The concept of medicalization rests on the assumption that some phenomena belong in the domain of medicine and some do not.

However, where a thing “belongs” is the result of how we classify the “thing,” that is, the result of (more or less arbitrary) human action. Is an anencephalic baby a human being? Is smoking crack a crime, a disease, a right? Answering such questions is what religion, politics, and, today, medical ethics are all about. The point to keep in mind is that, unless we agree on clearly defined criteria that define membership in the class called “disease” or “medical problem,” it is fruitless to debate whether any particular act of medicalization is “valid” or not.

Everything that we do or happens to us affects or depends on the use of our body. In principle we could treat everything that people do or that happens to them as belonging in the domain of medicine. Conversely, we could maintain that nothing that we do or happens to us belongs in the domain of medicine because all is ordained by God and belongs in the domain of religion. Such, indeed, was the case in ancient times, before people distinguished between faith healing and medical healing. A similar view is held today by Christian Scientists, whose faith is based on a radical denial of the reality of the material world. For them, only the spiritual realm exists or is “real.” Nothing belongs in the domain of materialist medicine. Christian Science represents the most radical case of demedicalization possible.

Contemporary public health is the mirror image of Christian Science. Everything in our lives—housing, food, education, work, recreation, and procreation—affects our health. Hence, everything—not only health care narrowly defined—belongs in the domain of medicine as health care. Linda Landesman, a former president of the Public Health Association of New York City, states: “We expect and demand that government ensure that we breathe clean air, drink safe water, work with minimum danger . . . . Left on our own, we don’t always make the healthiest choices.” In this view, we are uninformed, undisciplined children whose health and well-being require the unremitting protection of the therapeutic state.

In practice we must draw a line between what counts as medical care and what does not. The question is where to draw that line. What is a disease and what is not? What should be treated medically, by physicians or medical personnel, and what should not? Because people in modern societies expect the state to defray all or most of the cost of what is deemed a “medical service,” where we draw the line between “health care” and “not health care” is informed more by economic and political considerations than by medical or scientific judgments.

Moreover, not only must we demarcate disease from nondisease, we must also distinguish between medicalization from above, by coercion, and medicalization from below, by choice. Not by coincidence, these strategies match psychiatry’s two paradigmatic legal-social functions, civil commitment and the insanity defense, social control and excuse-making.

Disease and the Patient Role

The difference between disease as objective physical condition and the patient role as social status is obvious, provided we are willing to recognize it. Having a disease and occupying the patient role are independent variables: not all sick persons are patients, and not all patients are sick. Physicians, politicians, the press, and the public nevertheless continue to confuse and conflate the two categories. This is a cultural setting conducive to the growth of medicalization.

Medicalization is a two-way street. Until recently, homosexuality was considered a disease. Today it no longer is. Has it been cured out of existence? No. It has been demedicalized. At the same time, hundreds of behaviors never before treated as medical problems are now diagnosed as diseases: for example, “gender disorder” and “substance abuse.” Have these new diseases been discovered? No. They have been invented; that is, they are the products of medicalization.

Ironically, technological advances in medicine, combined with the conflation of the concepts of disease and patient role, facilitate not only medicalization but also confusion between discovering diseases and creating diagnoses. As a result, when a behavior categorized as a disease is “declassified”—as happened with homosexuality—journalists, science writers, and the public are easily persuaded by the stakeholders in medicalization that demedicalization is also a product of scientific progress and moral enlightenment, and not the product of a power struggle between stigmatizers and stigmatized.

Neither medicalization nor demedicalization is a new phenomenon. Formerly, people spoke about imaginary diseases and persons who pretended to be ill. Molière (1622–1673), the great satirist of malingerers and of the quacks whose harmful ministrations they invite, titled one of his plays The Imaginary Invalid (Le malade imaginaire).

