When medical information comes from Nazi atrocities
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.l7075 (Published 23 January 2020) Cite this as: BMJ 2020;368:l7075
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear Editor
We felt compelled to respond to your article, When medical information comes from Nazi Atrocities (BMJ 23 January 2020). In this, the author, Professor Susan Mackinnon, tries to justify the use of an atlas of human anatomy, edited by Eduard Pernkopf, based on the systematic dissection of bodies of Holocaust victims. To make it worse, Pernkopf and his chief collaborators were all convinced Nazis to the point that the Swastika became part of their signatures. Although Professor Mackinnon consulted Jewish religious and ethical experts, we feel that the use of this atlas is controversial at best.
After the tragedy of World War 2, the Nuremberg Military Tribunal in 1947, reflecting on the atrocities committed, issued the Nuremberg Code on medical research. This is composed of ten points, the first of which states of what has become the basic guiding principle of all human medical research: ' The voluntary consent of the human subject is absolutely essential.' Although the first volume was published in 1933, Pernkopf and his associates continued to work on the third volume in the 1950s, while the fourth and last volume was published in 1960 well after his death in 1955. The very publication of these two volumes has clearly transgressed the basic principle of the Nuremberg Code as it used images of the victims of Nazism. The question also arises whether this particular atlas is the only essential aid for surgeons specialising in peripheral nerves or whether there might be alternatives of high standard, including Sobotta's Atlas of Human Anatomy? Did the BMJ editorial board consider the victims’ consent to publishing pictures of their bodies 75 years later?
It is not an unusual approach of the BMJ to controversial subjects to have two opposing views expressed in the same issue. We hope that our brief letter may go some way to redress this imbalance.
Yours faithfully,
Dr Simon Gordon MB ChB
Dr Thomas Kadas NHS 1961-2013
Professor Emeritus Peter Lantos MD PhD, DSc, FRCPath FMedSci
Dr Afsana Safa MBBS MRCP MRCGP
Competing interests: No competing interests
Dear Editor
I should appreciate your explanation of the decision to publish Dr Susan Mackinnon's essay "When medical information comes from Nazi atrocities" 25.01.2020 regarding the Pernkopf anatomy atlas. It seems strange to me that this was published on the anniversary week of the 75th Anniversary of the liberation of Auschwitz. The essay does not appear as a BMJ tribute to the victims. No reference is made in the editorial piece to the anniversary. It appears as a stand alone article which indicates that the BMJ either was ignorant of the anniversary (which would be surprising) or that the thought provoking article was published in spite of the anniversary.
The article appears to be written with sensitivity with use of the Hebrew word Shoah for holocaust. However the author also uses reference to the yiddish word bashert for destiny (which I find insulting and inappropriate). These people were murdered, then skinned and dissected for an anatomy atlas. That is not bashert. I have discussed this with other Jewish and non Jewish doctors who all have connections of family loss in the Holocaust. The article walks the reader through the moral dilemma and then presents the opinion of 76% of 750 American neurosurgeons who agree that it is ok to consult the atlas with disclosure, respect, gratitude and solemnity. The author spoke to a rabbi who felt this was also the case. There is a standard joke -ask five Rabbis for an opinion and you'll get ten! Ms Mckinnon found the rabbi with the answer she wanted to comply with her obsession of this work.
She has not referenced the bioethicist Charles A Foster, who concluded after wide debate amongst experts that this atlas " should be permitted to show its duplicitous face only rarely and then for very good reason in the teaching of history, medical ethics and medical law so that its lessons will be learned, it's history never repeated." Other professors concluded that its benefits as an educational tool have been superseded by other projects such as the Visible Human Project.
In reality, surgeons find that patients are happy with a basic explanation and diagram.
This essay seeks to lead the British Medical community into believing that this atlas is a necessary evil for medical learning. This is false. Nothing good came from the Holocaust. This article should not have been published especially in this remembrance week.
