Medicine after the Holocaust Previously published by Sheldon Rubenfeld: Could It Be My Thyroid? Medicine after the Holocaust From the Master Race to the Human Genome and Beyond

Edited by Sheldon Rubenfeld In Conjunction with the Holocaust Museum medicine after the holocaust Copyright © Sheldon Rubenfeld, 2010 Softcover reprint of the hardcover 1st edition 2010 978-0-230-61894-7 All rights reserved. First published in 2010 by PALGRAVE MACMILLAN® in the United States - a division of St. Martin’s Press LLC, 175 Fifth Avenue, New York, NY 10010.

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Portions of Chapter 7, “Genetic and Eugenics,” are from A Passion for DNA: Genes, Genomes and Society, pp. 3–5, 179–208, 209–222, by James D. Watson, Cold Spring Harbor Laboratory Press 2000. c James. D. Watson. Reprinted with permission of James D. Watson. Chapter 5, “Mad, Bad, or Evil: How Physicians Healers Turn to Torture and Murder” was discussed and published in “Physicians and Torture: Lessons from the Nazi Doc- tors,” by Michael A. Grodin and George Annas, International Review of the Red Cross, Volume 89, Issue 867, September 2007, pp. 635–654. c International Commit- tee of the Red Cross 2007. Reprinted with the permission of Cambridge University Press. Chapter 9, “The Legacy of the Nuremberg Doctors’ Trial to American Bioethics and Human Rights,” is adapted and updated from the final chapter of American Bioethics: Crossing Human Rights and Health Law Boundaries , pp. 159–166, by George Annas, by permission of Oxford University Press, Inc. 2004. Excerpt from “Little Gidding” in FOUR QUARTETS, copyright 1942 by T.S. Eliot and renewed 1970 by Esme Valerie Eliot, reprinted with permission of Houghton Mifflin Harcourt Publishing Company. Excerpt from “Little Gidding” in Four Quartets by T.S. Eliot reprinted with permission of Faber and Faber Ltd. Figure 5.1. The Defendants’ Box at the Doctors’ Trial; Figure 5.2. Adolf Hitler as the Physician to the German People; Figure 5.3. “You Are Sharing the Load!”; Figure 10.1. Glass Man; and Figure 10.2. Maimed soldiers in Plötzensee near Berlin, summer 1916 are reprinted courtesy of the United States Holocaust Memorial Museum. The photograph on the cover is reprinted courtesy of the Holocaust Museum Houston. This page intentionally left blank Contents

List of Tables and Figures ix List of Contributors xi Acknowledgments xv Foreword: This Past Must Not Be Prologue xix Francis S. Collins

Introduction 1 Sheldon Rubenfeld

Part 1 Eugenics, Euthanasia, Extermination 9 1 When Evil was Good and Good Evil: Remembrances of Nuremberg 11 Edmund D. Pellegrino 2 Medicine during the Nazi Period: Historical Facts and Some Implications for Teaching Medical Ethics and Professionalism 17 Volker Roelcke 3 Academic Medicine during the Nazi Period: The Implications for Creating Awareness of Professional Responsibility Today 29 William Seidelman 4 Misconceptions of “Race” as a Biological Category: Then and Now 37 Theresa M. Duello 5 Mad, Bad, or Evil: How Physician Healers Turn to Torture and Murder 49 Michael A. Grodin 6 Genetic Diversity Has Prevailed, Not the Master Race 67 Ferid Murad

Part 2 Medicine after the Holocaust 69 7 Genetics and Eugenics: A Personal Odyssey 71 James D. Watson viii C ONTENTS

