National Health Care: Medicine in Germany 1918-1945
Does the Modern Bureaucratization of Medicine Risk a Return to the Horrors of National Socialist Medicine?
Marc S. Micozzi, M.D., Ph.D., a physician and anthropologist, directs the National Museum of Health and Medicine in Washington, D.C., which recently brought from Berlin the exhibition, “The Value of the Human Being: Medicine in Germany 1918-1945,” curated by Christian Pross and Götz Aly.
Today we are concerned about issues such as doctor-assisted suicide, abortion, the use of fetal tissue, genetic screening, birth control and sterilization, health-care rationing and the ethics of medical research on animals and humans. These subjects are major challenges in both ethics and economics at the end of the twentieth century. But at the beginning of the twentieth century the desire to create a more scientific medical practice and research had already raised the issues of euthanasia, eugenics, and medical experimentation on human subjects. In addition, the increasing involvement of the German government in medical care and funding medical research established the government-medical complex that the National Socialists later used to execute their extermination policies.
The German social insurance and health care system began in the 1880s under Bismarck. Ironically, it was part of Bismarck’s “anti-socialist” legislation, adopted under the theory that a little socialism would prevent the rise of a more virulent socialism.
By the time of Weimar, German doctors had become accustomed to cooperating with the government in the provision of medical care. The reforms of the Weimar Republic following the medical crises of World War I included government policies to provide health care services to all citizens. Socially minded physicians placed great hope in a new health care system, calling for a single state agency to overcome fragmentation and the lack of influence of individual practitioners and local services. The focus of medicine shifted from private practice to public health and from treating disease to preventable health care. During the German “economic consolidation” of 1924-1928, public health improved under new laws against tuberculosis, venereal disease, and alcoholism, with new advisory centers for chemical dependency and counseling bureaus for marriage and sexual problems.
Medical concerns which had largely been in the private domain in the nineteenth century increasingly became a concern of the state. The physician began to be transformed into a functionary of state-initiated laws and policies. Doctors slowly began to see themselves as more responsible for the public health of the nation than for the individual health of the patient. It is one thing to see oneself as responsible for the “nation’s health” and quite another to be responsible for an individual patient’s health. It is one thing to be employed by an individual, another to be employed by the government.
Under the Weimar Republic these reforms resulted in clearly improved public health. However, the creativity, energy, and fundamental reforms found in social medicine during the Weimar Republic seem in retrospect a short and deceptive illusion. Medical reformers had wanted to counter the misery inherited from the first World War and the Second Empire on the basis of comprehensive disease prevention programs. In the few years available to the social reformers, they had remarkable success. But in connection with these reforms the doctor’s role changed from that of advocate, adviser, and partner of the patient to a partner of the state.
Where traditional individual ethics and Christian charity had once stood, the reformers posited a collective ethic for the benefit of the general population. Private charity and welfare were nationalized. The mentally ill, for example, having been literally released from their chains in the nineteenth century and placed in local communities and boarding houses in regular contact with others (the so-called “moral therapy”), were returned to state institutions to become the ultimate victims of state “solutions.”
With the world economic crisis of 1929, welfare state expenditures had to be reduced for housing, nutrition, support payments, recreation and rehabilitation, and maternal and child health. What remained of the humanistic goals of reform were state mechanisms for inspection and regulation of public health and medical practice. Economic efficiency became the major concern, and health care became primarily a question of cost-benefit analysis. Under the socialist policies of the period, this analysis was necessarily applied to the selection of strong persons, deemed worthy of support, and the elimination of weak and “unproductive” people. The scientific underpinning of cost-benefit analyses to political medical care was provided by the new fields of genetics and eugenics.
Genetics and Eugenics
At the same time as these economic and political developments, the application of nineteenth- century scientific discoveries began to make their way into twentieth-century public health and medical practice. Charles Darwin’s studies on natural selection were of course based upon animal populations living in nature and not human populations living in complex societies. But the biological basis of natural selection gave rise to a concept of “survival of the fittest” in human civilizations. This term was coined by the British social anthropologist Herbert Spencer, and the concept led to “Social Darwinism.”
Darwin’s theories (developed in parallel with Alfred Russel Wallace—another British natural scientist) had been published prior to full elucidation of the principles of genetics. With subsequent understanding and acceptance of the science of genetics, the underlying basis of natural selection could more completely be described. While scientists still did not understand what made up the gene (awaiting Watson and Crick’s discovery of DNA in the 1950s) they began to search for outward expression of inner genetic tendencies. In the absence of being able to pinpoint individual genes, they sought outward expression of genetic “types.” These “typologies” were largely based upon external measurements of the body.
