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Nazi Medicine and Public Health Policy
By Robert N. Proctor
It is poor scholarship and perhaps even dangerous to caricature the Nazis as irrational or anti-science. What we have to look at more carefully is the relationship between science and ideology at this time.
We often hear that the Nazis destroyed science and abandoned ethics. Telford Taylor, in his opening statement at the Nuremberg "Doctors' Trial" of 1946-7,
The Nazis...supported many kinds of science, left politics (as we often think of it) out of most, and did not abandon ethics. There was an ethics of Nazi medical practice -- sometimes explicit, sometimes not.
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claimed that Nazi doctors had turned Germany "into an infernal combination of a lunatic asylum and a charnel house." "Neither science, nor industry, nor the arts could flourish in such a foul medium,"1 Taylor asserted about the Third Reich. Taylor was not the first to suggest that Nazism and the scientific spirit were fundamentally incompatible. Franz Neumann, in his 1942 book Behemoth, had already posited "a most profound conflict" between what he called the "magic character" of Nazi propaganda and the "rational" processes of German industry, a conflict he believed would culminate in an uprising on the part of engineers to combat Hitler's irrationalist regime.2 Such an uprising, needless to say, never materialized.
The problem with the "science vs. fascism" thesis is that it fails to take into account the eagerness with which many scientists and physicians embraced the Reich, and the many scientific disciplines which actually flourished under the Nazis. Anyone who has ever examined a V-2 engine will have few doubts about this, and there are numerous other examples. During the Nazi era, German scientists and engineers either developed or greatly improved television, jet-propelled aircraft (including the ejection seat), guided missiles, electronic computers, the electron microscope, atomic fission, data-processing technologies, pesticides, and, of course, the world's first industrial murder complexes. The first magnetic tape recording was of a speech by Hitler, and the nerve gases Sarin and Tabun were Nazi inventions.
The story of science under German fascism is not, as conventional wisdom would have it, only a narrative of suppression and survival; a truthful account will explain how and why Nazi ideology promoted certain areas of inquiry, and how projects and policies were championed or disappeared because of political considerations.
In this article, I want to explore some of the obstacles that have hindered our efforts to understand Nazi science and medicine. I will concentrate on two myths: the myth of flawed science and the myth of abandoned ethics. The Nazis, I shall suggest, supported many kinds of science, left politics (as we often think of it) out of most, and did not abandon ethics. There was an ethics of Nazi medical practice -- sometimes explicit, sometimes not; often cruel, but sometimes not. This is important to understand if we are not to perceive the German physicians who endorsed Nazism as absolutely alien and otherworldly. The question of questions, after all, is how did these men and women, who were convinced they were doing good, come to commit crimes that we today regard as the embodiment of evil?
Understanding the power of these myths -- of science destroyed and ethics abandoned -- is important not just for setting the historical record straight, but also for understanding why it has taken so long to come to grips with Nazi medical crimes. And comprehending the Nazis' support for science and medicine can also help us understand the appeal of Nazism within German intellectual culture; this, in turn, might help us better discern how fascism came to triumph in the first place.
Nazi Ideology and Anti-Tobacco Research
If you ask most experts when the first good evidence arose that tobacco was a major cause of lung cancer, they will point to a series of epidemiological studies by English and American researchers in the early 1950s. If you ask when a medical consensus on this question first arose, they will most likely point to the 1964 Surgeon General's report, which took a strong stand on this question, or a similar report by Britain's Royal College of Physicians two years earlier.
I have become convinced, however, that there was an earlier and overlooked consensus, a consensus within the German medical and scientific community, that emerged during the Nazi period. The Nazis had a powerful anti-tobacco movement, arguably the most powerful in the world at that time. Tobacco was opposed by racial hygienists fearing the corruption of the German "germ plasm" (i.e., genetic material), by industrial hygienists fearing a reduction of people's capacity to work, by nurses and midwives fearing harm to the "maternal organism." Tobacco was said to be a "corrupting force in a rotting civilization that has become lazy." The Nazis' anti-tobacco rhetoric drew from an earlier generation's eugenics rhetoric and also reflected an ethic of bodily purity and zeal for work.3 Tobacco use was attacked as an "epidemic," a "plague," as "dry drunkenness," and as "lung masturbation"; tobacco and alcohol abuses were "diseases of civilization" and "relics of a liberal lifestyle."
