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The Death of Hippocrates: When Medicine Turns Evil

Posted: 2004-09-13

A distinquished physician reflects on why the German medical etablishment behaved the way they did during the 1930ies and 40ies (and why scientists and politicians in other countries joined in the eugenics movement), observing that though some of these researchers were rabble-rousing quacks, many were serious scientists whose aim was to discover ways in which the very best of the inherited characteristics might be encouraged and the very worst eliminated, with the ultimate goal of curing the ills of society. Nuland details how scientists today are trodding dangerous paths. Although not mentioned, the parallels with "science" in education research and practice are obvious.

from The New Republic, September 13, 2004


In a court of law, a witness becomes a person who testifies. What he has seen or heard is transformed into what he describes. Intended or not, the nuances and subtleties of his narrative, the variations in pitch of his voice, the expressions on his face, and the very way he holds his body--all of these are editorial comments on his words, and even those words convey feeling. He has been affected by the experience that he describes, and no amount of restraint or force of will can prevent his listeners from perceiving its influence on his thoughts. He is a man transmitting not only an account but an opinion, too, and everyone who watches and listens while his narrative unfolds will perceive what that opinion is. Some witnesses do this deliberately, while some attempt to speak without an iota of judgment. But even with the most determined detachment, every man or woman who testifies communicates a viewpoint. That viewpoint becomes the context in which his observers reach their conclusions, for they have indeed seen and heard the evidence through his eyes and his ears, and filtered it through his mind and his mouth.

I found myself thinking about these matters a few weeks ago, shortly after my first visit to the United States Holocaust Memorial Museum in Washington. I had spent two days there, viewing the extraordinary exhibition that runs until October 16, called "Deadly Medicine: Creating the Master Race." I devoted the first day to the materials I had come to study and the second to the permanent exhibit. The conclusions I reached about my experience were the result of a process that I realized only in retrospect was fostered by the atmosphere that must surely be among the strongest of the influences that the museum has had on the nearly twenty million men, women, and schoolchildren who have visited it since its opening in 1993. By this I mean that the Holocaust Museum is not a place of testimony, it is a place of witness.

The scenes, the artifacts, the reconstructions, and in some instances the sounds of the rise and the fall of the Third Reich and its Final Solution are laid out before the visitor without editorial comment, real or implied. They are accompanied by text that is descriptive, factual, and clear, containing precisely the amount of information necessary to explain what is being presented at each location in the building. In aggregate, the sequence of legends forms an eminently readable narrative of the events of that time and place. It is just that: narrative--no more, no less. Not until near the end of the permanent exhibit, where one hears the voices of the soldiers who liberated the camps, is there an iota of testimony. Only in the final moments of a visitor's pilgrimage to these horrors does he see interviews in which the survivors speak of their experiences. And even here the stories, though told with obvious anguish, are singularly devoid of condemnation of the brutes who are their reason for being. These elderly men and women are simply telling what they lived through.

Of all the reasons for the immense power of the museum's permanent exhibition, this one--its stature as a witness whose effect is not diluted by unnecessary testimonial attempts to persuade--may be the most forceful. As seen by visitors on a spectrum ranging from teenagers to survivors themselves, from the middle-aged children of those survivors to the middle-aged children of the worst of the perpetrators--to each of them and each of us--the Holocaust Museum has been a place to learn, to look within oneself, and to ponder the nature of our shared humanity. There is no need to tell us what to think.

The diversity in the range of responses to the museum cannot but be as wide as the diversity of its visitors. But some reactions are certain. The great majority of people will be horrified by what they see, particularly if they had only minimal knowledge of its vicious magnitude beforehand. Predictably, there will be very few who will, for whatever reason, somehow find themselves empathizing with those who carried out these contemptible acts, and fewer still, if any, who can put themselves in the place of those who instituted the policies that led to them. And this is precisely why I was so taken aback by my own response to the material presented in "Deadly Medicine." To my startled dismay, I found myself understanding why so much of the German medical establishment acted as it did. I realized that, given the circumstances, I might have done the same.