Perhaps the BMJ could have paid tribute to doctors who were murdered in the camps for being communists, Jews or LGBT or focused on the amazing work of the Red Cross in the liberation of the camps, rather than this "tribute".
Kind Regards
Dr Dawn Tragen
GP
Competing interests: No competing interests
Dear Editor
As a genitourinary physician I was taught about the Tuskegee syphilis experiment early on in my training, where it was acknowledged that much of what we know about syphilis was obtained unethically [1]. It is now taught to a much wider audience as part of Good Clinical Practice research ethics training. However much less known are the Guatemalan syphilis experiments also carried out by the US government on soldiers, sex workers, prisoners and those with mental health issues without their consent in the late 1940s, which also made a significant contribution to our knowledge of syphilis [2].
The Tuskegee and Guatemalan syphilis experiments, along with Pernkopf’s Atlas of Topographical and Applied Human Anatomy, are some of the many examples of unethical research and experimentation done on populations claimed by many North American and European scientists at the time to be subhuman or of an inferior race. To name just a few examples: J. Marion Sims “the father of modern gynaecology” developed surgical techniques that are used today by operating on enslaved women of African descent without their consent and with inadequate pain relief [3] (it was claimed that Black people had thicker skin and felt pain less than white people [4]); grave robbing to provide bodies of enslaved people for dissection at medical schools [5]; testing the oral contraceptive pill on low-income Puerto Ricans and the mentally unwell [6,7].
Much of our medical and surgical knowledge is based on the unethical experimentation and exploitation of people from marginalised groups, a topic that is little discussed in the medical curriculum. I wholeheartedly agree with Mackinnon when she says, “As physicians and educators, we have an enduring moral duty to recount history, share knowledge with generations that follow, and protect against new versions of the atrocities of the past.” This should be an integral part of the undergraduate medical curriculum, in order to acknowledge those who suffered for the advancement of medical science. It may also help us to better understand why some communities distrust healthcare providers.
1. Jones JH. Bad Blood: the Tuskegee syphilis experiment. The Oxford Textbook of Clinical Research Ethics. New York: Free Press; 1981
2. Rodriguez MA, García R. First, do no harm: the US sexually transmitted disease experiments in Guatemala. Am J Public Health. 2013;103(12):2122–2126. doi:10.2105/AJPH.2013.301520
3. Ojanuga D. The medical ethics of the 'father of gynaecology', Dr J Marion Sims. J Med Ethics. 1993;19(1):28–31. doi:10.1136/jme.19.1.28
4. Cartwright SA. Report on the diseases and physical peculiarities of the Negro race. New Orleans Med Surg J. 1851;7:691–715
5. Humphrey DC. Dissection and discrimination: the social origins of cadavers in America, 1760-1915. Bull N Y Acad Med. 1973;49(9):819–827.
6. The Puerto Rico Pill Trials https://www.pbs.org/wgbh/americanexperience/features/pill-puerto-rico-pi... accessed 26/1/20.
7. Liao PV, Dollin J. Half a century of the oral contraceptive pill: historical review and view to the future. Can Fam Physician. 2012;58(12):e757–e760.
Competing interests: No competing interests
Dear Editor
I visited the temporary exhibition at the Josephinium Museum in Vienna in 2018. It was not the purpose of my visit to Vienna, but a surprise addition. This exhibition was open and honest, with tales of Jewish medical students and staff having to jump from windows at the back of the medical school to escape Austrian Nazis rampaging into the faculty, medical complicity with Nazi projects and much more.
Austria is now dropping the "anschluss" tale of unwilling participation in Nazi acts. The House of Austrian History, for example, has the wooden Waldheim Horse dressed in stormtrooper's hat, hinting strongly at the leader's Nazi connections.
I am delighted to hear that a permanent exhibition is being produced. The museum is a delight, but the 1930s exhibition was shocking, informative and thought provoking. Well worth a visit when it re-opens, unless the Sound of Music is your favourite story.