8 The Stain of Silence: Nazi Ethics and Bioethics 83 Arthur L. Caplan 9 The Legacy of the Nuremberg Doctors’ Trial to American Bioethics and Human Rights 93 George J. Annas 10 A More Perfect Human: The Promise and the Peril of Modern Science 107 Leon R. Kass 11 What Does “Medicine after the Holocaust” Have to Do with Aid in Dying? 123 Kathryn L. Tucker 12 Is Physician-Assisted Suicide Ever Permissible? 135 Wesley J. Smith 13 Cinematic Perspectives on Euthanasia and Assisted Suicide 153 Glen O. Gabbard 14 Science, Medicine, and Religion in and after the Holocaust 163 John M. Haas 15 Why Science and Religion Need to Cooperate to Prevent a Recurrence of the Holocaust 171 Irving Greenberg 16 The Status of the Relationship between the Citizen and the Government 181 Ward Connerly 17 From Nuremberg to the Human Genome: The Rights of Human Research Participants 185 Henry T. Greely 18 Medical Professionalism: Lessons from the Holocaust 201 Jordan J. Cohen 19 Assessing Risk in Patient Care 209 George Paul Noon 20 Jewish Medical Ethics and Risky Treatments 213 Avraham Steinberg Afterword 221 Michael E. DeBakey

Appendix A: Additional Information 225 Index 227 List of Tables and Figures

Tables

5.1 The Formation of a Torturer 57 5.2 Why Physicians are Vulnerable to Becoming Perpetrators 58 13.1 Films from 1970 to 2006 Showing Variations of Euthanasia 155 18.1 Physician Charter: Responsibilities of Individual Physicians 202 18.2 Contrasting Terms: Professionalism and Commercialism 203

Figures

5.1 The Defendants’ Box at the Doctors’ Trial 50 5.2 Adolf Hitler as the Physician to the German People 54 5.3 “You are sharing the load!” 60 10.1 Glass Man 109 10.2 Maimed soldiers in Plötzensee near Berlin, summer 1916 111 This page intentionally left blank List of Contributors

George J. Annas, J.D., M.P.H., is the Edward R. Utley Professor and Chair, Depart- ment of Health Law, Bioethics & Human Rights, Boston University School of Public Health, and professor in the Boston University School of Medicine and School of Law. He is the cofounder of Global Lawyers and Physicians and a member of the Institute of Medicine and the Committee on Human Rights of the National Academies. Professor Annas is the author or editor of 17 books on health law and bioethics. Michael E. DeBakey, M.D., a pioneer in the field of cardiovascular surgery, was chancellor emeritus of Baylor College of Medicine. Dr. DeBakey also developed the concept of mobile army surgical hospitals (MASH) and was a driving force behind the development of the Veterans Administration Medical Center System and the National Library of Medicine. Dr. DeBakey received numerous medical awards, including the Presidential Medal of Freedom with Distinction, the Albert for Clinical Research, and the Congressional Gold Medal. Arthur L. Caplan, Ph.D., is the Emmanuel and Robert Hart Professor of Bioethics and chair of the Department of Medical Ethics at the University of Pennsylvania. Dr. Caplan is the author or editor of 25 books, including When Medicine Went Mad: Bioethics and the Holocaust, and more than 500 papers in refereed journals of medicine, science, philosophy, bioethics, and health policy. Jordan J. Cohen, M.D., is president emeritus of the Association of American Medical Colleges and professor of medicine and public health at George Washington University. Dr. Cohen has held many leadership positions in academic medicine, and he is also chairman of the Arnold P.Gold Foundation, which advances humanism in medicine through innovations in medical education. Francis S. Collins, M.D., Ph.D., is director of the National Institutes of Health and the former director of the National Human Genome Research Institute at the National Institutes of Health, where he led the successful effort to complete the Human Genome Project. In recognition of his contributions to genetic research, Dr. Collins received the Presidential Medal of Freedom, the nation’s highest civil award. Ward Connerly is chief executive officer of Connerly & Associates, Inc., and the founder and president of the American Civil Rights Institute. Mr. Connerly stimu- lated the University of California to end the use of race as a means for admission in xii L IST OF C ONTRIBUTORS

