Medical Ethics after the Holocaust: Lessons for Modern Medicine – PediaCast CME 115

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Show Notes

Description

The Holocaust remains one of history’s darkest chapters. It also stands as one of medicine’s greatest ethical failures. Dr Dara Albert and Dr Ashley Fernandes visit the studio as we consider the physicians who were leaders, collaborators, and decision-makers in the atrocities of Nazi Germany. We’ll consider the roots of these ethical breaches, the culture of medicine that enabled them, and the continuing responsibility of physicians to protect the dignity, rights, and lives of every patient.

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3. Complete the post-test at Nationwide Children’s CloudCME.

• CME credit expires 3 years from this episode’s release date.
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Topics

Medical Ethics
The Holocaust

Presenters

Dr Mike Patrick
PediaCast and PediaCast CME
Nationwide Children’s Hospital

Dr Dara Albert
Pediatric Neurology
Nationwide Children’s Hospital

Dr Ashley Fernandes
Primary Care Pediatrics
Nationwide Children’s Hospital

Learning Objectives

At the end of this activity, participants should be able to:

1. Describe the historical role of physicians in the medical crimes of the Holocaust.
2. Analyze the social and professional factors that enabled ethical collapse within German medicine.
3. Evaluate parallels between past abuses and modern ethical challenges in healthcare.
4. Apply principles of ethical vigilance and human dignity to clinical decision-making today.

Links

The Lancet Commission on medicine, Nazism, and the Holocaust: historical evidence, implications for today, teaching for tomorrow

Center for Medicine after the Holocaust

Teaching Hard Truths About Medicine and the Holocaust

The Benjamin Ferencz Institute for Ethics, Human Rights and the Holocaust

 

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No one in a position to control content has any relationships with ACCME-defined ineligible companies.

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Episode Transcript

[Dr Mike Patrick]
This episode of PediaCast CME is brought to you by Nationwide Children's Hospital. 

[Music]

[Dr Mike Patrick]
Hello everyone, and welcome to another episode of PediaCast CME. We are a pediatric podcast for healthcare providers.

This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio. It is episode 115 and we're calling this one medical ethics after the Holocaust lessons for modern medicine.

I want to welcome all of you to the program. This is going to be a, you know, a heavy conversation as we consider the atrocities of the Holocaust and in particular how the medical profession contributed to the horrors that ensued. The Holocaust does remain one of history's darkest chapters, but it also stands as one of medicine's greatest ethical failures.

Physicians, as it turns out, were not bystanders. They were leaders, collaborators, decision makers in atrocities that really flew in the face of first do no harm. And in this episode, we're going to explore how medical professionals once healers became instruments of destruction and how those lessons still echo in our world today.

We'll discuss the roots of these ethical failures, the culture of medicine that enabled them and the continuing responsibility of physicians to protect the dignity rights and lives of every single patient. Of course, in our usual PediaCast CME fashion, we have a couple of terrific guests joining us in the studio for the conversation. Dr. Dara Albert, her grandmother was a Holocaust survivor. She was in Auschwitz as a 15-year-old girl. So, Dara is a pediatric neurologist here at Nationwide Children's Hospital, but she is going to talk about some of her family's history and legacy and lessons learned. Dr. Ashley Fernandes is a bio ethicist and primary care pediatrician at Nationwide Children's Hospital. And we'll soon discover more details on why these two are experts on medical ethics and the Holocaust and how this topic became a passionate calling for each of them. Before we get started, I do want to remind you that you can claim category one CME credit for listening and it is free category one credit. After listening to this episode, all you have to do is head over to the show notes at pdacastcme.org.

You'll find a link to the post test in the show notes. Follow that link to cloud CME, click on the materials tab taken past the posttest and the category one credit is yours. And we do offer a CME credit for physicians, but also, we offer medical education credit for nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists.

And it's because Nationwide Children's is jointly accredited by all of those professional organizations that we can offer the credits you need to fulfill your state's continuing medical education requirements. Of course, you want to be sure the content of the episode matches your scope of practice. And this is one of those episodes that really impact everybody.

So, with medical ethics, this is within the scope of every single medical practitioner that is out there. Complete details on the CME credit are available over at pdacastcme.org. Also want to remind you, the information presented in our podcast is for general educational purposes only.

And your use of this audio program is subject to the PediaCast CME terms of use agreement, which you can find at pdacastcme.org. Let's take a quick break. We'll get Dr. Dara Albert and Dr. Ashley Fernandes settled into the studio. And then we will be back to talk about medical ethics after the Holocaust and the lessons for all of us. It's coming up right after this. 

[Music]

[Dr Mike Patrick]
Dr. Dara Albert is a pediatric neurologist at Nationwide Children's Hospital and an associate professor of pediatrics at the Ohio State University College of Medicine. She also serves as co-director of the Advanced Competency in Medical Ethics after the Holocaust, which is a course for medical students at Ohio State. Dr. Ashley Fernandes is a primary care pediatrician at Nationwide Children's and a professor of pediatrics at Ohio State. He also serves as co-director of the Advanced Competency, and he is associate director of the Center for Bioethics at the Ohio State University College of Medicine.

Both have a passion for advancing medical ethics with a particular focus on the Holocaust and what today's clinicians need to know regarding Nazi Germany's impact on medical ethics and the importance of avoiding mistakes of the past. Before we dive into this important topic, let's offer a warm PediaCast welcome to our guests, Dr. Dara Albert and Dr. Ashley Fernandes. Thank you both for joining us today.

[Dr Dara Albert]
Thank you, Dr. Mike. 

[Dr Ashley Fernandes]
Happy to be here.

[Dr Mike Patrick]
Yeah, we are very happy to have you as well to discuss this. It's, you know, it's a heavy topic.

It's also an interesting topic and it's an important topic. So, it's like a triple threat episode here. So, Dara, I wanted to start with you, and I know that this is a story that's personal for you.

So, if you could just sort of explain that to us right out of the gate and then just talk a little bit about why it's important for today's clinicians to study medical ethics through the lens of the Holocaust.

[Dr Dara Albert]
Yeah, absolutely. So, I am the granddaughter of Holocaust survivors. My ancestors were many, many ancestors were murdered in the Holocaust and my grandparents survived.