Much of this work was carried out by German anthropologists and physicians (often one and the same at that time) in newly acquired colonies in German East and Southwest Africa, prior to the loss of these colonies to Allied protectorates in World War I. Such work resumed following the war, however, and by 1927 the opening of the Kaiser Wilhelm Institute of Anthropology, Human Genetics, and Eugenics was celebrated in Berlin as the advent of the “German Oxford.” The annual report of the Institute in 1932 stated: “The term eugenics means to establish a connection between the results of the studies in human genetics and practical measures in population policy.”
Under the new “scientific understanding” of human biology provided by genetics and its implementation under eugenics, poverty, for example, would become merely an expression of degeneracy (Entartung) and genetic inferiority. “Inferior” and “superior” became natural terms used by persons of nearly all political persuasions, as readily as the terms “handicapped,” “impaired,” “socially dependent,” or “disadvantaged” are used today.
Life Unworthy of Living
Following World War I there had been concern among some in Germany that the war had decimated the ranks of the qualified and strong while weak, unqualified, and inferior people had been spared. Many felt that scant resources should not be wasted on the sick and suffering. The philosophy of the unimportance of the individual in favor of the people (das Volk) led to the belief that individuals who had become “worthless, defective parts” had to be “sacrificed or discarded.”
Alfred Hoche, a neuropathologist (as Freud had been) and Karl Binding, a lawyer, published a pamphlet in 1922, The Sanctioning of the Destruction of Life Unworthy of Living. Binding relativized the legal and moral prohibition, “Thou shalt not kill,” and Hoche alternated between economic and medical arguments. Neurologists in Saxony formally discussed the topic, “Are Doctors Allowed to Kill?” A physician in Dresden pointed out “the contradiction that many persons (reformers) demand an end to the death penalty for crimes, but the same people are for putting imbeciles [sic] to death.” By the time the National Socialist Party came to power in Germany, the mentally ill and the mentally retarded had begun to be sterilized and to be subjected to euthanasia in large numbers in German government institutions.
National Socialism and the Nation’s Health
No profession in Germany became so numerically attached to National Socialism in both its leadership and membership as was the medical profession. Because of their philosophical orientation toward finding a more scientific basis for medical research and practice, government funding for research, and the practical benefits of acquiring university positions and medical practices from the many banned and exiled German Jewish doctors, many physicians supported Nazi policies. One of the first Nazi laws, passed July 14, 1933, was the “Law for the Prevention of Progeny of Hereditary Disease,” intended to “consolidate” social and health policies in the German population and prohibit the right of reproduction for persons defined as “genetically inferior.” After 1933, the connection between the theory and practice of politicized medicine advocated by many in Weimar Germany became actual in Nazi Germany.
A “Genetic Health Court” consisting of judges and doctors made decisions about forcible sterilization. As “advocates of the state,” doctors prosecuted those persons charged with being “genetically ill” in sessions lasting generally no more than ten minutes and from which the public was barred. In 1935, an adjunct law allowed forcible abortion in such cases up to the sixth month of pregnancy. A total of 300,000 to 400,000 were sterilized and approximately 5,000 (nearly all women) died as a result of these operations. After 1945, it was argued to the Restitution Claims Commission of the German Bundestag that the “Law for the Prevention of Progeny of Hereditary Disease” not be considered in the same category as subsequent National Socialist race laws and other Nazi abuses. The sterilization law had been drafted earlier under the Weimar Republic as part of progressive health reform, and as late as 1961 was defended by an expert at the Max Planck Institute on the basis that “every cultured nation needs eugenics, and in the atomic age, more so than ever before.”
German Youth and Euthanasia
Following the sterilization laws, the National Socialists next implemented a strategy of euthanasia to solve the remaining problem of those whose conception and birth had preceded these laws. The pediatrician Ernst Wentzler, while developing plans to improve care in the German Children’s Hospitals in Berlin, personally decided (as consultant to Hitler’s Chancellery) on the deaths of thousands of handicapped children. Hans Nachtsheim placed delivery orders for handicapped children for his pressure chamber experiments on epilepsy. Joseph Mengele delivered genetic and anthropological “material” from Auschwitz to the Kaiser Wilhelm Institute and conducted his infamous twin experiments on the child victims of the Holocaust.
