 Good afternoon, everybody. I'm Mark Siegler, and I'm honored to be able to introduce you and to Dr. Matt Winnea. I'm so happy to welcome Matt back to Chicago, although he's still in Colorado. We've missed him greatly in the past seven years since he moved from Chicago to Colorado. That Dr. Winnea is the director for Center for Bioethics and Humanities and a professor at the University of Colorado School of Medicine and the Colorado School of Public Health and at the University of Colorado and shoots medical campus. Matt is board-certified in internal medicine and infectious disease with additional training in public health and health services research. He led the Institute for Ethics at the American Medical Association in Chicago for 15 years working nationally and internationally on issues related to professionalism and the social rules of physicians. In 2015, as I mentioned, he moved to Colorado to become the director of the University of Colorado's Center for Bioethics and Humanities, an image of which is over Matt's left shoulder right now. It's quite beautiful. The Center for Bioethics is involved in the education of all health professional students at Colorado University. It facilitates clinical ethics, case consultation for hospitals on the Anschutz medical campus. And it carries out a research agenda to better understand ethical challenges facing medicine and society. Dr. Winnea has led national projects on issues, including public health and disaster ethics, on ethics and quality improvement, on communication, on team-based care, and engaging patients as members of the team, and on medicine in the Holocaust. He served on many committees and panels for the National Academy of Medicine, the Joint Commission, and others, including serving on the Blue Ribbon panel that examined changes in ethics policies and structures of the American Psychological Association that followed the group's involvement in the Bush administration's coercive interrogation, otherwise known as a torture program. Matt has delivered more than two dozen named lectures and visiting professorships, has authored more than 150 published articles, co-edited several books, and co-author of a book on fairness of health care benefit design. Among other leadership roles, he's president of the, has been the past president of the American Society for Bioethics and Humanities, and the past chair of the Ethics Forum of the American Public Health Association, and of the Ethics Committee of the Society for General Internal Medicine. Today's title of Dr. Winnie's talk is as follows. How healers became killers, Nazi doctors, and contemporary bioethics. I'm honored to introduce you to Dr. Matt Winnie. Matt, please. Yeah, thank you so much, Mark. It is a pleasure to be even virtually back in Chicago and with old friends yourself, Mindy. We were talking just before we got started, this lecture series this year that Mindy has put together is just so outstanding. It's really been a lot of fun to listen into some of these. And I anticipate going back and listening to a number of others on video later. I'm going to speak today about work that I started to become interested in because I was invited to the Holocaust Museum when I was working at the AMA to see this special exhibition called Deadly Medicine, Creating the Master Race, when it was still on storyboards. So it hadn't been mounted yet. And the staff at the museum, the historians there, wanted to know how physicians might respond to this information because at least at that time was not a very well-known history. There had been several books written about this, so it wasn't exactly a hidden history. But on the other hand, it was not a much talked about history. And we've subsequently done some research on this and found that relatively small proportion of medical schools have any formal curriculum that addresses the legacy of medicine's involvement in the Nazism and the Holocaust and how it affects the way we think about medical issues and ethical issues today. So the title of the talk today is about health professionals in the Nazi era, how healers become killers. And I've adjusted the talk a little because I want to be very explicit here that I think it's important to learn from the past in order to both understand the present and to build the future that we want. And at risk of being trite, the Santiana quote has something to it. Those who fail to learn from the past are condemned, not necessarily to repeat it, but to misunderstand or misinterpret echoes of the past that continue to affect today and understanding how our profession became so involved in the Nazi program. I think you will see the echoes today. There is a way of giving this talk, I think, where you sort of toggle back and forth between past and present. I will say I find that to be challenging for a couple reasons that I'll say more about in a moment. But what I'm going to do today is just tell the story. And I think you will see the resonance. You will see the echoes. I'll give you a few examples towards the end of the ways in which I tend to think about how to learn from this past to create a better future. But mainly today, I'm just going to kind of tell the story, which, by the way, this will not come as a shock, but it is a difficult story. It is a painful story because, as my colleague at the museum, Dr. Patricia Haber-Rice likes to say, this is an understudied and underexplored aspect of the history of the Holocaust. And in part, it's that way because it is so comforting to think of our ethics, the ethics of medicine and of health professionals as being those of caring, of compassion, of help for the least vulnerable, and that that core of our ethics is immutable, that it is solid, that it rests on firm foundations. And yet, as you all know, the history of medicine in Nazism and the Holocaust is probably the best documented example of the tenuous nature, in some ways, of our professional ethics. And in fact, this history is incredibly powerfully influential on the way we think about ethical issues today, even when we don't realize it. So I defy you to think of a topic today that is not in some way influenced by the legacy of health professional involvement in the Holocaust, whether it's beginning and end of life issues, issues related to disability, issues related to certainly abortion, issues related to genomics, to public health, to high health care expenditures, to access to care. All of these issues are sort of seen through the lens of this history and this experience. I have an intentionally blank slide here. And I have it blank because I want to say something just to you without the distraction of a slide before I jump into this. This is undoubtedly the most difficult talk I give. And I like to say every talk I give is a little bit difficult because the only talks that are ethics talks are talks about issues that are difficult. If it's an issue that we all agree on, it's not really an ethical issue anymore. It may be challenging in other ways, but it doesn't have the ethics angle on it. But this one is hard for two reasons, one personal and one professional. The personal reason is that you all know probably most of the people listening right now give talks. And when you give a talk, it is possible that someone in the audience knows the material better than you do. That's always an issue that there are going to be people in the audience who know pieces of whatever you're talking about better than you do. This is different because there are people including some listening right now who own this material in a way that I never will because I'm not Jewish. I'm not German. I have no personal familial connection to this history. And