Anti-tobacco research flourished in the Third Reich. Animal experimental work demonstrated that the tar extracted from cigarette smoke could cause cancer; and physical chemists distilled tobacco tars to identify the carcinogenic components. The editor of Germany's Monatsschrift für Krebsbekämpfung (Monthly Anti-Cancer Journal) organized animal experiments to test whether smoking causes lung cancer: rats were put into a "gas chamber" and cigarette smoke was pumped in from the top (many animals suffocated).4 Germans under the Nazis established ambitious tumor registries, which included the first broad registries of cancer incidence, and not just cancer mortality.
Third Reich scientists also performed extensive work in the area of occupational carcinogenesis. Physicians documented the health hazards of asbestos, and in 1943 Germany became the first nation to recognize lung cancer and mesothelioma caused by asbestos inhalation as compensable occupational illnesses. Nazi Germany also pioneered what we now call experimental epidemiology: two striking papers -- a 1939 article by Franz H. Müller of Cologne, and a 1943 paper by Eberhard Schairer and Erich Schöniger of Jena -- presented the most convincing demonstrations up to that time that cigarettes were a major cause of lung cancer. Let me say a few words about these papers because they represent a different kind of science than we are accustomed to associating with the Nazi era.
Franz H. Müller, a physician at Cologne's Bürgerhospital, analyzed the smoking habits of 86 male lung cancer patients and compared them with the habits of age-standardized "controls" not suffering from lung cancer. His findings were clear-cut and striking: the lung cancer patients were much more likely to be heavy smokers and much less likely to be nonsmokers. Sixteen percent of the healthy group were nonsmokers, compared with only 3.5 percent for the lung cancer group. The 86 lung cancer patients smoked a total of 2,900 grams of tobacco per day, while the 86 healthy men smoked only 1,250 grams. Müller concluded that tobacco was not just "an important cause" of lung cancer, but also that "the extraordinary rise in tobacco use" was "the single most important cause of the rising incidence of lung cancer" in recent decades (emphasis in original).5
Müller's work was taken one step further by Eberhard Schairer and Erich Schöniger, physicians working at Jena's Institute for Tobacco Hazards Research. The Jena scientists were well aware that German lung cancer rates were on the rise, and that many of the nontobacco explanations of the rise were flawed (the automotive exhaust theory, for example, failed to explain the fact that rural rates were also rising). Schairer and Schöniger drew attention to the fact that a heavy smoker could inhale as much as four kilograms of tar over a lifetime, a frightening figure given Angel H. Roffo's demonstration that animals painted with tobacco tars develop high rates of cancer.6
Closely following the method pioneered by Müller, Schairer and Schöniger sent questionnaires to the relatives of 195 lung cancer victims, inquiring into the smoking habits of the deceased. Going beyond Müller, however, they sent an additional 555 questionnaires to the families of patients who had died from other kinds of cancer -- the presumption being that smokers would be more likely to develop certain kinds of cancer rather than others. Questionnaires were also sent to 700 male residents of Jena to determine the smoking habits among a population apparently free of cancer. The results were clear: among the 109 lung cancer cases for which usable data were obtained, only three were nonsmokers, a far lower proportion than among the population as a whole (about 3 percent, vs. 16 percent for the noncancer controls). The smokers were not necessarily "cancer prone," because when cancers other than lung cancer were looked at -- stomach cancer, for example-- smokers were found to be no more likely to succumb than nonsmokers. Schairer and Schöniger's conclusion: smoking was very likely a major cause of lung cancer. The results were of the "highest" statistical significance, though the investigators did not have the mathematical tools to quantify that level of significance. A 1994 re-evaluation of Schairer and Schöniger's study showed that the probability that the results could have come about by chance was less than one in 10 million.7
The Significance of Nazi Tobacco-Use Research
How should we interpret such studies? How can we explain the fact that Nazi Germany was home to the world's foremost tobacco-cancer epidemiology and the world's strongest cancer prevention policy? Do we say that "pockets of innovation" existed in Nazi Germany, resistant to ideological influence?8 What if we find, on closer inspection, that Germany's anti-tobacco research flourished not in spite of the Nazis, but in large part because of the Nazis? And would it then be appropriate, from a moral point of view, to cite such research in scientific studies today?9
I ask this last question partly because the two tobacco studies I have just discussed have, in fact, been repeatedly cited by postwar scientific researchers, though rarely with any mention of the social context within which they were carried out. There is never any mention, for example, of the fact that the founding director of Schöniger and Schairer's Institute was Karl Astel, Rector of the University of Jena, a vicious racial hygienist, and an SS officer. One never hears that the grant application for the Institute was written by Gauleiter Fritz Sauckel, chief organizer of Germany's system of forced labor and a man hanged after the war for crimes against humanity (most leaders of Nazi Germany's anti-tobacco movement were silenced in one way or another after 1945). No mention is ever made of the fact that funding for Astel's Institute, and therefore for Schairer and Schöniger's study, came from a gift of 100,000 Reichsmarks from the Führer-- himself an ardent anti-smoking activist. It is clear to anyone who follows the money trail and the research interests that Schairer and Schöniger's study would not have been undertaken had it not been for Hitler's anti-tobacco sentiments and those of his like-minded underlings. Hitler once even attributed the rise of German fascism to his quitting smoking: the young artist-architect had smoked a couple of packs a day until 1919, when he threw his cigarettes into the Danube and never reached for them again.
