I stood in front of the black Sphinx statue in the midst of a bustling crowd of fellow medical students who were rushing up the stairs to the next lecture. In Greek mythology, the Sphinx is thought to have guarded the entrance to Thebes. It used to pose a riddle to anyone wanting to pass through the gates. But standing in front of our Sphinx in the anatomy institute of Ludwig-Maximilians-Universität in Munich, I was the one who had a question. My silent question directed at the mute Sphinx was evoked by my recent visit to the Dachau concentration camp memorial site: Why did you fail to guard the entrance of our medical school in the years leading up to the Third Reich?

Dachau is a Bavarian town located roughly twenty kilometres northwest of Munich. Prior to 1933, Dachau was a well-known refuge, serving as a summer residence for the Bavarian royal family and as a sanctuary for German artists who were inspired by the melancholic beauty of the surrounding wetlands and forests. However, soon after Adolf Hitler and the Nazi party came to power in January 1933, Dachau became an infamous symbol of the Nazi terror and atrocities. In March of 1933, the Nazi government announced the opening of the Dachau concentration camp on the site of a former ammunition factory. The Dachau camp was one of the first concentration camps in the Third Reich and its initial purpose was to detain political enemies of the Nazis such as social democrats, socialists, trade union leaders and communists. The Nazis and the paramilitary SS (Schutzstaffel) organisation used the cynical expression ‘protective custody’, suggesting that they were merely detaining their political opponents in order to protect them from the righteous anger of the public. The official purpose of the Dachau concentration camp was to ‘educate’ the political dissidents to think in a manner that would conform to the Nazi government’s ideology.

The initial prisoners of the Dachau camp were primarily left-wing political opponents of the Nazis. The prisoner population massively expanded during the subsequent years and soon included members of many other groups persecuted by the Nazis, such as Jews, Gypsies, homosexuals, members of the clergy, and later on Poles, Russians and other prisoners of war captured during the Second World War. The Dachau camp was never a death camp or extermination camp of the likes of Auschwitz, but thousands of prisoners died in Dachau and many Jewish prisoners held at Dachau were also sent to their death to the extermination camps. Exact numbers of prisoners held and murdered at Dachau are difficult to obtain, but current estimates suggest that during the years of 1933-1945 at least 200,000 prisoners were held at the Dachau camp and at least 41,000 prisoners died. The common causes of death were executions, starvation and the spread of epidemics such as typhoid. After the war, the Dachau concentration camp was converted into a memorial site and museum which would allow visitors from all over the world to help remember the atrocities and convey a realistic portrayal of the Nazi terrors.

The burden of the Nazi legacy has been one of the cornerstones of German post-war education and culture. The atrocities committed by the Nazis in the Third Reich and the horrors of the Holocaust are the most widely covered aspects of the German secondary school curriculum. We extensively studied the Third Reich not only in our history classes, but also in classes about literature, ethics, philosophy, art and even music, because the impact that the Nazis and the trauma of the Second World War had on German culture and society was so pervasive. The Nazi atrocities and the role of the general German public as passive or not so passive accomplices of the Nazi criminals were the topics of numerous discussions that we had in our classes and in essays that we had to write. Many German school classes also supplement the theoretical learning about the Nazi atrocities with visits to museums or concentration camp memorial sites. However, even though I had also visited the Dachau concentration camp memorial site on multiple occasions when I was still in school, my most recent visit just prior to starting medical school was haunting me in a manner that I had not previously experienced.

In school, we had learned about the six million Jews that had been murdered by the Nazis and their SS-commanders, and we also learned about the millions of non-Jewish victims, such as the Sinti and Roma (Gypsies), Poles, Russians, disabled citizens, clergy members, socialists and communists who had perished during the Nazi reign. Unlike many of my German class-mates, I had the luxury of an immigrant background. The term ‘luxury’ may seem odd, because in the 1970s and 1980s (and to a certain extent even today), being an immigrant in Germany was often associated with a lower socio-economic status – quite the opposite of a ‘luxury’. However, there was one key area of German culture, where we immigrants were granted an unspoken privilege: The Past. Like many fellow immigrants, I enjoyed the comfort of knowing that my ancestors had no part in the Nazi crimes, because during the years when the Nazis were perpetrating the genocide, my ancestors had been subjects of the British Empire in India.

