History and Philosophy of Medicine The Doctor’s Dilemma: The Utilitarian Medical Ethics of Nazi Physician Karl Brandt Joshua J. Schultz, MA, BHSc candidate, Brock University medicine, which had spawned advances in public health, Abstract pharmaceuticals, and vaccines. He recognized the precipi- Before World War II German physicians and scien- tous decline that had occurred when German medicine be- tists were responsible for major advances in medi- came Nazi medicine. Lead prosecutor General Telford Taylor identified a similar decline. In his view, Nazi medicine was cine. The actions of doctors in the Nazi system were thanatology – the science of death. He argued that Nazi medi- an aberration of this legacy; however, not all Nazi cine’s contribution was techniques for ending life.2 It had not doctors operated in an ethical vacuum. This paper added relevant medical advances through its inhumane ex- examines the doctors’ trial at Nuremberg in 1946. perimentation. Contrary to Telford’s view, not all Nazi doc- This paper draws attention to the utilitarian medi- tors operated in an ethical vacuum. The medical ethics of cal ethics of the Nazi doctor Karl Brandt and dis- some Nazi doctors represented an extreme form of utilitari- cusses how utilitarianism still informs medical prac- anism that instrumentalized human life and disregarded in- tice today. The Hippocratic Oath was cited by the dividual autonomy. The defense of Brandt at the Nuremberg prosecution at the Nuremberg doctors’ trial as part Trials provides a glimpse into the logic behind this peculiar of the common law of medicine. Brandt and his de- medical ethics. This paper draws attention to the utilitarian fense lawyer Dr. Robert Servatius countered by argu- medical ethics of the Nazi physician Brandt and discusses how ing that Brandt was acting in the best interests of the utilitarianism still informs medical practice today. state. He and Servatius argued that the morality of German doctors in the Nazi system represented an Background alternate medical ethics to that practiced in western The trial of Nazi doctors at Nuremberg in 1946 reveals democracies. In the end Brandt was found guilty much about the ethical backdrop in which said doctors prac- of negligence due to the presence of non-German ticed medicine and carried out their research. The Nurem- citizens in the T-4 “euthanasia” program of which berg doctors’ trials were a means for the allied powers to ar- Brandt had been in charge. “Brandt’s trial high- gue for the universality of ideas central to modern medical lights utilitarianism in medical ethics whereby phy- ethics – values such as informed consent, the non-maleficence sicians are responsible for determining the cost that principle, and the beneficence principle. From the perspec- treatment of the individual represents to the com- tive of the prosecution, such values were integral to medical experimentation and medical practice. Under this paradigm munity. The community sets limits and physicians Nazi physicians were duty bound to practice according to must work within those limits, but in order to act these principles. Conversely, the defense argued that the ac- as a bulwark to malevolent state power as existed in tions of German doctors were utilitarian – they were for the Nazi Germany, physicians have a duty to advocate benefit of the German people and the German state. Thus, for life and treatment whenever possible. Nazi physicians like Brandt felt that duty was secondary to consequences. As long as the majority of Germans benefitted, the actions of Nazi physicians were justified. The notion of common law drove the prosecution of Ger- Introduction man war criminals. The Hague Convention of 1907 served as et me remind you only of names like Robert Koch, precedent for deciding what constituted crimes against hu- Emil von Behring, Paul Ehrlich, Theodor Billroth, manity.3 Defense lawyers for German war criminals protested “Land August Bier, or medicines such as Germanim, that the Axis powers were not signatories of this convention.4 Atabrine, Salvarsan, diphtheria serum, tetanus serum, and The prosecution countered that since the bulk of nations had many others.”1 Hans Pribillia’s closing statement for the been signatories, Germany was still bound by its laws. Crimes defense of Nazi physician Dr. Paul Rostock at the Nurem- committed against humanity were recognized as part of the berg trials in 1946 recounted the former glory of German common law of all nations. The prosecution of Nazi doctors similarly found its basis in common law. Expert medical witnesses Dr. Andrew Ivy and Corresponding Author: Dr. Leo Alexander cited the Hippocratic Oath as the prima- Joshua J. Schultz ry code of ethics for any doctor educated in the traditions E-mail: [email protected] of Western medicine. For Ivy, the Hippocratic Oath was a 176 UTMJ • Volume 90, Number 4, May 2013 History and Philosophy of Medicine The Doctor’s