Julius Hallervorden at the Kaiser Wilhelm Institute for Brain Research at Berlin-Buch carried out several research projects based on euthanasia programs. Hallervorden and others systematically collected the brains of their patients who had been killed, taught the murdering doctors how to dissect, and cooperated closely with institutions where murdered children had previously been given thorough examinations and tests. During interrogation by an American officer in 1945, he stated, “I heard that they were going to do that . . . and told them . . . if you are going to kill all these people, at least take the brains . . . . There was wonderful material among these brains beautiful mental defectives, malformations and early infantile disease. I accepted these brains, of course. Where they came from and how they came to me, was really none of my business.” The collection was until recently kept by the Max Planck Institute (formerly the Kaiser Wilhelm Institute) in Frankfurt and used for brain research.
In a system in which so many were routinely condemned to die, the temptation proved strong to use human subjects in medical experimentation prior to their tragic and terrible deaths.
The Luftwaffe had developed aircraft which could climb to altitudes of nearly 60,000 feet, altitudes unattainable by Allied fighter aircraft. However, tolerance of these altitudes on the part of pilots had not yet been tested. Trials on volunteers at altitudes above 36,000 feet had to be discontinued due to severe pain. For this reason, lethal altitude experiments in pressure chambers were conducted on 200 victims held prisoner in Dachau concentration camp in a program called: “Trials for Saving Persons at High Altitude.”
Many German ships were also being sunk in the North Atlantic and North Sea, and the same group of medical investigators conducted painful ice bath experiments on 300 Dachau prisoners in a research program entitled “Avoidance and Treatment of Hypothermia in Water.” Other medical experiments were carried out with chemical and biological warfare agents and infectious diseases.
Following World War II much of this data was kept classified by Allied military authorities on the basis of national security. Debate continues to this day on the validity of these experiments and the ethical implications of any use of such data.
The Banality of Evil
We now know the end of this historical horror story of massive crimes against humanity and the leader of the thousand-year Reich burning in a bunker in Berlin. But it is not so easy to recognize the steps on the path down the slippery slope when we don’t yet know the end of the story—as today we do not know which social health reforms in combination with which new medical technologies have the potential to plunge modern society over a brink in which disaster might result. Is legalized abortion a new form of medicide? Is doctor-assisted suicide a step toward positive euthanasia? Is modern genetic testing and the Human Genome Project the first step to a new eugenics? Is health care rationing, which is always a result of government involvement in medical care, a step toward the new definition of”life unworthy of living” ? Is our present “quality of life index” a new way of saying it?
Nazi medicine was implemented by a political-medical complex—on the basis of political health care—a scientific and social philosophy imposed by a totalitarian regime. It should never happen again, but could it ever happen again?
In the United States the medical profession operates in a mixed (not a national socialist) economy which does not yet have the institutionalized mechanisms of control and regulation of Weimar Germany and in a democratic political system which thankfully does not have the political ideology of the Third Reich. But the “banality of evil” described by Hannah Arendt in the Third Reich may stem largely from a government bureaucracy in which 90 percent of the people think 90 percent of the time about process—not purpose. Does the modern bureaucratization of medicine hold any real risk for a possible return with new health reforms and new medical technologies—to some of the horrors of National Socialist medicine? Removal of personal responsibility (“I was only following orders”), personal authority, and personal choice in a bureaucratized system may leave less and less room for individual ethics in the conduct of medical science and practice.
Politicized medicine is not a sufficient cause of the mass extermination of human beings, but it seems to be a necessary cause. The Nazi Holocaust did not happen for some inexplicable German reason; it is not an event that we can afford to ignore because we are not Germans or not Nazis. The history of Germany from 1914 to 1945 is a telescoping of modernity from monarchy, war, and collapse to democracy and the welfare state, and finally to dictatorship, war, and death.
Medical ethics is the responsibility of all members of a society, not just doctors and scientists. Medicine and science alone do not have the answers to such questions as: When does life begin? When should it end? Are humans just the sum of their genetic parts or genetic programs? While bioethicists debate, individual medical choices are made a million times a day among doctors, patients, their families, and increasingly the government. The product of all these choices ultimately constitutes the ethical, legal, and social framework in which the practice of medicine and of medical research are conducted. In the end it is the preservation of freedom that will guide us to the best application of new health reforms and technologies in the future.
Dr. Robert Ritter of the German National Department of Health (right) and his associates carried out anthropological measurements and genealogical research. They prepared fingerprints and photographs in order to ascertain the “proportion of gypsy blood” in all of the Sinti and Roma of “Greater Germany.”
Nazi medicine was implemented by a political-medical complex, a scientific and social philosophy imposed by a totalitarian regime.