Throughout my childhood, I was convinced that even if my family had lived in Nazi Germany, we would have probably also ended up as prisoners in a concentration camp. Growing up as a Muslim, I was aware of the many similarities between how Muslims and Jews practise their religion and I had always felt a deep kinship with Judaism. I assumed that with my dark-skinned appearance, I would not have met the Nazi standards of a respectable human being. I only had a few unfortunate encounters with German neo-Nazis or skinheads in the 1980s, and in one of the exchanges that I still remember, the Neo-Nazi yelled that I and my ilk deserved to have been ‘gassed’ in a Nazi concentration camp. All of these experiences made it easy for me to think of myself as someone who would have been a potential victim of the Nazis, if I had lived during the Third Reich. This enabled me to avoid the torturous introspection that many other Germans had to undertake when trying to understand their families’ or communities’ guilt and complicity in the Nazi crimes. Some of my class-mates had grandparents who had been members of the Nazi party or the SS. I remember how they described the painful conversations they had with their grandparents, interrogating them about their motives for joining the Nazi party and whether they felt shame for their actions.

During all my previous visits to the Dachau concentration camp, I had been horrified by the crimes committed by Germans who had lived in or near my home city of Munich. I could sense the palpable evil exuding from the walls of the buildings of the Dachau camp, and I was able to feel the pain and suffering of thousands of human beings that had been murdered there. During these visits, all my relativistic musings about the nature of evil that are so common during adolescence would usually disappear. Moral relativism is an intriguing approach for class-room debates, but at the concentration camp site, I knew that true evil did exist and had taken place at this very site only half a century ago. The magnitude of the Nazi evil was so enormous that it always remained beyond my comprehension. In order to understand and describe evil, we often use categories and numbers to enumerate the victims or types of atrocities committed. On a subconscious level, I think that these abstractions are just our way of processing evil without having to directly confront it. Most of us have difficulties to emotionally and cognitively process news about a tragedy in which a single family is killed. The murder of a few hundred or a few thousand humans lies so far outside of our experience that it transcends our ability to comprehend the extent of the tragedy. In the case of the Holocaust, we may cognitively know that millions of human beings perished, but it is unlikely that any of us are able to even remotely grasp the extent of the tragedy and suffering of these millions of innocent human beings.

This recent visit to Dachau in the autumn of 1990 forced me to confront one aspect of the Nazi atrocities that had previously eluded me: medical experiments on human beings. Learning about the details of the horrific and deadly experiments carried out by German physicians on the Dachau concentration camp prisoners had shaken me to my very core. I had previously known that medical experiments on human prisoners were performed in the concentration camps, but I had just seen it as yet another proof of the monstrous nature of ‘those Nazis’. During this recent visit, I not only saw the specific sites where the medical experiments had been conducted, but I also read details about the suffering and torture that the prisoners had to endure. The fact that I was about to start medical school is probably why I took a much deeper interest in these crimes than I had in the past. My reason for going to medical school was that I wanted to become a scientist, a physician who would not only treat individual patients but someone who would also study the mechanisms of disease and help develop novel therapies. Up until that Dachau visit in 1990, I had always assumed that combining the profession of a healer with that of a scientist was the pinnacle of nobility and morality. My naïve idealism in regards to my future career as a physician was shredded when I realised that many of the horrific human experiments were carried out and supervised by German physicians who had studied medicine at some of Germany’s leading universities and then gone on to murder the Dachau prisoners in the name of medical research.

