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Annals of Internal Medicine
EDITORIALS
Exactly 50 years ago, the world learned of the moral depravity of the 20 Nazi physicians who were tried and convicted in Nuremberg for the part they played in the brutal human experiments at Auschwitz (1-4). Ethicists have since expounded on the moral lessons to be learned from the Nuremberg Trials. So obvious these moral lessons seem now, and so gross the malfeasance, that it seems redundant to revisit them. Certainly we do not need to study such gross moral pathology that could never happen again.
That is a dangerous conclusion. Moral lessons are quickly forgotten. Medical ethics is more fragile than we think. Moral reasoning based on defective premises tends to recur in new settings. Not all of the Nazi physicians were mentally deranged—they believed they were doing the right thing. If we are to avoid even attenuated errors of the same kind, we are obliged to examine a few of their errors even now.
In light of the enormity of the crimes of the Nazi doctors, it seems easy to acquiesce to the 10 basic principles promulgated by the Tribunal to keep human experimentation within moral, legal, and ethical boundaries (5). But acquiescence does not equate with comprehension. The first principle of the Nuremberg Code is this: "The voluntary consent of the human subject is absolutely essential." However, this principle was compromised almost immediately after the Nuremberg trials. The Helsinki Declaration, which superseded the Nuremberg Trials, weakened the provision by placing too much emphasis on the advancement of science and not enough on the integrity of the subject. Katz faults the U.S. Department of Health and Human Services Rules and Regulations for lack of a similar failure fully to protect human research subjects (6).
Even more distressing are the instances of unethical research behavior that have occurred since the revelations of the Nuremberg Trials and wide acceptance of the 10 principles they promulgated. Only a few such instances need to be listed here: the Tuskegee Syphilis Study, the Willowbrook Hepatitis Study, U.S. radiation experiments, the Jewish Chronic Disease Hospital Study and the lysergic acid study supported by the Central Intelligence Agency, and others that have not been brought to light (7-10).
Clearly, the major lesson of the Nuremberg Trials has not been learned. Ethicists have the painful responsibility of reaffirming that lesson even in the United States. Failure to respect the absoluteness of the requirement for truly informed consent is a major factor behind current moves to strengthen regulatory mechanisms regarding research involving humans.
The integrity of medical ethics is important not because it protects the physicians' prerogatives but because it is a bulwark against the use of medical knowledge for purposes other than for the good of the sick. The German physicians indicted at Nuremberg had been taught by some of the world's best historians of medicine and ethics (11). They could not plead ignorance of ethics and, in fact, made constant allusions to medical ethics and the Hippocratic tradition in their testimony (12). They even convinced themselves that their heinous acts were consistent with those principles.
What the Nazi doctors illustrate is that ethical teaching has to be sustained by the ethical values of the larger community. In Germany, this support system was weakened well before the Holocaust and the experiments at Auschwitz. German academics, especially psychiatrists, were leaders in theories of racial superiority, social Darwinism, and the genetic transmissibility of mental illness before Hitler came to power (13). They even urged the Hitler regime to adopt these nefarious ideals.
Clearly, protection of the integrity of medical ethics is important for all of society. If medicine becomes, as Nazi medicine did, the handmaiden of economics, politics, or any force other than one that promotes the good of the patient, it loses its soul and becomes an instrument that justifies oppression and the violation of human rights.
Subversion becomes a greater danger whenever medicine comes too close to the power of the state (14). The German medical profession eagerly supported Hitler's Third Reich and made itself the Reich's willing agent. Hitler, like his counterparts in Stalinist Russia and Imperial Japan, recruited medicine at the very beginning of his regime. Physicians should have refused. Even Hitler would probably not have prevailed against a united profession exerting its collective moral power. But the caduceus joined the swastika in a lethal symbiosis that cost millions of lives and forever branded German medicine as a traitor to every tradition that ever made medicine a beneficent rather than a maleficent enterprise.
This lesson becomes even more important as medicine becomes increasingly bureaucratized, institutionalized, and dependent on government and politics for its support. Medical power is too great to be left unregulated, but it is also too great to be enslaved by government, however benign the government's intentions might be.
The Nazi doctors were rational beings. To be sure, they acted within psychological and sociohistorical contexts (15-17). Ultimately, they justified their actions by what they considered to be moral reasons that have received insufficient attention (18). During the testimony, the defendants and their lawyers repeatedly advanced a few moral premises with a familiar ring: They were not killing by their own authority but obeying the laws of the state, which can determine the method of death (12). To resist would have been treasonous; ethics must be subordinate to the demands of war. Consent from those condemned to death was unnecessary. The death of a few prisoners would save many German lives; medical ethics could be set aside by law.
We see here the initial premise s that law takes precedence over ethics, that the good of the many is more important than the good of the few, that national emergencies supersede ethics, and that some persons (prisoners in this case) can lose their claim to humanity. The lesson here is that moral premises must be valid if morally valid conclusions are to be drawn. A morally repulsive conclusion stems from a morally inadmissible premise.
Perhaps, above all, we must learn that some things should never be done. We will know when to say "no" if we extrapolate our moral premises to their logical conclusions. This the Nazi doctors did not do.
Clearly, there are moral lessons still to be learned from the Nuremberg Trials and there always will be. These lessons must be repeatedly relearned. They are pertinent to other contexts and other issues in today's intensive bioethics debates. The Nuremberg Trials and the Holocaust are metaphors for absolute moral evil, the lessons of which are as old as ethics itself (19). This we must never forget if we wish to be certain that the moral disasters revealed at Nuremberg never occur again.
Edmund D. Pellegrino, MD
Georgetown University Medical Center
Washington, DC 20007
Current Author Address: Edmund D. Pellegrino, MD, Center for Clinical Bioethics, Georgetown University Medical Center, 400 Reservoir Road, NW, Washington, DC 20007.
Ann Intern Med. 1997;127:307-308. Annals of Internal Medicine is published twice monthly and copyrighted © 1997 by the American College of Physicians.
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