Remember our past in order to protect the future of medicine

acp new logoA guest column by the American College of Physicians, exclusive to

Her name is Wanda Poltawska. She is currently 96 years old and showing the physical signs of advanced aging, but remains mentally sharp and insightful.

What makes her special is that in 1941, at 19 years of age, she was sent to a concentration camp in Germany, and while there was subjected to medical “experimentation” by Nazi physicians.  She was administered multiple drugs and underwent a variety of non-indicated procedures. And because she was Polish and imprisoned for subversive activities, using her as a subject for medical experimentation was considered completely acceptable by the greater German physician community.  Amazingly, she survived both the experiments and the war, although she was one of the few.  She ultimately went on to become a psychiatrist and has written extensively and conducted research on the effects of incarceration on children in the Auschwitz-Birkenau concentration camp.

I recently had the opportunity to attend the Medical Review – Auschwitz: Medicine Behind the Barbed Wire conference in Poland where I met Dr. Poltawska.  This conference focused on the pseudo-medical experiments carried out on the prisoners of Nazi concentration camps by physicians, the consequences of imprisonment to inmates’ health, and most importantly, the ethical implications of Nazi medicine for contemporary medical practice.  Appropriately, the conference took place in Krakow, a beautiful city only 65 kilometers from the Auschwitz-Birkenau site where many of the most egregious medical experiments took place, not to mention the wholesale extermination of well over a million mostly Jewish people as part of the Nazi “Final Solution.”  To visit the camp site and view where so many of these tragic events occurred is both personally and professionally jarring, and cuts to the core of what it means to be a physician.

From where we sit today, it is relatively easy to say that the behavior of physicians in the Nazi regime over 70 years ago was an extreme aberration and limited to only a few high profile doctors (such as Josef Mengele).  However, what is less appreciated is that the beliefs, values, how patients are viewed, and the accepted role of the physician underlying these horrible behaviors were not limited to only several individuals, but rather had relatively widespread acceptance within the broader physician community.  A significant percentage of German doctors participated willingly in selecting individuals for experimentation or extermination, or remained silent while they took place.

And it has not only been in mid-20th century Germany where such significant shifts in the ethos underlying medicine have occurred, deviating from what most consider the traditional values of medicine and how we physicians approach the care of our patients.  Examples range from doctors in the U.S. and other countries actively participating in eugenics-based forced sterilization programs that predated World War II, carrying out ethically-flawed medical interventions or experiments without the knowledge or consent of patients as seen in the Tuskegee syphilis experiments and the case of Henrietta Lacks, and most recently, physician participation in “enhanced interrogation” techniques of suspected terrorists.

What this history tells us is that the traditionally-accepted core values of medicine that guide our practice – the physician’s obligation to always favor the well-being and interests of the patient (beneficence) and the mandate to relieve suffering, heal when possible, and comfort always – are not immutable, but in fact are vulnerable to distortion and subversion by a variety of different forces ranging from personal biases and agendas to societal, state, and business interests.  And that these distortions can translate into behaviors that expose those we have committed ourselves to serve to tremendous suffering and harm.

What this also means is that we must be ever alert to challenges to the integrity of the ethical foundations upon which we base our profession, and be vigilant in understanding why we do the things we do as physicians.

Medicine is a highly moral enterprise and many of the decisions we make frequently occur in the gray area between what is right and wrong.  And particularly with newer knowledge in medicine and dramatic technological advances, we can do things that were inconceivable even a decade ago.  However, these potentially beneficial opportunities also pose great challenges to how we choose to apply them our patients in a way that is consistent with the core values of medicine.  For example, many of us struggle on an almost daily basis with issues such as the physician role in end-of-life care, including provision of potentially “futile” interventions to the controversies around physician-assisted suicide.  And on a larger scale, our increasing ability to manipulate the human genome opens up an entirely new realm of ethical controversy.  And there are and certainly will be many more.

Dr. Poltawska is one of the last survivors of this extreme breach of medical ethics by physicians, and one of the few who can still voice what it was like to be so cruelly harmed by those she had believed were dedicated to the healing arts and could be trusted to care for her as a human being.  Unfortunately, she will not be around much longer to continue reminding us of what happened to medicine at that time and force us to confront the impact it had on so many personal lives and our culture in general; it is therefore incumbent upon us to carry forward the process of professional ethical and moral self-examination.  And what happened during the Holocaust provides an extreme but incredibly helpful lens through which we can understand how and why the values of physicians in the past drifted away from what we consider the core foundation of our profession, and help us examine the ethical challenges we face as medicine progresses.

At one of the places where medical experiments were performed on prisoners at Auschwitz-Birkenau are inscribed the words of the philosopher George Santayana – “those who cannot remember the past are condemned to repeat it.”  What is clear is that as physicians, it is imperative that we constantly remember our past in order to protect the future of medicine.

Philip A. Masters is vice-president, Membership and International Programs, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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