Standing in front of the Sphinx, I knew that some of these murderous physicians had probably walked past this same statue. I tried to tell myself that the vast majority of German physicians did not partake in the Nazi crimes and did not conduct experiments on prisoners at the concentration camps, but somehow this did not provide me the comfort that I sought. A strange memory of an analogy surfaced, which my elementary school teacher in third grade had taught us. She was telling us about the pollution of water by oil and that a single drop of oil could pollute a thousand litres of drinking water. I knew that only a fraction of German physicians had committed the crimes in the concentration camps, but somehow these physicians had tainted the whole profession. I was now struggling with my own aspiration to become a physician before my career had even begun. As I walked away from the Sphinx to finally attend the anatomy lecture, I knew that I needed to learn more about how and why physicians had actively participated in the Nazi crimes. I also realised that my exuberant passion for medicine and science would be replaced with a cautious enthusiasm, always keeping in mind that there is a dark side to medicine and research that should not be forgotten.

In the weeks, months and years that followed, I read a number of books about the atrocities committed at Dachau. I think that deep down, I had initially wanted to prove to myself that these murderers had not been scientists or physicians. I wanted to believe that they constituted a special breed of monstrous individuals, a cruel and unique aberrancy in the history of mankind that had occurred during the Third Reich, products of their time which had now gone extinct. I hoped to find signs of severe mental illnesses, not to excuse their crimes but to in part to help restore the mystique of nobility to the professions of medicine and science. If the Nazi physicians were indeed mentally deranged murderers, one could hardly blame the medical and scientific establishment for the crimes committed by these individuals. In retrospect, I attribute my silly aspirations to my youthful immaturity and naïveté. During the subsequent years, I learned that many of the Nazi physicians were not mentally ill, they did not constitute some genetic aberrancy and they did see themselves as physicians and scientists. They weren’t even rabid anti-Semites or passionate followers of the Nazi ideology. Instead, they were middle-class physician-scientists, who saw human experimentation and murder at the concentration camps as an opportunity to advance their medical research and careers, fulfill their ambitions for fame and prestige and pursue their quest for scientific truth. More recently, I have also come across literature about the careers of the physician scientists who actively or passively supported the torture and suffering inflicted on human beings in the name of science. It was shocking to find out that a number of such individuals were able to avoid the post-war prosecution for their crimes and instead, they went on to become faculty members at German universities. I know that most of my professors in medical school were in their forties, fifties or sixties and were either born after the Third Reich or were only children during the Third Reich. Knowing that none of my teachers participated in the Nazi crimes provided me some solace, but I also know that their mentors and professors likely included people who participated in the Nazi crimes.

There were numerous physicians who conducted human experiments in the concentration camps, but I just want to highlight the atrocities committed by one such individual. Sigmund Rascher was born in 1909 into a middle class family in Munich. His father was a physician who encouraged his family to actively play classical music and was a big supporter of the anthroposophic philosopher Rudolf Steiner. This probably explains why Sigmund Rascher’s father enrolled his children in a Waldorf school. Waldorf schools were founded on Rudolf Steiner’s philosophy which strives to achieve a balanced and holistic education by targeting the mind, body and soul of the student and by fostering the student’s creativity. Sigmund Rascher appears to have been an average student and completed his A-Levels at the age of 21, after which he entered medical school at the University of Freiburg. In 1933, Rascher joined the NSDAP (Nazi party) and in 1934 he decided to move to Munich, where he completed medical school in 1936. Instead of starting a clinical practice, Rascher focused on medical research and worked in a cancer research laboratory in Munich. It appears that he impressed his peers and mentors by developing innovative tests to diagnose cancer. He then decided to voluntarily join the SS and was also conscripted into the Luftwaffe (air-force) as a physician. Most biographical sketches of Rascher explicitly describe him as being ambitious, talkative and attention-seeking. It may therefore come as a surprise that he would have joined the SS instead of pursuing his burgeoning career in cancer research. However, by joining the SS and by using some personal connections of his wife, Rascher had gained access to the head of the SS, Reichsführer Heinrich Himmler, who was one of the most powerful men in the Third Reich. Thus joining the SS may have been a strategic career move for Rascher.

