Doing No Harm To Hippocrates: Reality and Virtual Reality in Ethics Education

 

 “How could physician healers have turned into murderers?  This is among the most profound questions in medical ethics.”1

“How could men and women sworn to the Hippocratic oath, trained as professionals in the world’s most advanced scientific culture, come to commit crimes that even today stand as exemplars of evil?”2

“They were all doctors.”  – Auschwitz survivor3

On July 23, 1944, Nazi officers ordered the entire Jewish population of Kos to leave their homes and, along with the Jewish population of nearby Rhodes, to board three small cargo boats.  Stripped of their personal belongings and identity papers, these families were taken on an eight day voyage by sea to Piraeus, and from there, crowded into cattle cars, North by train for the 13 day journey to their final destination at Auschwitz.  Such was the fate of many Jewish men, women and children throughout the Nazi-occupied territories in Europe, who were forcibly exiled and sent to their deaths.  Auschwitz, the largest of the Nazi death camps, alone claimed approximately 1.3 million victims.4 Of the 116 deportees from Kos, 104 perished, and only one survivor returned to the island. 5

Kos, the second largest island of the Dodecanese in the Aegean Sea, was the birthplace of Hippocrates (ca. 460 – 370 BC).  From the corpus of Hippocratic writings came the often cited maxim “First, do no harm.”6 From the Hippocratic school also came the Hippocratic Oath, which for thousands of years has, despite episodic breaches, remained the ethical cornerstone of medical professionalism.  The Oath of Hippocrates holds the physician to the moral standard of serving the interests of the patient above competing interests:  “Whatever houses I may visit, I will come for the benefit of the sick.”  About the Oath, Allen Verhey writes, “It treats medicine as a form of human activity with goods internal to it and standards of excellence implicit in it, not simply as an assortment of skills which can be made to serve extrinsic goods with merely technological excellence.”7 Accordingly, the Oath binds physicians to the duty to heal and prohibits applying the techniques of medicine to the taking of life:  “I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.”8

Upon their arrival at Auschwitz, the prisoners from Kos would have been greeted by a physician, but not for the purpose of medical care.  The account of Dr. Otto Wolken, a surviving prisoner physician, documents the process:

“When the transport trains came in, the arrivals had to pass before the camp doctor . . . on duty.  He pointed his thumb either to the right or to the left.  Left meant death by gas.  From a transport consisting of about 1,500 people, about 1,200 to 1,300 went to the gas chambers.”9

Medical expertise contributed to the formulation and implementation of the extermination program euphemistically called the selection process, and virtually all physicians assigned to Auschwitz participated in such selections.10 At Auschwitz, physicians selected who would be killed, supervised their suffocation in the gas chambers, and determined when the victims were dead.11

Camp hospitals provided limited medical care but functioned primarily as camouflage for the killing of prisoners who were officially registered as patients.  There, SS physicians sorted out which prisoners were too sick or weak to work, who were then killed by injections of phenol to the heart or sent to underground homicidal gas chambers disguised as showers.  Physicians certified that their near starvation diets were sufficient for life.   Physicians rode in ambulances or Red Cross cars to the crematoria to specify the quantity of Zyklon-B pellets to throw down the holes according to the number of people awaiting death.  Physicians falsified their causes of death in the medical records.12

The German SS dispatched more than 300 physicians to the concentration camps.13  At Auschwitz and the other camps, physicians also conducted harmful medical experiments on nonconsenting prisoners (most of whom who were going to die anyway), exposed them to toxic chemicals, infected them with typhus and tuberculosis, and performed vivisections.14  

Following the liberation of the surviving prisoners of Auschwitz by the Soviet army on January 27, 1945, the world became aware of the atrocities committed in the Nazi concentration camps.  At the trial in Nuremberg known as “The Case Against the Nazi Physicians,” Telford Taylor, in his opening statement for the prosecution, argued,

“They are not ignorant men.  Most of them are trained physicians and some of them are distinguished scientists.  Yet these defendants, all of whom were fully able to comprehend the nature of their acts, and most of whom were exceptionally qualified to form a moral and professional judgment in this respect, are responsible for wholesale murder and unspeakably cruel tortures. . . .   All of them violated the Hippocratic commandments which they had solemnly sworn to uphold and abide by, including the fundamental principle never to do harm – ‘primum non nocere.’”15

Medicine under the Third Reich, summarizes ethicist Nigel Cameron, “was a betrayal of the Hippocratic tradition.”16 Psychiatrist Robert Jay Lifton concurs, adding,

“When we think of the crimes of Nazi doctors, what comes to mind are their cruel and sometimes fatal human experiments.  Those experiments, in their precise and absolute violation of the Hippocratic oath, mock and subvert the very idea of the ethical physician, of the physician dedicated to the well-being of patients.