yet, if there is one thing I've learned from working with the museum, it's that somehow we all have to come to own this history. This is not just Jewish history. This is the history of the profession that we are all involved in. It is our shared history, and it has players that are, in some ways, I find it actually a little unfair to leave remembrance of this history to the Jewish community. They weren't the perpetrators here. So I feel it's important for people who are not from a Jewish background, for people who are not German, for people who are just interested in how our profession came to be where it is today to own this history in a way. The second way this is difficult is on a professional level. I just find it to be an incredible challenge for people to learn from this history. And the reason for that is any time you make any kind of comparison between then and today, you immediately risk what people call playing the Nazi card or reductio ad hitlerum as it's been called. And there's a good deal of truth to that type of accusation because there is nothing that I can think of today that is exactly comparable. There's not a direct analogy to what happened then. We do a lot of worrying about research ethics today, but I will say there is nothing that is going on today that is the same as intentionally infecting a young child with typhus watching until they die and then killing their healthy twin so that you can compare their organs. That nothing that we can think of today is going to be the same as that. And yet somehow we have to figure out how to learn from this history, the echoes of this history, the lesser versions of this history. Or as I said, we are condemned to see repeat episodes. And I'll give you some examples of these as we move forward. So here's the question. And the history we're going to explore. How did healers become killers? And to really understand this, you actually have to go quite a ways back well before the Nazi period. In fact, as we explore this, I'm going to come to this sort of difficult realization, which I'm going to try to defend. And it'll sound a little outlandish, but it is not mine to own in the sense that I'm not the first to have had this insight. This is Dr. Andrew Ivy at the Nuremberg Doctors Trial, who essentially, as he learned more and more about the role of health professionals in the Nazi regime, came to believe that the entire idea and technique of death factories for genocide would not have materialized without the involvement of the medical community and that that involvement had started long before the era of the Nazis. In fact, I think you can probably trace this at least back as far as Plato, who in Book Five of the Republic talks about protecting the purity of the Guardian's breed and having healthy and valued people beget as many children as possible, while those who are less healthy, less valuable, not only should they have fewer children, but their offspring, if they are born and are seen to be inferior, they be properly disposed of in secret. So the idea here is the beginnings of what we would later come to call eugenics. And the basic ideas of eugenics are those of selective breeding. The idea that if you can create a stronger ox or a faster horse, that you can also create a more strong human race or breed. And the core of eugenics is in these two arms. Positive eugenics is where you define people who are valuable. You support them in healthy living and in reproduction. But it's often paired with this idea of negative eugenics, which is there are also those then who are less valuable. Those people will be marginalized, discouraged from reproduction, and so on. And this really comes to a head in this almost perfect storm of the new science of public health and epidemiology. So people start counting things and developing P values and ideas of regression to the mean. And all of these notions of epidemiology and public health are being created at the end of the 1800s, beginning of the 1900s. This coincides with the rediscovery of Mendelian genetics and with Darwinian evolution, which generates this notion of social Darwinism. And so Galton is the one credited or discredited with coining the term eugenics. But these ideas are really the confluence of multiple strands of scientific investigation leading up to them. Eugenics is not a German invention. If anything, it is most tied to the UK and to the Americas, to the US, in particular, Carl Pearson. Some of you will probably recognize as the namesake of the Pearson Chi Square test. He's also the person who discovered the final amount of regression to the mean. Very famous guy, the Grammar of Science, became an incredibly well-known science book. In fact, Albert Einstein assigned to this book as the first reading in his Olympia Academy in New York when he moved there. And you'll notice here that the idea of struggles of race against race, and by the way, the notion of an Aryan race, are already in the sort of scientific literature in 1901 when Adolf Hitler is 11 years old. The Eugenics movement is an international movement. Again, you will notice a few of the folks from this first international Eugenics conference who will go on to become infamous Nazis, Alfred Plotz, Ernst Rudin. But most of these are not Germans. And you will also recognize a number of these folks as becoming or as being really the luminaries of American and European science. This conference is remarkable in many ways. And the entire proceedings are readily available to you if you ever want to look through this. But this is Alfred Punnett. By the way, Punnett Squares, if you remember your high school biology. So Punnett talked about feeble-mindedness, which was considered to be a genetic condition that was passed along from generation to generation, saying that if we could just prevent feeble-minded people from marrying and having babies within a few generations, we could eliminate feeble-minded people from our community. This is reproduced in a number of organizations and programs around the US. This is the International Conference on Race Betterment held in Battle Creek, Michigan, just a couple of years later. Again, the luminaries list of attendees here, including a guy named Harry Laughlin who would end up writing a model law for race betterment, which was oriented around forcible sterilization of people who were deemed to be dangerous to the community. Harry Laughlin's model law would be adopted across the United States. Most states had forcible sterilization programs. Again, well before the Nazi era, this is a speaker, I found this at a used bookstore in Chicago a number of years back, and it's from 1913. You could invite someone from the AMA out to your state or specialty society, well, not specialties at that time, but to your state society or to your church group to give talks. Now I'll just show you the page from Colorado, which shows Dr. Corwin here who will talk about eugenics and how it's going to save society. I would say probably 20% of the talks that you could invite people out to give were around issues of race betterment and eugenics. Americans, by the way, before I get to the eugenics laws around sterilization, I should say we were very much in the forefront of race policy, right? The idea that races were a thing, that they were a biological thing, that one race posed a threat to another race as a biological matter, that was very American, and it comes out of, and so we were at the forefront of things like making laws to define who counts as being black versus who counts as being white, which ends up becoming very important in Nazi Germany, right? They have to make a law about who's going to count as being Jewish and who's