MAZAL LIBRARY
.	GERMAN MEDICINE AND NAZISM: LESSONS FOR AMERICAN DOCTORS?   Michael J. Franzblau, M.D.   The historical relationship between Nazism and German Medicine can be linked to the failed German revolution of 1848 and the creation of modern Germany in 1870 under the leadership of Count von Bismarck of Prussia. In the 1840’s, Europe was the center of political upheaval. Liberals were winning victories in many countries disparate as Poland, Switzerland and Denmark. In February of 1848, Parisians forced Louis Philippe off the throne and proclaimed the second republic. Liberals in German principalities, influenced by these other successes, and especially the one in France, demonstrated for changes. The struggle that ensued was a bitter one for the Liberals who were eventually defeated by the Royalists. (Holborn, 1969; Weindling, 1989; Aly, 1994) The ferment in Germany following the failed revolution of 1848 produced fertile ground for the explosion of interest in science. Important German biologists such as Haeckel and Virchow became leaders during a period that has been called the “Golden Age of Liberalism”. The leaders of the movement sought to influence public policy by using their scientific discoveries as a basis for political action. As an example, Virchow used his seminal  discovery, that all life starts from individual cells growing into colonies, as a logical extension to the political scene, justifying German expansion. (Weindling, 1989) The unification of Germany under Bismarck occurred just at this time of scientific and political changes. The decision to industrialize immediately was central to Bismark’s strategy for Germany to become the dominant power in Europe. With the United Kingdom as the model, it became apparent very early that economic power was paramount to political and military power. The British had begun to industrialize in the eighteenth century and were one hundred years ahead of the Germans. The commitment of the Germans to rapid industrialization was successful. In the next forty years Germany became the most formidable power on the European continent. By 1914, Germany felt it was the equal of the British in economic, political, and military power and went to war to prove it. (Holborn, 1969) The short-lived period of emancipation and freedom of those supporting the failed revolution of 1848 produced far-reaching results. The desire for freedom and economic opportunity motivated between one and two million Germans to leave Germany. Most of them came to the United States where cities such as Cincinnati and Milwaukee grew significantly because of the new immigrants. For example, Carl Schurz, who escaped from Germany after fighting on the losing side in the revolution of 1848, became Lincoln’s United States Ambassador to Spain and eventually a United States Senator from Missouri. The depopulation of Germany was to have a significant effect on German policy during the following forty years. (Holborn, 1969; Weindling, 1989) At the time that these events were occurring, German medicine began to organize itself on the basis of the scientific knowledge it was assimilating into the practice of medicine. Physicians desired recognition by the State so that they could take control of the profession with state support. (Holborn, 1969) The decade of 1860-70, a liberal period of German thought, was followed by a swing to conservatism that evolved as Bismarck and his government gained political power in the new unified Germany. An uneasy alliance with the liberals was eventually shattered by the conservatives. Rapid industrialization and concomitant urbanization led to serious problems. In addition to a falling birth rate, there was a precipitous rise in infant mortality among the poor directly related to the crowding and squalid conditions in German cities. (Weindling, 1989) Bismark instituted “Krankenkassen”, or social welfare health plans, to help workers gain access to health care. (Holborn, 1969; Proctor, 1988) Significant state funds were spent to control tuberculosis, infant mortality, venereal diseases, and alcoholism. During the period 1876-82, epoch-making discoveries of the causes of anthrax and tuberculosis by Koch indicated the scientific tour de force of German medicine. Physicians became more organized because of the creation of the Krankenkassen, and began to see the importance of political action to protect their interests. (Holborn, 1969; Proctor, 1988; Weindling, 1969) Meanwhile, Bismarck, fearing the growing power of the Social Democrats, banned the party after stealing their social action agenda, which included unemployment insurance and pension benefits for workers. Physicians began to leave their apolitical positions and become active in the political parties of the day, Bismarck’s Conservatives on the right and Social Democrats and Communists on the left. Physicians were described not just by their specialty but also by their political ideation and affiliation. This indeed was the beginning of the relationship between organized medicine and the government of Germany. (Holborn, 1969; Weindling, 1989) Three other events occurred in the scientific world that had