And I grew up hearing their stories of survival, which even at a young age, I often found really remarkable and incredible and horrifying all at the same time. And my grandmother in particular, who survived Auschwitz was very passionate, especially later in her life about sharing her story. She felt that it was really important for the world to know what had happened, not only to her, but to the people who lost their lives and didn't have that voice to speak for themselves anymore.

And so, she shared her story all over the world. And after she passed away, you know, I sort of wondered, what do I do with this legacy? I want to continue to share her story in some capacity.

And then maybe six or seven years ago, there was this, this group referred to as the Lancet Commission, which was a group of experts that came together to create rationale and a, and a process or a way to be able to teach medical students about what happened during the Holocaust and how physicians were really involved implicit. We will get more into more of the details as we go through our conversation, but I never realized hearing my grandparents' story, how much of a role physicians actually played in what happened to them and my ancestors. And when I realized that I thought, man, this is really shocking.

People need to know about this. This applies, you know, still has relevance to today, to the way we practice medicine and serve our patients today. And so, I managed to get lucky and find Ashley and partner with him and been able to kind of bring these two pieces of my, of me together of like my family's legacy and history, and also teaching this topic to medical students and to sort of your other question of why, why teach this topic?

Why is this topic important? You know, as I already alluded to many, including myself, even being the, the descendant of survivors, we're not really aware of the extensive and critical central role that physicians and the medical profession writ large really played in the mass murder of human beings during the Holocaust. This included disabled children, people with mental illness, those considered undesirable, political dissidents, Roma and Sinti, and of course the Jewish people.

And you know, physicians really turned away from their roles as healers and became the deciders of life or death for millions of victims. And this is not just a history lesson. It's, it's a warning from the past to the present that how, you know, vulnerable our patients and families still are when they come to see us as physicians and, you know, the role that scientists play in, in medical research, you know, the importance of recognizing how vulnerable patients and families are and, and how we, we need to, you know, maintain that sacred trust and, and do the right thing for our patients and families when they come to us because of that vulnerability.

[Dr Mike Patrick]
Yeah. Yeah, absolutely. I just want to acknowledge real quick here out of the gate that that must have been really difficult for your grandma, not only the trauma of surviving Auschwitz, but then sharing that story is sort of like opening wounds and trauma again, which is, you know, never a great thing, but she felt it was so important to get the word out about what had happened there.

She was willing to sort of sacrifice that personal trauma to get the word out. And then you've continued that legacy, which I think is really fantastic. So just hats off to you and your family.

And I'm just so, you know, sorry that that, that, that, that trauma has been there in your life, but it's wonderful to be able to talk about this and avoid making the same mistakes of the past. Ashley, you know, a lot of folks when they think about physicians and the medical system during the Holocaust, the name Dr. Mengele comes to mind. Who is he?

Was he unique or was there really lots of Dr. Mengele?

[Dr Ashley Fernandes]
That's a great question. Dr. Mengele was probably the most famous Nazi physician. And when that name is often associated with people in the know, like, oh, this is a crazy doctor.

He actually was considered a brilliant physician and that's why he got the post he did at Auschwitz. He was sort of the head, if you would call it the medical director at Auschwitz. And so, he was responsible for a lot of planning and execution of the, of the medical experimentation, the dark medical experimentation that we know that happened, not just at Auschwitz, but at other camps throughout the German Reich.

And he was definitely not unique, but he was someone who has name recognition. I think the fact that he was not unique is really important for your listeners to understand Nazi. So the sort of Nazi ideology had infiltrated medical education itself so that physicians, trainees, nurses, they were all imbibed and sort of so saturated with, with a philosophy of medicine that goes against the tradition of medicine in the West, but because of the hierarchical nature of medicine and because of certain temptations and vulnerabilities that physicians have, they bought into it.

So, it was not small. The role of physicians was not small. I've, I said to my, the classes I've taught over the years that the horror of the Holocaust simply would not have happened without physicians in the, in the planning, the execution.

And for me, you know, as someone with a doctorate in philosophy, the philosophy, the foundational principles that underlie their medical ethics, you wouldn't have had the Holocaust happen at all. The witnesses, the people like Dara's grandmother who survived, they, the witnesses there had a perception that people were, that everyone, there's a quote, the famous quote, they were all doctors of an Auschwitz survivor because the perception was that the doctors were everywhere in that most infamous camp. And, you know, to echo the sentiments you said, you talked about, Mike, at the beginning regarding Dara, it's such an honor to teach with her because of this legacy and her grandmother's legacy, who I think she'll talk about a little bit later, but was a teacher herself.

And that is, and that's an absolute good that we can, we can remember and honor the victims of medicine and still teach something real to future generations of trainees.

[Dr Mike Patrick]
Yeah. Yeah. I would imagine that the physicians that were in the concentration camps did not go to medical school thinking I'm going to exterminate a race that, or I'm going to experiment unethically on human beings.

I would imagine that they went to medical school just like, like us, that we enjoyed, you know, medical science. We liked anatomy and biology and the sciences. So, Dara, how like, I can't imagine that just out of the gate you would like flip a switch and suddenly start doing these things.

It must've been more of a trickle, like, like one thing leads to another, to another, and the next thing, you know, you're, you're full into it. Were these physicians coerced to make those steps into this or did they participate willingly?

[Dr Dara Albert]
Yeah. So, I think that is a great question and, you know, could be a misconception that a lot of people had, including myself before I really understood this history. But in fact, physicians joined the Nazi party in greater numbers than any other profession in the Reich, seven times higher than that of other men, professional men at the time.

And they were the highest profession represented in the SS, you know, one of the Nazi groups, the SS. So, there was a willingness for sure. Physicians also really benefited from their collaboration and their participation.

They had access to better jobs and institutions, especially after very early in the sort of Nazi takeover of Germany, many or most Jewish physicians were stripped of their positions and their titles. And even at, at some point during this trickle or, or slippery slope were stripped of the ability to practice medicine and no longer allowed to be called physicians. And before the war, there were many, many prominent Jewish physicians in leadership positions at institutions that once they were forcibly removed, there were many physicians who were more than happy and more than willing to take up those positions of leadership that meant, you know, more prestige, more opportunity, higher wages.

