The Holocaust as end stage disease: medical education as a moral imperative

Hedy S. Wald, PhD, Sheldon Rubenfeld, MD, Joseph J. Fins, MD, MACP

(Spring 2016)

“Medicine was used for villainous ends during the Holocaust. The Holocaust was an enormous trauma inflicted on human dignity and the human person; medicine was implicated in crimes against humanity.” His Eminence Daniel Cardinal DiNardo, Archbishop of Galveston-Houston.a

Introduction

While few would contest the importance of educating health care professionals about the Holocaust within the complicity of the medical profession in such crimes against humanity, the staggering nature of the event easily leads to trainees’ dismissing the possibility that they could ever become involved in such a morally bankrupt enterprise. Much like the healthy house officer, fresh from a morning run, who cares for a patient with advanced heart failure and cannot imagine having a similar fate, young trainees might consider the Holocaust an improbable and distant evil unrelated to their current circumstances. But like end stage heart disease, the Holocaust as a societal end stage disease had precipitants, early warning signs, within an historical perspective. If our trainees were to consider the Holocaust as “End Stage Disease”, the horrific culmination of incremental injustices, they might be able to better grasp how such events could occur and engage in preventive strategies to maintain medical professionalism and avoid transgressions that marked Nazi medicine. This perspective utilizes the end stage disease metaphor to deconstruct the pathogenesis of the Holocaust with serious contemplation of its relevance for contemporary medical education and practice. It is only through this inductive process of diagnostic and normative reasoning that we can identify the pathogens that led to the Holocaust. Only then can we hope to immunize our learners and perhaps society from a tragic recurrence.

Cascade of “Small” Indignities

“As a lighthouse can mark a reef, medicine can and must use the light from the flames of hell, the lessons learned from the Nazi doctors, as a warning beacon.” Wynia and Wells1

Within a pervasive breakdown of medical professional ethics, the Nazi medical establishment transformed the physician-patient relationship into a new relationship – the state becoming the physician and the German people (volk) the “patient” – with depersonalization eventuating in genocide.2 Our task, as medical educators, is to trace the progression of this malignant process in an accessible manner for our students: how presumed healers within mainstream medicine became killers. How the Holocaust, one of the greatest evils ever perpetrated on humankind, could not have occurred without the complicity of physicians, a community “sworn to serving and protecting life.”Like all end stage disease, the pathogenesis of the corruption of medical practice and societal disintegration began with “small” steps, a cascade of subtle indignities. For example, German Professor of Medicine Dr. Eugen Fischer’s 1908 relatively obscure research on intermarriage between German soldiers and native Hottentot women in Namibia advanced negative eugenic theories that infected German science and health policy and ultimately led to the development of the Nazi sterilization law and the Nuremberg laws prohibiting intermarriage with non-Aryans. Hitler cited a eugenics textbook by Baur, Fischer and Lenz (1921) to support his racist views.3 Fischer’s disciples included Dr. Otmar Freiherr von Verschuer, who trained Dr. Josef Mengele, the “Angel of Death” in Auschwitz.3 Similarly, the notion of “life unworthy of life” applied to the disabled in a 1920 book by Binding and Hoche, the latter a psychiatrist and professor, helped fuel the Holocaust’s central ideology of “racial hygiene.”Engaging these antecedents in the history of Nazi medicine and their devolution into the brutal experimentation and mass extermination of the Holocaust can inform medical education. This pedagogical exercise can foster awareness of, and illuminate our own potential “cascade of small indignities” relevant to the moral development of physicians.

Holocaust and Medicine Curricula

Almost every aspect of contemporary medical ethics is influenced by the history of physician involvement in the Holocaust.” Wynia et al4