Again, how should we interpret such Nazi-era papers? How should we judge the fact that Nazi ideology in this case (and there are others) appears not to have hindered research, but actually to have promoted it?
In drawing attention to such questions, my intention is not to be provocative, or to argue that "something good" came from the Nazi regime. I have no desire to rescue the honor of the Nazi regime, or to "balance the historical record" for balance's sake. You cannot balance genocide with a few flashy studies or a dazzling V-2 engine. I should also say that I have little sympathy for those who argue that republishing the results of brutal Nazi medical experiments is a way to ensure that the victims of such experiments "did not die" in vain. They did die in vain, and a well-designed life jacket or Apollo spacecraft is no compensation.
I raise the questions I do about Nazism and science because it is poor scholarship and perhaps even dangerous to caricature the Nazis as irrational or anti-science. What we have to look at more carefully is the relationship between science and ideology at this time. It is not the case, for example, that the papers on tobacco epidemiology I have mentioned were uninfluenced by Nazi ideology. The Reich's anti-tobacco program was motivated by Nazi ideals of bodily purity and racial hygiene: there was a kind of "homeopathic paranoia" pervading Nazi ideology that led many of its adherents to believe that tiny, corrosive elements were insinuating themselves into "the German body," sapping its strength, causing harm. Appreciating this helps us understand how Nazi science/ideologues could declare that tobacco tar, lead, mercury, asbestos -- and Jews -- all posed a threat to the Nordic race. It also may help us better understand why so many doctors were supporters of Hitler's regime.
The Moral Failure of German Medicine
The complicity of German physicians in the Nazis' crimes against humanity is a well-established historical fact. Explaining that fact is far more difficult. Why were German doctors such avid fans of fascism? Why did nearly half of all German physicians join the Nazi party?
I don't think it was the tirades of Julius Streicher in Der Stürmer that attracted their interest, but rather the promises of Nazi leaders to solve Germany's problems medically, surgically. The Nazi state was supposed to be a hygienic state; Nazism was supposed to be "applied biology" (Fritz Lenz coined this phrase in 1931). Hitler was celebrated as the "great doctor" of German society and as the "Robert Koch of politics" (Koch was a nineteenth century pioneer in studying the bacterial origin of diseases). The seductive power of National Socialism for many physicians lay in its promise to cleanse German society of its corrupting elements -- not just communism and Jews, but also metallic lead and addictive tobacco, along with homosexuality and the "burdensome" mentally ill.
The relation of science and politics in Nazi Germany was therefore more complex than most people like to think. Part of the misunderstanding, I would suggest, lies in the widely accepted belief that when science is politicized, "real" science inevitably suffers: the freedom of scientists is abrogated, distorting biases are introduced into research, minds are closed, avenues of inquiry are blocked. In many areas of science, of course, that is indeed what happened in Nazi Germany; one thinks of the fate of Einstein's relativity theory, for example. But in other areas -- e.g., many areas of public health -- that was not the case at all.
Biology was another field that thrived. Ute Deichmann in her book, Biologists Under Hitler (Harvard University Press, 1996), shows that the majority of biologists in the Thirties and early Forties joined the Nazi party; but it was still quite possible for non-Nazi biologists to obtain grants from the Deutsche Forschungsgemeinschaft, Germany's leading scientific grant agency. Not only possible but easy: Deichmann discovered that there was no correlation at all between a researcher receiving a grant and whether that researcher belonged to the Nazi party. I would argue that biology prospered under the Nazis because it was so integral to their worldview. Apart from the reasons I have already discussed, there is the fact that Nazism placed a much higher value on nature than on nurture in the development of human talents and disabilities.
