Lessons from the Holocaust for perinatal care today.

Abstract

The Second International Scholars Workshop on Medicine during the Holocaust and Beyond (7-11 May, 2017) culminated with the launch of the Galilee Declaration (http://english.wgalil.ac.il/category/Declaration) endorsed by historians, health care professionals, educators, and ethicists. The Declaration calls for Medicine in the Holocaust, and its implications, to be included in medical education. Subsequently, UNESCO Bioethics, Medical Ethics and Health Law Conferences have included sessions on Medicine and the Holocaust. Reis et al1 exposed the importance of this teaching not only to emphasize medical ethics but also to illustrate just how easily doctors, midwives, and nurses became a party to, and ardent collaborators with, the Nazi genocide of those regarded as inferior to the “Aryan” ideal, and particularly Jews. Nazi obstetricians, midwives, and nurses were an integral part of the genocide against Jews and instrumental in its effectiveness. In Germany, 45% of physicians joined the Nazi party compared with 7% of teachers.1 The Nazis used, and abused, reproduction to achieve their ideological goal of creating a “Master” “Aryan” race.2 They prevented women and men regarded as not meeting idealized Nazi racial standards—and particularly Jewish women—from having children through legal, social, psychological, and biological means, and by murder.2 Imposing measures to prevent births is included in the definition of genocide found in Articles II and III of the 1948 United Nations Convention on the Prevention and Punishment of Genocide.3 Doctors, midwives, and nurses played a central role in manipulating reproductive lives through eugenics and euthanasia programs, medical experimentation, and exterminations. An estimated 350 000 people were sterilized, between 70 and 93 000 were euthanized, 18 000 experimented on, and millions exterminated.1 Virtually, the entire medical profession was involved in the sterilization program, and for some, moving to euthanasia was but a short step.2 In addition, the Nazis prevented those they regarded as “undesirable” from reproducing through segregating men and women in camps, forbidding births in ghettos on pain of death, and enforcing abortion for pregnant women. Among Jews, reproduction was further prevented by murdering pregnant women on arrival at camps or later, if pregnancy manifested after admission. Mothers and their newborns were murdered if a birth occurred.2 Doctors fulfilled numerous additional roles during the Holocaust that contributed significantly to achieving Nazi goals.2 In the camps, they selected prisoners from the incoming transports; supervised the extermination process in the gas chambers; supervised the removal of gold teeth and all valuables that were hidden in the bodily orifices of gassed victims; selected prisoners who could no longer work, or those with infectious diseases, for extermination; decided which bedridden inmates they would kill with lethal injections or which would be sent to gas chambers; had to be present at executions and certify that the executed were dead; and had to perform abortions on foreign women. In addition, many doctors and medical institutes were directly involved in medical experimentation and some like Profs Clauberg, Schumann, and Mengele worked on medical experiments involving reproductive function.2 The period between the arrival of prisoners in the camps and their ultimate murder provided Nazi doctors with an opportunity to conduct experiments. Significant attention was dedicated toward determining means of mass sterilization as a means of eliminating Jewish progeny while continuing to exploit Jewish labor. Three methods were tried: sterilization by medication, by X-rays, and by chemicals.2 The first—largely unsuccessful—approach used drugs designed to induce infertility developed from a South American plant caladium seguinum. It was believed to reduce sexual excitation and to induce impotency in males: For females, the effect was temporary. Dr Horst Schumann's experiments castrated men by x-raying their genital organs. Victims were forced to masturbate, had their prostate glands brutally massaged by means of wooden or iron instruments inserted into the rectum to induce ejaculation, and had their sperm collected, and later had one or both testicles removed, or a portion of a testicle. They were questioned about their desires, nocturnal emissions, and loss of memory.2 Brutality and minimal anesthesia characterized these procedures and men died rapidly. Unusually high doses of X-rays were given to others causing their genitals to rot away. After long suffering, the men were murdered.4 Schumann's experiments on women involved x-raying their pelvic organs by positioning them between two X-ray machines. Ovariectomies were later performed without sterile procedures and executed extremely rapidly—in about 10 minutes—followed by hasty and rough suturing. In women, cessation of menstruation, changes in body hair, and changes in metabolism resulted. Irradiation sickness and burned skin ensued.2, 5 Prof. Carl Clauberg injected chemicals into the uterus.6 By so doing, he could sterilize as many as a thousand women a day. He suggested that a single injection into the cervix was sufficient and it could be administered during the “usual gynaecological examination familiar to every physician.”2 At the Nuremberg Nazi doctor's trial, none of those charged with the most heinous of these or other experiments expressed remorse or regret: They remained convinced of the value of their actions.7 Their research appeared, to them, to have achieved the highest goals of purifying and removing degeneracy from the superior, “Aryan” race, and they believed they should be honored for their achievements rather than criminalized. Estimates suggest that between 200 and 350 German doctors, including university professors and lecturers, were