key: cord-0854121-ds7635a5
authors: Copeland, Darcy
title: Nurses' participation in the Holocaust: A call to nursing educators
date: 2020-05-15
journal: J Prof Nurs
DOI: 10.1016/j.profnurs.2020.05.003
sha: ba1512880c0e2bce1e3def5cbf48fdb40340bb2a
doc_id: 854121
cord_uid: ds7635a5

This year marks the 75th anniversary of the liberation of Auschwitz. The number of people able to provide first-person accounts of the atrocities of the Holocaust is dwindling in numbers. Prior to the mass extermination of Jews at Auschwitz and other extermination camps, nurses actively participated in the execution of tens of thousands of mentally, physically, and emotionally ill German citizens. Nursing educators must ensure that nursing students not only know about the Holocaust, but that they know that ordinary nurses were directly involved in the identification of vulnerable humans to be killed, and actually murdered them. Social, economic, and political pressures existed enabling the Nazi regime to involve nurses in this way. Similarly, social, economic, and political pressures today have the potential to encourage nurses to act in ways that violate personal or professional values. This paper provides four learning objectives that can be incorporated into existing nursing curricula to ensure that nurses do not forget how and why nurses in Germany came to murder more than 10,000 people in their care. With the passage of time comes the risk that the legacy of the Holocaust will be forgotten, nursing educators must participate in preventing that from happening.

J o u r n a l P r e -p r o o f Long before the "final solution of the Jewish question" and mass extermination of Jews at Auschwitz and other extermination camps, nurses actively participated in the execution of tens of thousands of mentally, physically, and emotionally ill German citizens. The 1920 book The Sanctioning of the Destruction of Lives Unworthy to be Lived by German psychiatrist Alfred Hoche and jurist Karl Binding provided inspiration and justification. In this book the term euthanasia was used to describe the "mercy killing" of patients with terminal illness, lunatics, and those who were comatose or living miserable lives (Benedict, 2003) . (An analysis of the terms "euthanasia" and "mercy killing" is beyond the scope of this article; however it is important to note that they both typically imply a degree of voluntariness and/or the presence of incurable and painful conditions which cause suffering. What happened in Nazi Germany was not euthanasia or mercy killing as traditionally understood.) The German Law for the Prevention of Hereditarily Diseased Offspring was passed in 1933 legalizing racial health courts and involuntary sterilization. Then, in 1938, the father of a child born blind, "retarded" and missing an arm and a leg wrote to Hitler asking that his child be granted a "mercy death", or euthanasia (Proctor, 1988, 186) . His request was granted. A 1939 law mandated that midwives register with local health authorities any child born with congenital deformities; they were paid 2 Reichsmarks for every registration (Proctor, 1988) . In 1941 doctors, nurses, and teachers were ordered to report any handicapped minor to authorities. This reporting and registration resulted in the killing of 5,000-10,000 infants and children (Proctor, 1988) as nurses injected children with morphine or scopolamine, forced the ingestion of phenobarbital, or starved them in facilities across Germany (Benedict, 2003) .

The "euthanasia" program then shifted to institutionalized physically and mentally disabled adults. These individuals were described as not contributing to society in any material Journal Pre-proof J o u r n a l P r e -p r o o f way, in fact they were portrayed as draining society of resources, and were ultimately labeled "useless feeders." Policies and propaganda were developed to convince German citizens that it was in their own best interests to differently manage scarce healthcare resources. This argument became even stronger as the war escalated and all German resources, including food, hospital beds, and healthcare providers, were needed to support the war effort. Between 1939-1945 more than 10,000 ill and disabled German adults were murdered by nurses in psychiatric hospitals (Benedict, 2003) . This program of systematic killing is known as Aktion T4, an abbreviation for the street address in Berlin from which the program was operationalized.

How is this relevant today?

