In addition to resting on poor science, the atrocities of the German psychiatric establishment were based upon several fundamental errors of ethical, professional, and scientific conduct. While many may simply brush off any deeper consideration of the issues with the stance that "they were just evil", such an approach only deepens the risk that such events will be repeated. The truth cannot be more different: perversion of ethical medical practice due to theoretical misjudgment and fundamental error in approach to the patient are what led to these atrocities of catastrophic proportions. So where did they go wrong? Several misconceptions lay at the source:
1) Medical ethics is ethnic, cultural, and time sensitive
The theory behind such a proposition is that much of medical ethics is time and culture bound . Therefore what may be unethical now may not necessarily have been unethical then. This approach inculcates a relative attitude to the atrocities, minimizing the severity of the injustice and gross professional negligence so inherent in what transpired. Certain aspects of medical ethics transcend time and culture. Except under very specific and precise circumstances, such as when there is a serious and immediate risk to others, a physician should always respect autonomy, beneficence, and patients' confidentiality and dignity. Although it may be suggested that there is a major leap between disregard of these time-honored factors and the genocide of euthanasia, this is how it all began – it may even define the central thread of the atrocities to the mentally ill. While the form of ethical medical practice may depend on resources and cultural nuances (Tarasoff etc.), the basis for ethical behavior should remain constant, irrespective of time and place. Thus, while some maintain that for one generation a practice may be considered unethical but not for another , this is a misconception, as certain practices and concepts do not change with context. It is therefore never appropriate to kill one's patients en masse based on diagnosis and economic and racial-hygiene considerations for the community at large.
2) Philosophical constructs and ideas should define clinical practice
During the period of the Nazi regime, psychiatry supported compulsory sterilization and euthanasia of the physically and mentally ill, and subsequently, the killing of "inferior" races. They did this by applying scientifically invalid conclusions from evolutionary biology . Aside from the fact that these philosophical constructs and scientific paradigms of evolutionary theory were flawed, they were also immoral and contravened basic tenets of medical ethics and clinical practice. Much of this approach was based on theories of neo-Darwinism. Furthermore, ever since Francis Galton in 1865 first published the idea of eugenics (a term rooted in the Greek "good in birth" or "noble in heredity"), individuals with mental illness had been targeted by eugenics programs, with psychiatrists intimately involved in the theoretical debate. The eugenics movement was not limited to Germany, and proponents of eugenics were prominent in several other countries including most notably Britain and the USA . Interestingly, during the period in which euthanasia of the mentally ill was taking place in Germany, a fascinating debate transpired between two prominent American academics and was published in the American Journal of Psychiatry in 1942. Foster Kennedy, professor of neurology at Cornell University in New York, argued that all children with proven mental retardation ("feeblemindedness") over the age of five should be put to death. Leo Kanner, however, maintained that such individuals might still serve a purpose to society – garbage collection, postmen, etc. – as well as give meaning to their parents by virtue of having to care for them. Astoundingly, no one emphasized the unethical nature of putting individuals with disability to death. Instead, the editorial, published anonymously, appeared to side with Kennedy, and advised help for the parents in coming to terms with such a reality for their children and for the need for "enabling legislation" in order to facilitate the process legally (apparently in contrast to that of the German experience) . The Nazi experience, which took much of the concept to fruition, was an extreme perversion of this movement, which existed already (at least at the conceptual level) in the minds of many psychiatrists supporting the idea.
3) Preventative medicine is more important than curative medicine
In the interests of preserving the future quality and purity of the Aryan race, racial hygiene became the battle cry of the German nation with Nazi medicine attempting to prevent the proliferation of illness. Within this context, it became the role of physicians in general, and psychiatrists in particular, to define who should be eliminated in order to best preserve the German nation's uniqueness and "higher-being". Thus in place of managing mental illness with the available tools (which were minimal) or investing resources in research for more appropriate treatment, it became important for physicians and psychiatrists to prevent such forms of illness or defects through euthanasia . A particular focus was placed on psychiatric patients in the racial-hygiene program because they were perceived as weakening the "master-race" with no known cure. Therefore these "lives not worth living" were deemed useless and dangerous to German society and, in order to prevent their dissemination, the process of eliminating them in the context of the sterilization and euthanasia program came about. This procedure of trying to prevent illness, while a noble concept, should never be instituted at the expense of (and complete exclusion of) treating illness, as the disastrous Nazi program proved . Even if one accepts their reasoning – and in this case they were wrong – selective sterilization of the mentally-ill would never significantly reduce the frequency of mental illness based on the Hardy-Weinberg law of preservation of rare recessive genes in a population of phenotypically normal carriers . The Nazis embraced an exclusionary biological and racial determinism that removed any reparative function from clinical psychiatry. What remained was prevention of mental illness. Psychiatrists lived up to the challenge.