Competing interests: No competing interests
Dear Editor
Compulsory treatments with questionable clinical indications also for research were applied in the former Soviet Union e.g. to alcoholics: prolonged intravenous infusions, pyrotherapy with sulfozine (oil solution of sulphur for intramuscular injections), sorbent hemoperfusion, plasmapheresis, endolymphatic and endobronchial drug delivery, endoscopic and surgical biopsies of internal organs, endoscopic cholangiopancreatography and angiography [1,2]; more details and references are in [3-5]. Note that excessive endovascular and endoscopic manipulations can lead to a transmission of viral hepatitis, which was known to happen to treated alcoholic patients. The compulsory treatment of alcoholics with tuberculosis included repeated bronchoscopies, while procedural quality assurance has not always been optimal. Furthermore, it was noticed that vigorous apomorphine- or mechanically induced vomiting as emetic therapy of alcohol dependence induced bleeding in some tuberculosis patients [6]. In 1994 it was reported that 60% of patients from a “phthisio-narcological hospital” for compulsory treatment of alcoholics with tuberculosis tried runaway while a half of them was brought back by the police (militsia) [7]. More details and references are in [8].
References
1. Makhov VM, Abdullin RG, Gitel' EL, Zavodnov VIa, Podzolkov VI, et al. (1996) Visceral lesions in alcoholism. Ter Arkh (8): 53-56.
2. Krut'ko VS (1990) Pneumonia in patients with pulmonary tuberculosis and alcoholism. Probl Tuberk (1): 64-66.
3. Jargin SV (2017) Invasive procedures with questionable indications used in Russia: Recent history. J Surgery 5: 8. DOI: 10.13188/2332-4139.1000039
4. Jargin SV (2015) Alcohol abuse and alcoholism in Russia. Int J Emerg Ment Health 17: 603-604.
5. Jargin SV (2015) Some aspects of renal biopsy for research. Int J Nephrol Kidney Fail 1: 1-5.
6. Entin GM (1990) Treatment of alcoholism. Moscow: Meditsina. (in Russian)
7. Rudoi NM, Dzhokhadze VA, Chubakov TCh, Stadnikova AV (1994) Current status and perspectives in hospital treatment of patients with tuberculosis complicated with alcohol abuse. Probl Tuberk (4): 8-10.
8. https://www.researchgate.net/publication/321245511_Invasive_procedures_w...
Competing interests: No competing interests
Dear Editor
Sadly much of science is full of valuable information whose original source is offensive to the moral sense. It probably grates more when some groups of us have been directly involved in the receiving end of the atrocious events or our historical connectivity to the victims jars our senses even harder. I am not sure how much of today’s science would survive intact if we were to dig deeper and dispassionately into its sources or methodologies.
The gruesome practice of dropping skulls from heights that led to Le Fort’s classification of maxillofacial fractures for instance.
The many instances in which minorities in the US were used offensively as guinea pigs in research methodologies remain just as offensive today as they were then when one thinks about them.
HeLa cells and the proven dubieties surrounding their use.
The list can be as long as one cares to dig.
And, just as in this case, users continue to benefit from the ‘proceeds of crime’ ( arts and science ) even after all the moralizing haranguing.
By and large it seems the bottom line is ‘pinch your nose’ (including finding appropriate psychologic recourse and ethical manouvres) and continue with the intellectual or artistic benefits from these proceeds.
Competing interests: No competing interests
Re: When medical information comes from Nazi atrocities
Dear Editor,
Susan Mackinnon's account of her approach to using the Pernkopf Atlas is no doubt sincere. However, I found in it no possible justification for the use of the atlas. It is inconceivable, after more than 70 years of anatomical study, modern dissection techniques and tools, and imaging, that there is not a sufficiently good range of anatomical studies in print and in other media, to ensure availability of the highest quality information for surgery and teaching. If this is not the case, then this should be rectified by creating such reference works using all available, and ethically sound, methods.
I can see no good reason to afford the Pernkopf atlas any positive recognition, no matter how carefully those who suffered in its creation are acknowledged.
Yours sincerely,
Tim Lambert
Dr M T Lambert
Competing interests: No competing interests