From The Exhibition, “The Value of the Human Being.”
Comment by Bernard Rosen on 24 August 2009:
Bureaucracies have no use for morality. In the U.S. insurance company bureaucrats deny insurance, and thus timely medical care, for certain pre-conditions. The value sought is not the illusory defect free people, but profit. Both bureaucracies could have functionaries report, \"There\’s nothing persona in this decision.\"
Comment by amnita on 6 October 2009:
hmmmmmm this was very interesting infact i never knew anything about this..thank you so much this really helped in my project
Comment by Terry on 9 November 2009:
The bill that went before the house had an inclusion requiring almost all people in health care services to be fingerchecked and an FBI file opened (this is from volunteers, to janitors, to physicians) I beleive it said it needed to be updated every 2yrs. It had a lot of text dedicated to “Research”, and established a centralized data bank on everyone’s medical information. The “commissioner” was allwed access to this file and ‘any other dept or Agency file” they wanted. This would enable cross checking of people’s religious background, irs records, etc. all in the name of Research. Please comment. Was their any centralized collection of information on health care providers in Germany? Should we be concerned about such a collection of information for “what ever purpose”, and why would such a thing as this requirement even be in a health care bill. Do you see any dangers with any of the above? I also raise questions about ethics of using people’s medical information for ANY research without informed consent. I am a nurse and am concerned about a number of things I read in the bill.
Pingback by Plurality Still Skeptical of Health-Insurance “Reform” : The Freeman | Ideas On Liberty on 25 November 2009:
[...] Timely Classic “National Health Care: Medicine in Germany, 1918-1945″ by Marc S. [...]
Comment by Terry on 27 November 2009:
I want to thank you for re-publishing your article. As I continue to look at the “health care” bill, I am almost overwhelmed at its imiplications. The idea of the entire health care system being under the control and dictates of one person — in the form of the executive “branch” and empowered czars is truely terrifying….and of course…everything is done…for “your own good and the good of society”. I do find it interesting that this years flu shot campaign marks a significant change in marketing. In years past it was always..protect yourself. This is the first year that it has moved to a campaign of something to the effect that …if you love your family, care about your neighbors, you will get the flu shot. It is not longer for ‘Your” protection but for the “good of the society” that you get injected with a substance in which the government has said you have no recourse at all if there is a problem with the vaccine. It has moved into the realm of social obligation. I do still remember thalidomide. I am still left wondering about the cervical cancer injections and the long term effects on an entire generation of young women (and I think I heard someone say it was going to be offered to men for some reason or another.) I’m not necessarily saying there is anything wrong with the flu shot injections, but production and manufacture is done off shore in places where mercury and heavy metal and other contaminations have been a problem with other items. I just learned about Pennsylvania House Bill 492. I find the following paragraph particularly alarming:
(iii) The medical examination or testing shall be
performed immediately upon the order of the public health
authority without resort to judicial or quasi-judicial
authority
(iv) If the public health authority is uncertain
whether a person who refuses to undergo medical
examination or testing may have been exposed to an
infectious disease or otherwise poses a danger to public
health, the public health authority may subject the
individual to isolation or quarantine as provided in this
article.
(2) To require any physician or other health care
provider to perform the medical examination or testing, or
both.
(b) Enforcement.–An order of the public health authority
given to effectuate the purposes of this section shall be
immediately enforceable by any law enforcement officer.
(c) Penalty.–A person who refuses to submit or perform a
medical examination or test under this section commits a
misdemeanor of the third degree.
This is all in the name of emergency measures…it forces not only a person to undergo undertermined “testing” but also forces a medical practitioner to perform the “medical examination” and “testing” or be threatened with arrest.
As a health care practioner…these are very frightening times. Although it may be written with the best of intentions, you know what they say about good intentions.
Again, thank you for your reprint!
Comment by Lois on 29 November 2009:
could this happen again? in the usa?
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I have a project on Maternal Mortality to bring it to zero percent
Are u people interested?
Pingback by PROPONENTS OF EUGENICS,GENOCIDE,EUTHANASIA « Riffenberg's Blog on 12 March 2010:
[...] Kaiser Wilhelm Institute *and Nazi Germany Joseph Mengele delivered genetic and anthropological “material” from Auschwitz to the Kaiser Wilhelm Institute http://www.thefreemanonline.org/columns/national-health-care-medicine-in-germany-1918-1945/ [...]