Although medicalization encompasses much more than psychiatry, we must be clear about one thing: Psychiatry is medicalization through and through. Whatever aspect of psychiatry psychiatrists claim is not medicalization can only be such if it deals with proven diseases of the central nervous system, which belong to neurology, not psychiatry. (Psychoanalysis and other forms of psychotherapy, qua medical practices, are of course also instances of medicalization.)

Semantic-Social Strategy

In short, medicalization is not medicine or science; it is a semantic-social strategy that benefits some persons and harms others. In the past the persons most clearly benefiting from medicalization were psychiatrists and the persons most obviously injured by it were mental patients. “[T]he medical treatment of [mental] patients began with the infringement of their personal freedom,” observed Karl Wernicke (1848–1905), the pioneer German neuropathologist. Today the situation is more complex, more “democratic.” Anyone may, at some time, be helped or harmed by medicalization; the only consistent gainers from it are the agents of the therapeutic state.

Formerly the priest was both protector and punisher. Today the physician plays both roles. Formerly people could not imagine living in a society unguided and uncontrolled by God: church and state formed a holy union called “theocracy.” Today people (in the West, but not in the East) cannot imagine living in a society unguided and uncontrolled by science, especially medical science: medicine and the state form a “healthy union” called “pharmacracy.”

The physician’s job, among other things, is to help: cure disease with the consent of the patient. The judge’s job, among other things, is to harm: punish lawbreaking without the consent of the defendant. (Physicians and judges have other jobs as well, such as performing autopsies and protecting due process.) When judges sentence lawbreakers to treatment—“drug rehab,” “counseling,” “therapy”—they punish the subjects. When psychiatrists and other mental-health professionals implement the sentences, they harm the “patients.”

Let us keep our language and ideas clear. Wardens who carry out sentences imposed by judges harm their prisoners, regardless of the outcome of the intervention. Psychiatrists who carry out sentences imposed by judges also harm their patients, regardless of the outcome of the intervention. In each case, an agent of the state—prison or mental-health personnel—forces a subject to submit to legally mandated coercion. The difference is that jailers do not claim to be their prisoners’ benefactors, whereas psychiatrists insist that they are the benefactors of their involuntary patients. Herewith a few recent examples.

Wisconsin—Audrey Seiler, 20, a student at the University of Wisconsin in Madison, is found guilty of faking her own abduction, a crime that led to a “massive manhunt shown live around the nation. . . . She first told police she had been abducted from her apartment at knifepoint, then later said she had left on her own but was abducted elsewhere in Madison. . . . She never fully admitted to police that the story was a hoax, but was seen on a convenience store security video purchasing rope, duct tape and other items she had claimed her kidnapper used to restrain her.” Her attorney said, “Seiler was suffering from depression triggered by the death of a close aunt a year and a half ago, as well as her transfer to Madison, which took her too far away from her family.” She is sentenced to “continue therapy” (and to some restitution and community service). (See www.cnn.com/2004/LAW/07/01/missing. student.sentence/; July 1, 2004.)

California—Singer Courtney Love, found guilty of “trying to break into her ex-boyfriend’s home while high on cocaine,” is sentenced to 18 months in “drug rehab.” (International Herald Tribune, July 29, 2004, p. 9)

France—Marie-Leonie Leblanc, found guilty of falsely claiming “that she had been a victim of a vicious anti-Semitic attack,” is ordered “to undergo psychiatric treatment.” (International Herald Tribune, July 27, 2004, p. 3)

Scotland—A teenage girl giving evidence in a courtroom swears at the judge and tells “him where to go.” Her sentence? Probation for a year and an order “to attend anger management classes.” (http://news.bbc.co. uk/1/hi/magazine/3569250.stm; August 16, 2004)