Also remember that at the start of the Nazi regime, Germany was in economic, you know, depression after World War one. And so even physicians were feeling, you know, we're not having opportunities, economic opportunities. And so Jewish physicians being vacated German physicians that joined the Nazi party could make a living.

So, there was financial incentive as well. As Ashley sort of alluded to this, you know, ideas were taught in medical school. I mean, there are some really chilling images of medical school classrooms with the physicians and the medical students doing Nazi salutes and having Nazi ideology taught in the medical school.

And then because of the hierarchical structure of medicine, there was sort of this disincentivization to speak up, right? Like, and that still exists today. We have a hierarchical structure of medical education with a junior medical student, sort of quote unquote, at the bottom who might not feel that they can speak up if they're attending or their senior resident says something that may be, eh, I'm not sure if that's correct, but I'm not going to say anything because I don't want to get a bad grade on this rotation.

Those sort of, you know, hierarchical structures existed at that time as well as they do today. And also, physicians are ambitious, right? We're smart people.

We are driven to succeed. You know, it takes a lot of effort to get into healthcare, right? To become a doctor.

And we have aspirations to sort of leave our mark on the system. Many of us want to want positions of power and leadership. And so, you know, it was a, it was opportunism meeting, you know, true believers as well that kind of created that, that space for physicians to really work closely with the Nazis.

There were certainly some examples of physicians who were sort of coerced. And typically those are stories of Jewish physicians that in the, within the camps, so they were prisoners themselves were sort of forced to participate in either selecting people for the gas chamber, removing the bodies after people were murdered in the gas chambers was often a job for people who were physicians prior to being in the camps or even participating in some of the experiments. There was a really harrowing tragic story by a Hungarian, I believe physician named Miklos.

I'm going to butcher his last name. Nice, nicely. I'm not sure how to pronounce that.

Who wrote a book shortly after being liberated from Auschwitz telling his story about being coerced to participate in experiments. And then the German SS doctors like Mengele took credit. So, this, this Dr. Miklos was very skilled and gifted anatomist before the Cold War. And so, Mengele sort of took advantage of that and had him participate in the experiments under coercion, of course, and then took credit for the results from, you know, these experiments. So yes, there was some covert coercion, but it's more like the Jewish physicians in the camp. The vast majority of German physicians at the time were very much eager, willing, ready to, to join and participate in various ways.

[Dr Mike Patrick]
And these are professionals who grew up during World War I. And I would imagine from a cultural standpoint, you know, you feel like it's the world against Germany and not to say in any way that that excuses it, but there are some cultural factors, right, Ashley, that sort of led it to seem like this was okay. Behavior at the time.

[Dr Ashley Fernandes]
Yes, of course. I mean, we are not immune from those cultural factors even today. There are obviously nationalist elements that rise up in a lot of people in a lot of countries feel like it's us against the world.

And we even have in Ohio, Ohio versus the world, not that it's anything close, but you can see it's a, it's a, I only bring that up to suggest that that is a very, a very strong draw for people to be pulled toward something because it can be unifying, right? It's a unifying message when people are down and out or when something very, very tragic happens. We saw that in a good way in many ways after 9-11, but it's so easy for that to be shattered when that's not tempered with truth and virtue, which is precisely what happened.

Even within the professional culture of medicine, you know, as Dara suggested, there's medicine has its own culture and that culture exists in a, in a bi-directional influential way with the culture. So, culture influences medicine and science and science and medicine definitely influence the culture. And, and that's something important.

Again, another thing for our viewer, for our listeners to think about is how much does what we do in medicine actually influence the culture and vice versa. So, when you, when you think about the culture of medicine in Germany, which was, which was the most advanced in the world, in the Western world, people thought of German medicine as the best. So even, even in this dark, you know, sort of interwar period, Americans would go, American doctors would do their postdoctoral studies in Germany.

That is how good the German medical system was considered. And when you think about that, you have to think about these qualities that medicine as a whole and people that go into medicine and people that go into nursing and, and a lot of our health professions have, they have intellect and intellectual curiosity. They have prestige that comes with their position.

They have power and ambition that's given to them, power that's given to them by society. And then an ambition that comes from just the nature of doing a very, very hard demanding job. And they get a lot of adulation from society.

Okay. So, think about this combination of things, intellect, intellectual curiosity, prestige, adulation, power, ambition, those if not tempered with virtues like humility and integrity can go completely the opposite way. And, and that is the danger.

That's one of the things we can learn from teaching about medicine and the Holocaust is the great things and privileges that medicine have given us have to be tempered with foundational beliefs that uphold the dignity of the person and also reinforce virtues like integrity and humility in the professional themselves. Yeah.

[Dr Mike Patrick]
Yeah. And that really does have an impact then on the general public, so to speak, that, you know, you may not have known what was happening in the concentration camps, but you knew that the Jewish folks were being rounded up and taken somewhere. And if you knew that the medical system that was the best, you know, of the Western world and these doctors are doing it, you know, you do start to think, well, there must be a good reason for it.

And so that sort of reinforces the whole, this is okay. When, if, you know, an outsider looking in would, would say definitely this is not okay. Right.

Dara, what then were some of the, you know, we talked about medical experiments in the concentration camps. Of course, everyone, you know, knows about the gas chambers and the mass murder that took place there. What were some of the experiments that were, that were done in the concentration camp?

And are they the sort of thing that that is terrible and horrible as it is? Were they things that could advance medicine?

[Dr Dara Albert]
Yeah. So, this is a really hard truth to, to look at, you know, again, before I really dug into this, this piece of the history, you know, I sort of heard the stories of Dr. Mengele's experiments in Auschwitz and thought this was just sadistic, purposeless human experimentation, but that's actually not true. Many or most of the experimentation done on victims of the Holocaust was really hypothesis driven.

So again, German medicine at the time was very advanced, very scientific. By the way, there were research ethics published in the 1920s that governed medical research ethics. So, it's not as though this was a medical profession without ethics.

They had an ethical code, but the, but the experiments were hypothesis driven, but the goals were always to benefit the German society, what they called the Volk, the, the German body or the German society at the expense of, of course, the, the victim or the person that they were experimenting on. For example, there was a whole body of experimentation that was aimed towards helping German soldiers in the, in the fields. So, at the concentration camp at Ravensbruck, for example, they experimented on women.