Dilemma: The Utilitarian Medical Ethics of Nazi Physician Karl Brandt universally binding oath that applied to all doctors, and it su- The crux of Taylor’s argument is that violation of the in- perseded laws and directives of the state that demanded ac- dividual’s right to choose is a violation of universal common tion contrary to it. When asked during his testimony whether law. He strongly indicts systems that endorse such a violation. he felt the state could assume the moral responsibility of the His argument has the individual taking precedence over the physician, Ivy replied that the state is incapable of monitor- good of the nation state. The consequences of emphasizing ing the actions of a physician in his or her daily practice.5 individual rights do not factor into his argument. There is Indeed, he argued that physicians have a moral responsibility no recognition of the benefits and downsides such a view has to act according to the Hippocratic Oath.5 Included in Ivy’s for medical practice; instead, consent and autonomy are most testimony was the mention of specific standards for research important because that is what had always been done. In Tay- and experimentation that existed in the United States as part lor’s view consent and autonomy were part of the common of the American Medical Association’s (AMA) guidelines.6 law of medicine. Incidentally, such principles dealing with experimentation Ironically, it was adherence to democratic notions of jus- done on human beings had not existed prior to December tice underlying the Nuremberg trials that made it difficult for 28, 1946. Having become acquainted with the nature of Nazi the prosecution to piece together a case against Nazi doctors. experiments through the reading of the prosecution’s pre- Due to the questionable jurisdiction that the United States trial records, Ivy had reported his findings and given general claimed in prosecuting German citizens, the opening state- recommendations regarding human experimentation to the ment of the prosecution stressed the genocide of Jewish per- AMA, who subsequently codified said recommendations.6 sons.9 This had a two-pronged effect: it downplayed crimes Globally speaking, there were no pre-existing written stan- against other ethnic minorities such as the Roma, and it de- dards for human experimentation before 1946. Ivy claimed emphasized the “euthanasia” program, which had involved that the AMA standards only recently put in to writing had mostly German citizens. The primary defendant among the been common practice.7 In his view, physicians had a duty at 21 doctors at the Nuremberg trial, Dr. Karl Brandt, was head the very least to do no harm. of the Tiergartenstrasse-4 (T-4) “euthanasia” program and only Since written standards to guide doctors in carrying out minimally involved with the genocide of foreign nationals. human experimentation had not existed prior to 1946, the Aktion T-4, which was instituted by the German govern- prosecution had to gather expert testimonies from practic- ment in September, 1939, was a program designed to end the ing physicians and synthesize a code therefrom. Such a code suffering of the so-called “incurably ill”.10 Those judged incur- could be used by the Nuremberg judges in rendering a deci- ably ill tended to suffer from mental illness or mental and sion. The result of this synthesis was the Nuremberg Code, physical disabilities. They had depended on the state for sup- which contained ten principles to which doctors were re- port and resided in state institutions. The scarcity stemming quired to adhere before human experimentation could be from World War I and the 1930s had made Germans much carried out.8 The first principle is most relevant to medical more receptive to ending life that was a drain on the system.10 practice. It states that voluntary consent of the human sub- The Nazi party also portrayed the lives of the “incurably ill” as ject must be attained prior to any research taking place.8 The filled with suffering and devoid of meaning through various ninth principle also addresses the question of consent since propaganda films.10 Throughout the 1930s and World War it requires the researcher to halt his experiment if the hu- II, panels of experts decided on the fate of institutionalized man subject suddenly feels she/he might come to harm.8 The children and adults. As scarcity of resources became a greater Nuremberg Code embodies a core democratic axiom: an in- problem for Germans, the number of institutionalized pa- dividual cannot be controlled or coerced into doing anything tients who were euthanized grew. Brandt was in charge of that may bring her/him harm. According to the code, physi- Aktion T-4. For him the ethical practice of medicine involved cians have a duty not to harm not because it is good for the ending the suffering of the “incurables” in order to free up many, but because human life is valuable in and of itself.