Sweden—The lawyer for Mijailo Mijailovic, who killed Swedish Foreign Minister Anna Lindh, “argued that his client—under the influence of a cocktail of anti-depressants when he stabbed Lindh—did not intend to kill her. . . . Anders Forsman, an expert with the National Board of Health, said Mijailovic was seriously mentally ill.” In a unanimous decision, the Swedish Court of Appeals rules that the defendant “had acted on an impulse. . . . No motive for the deed has emerged.” Sentenced “to psychiatric care, Mijailovic will be moved to a hospital forensic psychiatry ward for analysis [sic]. . . Hypothetically, he could be set free in six or seven months.” (International Herald Tribune, July 9, 2004, p. 3)

Therapeutic Jurisprudence

The idea of using psychiatric treatment as punishment is not new. Only the practice of it is. Two hundred years ago, Benjamin Rush (1746–1813), the father of American psychiatry, declared: “Were we to live our lives over again and engage in the same benevolent enterprise [politics], our means should not be reasoning but bleeding, purging, low diet, and the tranquilizing chair.”

In recent decades, this brutality masquerading as humanism has been elevated to a special branch of legal studies. Law professors David B. Wexler and Bruce J. Winick call it “therapeutic jurisprudence” and define it as “the study of the role of the law as a therapeutic agent.” However, therapeutic jurisprudence is not about studying the law; it is about perverting justice and law. The practice of therapeutic jurisprudence epitomizes the ethics of primum nocere—harming patients but defining it as helping them.

Most persons experience their coerced psychiatric treatment as punishment. That is why psychiatrists insist that the persons subjected to psychiatric coercion are psychiatric patients, not psychiatric victims; that psychiatric coercion is treatment, not punishment; and that individuals who oppose their “benevolence” are wicked enemies of caring for the sick, not defenders of liberty and justice. He who controls the vocabulary controls social reality.

The erosion of our liberties is not a mystery. Overwhelmingly, it is the result of the alliance between medicine and the state, intensifying people’s dependency on pharmacratic authority and psychiatric controls, fostering and fostered by a hyperinflationary definition of disease and treatment.

When the government controls religion, not only religious liberty but all liberty becomes a chimera. When the government controls health, not only medical liberty but all liberty becomes a chimera.

The Model State Emergency Health Powers Act, proposed by the Centers for Disease Control and Prevention (CDC), would provide a state’s governor with sole discretion to declare a public-health emergency. Once the emergency was declared, public-health officials would assume police powers, the militia would be mobilized, and the legislature would be prohibited from intervening for 60 days. Any new orders and rules issued by the governor would have the full force of law. Existing laws and individual rights could be suspended.

To promote the legislation, state officials and legislators have related it almost exclusively to the threat of bioterrorism. But broader authority is proposed. The new powers would be authorized during any declared public-health emergency. An emergency could be declared with the occurrence or imminent threat of a health condition or illness that is believed to be caused by bioterrorism, or the appearance of a novel, previously controlled, or previously eradicated infectious agent or biological toxin. That belief is the only criterion. And although there must be potential for a large number of people to be affected, there is no definition of “large number.” The governor, in consultation with health officials, would decide.

The 40-page proposal would require individuals to submit to state-ordered vaccinations, examination, testing, treatment, and specimen collection. Resisters would be charged with a misdemeanor and quarantined. Physicians and other health-care professionals would be required to perform medical procedures or be charged with a misdemeanor.

Quarantine, or isolation, could be imposed without a court order, although an order would have to be obtained “promptly” thereafter. Medical care could be rationed or withheld; private property could be taken or destroyed; compensation for loss of property would be limited; and no person acting under the orders of government officials would be held liable for death, injury, or property damage.

The names, addresses, and physical conditions of, and any other necessary information about, individuals suspected of harboring diseases or health conditions that might have been caused by bioterrorism or an epidemic would have to be reported immediately by doctors and pharmacists. No patient consent or notification would be required.