This was a women's concentration camp to test the effectiveness of different potential antibiotics and, and specifically the sulfa drugs. And so, what they would do was intentionally create battlefield style injuries, mutilate these women's bodies, of course, without anesthesia, right? So, cause battlefield like injuries, and maybe even also try to induce an infection in said wound.

And then use different chemical substances like the sulfa products to try to stave off infection with the goal of helping German soldiers who might have a battlefield injury to prevent infection. I mean, in the 1930s and 40s, you know, wound infection was a, was a death sentence in many cases, right? There were very few antibiotics available and, you know, certainly the rest of the world wasn't going to send Germany penicillin, for example, to help their, their war effort.

So, they needed to figure this out for themselves. Other similar like-minded experiments include the famous high-altitude experiments where they put victims into situations of low air pressure to simulate high altitude to see how a German pilot could, you know, how high up could a German pilot fly to safely. So, there was this whole body of research to help the German soldiers.

There was also this very, you know, group of experiments towards sterilization. So, this belief that like, you know, the, the undesirable people in society, you know, should be sterilized so they cannot procreate and continue to make more, for example, Jewish people or Roma and Sinti people. So, there was a lot of, there was some experimentation around what are effective strategies for sterilization that was sort of earlier in the war.

And then eventually they sort of thought, well, it's cheaper to just kill these people than try to sterilize them. So, we'll just kill them instead. But there were definitely really grotesque, awful sterilization research and one particular horrifying example, I'm blanking on the doctor's name right now, but there was an obstetrician gynecologist in a Polish, non-Jewish, obviously obstetrician who worked at Auschwitz experimented on women prisoners doing sterilization procedures and then would, you know, for a few days a week or what have you.

And then he would go out in the community and practice normal medicine to his Polish non-Jewish patients out in the community. This doctor was never; you know, prosecuted and continued his practice afterwards. And then there was also this body of research that was sort of aimed at, well, if we, you know, we as German society, ultimately our goal is to colonize Europe and create this Aryan paradise where everyone is Aryan.

And so, are there ways to sort of convert people who aren't Aryan into Aryan? So can we change their eye color, for example, which is one of Mengele's studies, the eye color changing research or experimentation. He was also very interested in twins.

Maybe people have heard of the Mengele twin studies. This was because he wanted to increase the birth rates of Aryan people, right? If we want to colonize Europe and have as many Aryans as we can, we want to learn how can we increase, you know, twin births, for example.

So yeah, it's really hard to imagine, but quite shocking, you know, truth to look at that these experiments were hypothesis driven and had aims that, that obviously superseded the dignity of the human person being experimented on.

[Dr Mike Patrick]
Yeah, absolutely. Given that there are all these doctors running around the concentration camp, we know there's extermination going on. We know there's experimentation, unethical experimentation.

Was there healthcare? Were there actually, like, if someone got sick, were they treated or just left to die?

[Dr Dara Albert]
Yeah, this is another part of a hard truth to look at. So, most of the concentration camps did have some sort of hospital. Part of that was part of the Nazi regime's like deception campaign.

So oftentimes the hospital building was sort of on the exterior or close to the edge of the concentration camp that, you know, visitors or other people might be able to come and see and say, oh, it's not so bad. Look, there's a nice clean hospital here. So, you know, to sort of portray that these were actually humane institutions.

But in reality, most of the time, these hospitals, you know, the main goal of many of the camps was forced labor. And so, the hospital sort of served as this place where if somebody was sick, you know, could, could we get them healthy again to get back out to work to continue the labor that was required? Or are they not going to recover and just send them to the gas chambers for extermination?

And doctors in those quote unquote hospitals, these were sort of the decisions that they were making, you know, is this a person who's going to be able to recover or not?

[Dr Mike Patrick]
Yeah. Yeah. And were there experimentations happening in the hospital itself?

[Dr Dara Albert]
Yeah. Yeah. That as well.

Yes, definitely.

[Dr Mike Patrick]
Ashley, how does the moral identity of these physicians shift? Like when you, when you, you take the Hippocratic oath, I don't know if that was a part of the fabric of German medicine, but certainly their moral identity, I would think starts to change when you start taking people to a gas chamber and then burning their bodies. Can you describe a little bit of that shift and how that happens?

[Dr Ashley Fernandes]
Yeah. And it's, it's pretty, I mean, it's frightening how easy it is for that shift to occur again for people that are revered in society and that culturally now are being used as a group by Nazis to advance their aims. So, you know, we, we always have this, and again, Western medicine, at least the Hippocratic oath is very important to us.

Most medical schools take some version of it. The Nazis themselves had a textbook of medical ethics and research ethics as Dara had alluded to. The problem comes in when the physician loses sight of their role, the physician or the nurse, right?

So, in the philosophy of medicine, we talk about a telos. It's a Greek word that means the purpose or the what's it for medicine. So, for example, of anything like the telos of a chair is for sitting.

What's the telos of medicine? What is the purpose of medicine? What is it to do?

And we have historically tried medicine, nursing, have always tried to be service professions that really benefit an individual patient. Once you lose that and you start to say there are goods, higher goods that eclipse the benefit of that specific patient or family, the moral identity of medicine starts to change. And we're tempted by this even in today's society.

And I keep, I know I keep harping on this, like trying to draw it back to today, but think about if physicians were to make decisions about this patient in front of us based purely on the economics. Now, sometimes we do, you know, it's judicious, it's prudential to take into account cost, obviously, when you're, when you're thinking about any therapy, but suppose that was our primary criteria. Suppose that was what we thought was more important than anything else.

Or how about security for the nation? Okay. How about in, in the case of Nazi Germany, the race, what Nazi Germany was able to do was to create a culture where they created, it's, it's even, I say it's even more powerful than a simile.

They created a medical metaphor. The German nation is a body. Okay.

The German nation is a body, and this body is diseased and it is under constant onslaught by disease. And that disease is the Jewish people. That disease is these other undesirables, the disabled children, that disease are the Roma people, et cetera.

Now, who better if you buy into that, if you suddenly say, look, our life as a people is diseased and on life support, so to speak, what people are better to heal that body than physicians and nurses and people in the health profession. So now they can think of themselves not as serving the patient primarily, but as serving this, the German Volk, the, the, the nation, the people, and I am removing the disease from the body. In fact, there, there was a quote from a German OBGYN who said that exact thing is essentially when he was on trial, his defense was, I am a physician.

