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increasingly utilitarian society these There has never in history been a patients are being looked down upon shortage of money for the developwith increasing definiteness as un ment and manufacture of weapons wanted ballast. A certain amount of war; there is and should be none of rather open contempt for the peo now. The disproportion of monetary ple who cannot be rehabilitated with support for war and that available present knowledge has developed. for healing and care is an anachronThis is probably due to a good deal ism in an
era that has been deof unconscious hostility, because scribed as the “enlightened age of these people for whom there seem to the common man” by some observto be no effective remedies have be The comparable cost of jet come a threat to newly acquired de planes and hospital beds is too oblusions of omnipotence.
vious for any excuse to be found Hospitals like to limit themselves for a shortage of the latter. I trust to the care of patients who can be that these remarks will not be misfully rehabilitated, and the patient understood. I believe that armament, whose full rehabilitation is unlikely including jet planes, is vital for the finds himself, at least in the best security of the republic, but adeand most advanced centers of heal quate maintenance of standards of
ing, as a second-class patient faced health and alleviation of suffering o with a reluctance on the part of are equally vital, both from a pracel both the visiting and the house staff tical point of view and from that of
to suggest and apply therapeutic morale. All who took part in induc
procedures that are not likely to tion-board examinations during the s! bring about immediately striking re war realize that the maintenance
sults in terms of recovery. I wish and development of national health
to emphasize that this point of view is of as vital importance as the Copy did not arise primarily within the maintenance and development of Drei medical profession which has always armament. Ed! been outstanding in a highly com
The trend of development in the o
petitive economic society for giving facilities available for the chronicalE freely and unstintingly of its time ly ill outlined above will not necescle and efforts, but was imposed by the sarily be altered by public or state WE shortage of funds available, both medicine. With provision of public hi private and public. From the atti funds in any setting of public ac
tude of easing patients with chronic tivity the question is bound to come rete diseases away from the doors of the up, “Is it worth while to spend a eli best types of treatment facilities certain amount of effort to restore a
available to the actual dispatching certain type of patient?” This rať of such patients to killing centers is tionalistic point of view has insididi a long but nevertheless logical step. ously crept into the motivation of
Resources for the so-called incurable medical effort, supplanting the old th patient have recently become prac Hippocratic point of view. In emerbistically unavailable.
gency situations, military or otherle
wise, such grading of effort may be Under all forms of dictatorship pardonable. But doctors must be the dictating bodies or individuals ware lest such attitudes creep into claim that all that is done is being the civilian public administration of done for the best of the people as a medicine entirely outside emergency whole, and that for that reason they situations, because once such con look at health merely in terms of siderations are at all admitted, the utility, efficiency and productivity. more often and the more definitely It is natural in such a setting that the question is going to be asked, eventually Hegel's principle that “Is it worth while to do this or that "what is useful is good” wins out for this type of patient?" Evidence completely. The killing center is the of the existence of such an attitude reductio ad absurdum of all health stared at me from a report on the planning based only on rational prinactivities of a leading public hospital ciples and economy and not on huunit, which stated rather proudly mane compassion and divine law. To that certain treatments were given be sure, American physicians are only when they appeared promising : still far from the point of thinking
of killing centers, but they have arOur facilities are such that a rived at a danger point in thinking, case load of 20 patients is regu at which likelihood of full rehabililarly carried ... in selecting cases tation is considered a factor that for treatment careful considera should determine the amount of tion is given to the prognostic time, effort and cost to be devoted to criteria, and in no instance have a particular type of patient on the we instituted treatment merely to part of the social body upon which satisfy relatives or our own con this decision rests. At this point sciences.
Americans should remember that the
enormity of a euthanasia If only those whose treatment is ment is present in their own midst. worthwhile in terms of prognosis To the psychiatrist it is obvious that are to be treated, what about the this represents the eruption of unother ones? The doubtful patients conscious aggression on the part of are the ones whose recovery appears
certain administrators alluded to unlikely, but frequently if treated above, as well as on the part of relaenergetically, they surprise the best tives who have been understandably prognosticators. And what shall be frustrated by the tragedy of illness done during that long time lag after in its close interaction upon their the disease has been called incurable own lives. The hostility of a father and the time of death and autopsy ? erupting against his feebleminded It is that period during which it is son is understandable and should most difficult to find hospitals and
be considered from the psychiatric other therapeutic organizations for point of view, but it certainly should the welfare and alleviation of suffer not influence social thinking. The ing of the patient.