After Rascher was conscripted into the Luftwaffe, he contacted Himmler to see if he could get his medical research career back on track. The SS had full control over the concentration camps, so Rascher proposed performing experiments on the camp prisoners to study the effects of high altitude on air-force pilots. He explained that the experiments could not be performed on the pilots themselves, because they were too dangerous and potentially fatal. However, if prisoners from the Dachau concentration camp were used, one could mimic high altitude conditions with a low pressure chamber and monitor the responses of the prisoners to these potentially fatal conditions. Himmler and the Luftwaffe agreed to these proposed studies and Rascher began his first series of experiments. He documented the experiments with photographs of the prisoners as they suffered in the low pressure chambers. Of the 200 Dachau prisoners that were forced to participate in these studies, at least seventy or eighty died a painful death during the experiments while some of the survivors may have been executed after the experiments. Rascher reported his results directly to Himmler, who took a personal interest in these studies. In one series of experiments, Rascher reported the death of ten out of ten Jewish prisoners due to fatal air embolisms to the brain and there are reports of Rascher dissecting the bodies of prisoners after the experiments while they were still alive.

These horrific high altitude experiments represent only some of the unimaginable pain inflicted by Rascher on the Dachau prisoners. After reporting his results, Rascher suggested a different set of studies to Himmler. He wanted to study the effect of severe cold on human physiology to mimic the conditions that an air-force pilot might encounter if his plane had been hit while flying over the sea. Rascher received approval to complete these studies in which naked prisoners were placed in near-freezing water. A horrific table of numbers that Rascher generated from one of these sets of experiments is forever etched into my memory. In this specific table with the title ‘Exitus’ (medical terminology for death), Rascher lists the data for seven prisoners who were placed in near freezing water and logs the time it took for them to die and the body temperature at which they died. One prisoner was kept in the near-freezing water for ninety-five minutes and then died five minutes after he was pulled out of the water. I have stared at this table so many times, but the thought of the prisoner’s painful and prolonged death in the freezing water still brings tears to my eyes. It is estimated that at least 90-100 prisoners were murdered in these hypothermia experiments.

In an odd twist of events, Rascher and his wife were arrested in 1944 on grounds of suspected kidnapping of children. The exact circumstances of these accusations remain somewhat mysterious, but even Himmler’s intervention could not save Rascher. He was imprisoned in a concentration camp, transferred to Dachau and executed by the SS, just days before the Dachau camp was liberated by the Allied Forces in April of 1945.

When we find out about a genocide, our first natural reaction is to empathise with the suffering of the victims and view the perpetrators as non-human monsters. If we dig deeper, however, we are bound to find that in most cases, the perpetrators were, sadly, very human. In my readings about the Holocaust, especially in regards to the role of physicians and scientists, I have been terrified by the realisation that the perpetrators bore characteristics that are all too common among most human beings, including myself. Many of us carry within ourselves the potential to be ambitious and opportunistic, to seek prestige and power and to believe that the ‘ends justify the means’. In the case of the Nazi physicians, it seems that these characteristics were the primary drivers for their actions; the Third Reich just represented a fertile ground that allowed these characteristics to give rise to horrific crimes. This realisation has had a profound effect on how I relate to the Holocaust and on how I approach the practice of science and medicine. I have lost the immigrant immunity that I had issued to myself when it came to dealing with the crimes of the Third Reich. I forced myself to undergo the same kind of introspection that non-immigrant Germans had routinely undergone during the post-war decades. Even though my genetic ancestors had not been part of the Third Reich, the German physicians who committed the atrocities shared many of my German cultural roots. They had probably also read the poetry of Goethe and Rilke in school, they would have listened to Beethoven’s symphonies and probably studied the philosophy of Immanuel Kant. They wanted to leave their mark on science and break new ground in scientific discovery. I found similar ambitions within myself, my colleagues and my students. Importantly, I realised that these desires and ambitions needed to be kept in check by necessary ethical safeguards, so that we physicians and scientists will never again sacrifice the well-being of our patients and fellow human beings for our goals.