The public first got wind of the government’s plan when the CDC published a draft proposal last October. What began as a murmur of concern through e-mail soon became a wave of opposition around the country. The Health Privacy Project at Georgetown University took the first shot. It sent a letter to Lawrence Gostin, author of the proposal and director of the CDC’s Center for Law and the Public’s Health at Georgetown University. The letter attacked the draft’s lack of definitions for “epidemic” and “pandemic,” terms critical to determining when an emergency could be declared. It also expressed concern over the “breathtakingly expansive scope of the definition of ‘public health emergency.’”¹

Final Details Unveiled

On December 21, the CDC unveiled its final proposal. Responding to public criticism, the wording had been softened and the definitions made less vague, but there were few substantive changes. In fact, some sections are more egregious than before.

Due process is virtually eliminated. Health officials could pluck citizens out of their homes, place them in quarantine, and need not apply for a court order until ten days later. Nothing specifically would prevent officials from using quarantine or its threat to coerce individuals into submitting to medical procedures they would otherwise refuse. And although a court hearing would be required 48 hours after the court order was received, health officials could request a delay.

Doctors, other health professionals, and health-care institutions would also face coercion. If they refused to follow state-ordered medical directives, officials could strip them of their licenses to practice or operate in the state. On the order of an official, those who take an oath to protect patients might be compelled by state law to harm them (such as by administering a vaccine or performing a high-risk procedure). If a physician questioned directives, followed his conscience, advised citizens to refuse, or obstructed the plans of state officials, he could end up flipping burgers to support his family.

Additional provisions of the final proposal are just as alarming. Isolation of the sick and quarantine of the exposed must be in different locations, assuring the separation of children and parents. As in the first draft, state officials could ration care, initiate continuing health surveillance, commandeer and control medical supplies, and confiscate personal property. And although the misdemeanor charges were dropped for citizens who don’t comply with medical procedures, those who refuse to submit to quarantine and isolation could still be charged with a crime.

The media soon sounded the alarm. By January 2002, the San Francisco Chronicle had warned of endangered civil rights. Investor’s Business Daily called the bill “unhealthy tyranny.” Jewish World Review said it is a “prescription for disaster,” and the Wall Street Journal reported that a “new battleground” had been created between health officials and civil libertarians. In early April, Time magazine covered the issue of detention powers in an article aptly titled “Mr. Quarantine, meet Miss Liberty.”

Public-policy groups began to rally their constituents. The American Legislative Exchange Council (ALEC), a group of 2,400 conservative state legislators, opposed the model act and set up a Web page to track the legislation in every state.² The Eagle Forum dedicated an entire radio program to the issue. The Free Congress Foundation denounced the act as a “bad idea.” The Association of American Physicians and Surgeons expressed concern about granting governors “dictatorial power.” And the Institute for Health Freedom warned of “new state medical police powers.”

Proposal Defended

Gostin defended the proposal’s purported modernization of the public-health laws. In the December Insight magazine he claimed the September 11 attack had one silver lining: “The political community is coming together with a clear determination to protect the civilian population from harm.”³

In a classic doublespeak, Gostin also claimed that data-privacy safeguards would be in place. But his proposal would permit state public-health agencies to share an individual’s medical information with law-enforcement officials, other government agencies, and public-health officials in other states.

The CDC reportedly agreed to pay Gostin $300,000 a year for up to three years to write the model act.⁴ He is professor of law at Georgetown and Johns Hopkins universities and sits on the Institute of Medicine’s Committee on Assuring the Health of the Public in the 21st Century.

Expanded health powers have long been on Gostin’s agenda. The CDC Center for Law and the Public’s Health, which he heads, spent the past couple of years culling existing state public-health laws in order to write a uniform comprehensive law that all states could enact. In 1998 Gostin co-wrote a paper proposing that states provide health officials with “a broad and flexible range of powers. By equipping public health authorities with graded powers ranging from isolation, quarantine, and directly observed therapy to cease-and-desist orders or mandated counseling, education, or treatment, authorities will be able to tailor interventions to the specific situation and disease threat.”⁵

Health surveillance is the key. To identify emerging health threats, Gostin claims government officials must be empowered to monitor the most minuscule medical details of American life. “If there’s a run on anti-diarrhea medications, how would [the federal government] know that?” Gostin asked.⁶ Therefore, the health-powers proposal would require an active disease-surveillance system, forcing doctors, hospitals, and pharmacists to share patient data with state health officials.