The exhibition details the influence of eugenics on determining Nazi policy from the time of the party's assumption of power in 1933 until the end of World War II. But its curator, the accomplished Susan Bachrach, has wisely chosen to begin her narrative long before that time, briefly sketching the intellectual background against which the notion that biology is destiny achieved its authority. Though some have thought of it as an applied science, eugenics is in fact more a philosophy than a science. Its proponents based their notions on genetics, having as their purpose the improvement of the breed. The word was defined exactly that way in 1911 in a book by the eminent American biometrician and zoologist Charles Davenport, director of the Eugenics Record Office at Cold Spring Harbor, New York (elected to the National Academy of Sciences in the following year), who called it "the science of the improvement of the human race by better breeding."

Eugenicists believed that it is possible, and even a good idea, to attempt to enhance the quality of our species by regulating the reproduction of traits considered to be inheritable. Thus, couples who demonstrate characteristics believed to be beneficial to society are given incentives to have children, while those who are judged to be in the opposite category are subjected to disincentives or prohibitions. A convinced eugenicist does not hesitate to recommend forced sterilization for those who might not voluntarily submit. In these ways, the "desirables" are multiplied and the "undesirables" gradually disappear from society.

The thesis of eugenics arises from the late nineteenth-century principle known as social Darwinism, the belief that not only individuals but also social groups such as races and nations are in constant competition for achievement and even survival, with certain inherent traits being maladaptive and others beneficial. As conceived by proponents of this theory of intergroup struggle, the laws of natural selection apply just as they do in Darwin's theory of evolution, which means that societies evolve in much the same manner as individual species, by the method to which the British philosopher Herbert Spencer gave the name "survival of the fittest."

At the personal level, social Darwinism was used to justify the dominant position of the upper classes, since their perceived moral and intellectual superiority was the reason for their attainments, as opposed to the lower station of the less well endowed. At the social level, nations or ethnic groups of seeming poorer abilities or drive were treated with the disdain appropriate to their inferior qualifications, a philosophy that provided a rationale for imperialism and racism. When Gregor Mendel's forgotten experiments on inheritable characteristics were rediscovered in 1900, a certain biological legitimacy was conferred on these notions, as unknown factors (later shown to be genes) were identified as the source of traits immutably passed on to offspring, and it was perceived that some are dominant and others recessive.

Such a background led quite logically to the acceptance of the notion of eugenics, a word that had been introduced by Charles Darwin's cousin Francis Galton in the late 1860s to give a name to his thesis of selective mating to improve human possibilities. Though the basis of social Darwinism--and with it eugenics--was gradually discredited after perhaps the late 1940s, it was for more than half a century a major influence on prominent thinkers, particularly in those countries considering themselves among the natural leaders of the world. I refer here not to a lunatic fringe, but to men whose opinions were highly regarded by serious social and scientific commentators. Once the Mendelian laws of heredity were widely known, eugenics movements were founded in the United States, Great Britain, Canada, Russia, several of the nations of Europe, and even Latin America and Asia. Eugenics research institutes were established in more than a few of these countries, most prominently the United States, England, Germany, Denmark, and Sweden. The work done in these places was well funded and taken very seriously by many leading scientists, often becoming the subject of influential and widely read books and journal articles.

Not unexpectedly, eugenics was a creed that appealed to social conservatives, who were pleased to blame poverty and crime on heredity. Liberals--or progressives, as they were then usually called--were among its most vigorous opponents, considering the inequities of society to be due to circumstantial factors amenable to social and economic reform. And yet some progressive thinkers agreed with the eugenicists that the lot of every citizen would be improved by actions that benefited the entire group. Thus were the intellectual battle lines drawn.

It is hardly surprising that National Socialism in Germany would embrace the concept of eugenics. But from the beginning, there was more to Nazi support than the movement's political appeal or the promise of its social consequences. As is clear from the exquisitely structured and thoroughly reliable accounting of "Deadly Medicine," the stage was set for the emergence of a drive toward a uniquely German form of eugenics long before the average citizen had ever heard of Adolf Hitler. It was based on seemingly scientific evidence derived from the studies of highly regarded researchers. Not surprisingly, an endowed chair for the study of "racial hygiene," as the Germans called eugenics, had been established at the University of Munich as early as 1923, the year after Sweden created the State Institute for Racial Biology in Uppsala.