If I see a tumor, I remove the tumor. The Jewish people are the tumor on the German nation. And that is something that's so simple, diabolically simple for people to get an intuit.

Oh, doctor, they remove disease. Okay. Here's the doctors heading up the gas chambers, doing these experiments.

They're doing it for some good. That's higher. So that, that moral identity can shift if we don't keep ourselves grounded in what medicine's telos is the what's it for.

Yeah.

[Dr Mike Patrick]
Yeah. I'm just going to put this out there and I'm sure that others in the audience, this crossed your mind as well, as you're describing that, it sounds chillingly like today in terms of folks who aren't here legally and just, you know, grabbing them, taking them who knows where, shipping them off to other countries because they are looked at as the disease on the American body. And so that parallel, you know, this is why it's important to study these things because it, it doesn't just happen overnight.

It happens over years. And you know, we start to go down one path and as a medical professional, we have to make sure that we are not complicit in anything like that moving forward. Right.

[Dr Dara Albert]
Yeah. I mean, putting the human person as an individual always has to be front and center. As soon as we, as a society, start to dehumanize whatever that other is, whether it's immigrants who are here illegally, whether it's the Jewish people, whether it's the Roma and Sinti, as soon as we dehumanize people in our criminal justice system, for example, as well, then it makes it so much easier for society to sort of do what they want with them.

[Dr Ashley Fernandes]
Yeah. Yeah.

[Dr Dara Albert]
Yeah.

[Dr Ashley Fernandes]
I mean, you see, and you see, you know, the experiments that that Dara were just was describing by the top, these would be like our NIH grant funded physicians today, you know, like imagine this and they are amputating limbs from one person and trying to attach them to another person to, to help solve this crisis of battlefield wounds. Now, I'll bet you in some places in this world, if you say we can save our soldiers, if we try to do these kinds of experiments, there would be people who would be in support of that. If you take death row inmates and we say, okay, well, they're going to die.

Anyway, let's at least use them for some good. There would be people who would support that. I think one of the things that Dara and I try to emphasize when we teach the class to our students, and now we're, we're kind of, we, we received a grant from the state of Ohio to help to train other medical educators around our state in how to teach these kinds of courses.

But one of the things we try to emphasize is that lessons about medicine and the Holocaust can't just be about death. And one of the things that, you know, that when you bring this up, Dr. Mike, I think about is it is in a way gratifying if we as doctors, nurses, and other health professionals can remember our roots that yeah, medicine kind of stands above politics and ideology, and that's the way it should be. If we have an ICE agent and their family that come into our clinic and, you're mad at ICE, you can't, you're not allowed to treat that child or that family differently than you would any other person and any differently than a person that's come into this country illegally.

They're the same. Medicine has to be able to rise above and root itself in something far more foundational and, and steady than the rising and falling tides of our culture.

[Dr Mike Patrick]
Yeah. Yeah, absolutely. I want to shift our focus a little bit to now after the Holocaust.

Dara, what's the legacy of these, of these physicians after the war? Were they held accountable for their actions, or did they just return to practicing medicine?

[Dr Dara Albert]
Yeah. So, the vast, vast, vast majority just returned to practicing medicine. Only 20 doctors were actually tried at Nuremberg.

Mengele himself escaped to, I, we believe Latin America, I think was the, the rumor, but he was never held accountable for sure. And the, those that were actually prosecuted at the Nuremberg trials were extremely and chillingly rational in their defenses. You know, Ashley brought up a quote earlier of one of the physician's defenses, and I just want to read another defense from Carl Brandt, who was Hitler's personal physician and an architect of the whole, you know, medicalization or medical murder, mass medical murder, whatever you want to call it.

But as I read this, those, those in the audience who are in the healthcare professions, just, just think about the vulnerability of our patients, you know, and, and how distorted this thinking is. So, he says, the human beings who cannot help themselves, whose tests show a life of suffering are to be given aid. This consideration is not inhumane.

I never felt that it was not ethical or was not moral, but one thing seems necessary to me that if anybody wants to judge the question of euthanasia, he's talking about euthanasia, quote unquote, euthanasia of people with disabilities, for example, or those considered unworthy of life, including the Jewish people. So, if anybody wants to judge the question of euthanasia, he must go into an insane asylum, and he should stay there with the six sick people for a few days. Then we can ask him two questions.

The first would be whether he himself would like to live like that. And the second, whether he would ask one of his relatives to live that way, perhaps his child or patient. So again, a very rational, logical explanation that is so twisted and distorted from what we understand as our role to of giving aid to the suffering, right?

In modern medicine, we'd like to think, you know, it is our role to give aid to those who are suffering. That is, that is still a theme, right? In medicine.

But if you put the dignity of the human person at the center of that, then, you know, we don't consider killing that person and aid to their suffering. Right. So, as I said, most physicians who participated and perpetrated medical crimes and murder were really never held accountable.

And many continued to work as doctors after the war, maintaining influential posts. There were many published papers, you know, in medical journals that featured data gathered from victims of the Holocaust. One name that I will point out specifically since we are pediatricians was that of Dr. Asperger, who was an Austrian pediatric psychiatrist who led a children's hospital in, in, I think it was Vienna in Austria. And he participated in selecting children for euthanasia at his hospital when they were, you know, on deemed life, unworthy of life was sort of how the Germans phrased it. And yet we all know that name, right? He had a disorder named after him, you know, having an eponym to a disease is considered notoriety, right?

His name lives on even after he's gone. And yet he was very much complicit in, in the murder of thousands of children. I forget the exact number, but thousands of, of children.

[Dr Ashley Fernandes]
What's very interesting too, is that he justified, you know, his, his, his defenders said, well, Dr. Asperger saved some children by not, by not sending them to the camps because what he was actually interested in were these really high performing children with autism on the, the ones that could memorize phone books or do quick mathematical calculations. The Germans were very interested in harnessing this power of the human brain. So, his defenders tried to say after the war, look, he never joined the Nazi party, and he did what he could by saving these high functioning autistic children.

But however, he never did anything to stop the low functioning autistic children who were almost universally gassed.