development of effective analgesics
und pain-relieving operations has
chronic diseases that have sprung "taken even the last rationalization up and are dedicating themselves to away from the supporters of eutha guidance and information for their nasia.
fellow sufferers and for the support The case, therefore, that I should and stimulation of medical research. like to make is that American medi Among the earliest was the mental cine must realize where it stands in hygiene movement, founded by a
its fundamental premises. There can former patient with mental disease. · be no doubt that in a subtle way the Then came the National FoundaHegelian premise of "what is useful tion for Infantile Paralysis, the is right” has infected society, includ tuberculosis societies, the Ameriing the medical portion. Physi can Epilepsy League, the National
cians must return to the older Association to Control Epilepsy, : premises, which were the emotional the American Cancer Society, The
foundation and driving force of an American Heart Association, "AlcoE
amazingly successful quest to in holics Anonymous” and, most recentcrease powers of healing and which ly the National Multiple Sclerosis are bound to carry them still farther Society. All these societies, which
if they are not held down to earth are coordinated with special medi· by the pernicious attitudes of an cal societies and which received inoverdone practical realism.
spiration and guidance from outWhat occurred in Germany may standing physicians, are having an have been the inexorable historic extremely wholesome effect in inprogression that the Greek histor troducing fresh motivating power ians have described as the law of the into the ivory towers of academic fall of civilizations and that Toyn- medicine. It is indeed interesting bee18 has convincingly confirmed and an assertion of democratic vitalnamely, that there is a logical se ity that these societies are activated quence from Koros to Hybris to Ate, by and for people suffering from which means from surfeit to dis illnesses who, under certain dictatordainful arrogance to disaster, the ships, would have been slated for surfeit being increased scientific and euthanasia. practical accomplishments, which, , It is thus that these new societies however, brought about an inclina have taken over one of the ancient tion to throw away the old motiva functions of medicine-namely, to tions and values by disdainful arro give hope to the patient and to regant pride in practical efficiency. lieve his relatives. These societies Moral and physical disaster is the need the wholehearted support of the inevitable consequence.
medical profession. Unfortunately, Fortunately, there are develop this support is by no means yet ments in this democratic society unanimous. A distinguished physithat counteract these trends. Nota cian, investigator and teacher at an ble among them are the societies outstanding university recently told of patients afflicted with various me that he was opposed to these
special societies and clinics because they had nothing to offer to the patient. It would be better to wait until someone made a discovery accidentally and then start clinics. It is my opinion, however, that one cannot wait for that. The stimulus supplied by these societies is necessary to give stimulus both to public demand and to academic medicine, which at times grows stale and unproductive even in its most outstanding centers, and whose existence did nothing to prevent the executioner from having logic on his side in Germany.
Another element of this free democratic society and enterprise that has been a stimulus to new developments is the pharmaceutical industry, which, with great vision, has invested considerable effort in the sponsorship of new research.
Dictatorships can be indeed defined as systems in which there is a prevalence of thinking in destructive, rather than in ameliorative terms in dealing with social problems. The ease with which destruction of life is advocated for those considered either socially useless or socially disturbing instead of educational or ameliorative measures may be the first danger sign of loss of creative liberty in thinking, which is the hallmark of democratic society. All destructiveness ultimately leads to self-destruction; the fate of the SS and of Nazi Germany is an eloquent example. The destructive principle, once unleashed, is bound to engulf the whole personality and to occupy all its relationships. Destructive urges and destructive concepts
arising therefrom cannot remain limited or focused upon one subject or several subjects alone, but must inevitably spread and be directed against one's entire surrounding world, including one's own group and ultimately the self. The ameliorative point of view maintained in relation to all others is the only real means of self-preservation.
A most important need in this country is for the development of active and alert hospital centers for the treatment of chronic illnesses. They must have active staffs similar to those of the hospitals for acute illnesses, and these hospitals must be fundamentally different from the custodial repositories for derelicts, of which there are too many in existence today. Only thus can one give the right answer to divine scrutiny: Yes, we are our brothers' keepers.
1 Bumke, 0. Discussion of Faltlhauser, K. Zur Frage der Sterilisierung geistig Abnormer. Allg. Ztschr. f. Psychiat., 96:372, 1932.