4) Psychiatrists have a particular role in channeling societal issues and public discussion
Many psychiatrists maintain that they have an inherent responsibility more than other medical professions to be involved in community affairs. This is because psychiatry by nature advocates a holistic approach to the patient, which often includes taking into account societal factors and contemporary ideology. Thus while the unique role of psychiatry in the genocide may be overstated, since other areas of medicine were also involved, psychiatrists fitted in particularly well. The dangers inherent in such involvement, while not obvious, are, however, prominent when important boundaries become blurred. Clinical practice and political machinations need to be kept separate. Many psychiatrists during the Nazi era were state-controlled and this further facilitated their conforming to the program. The rights of individuals cannot be totally ignored in the interests of society. The dangers become particularly acute in psychiatry compared to other subspecialties in medicine since it may be suggested that the field of psychiatry is often used in order to remove undesirables from society and place them in asylums. It may be argued that labeling of mental disease and its classification is a means of controlling members of the community who do not comply with accepted norms; therefore their freedom should be taken away and replaced with hospitalization. However, while at times there may be a fine line separating mental health and illness, it becomes very clear that the extent to which Nazi psychiatry allowed the political and community atmosphere to influence and govern clinical practice was grossly unethical, murderous, and unacceptable to an extreme extent.
5) Political and economic pressures may influence clinical practice
The management of patients must be dictated primarily by the patient's best interests and not by virtue of any ideology that may be prevalent at the time in society. This may include economic "ideological" considerations. Thus while pressures may exist "encouraging" the physician to make decisions one way or another based on the prevailing mood or tendency of the community at any time or place, this should be resisted and medical management should continue, unaffected by external considerations. The patient has to receive individual management and not be treated according to what is in vogue at the time. Psychiatrists should be wary of political and economic pressures that impinge upon medical decisions and health service provision. Nazism was supposed to be "applied biology" . Science in general and psychiatry in particular needs to be independent from contemporary sociological and political contexts as well as protected from political abuse, even when embraced by the medical establishment. It has been proposed that the primary downfall of Nazi medicine was the failure of physicians to challenge the substantive core of Nazi values "Too many physicians were willing to go with the political flow; too many were unwilling to resist, to 'deviate' from 'commonly accepted' practices" . Sound medical practice should be protected from the movement of political forces.
6) Psychiatrists/scientists have a responsibility to "enhance" mankind
Much of the early involvement by psychiatric clinicians and researchers in the process of "racial purification" arose from a genuine desire to improve mankind and not necessarily from the perspective of racist genocide. While no direct parallel can be drawn, today many continue in a sincere scientific effort towards the "enhancement" of man through molecular biology and genetic engineering . Appropriate dialogue is required in order to ensure that the desire for "improving man", creating a "better human", does not come at the expense of the individual patient.
7) The interests of science take priority over the interests of the individual patient
Clinical management and research participation may appear to be equivalent, but they are not. A clear distinction must be made between the two and the patient must be aware of this. Research is critically important for the future of good medical practice and is fundamental to the philosophy of medical ethics in psychiatry which would be reflected in the long-term striving for excellence in clinical management. However, it should always be made clear to the patient that participation is voluntary and that more conventional treatment regimes exist and are available if preferred. Particular issues such as scientific validity, favorable risk-benefit ratio, voluntaryism, and decisional capacity, while important in all aspects of clinical practice, become of acute importance with respect to individuals with mental illness [16, 17]. The Nazi experience, which completely disregarded such factors in the interests of "science" and racial-hygiene, is a prime example of the dangers inherent when such factors are not respected. Ethical commitment to research safeguards needs to be reflected in appropriate standards, guaranteeing appropriate study participation . Refusal to participate in a study should likewise never interfere with the doctor-patient relationship and in the case of a patient agreeing to participate in research, it remains the duty of the physician to protect the health of the individual.
8) High-quality science and high-quality ethics always co-exist
It has become easy for those in the West to dismiss the depths of unethical medical practice of the Nazi physicians by categorizing it as bad science. This is easier to accept than the possibility that even within the context of good science, ethical behavior by physicians may go astray. In fact, the Nazi era in Germany was a time of remarkable scientific advances in several areas including cancer research and treatment, biochemistry, and quantum mechanics to name a few. In addition, the Nazis were pioneers of jet-propelled air flight, guided missiles, electronic computers, electron microscopes, and atomic fission . Thus, scientific advancement does not necessarily go hand in hand with ethical advancement. It would be incorrect to brush off the ethical challenges that true scientific advancement in medicine may present, since the connection with true ethical practice is not necessarily a natural one.