1995 and has led campaigns in several states to require equal treatment under the law for all residents in public education, public employment, and public contracting. Theresa M. Duello, Ph.D., is the assistant director of the Diversity Initiatives Endocrinology-Reproductive Physiology Program and associate professor in the Department of Obstetrics and Gynecology at the University of Wisconsin-Madison. She teaches medical school and undergraduate courses on health disparities with an emphasis on the need for medical history to inform the training of future health professionals. Glen O. Gabbard, M.D., is the Brown Foundation Chair of Psychoanalysis, pro- fessor of psychiatry, and director of the Baylor Psychiatry Clinic at Baylor College of Medicine. He has published over 290 scientific papers and book chapters and authored or edited 23 books, including Psychodynamic Psychiatry in Clinical Practice and Psychiatry and the Cinema. Henry T. Greely, J.D., is the Deane F. and Kate Edelman Johnson Professor of Law and professor (by courtesy) of genetics at Stanford University. He is also the director of both the law school’s Center for Law and the Biosciences and the Stanford Center for Biomedical Ethics Program in Neuroethics. Professor Greely specializes in the implications of new biomedical technologies, especially those related to genetics, neuroscience, and stem cells. Irving Greenberg, Ph.D., is an ordained Orthodox rabbi and scholar who has been a seminal thinker in confronting the Holocaust as a historical transforming event. A pioneer in Holocaust education, theology, and in Jewish-Christian dialogue, Rabbi Greenberg has published numerous articles and monographs on Jewish thought and religion and was one of the founding figures of the United States Holocaust Memorial Museum. Michael A. Grodin, M.D., is professor of health law, bioethics, human rights in the Department of Health Law, Bioethics, and Human Rights, Socio-Medical Sciences, Community Medicine, and Psychiatry at Boston University Schools of Public Health and Medicine. He is director of the Project on Medicine and the Holocaust at the Elie Wiesel Center for Judaic Studies at Boston University and is the author of more than 200 scholarly papers and editor or coeditor of five books, including The Nazi Doctors and the Nuremberg Code: Human Rights in Human Experimentation. John M. Haas, Ph.D., S.T.L., is president of the National Catholic Bioethics Center, established in 1972 to apply the teachings of the Catholic Church to ethical issues arising from developments in medicine, the life sciences, and civil law. Dr. Haas was recently named by Pope Benedict XVI to serve as an Ordinary Member of the Pontifical Academy for Life. Leon R. Kass, M.D., Ph.D., is the Hertog Fellow of the American Enterprise Institute and Harding Professor, Committee on Social Thought at the University of Chicago. He was a founding member of the Hastings Center, has published numerous articles and books on ethical and philosophical issues, and, from 2001 L IST OF C ONTRIBUTORS xiii to 2005, served two terms as the first chairman of the President’s Council on Bioethics. Ferid Murad, M.D., Ph.D., is the John S. Dunn Distinguished Chair in Physiology and Medicine, director emeritus of the Brown Foundation Institute of Molecular Medicine, and professor of integrative biology & pharmacology at the University of Health Science Center at Houston. Dr. Murad was awarded the 1998 Nobel Prize in Physiology or Medicine as one of the discoverers of nitric oxide as a signaling molecule in the cardiovascular system. George Paul Noon, M.D., is professor of surgery in the Michael E. DeBakey Department of Surgery and chief, Division of Transplant and Assist Devices at the Baylor College of Medicine. Dr. Noon has authored numerous book chapters and articles for scholarly and professional journals on subjects that include and mechanical heart-assist devices. Edmund D. Pellegrino, M.D., is chairman of the President’s Council on Bioethics and professor emeritus of medicine and medical ethics at Georgetown University. Dr. Pellegrino, a member of numerous editorial boards, is the author of over 600 published items in medical science, philosophy, and ethics. He is the author or coau- thor of 23 books, the founding editor of the Journal of Medicine and Philosophy, and recipient of 46 honorary doctorates. Volker Roelcke, Prof. Dr. med., M.Phil., is the chair and director of the Institute for the History of Medicine at the University of Giessen in Germany. Prof. Dr. med Roelcke is a clinical psychiatrist with a degree in social anthropology. In addition to publishing numerous articles in scholarly journals, he has published four books, including Twentieth-Century Ethics of Human Subjects Research: Historical Perspectives on Values, Practices, and Regulations. Sheldon Rubenfeld, M.D., is clinical professor of general medicine at Baylor College of Medicine. He has taught Jewish Medical Ethics at Baylor College of Medicine for seven years as well as Healing by Killing: Medicine in the Third Reich for three years. Dr. Rubenfeld created the concept for and developed, in conjunction with the Holocaust Museum Houston, Medical Ethics and the Holocaust, which included an exhibit entitled How Healing Becomes Killing: Eugenics, Euthanasia, Extermination and the 17-part Michael E. DeBakey Medical Ethics Lecture Series. William Seidelman, M.D., is emeritus professor in the Department of Family and Community Medicine at the University of Toronto and an internationally recognized authority on the history of medicine in the Third Reich, especially the role of German and Austrian universities and research institutes. His work has been published in many medical journals including the British Medical Journal and the Journal of the American Medical Association. Wesley J. Smith, J.D., a senior fellow in human rights and bioethics at the Discov- ery Institute, is the associate director of the International Task Force on Euthanasia and Assisted Suicide. He has authored or coauthored 12 books, including Forced Exit: Euthanasia, Assisted Suicide, and the New Duty to Die; Culture of Death: xiv L IST OF C ONTRIBUTORS