The earliest hint of the coming storm had appeared around the turn of the twentieth century, when the German biologist August Weismann definitively showed that changes acquired by an organism during its lifetime cannot be inherited. Weismann's findings overthrew a theory promulgated a hundred years earlier by Jean-Baptiste Lamarck, holding that such adaptations could be passed down to succeeding generations. So-called Lamarckianism had incited controversy since its inception, and its debunking added fuel to the fire of those who believed that human beings inherit not only fixed physical characteristics but also mental and moral ones. When intermixed with the flammable material of social Darwinism and eugenics, the notion of the inevitability of one's biologically determined lifetime patterns took on a scientific certainty that catalyzed research by a variety of workers.

Though some of these researchers were rabble-rousing quacks, many were serious scientists whose aim was to discover ways in which the very best of the inherited characteristics might be encouraged and the very worst eliminated, with the ultimate goal of curing the ills of society. This was the work of the eugenics research institutes and similar groups, whether of the most or least legitimate sort. As the "Deadly Medicine" exhibition notes, "By the early 1900s, proponents of eugenics everywhere began to offer biological solutions to social problems common to urbanizing and industrial societies." The First International Eugenics Congress was held in London in 1912, and was attended by experts from all over the world. Ironically, among the best known of those who believed in the concept of degenerate individuals and groups were two prominent Jewish thinkers, the criminologist Cesare Lombroso and the physician and cultural critic Max Nordau.

The exhibition's "everywhere" means not only countries such as the United States, Britain, and Germany, which were among the leaders in such endeavors, but other nations throughout the world. To large numbers of its host of well-meaning adherents, eugenics was a scientifically and even mathematically based discipline, and many of them actually thought of it as a measurable, verifiable branch of biology that held the promise of becoming an enormous force for good.

Though it must be admitted that the United States, Britain, and Germany became centers for eugenics in part because of each nation's certainty of its own superiority over all peoples of the world, the fact is that these countries were hardly more chauvinistic than most others. The primary reason they led in eugenic studies is traceable to a far more significant factor: their leadership in science. Around the turn of the twentieth century, the American scientific establishment had recently begun the upward surge that would by the 1940s result in its dominance until the present time; and England and Scotland had since the seventeenth century been the source of one major discovery after another. But the basis upon which eugenic philosophies were able, in the long run, to gain more ground in Germany than elsewhere may lie in a point not sufficiently emphasized by "Deadly Medicine." Beginning in the middle of the nineteenth century, German-speaking universities and research centers had been the unquestioned leaders in medical science.

The German-speaking institutions were so far ahead of those of every other nation that leading clinicians, researchers, and educators in Europe, Asia, and the Americas considered their training incomplete unless they had spent a period of study at such centers of learning and innovation as Berlin, W?rzburg, Vienna, and Bern, or one of the small academic gems among the many outstanding universities in Germany, such as G?ttingen, Heidelberg, or T?bingen. Though World War I wreaked havoc on Germanic medical hegemony, the country's reputation as a bastion for such studies as pharmacology, biochemistry, pathology, anatomy, physiology, and clinical medicine continued to influence its image throughout the world, especially as seen by German physicians themselves and by the citizenry that supported them. The meticulous German mind, it was generally accepted (and not only by Germans), was uniquely suited to research in medicine and its allied sciences.

Herein lies my only criticism of the Holocaust Museum's exhibit. It does not properly emphasize the legitimacy that lay at the basis of the German fascination with the notion of improving the population by means of principles that their scientific and cultural history had convinced them were authentic. The Germanic medical establishment was heir to a grand tradition of accomplishment and international respect; when it took on eugenics as a worthy goal, it was convinced of the righteousness of its intent. Even when some of its own members began to voice concerns about the direction in which the research and its application were going, many authoritative voices drowned out the relatively few protests.