going to count as being non-Jewish or Aryan, and you have to look at how many grandparents, how many generations back, and of course, as many of you know in the American states, there were a number that had so-called one drop rules where a single prior ancestor at any remove would make you a black person, and that was written into the law. The Germans actually, when the Nazis came to power, they sent a delegation to the American South to study American race laws and see whether they could use any of these laws as to help inform their laws for defining who would be Jewish, which would become, by the way, the Nuremberg codes, right? The Nuremberg laws around the racial purity, in Germany, and actually they saw our one drop rule in the US and said, that's way too extreme for the Nazis. The Germans will never accept that, and in fact, when the Nuremberg laws are passed, you have to have three grandparents Jewish in order to count as fully Jewish. If you only have two, you're mixed, as they call it, Michelin, and if you have less than two, then you are actually considered to be Aryan. But this is a more direct, even a more direct way in which American race policy effect, a eugenics policy affected German policy well before the Nazis come to power. We had been experimenting with sterilization laws. And so these had started in Indiana in 1907, and Indiana's law actually was adopted and then reversed and then adopted again a couple times while they figured out how to create due process provisions and so on. So Americans had been, the laboratory of the states in the US had been working on how to create a sterilization law that would pass constitutional muster in the US for a generation by the time the Nazis came to power. And most US states had laws that allowed for the forcible sterilization of individuals on eugenic grounds. Even states, by the way, like Colorado, which is listed as not having a law, we have well documented cases of people being sterilized against their will. So this was really ubiquitous across the US at this time, that you could be sterilized against your will if you were seen to pose a threat. And these laws were endorsed and authorized by the Supreme Court in 1927. Again, before the Nazi era. And I highlight this because there's a famous or an infamous quote here from Justice Oliver Wendell Holmes that three generations of imbeciles are enough and that justifies forcible sterilization of Kerry Buck. But I highlighted also the sentence before that because it shows how this was entirely framed around public health. This was about preventing this person from infecting the rest of the community with feeble-mindedness, which again was considered to be a genetically heritable trait. I will say by the way that Kerry Buck herself was not feeble-minded, nor was her daughter, her daughter grew up only to about the age of eight before she died of an infectious illness, but she got normal grades in school, Kerry herself received average grades in school. So neither one of them was feeble-minded, but Kerry got pregnant outside of wedlock. She was probably raped by the nephew of the foster family she was living with. Her mother may actually have had a cognitive disability and she was institutionalized with a cognitive disability, but Kerry ended up because she became pregnant, she was institutionalized because the family essentially said she must be promiscuous and that's a trait of feeble-minded individuals. So when the Nazis come to power in 1933, January, one of the first laws they pass is this law for the prevention of progeny with hereditary diseases. They base this law on the American law, the Harry Loughlin's model eugenic sterilization law. So this looks very almost word for word in many instances translated into German, but this is essentially the California law. California was the most active of the US states. Germany is going to implement this law in a very aggressive way. So in the United States, we have these laws on the books for about 70 years and over those 70 years, we would forcibly sterilize in the medical system about 70,000 people. Germany will sterilize 400,000 people in about five years in a country roughly a third the size of the US. So they're very aggressive about this, but they do it using the American model law. So they create these hereditary health courts which operate in parallel to the German judicial system. Hitler is a dictator. He hates the courts because the courts are potentially a constraint on his rule. So he sets up separate from the court system, these hereditary court systems, which are manned by two doctors and one judge. So the doctors have the decisional authority. The judge on the other hand has tie breaking authority. So both play very important roles, but there are about 250 of these set up all around the country. The Nazis are very well aware that they are basing this on international other countries. So they have this, we are not alone poster that essentially is advertising the fact that they're not the only ones doing this forcible sterilization. That this is a widely accepted strategy. So you might think, okay, so we are trying our best to prevent people with these congenital illnesses from being born. What happens if a child is born with a congenital illness anyways? What if they slip through the cracks? And this is from Karl Brandt, who was Hitler's personal physician and he becomes the chief defendant at the number of doctors trial. So you have to take what he says with a giant grain of salt because he lies a lot on the stand. But according to Karl Brandt, there was a child born with a severe deformity named Nauer. He was sent to examine the child and determine whether that child should be granted a mercy death. And what he decides is that this is warranted, but we should do it in such a way that the parents won't find, won't believe that they had to be the ones who had to make this difficult decision. That that's a challenging decision and doctors should be the ones who make that decision. This is, in fact, the beginning of what would become the so-called child euthanasia program. And I have euthanasia in scare quotes here because this is not euthanasia as you might envision the debate over euthanasia happening today. These are not parents asking for help allowing their child a gentle death. These, this is a cynical program of mass murder implemented by the Nazis in which parents are tricked. So any child who is born with one of these conditions will receive a letter from the state saying that they should be sent to a special treatment program. They would arrive at the special treatment program. They would then be starved to death or sometimes killed through an injection of phenol directly into the heart. But the parents would be told that the child was initially doing well then they would get another letter saying, so sorry they've taken a turn for the worse and then they would get a letter saying they've died typically of pneumonia. Those children would then have brain samples taken and they would be disposed of or sometimes their bodies would be kept for research purposes. This is the first mass murder program of the Nazis preceding the Shoah or the attempted genocide of European Jews by roughly two years. And in this program or between five and 10,000 children with disabilities will be murdered. This program, the child program pretty quickly expands to older and older children. And it becomes what we are now, now call the T4 program, a very infamous program in which from Tiergartenstrasse 4, hence the name T4, this is the address of the central office in Berlin. In the T4 program, seven killing centers are established around the country, mostly in the