Arguments that the involvement of nurses in the Holocaust was isolated to evil, Nazi nurses, that individual values and institutional codes are preventative, or that such things could never happen again or here in the United states are fallacies. Religion, codes, American values, and individual resistance cannot be relied upon as defenses against future abuses and American history is filled with its own examples of mistreatment of vulnerable citizens. The eugenics movement is an example. The term eugenics was coined by Sir Francis Galton, Charles Darwin"s half-cousin, and literally translates to "well born" in Greek. In 1902, the American biologist Charles Davenport, visited Galton in London. The two shared a passion for understanding, and improving, human heredity. During the first few decades of the 20 th century eugenicist ideas were widely accepted by the scientific and public health communities in America. It was believed that selective breeding had the potential to transform the human race. Control of human reproduction was viewed as a scientific solution to social problems, a way to weed out the unfit and propagate talent and intelligence. The creation of a stronger society was thought to be possible through the breeding out of certain characteristics and the breeding in of other J o u r n a l P r e -p r o o f characteristics (Pernick, 1997) . In 1907, Indiana passed the first law to legalize compulsory sterilization on eugenic grounds (Klautke, 2016) and several other states followed suit. When German racial hygienists were crafting their own law, they looked to America for guidance (Proctor, 1988) .

A 1937 Gallup poll showed that 45% of the American population was in favor of euthanasia for "defective" infants (Proctor, 1988, 180) . In 1947, in response to the trial of 23 doctors and associates accused of crimes against humanity and human experimentation, the Nuremberg Code was created. It outlined ten rules that were to guide the conduct of human experiments. It stressed the need for voluntary consent, an assessment of risks and benefits, the ability of the human participant to cease participation, and the requirement that researchers end any experiment likely to result in injury, disability, or death of the participant (Moreno, Schmidt, Joffe, 2017) . The ethical principles of research involving human subjects articulated in the Nuremberg Code were unfortunately perceived by American scientists as applicable to Nazi researchers, and not to them. This code did not successfully dissuade American scientists from perpetrating horrendous acts of human experimentation. The Tuskegee syphilis study was conducted by the U.S. Public Health Service from 1932-1972 to understand the natural history of syphilis among black men. An effective treatment was identified in 1947, but was not offered to participants (Centers for Disease Control and Prevention, 2020). The Willowbrook study involved the intentional exposure of Hepatitis to mentally disabled children to study antibodies and immunity to the disease. The study ran from 1956 -1971 . From 1944 -1974 the U. S. government facilitated radiation studies in which human participants, many of whom were terminally ill, were injected with plutonium in an effort to understand the effects of radiation exposure (U. S. Department of Energy, n.d.). The Holmesburg prison in Pennsylvania was used J o u r n a l P r e -p r o o f as a human laboratory for chemical warfare and pharmaceutical testing from 1951-1974 (Hornblum, 1998) . These are only a few examples of unethical human subjects research that occurred in the United States after formulation of the Nuremburg Code. In light of these historical facts it is possibly by chance alone that the United States has not undertaken even more horrendous acts.

What should nurses know?

Given the crucial role that German healthcare providers had in orchestrating the Holocaust, healthcare providers and researchers need to appreciate how these socially powerful institutions have the potential to influence public opinion and public policy. Nurses specifically ought to know the history of our role in the Holocaust so that it may not be repeated.

German physicians had oversight of approximately half of the training that nurses received (Lagerwey, 1999) ; it is estimated that 45% of physicians were members of the Nazi party (Proctor, 1988) . The championing of racial hygiene and Nazi ideology by physicians thus infiltrated nursing. Several nursing organizations existed at the time, but there was no central or unified nursing organization defining or directing nursing activities. Individual nurses did refuse to honor policies and participate in the killing of patients, but individual resistance did not carry the power that organized resistance would have.

How can these lessons be taught?

One question guiding the development of an educational program for nurses was posed by Wynia & Wells, "How could a professional group, entrusted with protecting human health, use this very social mandate as a reason to torture, maim and kill? " (2007, 186) . This question was directed at medical students, but it may nevertheless inform the identification of learning outcomes for nurses regarding the legacy of the Holocaust. These outcomes can be grouped into This education would benefit nurses, yet the reality is that there is little space in any nursing curriculum. The concession that can be made is to incorporate a few learning outcomes into existing courses across the curriculum. With the passage of time comes the risk that the legacy of the Holocaust will be forgotten, nursing educators must participate in preventing that from happening.

The author has no conflicts of interest to declare. This project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

The Nadir of nursing: Nurse-perpetrators of the Ravensbruck Concentration Camp

The Tuskegee Timeline

Holocaust knowledge and awareness study

Acres of Skin: Human Experiments at Holmesburg Prison. Routledge

The Germans are beating us at our own game": American eugenics and the German sterilization law of 1933

Nursing ethics at Hadamar. Qualitative Health Research

The Nuremberg Code 70 years later

The author would like to thank Matt Wynia for reviewing this manuscript.

J o u r n a l P r e -p r o o f