The process rolled on within a worldwide cultural milieu conditioned by the universally accepted belief that the earth's population was divided into races, and further subdivided into ethnic groups within them. The notion of the German Volk--a distinctive nation of cultural and heritable unity characterized by ancient tribal ties of purebred blood--had permeated the society since the early Middle Ages, the idealized Mittelalter of legend, when it first took root. With that vaunted heritage came the particular arrogance that went beyond even the chauvinism of so many other peoples. Add the conviction of a scientific basis to this mixture, and the result is a product so incendiary that it was destined to destroy not only those against whom it was intended but its promulgators as well.

The rising power of the international eugenics movement manifested itself in predictable ways, from anti-immigration laws to compulsory sterilization for those deemed unfit, enacted in such "progressive" countries as Sweden, Denmark, Finland, Norway, and parts of Canada and Switzerland--as well as the United States, where some two dozen states had enacted sterilization laws by the late 1920s. The most dramatic moment for Americans came on May 2, 1927, when the Supreme Court upheld the constitutionality of the state of Virginia's intention to carry out tubal ligation on a "feebleminded" young woman named Carrie Buck, who had given birth to an illegitimate daughter also judged to be retarded, as was Carrie's mother. Writing the majority opinion in Buck v. Bell, Justice Oliver Wendell Holmes Jr. stated

It is better for all the world, if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind. The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes.... Three generations of imbeciles are enough.

To a twenty-first-century sensibility, the equation with vaccination is at the very least questionable, but at the height of eugenic thinking, the eight-to-one majority among the justices reflected the general mood of a nation fifteen of whose states (the only ones of the twenty-seven reporting) would by 1933 have sterilized 6,246 of the insane, 2,938 of the feebleminded, fifty-five epileptics, sixteen criminals, and five persons with "nervous disorders." More than half of these procedures were carried out in four state mental hospitals in California. In almost every state, the law applied only to residents of public facilities, which meant that lower-income groups were affected far out of proportion to their numbers in the population. Some sixteen thousand Americans would eventually be sterilized.

At this time Germany had not yet enacted any sterilization laws, in spite of strong advocacy and much expression of admiration for the American system by the so-called racial hygienicists. All of this foot-dragging ended when Hitler came to power in 1933, and it ended with a vengeance. Taking effect on January 1, 1934, the German Law for the Prevention of Genetically Diseased Offspring went far beyond those in any other land, being compulsory for all people suffering from disabilities designated as hereditary, including feeblemindedness, schizophrenia, manic-depressive disorder, Huntington's disease, severe physical deformity, and chronic alcoholism, as well as forms of blindness, deafness, and epilepsy judged to be genetic in origin. Between 1934 and 1945, some four hundred thousand people would be forcibly sterilized, most before the war began in 1939. These included, in 1937, about five hundred racially mixed children of German mothers and black colonial soldiers in the French army occupying the Rhineland.

The basis for sterilizing these children was the outgrowth of the notion that a hereditarily gifted nation can retain its greatness only if the heredity remains pure, a thesis that had been widely accepted in Germany (and by many citizens of other countries as well, including our own) for generations. Though the Nazi sterilization program was at first independent of the party's policy toward the Jews, the notion of maintaining racial purity was its necessary accompaniment. By 1937, the principle of pure blood had manifested itself in many ways, most particularly in the persecution of Jews and the passage of the Nuremberg laws of 1935, officially called "the Law for the Protection of German Blood and German Honor," by which marriage and sexual relations were prohibited between Jews and people of "pure" German blood. Shortly thereafter the Reich Citizenship Law went into effect, declaring that only "Aryan" Germans were citizens and Jews were to be considered "subjects." This law defined who was a Jew and who was a so-called Mischling, an individual of mixed parentage. From these beginnings as an outgrowth of eugenics--itself a misconceived attempt toward utopia--Nazi racial policy would culminate in the murder of millions and the near-annihilation of European Jewry.

By 1937, the moral slippage since the Nazi takeover had become considerable. A concept that had been thought to be based on science had been transmogrified into the doctrine of German racial purity, which, in the hands of the Nazis, was being taken far beyond its original meaning. Misconceived as the movement was, eugenics had never been overtly intended by its proponents as a weapon of racial warfare or political domination. But the concept had been hijacked. In Germany, eugenics was now Nazi eugenics, by which the party claimed a scientific basis for its own unique form of racism. "National Socialism is the political expression of our biological knowledge" became a much-used slogan, and one credited by ordinary people. The theorists and the scientists who had until 1933 been able, and sincerely so, to claim detached objectivity for their research, could no longer delude themselves about the purposes for which it was being used. With the ascent to power of the Nazis, they had become, willy-nilly, active participants in the beginnings of genocide.