basements of existing psychiatric or other long-term care facilities. And what will happen is across the country, people who run long-term care facilities are required to fill out a form in which they describe each patient and whether that patient is likely ever to be recovered or well enough to work. And if they are deemed to be not recoverable or they'll never be well enough to work, then they are seen as useless eaters, as being a dead weight within the state or even as a fifth column, a danger to the state because they're taking resources that ought to be better used in the war effort as the war comes on. And Hitler, in fact, backdates the approval for this program to the beginning of the war because he felt it would be easier to carry this program out in wartime. The idea here is that people who are non-productive and in a long-term institutional facility will be sent again to these special treatment programs, same language is used when they arrive at these special treatment programs. They are stripped down, told they're going to take a shower. They go into what looks like a shower, but is in fact a gas chamber. They are gassed to death. Their dental gold is then removed and they are burned in specially designed crematory ovens. And if that process sounds familiar to you, it should because many of the camouflage techniques that were then later transported to use in the Holocaust itself are developed and perfected in the T4 program by the medical personnel running these programs. So there is a moment in the war in the summer of 1941 when some church leaders and people in the community, this is all a secret illegal clandestine program. It's still illegal to murder people in Germany, even on the Fuhrer's orders. So this is an illegal program under German law and so it is secret, but it becomes an open secret. And in fact, there are stories of children because these bodies are being cremated. Hair will come down in the smoke into the local towns and the parents will sometimes tell their children, don't be bad or they'll take you up and put you in the ovens in there. So this becomes a widely recognized secret. In fact, there's an article written about this in an American journal about how Germans are killing their disabled community. And so Hitler again, he's a dictator, but he cares about public opinion. And so in 1941, he pauses the euthanasia program or stops it just before he stops it. He had actually started already to transport pieces of the strategy used for the T4 program to the camps. And the purpose of this, this is called the 14 F13 program. The purpose of this is there are people in the camps who are becoming unproductive. And rather than keeping them alive when they can no longer work, they're going to murder them in the same way that they're murdering people in this T4 program because these were productive workers in labor camps, but they're no longer productive. And so if there's a judgment made that this person will never be able to return to work, we are not going to keep them in the infirmary and keep using resources on them. Instead, we're going to kill them and cremate them. So the technique of the T4 program has been brought to the labor camps. And then when it's paused, you're left with about a hundred individuals who are trained in the killing process. They're inured to the killing process. They're known to be reliable because they've kept this secret for a long time and they're now all out of work because the T4 program has been halted. So many of them are actually moved to help create and run the Reinhardt camps. So for example, the first commandant, the Reinhardt camps, by the way, are Belzech, Sobibor, and Treblinka. So the first commandant at Treblinka is a guy named Dr. Infred Eberl, who had been a leader in the T4 program. Treblinka, by the way, is the camp to which the Warsaw ghetto is evacuated for killing. About 900,000 people died at Treblinka. So this is the Euthanasia Center at Bernberg and here's the one at Auschwitz. And I just wanna say that this similarity is not an accident. The apparatus, the techniques of camouflage, the variety of tools, including the specific crematory technology was developed in the T4 program and then used for the attempted extermination of the Jewish community. And the Roma-Sinti community and the LGBTQ community and the African-German community, et cetera, in Germany. So I just wanna back up for a moment here and talk a little because you might think given how this evolves, the German medical community before the war was in the ethical dark ages. And unfortunately, really nothing could be further from the truth. A great irony of the number of doctors' trial is that at the time of the trial, which as you all know, largely focused on research abuses, which I haven't said anything about research abuses, but they went looking for ethical standards for conduct of research on human beings. National standards, international standards, they were looking all over for what are the standards for doing research on human beings. And ironically, they found only two, both were German. So the German scientist Albert, a Prussian scientist, Albert Nyser, whom some of you may recognize as the namesake for Nyseria gonorrhea, Nyser had done trials in which he intentionally infected orphans and prostitutes with syphilis as a way to test different treatments. When that became known by the local community, the Prussian government passed a law requiring the informed consent of human subjects of medical research. That idea of the unambiguous consent is the way it was framed of the human subject of medical research, as well by the way as the idea of an IRB was called something else, but an ethics review panel that was all implemented in the Weimar Republic in 1931. So this was a nationwide German law which was never explicitly repealed during the war. So the Germans were actually ahead of their time with regard to regulations of research on human subjects. They were also ahead of their time in terms of scientific advances. This is the Siemens electron microscope which was developed in Germany, the electron microscope. And just to give you one quick illustration of this, if you wanted training in, the best training in the world in medicine and science, you went to Germany in this era. So if you were training in the 1920s and 30s, just again, quick anecdote here of the 10 Nobel Prizes awarded between, in the 10 years before the war, six German speakers won Nobel Prizes in the 10 years before the war. Imagine if the US got six of 10 Nobel Prizes in a decade. So Germany was at the top of the heap in terms of science and technology. It was also at the top of the heap in terms of application of science to public health. So this is one of the first public epidemiology research projects looking at smokers and non-smokers and different types of cancers. Also looking at gender here, because you'll notice that if you happen to speak German, the cancers that are very prevalent among non-smokers are things like breast cancer because women tended not to smoke. Men were smokers, and so you see these very strong correlations. The Nazis used what they were learning to do things like encouraging women to do breast self-examination and to track their period for evidence of early breast or uterine cancer. They encouraged women to have plenty of babies and to treat their bodies well while they were pregnant to drink apple cider instead of alcohol and avoiding nicotine during pregnancy. They even banned smoking in party offices as well as many other public spaces. And by the way, I'll just highlight on that cigar. You'll see the sort of African looking head. They were very explicit about smoking being