Holocaust and medicine curricula provide raw material for recognizing such indignities and calibrating our moral compass5 within clinical and research practices. Contemplating the Holocaust as “end stage disease,” and “villainous” medicine as one of its most important pathogens, is a pedagogical strategy to help prevent transgressions big and small by cultivating an appreciation of the medical profession’s role in the history of the Holocaust.6 A medical student reflecting upon this curricula observed, “There was such extreme dehumanization of individuals during the Holocaust. It’s when the individuality of the person in front of you is lost that bad things can happen. For all the good we do, we have this dark history and need to be aware of it.”7Medicine and the Holocaust courses with longitudinal curricula, modules, and educational trips are well developed, applied practically, and evaluated systematically.7-11 Utilizing an interdisciplinary approach to learning these curricula robustly integrates the study of medical science and clinical practice with medical ethics and the medical humanities, addressing key Liaison Committee for Medical Education (LCME) objectives including the “need for self-awareness among medical students regarding any personal biases in their approach to health care delivery” and “instruction in medical ethics and human values” (ED 22,23).12 Implementing such curricula with collaborative, guided critical reflection13 can promote sustained ethical vigilance8 and enhance professional development by bridging theory and practice so that students reflect upon ethical challenges in everyday practice otherwise potentially overlooked. For example, are we depersonalizing the patient by emphasizing “population-based statistics”? Are we privileging “evidence-based medicine” at the exclusion of the patient’s narrative? Does knowledge gleaned from an electronic medical record objectify the patient and lead to depersonalization? While these “small” indignities are clearly not as dehumanizing as a number tattooed on one’s forearm, the history of medicine and the Holocaust can remind trainees to maintain respect for human dignity in the context of patient care and clinical research, and compel medical educators to attend to the character formation of the emerging physician and clinical investigator. Contextualizing the ethics of routine practice against the backdrop of medicine and the Holocaust strengthens trainees’ ethical diagnostic skills, protects patients from objectification and dehumanization, and prevents progression to moral decay or “end stage disease”. This mix of reflective practice and historical awareness contributes to the establishment of a virtuous professional self-identity, contributing to the learner’s sense of meaning and purpose, reciprocally fostering emotional and moral resiliency.14 Such pedagogical efforts uniquely align with the Carnegie Foundation’s call for medical education reform to develop habits of mind and heart to advance professional identity formation.15 Given that “there is no moral app,”16 grappling with medicine and the Holocaust curricula can help fine tune an inner “GPS” for “Guiding Professional Sensibility” within reflection-before-action 17 and reflection-on-being18 for the being, doing, and relating of a humanized physician. Recent LCME survey data of U.S. and Canadian medical schools (2013) revealed that specific attention to “arguably the most influential set of events in the history of professional ethics in medicine is required at only a fraction of U.S. and Canadian medical schools—and this despite a uniform requirement to teach ethics and professionalism.”4pg 700 Only 22 of 140 (16%) medical schools in the U.S. and Canada reported any required curricular elements on the roles of physicians in the Holocaust, and half of these reported teaching this material in a lecture format only.4 The pedagogic value of including guided reflection within medicine and the Holocaust curricula on topics such as potential for our own abuse of power, compassion, cultural humility, and acceptance of the “other,” has been described and formal, effective curricula in this domain are available.8,9,11,19,20 In general, “the formation of ethical codes and books is not enough until their implementation. Implementation means education.”20

Medical Education as a Moral Imperative

“Should there ever be a medical student who does not hear what the power of the white coat can do when that power is not tempered with truth?  Our obligation as physicians and educators is to teach the next generation of medical students about the Holocaust.” Fernandes10

As we prepare our learners for a profession with the potential to heal and also abuse power, we need to acknowledge the educational importance of the Holocaust. We propose a curriculum that uses that dark past to illustrate how the quotidian indignities of everyday practice can erode respect for personhood, which when lost, results in the complete objectification of the patient. This is not a parochial argument but a universal caution.Ultimately, this process begins with a difficult realization: the doctors perpetuating the Holocaust were much like us, academic physicians who were the best and the brightest of their day. Nazi physicians, idealistic in a perverse way, earnestly believed they were doing the right thing. How traditional Hippocratic virtues morphed into such unspeakable evil is an enduring question that informs medical education about the Holocaust and, more generally, medical professionalism. Teaching the emergence of the Holocaust as an end stage disease process is a preemptive educational approach to help trainees appreciate that even seemingly insignificant ethical omissions can compromise professional integrity. Historians have asserted that the Holocaust “has become a feature of many people’s identity in the 21st century.”19 Will this be true for the next generation of physicians? For the sake of our profession and society, the answer to this query must be a resounding yes.

No disclosures.

 

References
1. Wynia MK, Wells AL. Light from the Flames of Hell: Remembrance and Lessons of the Holocaust for Today’s Medical Profession. IMAJ. 2007; 9: 186-188.

2. Livingstone EH. German medical group: Apology for Nazi physicians’ actions, warning for future. JAMA. 2012; 308:657–658.

3.Rubenfeld S. Healing by Killing: Medicine in the Third Reich. Houston Med. 2003; 1(1): 24-33.