a direct bearing on the evolution of political, scientific, social, medical and philosophic thought. In 1853, Joseph Arthur de Gobineau published a treatise that, for the first time, placed anti-Semitism on a pseudoscientific basis. Gobineau’s aim was to justify the continued dominance of the aristocracy while its power was eroding. He created the concept of an “Aryan” race which represented the aristocratic cast. All others were inferior, including Jews. This concept added the patina of science to the anti-Semitism which had existed in Germany since Luther charged that Jews killed Jesus Christ and should suffer forever. There was some, but not universal, support for Gobineau’s theories. Nevertheless, Jews experienced difficulties in entering universities and professional schools, and in participating fully in German society. A significant number of middle and upper class Jews during this period converted to Christianity. Jewish physicians, along with their co-religionists, felt marginal to the rest of German society. The prominence of anti-Semitic beliefs by Germans in every strata of society helps to explain why German physicians embraced Nazism with such enthusiasism. (Holborn, 1969; Weindling, 1989) In the 1880’s, with the advent of the creation of Krankenkassen, the rise of scientific medicine, and the availability of access to medical care by the workers in industry, medicine became an attractive profession. Increasing amounts of monies were appropriated for the growth of German universities. The middle class eagerly wished to participate in gaining university education. All these events increased the power of the universities and enhanced the political power their high officers enjoyed. During this period, the number of Jewish physicians increased significantly. The resentment of German physicians to the competition from Jewish physicians mirrored the general hatred of Jews. The second and third events, the publication of The Origin of the Species in 1859 by Charles Darwin and the publication of the scientific basis of the laws of inheritance in 1870 by the Austrian monk Mendel, were world shaking. They were as significant to the development of political policy in the nineteenth century as the development of nuclear power has been to our century. There was intense debate over the significance of these scientific achievements in all industrialized nations, but only the Germans crafted a theory called “racial hygiene”. The core belief of “racial hygiene” was based on “Social Darwinism”, with its goal of protecting the purity of the German Aryan Race by making sure that only fit Aryans survived. There evolved a philosophy of “Volkischism” which gained strong support among the intelligensia and was the direct result of racial hygiene theories. The concept of the “German Volk” took on a mystical aspect larger than life, and on the basis of Mendel’s genetic work, nature was viewed as the paramount factor affecting heredity. The battle between the followers of Lamarck, a biologist who felt environmental factors were more important than nature in the transfer of characteristics, and the followers of Mendel, was won by the Mendelians. (Proctor, 1988; Weindling, 1989) The theory of racial hygiene was vigorously debated from the end of the nineteenth century to the time of the assumption of control of the German government by the National Socialist Workers (Nazi) Party in 1933. The original debates did not automatically denigrate Jews as Jews. Some theorists even suggested that Jews could be considered Aryans, a view unacceptable to the right-wing racial hygienists whose view prevailed. In 1903 an essay contest was sponsored by Herr Krupp, of the Krupp Armament Company, for the best paper on the subject of racial hygiene. There was intense interest and contestants entered from all over Germany. The prize of twenty-five thousand Reich Marks went to Wilhelm Schallmayer, one of the fathers of racial hygiene. By the time Hitler came to power there were 23 chairs of racial hygiene in German Universities. There is no record of chairs of racial hygiene in any other industrialized nation. (Mueller-Hill, 1988; Proctor, 1988) The tenets of racial hygiene crept into German law. In 1908, another of the fathers of racial hygiene, Dr. Eugen Fischer, became deeply concerned about the German settlers in German West Africa who were cohabiting with native women and producing babies of mixed race. Dr. Fischer was able to get the German Government to revoke the citizenship rights of the German settlers, and further, he published an article suggesting that the children were basically inferior and should be given only the barest of economic support, with the hope that they would die. Dr. Fischer played a significant role in the continuing evolution of racial hygiene during the next thirty years. (Mueller-Hill, 1988; Proctor, 1988; Friedlander, 1995)   1919 to 1945    The first World War had a profound effect on German political thought. The defeat by the Allies was a bitter blow to German national pride. The Versailles Treaty was viewed as a severe, unfair treaty. The Germans felt humiliated and abused. By 1919, political