a vice of degenerate Africans. And by the way, I use degenerate in a very explicit way here, right? The idea of degenerate comes from the notion that there are genetic generate, there are genetic components of degeneracy. Right, a degenerate person is someone who has a biological inferiority baked in. This notion, of course, is all part of this eugenic paradigm and in Germany, again, early in the regime, you are required to go to a doctor's office or to a genetic counselor you would call them today to decide with you whether you are allowed to get married and have babies. And the idea here is very simplistic Mendelian genetics, but the idea here is that they're going to use medical science to create a master race. And this is, again, baked into the medical enterprise. The medical practice law for Germany has changed by 1938 in a way that says it is the explicit responsibility of the medical community to ensure racial purity and sound heredity of the German people. That is the primary aim of the medical community after 1938. This is, again, throughout the German sort of biology spectrum. So this is from a high school biology textbook. But I want to point out this is not much to do with actual biology, right? This particular image here is about the idea that people with biological hereditary illnesses are costly to the state. That's what they're really pushing here, not so much what causes these hereditary illnesses, et cetera. This is tying the well-being of these individuals with the well-being of the state, with the idea being that you want doctors to start to think of the state as their patient and not any given individual human being, right? So this is Adolf Hitler making this explicit claim that he is the doctor of the entire people, that he's going to create health across the community. And if you have to get rid of some people in order to make the larger whole healthy, that's not only acceptable, but that may become and does become, according to the German medical community, ethically required. And Hitler, again, very explicit about this early in his regime, he comes to the German medical community and says, I can do without engineers. I don't need teachers, but you, doctors. What I'm doing here is fundamentally a project of what one of his deputies, Rudolf Hess, called, what he's doing here is applied biology. He's applying biological principles across the entire community of the German people. So I asked at the beginning, how do healers become killers? And one answer is that they become synchronized around this goal and no longer around the goal of being the protectors of their most vulnerable patients. And this isn't just doctors, by the way, I put up the Hottemar nurses who were a number of them put on trial afterwards in a nursing trial. One of the papers I read recently suggested that 62% of oral and maxillofacial surgeons were members of the Nazi party. In different areas, over half of German doctors were members of the Nazi party. And there are many questions about why it is that such high proportions of the medical profession ended up as members of the Nazi party. Because after all, it's obviously not required. Half the people were not members of the Nazi party. So when you see a number like that, half being members of the Nazi party, and you look at engineers and lawyers where the numbers are much, much smaller on the order of 10 or 20%, why is it that the Nazi regime was so appealing to the medical community? And one of the reasons is that, there are, again, lots of hypothesizing about this. So not one answer. The German medical community was beaten down after the first world war. There was actually doctor unemployment at this time in Germany. So there was a lot of competition. The Jewish community had a lot of people in the medical field. And so there were plumb positions in medicine that would be vacated when the Jewish doctors were kicked out of the medical societies and were no longer allowed to practice, no longer allowed to hold positions of leadership. And again, this is very early in the Nazi regime. So the Nazis disband all of the professional associations and create a single national medical association, which is essentially run by the state. And this is in 1933, so six months after they come to power. This is reported on in JAMA and in other journals around the world. Very little protest, however, about this. People just sort of thought it was interesting, I guess, what was going on in Germany, but did not see where it was potentially heading. Outside, by the way, of the Jewish community, where of course there were protests when Jewish doctors were all kicked out of the medical professional bodies. But they pretty rapidly coalesce around this notion of creating a master race. They're given a lot of power in the German community. They have a lot of political power and a lot of sense of, I think, misplaced, obviously, I need to keep saying that, but pride in the role that they are playing in this whole enterprise, because it is a leading role in the Nazi enterprise. This is a very disturbing image, and I apologize for putting it up, but I want to hammer home the medicalization of the process of murder. This is not a photo of Treblinka, but I want to describe the killing pit at Treblinka. There are no known images of Treblinka. It was destroyed completely after the war and all the records that they could get to were burned, but it's described as having been a train station that looked like a real train station, like people came and went. There were posters that said, vacation in Corsica and as though timetables, as though there were trains coming and going, there were not, of course. This was a dead end stop. It was just a killing center. There was in this train station a door with a red cross over it, which you might think goes to the infirmary, but this was a cynical facade. It in fact led to a killing pit for people who were too weak to walk up to the gas chambers. People who came off the train and needed to be dispatched immediately would be taken to the killing pit and records were kept in which they would literally write, the patient was cured with one pill, meaning murdered with a single shot to the head. And from that level of medicalization of murder, it is maybe less difficult to envision the pieces of this history that are most likely that you've heard of like ramp duty at Auschwitz, which is probably the most famous outside of the experimentation accounts. This is probably the most famous duty of physicians. It was also a duty taken by pharmacists, by nurses, by all the health professionals, essentially took turns doing ramp duty, where they would decide as people came off the train, which ones would go straight to the gas chambers and which ones were healthy enough for forced labor or were twins and were sent for experimentation, that kind of thing. By the way, ramp duty was taken in rotation, but it was not required. There is no record of any physician or anyone else being punished for refusing to do ramp duty, but very few refused. Men like Dr. Hans Munch, who famously declined to do ramp duty, were simply assigned to something else. These two images are perhaps the most disturbing in their cartoons, but they're cartoons that really illustrate this question, because you may be surprised to learn that one of the first things that the Nazis do is to ban vivisection of lab animals in experimentation. So this has the lab animals of Germany saying Heil Goreng, because Goreng had said that he would commit to a concentration camp, anyone who thought they could treat a lab animal as a mere property. So one wonders, what are the Jewish people? What are the Roma, the Sinti, that they can