All of this is made very clear in "Deadly Medicine," as the events leading up to the Final Solution unfold with a chilling inevitability. The exhibition, beyond describing the work of those participating in the many eugenic and twin studies, does not detail the early and massive involvement of the German medical profession with the Nazis. This would require a completely different exhibition, and I would encourage the museum one day to mount it. Dedicated physicians who live by today's four principles of medical ethics--beneficence, non-maleficence, autonomy, and justice--and who unquestioningly embrace the ancient Hippocratic injunction to "do good or at least do no harm" need to examine the ways in which the nobility of their calling can be subverted by forces not only from without but also from within. The infamous degradation of medicine to the purposes of the Nazis is in its own way as important to study as the Holocaust itself. No association or guild was more complicit in the rise of Nazism and the desecrations committed by its leaders and followers than the profession of medicine, in the form both of its organizations and its individual members. This needs to be more widely known, and not only by today's doctors. In our shame, great lessons are to be learned.

Initially under the guise of eugenics, the grisly hand of medicine-gone-bad eventually reached into virtually every aspect of the Nazi death machine, though it was nowhere so odiously overt as in the wartime "research" using concentrationcamp inmates. These studies form a relatively small part of "Deadly Medicine," focused as it is on the overriding subject of Nazi eugenics, where physicians again and again participated in ways that were as murderous as though they had themselves been officers in Himmler's SS (as in fact so many of them were). Among them was the eugenically justified euthanasia program that was the forerunner of the gas chambers.

Hitler had long considered instituting a euthanasia program, but he realized that such an undertaking might not yet be palatable to the average citizen. Knowing that measures unacceptable under ordinary conditions are less difficult to implement during the national emergency of wartime, he postponed his plans until late in 1939, when he used a small pretext to launch his large-scale effort to rid the country of severely disabled children. The process began in July of that year, when a family petitioned the government to authorize "mercy killing" for their baby born with major deformities. Using that case as an opening, the Reich Ministry of the Interior ordered that the birth of any infant with such a condition as idiocy, hydrocephaly, phocomelia, spina bifida, or paralysis of any significant sort be reported.

The parents of these children and of others similarly afflicted, up to their teen years, were told that high-quality treatment was available for them in any of thirty specialized wards in various parts of the country, which were in fact killing centers. Though most of the children were murdered with drugs, some were simply left to starve. In each case, the parents were notified that death had occurred of natural causes. This program, in which five thousand children up to the age of sixteen lost their lives in the first large-scale action, was supervised by three Berlin pediatricians.

The murder of children was only the beginning. In October, 1939, Hitler authorized euthanasia for adults housed in German asylums. A division of the Chancellery was put in charge of the effort, which would have to be much larger in scope than that inflicted on the children. Since it would also require far more efficient methods of murder, carbon monoxide delivered through fake showerheads became the technique of choice. The entire operation, called T-4 for its headquarters at Tiergartenstrasse 4 in Berlin, was supervised by physicians. A group of leading psychiatrists chose the victims from a registry that recorded such information as their disabilities, the frequency with which they had visitors, and their aptitude for work. Those marked for death were transported by rail from temporary holding places to the centralized execution facilities. Between January, 1940 and August, 1941, some seventy thousand adult patients were gassed, their only crime being that they were unproductive members of the Nazi state.

As described in the excellent volume designed to accompany the museum's exhibit (which, unlike the museum, does allow itself some occasional editorial comment),

The facilities were staffed by specially selected physicians and nurses.... If the senior medical professionals ... were eugenics enthusiasts, they were also very much tantalized by their unaccustomed proximity to real power. They, in turn, used their prestige and influence upon impressionable (and fanaticized) former students, who became the killers in white coats--students being one of the groups in the population converted almost en masse to Nazism. The physicians' presence was only essential to give mass murder a medicalized appearance, since literally anyone could turn on a gas valve. These doctors now functioned as intermediary technicians, whose ethical training was perfunctory or nonexistent. Many had become accustomed to regarding patients as an assemblage of malfunctioning mechanical parts or, simply, a nuisance. Many of them were not immune to careerism, greed, or political fanaticism.