I am not sure I would agree with Deichmann that scientists in the Third Reich were more independent of the regime than we usually think. Independent research flourished in many fields but it was, after all, also in the Nazi state's interest to cultivate a strong scientific community, at least in certain disciplines. What is clearly wrong about the autonomy thesis, applied to science and medicine as a whole, is that many professionals did not retreat into the purely technical. It took a lot of medical enthusiasm to forcibly sterilize 350,000 Germans, to "euthanize" 70,000 people with physical or mental handicaps in gas chambers. (The latter figure is only for the period from January 1940 to August 1941; even more than that were killed in the informal euthanasia program launched after this time.) And there were the medical crimes committed in the concentration and death camps. Among doctors, there were far more volunteers than victims, more partisans than pawns.
There is nothing inherently evil about physicians working and cooperating with their government. The moral failure of the German medical profession was its willingness to collaborate with the Nazi state, its willingness to serve Nazi values. There is nothing wrong with physicians working to preserve the health of a larger community; that, after all, is the essence of responsible public health. What differentiated National Socialist public health from genuine public health in a reasonably civilized society was the exclusive nature of what the Nazis considered "the community." Nazi values excluded Jews and others deemed racially or genetically unfit from the völkisch community. It bears repeating: Most German physicians in the Reich failed to challenge the rotten substance of Nazi values, the murderous directions of Nazi initiatives.
There were, of course, physicians who did not collaborate, who retreated to the laboratory or the bedside while eschewing the Nazi regime's medical dogmas and its use of doctors to implement various heinous policies. It is surely fair to say that far too few of these "apolitical" physicians raised their voices to protest the Nazis' exploitation of their profession. The science historian Herbert Mehrtens has a nice name to describe these scientists or doctors: "irresponsible purity."10 The expression is apt, because it challenges the conventional wisdom that "pure" science and medicine are invariably laudable, and politicized science and medicine are inevitably immoral. In fact, the purity of silence embraced by a large fraction of physicians in the Third Reich was a great moral failing. These doctors did not take a sufficient interest in the life and death dealings of their colleagues. Doctors in Nazi Germany were not sufficiently politicized -- if by politicized we mean appreciating the larger political and ethical context of their particular professional practice. Nazi medical evils represent a failure of moral and social responsibility. More should have spoken out against the regime, more should have resisted.
The Fallacy of Abandoned Ethics
It is just as misguided to believe that scientists who cooperated with the Nazis were bereft of ethics as to believe the Nazis were intrinsically hostile to science. There was an ethic of Nazi medical practice, and it should be examined and understood.
We often hear that the Nazis abandoned ethics. A recent Israeli film on the euthanasia operation claims that the overzealous scientific curiosity of Nazi doctors led them "to abandon all moral sense in the pursuit of medical knowledge."11 The image created is of an unfettered quest for knowledge, a kind of scientific fanaticism, or science practiced without limits.
It might be hard to believe, but there were, in fact, ethical standards that governed medical research and the practice of medicine in the Third Reich. Medical students took courses on medical ethics; medical textbooks in Nazi Germany discussed medical ethics. There was a great deal of attention given to the obligations of physicians to society, the state, and sometimes even to the individual. Nazi medical philosophers were critical of the ideal of value-free science, which was often equated with useless ivory-tower liberal -- or Jewish -- "science for its own sake." Science was supposed to be "for the people," though not of course for all people: Science was supposed to be at the service of the German Volk, the healthy and productive white races of Europe. Nazi medical ethics was underpinned by sexist paternalism, Nordic supremacy, cleanliness, punctuality, orderliness,12 unquestioned obedience to authority, and public and environmental health. It tended to emphasize preventive medicine, cost efficiency, the natural lifestyle, and the superiority of the productive worker. Clearly, Nazi medicine was imbued with ethical principles -- some admirable, some despicable.