voices were heard blaming the Communists and the Jews for Germany’s defeat. (Friedlander, 1995) The Weimar Republic was created on the ashes of Germany’s ignoble defeat. From its beginning it faced serious problems. The Nazi goal was to overthrow the Weimar regime. (Holborn, 1969; Friedlander, 1995) The prominent role of Jews in the government presented an easy target for them and in 1925 the Foreign Minister, Walter Rathnau, a Jew, was assassinated. During this period, significant efforts were made to improve the health of the average German. A vast public health scheme was developed and clinics were created to deal with the problems of child and maternal health, venereal  diseases, alcoholism, and tuberculosis. These clinics were taken over by the Nazis in the 1930’s, and physicians were eager to work for the State. Karl Binding, a jurist, and Alfred Hoche, a psychiatrist, published a tract about euthanasia, Permission for the Destruction of Life Unworthy of Life, in 1920. The idea was considered by the Prussian Parliament, but not adopted as a law. (Burleigh, 1991, 1994) Between 1920 and 1925, Germany experienced hyperinflation, which was demoralizing to physicians as well as the rest of the middle class. By 1926 the hyperinflation had been controlled. Although this was a period of relative tranquility, physicians continued to suffer economically because German medical schools, which were thought to be the best in the world, trained and graduated more physicians than could find gainful employment. There are reports of unemployed physicians having to seek menial work to survive. (Kater, 1990) In 1929 the Nazi Physicians League was formed. It was very successful and grew rapidly. The Socialists formed their own physicians league, but it never reached the size of the Nazi League. When the world-wide depression hit Germany and the Nazi Party became the most popular political party in Germany, Nazi physicians gained even more power and prestige. (Kater, 1990; Friedlander, 1995) The first world war had increased the interest of the German leaders in the health of the nation. Many recruits were found to have illnesses and medical conditions that made them unfit for military duty. The serious disruption of orderly civilian life brought increases in the diseases associated with social chaos, i.e. infant mortality and sexually transmitted diseases, and brought starvation, especially in mental hospitals. By the end of the war, allegedly one half of all patients in mental institutions died. The need for corrective measures led to the development of the new specialty called “Social Medicine”. (Holborn, 1969; Weindling, 1995) There was opposition in some quarters of government, but the Weimar Republic appropriated more and more money for public health programs and “Social Medicine” gained legitimacy and support. Governmental clinics devoted to maternal and child welfare came into being. Significant efforts to control venereal diseases were made. Ironically, these Weimar Republic programs were easily taken over and became Nazi programs ten to twelve years later when Hitler came to power. It is of interest that concomitant with the expansion of public health programs, The Rockefeller Foundation came to the rescue of the German Medical Schools with a healthy infusion of funding at the critical period immediately after the first world war. German preeminence continued and the concepts of racial hygiene gained greater and greater acceptance during this period. (Kater, 1990; Aly, 1994) The eugenics movement in the United States, funded generously by the Carnegie Foundation, also played a significant role in that the racial hygienists in Germany and the eugenicists in the United States established close professional relationships. This led to cross fertilization of ideas and programs and added to the legitimacy of the stated goals of the racial hygienists in Germany. (Mueller-Hill, 1988; Proctor, 1988; Weindling, 1989) Support for the improvement of the sacred German germplasm by the techniques of positive and negative eugenics continued to gain approval of German physicians, philosophers, theologians, biologists, and political leaders representing the broadest spectrum of political thought. Proposals to permit sterilization of those seen as a threat to the German gene pool were introduced into the legislature of Bavaria. The bills required the consent of the patient before sterilization could be performed. The bills did not pass, but physicians on the left as well as on the right spoke out in their favor. (Holborn, 1969) Physicians had been politicized from the time of Bismarck, but during the Weimar Republic, with the Freikorps on the right and the Spartacus League on the left, armed battles occurred in the streets of major cities in Germany. Physicians and medical students participated both as fighters and as medical aid givers. It became a badge of honor during the Third Reich to have fought in the Freikorps and the careers of many physicians were advanced in the Thirties because of their activity in the Twenties. (Holborn, 1969; Proctor, 1988; Friedlander, 1995) Men like Gerhard Wagner, Otmar von Verschauer, and