The Bush administration likes the idea of health surveillance, and in January the Department of Health and Human Services made $1.1 billion available for bioterrorism preparedness. Federal funding will be directed to, among other things, the development of round-the-clock disease-reporting systems involving hospital emergency departments, state and local health officials, and law enforcement.⁷

Thus far, Arizona, Florida, Georgia, Louisiana, Maine, Maryland, Minnesota, New Hampshire, South Dakota, and Utah have passed versions of the CDC proposal. Nine states-Connecticut, Idaho, Kentucky, Mississippi, Nebraska, Oklahoma, Washington, Wisconsin, and Wyoming-have defeated similar legislation. In 13 states, bills are pending in the legislature, and officials in five more are considering whether to introduce legislation.⁸

Battle in Minnesota

In Minnesota, where several citizen health-policy organizations exist, the legislative battle was intense. While the commissioner of health tried to shepherd the bill to passage by personally attending every hearing, citizens repeatedly testified against it. Health-care professional associations were unethically silent, asking only for immunity from lawsuits.

The original 44-page bill was cut to nine pages in the Senate and 11 pages in the House. Requirements that health-care professionals provide, and citizens submit to, medical examinations, vaccination, and treatment were deleted. A right to refuse such procedures was added. Legislators demanded authority to rescind the governor’s declaration. And a provision allowing the governor to endow a “designee” with the governor’s authority to issue orders and write rules was removed.

The legislature initially voted to return the bill to conference committee–a signal that the bill was dead. However, last-minute amendments to appease gun owners and AIDS activists were added and the bill passed on the final day of session. The legislation allows broad declaration authority for public-health emergencies, commandeering of private property, unprecedented empowerment of the governor, and year-around authority to impose quarantine and isolation-without a court order or declaration of a public-health emergency.

The potential effectiveness, or lack thereof, of the CDC’s heavy-handed proposal has received little attention. The inauspicious, at times violent, history of martial law has been ignored. Disregarding human nature and all wisdom to the contrary, health officials continue to march a top-down command-and-control proposal across the nation.

Public trust requires thoughtful contingency plans that uphold constitutional rights and freedom of conscience, support medical ethics, and encourage voluntary cooperation with disease containment strategies. State legislatures should not rush to enact ill-conceived, ineffective legislation. Public policy must always recognize and respect the rights, dignity, and intelligence of individuals. An angry public is not a cooperative public. If health officials are empowered to harm the very people legislators want to protect, a public-health emergency may soon become a crisis of the public’s trust.

Twila Brase, R.N. is president of the Citizens’ Council on Health Care, a free-market health-care policy organization in St. Paul Minnesota (www.cchconline.org).

Notes

1. Letter from Health Privacy Project to Lawrence O. Gostin, November 7, 2001.
2. See www.alec.org.
3. Lawrence O. Gostin, “YES: New Laws Are Needed to Enable Federal and State Agencies to Work Together in an Emergency,” Insight, December 18, 2001.
4. Meryl Nass, “The Model Emergency Health Powers Act Creates Its Own Emergency,” redflagsweekly.com, April 8, 2002; www.redflagsweekly.com/nass/2002_april08.html
5. Lawrence O. Gostin et al., “Improving State Law to Prevent and Treat Infectious Disease,” Milbank Memorial Fund, 1998, p. 2.
6. Quoted in Matt Mientka, “CDC Releases Model Bioterrorism Law,” U.S. Medicine, December 2001.
7. “HHS Announces $1.1 Billion in Funding to States for Bioterrorism Preparedness,” HHS Press Release, U.S. Department of Health and Human Services, January 31, 2002.
8. See the map at the American Legislative Exchange Council website, www.alec.org.

