National Health Care; M. Micozzi, M.D,

The German social insurance and health care system began in the 1880s under Bis marck. Ironically, it was part of Bismarck's "anti-socialist" legislation, adopted under Marc S. Micozzi, M.D., Ph.D., a physician and anthropologist, directs the National Museum of Health and Medicine in Washington, D.C., which recently brought from Berlin the exhibi tion, "The Value ofthe Human Being: Medicine in Germany 1918-1945," curated by Christian Pross and Gotz Aly. the theory that a little socialism would prevent the rise of a more virulent socialism. By the time of Weimar, German doctors had become accustomed to cooperating with the government in the provision of medical care. The reforms of the Weimar Republic following the medical crises of World War I included government policies to provide health care services to all citi zens. Socially minded physicians placed great hope in a new health care system, callingfor a single state agency to overcome fragmentation and the lack of influence of individual practitioners and local services.

The focus of medicine shifted from private practice to public health and from treating disease to preventable health care. During the German "economic consolidation" of 1924-1928, public health improved under new laws against tuberculosis, venereal disease, and alcoholism, with new advisory centers for chemical dependency and coun seling bureaus for marriage and sexual problems. Medical concerns which had largely been in the private domain in the nineteenth century increasingly became a concern of the state. The physician began to be trans formed into a functionary of state-initiated laws and policies. Doctors slowly began to 416 see themselves as more responsible for the public health of the nation than for the individual health of the patient. It is one thing to see oneself as responsible for the ,'nation's health" and quite another to be responsible for an individual patient's health. It is one thing to be employed by an individual, another to be employed by the government.

Under the Weimar Republic these re forms resulted in clearly improved public health. However, the creativity, energy, and fundamental reforms found in social medicine during the Weimar Republic seem in retrospect a short and deceptive illusion. Medical reformers had wanted to counter the misery inherited from the first World War and the Second Empire on the basis of comprehensive disease prevention pro grams. In the few years available to the social reformers, they had remarkable suc cess. But in connection with these reforms the doctor's role changed from that of ad vocate, adviser, and partner of the patient to a partner of the state. Where traditional individual ethics and Christian charity had once stood, the re formers posited a collective ethic for the benefit of the general population. Private charity and welfare were nationalized. The mentally ill, for example, having been liter ally released from their chains in the nine teenth century and placed in local commu nities and boarding housesin regular contact with others (the so-called "moral therapy"), were returned to state institutions to be come the ultimate victims of state "solu tions. "

With the world economic crisis of 1929, welfare state expenditures had to be re duced for housing, nutrition, support pay ments, recreation and rehabilitation, and maternal and child health. What remained of the humanistic goals of reform were state mechanisms for inspection and regulation of public health and medical practice. Eco nomic efficiency became the major concern, and health care became primarily a question of cost-benefit analysis. Under the socialist policies of the period, this analysis was necessarily applied to the selection of strong 417 persons, deemed worthy of support, and the elimination of weak and "unproductive" people. The scientific underpinning of cost benefit analyses to political medical care was provided by the new fields of genetics and eugenics. Genetics and Eugenics At the same time as these economic and political developments, the application of nineteenth-century scientific discoveries began to make their way into twentieth century public health and medical practice.

Charles Darwin's studies on natural selec tion were of course based upon animal populations living in nature and not human populations living in complex societies. But the biological basis of natural selection gave rise to a concept of "survival of the fittest" in human civilizations. This term was coined by the British social anthropologist Herbert Spencer, and the concept led to "Social Darwinism. " Darwin's theories (developed in parallel with Alfred Russel Wallace-another Brit ish natural scientist) had been published prior to full elucidation of the principles of genetics. With subsequent understanding and acceptance of the science of genetics, the underlying basis of natural selection could more completely be described. While scientists still did not understand what made up the gene (awaiting Watson and Crick's discovery of DNA in the 1950s)they began to search for outward expression of inner genetic tendencies. In the absence of being able to pinpoint individual genes, they sought outward expression of genetic "types." These "typologies" were largely based upon external measurements of the body.

Much of this work was carried out by German anthropologists and physicians (of ten one and the same at that time) in newly acquired colonies in German East and Southwest Mrica, prior to the loss of these colonies to Allied protectorates in World War I. Such work resumed following the war, however, and by 1927 the opening of the Kaiser Wilhelm Institute of Anthropol418 THE FREEMAN • NOVEMBER 1993 ogy, Human Genetics, and Eugenics was celebrated in Berlin as the advent of the "German Oxford." The annual report of the Institute in 1932 stated: "The term eugenics means to establish a connection between the results of the studies in human genetics and practical measures in population policy." Under the new "scientific understand ing" of human biology provided by genetics and its implementation under eugenics, pov erty, for example, would become merely an expression of degeneracy (Entartung) and genetic inferiority. "Inferior" and "superi or" became natural terms used by persons of nearly all political persuasions, as readily as the terms "handicapped," "impaired,"