Comment by Jackson on 30 March 2010:
This entire argument is ridiculous. I will demonstrate:
“The Germans, under Weimar, began building roads. These were not private roads, but roads built by the government “for the good of the people.” Government bureaucrats decided where the roads should be built and who they would benefit. When the Nazis came into power, it was easy for them to continue justifying the building of roads. These roads were used for the war effort, including invasions of Austria, Poland, and France. When the Nazis wanted to round up the Jews, they did it by marching through the streets — streets build by the government. Many Jews traveled to their concentration camps, for at least part of the journey, on these government run roads.
“Politicized road-building is not a sufficient cause of the mass extermination of human beings, but it seems to be a necessary cause. If we allow our government, in America, to build roads, we are surely on the slippery slope to enslavement and holocaust, and it will all be because you people didn’t stand up and tell the government not to build roads.”
If you find this argument compelling, please take a course in remedial logical fallacies.
Comment by Ted on 30 March 2010:
Most of Europe adopted socialized healthcare at the same time as Germany, or in the following decades, yet only Germany created a war of empire-building, combined with an internal holocaust.
To claim that socialized healthcare is a “necessary cause” of the holocaust is a bald-faced distortion of the truth.
This article is shameful.
Pingback by Capitol Report July 28, 2009 Rationing Healthcare on 2 May 2010:
[...] provides some answers. We can look at Cuba, the Soviet Union, Nazi Germany, or more recently, Canada.  Proponents of government-rationed healthcare seldom promote it based [...]
Comment by Tom Langley on 13 June 2010:
I searched ‘Max Planck Institute’ and discovered they retained the Kaiser Wilhem Institute’s brain collection through 1990. Talk about shivers up and down your spine.
And we have a president (while in the Illinois legislature) who favors abandoning a child to die when the attempt to kill it via abortion fails. I must ask myself how far away we are from the atrocities of the Nazi’s.
Comment by David Edward Garber on 14 July 2010:
Sadly, this article is even more relevant now than it was in 1993.
When I attended some health care town hall meetings in Utah in 2008, the hosts voiced some worrisome concepts like those discussed in this article, such as whether or not it was worth the cost to our society to grant as much health care to the elderly as “we” currently do. I can see America treading this same collectivist path, sadly.
I’d be very curious to see just how closely Obama’s new corporatist health care plan (or Schwarzenegger’s or Romney’s before it, for that matter) parallels that of Nazi Germany, point by point.
Pingback by Unified Discussion Is Natural Selection a Belief or a Fact on 16 October 2010:
[...] program and national healthcare as well. They began getting rid of unwanted components of society. http://www.thefreemanonline.org/colu…ny-1918-1945/# It's interesting to see that some comments appear to actually be wading that way and I'm truly [...]
Pingback by Lest We Forget: Liberal Progressive ‘Science’ Was At The Core Of The Holocaust « Start Thinking Right on 19 October 2010:
[...] eugenics movement devised and championed by 20th century American progressive liberal Democrats also embraced the government health care and embraced the environmental movement championed today by 21st century American progressive [...]
Comment by Tucker on 19 March 2011:
Regardless of how people feel about health care reform it is worth noting that the first two things the Nazis did once in power was ban unions and outlaw abortion. If one is to make Nazi analogies let’s continue and take an honest comparison.
Pingback by Energy « incapp.org on 20 March 2011:
[...] Coal to oil is a possibility but environmentalists have labeled it as Nazi oil, because the Nazis used this technique to produce oil for their industry when the Allies had destroyed Germany’s access to the sources of oil. The label seems to have weight because no plant has been successfully permitted in the USA that I know of. But I never hear anyone, except me, calling nationalized healthcare Nazi healthcare, even though it was the Nazis the introduced single payer to Europe. [...]
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Comment by Claire Solt PhD on 13 March 2012:
Ironically, the progress of genetic science since that time nullifies those policies. First, genetics shows that the best genes are selected in forming new organisms and undermines the idea that “defectives” only produce like organisms. In fact, evolution could not happen, if the former were, in fact, true. Second, human genome science argues powerfully for the individual as the basis of humanity, as DNA is unique to each person, as far as we know.
Comment by Alex on 13 March 2012:
Solt,
Since you found it necessary to include your alleged degree with your name, I feel obligated to ask: in what online school did you purchase that PhD? The four lines you wrote are so full of pseudo-scientific nonsense I won’t even bother refuting it.
What does this sentence — “Second, human genome science argues powerfully for the individual as the basis of humanity, as DNA is unique to each person, as far as we know” — even mean?
Pingback by The Sixties Radical-Obama Care-The Death of The Constitution « Thegeeman's Blog on 27 March 2012:
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