The Holocaust and German Medicine (1933–1945)

Summary

Between 1933 and 1945, German medicine was systematically recruited into the Nazi project of racial purification. Beginning with the 1933 Sterilization Law, which produced 225,000 forced sterilizations within three years, the apparatus escalated through the Nuremberg racial laws (1935) to the T4 euthanasia program (1939), which designated roughly 70,000 asylum patients for death, and finally to lethal medical experiments in the concentration camps. Viktor Frankl, a Viennese psychiatrist who survived Auschwitz and three other camps, left the primary clinical account of what the experience of systematic dehumanization did to the human person. The Nuremberg Doctors’ Trial (1947) produced the Nuremberg Code, establishing voluntary informed consent as the absolute precondition for any human experimentation, and inaugurating the bioethics tradition that Western medicine has lived with since.

Background: Eugenics and the German Medical Profession Before 1933

The German sterilization program of 1933 did not emerge without precursors. The international eugenics movement, which included British, American, and German participants, had spent three decades arguing that “degenerate” hereditary stock required medical management. In the United States, California had by 1929 performed 6,255 eugenic sterilizations, almost twice as many as all other states combined.(Kevles, Daniel J., 1995) Harry Laughlin, superintendent of the Eugenics Record Office at Cold Spring Harbor and the prime mover behind American model sterilization legislation, received an honorary doctorate from the University of Heidelberg in 1936 for his contributions to eugenics.(Kevles, Daniel J., 1995) By 1941 the US national sterilization total had reached nearly 36,000, with Virginia state authorities having raided whole families of “misfit” mountaineers for compulsory transfer to hospitals.(Kevles, Daniel J., 1995) The traffic in ideas was not one-way: American sterilization statutes served as explicit models for the German law.

By 1935, the geneticist and future Nobel laureate Hermann Muller could write that eugenics had become “hopelessly perverted” into a pseudoscientific facade for “advocates of race and class prejudice, defenders of vested interests of church and state, Fascists, Hitlerites, and reactionaries generally.”(Kevles, Daniel J., 1995) His diagnosis named the direction of travel accurately. The scientific criticisms of mainline eugenics’ racial and intelligence claims had been accumulating since the early 1920s: from Julian Huxley and A.C. Haddon’s argument that “race” made no biological sense, to Franz Boas’s anthropological work, to Carl Brigham’s 1930 recantation of his own earlier IQ studies.(Kevles, Daniel J., 1995)(Kevles, Daniel J., 1995) None of this slowed the German program.

Opposition existed elsewhere. Pope Pius XI condemned eugenics in the encyclical Casti Connubii (1930); a range of Catholic, liberal, and civil libertarian voices challenged the scientific and ethical pretensions of compulsory sterilization before the Nazis came to power.(Kevles, Daniel J., 1995) Their critiques did not penetrate a profession that was rapidly aligning itself with the new state.

The Medical Apparatus: Sterilization to Euthanasia

Germany’s 1933 Eugenic Sterilization Law went far beyond any American statute. Within three years, German authorities had sterilized approximately 225,000 people, almost ten times the American total accumulated over thirty years. About half were classified as “feebleminded.”(Kevles, Daniel J., 1995) The law did not proceed in isolation. After 1935, the Nuremberg racial laws fused the eugenic and anti-Semitic programs into a single administrative structure.

In 1939, the Third Reich moved beyond sterilization to inaugurate euthanasia upon certain classes of the mentally diseased or disabled in German asylums. Among the designated classes were all Jews, regardless of their mental health. Some 70,000 patients were eventually marked for death.(Kevles, Daniel J., 1995) This was not a covert operation conducted without medical knowledge or participation: physicians evaluated patients, signed forms, and authorized transfers. The program’s code name, T4, referred to the Berlin address of its administrative headquarters. The T4 killings served, in Kleinman’s analysis, as the prototype for the later killing of Jews: the medicalization of murder preceded and enabled the genocide proper.(Arthur Kleinman, 1988)

The medical profession’s participation in the Nazi killing programs represents what Kleinman calls “psychiatry’s darkest hour,” the moment when medicine’s institutional authority over classification and treatment was turned toward destruction.(Arthur Kleinman, 1988) What made this possible was not aberrant science but the application of a coherent, internally consistent program of social control that had been developing for decades in the form of eugenic legislation and racial hygiene theory.