4. Wynia MK, Silvers WS, Lazarus, JA. How Do U.S. and Canadian Medical Schools Teach About the Role of Physicians in the Holocaust? Acad Med. 2015; 90(6): 699-700.

5. Swenson SL, Rothstein JA. Navigating the wards: teaching medical students to use their moral compasses. Acad Med. 1996; 71(6): 591-4.

6. Fins JJ. Teaching the Holocaust to Medical Students: A Reflection on Pedagogy and Medical Ethics. In: Rubenfeld S, Benedict S, eds. Human Subjects Research after the Holocaust. Cham, Switzerland: Springer; 2014: 269-282.

7. Duffy TP. Holocaust Studies Focus Discussion of Medical Ethics. Yale Medicine. http://yalemedicine.yale.edu/spring2012/people/students/127773/Accessed February 3, 2016.

8. Reis SP, Wald HS. Contemplating Medicine During the Third Reich: Scaffolding Professional Identity Formation for Medical Students. Acad Med. 2015; 90(6): 770-3.

9. Reis S, Wald HS. Medicine in the Third Reich: The new medical education agenda. In: Giardino AP, Giardino ER, eds. Medical Education: Global Perspectives, Challenges and Future Directions. New York, NY: Nova Science Publishers; 2013:261–288.

10. Fernandes, AK. What medical students can learn from the Holocaust. June 12, 2014. http://humanism-in-medicine.org/what-medical-students-can-learn-from-the-holocaust/ Accessed February 3, 2016.

11. Center for Medicine After the Holocaust. Content Modules. http://www.medicineaftertheholocaust.org/curriculum/content-modules/ Accessed February 4, 2016.

12. Liaison Committee on Medical Education. Functions and Structure of a Medical School – Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. https://www.lcme.org/publications/functions.pdfAccessed February 3, 2016.

13. Wald HS, Reis SP. Beyond the Margins:Reflective Writing and Development of Reflective Capacity in Medical Education. Journal Gen Intern Med. 2010; 25(7): 746-749.

14.Wald HS. Professional identity (trans)formation in medical education: reflection, relationship, resilience. Acad Med. 2015; 90(6): 701-6.

15. Irby DM, Cooke M, O’Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med. 2010; 85(2): 220-7.

16. There is no Moral Compass App. https://www.flickr.com/photos/university-of-san-francisco/6863380322/ Accessed February 4, 2016.

17. Greenwood, J.Reflective practice: a critique of the work of Argyris and Schön. J Adv Nursing. 1993; 18(8): 1183-1187.

18. Wald HS. Refining a definition of reflection for the being as well as doing the work of a physician. Med Teach. 2015 Apr 21: 1-4 [Epub ahead of print].

19. Reis SP, Wald HS. Learning from the past: medicine and the Holocaust. Lancet.2009;374(9684): 110-111.20.

20. Chelouche T, Brahmer G. Casebook on Bioethics and the Holocaust. Haifa, Israel: UNESCO Chair in Bioethics; 2013.

 

Acknowledgements: We thank His Eminence Daniel Cardinal DiNardo for permission to quote his remarks at the First International Scholars Workshop on Medicine After the Holocaust, Houston, Texas, March 2-4, 2015, which was supported by the Houston Methodist Research Institute and by grants from The Claims Conference and The International Holocaust Remembrance Alliance to the Center for Medicine after the Holocaust.

 

Hedy S. Wald, PhD is Clinical Associate Professor of Family Medicine at the Warren Alpert Medical School of Brown University where she directs the reflective writing curriculum in the Family Medicine Clerkship. She conducts interprofessional faculty development workshops and faculty retreats internationally on using interactive reflective writing to foster reflective capacity supporting professional identity formation in health care professions education as well as on promoting faculty resiliency and vitality.

Sheldon Rubenfeld, M.D. is Clinical Professor of Medicine at Baylor College of Medicine and, after 36 years in the private practice of endocrinology and internal medicine, is the Executive Director of the Center for Medicine after the Holocaust. His latest book is Human Subjects Research after the Holocaust published by Springer.

Joseph J. Fins, M.D., M.A.C.P. is the E. William Davis, Jr. M.D. Professor of Medical Ethics, Professor of Medicine and Chief of the Division of Medical Ethics at Weill Cornell Medical College and Senior Research Scholar and Solomon Center Distinguished Scholar in Medicine, Bioethics and the Law at Yale Law School. His latest book is Rights Come to Mind: Brain Injury, Ethics and the Struggle for Consciousness published by Cambridge University Press.

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