be treated as less worthy of respect even than a lab animal? And here is the answer. Here you see the scientific gaze of the microscope looking down on the Petri dish of society. Here people have become pathogens. So to close this up, I wanna have just a reflection here on the obligations of remembrance. What are our obligations recognizing the integral leading roles that our profession played in bringing about one of, if not the greatest crimes against humanity in human history? And I think there are some contemporary implications that people often talk about, the most famous being consent and the idea of human research subjects experimentation rules coming out of the Holocaust. And there is something about the Nuremberg Code that it does in many people's minds, mark the sort of birth of modern research ethics. But when Dr. Ivy was sent to Nuremberg to testify, as I mentioned, they were looking for human subjects research standards. And he went back to the AMA during the trial and said, we're gonna need some ethics standards around human subjects research. So in December of 1946, in the middle of the trial, the AMA passes this little paragraph of ethical standards for human subjects research. So we did not have these standards. They were created only because we needed them in the context of a trial. And it didn't even work at the trial, by the way, because the prosecutors were good, but the defending attorneys were also very good at their jobs. And they figured out that this was a brand new document. So it didn't even help in terms of the context of the trial. And worse yet, because these were written for Nazi monsters and not for fine upstanding American scientists, and those by the way are quotes from the time, they were not applicable to us. And so for another 30 years after the Nuremberg Code, we continue things like the Willowbrook experiment and the US Public Health Service study at Tuskegee. And this is one of the reasons why it's so important to try to learn from this history. In many ways, I think the ongoing research study at Tuskegee is a result of our inability to learn from the experience of the Nazi doctors. So let me give you a couple of echoes just to spark some thoughts about this. And these are difficult, right? These are not simple answers. These are not simple questions. How do we balance devotion to serving every individual in front of us? And our obligations to the larger community, which are real, right? We can't just take out of this history that the only thing we care about is the one person sitting in front of us and we have no social or societal level responsibilities. We do. In fact, if you wanna boil it down to a really simplistic example, every time I'm seeing one patient, that patient might benefit from me spending some more time with them. But I have other patients who are waiting. So every time I have to say, let's pick up this conversation next time because I have other people I need to get to, I am balancing the needs of the one and the needs of the many, let alone when I make a report on someone's infectious illness to the public health system or when I tell someone that I don't think they're actually safe to drive anymore. These are all areas where we actually do have to balance the needs of the community and the needs of our individual patients. How do we do that in a way that is respectful of this past that where we learned from this past and also where we move forward with, reasonable expectations for all of us. How do we think about novel science like eugenics as a theory, which had this inflated expectations for how it was going to create a new world. This, by the way, this graph is not from medicine so much as from tech, but it's called the hype cycle. And the idea is that people have this tremendous expectation of a new idea that it's gonna change the world. And then they go through the trough of disillusionment and eventually hit a plateau in which you actually are using this new thing. But how do we balance skepticism of new science, humility around new science, but also recognize that science is right sometimes, right? So how do we, we don't want, we also don't want people to be skeptical of climate science, of vaccine science, right? You can see over skepticism, you can also see under skepticism. So what's the right balance of skepticism and humility? What about a professional self-regulation around this? The Nazi doctors were incredibly good at self-regulation. They were terrific at enforcing their professional ethical standards. In the wake of the war, we were terrible at enforcing professional ethical standards. Very few Nazi doctors ever were brought to trial. There was one former Nazi who became president of the World Medical Association, another who almost became president before the AMA and the Israeli Medical Association outed him and we prevented him from becoming president of the WMA. We have a terrible history of actually holding people to the ethical standards that we claim to hold as very dear. And somehow we have to figure out how to apply our ethical standards, recognizing that our ethical standards can be wrong over time as well. What about this issue of professional distance and empathy and the fact that as we go through our training, we do become somewhat inured to human suffering? That's real, right? As you become a doctor, as you become a nurse, in order to do this work, you have to be able to move from one suffering person to another and treat the second person really well and have a smile on your face, even though you're still thinking about that last person. That does cause you to become a little bit hardened. And so we use literature, we use history, we use a variety of techniques for trying to help people retain their humanity while they enter this field. And I'll just end with this quote from Robert Proctor, the Holocaust historian, who said that, you know, I will read this, you all can read the quote, but I'll just add to it that in addition to our ability to understand the origins of these crimes, we also, if we can't learn from this history, we can't apply any of the things that can be learned to the world moving forward. We can't apply them to learning how to create a world in which similar crimes are not likely to arise again in the future. Because I think what we really have to grapple with here is not so much maybe what some people come to this history thinking, if what you've heard of is Mengele, you might think the question is, how do you prevent a few rogue actors from infecting the medical community? But this was not that. The question we have to grapple with here is how did most medical professionals in the most advanced industrialized nation on the planet become murderers together and not despite their training, not despite their ethics, but in the name of medicine and science and public health? I'll just close with that question. Well, thank you, Matt. I mean, obviously that was an unbelievably powerful lecture. And I think, you know, if we wanted to, but not that we're gonna do that today, but it's easy to have a workshop on what happened and what led up to it and what we did. And there's a couple of questions and answers in a minute, but one of the things I think is most fascinating is how something as wanting to have better babies, it's almost like a takeover from agriculture because on the superficial level, it's not really a bad thing to make sure that the kids will live, especially in an era of real life, you know, infant mortality, to do everything we can to really give people like the best opportunity to get a good start in life. So the question is, how does that go, Rogan? And I was trying to find your slide about who