 

. . . the Hippocratic oath, though a pledge to remain a healer and to disavow killing or harming those one treats, was all but abandoned in Auschwitz.  The oath was perceived as little more than a distant and muted ritual one had performed at medical school graduation, and was readily reversed by the searingly immediate selections ritual, as well as by the array of direct pressures and rewards in the direction of a Hippocrates-free Auschwitz self.”17

That was then.  Theirs was another time, another place, another world, was it not?  If the factors from which emerged the Nazi ideology of hatred really belonged to some alternative universe shut off from our own, then it might be possible to relax in safety.  There would also be less need to preserve the evidence and memory of such events.  So many of the photographs from that era are in shades of grey or stark black and white, which gives the impression that the mid 20th century was a reality separate from the richly colorful modern world.  The greyness of old photographs is, however, only an artifact of earlier camera technology. 

That history, that geography, and that human nature overlap with and are continuous with our own.  The uncomfortable words of Russian novelist and historian Alexander Solzhenitsyn are once again relevant:  “If only there were evil people somewhere insidiously committing evil deeds and it were necessary only to separate them from the rest of us and destroy them. But the line dividing good and evil cuts through the heart of every human being.”18

As I write this article, the memories of having visited the Auschwitz-Birkenau museum and the remains of the death camps just this week are etched on my mind like an open wound.  Traveling to the site, there is no chasm in the Earth’s crust separating what remains of Auschwitz from the rest of the European continent.  That bleak place exists in our own world.  Auschwitz, once connected to every major European city by railroad, is still connected to present reality – geographically by roads, temporally by only a few years, and morally by universal fallen human nature. 

The deceitful slogan, “Arbeit Macht Frei” (work makes one free), hangs over the entry gate.  Formerly electrified barbed wire stretches around the camp, the 13 km borders of which are punctuated by signs reading “Halt!” (Stop!) or “Vorsicht” (Beware).  One walks through the same mud through which Nazi physicians marched and prisoners trudged, too emaciated to shiver in the severe cold.  The living quarters are appallingly horrid, unheated, unspeakably unsanitary, and were once infested with lice and rats.  Three-tiered wooden bunks, each intended to sleep 15 prisoners – 5 to a bed – often held more.  There is no shortage of sites of punishments and executions, including poorly ventilated dark cells, gallows, “the post” at block 11, gas chambers, and the infamous “Wall of Death.”  Piles of empty canisters of Zyklon-B correspond to thousands of lives lost.  Walking into the Nazi’s first crematorium, one can see layers of ash coating the ceiling.  The smell of smoke lingers still.

Physical evidence of the authenticity of the historical record is preserved throughout the museum.  Archival Nazi documents are displayed for the visitor to inspect.  Lined along the walls are the names and faces of thousands of prisoners photographed upon entry to the camp.  Huge piles of personal belongings, including 40 kg of eyeglasses, 80 thousand shoes – even the tiny shoes of children – and two tons of clipped human hair to be sold and woven into cloth, are almost more than the buildings can contain. 

Monstrous crematoria and large-scale gas chambers await the visitor who ventures to nearby Birkenau (Auschwitz II).  The total area of these gas chambers was 2255 square meters and the capacity of the crematoria 4420 people.  Death took just 20 minutes.  In the center of the railroad track entering the camp and leading to the crematoria is the concrete platform where the selections occurred.  The vast size of this grim landscape of horror staggers the senses.

The visitor also encounters heroic points of light amidst the moral darkness of the camp.  Cell #18 of block 11 marks where Maximilian Kolbe, a Polish Franciscan friar, was executed, having offered his own life in place of a stranger condemned to death. 

A gentle rain fell the day I visited Auschwitz, as if Heaven continues to shed tears for those who suffered there.

Natural erosion and deterioration are gradually threatening the continued conservation of the remaining buildings and relics of Auschwitz.  Incrementally, the fragile ruins of the Birkenau gas chambers are collapsing.  The Auschwitz-Birkenau Foundation, with the help of funding from the governments of Poland and other nations and generous individuals, is currently working to raise a Perpetual Fund to ensure the long-term preservation of the Auschwitz-Birkenau Memorial and Museum.  Stewards of the site have indicated that funds to date are insufficient to preserve indefinitely all of the crucial relics, and there are some remains that no amount of funding can save.19

Photographs and recordings of interviews of camp survivors can help to safeguard the preservation of the history of Auschwitz so that future generations can be educated about this important yet painful chapter in the history of medical ethics.  Perhaps, then, with concerted efforts shared by nations around the globe, such tragedies can be avoided in the future.

Film also allows the viewer to enter vicariously into the story of the death camps and feel something of the terrible weight the victims endured.  Of the many films made about the Holocaust, the 1992 movie, The Grey Zone,20 despairingly considers moral decisions within a system of constrained choices in which survival may require cooperation with evil.   The film’s title refers to the profuse grey ash of the dead, which covered everyone and everything.