The Assault on Medical Ethics in America; and Consumer’s Guide to a Brave New World. Avraham Steinberg, M.D., is the director of the Medical Ethics Unit and senior pediatric neurologist at Shaare Zedek Medical Center in Jerusalem and head of the editorial board of the Talmudic Encyclopedia. He has authored 30 books and 240 scientific articles and chapters related to medical ethics. Dr. Steinberg has received numerous awards, among them the Israel Prize in 1999 for his Encyclopedia of Jewish Medical Ethics. Kathryn L. Tucker, J.D., is director of legal affairs of Compassion & Choices, a national non-profit organization dedicated to improving end-of-life care. Ms. Tucker served as lead counsel representing patients and physicians in two federal cases decided by the U.S. Supreme Court in 1997, asserting that competent dying patients have a constitutional right to choose aid in dying. She has successfully defended the Oregon Death with Dignity Act and coauthored the Washington Death with Dignity Act, as well as a number of model legislative measures to improve end-of-life care. James D. Watson, Ph.D., is chancellor emeritus of Cold Spring Harbor Laboratory. In 1953 Drs. Watson and Francis Crick determined the structure of DNA for which they shared the 1962 Nobel Prize for Physiology or Medicine with Maurice Wilkins. Dr. Watson served as director of the Human Genome Project from 1989 to 1992. He has authored ten books, including Molecular Biology of the Gene and the international best seller The Double Helix. Acknowledgments