[Dr Dara Albert]
Yeah. Very complicated history. Also, I'd just like to point out that the German current, you know, German medical society finally acknowledged and apologized for their role in the Holocaust in 2014.

So just about 10 years ago and the victims of what was referred to as the T4 euthanasia program, which was the mass murder of patients with mental illness, children with disabilities that occurred in hospitals. We didn't even talk too much about that, but this is mass murder of, you know, many, many people in inside hospitals. It's referred to as the T4 program.

They just, this was sort of the last victim group to be recognized as victims of the Nazi regime within the last 10 years. There's, a memorial that was built in 2014. And the reason why we teach this course is, you know, probably most physicians and medical students today are not really aware of this history or the legacy that these physicians, you know, what they, what their role was in during the Holocaust and what they continue to contribute to medicine after the Holocaust.

[Dr Mike Patrick]
Yeah. Yeah. I had no idea there were that many physicians in the concentration camps.

You know, I was thought, oh, they're soldiers or part of the SS or, you know, the, the guards of the, of the concentration camp. But to know that the physicians were really there for the day-to-day operations and running things is, is sobering. And, you know, I can definitely understand why there is a passion to never let this happen again, not just with our profession, but with, with any profession.

Ashley, I wanted to talk a little bit about the research data that came out of these experiments. Is that data that we continued to build upon? Cause you know, research builds upon itself or did we throw that away and sort of start over in an ethical way?

What's the right thing to do there?

[Dr Ashley Fernandes]
Yeah. So that's, that's another great question. Of course, physicians and scientists are very reluctant to throw out any data.

And we have to remember that a lot of the, certainly some as, as Darren and I have intimated, some of the research that was done was frivolous and data that wouldn't be used, but some of it would be considered important because these were German scientists who had hypotheses and they were serious scientists. So, what to do with that data that has been collected by unethical means. And, you know, here at Nationwide Children's, we sometimes take for granted because one of the things we do the best is research.

We are known internationally for being an, a center of excellence for research. And so many of our faculty participate in it and millions and millions of dollars of grants, but a lot of the safety, quality and ethics that go into the conducting of excellent scientific research stems from the ethical lapses of the Holocaust. So, this is one thing where at least we feel like we got right, or maybe a little bit right.

Things like the Belmont Report, the creation of the IRB. For those of us that have filled out IRBs, we know how tedious that can seem sometimes, no offense to the IRB, people that might be listening to your PediaCast, but we appreciate you because I will say that when we think about what the IRB is trying to do, it's trying to ensure that there is no temptation, no secondary good, that nothing will compromise the dignity of the subject or the patient. And that's very important.

Now what to do with research that's been conducted by unethical means. And this is a challenge. And Dara and I actually have our students grapple with this question in a reflection.

There was a professor Pernkopf of, in a German medical school, who was the head of a German medical school, who was a beautiful, I mean, not beautiful anatomist, but he was very talented at anatomical drawings. And he created a textbook in which he utilized the, the bodies allegedly of concentration camp victims. Now it was such a good atlas that people didn't want to give this up.

And there were other Germans who were also excellent anatomists who did other drawings. And in fact, our own recently retired, I believe Dr. Pedro Weissweider, who's also in the department of pediatric neurology, he gives an excellent presentation on this, on these anatomical drawings that had little swastikas in the corner next to the artist's signature and how after the war into the 1950s in the American editions, they scrubbed the swastika off. So, they were still using the, you know, some of these, this research, the anatomical drawings in these atlases, but not acknowledging the origins.

So, we ask our medical students about the use of Pernkopf's atlas, for example, and it's not as, it's not as straightforward as you think, because the larger question is the research data, as you ask, Mike, if something is obtained through unethical means, is it okay to use it? And a lot of medical school, our medical students are often split on this question. A lot of them say, of course we wouldn't throw away data.

We should use it. And some say that we shouldn't. And I think it depends again, on foundational ethical principles, people that are more of a philosophical bent towards utilitarianism would say, well, the needs of the greater number of people outweigh the needs or feelings of a few people.

Some people that have what we call a duty-based or deontological approach, or even theological ethics, for example, might say, Hey, we have a duty to these individual people to not benefit from something that was done to them, or to put it more plainly, maybe there are some things we should just never do. Okay. So, you have these kinds of two sides.

And when, when Dara and I have conversed with the students about it, you know, some of them have this sort of compromise, which is maybe we use the good data, but we acknowledge the origins of the data and utilize that as a teaching point to honor the people from which the data was wrongfully obtained. But again, it's an interesting question because you can see how teaching about medicine and the Holocaust isn't just a lesson for the past. You could study these research experiments, but what do you get out of it?

Well, you get out of it a reflection on the future. How should we be treating human subjects in research, human patients and clinical trials? How should we be treating data itself and the ethical use of data?

Yeah, absolutely.

[Dr Mike Patrick]
Ashley, you know, as a person who is an expert in medical ethics, what kind of ethical challenges do we face in medicine today that sort of echo the dangers of that era? And I know we have alluded to some of those, but can we talk a little bit in more detail about some challenges, especially ethical challenges that are reminiscent that we can use by studying the Holocaust, that we can use the discussion that we've had to help us grapple with current day ethics?

[Dr Ashley Fernandes]
Yeah, absolutely. I think this is an excellent, the kind of our Dara's and my sort of take-home points in a way. It's sort of how we end the classes we teach with having students reflect on these things.

And when we present on this subject, we sort of end with these kinds of lessons. I'm just going to talk about three that I think are probably for me the most important. One of them is when we think about the nature of medicine and science, I think all of your listeners have to avoid the temptation of thinking of science as a God.

So, science is a discipline of skepticism. Medicine derives what it does, the good that it does from this, from this discipline of skepticism. In other words, we have to be humble enough to say that we can be wrong in the way in which we conduct research or in our clinical conclusions.

But once we start using science as a means to justify ethical actions, then science becomes dogmatic. When you can't question medicine or science because it's, you know, what's the phrase, trust the science or believe the science. Okay.

I don't like those phrases. That worries me. Because I know we used them in the past recently with COVID and things like that.

And I understand the sentiment behind it but be careful of the language. You believe in something on a principle of faith. You can trust science.

You can have respect for science, but to believe science makes science into a kind of God. And that is one of the principal flaws that happened during the Nazi era was that you were not allowed to question it. You're not allowed to question science.

