale was being covered up. This protective mechanism meant senior figures from the wartime generation continued in office during the 1950s and 1960s. If junior doctors ventured into the institute or hospital cellars to examine past records, they did so at considerable risk to their careers. German laws on data protection and privacy backed up such suppression. A situation thus arose in which the professional leadership enforced silence on issues of medical atrocities, whilst a dissident grassroots movement campaigned to make evidence accessible. In the early 1990s, the German Medical Association refused to fund a publication of the Nuremberg Doctors' Trial documents. In response, psychiatrist Klaus Dörner appealed directly to health professionals and hundreds of individual physicians gave personal donations, which made the publication of a superb teaching resource possible in 1999. More recently, an instance of professional denial was evident in the case of Hans-Joachim Sewering, a past president of the German Medical Association who died in 2010. Sewering had referred children to a euthanasia killing centre during the Nazi era but evidence in this regard was only reluctantly disclosed in the German Medical Association's journal Deutsches Ärzteblatt.
Time and time again, the idea of the profession taking responsibility for past malpractice was met by denial and disassociation. The German Medical Association seems to have fought a rearguard action for some 65 years so that the older generation and their acolytes could pass away with honour. This can be seen in a bibliographical guide sponsored in 2011 by the German Medical Association on medicine and National Socialism. The guide omits not only important studies on Nazi medicine, such as work by Alice Platen-Hallermund (part of the German medical delegation at the Nuremberg Doctors' Trial) and Werner Leibbrand (a psychiatrist who testified at the Nuremberg Doctors' Trial), but also the evidence-based research findings of critically engaged physicians since the 1980s.
Effectively, the denial of medical crimes under National Socialism represented an endorsement of a medical science bereft of a patient-oriented and consensual ethics. There was a legacy of the authoritarian pursuit of scientised medicine that could not be questioned from an ethical or evidential basis. The apology resolving this conflict comes late—but not too late in terms of those who were directly affected, who include a handful of expelled doctors, individuals who were sterilised, and close family of victims of “euthanasia”. Given that children became a target group of the human experiments as the war progressed, victims still survive.
Focusing on the victims: an exhibition about the withdrawal of medical licences from Jewish physicians in 1938 that has been shown in 25 German cities, in May, 2012, it was shown in Nuremberg for the second time
What is also clear is that in terms of care for victims of these atrocities, the medical systems have shown appalling neglect. Victims of sterilisation demanded refertilisation and hormone therapy after the war, measures that were provided only when a victim could afford these. Compulsory sterilisation was officially deemed not to have been a Nazi measure; this view began to change in the 1980s but an unreserved apology from the German state remains outstanding. Moreover, the medical profession has generally failed to provide recognition and support for victims.
What is chilling is that the politics of denial meant that authoritarian and inhumane structures in medicine could persist in Germany. The apology should be taken as a constructive starting point in ethical disclosure. The German Medical Association should be transparent with regard to its own conduct and deliberations both to its membership and a wider public. An apology should not mean drawing a line under the past. What is necessary is a constructive process of active engagement with past legacies. Such a process can only be salutary for an ethically and evidence-based medicine, not only in Germany but also for best practice in medicine more generally.