direct participants in research, whereas hundreds or perhaps thousands stood silently by.8 Nazi plans of eugenics, euthanasia, experimentation, and extermination could not have been achieved without the medical community playing a decisive role in them.1 Among these medical care providers, the power of misguided ideological conviction, combined with selfish achievement motivation, clearly outweighed the humanitarian underpinnings of their Hippocratic Oath. In contrast, prisoner doctors resisted their oppressors under conditions of extreme brutality providing inspirational role models, even at the cost of their lives.1, 2 The Nazi medical experiments were horrendous. They did, however, stimulate a process of developing and refining ethical guidelines for research on human participants that is still in progress. Whereas this in no way justifies their occurrence, it is, at least, one positive outcome of these horrors. Our unwillingness to examine Nazi medicine in the decades after the end of World War II, or to teach about it in medical and allied medical profession schools, might have contributed to the ability of scientists to proceed with research that was, on occasion, questionable. For example, Katz reports that the mustard gas experiments conducted by the United States armed forces between 1950 and 1970 continued patterns of abuse and neglect where participants were recruited through lies and half-truths for experiments using chemicals known to cause debilitating long-term effects.9 Similarly, the Tuskegee Syphilis studies conducted between 1932 and 1972 by the US Public Health Service allowed for the monitoring of the natural history of untreated syphilis from its inception until death in 400 African Americans, denying them treatment.10 These studies share a common disregard of the human participants’ interests for the “noble, scientific” purpose of alleviating the pain and suffering of others. Nazi doctors might well have used the same argument. It need be noted, however, that whereas these questionable research instances have occurred in the decades since the end of World War II, these are nowhere near equivalent to Nazi era experiments and are not in any way representative of North American research in general. What is most remarkable is that these studies were conducted long after a medical code of experimental ethics emerged from the ashes of the Holocaust. The Nuremberg Code of 1947, emerging from the Nuremberg trials, had as its first and most significant clause that the voluntary consent of human participants in research is absolutely essential.9 Remarkably, the World Medical Association Helsinki Code of 1964 removed this requirement and emphasized the importance of the scientific research instead. Later versions of the code, in 1975, 1983, and 1989, did once again include informed consent, but this was listed as principle 9, 10, or 11, respectively.9 Judges and lawyers devised the Nuremberg Code, whereas physicians developed the Helsinki Code for their own guidance.11 In conflict here is the principle of doing the best for the individual vs the potential benefits of research for population health. This raises the question: Are physicians now more concerned with the science of medicine than the art of healing?9 In 1982 and again in 1992, the World Health Organization together with the Council for International Organization of Medical Sciences replaced the requirement for individual consent with an independent “impartial perspective” review of all protocols.11 To compound the problem, all these guidelines are advisory only: They have no legal standing in most countries and do not carry any ability for sanction of researchers who disregard them.11 As Grodin notes, economic pressures currently force doctors to make research decisions based on economic constraints (including lucrative sources of research funding and pharmaceutical companies’ interests) and not necessarily in the best interests of patients—pressure that might well lead physicians down a wrong path.12 The fundamental relationship between physician and patient must not become subordinate to the needs of the state, as it did in Nazi times.12 Medical ethics should never allow potentially damaging experiments on persons.9 Drawing analogies between present actions and Nazi Holocaust behavior arouses strong emotive reactions and may result in the moral argument discounting any possibility of logical analysis as to when some reproductive care practices or research might be warranted. When, where, how, and why some pregnancies might be terminated is a case in point, as possibly linked to concepts of eugenics or even euthanasia.13 James Watson (Nobel Prize winner for discovering the structure of DNA and the first director of the Human Genome Project) believes that society needs to eliminate defective genes. Such thinking might justify embryo selection, abortion, infanticide, and gene altering techniques.13 Debates about the ethics of such actions continue: Whereas many countries, but not all, allow for abortion and embryo selection in particular circumstances, emotional and religiously based arguments abound decrying each of these possible steps and making constructive development of guidelines for their appropriate use difficult. Prenatal caregivers and women worldwide have long accepted the value of routine prenatal screening with the intention of terminating some pregnancies. We have the technological ability to implement these actions and, increasingly, those relating to gene manipulation, but still lack the guidelines that determine when, how, and under what circumstances they are acceptable. The importance of discussing and determining ethical guidelines for these practices remains a challenge for today's world of stem cell research and gene manipulation and modification. To meet this demand, we need to study, understand, and consider the horrors of Nazi medicine, to examine the