The Camps: Selection, Dehumanization, and Experiments

The concentration and death camps placed German medicine in a further role: selecting who would live, managing the exploitation of prisoner labor, and conducting what was described as scientific research on prisoners who could not consent and could not refuse.

Viktor Frankl arrived at Auschwitz with a manuscript ready for publication, which was immediately confiscated.(Frankl, Viktor, 1946) His account of the arrival process describes the systematic stripping of every material marker of identity: documents were taken, possessions confiscated, numbers tattooed on skin and sewn to clothing. “The authorities were interested only in the captives’ numbers. These numbers were often tattooed on their skin, and also had to be sewn to a certain spot on the trousers, jacket, or coat. Any guard who wanted to make a charge against a prisoner just glanced at his number.”(Frankl, Viktor, 1946)

Frankl documented three distinct psychological phases in prisoners: shock at admission; apathy and emotional numbing during imprisonment; and a disorienting period following liberation.(Frankl, Viktor, 1946) The apathy of the second phase was not passivity but a defensive adaptation: “the blunting of the emotions and the feeling that one could not care any more” created a necessary protective shell against daily beatings and systematic horror.(Frankl, Viktor, 1946) Frankl observed that the most painful aspect of a guard’s blow was often not the physical pain but the existential insult of being treated as something less than human, as an animal to be redirected rather than a person to be addressed.(Frankl, Viktor, 1946)

What Frankl called “an abnormal reaction to an abnormal situation is normal behavior” was both a psychological observation and a clinical corrective to the tendency to pathologize the responses of people in extreme conditions.(Frankl, Viktor, 1946) The camps produced psychological states that, measured by ordinary clinical criteria, would appear disordered; measured against the actual situation, they were adaptations to what could not be endured otherwise.

The experiments conducted at Auschwitz and other camps by Josef Mengele and other physicians operated without consent, without ethical review, and frequently with no coherent scientific design. As the Nuremberg tribunal later established, the experiments included high-altitude research that deprived victims of oxygen until death, deliberate freezing, infection with malaria, typhus, hepatitis, cholera, smallpox, and diphtheria, battlefield wound simulation and infection, and experiments in mass sterilization methods designed to identify the most efficient techniques for population-level application.(Jonsen, 2000) Most of these procedures produced deaths, disabilities, and suffering without generating scientific knowledge of any durable value.

The opening of Eastern European archives after 1989 has extended scholarship on physician participation beyond the German core. As Jackson’s survey of Eastern European medical historiography notes, the archives led to “a careful analysis of historical documents that sought to understand the ‘truth’ behind some of the twentieth century’s hitherto unapproachable topics, such as the participation of Eastern European physicians in the Holocaust.”(Jackson (ed.), 2011) The pattern of physician complicity was not German alone.

Frankl and the Phenomenology of Survival

Frankl wrote Man’s Search for Meaning with a specific evidential intention: “I had wanted simply to convey to the reader by way of a concrete example that life holds a potential meaning under any conditions, even the most miserable ones. And I thought that if the point were demonstrated in a situation as extreme as that in a concentration camp, my book might gain a hearing.”(Frankl, Viktor, 1946) The concentration camp memoir was thus conceived as both testimony and argument: the Auschwitz experience was to validate the therapeutic framework he had been developing before deportation.

The core observation was about survival. Prisoners who gave up on meaning and abandoned their sense of a future were the first to die, and they “died less from lack of food or medicine than from lack of hope, lack of something to live for.”(Frankl, Viktor, 1946) Frankl found that those who had a specific task awaiting them (a person to return to, a manuscript to complete, a work to finish) were most apt to survive even the worst conditions.(Frankl, Viktor, 1946) When a prisoner lit a previously hidden cigarette, it was a reliable signal that he had given up: “once lost, the will to live seldom returned.”(Frankl, Viktor, 1946)