Leopold Conti were rewarded for their commitment to National Socialism during the 1920’s. Wagner and Conti became Reich Fuhrers for the Gesundheit Office and von Verschauer became director of the Kaiser Wilhelm Institute for Anthropology, Genetics, and Heredity. (Burleigh, 1991) At the time that the interest in anthropology, heredity and genetics was growing, the specialties of dermatology, social hygiene, pediatrics, and dentistry increased in importance. It is of interest that because of prejudices against Jewish physicians in the traditional specialties of internal medicine and surgery, they entered dermatology in great numbers. While Jewish physicians represented approximately thirteen per cent of all German physicians, their numbers in dermatology reached twenty to thirty per cent. Giants of dermatology with world-wide reputations flourished in academic positions even though prejudice exhibited by their non Jewish peers frequently caused difficulties with promotions. (Kater, 1990). One of the unintended consequences of the expansion of public health programs was the creation of a special class of medical administrators who supplanted legal administrators during the 1920's. The dominance of physicians in programs dealing with maternal and child health, venereal diseases, tuberculosis and alcoholism was a significant change in the importance of physicians in the welfare state of the Weimar Republic. (Weindling, 1989; Friedlander, 1995) In 1921, the three grand old men of racial hygiene, Lenz, Bauer, and Fischer, published their monumental work on genetics, eugenics, and racial hygiene, Outline of Human Genetics and Racial Hygiene. The book was translated into English and enjoyed broad acceptance in the United States where favorable reviews were published in several scientific journals. (Proctor, 1988; Friedlander, 1995) In 1923, Hitler staged an abortive Putsch in Munich, Bavaria and was imprisoned for his crime. During his incarceration he was visited by Herr Lehrmann, the most prominent publisher of literature on racial hygiene in Germany. Lehrmann gave Hitler a copy of Outline of Human Genetics and Racial Hygiene. Hitler, recognizing that the the book by the three respectable scientists would give the Nazi Party the patina of scientific rectitude, boldly lifted the salient points from the book and incorporated them into his seminal work, Mein Kampf   (My Struggle), in 1925. (Proctor, 1988; Friedlander, 1995) The Nazi Party grew from two per cent of the vote in 1928 to over thirty-seven per cent of the vote in 1933. Under the rules of a parliamentary system, the last President of Germany, Otto von Hindenburg, asked Hitler to form a government in late 1932 and early 1933. Hitler included some centrists in his government for a short time, but quickly drove them out. The Reichstag burned down under suspicious circumstances on February 27,1933. Hitler used the event to establish dictatorial powers and governed largely by decree during the thirteen years of the Third Reich. (Holborn, 1969) Hitler was an astute and popular politician. The German people responded to his claim that the Treaty of Versailles was an effort to subjugate Germany forever and resulted from the duplicity of Communists and Jews during the First World War. It is believed that had Hitler run for office within two years of his taking power, he would have won overwhelmingly. His political agenda made the average German feel proud to be a German. Hitler’s speeches were almost hypnotic. His agenda, which had been laid out in Mein Kampf in 1925, was quickly implemented. (Friedlander, 1995) Under Hitler, racial hygiene became the basis for many laws. The first law, passed in 1933, required all members of the federal government to be Aryans. All Jews who held government jobs had to leave public service. This included bureaucrats, judges, civil servants, and most physicians. (Kater, 1990) Even tenured Jewish physicians in German medical schools were not spared. Over two hundred were summarily dismissed, including five Nobel Laureates. (Proctor, 1988; Aly, 1994) It was the beginning of a plan to destroy the ability of Jews to earn a living and then to isolate them physically and psychologically from the rest of German society. (Kater, 1990) While it was never said aloud, the ultimate goal was the total destruction of Jews. Jews represented approximately 1.3% of the German population, or 650 thousand out of a population of 60 million. The Nazi Party was successful in spreading the propaganda that the Jews were the cause of all that was wrong in Germany and that making Germany “Judenrein” (free of all Jews) would solve all of Germany's problems. (Proctor, 1988) The second law, passed on July 14,1933 to further implement racial hygiene, was the Law for the Prevention of Genetically Diseased Offspring. It mandated the sterilization of all Aryan Germans who had schizophrenia, bipolar-disorder Huntington’s Chorea, intractable epilepsy, chronic alcoholism, or “asocial behavior” (opposition to the Nazi Party). The basis for the law was negative eugenics, a plan to discourage procreation among those who were viewed as a threat to the purity of the