Jewish, Hippocratic, Nazi and Contemporary Secular Bioethics Principles
Sheldon Rubenfeld, M.D., Clinical Professor of Medicine, Baylor College of Medicine
German physicians played a central and critical role in the design and implementation of the medical crimes of the Third Reich, including the Holocaust. They developed programs to sterilize 400,000 German citizens, prevent marriages between Aryans and non-Aryans, perform cruel and murderous experiments on tens of thousands of prisoners, and euthanize 200,000 German children and adults. The gas chambers and expertise developed for the euthanasia programs were subsequently utilized in numerous concentration camps to murder Jews, Roma, homosexuals, blacks, Jehovah’s Witnesses, and other “lives not worth living”.
German physicians justified their actions by transforming the traditional Hippocratic doctor-patient relationship into the state-Volkskörper relationship, by the loyalty oath to Hitler that superseded the covenant relationship inherent in both Hippocratic and religious medical ethics, and by highlighting the cost of caring for those with alleged undesirable genetic traits. As a result of the shift in focus from caring for the patient to caring for the state, Nazi bioethics elevated quality of life above life itself and simultaneously provided moral justifications for the most egregious violations of medical ethics.
One might expect that after the Nuremberg Doctors’ Trial both traditional religious and Hippocratic medical ethics would be reclaimed and reinvigorated, but that is not what happened. The covenantal doctor-patient relationship and the supreme value of human life, both essential to traditional religious and Hippocratic medical ethics, were replaced as early as 1948 by the World Medical Association’s Declaration of Geneva, which lacks a theological center.
In addition, the Nuremberg Code created at the Doctors’ Trial was widely ignored in the United States and elsewhere in the Western world until Henry Beecher’s 1968 paper in the New England Journal of Medicine and a 1972 newspaper article about the Tuskegee Syphilis Experiment highlighted American human subjects research scandals. Concern over the treatment of human subjects led to the 1978 Belmont Report and a new principlist bioethics that is highly skeptical of prior ethical systems. For example the opening of the fifth edition of Principle of Bioethics states that “these writings are inadequate for contemporary biomedical ethics.”
The principlist approach of the new bioethics contrasts with Judaism’s and Hippocratic casuistic approach and, in its reliance on a dominant principle other than life—autonomy—bears some similarity to the National Socialist reliance on eugenics.
If we “principlize” Jewish, Hippocratic, and Nazi medical ethics, then the comparison to contemporary secular bioethics looks like this:
LIFE nonmaleficence beneficence justice
nonmaleficence beneficence
EUGENICS nonmaleficence beneficence justice
AUTONOMY nonmaleficence beneficence justice
Displayed this way, the importance of the dominant principle in the definition of the other principles becomes apparent, as do the consequences of those definitions. For example, according to Judaism and the Hippocratic oath, the dominant value of life forbids euthanasia; eugenics virtually obligates involuntary euthanasia of selected individuals; and autonomy permits voluntary euthanasia on a case-by-case basis.
This and other contemporary consequences of the abandonment of traditional religious and Hippocratic medical ethics after the Holocaust will be discussed.
German physicians played a central and critical role in the design and implementation of the medical crimes of the Third Reich, including the Holocaust. They developed programs to sterilize 400,000 German citizens, prevent marriages between Aryans and non-Aryans, perform cruel and murderous experiments on tens of thousands of prisoners, and euthanize 200,000 German children and adults. The gas chambers and expertise developed for the euthanasia programs were subsequently utilized in numerous concentration camps to murder Jews, Roma, homosexuals, blacks, Jehovah’s Witnesses, and other “lives not worth living”.
German physicians justified their actions by transforming the traditional Hippocratic doctor-patient relationship into the state-Volkskörper relationship, by the loyalty oath to Hitler that superseded the covenant relationship inherent in both Hippocratic and religious medical ethics, and by highlighting the cost of caring for those with alleged undesirable genetic traits. As a result of the shift in focus from caring for the patient to caring for the state, Nazi bioethics elevated quality of life above life itself and simultaneously provided moral justifications for the most egregious violations of medical ethics.
One might expect that after the Nuremberg Doctors’ Trial both traditional religious and Hippocratic medical ethics would be reclaimed and reinvigorated, but that is not what happened. The covenantal doctor-patient relationship and the supreme value of human life, both essential to traditional religious and Hippocratic medical ethics, were replaced as early as 1948 by the World Medical Association’s Declaration of Geneva, which lacks a theological center.
In addition, the Nuremberg Code created at the Doctors’ Trial was widely ignored in the United States and elsewhere in the Western world until Henry Beecher’s 1968 paper in the New England Journal of Medicine and a 1972 newspaper article about the Tuskegee Syphilis Experiment highlighted American human subjects research scandals. Concern over the treatment of human subjects led to the 1978 Belmont Report and a new principlist bioethics that is highly skeptical of prior ethical systems. For example the opening of the fifth edition of Principle of Bioethics states that “these writings are inadequate for contemporary biomedical ethics.”
The principlist approach of the new bioethics contrasts with Judaism’s and Hippocratic casuistic approach and, in its reliance on a dominant principle other than life—autonomy—bears some similarity to the National Socialist reliance on eugenics.
If we “principlize” Jewish, Hippocratic, and Nazi medical ethics, then the comparison to contemporary secular bioethics looks like this:
LIFE nonmaleficence beneficence justice
nonmaleficence beneficence
EUGENICS nonmaleficence beneficence justice
AUTONOMY nonmaleficence beneficence justice
Displayed this way, the importance of the dominant principle in the definition of the other principles becomes apparent, as do the consequences of those definitions. For example, according to Judaism and the Hippocratic oath, the dominant value of life forbids euthanasia; eugenics virtually obligates involuntary euthanasia of selected individuals; and autonomy permits voluntary euthanasia on a case-by-case basis.
This and other contemporary consequences of the abandonment of traditional religious and Hippocratic medical ethics after the Holocaust will be discussed.