Book Review

When Medicine Went Mad: Bioethics and the Holocaust

Medicine Betrayed: The Participation of Doctors in Human Rights Abuses

N Engl J Med 1993; 328:1430-1431May 13, 1993

Article

When Medicine Went Mad: Bioethics and the Holocaust
Edited by Arthur L. Caplan. 359 pp. Totowa, N.J., Humana Press, 1992. $22.50. ISBN: 0-89603-235-3

Medicine Betrayed: The Participation of Doctors in Human Rights Abuses
By a working party of the British Medical Association. 234 pp. London, Zed Books, 1992. $55 (cloth); $19.95 (paper). ISBN: 1-85649-104-8

Authors are aware of the predilection of publishers to pick titles that sometimes make it difficult for a reader to judge the book by its cover. Of the two titles above, the latter is a more accurate choice than the former. The perversion of medicine in Nazi Germany, unfortunately still being duplicated today in many parts of the world, is much closer to betrayal than to madness. To label what happened in Germany simply as madness is to undermine a fundamental point of both books -- that medical abuses under totalitarian regimes are explainable (although they remain inexcusable and unacceptable) and thus, ideally, preventable.

The title When Medicine Went Mad projects a fundamental lack of understanding about what really happened to medicine in Germany from 1918 to 1945 and how it came about. This problem goes beyond the title: it is reflected throughout the book in a paucity of historical perspective.

Much of the modern popular wisdom is that what happened in Nazi Germany, while clearly unacceptable, also remains inexplicable and thus ultimately unknowable -- in short, it was madness. As the editor of When Medicine Went Mad himself states, however, “Once identified, the myths of incompetency and madness make absolutely no sense.” Madness takes events out of the context and continuity of human social history., and if Nazi Germany is not legitimately part of human history, then we really have no business talking and writing about it. This point bears directly on what appears to be the basic purpose of When Medicine Went Mad: to discuss and determine the validity and ethics of using information derived from Nazi medical experiments on prisoners in the death camps.

The book is organized somewhat loosely, with 18 chapters. It begins with testimony from three surviving victims of Nazi medicine; continues with contributions on Nazi biomedical policies and eugenics, use of information from Nazi medical experiments, and euthanasia; and concludes with a discussion of the modern Human Genome Project, largely by bioethicists.

These chapters do not resolve the issue of the scientific quality of the data from Nazi hypothermia experiments (a seemingly straightforward question), let alone the ethical acceptability of their use (a much more difficult one). If the data have no scientific value in the first place, many of the ethical questions are not meaningful. As might be anticipated in such a discussion, many chapters contradict each other; one (by Jay Katz) even contradicts itself.

Responsible editing would provide the reader with 18 chapters expertly and progressively written to cover various aspects of a subject, rather than the same chapter written 18 times by different authors. Unfortunately, there is too much of the latter and not enough of the former in this book. For example, the reader is repeatedly assured that Nazi medicine did not arise from a historical vacuum, but is provided with little discussion of the philosophical and scientific underpinnings of late 19th- and early 20th-century European society, especially German society. Thus, the repeated assertion of historical precedent for Nazi medicine must be taken more on faith than as fact. In this way, despite the explicit and implicit assertion of the importance of history in human affairs, the book is quite unhistorical.

The best-written of the chapters is by Richard John Neuhaus, who states, “There are those who insist on the uniqueness, the utter singularity of the Holocaust in a manner that consigns it to the unusable past. If the Holocaust is like nothing else it is relevant to nothing else.” When Medicine Went Mad does attempt to make Nazi medicine relevant to something else, however.

Medical experimentation on prisoners in Japanese prisoner-of-war camps is one of the things to which Nazi medicine is relevant, but there is not a single reference to Japan (nor a listing under J in the index) in When Medicine Went Mad. That subject, among many others, is taken up by the editors of Medicine Betrayed. They reveal that in contrast to the experience in Germany, no prosecutions of Japanese doctors were carried out after the war because, according to a U.S. State-War-Navy Department Coordinating Committee that evaluated prosecution policy in 1947, “the value to the U.S. of Japanese [biologic warfare] data is of such importance to national security as to far outweigh the value accruing from `war crimes' prosecution,” during which such data would have had to be made public. The U.S. government had no difficulty in deciding -- in the interests of national security -- to keep secret and to use Japanese data on biologic warfare derived from unethical medical experiments.

This occurrence points out a remarkable and counter-intuitive fact about medical abuses and torture, as stated in the foreword to Medicine Betrayed by Lord Avebury (chairman of the British Parliamentary Human Rights Group): “It is practiced mainly by apparently ordinary men -- not psychopaths but family men who considered they were doing their patriotic duty in a life and death combat against dangerous enemies of society.” He continues, “There is actually little evidence of direct involvement of doctors in torture or ill treatment of detainees. The problems that do arise are those of forcible medication, force feeding and lack of care, rather than deliberate ill treatment.” The persistence of these problems worldwide is described in the remainder of the book, which covers medical involvement in torture, abuse of psychiatry, corporal and capital punishment under judicial penalties, hunger strikes and human rights of prisoners, and doctors as victims.

The book generally reads more like an annotated catalogue than a narrative. It is rich with anecdotes (parables) providing a set of proscriptive medical-ethical guidelines (Thou shalt not . . . ) in a kind of Ten Commandments for clinicians, covering all the occasions and near-occasions of medical sins.

The difficulty in setting ethical standards for medicine is highlighted by the difficulty encountered by the authors and editors of these books in trying to do so. The special difficulty of the medical profession in this regard is illustrated in both books. For physicians to experiment or practice inappropriately on individual humans in an effort to help human society or to further national goals is considered betrayal in a way that physicists' creation of a bomb that can destroy all human nations and society is not. As Neuhaus states,

The emergence of the profession of bioethics does testify to our culture's moral sensitivity. Maybe the profession has prevented, will prevent moral enormities that might otherwise be perpetrated. Maybe. With respect to what was not thought before, or with respect to what was thought and thought to be unthinkable before, bioethics may be producing more preventions than permissions.

Although it may not genuinely be the case, these books leave the reader with the impression (accompanied by a feeling of deja vu) that medical ethics is ultimately a matter of opinion -- or more specifically, a matter of choice -- and that there are few absolutes. Perhaps we would do better as physicians and medical researchers to choose a strong set of ethics, rather than to have more medical ethicists, and to look increasingly to history and human society as a whole for guidance. Samuel Johnson observed that “mankind needs less to be instructed than to be reminded.” These books provide some important reminders on a compelling topic.

Marc S. Micozzi, M.D., Ph.D.
National Museum of Health and Medicine, Washington, DC 20306-6000