sacred German germplasm. All physicians were required to report patients meeting the criteria to a central authority. Loyal Nazi physicians sitting on Genetic health courts then ordered the sterilizations. Approximately 250 of these courts were established. Patients could appeal the decision, and a few succeeded in their appeals. The sterilizations were carried out in local hospitals throughout Germany, with no record of opposition from the German Medical Association. The program lasted six years, during which four hundred thousand Aryan Germans were sterilized, with two thousand deaths. The program ended in 1939 in spite of the pleas of Racial Hygienists such as Eugen Fischer that the program should not stop until approximately fifteen percent of the Germans were sterilized. (Proctor, 1988) The next series of laws are referred to collectively as the “Nuremberg Laws”. They were enacted in September, October, and November of 1935. Nuremberg was the cradle of Nazism and these laws had a positive reception in Germany, coming after a major Nazi Party Congress in that city. One law forbade sexual relations between Jews and Aryans. As a corollary, specific definitions of who was a Jew and who was an Aryan were codified into German law. Another law required Aryans marrying Aryans to appear before Marriage Health Courts (similar in function to the Genetic Health Courts), established to implement the sterilization law. It is ironic that the framework for these courts was created during the Weimar Republic when marriage counseling centers were set up to educate the public. The Nazis merely converted them to their own purposes. Physicians became expert witnesses and some made a good living testifying as to the racial origins of their clients on the basis of physiognomy. This became a subject in medical schools and in continuing medical education courses which German physicians were required to take at regular intervals. A medical journal devoted just to the implementation of the second Nuremberg Law was widely read in Germany. A third Nuremberg law took away the civil rights of every Jew in Germany and also of all single, Aryan German women. In the case of the Jews, it was a logical extension of the plan to rid Germany of “racial polluters”. In the case of the German women, it was a clear signal that women’s responsibilities in the Third Reich required them to produce healthy Aryan babies in great numbers. German women physicians were subsidized to give up their practices and go home to the kitchen, the bedroom, and the church. (Proctor, 1988; Kater, 1990) The Nuremberg Laws required the active participation by physicians in every part of Germany. The public and more importantly, German physicians, enthusiastically supported the enactment and the implementation of these laws. It is of note that the official journal of the German Medical Association lauded these laws without reservation. German physicians felt that they were involved in an exciting adventure in which their role was to be central to the success of the New Order. By the end of the Third Reich close to fifty percent of the non Jewish physicians in Germany had become loyal party members. No other profession joined in these numbers. While driven by a mixture of motives, physicians willingly became agents of the State and carried out it's medical mandates with enthusiasm. The needs of the German State became the accepted basis for physician behavior. The individual patients’ needs became secondary, if considered at all. Between 1933-1939, while the debasement of the Jewish population was accelerating, German Jewish physicians lost their licenses to practice and Aryan German physicians enjoyed rising prestige, a feeling of empowerment, and a significant improvement in their incomes, surpassing the lawyers for the first time in 1938. (Friedlander, 1995) In keeping with the core belief of racial hygiene, the next program was directed toward “positive eugenics”. The birth rate of healthy Aryan Germans had been falling for many years. A national campaign was instituted to encourage more births. As an incentive, any woman giving birth to eight or more children was awarded a Gold Medal; if she gave birth to six she received a Silver Medal; and for four, a Bronze Medal. This program produced a change in birth rates of Aryan German women from 14.7/1000 to 18/1000 in a two year period. Pregnant women received outstanding obstetrical care. German physicians cautioned their patients to avoid smoking cigarettes and drinking alcohol (this was in the 1930’s remember). A decision at the highest level of the German Reich Health Office resulted in the enrichment with appropriate nutrients of all bread baked in Germany. German scientists made meaningful discoveries of the effect of heavy metals such as lead and cobalt on the fetus. These findings were published in scientific journals and were accepted throughout the world as quality investigational work. German science flourished during this period. The belief that science is apolitical and neutral was put to rest. German scientists embraced the Nazi racial theories and contributed ideas and recommendations on a voluntary