early on was involved in it. You've got people like John Harvey Kellogg, Sir William Osler. What was the woman who was the big birth control? Margaret Sainter. Margaret Sainter. You know, I mean, you know, this was in the public domain and on the surface, it's not a bad idea. So the question is how those things get morphed into things that just are unrecognizable. So I'm not, I don't know the answer to that, but I think it's looking at the context and the fact that things are always more complicated than we, you know, we think. So Jay, did you want to say something? Well, I'll just say that, so A, you're right, things are always more complicated than they seem. The roles of, you know, one of the reasons this history is not explored as much as it maybe should be and is not taught as often as it should be is because of the embarrassment, honestly, that the American medical community has in the roles that we played leading up to the Nazi era, which always raises this question of, so why did this happen in Germany? Why did we not see similar events in the US? And I think, you know, on the one hand, it's really helpful to know that, you know, you can be on your way off the rails and yet not go completely all the way there. There are choices, right? We have choices to make along the way. Not every country ended up looking like Nazi Germany. So we made different choices and how did that happen? How did we end up making, you know, different choices? I will also, by the way, just acknowledge we made plenty of terrible choices. Hitler also was very inspired by our treatment of the native peoples of the US. The fact that we, you know, successfully went from millions of indigenous people to only a couple hundred thousand indigenous people over the course of a few generations and we're not blamed for that, that we did not get moral opprobrium for that, that we, you know, that we cast that as, you know, they were savages. We actually killed most of them through unintentionally infecting them with things that they died from, but we also explicitly slaughtered people and did not get called to account for that. So that was inspirational to Hitler. So I don't wanna sugarcoat American history here, right? We have plenty of our own genocide in the past to look at. And we did not trace the eugenics path all the way to that. So why not? And I think one of the answers has to be that we continue to be a relatively free society. So eugenics continue to be a debated scientific theory in the US. There were people who thought it was bunk, right? Who thought it was Hocom, that it was pop science, that it didn't have a real scientific foundation, and those people eventually won the day because, you know, additional research came along that showed they were largely correct, that it was mostly pop science that didn't have a solid foundation. In Germany, they shut that debate down, having a single medical association, having everyone in tune, what they called synchronized, or there's a German word for that that I don't remember, but anyways, that they were very much around this idea of everyone pulling in the same direction. We have never had everyone pulling in the same direction, and that is sometimes extremely frustrating during a pandemic, for example, but it's also a protective mechanism. And so I sort of use that as a consolation prize when I think about how, you know, vitriolic, our debates can be sometimes in the U.S. that it is better to be having vitriolic debates than it is to have everyone in line. Yeah, I agree, I'm gonna read some, while I'm waiting for questions, let me read something from the chat here. And somebody said, we saw this happen very recently with COVID in many states like Alabama, Kansas, and others implemented medical resource rationing. This echoes a crisis similar to the German wartime crisis, the necessity of making quick decisions with limited supplies. These states put into policy that people with disability should be considered lower for lower priority for lifesaving care. Disability orgs had to push back to make sure medical providers weren't using ableist, perceptions of quality of life to deem people with disabilities less worthy of saving. Yeah, I will say, we actually did a program on this in March of 2020, right as the pandemic was getting underway, if you will, in the U.S. about the legacy of Nazis and the treatment of disabled people and the ways in which that ought to inform the development of policies around triage because it was likely that we were going to have to do triage in one way or another. And that we wanted this to be on the table as a warning sign that wars, pandemics, these are moments when you need to hue closely to your ethics and not ignore them because it's where your ethics are most challenged that you really need to maintain the footing. Yeah, I'm gonna let Aseel ask a question. Yeah, thanks, Matt, for this great lecture. So I like the question that you posed about how can we trust science and strike a balance between allowing science to advance while restoring the public's confidence. And so as a result of the past experiments, scientists in Germany could be held criminally liable for collaborating with researchers doing stem cell, developing stem cell therapies outside of Germany. How had the law changed to allow these researchers to continue, you know, provide better chances for debilitating disease as well as sharing the public that it's not necessarily going to go down the same path as it did in the past? Yeah, I think, Aseel, you're bringing up the whole notion of what some call the new eugenics trying to separate. And I shouldn't criticize too much because I don't think it's just trying. I think there are separable factors between the ways in which people use genetic knowledge today to try and improve the lives of everyone who is born, not just those who are deemed to be valuable in society, right? And that's an extremely important distinction. And at the same time, there are concerns with the so-called new eugenics. The idea being that, you know, there are European countries where essentially Down syndrome no longer exists because everyone who has a Down syndrome child has a prior genetic test or, you know, even just an ultrasound and ends up aborting that fetus. So prenatal genetic testing with in combination with ready access to abortion has population consequences. And they're not population consequences determined by the state, right? So the state didn't say you're not allowed to have a baby with Down syndrome. They are population consequences that are derived from the aggregate of individual choices. Those individual choices, of course, are influenced by social conditions and by social norms. And so you can get the same kind of outcome, but without the morally problematic things from the Nazi past. And the question is, is the outcome itself problematic? Is that a bad thing if you have a community in which everyone has come to an implicit understanding that if you do genetic testing on your fetus and you find that you have a Down syndrome child, you abort that child? Is that wrong? It's not wrong in the sense that the state is telling you what to do. It's not wrong in the sense that anyone else is telling you what to do. It's all about individual choice, but it leads to this eugenic consequence. And I don't have an answer to that, by the way. I pose that as a question. I think this is not a question that is liable to have a definitive, what someone calls substantive answer. It is a question that is likely more to have a procedural answer. Meaning there are ways to mitigate some of these risks through establishing processes for decision-making, but without saying what those