"socially dependent," or "disadvantaged" are used today. Life Unworthy of Living Following World War I there had been concern among some in Germany that the war had decimated the ranks of the qualified and strong while weak, unqualified, and inferior people had been spared. Many felt that scant resources should not be wasted on the sick and suffering. The philosophy of the unimportance of the individual in favor of the people (das Yolk) led to the belief that individuals who had become "worthless, defective parts" had to be "sacrificed or discarded. " Alfred Hoche, a neuropathologist (as Freud had been) and Karl Binding, a lawyer, published a pamphlet in 1922, The Sanction ing of the Destruction of Life Unworthy of Living. Binding relativized the legal and moral prohibition, "Thou shalt not kill," and Hoche alternated between economic and medical arguments. Neurologists in Saxony formally discussed the topic, "Are Doctors Allowed to Kill?" A physician in Dresden pointed out' 'the contradiction that many persons (reformers) demand an end to the death penalty for crimes, but the same people are for putting imbeciles [sic] to death." By the time the National Socialist Party came to power in Germany, the men tally ill and the mentally retarded had begun to be sterilized and to be subjected to euthanasia in large numbers in German government institutions.

National Socialism and the Nation's Health No profession in Germany became so numerically attached to National Socialism in both its leadership and membership as was the medical profession. Because of their philosophical orientation toward finding a more scientific basis for medical research and practice, government funding for re search, and the practical benefits of acquir ing university positions and medical prac tices from the many banned and exiled German Jewish doctors, many physicians supported Nazi policies. One of the first Nazi laws, passed July 14, 1933, was the "Law for the Prevention of Progeny of Hereditary Disease," intended to "consol idate' , social and health policies in the German population and prohibit the right of reproduction for persons defined as "genet ically inferior." After 1933, the connection between the theory and practice of politi cized medicine advocated by many in Wei mar Germany became actual in Nazi Ger many.

A "Genetic Health Court" consisting of judges and doctors made decisions about forcible sterilization. As "advocates of the state," doctors prosecuted those persons charged with being "genetically ill" in ses sions lasting generally no more than ten minutes and from which the public was barred. In 1935, an adjunct law allowed forcible abortion in such cases up to the sixth month of pregnancy. A total of 300,000 to 400,000 were sterilized and approxi mately 5,000 (nearly all women) died as a result of these operations. After 1945,it was argued to the Restitution Claims Commis sion of the German Bundestag that the "Law for the Prevention of Progeny of Hereditary Disease" not be considered in the same category as subsequent National Socialist race laws and other Nazi abuses. The sterilization law had been drafted ear lier under the Weimar Republic as part of progressive health reform, and as late as NATIONAL HEALTH CARE: MEDICINE IN GERMANY 1918-1945 419 1961 was defended by an expert at the Max Planck Institute on the basis that "every cultured nation needs eugenics, and in the atomic age, more so than ever before."

German Youth and Euthanasia Following the sterilization laws, the Na tional Socialists next implemented a strat egy of euthanasia to solve the remaining problem of those whose conception and birth had preceded these laws. The pedia trician Ernst Wentzler, while developing plans to improve care in the German Chil dren's Hospitals in Berlin, personally de cided (as consultant to Hitler's Chancellery) on the deaths of thousands of handicapped children. Hans Nachtsheim placed delivery orders for handicapped children for his pres sure chamber experiments on epilepsy. Jo seph Mengele delivered genetic and anthro pological "material" from Auschwitz to the Kaiser Wilhelm Institute and conducted his infamous twin experiments on the child victims of the Holocaust. Julius Hallervorden at the Kaiser Wilhelm Institute for Brain Research at Berlin-Buch carried out several research projects based on euthanasia programs. Hallervorden and others systematically collected the brains of their patients who had been killed, taught the murdering doctors how to dissect, and cooperated closely with institutions where murdered children had previously been given thorough examinations and tests. Dur ing interrogation by an American officer in 1945, he stated, "I heard that they were going to do that. . . and told them. . . if you are going to kill all these people, at least take the brains . . . . There was wonderful ma terial among these brains-beautiful mental defectives, malformations and early infan tile disease. I accepted these brains, of course. Where they came from and how they came to me, was really none of my business." The collection was until recently kept by the Max Planck Institute (formerly the Kaiser Wilhelm Institute) in Frankfurt and used for brain research.