I am grateful to the Holocaust Museum Houston for accepting my proposal for an exhibit, lecture series, and a book based on the role doctors played in events imme- diately before, during, and after the Holocaust. In particular, I would like to thank the museum chair, Peter Berkowitz, and executive director, Susan Myers, who chose to devote the museum’s resources to this concept. What resulted was a world-class program that eventually touched the lives of thousands of doctors, medical students, and museum visitors over the course of six months. In addition to the thousands who watched the Michael E. DeBakey Medical Ethics Lecture Series (in person or via Internet), more than 50,000 people visited the accompanying museum exhibit, How Healing Becomes Killing: Eugenics, Euthanasia, and Extermination. Credit is also due to other members of the project’s steering committee, including Melissa Brunicardi, Nancy S. Dinerstein, Kelli Cohen Fein, past chair Walter Hecht, Manuel D. Leal, Leo Linbeck III, Cheyenne Martin, Eric Pulaski, Anna Steinberger, Dr. John Thrash, Ileana Trevino, and to current chair Michael Goldberg. The project was aided by the advisory board comprising some of the most influential members of Houston’s medical community, and it would never have been possible without the financial support of more than 40 generous donors and supporters. I would also like to acknowledge the museum staff under the direction of Tamara Savage, who worked tirelessly to orchestrate this enormous project while ensuring the day-to-day operations of the museum continued. I thank the authors whose works are collected in this volume as well as the other superb speakers who contributed to the program, including Mark Addickes, Edwin Black, Jacquie Brennan, Sandra Carson, Lex Frieden, Michael Gross, , Susan Lederer, William Monroe, Richard Petty, and Christine Rosen. Many of those who spoke also wrote manuscripts, and my one regret is that there was insufficient space to include all of them in this book. Fortunately, videos of their lectures can be viewed online at http://www.utexas.edu/cola/centers/scjs/med-ethics/Lectures.php. The Schusterman Center for Jewish Studies in the College of Liberal Arts at the Uni- versity of Texas at Austin established this site to display the videos of all the speakers in the Michael E. DeBakey Medical Ethics Lecture Series. I thank Arthur Caplan for his singular contributions. He had “been there and done that” with his 1989 conference at the University of Minnesota and publication of collected articles from that conference in When Medicine Went Mad: Bioethics and the Holocaust. Art very generously shared his invaluable experience and advice, which enabled me to recruit the highest-quality scholars for the program. xvi A CKNOWLEDGMENTS

I also thank William Seidelman for his special contributions. Bill was a very early personal supporter and advisor. His many suggestions guided me along an unfa- miliar and rocky road and kept me from going into too many ditches. When I didn’t understand a historical or political point, I knew I could count on him to explain it. I gratefully acknowledge the late Michael DeBakey who graciously lent his name to the lecture series and who shared with me his eyewitness accounts of many rele- vant historical events. The early and consistent support for the project by Richard Wainerdi, Patricia Starck, Glenn Cambor, and Richard Materson is also greatly appreciated. I am very grateful to my aunt Thea Silber Steuer and to Colonel Josiah C. Wedgwood, a Christian Zionist member of the British parliament, who together rescued my mother eight months after the Nazis marched into Austria. I also thank my cousin René Lehr Steuer, who shared with me the documentation of the rescue. In addition, I would like to express my appreciation to Wolfgang Fritzsche, my wonderful guide whose historical knowledge and charming ways made my trips to Germany much more rewarding than they otherwise would have been. A project as large as this one encounters many roadblocks. Ben Tobor, Jeremy Steele, Mark Yudof, Randy Diehl, and Robert Abzug cleared many of them, and I thank them for their timely assistance. Sheree Bykofsky and Janet Rosen of Sheree Bykofsky Associates, my liter- ary agents, went the extra mile to ensure publication of the book. I gratefully acknowledge their patience, support, and encouragement. I am grateful to Chris Chappell, my editor at Palgrave, as well as to Samantha Hasey, Kristy Lilas, Sumitha Nithyanandan, and all their staff for providing a steady hand through the editing and publishing processes. I offer a special thank you to Kathy Kobos, my personal and indispensable assistant, for her unflagging energy and tireless devotion to the book and for getting everything just right. I gratefully acknowledge Phyllis Applebaum, Robin Dorfman, and Bobbie Gaspard for reading all of the manuscripts with their sharp red pencils in hand and also Diana Tisdale and Marcella Salas, who offered help whenever help was needed. Each Wednesday for the past ten years, I have studied Jewish medical ethics with Rabbi Yossi Grossman of the Torah Outreach Resource Center of Houston (TORCH). Rabbis Yaakov Lipsky and Eli Berakah started the class, and Naomi Myers, Alan Winters, Margo Restrepo, Ed Teitel, Stanley Hite, Judith Feigon, Amelia Kornfeld, Muriel Meicler, Jonathan Magid, and many others studied with us. I thank them all for sharing their wisdom with me. I am also grateful to the Baylor medical students in my classes on Jewish medical ethics and on medicine and the Holocaust for sharing their insights with me. What goes around comes around. More than 20 years ago, Rabbi Irving Greenberg introduced me to Jewish medical ethics at a Wexner Heritage Program seminar. When TORCH arrived in Houston, I asked the rabbis to study Jewish medical ethics with interested physicians including Ron Moses, who not only stud- ied with me nearly every week for the past ten years but also founded an annual Jewish medical ethics conference in memory of his grandfather. When he went to A CKNOWLEDGMENTS xvii his Wexner Heritage Program seminar, Ron told Rabbi Greenberg about the fruit from the tree the rabbi had planted more than 20 years before. I am grateful for the privilege of studying with both of them. Finally, I’d like to thank Linda, my loving wife, who fully supported me from the very start of this entire project and who genially managed without my company many nights and weekends. She has been my keenest critic and my best friend, and I am grateful to her for taking on both roles.