decisions are gonna be every time. But that's just my rough take on it. Anybody else have any questions? I just wanna, oh, Dr. Hekhmath, go ahead. Yes, can you clarify the situations of dark people like Darwin and Nietzsche and all? I tried a bit of a study to find out where they really these people intentionally where they were or they are people they pulled them or these people wrote something and the people refer to them in order to prove their own ideas. Yeah, and the answer is almost certainly both. That to some extent they were capitalized upon. They had written something and it was cherry-picked, right? So someone took the one quote that was the most supportive and pulled that forward and used it. As we tend to do, by the way, all of us tend to do this, find the one piece of thinking that supports our view and bring it forward and repeat it because we like it because it resonates with us. So I think there are ways in which people who have sort of become infamous as a result of their Nazi association, maybe don't deserve it because the Nazis use them in ways that they didn't intend to be used. On the other hand, these are really smart people. Maybe they should have seen where they were pointing the world, right? And so if you've got someone like Carl Pearson or you've got someone like Nietzsche, it's hard to fault those who fault them for failing to see where this was gonna lead. Thank you. Okay, Paulo Camacho, you wanted to say something? Yes. Well, first of all, thank you so much for that wonderful presentation. It was so wonderful and I learned so much. So thank you. Something I thought that just sort of occurred to me is you were talking about science and has been touched on the relationship between science and our ethics and the fact that the Nazis themselves had an ethical framework from which they were sort of drawing from I think it occurs to me that I mean, this certainly isn't to say that science is value free because it's not, I don't think, but there does seem at least to me to be this sort of chasm between the insight that genetics hold some, or genes or whether it's a Mendelian gene or Crick's gene that has some relationship to an organism's phenotype. The leap from that sort of insight and its relationship to the survival of the fittest and then this sort of eugenicist program, it seems to me that like there is a normative chasm there that needs to be bridged. This sort of normative, I guess, idea that needs to be imported to get from, you know, the theory of natural selection, Mendelian genetics, Crick's genetics, molecular biology to the, oh, you know, we can genetically manipulate a person's genes such that we can turn them into a stronger or make them a member of a stronger race or group. And I guess that's sort of a thought that occurred to me and I just wanted to see what your thoughts were regarding that. Again, I don't mean to say that science is value free or that the individuals, you know, supporting these theses are value free, but yeah, I just wanted to get your thoughts. Yeah, it's such an important area. And unfortunately, like many of the important sort of lessons, I almost hesitate to use that term coming out of this, it is hard to draw a single lesson from this because there is a sense in which, you know, what the Nazis thought they were trying to accomplish was based on science that was just bad. It was, you know, overly simplistic understandings of what comprises a genetic condition and overly simplistic understandings of ideas of race, right, like, which is barely genetic, if at all in its, you know, in reality. And so does that mean that we now that we have a much richer, more comprehensive, complex, albeit still very incomplete understanding of human genetics and, you know, single gene mutations versus multi gene mutations the roles of, you know, epigenetics, does that mean that we should go back and try again to create better, stronger, healthier people, which after all is the whole purpose of medicine is to give people a better chance at a healthier, you know, happier, longer life. Should we use those tools and is the fact that the Nazis use those tools, does that inherently put them off limits because the whole idea is wrong? And, you know, where we are going right now is to say no, it doesn't put them off limits. In fact, we need to be extremely cautious as we move into this new arena of genetic engineering and genetic enhancement. But we're not gonna stop doing that. That's the consensus right now that we are going to use these tools to try to create better, stronger, healthier people. And in the process, we are going to pay more attention to issues of equity and to issues of humility in understanding what we are actually capable of doing with these tools. And, you know, the more I dig into this history, the scarier that all sounds to me, and yet I don't think we're gonna stop. Maybe that is the perfect place to leave it. I know you're gonna come back and talk to the Ethics Fellows at 1.30, so at least you can go and get a lift. Actually, I have to go to a different meeting. Oh, okay. Yeah, sorry. I really wanted to talk to the Ethics Fellows. I'm happy to join you another day. Listen, we will continue to talk about this, but this was terrific, Matt. And one of the things I will do is I will email you after I get some resources for the group for further discussion, because I think this was excellent and timely. And if anything, your research and your interest is shown, especially in the last couple of years, you know, our naivete about these things cannot happen again. Our lived experience has shown that things are happening in our lifetime that many people did not anticipate what happened again, you know, the things in the capital, you know, the pandemic. There are many things we have personally lived through in the last several years that five years ago would have been. We had hoped we were passed. Yeah, absolutely. So on behalf of your friends at the McLean Center and the other people who have now heard you and have learned from you, I wanna thank you so much for coming and really give you kudos for a very stimulating talk. Mark, you can have the last word. Matt, that was fabulous. The entire talk was very moving. I had one question that I was saving for the next, our next meeting, which was of the estimated 6 million Jews who were killed during World War II as part of the medical process. What percent of those might have been killed in Germany as opposed to elsewhere in Europe? Oh, it's a very small number. We're German Jews. I did not mention, by the way, the programs I talked about, the T4 program and so on, killed very few Jewish people. Those were programs aimed at strengthening the German community. They were not aimed at eliminating Jewish people. Jewish people in Germany largely escaped, not entirely, obviously. So just, but on the numbers, the German community of Jewish people was relatively small compared to Poland, for example, or Eastern Europe. Yes. So it was a smaller community to begin with, and they had more time to decide whether they wanted to leave or not. And so a fair number of people got out of Germany before it was no longer possible. And the killing centers, the big killing centers were, as you know, largely outside of Germany. So Auschwitz is outside of Krakow, Poland, Treblinka. So all of these are outside of Germany. And so of the six million, the vast majority were not Germans. Thank you. Fascinating. I had not known that. Yeah. But my deepest thanks for your talk. And thanks, I wanna thank the group for being present and participating. And we look forward to having you visit us occasionally in Chicago. Me too. Thank you all. Thank you.