There, in a few sentences, is summarized so much of the explanation for medical complicity in the crimes of the Nazis. But the passage does omit several other factors, among them the long history of academic anti-Semitism that characterized the German universities. And it mentions only by implication one of the most significant components of the profession's embrace of eugenics: namely, that such a large proportion of doctors had believed it to be based on the legitimate scientific principles that had served Germanic medicine so well for almost a century, and many still chose to nurture what they must by then have realized was a fantasy.

Though a large proportion of the German populace allowed itself to be deluded by such terms as "mercy killing," foreign observers were not restrained in attempting to expose what was really going on. "Deadly Medicine" contains a reproduced page from the May 5, 1941 issue of this magazine, in which Michael Straight, under the headline "Germany Executes Her 'Unfit,'" wrote as follows:

[Persons] were not killed for mercy. They were killed because they could no longer manufacture guns in return for the food which they consumed; because the German hospitals were needed for wounded soldiers; because their death was the ultimate logic of the National Socialist doctrine of racial superiority and the survival of the physically fit.

But far worse was to follow. "The ultimate logic" would soon be extrapolated far beyond what Straight might have imagined, as it was extended to the Final Solution. The expulsion and coerced emigration of Jews had been going on almost since the Nazis attained power, but a new strategy for ridding Germany and eventually Europe of the pestilential disease of Judaism was near implementation. Even before the invasion of Russia in June, 1941, General Wilhelm Keitel signed an order permitting the SS to set up killing units once the attack began. On January 20, 1942, the Wannsee Conference established the policy that would lead to the Holocaust, and from then on the real question became not whether but how. The Einsatzgruppen, special squads of SS and police, had been following the German army as it penetrated ever more deeply into the Soviet Union, killing a million Jews and others in open-air shootings. But the combination of the public nature of such a method, its labor-intensity, and the psychological effect on the executioners of personally murdering men, women, and children at close range drove Heinrich Himmler to seek some improved means of carrying out his objective. What better example could have been found than the highly efficient--and eugenic--work being carried out by the T-4 program, including its utilization of rail systems for transporting victims?

In essence, the T-4 operation was copied in designing the killing centers that were built in Eastern Europe. Some of the most experienced of the directors of T-4 became consultants to the new program, and several were put in command of such facilities, soon to be using the infamous Zyklon B in place of carbon monoxide. The murders justified by the principles of eugenics had become the murders justified only by Hitler's vision of a Judenrein Europe; racial hygiene had finally revealed itself as racial hatred.


And in these ways, medical science went astray. Looking back with the wisdom of hindsight, it seems so clear that eugenics had always been a dangerous notion, and that its adherents were either deluded or racist. But the fact is that such a realization was slow in coming, and appeared only after matters had gotten completely out of hand and the stage set on which horrendous events would take place. Among the several reasons that medically trained students of eugenics allowed matters to turn so ugly was their failure to recognize a basic fact about the scientific enterprise, which is well known to historians and philosophers of the subject but continues to elude even some of the most sophisticated men and women who actually do the work. Though this fact characterizes science in general, it is even more applicable to the art that uses science to guide it, namely medicine, which was, after all, the underlying source of the momentum that drove the application of eugenic principles.

The basic fact to which I refer is that neither medicine nor science itself derives its "truths" in the thoroughly detached atmosphere in which its practitioners would like to believe they work. Especially in medicine and medical research, the atmosphere not only is not detached, but it is in fact largely the product of the very influences from which its participants seek to free themselves in order to isolate observations and conclusions from external sources and subjectivity. For an early explication of this, we may with profit turn to the father of Justice Holmes, Oliver Wendell Holmes Sr., who was for some years the dean of Harvard Medical School and bid fair to be called the dean of American medicine in the mid-nineteenth century. Here is what the elder Holmes said in an oration delivered to the Massachusetts Medical Society in 1860, titled "Currents and Countercurrents in Medical Science":

The truth is, that medicine, professedly founded on observation, is as sensitive to outside influences, political, religious, philosophical, imaginative, as is the barometer to the changes of atmospheric density. But look a moment while I clash a few facts together, and see if some sparks do not reveal by their light a closer relation between the Medical Sciences and the conditions of society and the general thought of the time, than would, at first, be suspected.