What survived most tenaciously was not courage in any heroic sense but a kind of “cold curiosity”: a detached, observational stance toward one’s own predicament that provided psychological distance from horror without requiring its denial.(Frankl, Viktor, 1946) Frankl also recorded a finding that is harder to accommodate: the survivors were not necessarily the morally best people. Those who returned had often been prepared to use every means, including brutal force, theft, and betrayal, to save themselves. “The best of us did not return.”(Frankl, Viktor, 1946)

Frankl chose to remain in Vienna with his aging parents rather than use an American visa to emigrate, a decision that preceded his deportation and that he framed as a matter of filial obligation and ethical responsibility.(Frankl, Viktor, 1946) The decision cost him nearly everything; it also gave his subsequent account of survival its particular moral seriousness, because he had not been an innocent bystander to events he had no chance of escaping. He had chosen to stay.

Reception: Salutogenesis, Cultural Psychiatry, and the Phenomenological Turn

Frankl’s testimony entered medical and psychiatric thought through multiple channels. Aaron Antonovsky, developing his concept of the sense of coherence in the 1970s and 1980s, found Frankl’s Auschwitz experience to be the clearest case for the type of person whose meaningfulness remains high even when comprehensibility and manageability are near zero. Antonovsky described this as “precisely the story of Viktor Frankl and an amazing number of others, though not most, in Auschwitz and the Warsaw ghetto,” people who showed “a profound spirit, deeply engaged in the search for understanding and resources,” without any guarantee of success but with a chance that those without such engagement lacked.(Antonovsky, 1987)

Antonovsky’s pilot study for the sense of coherence questionnaire included interviews with Holocaust survivors who had coped remarkably well despite their trauma. One survivor’s account: “While these events for me are living memories, they didn’t, as it were, refer to me specifically. I had no sense of personal affront. What happened, happened to all of us… I was pessimistic, didn’t believe that I or others would come out of it all alive… But I didn’t believe in giving up my identity just to stay alive.”(Antonovsky, 1987) The witness captures the SOC pattern precisely: accepting the objective situation without bitterness, maintaining identity as a value independent of survival, retaining purposive engagement under conditions where engagement was nearly without practical consequence.

Oliver Sacks documented a related phenomenon from the clinical side. Case 81 in his Migraine series was a Holocaust survivor who had suffered monthly classical migraines from childhood until his incarceration at Auschwitz. During six years in the camp, during which his wife, parents, and all other close relatives were killed, “he did not experience a single attack of migraine.” Migraines returned after liberation, along with chronic depression and psychotic episodes. As Sacks noted, the exemption from psychosomatic illness during the concentration camp years “is a feature which has been described to me by several other patients: all forms of psychosomatic illness, and also frank psychosis, were apparently extremely rare in such conditions, presumably because they would have been lethally mal-adaptive.”(Sacks, Oliver, 1970/1992) The body suspended its ordinary symptomatic repertoire when survival required total mobilization; those symptoms returned, sometimes with compound interest, when safety was nominally restored.

The catastrophe of the Holocaust also served, in the postwar period, as the context within which phenomenological and existential thought moved from Germany to France. The “ghostly specter of murdered millions haunting the intellectual scene” during the mid-twentieth century was, as Aho and Aho note, part of what carried Heidegger and phenomenology beyond its German origins and into the broader European conversation that produced Sartre, Merleau-Ponty, and Lacan.(James Aho, Kevin Aho, 2009) The intellectual inheritance was not clean: Heidegger’s own entanglement with National Socialism remained a lasting problem. But the phenomenological tradition’s emphasis on lived experience, embodiment, and the human person’s irreducibility to an object proved critical for the psychiatric response to trauma.

The Medical-Ethics Inflection: Nuremberg to Belmont

The Nuremberg Doctors’ Trial of 1947 was the direct legal consequence of what physicians had done in the camps. The tribunal found that “beginning with the outbreak of World War II, criminal medical experiments on non-German nationals, both prisoners of war and civilians, including Jews and ‘asocial’ persons, were carried out on a large scale in Germany and the occupied countries.” It then articulated ten principles for ethical human experimentation, acknowledging that “certain types of medical experiments conform to the ethics of the medical profession generally.” The first words of what became known as the Nuremberg Code are unambiguous: “The voluntary consent of the human subject is absolutely essential.”(Jonsen, 2000)

The Code was the first explicit international standard for ethical human experimentation. Its requirement of voluntary consent was not a principle borrowed from existing medical ethics but a response to what happened when that principle was absent. The Declaration of Helsinki (1964) extended these requirements to clinical research; the Belmont Report (1979) systematized three organizing principles (respect for persons, beneficence, and justice) that have organized bioethics pedagogy since. The institutional infrastructure of Institutional Review Boards and research ethics committees traces its lineage directly to the Nuremberg finding.