basis, not under coercion. (Proctor, 1988; Kater, 1990) In 1938 Germany took back the Rhineland and coerced the Czechs into giving up the Sudetenland. Austria had been annexed to the Third Reich and an alliance was forged with Mussolini. (Holborn, 1995) Meanwhile, on November 8th and 9th in 1938, a State-sanctioned Pogrom, under the direction of Deputy-Führer Hermann Göring, was unleashed in every part of Germany. When it was over, every synagogue had been burned or had its windows shattered. Most Jewish owned stores were destroyed. Three thousand Jews were murdered and thirty thousand imprisoned in concentration camps. Fire brigades were instructed to let the synagogues burn and to protect only the surrounding Aryan German property. Finally, a fine of billions of Deutch Marks was levied collectively on the remaining Jewish communities throughout Germany. (Friedlander, 1995) Events continued to move swiftly. Hitler had finished his plans for the conquest of Europe, both East and West. In the planning, concerns were raised about adequate facilities in hospitals for the care of German soldiers who would be wounded as war became a reality. (Holborn, 1969) Hence was born the T-4 Program, so named because it was drafted at Tiergartenstrasse 4. It was a carefully conceived plan to kill all inmates in German mental institutions who could not work for the Fatherland. (Burleigh, 1991; Friedlander, 1995) This concept had been openly discussed in the 1920’s, but only now was it to reach fruition. The phrases “Useless Eaters” and “Lives Not Worth Living” were effectively used to convince the medical profession, and the general public, that this form of “euthanasia” was in the best interest of the nation. In addition, Aryan German children with severe birth defects or disabilities were to be included in the program. (Burleigh, 1991, 1994) The organization of the T-4 program required the resources of the national German government, local health officers and physicians generally, who had to report the mental patients or the children who met the criteria of the program. The decision to kill the adults was made in Berlin by three eminent psychiatrists reviewing questionnaires sent to them from all over Germany. The children were selected in the same manner by three pediatricians. The program was well planned. Six “Healing Centers” were established throughout Germany. Transportation by bus or rail was provided. The methods of killing included starvation, phenol and alcohol cardiac injections, and carbon monoxide gas delivered in hermetically sealed rooms built to simulate shower rooms. Volunteer physicians were involved in the process at every step of the way. There is no record of any punishment for a physician who did not want to participate in the program. When the T-4 program ended, 400,000 inmates of mental institutions were killed, as were between 70,000 and 200,000 children. Heinrich Himmler, who as head of the S.S. was responsible for the programs, was very satisfied. (Proctor, 1988; Burleigh, 1994; Friedlander, 1995) The T-4 program can be viewed as the research and development program for the mass exterminations of Jews and others in concentration camps in Poland and Germany which followed. Many of the same physicians, nurses, and technicians who participated in the T-4 Program were transferred to the East in the early 1940’s to use their skills in mass extermination. One, Irmfried Eberl, even became the commandant of the Treblinka concentration camp. (Lipton, 1986) These medical workers believed that Jews were sub-human, that they were like a diseased appendix which had to be excised to save the patient (the German people). Collectively they were responsible for the murder of approximately three million Jews out of the six million killed by the Germans. (Proctor, 1988) These were physicians trained in the finest medical schools in the world, the models for our own medical school. These were physicians trained in the same nation that gave us Virchow, Koch, Roentgen, and Wasserman.   The Nuremberg Trials    Following the defeat of Germany in 1945, two trials were held in the city of Nuremberg. The first was a showcase trial of all the political leaders of Germany. It was conducted under the aegis of the United States, Great Britain, France, and the Soviet Union. The trial of interest to physicians was called the Nuremberg Doctors’ Trial. It took place in Nuremberg from mid 1946 to the end of 1947, and was conducted only by the United States Army. Twenty physicians and three medical administrators were indicted. The charge was murder and crimes against humanity. Five were acquitted, seven were sentenced to be hung, and the rest were given prison sentences of varying lengths. Among those sentenced to death were Karl Brandt, Hitler’s personal  physician, and Karl Gebhardt, Himmler’s personal physician. Neither man showed any remorse. On the contrary, they mounted a spirited defense led by defense counsel Robert Servatius, who later represented Adolph Eichmann at his trial in 1960. (Annas, 1992) Their defense proved inadequate as the testimony unfolded, revealing detailed records of barbarous and horrific