nuances and implications of current research practices in terms of morality, ethics, and science. As most of these modern reproductive practices involve perinatal health care professionals, including obstetricians, neonatologists, midwives, perinatal nurses, geneticists- and parents-studying the maleficent manipulation of reproductive function in the Nazi era, as a forerunner to current conflicts over pregnancy manipulation, is a logical necessity. Sadly, the Nazi Holocaust is not the only national or global disaster in which reproductive ethics have been severely breached. Despite the call for “Never Again” that follows most discussions of the Holocaust, society continues to implement unethical social and medical practices that affect reproduction, such as state-mandated controls of family size in China or pregnancy termination of female fetuses in India.14 In recent decades, we have recognized the reality of violence and abuse in our world, to the extent that measures of violence have been incorporated into United Nations Agencies Health Care Indicators.15 The incidence of violence against women and children far exceeds our previous expectations and provides a shocking reminder of the progress that we have yet to make in providing a respectful and healthy social environment. This concern is global. A mixed-methods systematic review has led to the establishment of seven categories of abusive or disrespectful care of women during childbirth. These include physical abuse, sexual abuse, verbal abuse, stigma and discrimination, failure to meet professional standards of care, poor rapport between women and providers, and health system conditions and constraints.16 According to a 2013 United Nations global review of available data, 35% of women worldwide have experienced either physical or sexual violence. In some individual countries, this figure rises to 70%.16 The implications of previous experience of violence, whether sexual, physical, or emotional, for obstetric and gynecological care are more significant than for other areas of health care.17 Widespread lack of informed consent for common procedures occurring at the time of birth (nonconsensual care), such as for episiotomies, hysterectomies, blood transfusions, sterilization, augmentation of labor, and even cesarean births, has also been reported in many childbirth settings with some women reporting lack of patient-doctor confidentiality.18 Many women report painful and frequent vaginal examinations in labor, sometimes conducted in nonprivate settings, and withholding of pain relief.17 Others report being neglected or ignored in labor (and even at delivery), having long wait times, being “punished” for not booking before delivery, having “rushed” care, and feeling that they were “bothering” or “putting the caregiver out.” Women often report receiving inadequate explanations about potential complications or impending delivery and that these explanations were often rushed if provided at all.17 Worse still is the blatant physical abuse and nondignified care of women during labor and birth in several countries through, for example, hitting or slapping with an open hand or instrument, pinching particularly on the thighs, kicking, shouting at, or scolding the mother, exerting excessive pressure on her abdomen to get the baby out, performing episiotomies or other procedures for financial gain, repairing episiotomies without pain relief, or even tying the woman down during labor or using mouth gags.17 Verbal abuse of women in childbirth is also reported. This includes the use of harsh or rude language, judgmental statements, threats of poor outcomes, or withholding treatment if women were noncompliant. Women from lower socioeconomic groups, migrants, those from ethnic minorities, adolescents, and older mothers of high parity more often report discriminatory care.16 The words most commonly used by women to describe the verbal abuse they experience include “rude, harsh language, sarcasm, swear, snap at, mock, threaten, scold, scream/yell/shout/raise voice, degrade, belittle, dehumanize, intimidate, ridicule, name-calling, humiliate, and insult” reflecting the wide array of disrespectful treatment provided.17 Reports of sexual abuse during labor have also emerged from Kenya and Nigeria.17 A further abusive practice involves the payment of bribes to doctors, nurses, midwives, receptionists, and guards. Women who pay believe that such payments ensure better, more timely care and the provision of medications.17 Whether we examine childbearing and reproduction today, matters of life and death, or medical ethics, lessons can be learned from Medicine in the Holocaust. As occurred then, health care providers today are not immune to the influence of power, autocracy, economics, pharma, ideology, exploitation of the vulnerable, and ambition.1 Large-scale surveys of respectful care—or, in reality, disrespectful care—have been undertaken in the United States and Canada, with a large nationwide scale being implemented at present in Canada.19, 20. Clearly, this issue is of importance today warranting education of reproductive health care students on these issues. Hundreds of professionals have already become signatories endorsing the Galilee Declaration, and more are welcomed (http://mededirect.org/mimeh/galilee.cfm). Many medical schools already include programs considering Medicine in the Holocaust to provide a prism through which health care providers can review their current roles and practices.1 What better time and place to start than to address these issues with medical students, and particularly those involved in reproduction? My sincere appreciation for inspiring the education of medical students about the Holocaust and for his support with the preparation of this manuscript goes to Prof. Shmuel Reis (MD MHPE), Academic Director, Center for Medical Education, Faculty of Medicine, Hebrew University, Jerusalem, Israel.