The Nuremberg Code did not immediately transform medical research practice everywhere. The Tuskegee Syphilis Study, begun in 1932 and continuing until 1972 (forty years during which 400 Black men with diagnosed syphilis were never told of their diagnosis or treated, even after penicillin became available), demonstrated that the problem of research without consent was not confined to the Nazi state.(Jonsen, 2000) The Tuskegee revelations, not the Nuremberg Code, were what finally catalyzed the American legislative and regulatory reforms that produced the Belmont Report.

Wider Significance

The Holocaust’s place in the history of Western medicine is not incidental. The German medical profession in the 1930s was not a backward or pre-scientific profession: it was one of the most technically advanced in the world. The eugenics programs that preceded the camps were embedded in the same intellectual tradition (heredity, population health, public hygiene) that also produced legitimate advances in epidemiology and genetics. The transition from coercive sterilization to euthanasia to genocide was incremental and each step was authorized by physicians who understood themselves to be acting scientifically.

Kleinman’s observation that the Nazi medicalization of killing “must surely stand as psychiatry’s darkest hour” points to what made this possible: medicine’s institutional capacity to classify persons as belonging to categories that require intervention, combined with the state’s power to enforce that classification, removed the constraint that individual physician-patient relationships had always provided.(Arthur Kleinman, 1988) When medicine acts not on behalf of patients but on behalf of the state’s theory of population health, it loses the ethical anchor of the therapeutic relationship.

The postwar bioethics tradition was built, in significant part, around the attempt to restore that anchor through external constraint: codes, declarations, review boards, and the institutionalization of informed consent. Whether those constraints are adequate to the risk remains an open question in the scholarship. What is not open is the historical sequence: the Nuremberg Code came after the camps, not before, and the Western medical tradition built the infrastructure for research ethics after learning what medicine could become when that infrastructure was absent.

See Also

• eugenics
• medical-ethics
• euthanasia
• viktor-frankl (if page exists)
• logotherapy
• salutogenesis
• nuremberg-code (if page exists — Nuremberg Code is currently covered in medical-ethics)
• world-war-ii (sister page — military and general history context)
• ptsd (postwar psychiatric consequences of mass trauma)

Sources

• Kevles, Daniel J. (1995). In the Name of Eugenics: Genetics and the Uses of Human Heredity. Harvard University Press. (source_id: kevles-eugenics-1995)
• Jonsen, Albert R. (2000). A Short History of Medical Ethics. Oxford University Press. (source_id: jonsen-short-history-medical-2000)
• Kleinman, Arthur. (1988). Rethinking Psychiatry: From Cultural Category to Personal Experience. Free Press. (source_id: kleinman-rethinkingpsychiatry-1988)
• Frankl, Viktor E. (1946/1992). Man’s Search for Meaning. Beacon Press. (source_id: frankl-manssearchformeaning-1946)
• Antonovsky, Aaron. (1987). Unraveling the Mystery of Health: How People Manage Stress and Stay Well. Jossey-Bass. (source_id: antonovsky-unraveling-mystery-of-1987)
• Sacks, Oliver. (1992). Migraine. University of California Press. (source_id: sacks-migraine-1992)
• Jackson, Mark (ed.). (2011). The Oxford Handbook of the History of Medicine. Oxford University Press. (source_id: jackson-oxfordhandbook-2011)
• Aho, James, and Kevin Aho. (2009). Body Matters: A Phenomenology of Sickness, Disease, and Illness. Lexington Books. (source_id: aho-aho-body-matters-2009)

Editorial Notes

Gaps the encyclopaedia compiler flagged for future evidence work, collected from inline markers in the body and frontmatter.

The Medical-Ethics Inflection: Nuremberg to Belmont