It just became the kind of dogmatic belief, but science always requires ethics. Science just tells you what you can do. Ethics tells you what you ought to do or answers this kind of open question.

Yes, but is it good? Right? The methodology, the methodology of science does not work when you are trying to answer the question of whether something is good or not, because it's science is an empirical discipline.

So that's number one is science cannot be a God. I think the second thing ethical sort of lesson from the Holocaust, which is sort of closely tied is that as physicians, nurses and other health professionals, we do work in an inherently hierarchical system and is important. That doesn't necessarily mean it's bad.

You always have to have a leader of the team. You always have people that are skilled in different areas. And so, it's important that within a hierarchy that people have the freedom to express dissent, that the culture is such, that people are not afraid to speak out.

And before you think, oh, well, I would have been one of those people that spoke out in those lecture halls. I want your listeners to just really close your eyes, do a thought experiment. Imagine yourself in one of these lecture halls where not only are they teaching you something that's ethically uncomfortable, but they're telling you it's science and everybody around you is believing it.

They're eating it up. You start. And not only that, but you're at a great institution.

You're at, you know, one of the best medical schools or whatever. You start to then not only question your ethics, but you start to question your own scientific ability. But what we need is for people to be able to speak out when they see something that is going wrong in medicine.

If the AAP comes out with an ethical paper, white paper or whatever, we need pediatricians to be able to say, well, let me read that first. Let me see if I agree with it. Let me be able to speak out if I don't agree with it.

And in particular, I just want to say something about antisemitism because we've seen this rise up recently, particularly in academia. And I think we have to be able to be free to also stand up for populations that really need us to stand up for them now, particularly given this history. So, I think that's number two.

And I think the third thing is that healthcare professionals in studying medicine in the Holocaust, it gives us an opportunity to really reflect on why we view human life the way we do and how important human life itself is to us. And I don't mean just biological life, but you know, one of the things that you learn is that when medicine starts excluding certain populations, like the disabled, for example, from full personhood or Jewish, you can do whatever you want to them. If you're not a person, you can do whatever you want to another person.

And so, if the view of human life, if our value, the value we place on it is based on purely utility, that can start to be problematic. And I think as we see, you know, some of it is the loss of, you know, sort of our religious culture that we've taken for granted for the last two millennia. But as we become more secularized and we lose a sense of transcendence, like there's something higher than the different parts of ourselves, it's not inevitable, but there's a danger of losing that.

Like what, what is it that makes human beings valuable? Is it just what I think makes human being valuable? Is it their utility to society?

Is there economic benefit to society? So, I think it gives, I think it gives us a good reason, religious, not religious, whatever ideology to pause and think about what makes the human person that's at the center of medicine so valuable and special. And how can I defend that better?

[Dr Mike Patrick]
Have you had any pushback on presenting this material? On the surface, you would think, no, I mean, this is an important thing to talk about, but in today's world as we are dealing with antisemitism, there are Holocaust deniers. Has this been an issue for you guys in terms of putting this advanced competency together and getting the word out about this?

[Dr Ashley Fernandes]
Well, I can speak for myself. Before I came to Ohio state, I used to teach this at my prior institution and at both places, I had some pushback. Honestly, it was mainly from faculty, from a few faculty who didn't like, like one person said, can't we just get over the Holocaust?

And this was someone on the progressive side of the ideological spectrum who really didn't want this being taught. And then when I was looking for someone to help me co-teach this here at Ohio state, a faculty member contacted me and said that she would love to help me teach, but not if it was called medicine and the Holocaust. And I had to call it, I had to change the title to medical ethics and genocide because this particular faculty member wanted to talk about, didn't want to focus on the Jewish people and wanted to focus on all different kinds of genocides.

And, you know, we do have to address this on almost every class. Like what about other genocides that have occurred? And I think that's a fair question.

The reason that we teach medical ethics after the Holocaust specifically, there are several reasons, but one of them is because this was by far the most, or almost exclusively medicalized genocide that the world has ever seen. So, when we're trying to teach to medical trainees, it's important to make that distinction. It's not that Rwandans or Bosnians are less valuable than, you know, Jewish Europeans.

It's just that this specifically teaches us lessons about medicine. But I do think the other thing is, you know, there are other genocides, but it is important because what medicine, what physicians did on the Holocaust was not an isolated incident in the history of antisemitism in the world. It was by far the greatest attempt at wiping out Jewish people, but it was not the only one.

And so, if we fail to focus also on antisemitism within our course, then we miss a whole part of history, which is, hey, someone didn't just pick randomly the Jewish people to do this to. This was part of a long pattern and our culture, and our discipline is still susceptible to those same temptations.

[Dr Dara Albert]
First of all, Dr. Mike, thank you for raising the question of antisemitism. And I totally agree with what Ashley said. I think another value of teaching about the Holocaust is to help everyone recognize the depths of depravity that human beings are capable of.

And that it was not just a Jewish tragedy. I mean, of course it was a horrific Jewish tragedy, 6 million Jews murdered, but there were so many other victims. And, you know, it's, it's important for us as Jews to, for the world to see that it wasn't just us and that every, every group who wasn't, you know, the Aryan Nazis could have been a target and to see that, you know, this, this historical event touched so many people and so many groups, and there is so many lessons that we can take out of it beyond just, you know, this was persecution of, of the Jews. Yeah.

[Dr Mike Patrick]
Yeah. And it would seem to me, you know, by saying that you it's wrong to pick a specific incident of genocide when there are so many other ones, you have to pick something, you know, if you're going to give a talk on diabetes, you've decided I'm going to talk about diabetes. And if it's on epilepsy, it's on epilepsy.

In this case, it's on the Holocaust and how that has impacted medical ethics moving forward. So, I, you know, I, I think that it is really an important thing for us to talk about. And especially as we get farther and farther away from the Holocaust, you know, we have collective memory loss, and we need to not forget this ever.

And, and we never want this to happen again. Dara, you know, in addition to you having a passion for sharing, you know, the, the stories that your grandma had shared with you, I would suspect that just hearing those stories and, and being a part of the whole thing, you know, since it was your, your grandma that was at Auschwitz, how has this shaped your, your perspective as a physician and a, and an educator?