Sheldon Rubenfeld Houston, Texas April 21, 2009 Yom HaShoah 5769 This page intentionally left blank Foreword This Past Must Not Be Prologue Francis S. Collins

In 1907 Eddie Millard was convicted of petty larceny and sentenced to prison in Indi- ana. There he encountered Dr. Harry C. Sharp, a respected member of the American medical profession. Dr. Sharp proceeded to interrogate Eddie and then informed him that it would be better for society if he were sterilized. Despite Eddie’s verbal protests and actual physical struggles in the operating room, a sterilization operation was performed. Many medical students and physicians today are probably shocked that one of their own colleagues in the honored profession of medicine would carry out this kind of unconsented sterilization on an unwilling prisoner. Yet, in 1907 Indiana had just enacted a law to make such actions legal. That was just the beginning: between 1907 and 1974, approximately 64,000 Americans were forcibly sterilized. Being associated with the Holocaust and other atrocities of the Nazi regime in Germany, the term “eugenics” carries appropriately dark connotations in the minds of most of us in the medical profession. Less well known are the origins of this pseudoscience in the United Kingdom and the United States. It was Francis Gal- ton, Charles Darwin’s cousin, who coined the term “eugenics” in 1883 and made the case for applying selective breeding to the human race. Many scientific and political leaders in America embraced these concepts over the next 20 years. Initially, the focus was on “positive eugenics” programs, such as contests for healthy families and better babies, but slowly the program shifted toward “negative eugenics” in the form of ster- ilization programs. The mainstream American scientific community played a deeply disturbing role in these events. The Cold Spring Harbor Eugenics Record Office, founded in 1910, carried out surveys of human heredity that went well beyond the boundaries of genetic conditions such as Huntington’s disease and claimed to discover Mendelian heritability for all manner of behavioral traits and social maldispositions. Harry Laughlin of the Eugenics Record Office subsequently testified in Congress in favor of sterilization laws and the need to greatly restrict immigration of populations he considered undesirable. The evidence behind his testimony was both scientifically unfounded and overtly racist. Meanwhile, Germany was reeling from the loss of a substantial proportion of its young men on the battlefields of World War I and was suffering great economic dis- tress as well. Seeking an opportunity to lay blame for Germany’s troubles on those xx F OREWORD less fortunate, Hitler embraced the eugenics mindset, attached it to his own con- cept of the German master race, and embarked upon a program of state-sponsored eugenics that represents one of the greatest nightmares in human history. Beginning with the involuntary sterilization of some 400,000 Germans, progressing to euthana- sia of children with birth defects or mental retardation, moving on to euthanasia of psychiatric patients, and, ultimately, to the massacre of six million Jews, Hitler and his band of genocidal criminals carried eugenics to a depth of evil that still evokes indescribable horror. Most medical students and physicians know the name of Josef Mengele, the physi- cian at Auschwitz who presided over many horrific medical “experiments,” including dissections of living individuals. Yet, relatively few members of the medical pro- fession are aware of the breadth and depth of involvement of German physicians across the country in the Nazi nightmare. By 1942, 40,000 physicians had joined the National Socialist Physicians League and were either directly engaged in the eugenic cleansing program or indirectly involved by their failure to object. Just as we now find it almost impossible to understand how the Christian church could have largely remained silent during this dark era, we must also seek to understand how the main- stream of the German medical profession, supposedly devoted to healing and to the Hippocratic Oath, could have become complicit with such a diabolical program. It would be a mistake, however, to dismiss this history with self-righteous smug- ness. Instead, we should ask ourselves whether this could ever happen again. Perhaps there is room for