Considering the possibility that, a generation from now, visitors to the remains of Auschwitz might have the opportunity to witness only part of what is now viewable, the option of virtual reality may offer a technologically sophisticated means to rescue a permanent record of the camp and provide the visitor with a memorable experience.  Internet surfers currently can access Auschwitz information and photographs interactively through a virtual tour sponsored by the State Museum of Auschwitz-Birkenau.21 Virtual reality has the advantage of minimizing cost while greatly increasing access.  Current technology supplies information, links to articles, and slideshow format images.  Future technologies might render the virtual reality tour more realistic, with high resolution computer graphics, motion simulating walks through the camp, sensory interaction with panoramic stereoscopic displays, tactile force feedback, even the opportunity to interact with avatars or computer-generated recreations of characters virtually reenacting the events of the camp. 

While there is much about virtual reality that can be affirmed for the purpose of educating students and the public about serious historical events, there is also reason to pause.  One suspects that a virtual reality tour of Auschwitz, no matter how convincingly realistic, would lack the authenticity of a genuine visit.  It might also lack credibility, since it would be all too easy to modify or otherwise tamper with the details and how they are presented.  Scale as measured by a finger gliding across a computer touchpad is not the same as distance measured by how fatigued one’s legs feel after walking the full length of the grounds at Birkenau.  The camp’s physical proportions echo its moral proportions.  Having recently walked there, the camp’s dust still clings to my shoes and its memories to my mind. 

Nor would a virtual representation adequately capture the irony of the string quartet greeting prisoners returning from slave labor factories to the locked confines of the camp.  Virtual recreations would altogether miss the contrast of the external innocence of quaint buildings concealing murder inside.  A visually enhanced Internet copy of Auschwitz could become, in addition to an educational tool, disturbingly, an open gate to the eyes of children too young for its content as well as an entertainment curiosity for the lighthearted.  Distanced from the actual scenes by windows that one can drop out of sight by a single click, the virtual viewer might no longer be able to shudder.  Without a proper moral relationship to the story of Auschwitz possible by visiting in person, a virtual reality link could all too easily disrespect the deceased victims of the camp. 

The Apostle Paul visited the island of Kos circa 58 AD during his third missionary journey to share the hope of life in Jesus Christ (Acts 21:1).  Paul, who described himself as a Jew of Jews (Phil 3:5), were he alive today, undoubtedly would have felt “great sorrow and unceasing anguish” for the loss of his Jewish kinsmen (Romans 9:2-5) during the Holocaust of the 20th century.  It is worth remembering the words of Psalm 34:18, which declares that, “The LORD is near to the brokenhearted and saves the crushed in spirit.” 

Editor’s Note:

The views expressed herein are Dr. Cheshire’s own and do not necessarily reflect the position of Mayo Clinic.  This article originally appeared in  Ethics & Medicine: An International Journal of Bioethics Volume 23, Issue 3, Fall 2010, and is used with permission.

 

References

1 Annas GJ and Grodin MA.  The Nazi Doctors and the Nuremberg Code: Human Rights in Human Experimentation. New York: Oxford University Press, 1992, p. 3.

2 Proctor RN. Nazi doctors, racial medicine, and human experimentation.  In: Annas and Grodin, p. 17.

3   Lifton RJ. The Nazi Doctors: Medical Killing and the Psychology of Genocide. New York: Basic Books, 1986, p. 163.

4 Http://en.auschwitz.org.pl

5 Franco HM. The Jewish Martyrs of Rhodes and Cos, translated by Joseph Franco, Harare, Zimbabwe: Harper Collins, 1994; http://www.sefarad.org/publication/lm/045/11.html

6 Hippocrates, Epidemics.  Book I, Section XI.

7 Verhey A. The Doctor’s Oath – and a Christian Swearing It. Linacre Quarterly, vol. 51, no. 2, pp. 139-158. In: Stephen E. Lammers and Allen Verhey, editors, On Moral Medicine: Theological Perspectives in Medical Ethics, 2nd edition, Grand Rapids: Eerdmans, 1998, p. 108.

8 Cameron N. The New Medicine: Life and Death After Hippocrates, Chicago: Bioethics Press, 2001.

9 Lifton, pp. 164-165.

10 Lifton, pp. 163-213.

11 Adam YG. Justice in Nuremberg: the doctors’ trial – 60 years later. Israeli Medical Association Journal 2007;9: 194-195.

Lifton, pp. 166, 186-192, 431; Http://en.auschwitz.org.pl

12 Adam YG. Justice in Nuremberg: the doctors’ trial – 60 years later. Israeli Medical Association Journal 2007;9: 194-195.

13 Lifton, pp. 347-374.

Telford Taylor, Opening Statement of the Prosecution, December 9, 1946, in Annas and Grodin, pp. 68, 87.

Cameron, p. 70.

Lifton, pp. 4, 207, 433.

Solzhenitsyn A. The Gulag Archipelago, part I.

Berg R. Cash crisis threat to Auschwitz. BBC News, January 26, 2009, accessed at http://news.bbc.co.uk/2/hi/europe/7800397.stm

The Grey Zone, directed by Tim Blake Nelson, Lions Gate Films, 2002, based on Miklos Nyiszli, Auschwitz: A Doctor’s Eyewitness Account, New York: Arcade, 1993.

Http://remember.org/auschwitz/

 

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