[Dr Dara Albert]
Yeah. So as Ashley said earlier, after the war, both my grandparents were teachers and, you know, my, my grandma, as I mentioned earlier, was not only was she an educator, but she was also a nursery schoolteacher. So, she loved little kids and taught them nothing about the Holocaust.

Of course, we're talking, you know, little three-year-olds and four-year-olds, but you know, wanted to educate older people, you know, about what had happened to her and her family and the, and the importance. I mean, she wrote in one of her pieces that, that she wrote about her experience, the, the importance of being a teacher and teaching the compassion and dignity of all people that, that, you know, her experience, you know, really shaped that, that mentality. And, and that's what she taught to us.

You know, my grandparents never taught me to hate. They never, you know, told us angry or negative things about Germans. For example, there was no like anti-German sentiment.

Of course there was anti-Nazi sentiment, but, but, you know, they didn't teach us to hate. They taught us to be compassionate. So, you know, just my call to become a physician comes from that ideal.

You know, I w I wanted to help and, you know, help, help people and, you know, live that value of dignity and compassion for all people. And again, I didn't really connect the dots necessarily until long after I was already a physician, I was practicing, you know, I was already here as faculty at Nationwide Children's before I really connected the dots between the role of physicians. But looking back, you know, just to share a little piece of her story, she was 15.

She was living with her mom and dad and 12-year-old younger sister in what was then Hungary when they were deported, shoved into a cattle car of 1200 people and taken to Auschwitz. And upon arrival, they stood on the platform as millions of people did that entered that, that place. And there was a physician that she recalled as being Joseph Mengele.

Now that I know there were at least 40 physicians at Auschwitz and they took turns standing on the platform to do what they called selection. So, this was a, a shift that the physicians in Auschwitz did as part of their job, but they, she arrived there with her family. And a physician, whether it's Mengele or not, stood at the front of the line and took one look at her and her family and pointed one direction for her mother and younger sister and the other direction for my grandmother.

And the direction that her mother and sister went was straight to the gas chambers. And she was saved because she was deemed to be quote unquote old enough. You know, they were separating younger children and pointing them straight to the gas chambers.

So how do I rectify this? That a physician was the one that, that made that decision by teaching this history and by making sure that never again, that never again will a physician be the decider, you know, standing on the platform, taking one up and down look at a human being and deciding you're not worthy. Go to your death.

Never again.

[Dr Mike Patrick]
Ashley, as we conclude, we've talked about a lot of heavy things. What message do you hope that clinicians carry forward from this conversation? What, what, what are the key things that we really need to remember and to take with us?

[Dr Ashley Fernandes]
That's, I'm, I'm so glad you asked me that question because picking up where we're with Dara's story, I just wanted to mention that the two of us traveled thanks in large part to the generosity of Nationwide Children's and Ohio State. We were able to and privileged enough to travel to Auschwitz this past May together to be able to study in the places where these events happened. Dara actually went to Berlin and, and to Auschwitz and I joined her in Poland.

We were able to study in these very places where doctors perpetrated these heinous crimes. And I want your, your listeners to think about this. This was so special for me to go with Dara.

I don't think it would have been the same because of her family's history. And when you walk through the gates that of Auschwitz that has that infamous wrought iron sign that says work, it's in German and I don't, I'm not going to try it in German, but it says work will set you free. To think that here, that Dara's grandmother walked through those gates and was liberated and walked out of those gates.

And here's her granddaughter walking through those gates in the, you know, in as a doctor, as a doctor at Nationwide Children's Hospital. I have this beautiful picture, which Dara didn't know I was taking at the time. Luckily, she's forgiven me, but her mom was housed in, in barracks C, which is now destroyed.

And Dara was reflecting on it, looking out over this sort of, you can see this, the chimneys of the old barracks and some of the ruins of the old barracks. And she's kind of looking out at this grassy field. And it just struck me that this is a message of hope.

This is the power of life over death in this place of destruction that her grandmother survived. Now a, a descendant of a survivor who's a doctor and saves people's lives is standing over this place of death. So, I want people to imagine this.

This is why we teach this course. And this is why we want your listeners to read more about this part of history. Remembrance, I like to say remembrance is both past and future.

It is past because it helps us to honor people that both died and survived the Holocaust. But it's future because it gives meaning to what we do now. The Holocaust is a story of cowardice and death, but it's also a story of life and courage.

And there were doctors that spoke up. There were doctors that refused to do what the Nazis wanted them to do. And we want our students to study that too.

What makes a person able to be courageous enough to buck the system when they know the system is wrong. So just to wrap up with what Dara has already emphasized, the Holocaust and medicine after the medical ethics after the Holocaust is a message for all people. And we want people to understand that anybody who's in healthcare, that this is a story about life and what medicine is capable of on the good side and on the bad side.

But in an era of increasing antisemitism, we think this is all the more important for us to study.

[Dr Mike Patrick]
Absolutely. Well, it has been an honor really to talk with both of you about this. For folks who would like to learn more, we are going to have some resources in the show notes for you over at pdacastcme.org.

It's episode 115. We will have a link to the Lancet commission on medicine, Nazism and the Holocaust historical evidence implications for today and teaching for tomorrow. I know you guys had had mentioned that we'll have a link to the Lancet in the show notes.

I'm also the center for medicine after the Holocaust from the AMA journal of ethics. There is teaching hard truths about medicine and the Holocaust. And then the Benjamin French Institute for ethics, human rights and the Holocaust.

I will also have a link to that in the show notes for you. So once again, Dr. Dara Albert from Nationwide Children's Hospital, pediatric neurologist and Dr. Ashley Fernandes, primary care pediatrician with Nationwide Children's. Thank you both so much for stopping by today.

[Dr Dara Albert]
Thank you, Dr. Mike. It's been a pleasure.

[Dr Ashley Fernandes]
Yep. Absolute pleasure. 

[Music]

[Dr Mike Patrick]
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast CME a part of it. We really do appreciate your support. Also, thanks again to our guests this week.

They were really fantastic. Dr. Dara Albert and Dr. Ashley Fernandes, both with Nationwide Children's Hospital. Don't forget you can find us wherever podcasts are found.

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And until next time, this is Dr. Mike saying, stay informed, keep it evidence-based, and take care of those kids. So long, everybody.

[Music]