2 Dierichs, R. Beitrag zur psychischen Anstaltsbehandlung Tuberkuloser. Ztschr. f. Tuberk., 74:21-8, 1936.
3 Dorner, A. Mathematik in Dienste der Nationalpolitischen Erziehung: Ein Handbuch fur Lehrer, herausgegeben in Auftrage des Reichsverbandes Deutscher mathematischer Gesellschaften und Vereine. Moritz Diesterweg, Frankfurt, 1935, pp. 1-118. Second edition (revised). 1936, pp. 1-118, Third edition (revised).
4 Alexander, L. Public Mental Health Practices in Germany, Sterilization and Execution of Patients Suffering from Nervous or Mental Disease. Combined Intelligence Objectives Subcommittee, Item No. 24, File No. XXVIII-50, Aug. 1945, pp. 1-173. 5
Neuropathology and Neurophysiology, Including Electro-Encephalography in War-time Germany. Combined Intelligence Objectives Subcommittee, Item No. 24, File No. XXVII-1, July 1945, pp. 1-65.
German Military Neuropsychiatry and Neurosurgery. Combined Intelligence Objectives Subcommittee, Item No. 24, File No. XXVIII-49, Aug. 1945, pp. 1-138.
Sociopsychologic Structure of SS: Psychiatric Report of Nurnberg Trials for War Crimes. Arch. Neurol. & Psychiat., 59: 622-34, 1948.
War Crimes: Their Social Psychological Aspects. Amer. J. Psychiat., 105:170-7, 1948. 9
War Crimes and Their Motivation: Socio-Psychological Structure of SS and Criminalization of Society. J. Crim. Law & Criminol., 39:298-326, 1948.
10 Madaus, G., and Koch, F. Tierexperimentelle Studien zur Frage der Medikamentosen Sterilisierung (durch Caladium seguinum)
(Dieffenbachia seguina). Ztschr. f. d. ges. exper. Med., 109:68-87, 1941.
11 Madaus, G. Zauberpflanzen im Lichte experimenteller Forschung, Das SchweigrohrCaladium seguinum. Umschau, 24:600-2, 1941.
12 Alexander, L. Miscellaneous Aviation Med. ical Matters. Combined Intelligence Objectives Subcommittee, Item No. 24, File No. XXIX-21, Aug. 1945, pp. 1-163.
13 Document 1971 a PS.
14 Document NO 220.
15 Alexander, L. Treatment of Shock from Prolonged Exposure to Cold, Especially in Water. Combined Intelligence Objectives Subcommittee, Item No. 24, File No. XXVI-37, July 1945, pp. 1-228.
16 Seiss-Inquart. Order of the Reich Commissar for the Occupied Netherlands Territories Concerning the Netherlands Doctors. (Gazette containing the orders for the Occupied Netherlands Territories), Dec. 1941, pp. 1004-26.
17 Bernal, J. D. The Social Function of Science. George Routledge & Sons, London, 1946, 482 pp. Sixth edition.
18 Toynbee, A. J. A Study of History, Abridgement of Vol. I-VI. By D. C. Somervell. Oxford Univ. Press, New York and London, 1947, 617 pp.
Reprinted from The New England Journal of Medicine, 241:39-47, 1949.
© 1949 by the Massachusetts Medical Society.
medicine's prime end of healing, it began its inexorable road to doom.
These are his words:
His stark experience as an official American medical expert at the Nuremberg Trials of German physicianexecutioners of Nazi medical atrocities clearly had a profound effect on A. The experience impelled him to record the insidious progression of corrosive medical thinking which led to the degradation of the German medical profession and to warn his American colleagues with startling prophetic insight and foresight that what happened there could happen here.
It must be remembered that in the decades preceding World War II, German medicine was preeminent. Germany was the leading world center for post-graduate medical studies. As the United States is to the world of medicine today, Germany was then. To see this great giant topple not only shocked the medical world but raised for the reflective the crucial question of how the giant's downfall came about.
A's answer has great simplicity-a simplicity that gets to the heart of the matter: that the moment German medicine forgot that cure etymologically derives from care and deviated from
Whatever proportions these crimes finally assumed, it became evident to all who investigated them that they had started from small beginnings. The beginnings at first were merely a subtle shift in emphasis in the basic attitude of physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as life not worthy to be lived.
This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans. But it is important to realize that the infinitely small wedged-in lever from which this en