Introduction

Mark Twain had it that whilst history does not repeat itself, it sometimes rhymes. The paper by Lòpez-Muñoz and Alamo Reference Lopez-Munoz and Alamo(1) is a cautionary reminder that the history of medicine, and particularly psychiatry, has showcased both the best and worst of human behaviour.

The crimes of the Nazi doctors have been well documented and the reasons for such moral lapses have been analysed from various angles. Lifton's account Reference Lifton(2) of the mechanism of ‘doubling’, in which those involved in abuses of patients dissociated their personal and professional lives, remains the most compelling examination of the question ‘How did this happen?’, although the ‘why’ remains elusive. Dudley and Gale noted that the ‘why’ emerged as a process of peer pressure, uncritical devotion to duty, faceless bureaucracy and careerism Reference Dudley and Gale(3). Moreover, the denial of reality necessary to commit such crimes appears to have been facilitated by the use of the kind of deceptive, political language that George Orwell warned us about Reference Orwell(4). Parallel outrages were committed by Japanese doctors at the Kempeitai Political Department and Epidemic Prevention Research Laboratory (Unit 731) in the Chinese city of Harbin Reference Barenblatt(5).

The paper by Lòpez-Muñoz and Alamo Reference Lopez-Munoz and Alamo(1) looks at one specific aspect of this most troubling chapter in the history of medicine—the pursuit of a research agenda by an amoral and opportunistic pharmaceutical company, and a group of previously respectable professionals. The article raises two issues pertinent to the current context of neuropsychiatric research—are we rid of the intellectual preconditions for such events and how adequate are our safeguards against their recurrence?

Miscarriages of justice

As Lòpez-Muñoz and Alamo Reference Lopez-Munoz and Alamo(1) note, IG Farben was prosecuted by the Allies in the Nuremberg war crimes trials in 1945–46. Despite the adverse publicity of the trial, the company appeared to escape serious consequences for its actions. This represents one of the great miscarriages of justice, in that the company was amongst the most ruthless in its treatment of slave labourers Reference Jeffreys(6) and it continued to resist paying compensation to survivors 60 years later (7). Although IG Farben was officially liquidated in 1952, it remained a trust and its shares continued to be traded on the Frankfurt Stock Exchange until late 2003. IG Farben's commercial descendants include Bayer, BASF and Hoechst.

Notwithstanding IG Farben's good fortune in avoiding serious punishment in the post-Nazi era reckoning other beneficiaries of the moral blackness of Nazism also appear to have evaded justice. As the authors note, Professor Julius Hallervorden profited from the murder of concentration camp victims, his well-documented pre-execution selection of ‘subjects’ making a lie of any claims that he was, at worst, merely making the most of opportunities. The tissue samples of the so-called ‘Hallervorden Collection’ remained at the Max Planck Institute until 1990, when those samples were eventually buried in a Munich cemetery Reference Shevell(8). Hallevorden's professional legacy is still innocently celebrated in the eponymous neurological syndrome he described with his co-conspirator Hugo Spatz. It is also worth noting that many of the Japanese war criminals who had committed human rights abuses in Unit 731 went on to prestigious post-war careers in academia or the pharmaceutical industry Reference Harris(9).

The intellectual genealogy of the Nazi doctors

Many bioethicists have grappled with the apparent intellectual preconditions to the Nazi project. Despite the contribution of the amoral bureaucracies of which Max Weber warned us Reference Weber(10), the eugenic movement remains the main culprit. Malthusian ideas Reference Malthus(11) gave oxygen to the viewpoint that the intrinsic value of human beings was negotiable. Eugenics was by no means unique to 1930's German psychiatry. The British academic Francis Galton was so enamoured of the seminal thesis of Darwin, that he called for all public policy to be based upon the notion of natural selection Reference Galton(12). Eugenic ideas permeated American psychiatry contemporaneously with German psychiatry Reference Sofair and Kaldjian(13). Long before Hitler's ascent to power, German psychiatry was enamoured of eugenics. In 1913, German psychiatrist Alfred Ploetz founded the ‘German Society for Racial Hygiene’. Another psychiatrist, Ernst Rüdin, became his enthusiastic acolyte, referring to the cause of eradicating ‘inferior genetic stock’ from the population as ‘schädlingsbekämpfung’ (pest control). In 1918, Emile Kraeplin, perhaps the most famous of German psychiatrists, had called for strong political leadership to effect ‘a decline in mental debility’Reference Freidlander(14).

Hitler's moral philosophy was predicated upon Darwinian principles. Many leading Darwinian biologists and social thinkers in Germany believed that Darwinism had superseded traditional Judeo-Christian and Enlightenment ethics, in particular their valuing of all human life. The moral relativism which emerged from the exaltation of the evolutionary ‘fitness’ of the species as the source of a moral good was at the core of this ‘pseudo-ethics’Reference Weikart(15). O'Mathúna argued that five key ideas were central to the actions of the Nazi doctors—moral relativism, blurred distinctions between animals and humans, acceptance of the proposition of the existence of human inequality, the notion that some lives have no value and the belief that natural selection was a valid determinant of human dignity Reference O'Mathúna(16).