reassurance in most developed countries, at least about state- sponsored eugenics, but there is no room for complacency. After all, widespread abortion of female fetuses has been recently practiced in parts of India and China as a means of gender selection, and presumably medical personnel must be participating. As for the possibility of eugenic applications to more complex human traits, we can look at the efforts of the Cold Spring Harbor Eugenics Record Office and ridicule the naïveté of those attempts to connect human behaviors and social circumstances to single genes. On the other hand, with the success of the Human Genome Project and subsequent efforts to develop a detailed catalog of human genetic variation, we are increasingly able to identify the heritable components of complex human dis- eases, and it is only a matter of time before those same approaches begin to identify genetic contributions to human personality, intelligence, and even sexual orientation. While those genetic factors will be individually weak and the environment will play a powerful role in shaping such characteristics, a society that seems willing to embrace a deterministic view of genetics may not always understand those limits. Perhaps more relevant than state-sponsored eugenics for today’s ethical debates, however, is the way in which “homemade eugenics” (a term introduced by Daniel Kevles) is becoming more and more commonplace. Now that preimplantation genetic diagnosis (PGD) is widely available, its application is spreading beyond the efforts to avoid the birth of a child with severe conditions like Tay-Sachs disease and into progressively milder and later-onset conditions. The most dramatic example is in gender selection, which is now offered by 42 percent of in vitro fertilization clinics, simply to provide a couple with the opportunity to choose the sex of their child. This kind of homemade eugenics provides a classic collision of ethical, legal, and social principles that make it difficult to regulate. After all, most societies in the West F OREWORD xxi generally consider the reproductive choices of couples to be an area that the state should stay out of. On the other hand, society believes that the state has an interest in supporting principles of benevolence, fairness, justice, and non-malevolence. To the extent that homemade eugenics focuses on “the perfect baby” and leads society to be less tolerant of those with disabilities (as may already be happening, for example, for children with Down syndrome), society does have a legitimate interest in overseeing certain reproductive applications of the new genetics. Fortunately, however, the most frightening scenarios of this kind of homemade eugenics rest upon a mistaken and overly deterministic view of the role of genes. The notion that a couple with unlimited resources could utilize PGD to optimize the traits of a future offspring will quickly run into trouble on scientific grounds. Sup- pose, for instance, that a couple wanted to optimize five traits for a future child, such as hair/eye/skin color, IQ, athletic ability, body weight, and musical talent. Each of those traits likely has contributions from at least 10 different gene variants. If each embryo had a 50 percent chance of inheriting a particular desirable variant from one of the parents, then getting all 50 of these outcomes “right” would require a thousand trillion embryos from which to select. Even then, the couple would likely be pro- foundly disappointed with the outcome, since the environment is a huge contributor to nearly all of these traits. Still, as our understanding of the human genome is increasing at a dizzying pace, it may not be possible to predict all of the potential uses and misuses of this infor- mation. Our best defense against a future eugenic nightmare is a sober consideration of the past, coupled with a vigorous and visionary effort to identify future challenges before they turn into crises. That has been the goal of the ethical, legal, and social implications (ELSI) program of the Human Genome Project, which today represents the largest investment in bioethics in human history. That experiment must continue vigorously. And the medical profession must never forget its role in the eugenic horrors of the past and must be vigilant against the appearance of any evidence of recurrence. This past must not be prologue.