The medical theory of any era--and to a somewhat lesser extent the science on which it is based--arises in a setting that is political and social. Not only that, but its directions and even its conclusions are influenced by the personal motivations, needs, and strivings of those who practice it, some of which may not be apparent to these men and women themselves. Though we would have it otherwise, there is no such thing as a thoroughly detached scientific undertaking. The danger in this lies not so much in its truth, but in the inability of society and the community of scientists to recognize the pervading influence of such an unpalatable reality, which flies in the face of the claims that form the groundwork for our worship of the scientific enterprise.

It is precisely because "Deadly Medicine," like the rest of the Holocaust Museum, allows the story of its subject to unfold without editorializing, that I found myself so taken aback and disturbed by my response to it. Like most physicians of my generation--born within a decade on either side of World War II--I knew a great deal about the nefarious activities of the Nazi doctors, and considered their behavior an aberration to be condemned, not explainable in the ordinary terms of professional behavior and requiring a combination of socially infectious mass mental pathology and distorted nationalism to make sense of. It had always seemed obvious to me, and to the several colleagues with whom I had discussed it over the years, that none of us would ever have fallen prey to such delusions as the justification of euthanasia and then genocide. Now "Deadly Medicine" has made me doubt the certainty of those convictions.

By itself, each of the small steps taken by the eugenics movement in the early part of the twentieth century seemed not just innocuous but actually of real interest as a subject for consideration. Attached to the names of highly regarded scientific thinkers, the theories intended to improve the general level and functioning of a nation had a certain appeal to men and women concerned about social issues. Especially during the years of the Depression, when strategies were actively sought for the betterment of the rapidly worsening conditions under which so many people lived, the notion of encouraging the propagation of the fittest held its own attractions. The public press frequently published photographs of people so ground down and debilitated by poverty that they seemed of a different species from those who viewed them. In the contemporary literature of sociology and psychology could be found articles upholding the notion of genetically feebleminded or otherwise disadvantaged families reproducing themselves generation after generation. Many liberals agreed that the Supreme Court had made the right decision in the case of Carrie Buck, and they supported sterilization laws. Very likely, more than a few Americans would have accepted the euthanasia of severely retarded infants and older boys and girls, at least with family consent. Think only of the sympathy shown by the public and the courts even today on the rare occasions when a distraught parent puts such a child to death.

Moreover, in a world where the concept of race--and even the belief that some races are superiorly endowed or more evolutionarily advanced than others--was unquestioned, and miscegenation viewed with fear, who but a few visionaries would see any danger in the promotion of purity? But of the several considerations, the most significant would seem to have been that to most observers of the time eugenics bore the imprimatur of medical science. Unknowing or unwilling to believe that "medicine, professedly founded on observation, is as sensitive to outside influences ... as is the barometer to the changes of atmospheric density," most of us, I suspect, whether concerned laymen or scientifically trained physicians determined to benefit humanity, would have found no fault with improving the breed or even with the compulsory sterilization of certain of the retarded. Like the worthy justices of the Supreme Court, we would have felt such actions to be consistent with the spirit of the time. One can only wonder: At what point would I have turned away? At what point would I have realized the direction in which all of this was hurtling? Perhaps not until it was too late. Looking back with unbridled condemnation on the beginnings of racial hygiene does not enlighten today's thoughtful man or woman in regard to how he or she might have responded at the time.

It is specifically because neither "Deadly Medicine" nor the Holocaust Museum itself tells its visitors what to think that I found myself ruminating over these things. Though the museum's unstated message is a call for neverending vigilance and individual responsibility, one can only wonder whether such a message should come with the caveat that we are all creatures of our time and our place, and there are limits to what can be expected. What we learn from history comes far less in studying the events than in the recognition of human motivation--and the eternal nature of human frailty.