One sees evidence of these principles in Nazi public health practice. Nazi health officials cleaned up water supplies and removed lead and mercury from consumer products. Doctors were urged to counsel patients against tobacco use,13 to maintain the efficiency of workers, safeguard public and genetic health, and ensure the best possible medical care for every pregnant woman and newborns judged "genetically fit." There were debates about medical malpractice -- whether, for example, natural healers were to be barred from treating cancer patients (they eventually were) -- and the limits of medical confidentiality and medical disclosure. A 1943 article in a leading German cancer journal cited the "demands of medical ethics" to inform patients of the severity of their diseases, and in at least one case a physician was prosecuted for failing to inform a woman she had cancer (physicians protested the ruling in print).14
Ethical norms were implicit even in the most horrific experimental practices in the camps. How else does one explain the fact that "healthy" German citizens were never experimented on? Those subjected to experimental violence were invariably people judged less than fully human in the Nazi scale of values. Jews and Gypsies were considered "diseased races," tumors in the German body politic. Nazi medical crimes simply don't make sense without this conception of healthy and diseased races, lives worthy and unworthy of living.
The doctors infamous today for brutalizing prisoners at Buchenwald or Dachau were not morally blind or devoid of the power of moral reflection. Acknowledging this, however, does not excuse the behavior of these physicians; on the contrary, it is crucial if we are to condemn them for their ethical transgressions. Possessing a sense of morality means one is not a lunatic. Nazi legal philosophy tended to blur the distinction between insanity and criminality, but it is a distinction we must keep clear. The Nazi doctors were not madmen; that is why we must work so hard to understand the origins of Nazism if we are to have any success in preventing its resurgence.
1. Telford Taylor, "Opening Statement of the Prosecution, December 9, 1946," reprinted in The Nazi Doctors and the Nuremberg Code, ed. George J. Annas and Michael A. Grodin (Oxford University Press, 1992), p. 69.
2. Franz Neumann, Behemoth: The Structure and Practice of National Socialism (Oxford University Press, 1942), pp. 471-472.
3. See my Racial Hygiene: Medicine Under the Nazis (Harvard University Press, 1988), pp. 228, 239-40; also Georg Boehncke, "Tabak und Volksgesundheit," Öffentlicher Gesundheitsdienst, 1 (1935): 625-630.
4. Victor E. Mertens, "Zigarettenrauch eine Ursache des Lungenkrebses? (Eine Anregung)," Zeitschrift für Krebsforschung, 32 (1930): pp. 82-91.
5. Franz H. Müller, "Tabakmissbrauch und Lungencarcinom," Zeitschrift für Krebsforschung, 49 (1939): p. 78.
6. Eberhard Schairer and Erich Schöniger, "Lungenkrebs und Tabakverbrauch," Zeitschrift für Krebsforschung, 54 (1943): pp. 261-269.
7. George Davey Smith, Sabine A. Ströbele, and Matthias Egger, "Smoking and Health Promotion in Nazi Germany," Journal of Epidemiology and Community Health, 48 (1994): p. 220.
8. On the "pockets of innovation" thesis, see Kristie Macrakis, Surviving the Swastika: Scientific Research in Nazi Germany (Oxford University Press, 1993), pp. 110-111; also my "Nazi Doctors, Racial Medicine, and Human Experimentation," in Annas and Grodin, The Nazi Doctors, pp. 17-31.
9. The New England Journal of Medicine has taken the position that it will not publish articles based on unethical research, though much research from the Nazi era continues to be cited; see Marcia Angell, "The Nazi Hypothermia Experiments and Unethical Research Today," New England Journal of Medicine, 322 (1990); pp. 1462-1464.
10. Herbert Mehrtens, "Irresponsible Purity: The Political and Moral Structure of Mathematical Sciences in the National Socialist State," in Renneberg and Walker, Science, Technology and National Socialism, pp. 324-338.
11. Sue Fishkoff, "They Called It Mercy Killing," Jerusalem Post International Edition, April 20, 1996, p. 17.
12. Hitler Youth Manuals stressed the virtues of orderliness, punctuality, and cleanliness. P. 80, Kitzing, 1941.
13, Wolfgang Klarner, Vom Rauchen: Eine Sucht und ihre Bekämpfung (Nuremberg: Med. Diss., 1940), p. 43.
14. G. Schläger, "Aufklärung und Verschwiegenheit bei Krebsverdacht," Monatsschrift für Krebsbekämpfung, 10 (1943): p. 154.
Robert N. Proctor is professor of the history of science at Pennsylvania State University. He is the author of Racial Hygiene: Medicine Under the Nazis, Cancer Wars and The Nazi War on Cancer. In 1994 he was the Shapiro Senior Scholar in Residence at the U.S. Holocaust Memorial Museum.
This article originally appeared in Dimensions, Vol 10, No 2, 1996
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