Regardless of the intellectual bankruptcy of Nazi racial ideology, Darwinian ideas and evolutionary psychiatry are still popular. Indeed, there is a strong contemporary ‘evolutionary psychiatry’ movement, which seeks to understand human psychopathology in terms of the natural history of our species Reference Stevens and Price(17). Moreover, the conceptualisation of psychiatric disorder is moving inexorably towards the molecular level Reference Hyman(18), where depression or anxiety may be defined more in terms of the possession of particular alleles of genes, rather than the traditional verstehen psychologie of Jaspers Reference Jaspers, Hoenig and Hamilton(19). Whilst it is not reasonable to assume a moral equivalence between the current, somewhat reductionist paradigms of evolutionary psychiatry or genetic diagnosis, there is a need to reflect upon neuropsychiatry potentially losing sight of the intrinsic value of humans. Kant's notion of ‘menscheit’ refers to the human potential for autonomy or unconstrained rational self governance Reference Kant and Gregor(20). This is one approximation of the intrinsic value of humans, even the most irrational or intellectually disabled persons. Kant's formula of humanity has it that humans must be ends in themselves and never a means to such an end Reference Kant and Gregor(21). Such notions were clearly lost in the Nazi era, a fact made all the more tragically ironic in that Adolf Eichmann, the Nazi functionary who was responsible for the so-called ‘Final Solution’, proudly proclaimed at his trial for crimes against humanity that he was a Kantian Reference Arendt(22).

The loss of sight of the essential value of humans seems to be at the core of the crimes of the Nazi doctors. The moral philosophy which emerged in the aftermath of the Holocaust, evident in the works of Baumann Reference Bauman(23) and Levinas Reference Levinas and Lingis(24), emphasised that the crisis in Western ethics brought about by the Nazi era resided in the loss of the value of persons, no matter what their background. In reflecting upon the crimes of psychiatrists and neurologists in the Nazi era, we ought to be mindful of whether our intellectual journeys in neurology and psychiatry lose sight of this.

The Nuremberg Declaration

The other main theme in Lòpez-Muñoz and Alamo's Reference Lopez-Munoz and Alamo(1) paper is the significance of the codes of ethics which emerged from the Nuremberg trials. The major ethical focus of the ‘Doctors’ Trial’ was the issue of research on human subjects, in particular the concept of informed consent to participate in biomedical research. A common method of argument in bioethical debate is to position a particular issue with reference to Nazism. Polemicists like Singer, whose advocacy for termination of grossly deformed foetuses is often compared to the excesses of Nazism, contribute to such emotive debates. What is not clear is the specifics of the fundamental moral failure of the Nazi doctors. Many rationalisations were offered by defendants in the ‘Doctors’ Trial’, yet it remains difficult to specifically articulate the core moral failing of the Nazi doctors. As such, the invocation of the Nazi doctors is problematic in contemporary bioethical discourse Reference Caplan, Annas and Grodin(25). ‘The Nuremberg Code’, the declaration of ethical principles which formed the basis of current Codes of Ethics for research, emphasises the importance of informed consent to research participation. Informed consent to participate in psychiatric research is amongst the most vexed of issues in the field Reference Roberts(26,Reference Roberts and Roberts27), and is brought into sharp relief by the Lòpez-Muñoz and Alamo article Reference Lopez-Munoz and Alamo(1). One lingering question is the notion of the universalisability of the Nuremberg Declaration. The Nuremberg Declaration, arguably, sees the global imposition of liberal Anglo-American values under the rubric of the emergent notion of ‘human rights’Reference Annas and Grodin(28). Regardless of the apparent validity of such constructs, the question of the universalisability of the concept of informed consent is problematic. A particular issue is whether data obtained from research participants from settings other than a researcher's own institution are subject to the same valid forms of consent as required in the researcher's own country. There is emerging evidence that ‘informed consent’ to participate in research programmes is problematic in settings such as China Reference Lynöe, Sandlund, Jacobson, Nordberg and Jin(29) and West Africa Reference Krosin, Klitzmanb, Levin, Cheng and Ranneyb(30), where increasing amounts of psychiatric and neuropsychiatric research are performed, presumably because of cost benefits and the availability of research participants. This then raises the question of what are the ethical grounds for publishing such research, if there are credible questions about the adequacy of informed consent. A common ethical quandary put to undergraduate students of bioethics is whether any data from Nazi experiments should ever be used in order to save lives. Again, this is an unfair comparison with the above dilemma, but does at least beg the question as to whether there should be more specific consideration given to such matters by research ethics committees and the editors of scientific journals.

Conclusion

Lòpez-Muñoz and Alamo's Reference Lopez-Munoz and Alamo(1) paper raises more questions than it answers. What is clear from their work, and much of the literature around the Nazi doctors, is that we do not have a thorough account as to why such crimes occurred. This then raises concerns about the adequacy of the safeguards we have to prevent such outrages being repeated. There is no credibility in equating any of the current processes in neuropsychiatry with any of the crimes of the Nazi doctors, as we do not fully understand the latter. Perhaps the lesson of the ‘Doctors’ Trial’ and the crimes of IG Farben is the need for ongoing reflection about any potential proximity our acts to this moral low-point in the history of medicine. As the philosopher Hannah Arendt observed of Eichmann in his role of architect of the gas chambers of Auschwitz, his failure to reflect upon his actions was the banal origin of his evil acts Reference Arendt(22). Lòpez-Muñoz and Alamo's Reference Lopez-Munoz and Alamo(1) account of neuropsychiatry in Nazi Germany highlights that the key to ethical research in neurology and psychiatry is to reflect upon how a research process addresses the intrinsic value of humans and the adequacy of the processes of consent.