This is not to say that there had not from the beginning been enough evil men lurking at the ready to push the notion of racial hygiene down the slope whose slipperiness they recognized long before men of goodwill awoke to the reality of what they had wrought. Nor is it to say that--even when the worst was becoming evident--many others did not continue to allow the slide to take place and to accelerate because, after all, those being sterilized and euthanized were so unlike themselves. But it is most certainly to say that there is good reason for so many wags and wise men down the centuries to have repeatedly observed that the road to hell is paved with good intentions. Sometimes "anarchy is loosed upon the world" not because "the best lack all conviction," but because they firmly and honestly believe they are doing the right thing.

Doing the right thing: there has never been a period in the modern era when our species has relaxed its fascination with the idea of improving itself. Whether as groups or as individuals, few of us have not fantasized about adding years to life, to vigor, to sexual potency. Some are content with better noses and fewer wrinkles. Many go far further than that, and look forward to a time in the near future when we might be able to order up the height, intelligence, or athletic ability of our children. Better yet, assert others with the assurance of those who honestly believe they are doing the right thing, is to incorporate these salutary changes into the very germplasm, the permanent heredity of generations of our offspring. A century ago the buzzword was eugenics. Today it is enhancement. Eugenics is meant to improve the breed and enhancement is meant to improve the individual, but they are too similar in concept to allow us to rest easy with either one.

Today's molecular biologists and geneticists have dipped a very powerful oar into the ongoing stream of debate about heredity versus environment. Every year--every month--we read about newly discovered genetic factors determining not only physical characteristics but those of morals and mind as well. Sometimes we are even told their precise locations on the DNA molecule. No one knows how much of this will hold up in the coming decades, but we can be sure that a significant proportion of it will be confirmed. Some authoritative scientific voices are telling us that we should take advantage of the new knowledge to fulfill our fantasies of improving ourselves and indeed our species.

These new findings--and the enthusiasm of some of our scientists--take us huge steps beyond the ultimately shaky theoretical platform on which the eugenics movement stood. The debate has for several years been raging between those who look to the lessons of the past and shout warnings and those who see only the utopia of an enhanced future and shout encouragement. In a powerful discourse against reproductive cloning--only one manifestation of the brave new world being foreseen--Leon R. Kass wrote in these pages of "a profound defilement of our given nature ... and of the social relations built on this natural ground." At the far other end of the spectrum is Gregory Stock, director of the Program on Medicine, Technology, and Society at UCLA and one of the new breed called "futurists," whose enthusiasm for bio-psychoengineering (Kass's cautionary term for such feats of creativity) and a post-human future is so unbounded that he has gone so far as to title his most recent book Redesigning Humans: Our Inevitable Genetic Future. Inevitable! Even more frightening than the confidence of Stock's vision for his fellow men and women is the title of the book's first chapter, in which he outlines his image of how the laboratory will come to control evolution: he calls it "The Last Human," meaning those few of us remaining whose bodies and minds have been formed by nature alone.

This is genuinely terrifying stuff. Not since the first half of the twentieth century have prominent thinkers been so starry-eyed at the thought of controlling the future of our species, or at least that privileged portion of it that will have the financial, cultural, and other wherewithal to take advantage of the offer being presented to us. I find myself somewhat less stringent than Kass but far more stringent than Stock. Though I admire Stock for his sincerity and the magnitude of his intellect, I am sure that I would have admired more than a few of the early German eugenicists for the very same reasons had I known them as well as I know him. What concerns me is not the progression of the technology, but the inherent creeping hazards in its philosophical underpinning, which is ultimately to improve the breed.

It all sounds very familiar. Looking backward, we can now see the danger in state-enforced policies of improvement, but too many of us have yet to awaken to the equally dangerous reality of improvement that is self-determined. We are once again standing on the slope, from the top of which the future we may be wreaking is already visible. Now is the time to recognize the nature of human motivation--and the permanence of human frailty.

Sherwin B. Nuland, Clinical Professor of Surgery at Yale School of Medicine, is a contributing editor at The New Republic.

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