In a system in which so many were routinely condemned to die, the temptation proved strong to use human subjects in medical experimentation prior to their tragic and terrible deaths. The Luftwaffe had developed aircraft which could climb to altitudes of nearly 60,000 feet, altitudes unattainable by Allied fighter aircraft. However, tolerance of these altitudes on the part of pilots had not yet been tested. Trials on volunteers at altitudes above 36,000feet had to be discontinued due to severe pain. For this reason, lethal alti tude experiments in pressure chambers were conducted on 200 victims held prisoner in Dachau concentration camp in a program called: "Trials for Saving Persons at High Altitude. " Many German ships were also being sunk in the North Atlantic and North Sea, and the same group of medical investigators con ducted painful ice bath experiments on 300 Dachau prisoners in a research program entitled "Avoidance and Treatment of Hy pothermia in Water." Other medical exper iments were carried out with chemical and biological warfare agents and infectious dis eases.

Following World War II much of this data was kept classified by Allied military au thorities on the basis of national security. Debate continues to this day on the validity of these experiments and the ethical impli cations of any use of such data. The Banality of Evil We now know the end of this historical horror story of massive crimes against hu manity and the leader of the thousand-year Reich burning in a bunker in Berlin. But it is not so easy to recognize the steps on the path down the slippery slope when we don't yet know the end of the story-as today we do not know which social health reforms in combination with which new medical tech nologies have the potential to plunge mod ern society over a brink in which disaster might result. Is legalized abortion a new form of medicide? Is doctor-assisted suicide a step toward positive euthanasia? Is mod ern genetic testing and the Human Genome Project the first step to a new eugenics? Is 420 THE FREEMAN • NOVEMBER 1993 Dr. Robert Ritter of the German National Department of Health (right) and his associates carried out anthropological measurements and genealogical research. They prepared fingerprints and photo graphs in order to ascertain the "proportion of gypsy blood" in all of the Sinti and Roma of "Greater Germany."

Nazi medicine was implemented by apolitical-medical complex, a scientific and social philosophy imposed by a totalitarian regime. FROM THE EXHIBITION,"THE VALUE OF THE HUMAN BEING." health care rationing, which is always a re sult of government involvement in medical care, a step toward the new definitionof "life unworthy ofliving"? Is our present "quality of life index" a new way of saying it? Nazi medicine was implemented by a political-medical complex-on the basis of political health care-a scientific and social philosophy imposed by a totalitarian re gime. It should never happen again, but could it ever happen again? In the United States the medical profes sion operates in a mixed (not a national socialist) economy which does not yet have the institutionalized mechanisms of control and regulation of Weimar Germany-and in a democratic political system which thank fully does not have the political ideology of the Third Reich. But the "banality of evil"

described by Hannah Arendt in the Third Reich may stem largely from a government bureaucracy in which 90 percent of the people think 90 percent of the time about process-not purpose. Does the modern bureaucratization of medicine hold any real risk for a possible return-with new health reforms and new medical technologies-to some of the horrors of National Socialist medicine? Removal of personal responsibil ity ("I was only following orders"), per sonal authority, and personal choice in a bureaucratized system may leave less and less room for individual ethics in the con duct of medical science and practice. Politicized medicine is not a sufficient cause of the mass extermination of human beings, but it seems to be a necessary cause. The Nazi Holocaust did not happen for some inexplicable German reason; it is not an event that we can afford to ignore be cause we are not Germans or not Nazis. The history of Germany from 1914 to 1945 is a telescoping of modernity-from monarchy, war, and collapse to democracy and the welfare state, and finally to dictatorship, war, and death.

Medical ethics is the responsibility of all members of a society, not just doctors and scientists. Medicine and science alone do not have the answers to such questions as: When does life begin? When should it end? Are humans just the sum of their genetic parts or genetic programs? While bioethi cists debate, individual medical choices are made a million times a day among doctors, patients, their families, and increasingly the government. The product of all these choices ultimately constitutes the ethical, legal, and social framework in which the practice of medicine and of medical research are conducted. In the end it is the preser vation of freedom that will guide us to the best application of new health reforms and technologies in the future. D THEFREEMAN IDEASON LIBERTY MEDICINE AND THE WELFARE STATE by Melchior Palyi T he essential idea of the Welfare State is as old as known history. Its concept and mechanism-the systematic dispensing, through political channels and without re gard to productivity, of domestic wealth were at the very core of the Greco-Latin city states, of the medieval city, and of the post-Renaissance absolute monarchy. In the city republics, ancient and medieval, it meant bloody civil wars. Their constantly recurring violent quarrels about constitu tional issues disguised bitter class warfare to seize the power that was dispensing all benefits. Most of them went on the rocks of their internal struggles for economic privi leges. A Lorenzo Magnifico in Florence or the Oligarchy of the Ten in Venice managed to "save" their cities-by grabbingthe power and robbing the citizens of every vestige of political freedom and civic rights. Jacob Burckhardt's allegation that the orgy of pa ternalism under Emperor Diocletian resulted in governmental money recipients larger in number than the taxpayers, might be appli cable to many other doomed civilizations.