experimentation on human beings. In the name of science, German physicians froze people to death, asphyxiated them by denying them oxygen at simulated high altitudes in hyperbaric chambers, and forced them to drink seawater to the point of serious illness. They injected tuberculous bacilli into children to study miliary tuberculosis, amputated limbs of prisoners of war, attempted heterologous graftings which all failed, and sterilized both men and women by the most bestial of techniques. The physicians did succeed in their most important mission, the development and use of Zyklon B gas as the preferred method of mass extermination. Physicians were required to supervise the entire killing procedure. The motivations of the these physicians were complex. Some believed in science for science sake regardless of cost. Some saw themselves as patriots and justified their behavior as being acceptable in wartime. Some truly embraced Nazi philosophy. Some saw concentration camp service as a method of advancing their academic careers. (Alexander, 1949; Berger, 1990; Michalczyk, 1994) The American jurists were appalled by the testimony. They demanded that the physician consultants to the U.S. Army Tribunal, Doctors Leo Alexander and Andrew Ivy, draft a code of medical ethics to prevent physicians throughout the world from ever again perpetrating the horrific, barbaric, and heinous acts of the German physicians. (Alexander, 1949; Annas, 1992) Thus was born the “Nuremberg Code of Medical Ethics”. The Code has ten parts. It represents a giant leap forward in the concept of the dignity of the individual. The first tenet of the Code requires that freely given, informed consent is mandatory before any experimental or therapeutic event between a physician and a patient can occur. The very basis of American physicians’ ethical conduct today is directly derived from the Nuremberg Code of 1946. (Beecher, 1966) In the United States today, there are a series of vexing issues related to the role of a physician in a free society. Physicians in all societies are vulnerable to pressures from outside forces such as state, local, and national governments, employers, union groups, and giant insurance entities. Health care is a one trillion dollar industry. In the past ten years, medicine has changed from a cottage industry to a series of major corporate entities controlled by large insurance companies. “Managed Care,” is the predominant mode of health care delivery. Physicians face the ethical dilemma of how to serve two masters. Who has priority, the patient or a third party whose concern is cost? Terms such as economic credentialing, “gag orders”, and HMO’s have become part of the lexicon of present-day American Medicine. The rationing of care, physician-assisted suicide, physician participation in executions, and the implementation of gene therapy are all being discussed by physicians, politicians, and the public. Physicians in the United States face threats to their ability to act in an ethical manner. The fundamental relationship between individual physicians and their patients is changing rapidly. The lessons of history, especially in Germany from 1933-1945, show what can happen when physicians violate their basic responsibility to their patients under pressure from a third party. The social, economic, and political pressures facing American physicians today are formidable. It is hoped that the physicians of the United States, members of an honorable profession, will never let economic decisions override ethical principles as they treat their patients.   REFERENCES   Alexander, L. (1949). Medical science under dictatorship. NEJM, 241:390-394   Aly, G., Chroust, P. & Pross, C. (1994). Cleansing the Fatherland. Baltimore, MD: John Hopkins Press.  Annas, G. & Grodin, M. (1992). The Nazi Doctors and the Nuremberg Code. New York, NY: Oxford Press.  Beecher, H.K. (1966). Ethics and clinical research. NEJM, 1435-1440.  Berger, R.L. (1990). Nazi science: The Dachau hypothermia experiment. NEJM, 556: 1256-1262.  Burleigh, M. (1994). Death and Deliverance. Cambridge, UK: Cambridge Press.  Burleigh, M. & Wippermann, W. (1991). The Racial State: Germany 1933-45. Cambridge, UK: Cambridge Press.  Friedlander, H. (1995). The Origins of Nazi Genocide. Chapel Hill, NC: University of North Carolina Press.  Holborn, H. (1969). A History of Modern Germany. Princeton, NJ: Princeton University Press.  Kater, M.H. (1990). Doctors Under Hitler. Chapel Hill, NC: University of North Carolina Press.   Lang, H. (1992). MD's first duty is patient advocacy. Calif. Phys. 12:8.   Lifton, R.J. (1986). The Nazi Doctors. New York, NY: Basic Books.  Michalczyk, J. (1994). Medical Ethics and the Third Reich. Kansas City, KA: Sheed and Ward.   Mueller-Hill, B. (1988). Murderous Science: Elimination by Scientific Selection of Jews, Gypsies, and Others in Germany. London, Eng.: Oxford University Press.  Proctor, R.J. (1988). Racial Hygiene. Cambridge, MA: Harvard University Press.   Weindling, P. (1989). Health, Race, and German Politics Between National Unification and Nazism, 1870-1945. New York, NY: Cambridge Press.
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