In the quest for novel medical cures, it is all too easy to fall into the trap of neglecting the well-being of individual research subjects for the purpose of the ‘greater good’. Claus Schilling, a physician who specialised in tropical medicine and infectious disease, conducted numerous experiments at Dachau in which he infected prisoners with malaria and watched scores of them die as he tried out novel cures that ultimately failed. When he was placed on trial for his crimes against humanity after the fall of the Third Reich, he did not deny that he had been in charge of the medical experiments that resulted in the death of so many prisoners. He merely believed that the experiments were necessary to find a cure for malaria and apparently viewed the victims of his experiments as collateral damage. He was found guilty and executed as a war criminal in 1946. Other German physicians who had participated in the atrocities of the Third Reich were tried before a US military tribunal in Nuremberg, in what became known as the Nürnberger Ärzteprozess (Doctor’s Trial in the city of Nuremberg) and many of the defendants either received the death penalty or life imprisonment for the crimes that they had committed.

In addition to these punishments, the tribunal also released an important document, ‘The Nuremberg Code’, which would help enshrine the ethical principles of how medical research should be conducted. The first of the ten principles of the Nuremberg Code is that for medical research to be ethical, one requires voluntary and informed consent of every research subject participating in the experiments. They cannot be directly or indirectly coerced into participating in research studies. Furthermore, all the risks and benefits of the experiment have to be fully explained to the potential research subjects, so that they can reach an informed decision as to whether or not they want to be a part of the research. This principle of the Nuremberg Code is a direct response to the medical experiments at Dachau and other concentration camps, where prisoners were coerced into participating and often did not know that the experiments would likely result in their death.

The Nuremberg Code itself is not a legally binding document, but many of its principles have found their ways into modern day laws and regulations of how medical research can be conducted. In the United States, all research involving human subjects has to be approved by an Institutional Review Board (IRB). The IRB committee at each research institution consists of practicing physicians, scientists and non-specialists who carefully assess the risks and benefits to an individual participant in a proposed research project. They try to ensure that potential research subjects are not coerced into participating in a study. Contemporary IRBs do not only look into obvious coercions such as forcing prisoners to participate in a research study, but they also try to ensure that less obvious forms of coercion are avoided. Refusing to treat a patient with standard medical therapies because he or she decided against participating in a study of a new experimental therapy, for example, would be a form of indirect coercion that the IRB would identify. The IRBs also curtail other subtle forms of pressure exerted on research subjects. For example, excessive monetary reimbursement for participation in high-risk studies is carefully scrutinised, because such a study could attract poverty-stricken research subjects whose decision to participate may be driven by financial pressures that confound their decision-making in regards to the risks and benefits of participation in the study.

In my work as physician scientist in the field of regenerative medicine and stem cell biology, I often come across colleagues in the US who complain of the over-reaching authority of the IRBs. Many proposed research studies in the US are rejected by the IRBs because of legal and ethical concerns about the risks that these novel therapies pose to human subjects. While I can sympathise with the concerns of my colleagues that medical progress is delayed due to these restrictions, my knowledge of the crimes committed by physicians and scientists at the concentrations camps allows me to understand and support our contemporary restrictions on medical research. When deciding about the safety of a medical experiment or the autonomy of the research subject, it is safer to err on the side of protecting the rights and well-being of the individual subject than invoking the ‘greater good’ argument. I have noticed that my colleagues who complain the most about IRBs have limited knowledge about the history of how regulations on the ethics or medical research evolved. Many of them know little about the crimes committed by physicians at the concentration camps and do not understand why we nowadays place such a high value on the individual’s rights and autonomy. I have a simple prescription for these colleagues: visit the Dachau concentration camp!

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