The Nazi “accomplishments” include the establishment of medical registries (that is, databases) and medical surveillance, both later used for “euthanasia,” and the linkage of occupational diseases and cancers to environmental poisons. The author, professor of history of science at Penn State, also details how Nazi scientists were the first investigators to link and ultimately prove with elegant epidemiological studies that cigarette smoking causes lung cancer.

Armed with scientific proof, Nazi officials moved aggressively in an all-out campaign against cigarette smoking, and tobacco was proclaimed an “enemy of the people” (Volksfeind). As the author states early in his prologue: “The participation of doctors in Nazi racial crimes is disturbing, but it is equally disturbing that Nazi doctors and public health activists were also involved in what we today might regard as ‘progressive’ or even socially responsible [programs].” But what disturbs Proctor is that he is uncomfortable in the company of some of history’s foremost butchers, for he shares with them the view that it is permissible to use state power for the advance of “public health.”

Proctor points out German physicians and scientists produced genuine medical research, not only during the Nazi era, but long before that. Through much of the nineteenth and twentieth centuries, Germany led the world in scientific achievements, particularly medical research. Nevertheless, those accomplishments must be viewed within their ethical, moral, and historical context. Proctor writes almost dispassionately and always objectively, as the science historian he is. Unfortunately, this book lacks the perspective of a medical ethicist. As a neurosurgeon with a background in medical history and a more than passing interest in medical ethics, I don’t see the Nazi “achievements” in the same positive light that the author does.

The subject of “bioethics” and “medical ethics” and their long-term consequences to German society (or for that matter ours) are not broached in this book until the very end, and then the author’s discussion is contained within only two pages. He even reproaches medical ethicists when he adds: “Bioethical discussions are full of facile identifications of Nazism with everything from abortion and rationalized medicine to doctor-assisted suicide.” That is, Proctor declines to discuss the ethics of the Nazi war on cancer because he dislikes the fact that some medical ethicists have gone too far in linking practices and policies they abhor with Nazism.

I side with the medical ethicists and with those souls, not all of them libertarians as the author implies, who are troubled by further government efforts in our country to protect us from ourselves—for the good of “society”—at the expense of our autonomy and liberties. In Proctor’s utilitarian calculus, freedom evidently counts for nothing. It counted for nothing to the Nazis, too.

Consider that the Nazis themselves declared that occupational medicine, one of the disciplines dear to their hearts, was to make a “worker who would remain productive until retirement and then pass away shortly thereafter.” The aim of the Nazis was “to reduce the difference between the age of retirement and the age of death ideally to zero.” And those were the lucky ones—the members of the master race. For the rest of the expendable “undermen” there was slavery, ghastly medical experimentation, and death in the abominable concentration camps.

There is danger in the unholy partnership of the medical profession and government planners, namely the perversion and subversion of the medical sciences and public health for the new collectivist ethics of population-based medicine. Once medical professionals ally with the state and abandon the individual-based ethics of Hippocrates in favor of the collective good, or as the Nazis put it, “the health of the nation,” the stage is set for a terrible drama.

Parallels must be drawn with our present situation, as much as the author wants to avoid it. In the areas of public health, the politicization of AIDS policy, mandatory vaccine programs, biased research on guns (and its publication in medical journals), and so on, the U.S. government is following the Nazi precedent by casting aside our cherished concepts of individualism in a quixotic crusade for “the common good.”

I strongly recommend this book, particularly to history buffs and those interested in the perpetual struggle between the individual and the state. Its history is immensely valuable, even if the author fails to draw the right conclusions. []

Miguel Faria, M.D., is editor-in-chief of the Medical Sentinel, published by the Association of American Physicians and Surgeons (AAPS), and author of Vandals at the Gates of Medicine: Historic Perspective on the Battle Over Health Care Reform and Medical Warrior: Fighting Corporate Socialized Medicine.

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.”