“Today nearly every healthcare ethics issue (eg. value of human life, dual loyalties, power and authority, professionalism and ethics education) can be better understood by considering the Holocaust’s legacies.”Footnote 1
Introduction
Although the relevance of the Holocaust for bioethics is obvious, the connection between the two has been complex. The Nuremberg Doctors’ Trial produced a code of ethics that seeded concepts of patient autonomy, beneficence, and justice, yet these would not take root as mainstays of bioethics for another 25 years. Physicians of the time held that Nuremberg had produced a fine code for barbarians, but it was unnecessary for the average civilized physician whose ordinary character was sufficient to guide ethical and humanistic behavior.Footnote 2 Moreover, while Nazi medical atrocities inform important bioethics principles and patient protections, significantly less attention has been paid to the health professionals, both Jewish and non-Jewish, in the ghettos and concentration camps who were caring for patients often out of explicit commitments to virtues they believed to be inherent within the medical profession.
Robust inclusion of the legacy of medicine during the Holocaust therefore represents a unique opportunity for contemporary medical education, but further curriculum implementation and assessment are needed.Footnote 3, Footnote 4 This content raises vital questions related to core principles of bioethics,Footnote 5 and data are emerging related to its capacity to promote reflection for learners at all stages of the professional lifecycle about professional identity formation,Footnote 6, Footnote 7 as well as moral courage, and medical humanism.Footnote 8, Footnote 9 Insights derived from studying this history also relate to diversity, equity, and inclusion education programs, generally, and the need for greater inclusion related to countering antisemitism within such programs.Footnote 10
Consistent with the call for greater inclusion of Holocaust and medicine education in health professions education,Footnote 11 we (authors HSW and JAW) developed a Holocaust and Medicine Program with a Study Trip to Auschwitz for the Oakland University William Beaumont School of Medicine (OUWB).Footnote 12 In this article, we report the results from a qualitative program evaluation identifying key substantive themes on the outcomes of this critically reflective, place-based learning experience, where the pervasive complicity of physicians, juxtaposed against the moral courage of others, is explored by students in situ. The program impact was assessed by independent evaluators, and the themes reported underscore the value of Holocaust and medicine education for critical reflection and transformative learning in bioethics, medical humanism, and professional identity formation.
Overview of the Program
The OUWB Study Trip to AuschwitzFootnote 13 is entirely donor funded and includes a pre-trip curriculum, a seven-day trip to Krakow and Oswiecim (the location of Auschwitz-Birkenau) in Poland, and a post-trip workshop where students prepare presentations in order to share their experiences and insights with the broader community. This includes other medical students; faculty, staff, and students across the university; schools and other organizations throughout our metropolitan area; and at both national and international forums.
The pre-trip curriculum includes three modules focused on general Holocaust history, an introduction to the history of medicine during the Holocaust, reflective writing and professional identity formation, and required multiple postings to a discussion board reflecting on various module components as well as the students’ expectations related to their upcoming study trip. The trip itself includes tours of historic sites and museums in Krakow followed by educational tours of Auschwitz I and II (Birkenau) in Oswiecim. Students also attend lectures by Auschwitz historians and participate in three reflective writing sessions, as well as one discussion session on the relevance of the Holocaust to contemporary medicine.
Upon return, students discuss and reflect upon the trip experience during a seven-week seminar and develop projects and presentations for sharing what they learned at a symposium dinner as well as with other community groups at the medical school, health system, the broader university, and at regional and national conferences.
Methods
This program evaluation employed a grounded qualitative approach that utilized systematic analysis of narrative for extracting key themes as patterns. The research team brought an array of expertise to the design, analysis, and audit that promoted appropriate reflexivity at each stage of the evaluation.Footnote 14 Co-trip leaders JAW and HSW did not participate in interview data collection or any analyses in order to mitigate conflicts of interest and any potential pro-social interview responses from participants. Additionally, students were instructed to de-identify their reflective writing submissions. ML and RS, who did not attend the trip or participate in any program activities, conducted all interviews and analyses. HSW and JAW reviewed and provided further commentary on the results to deepen interpretation with additional information about the experience. This study was approved by the Institutional Review Board at Oakland University.
Data
Two types of narrative data were collected from the student participants: written reflections and semi-structured open-ended interviews. Reflective writing was conducted in three evening sessions during the study trip, followed by a debriefing and discussion. Writing prompts included 1) reflecting on moral failures and atrocities of Nazi physicians and the medical-scientific establishment and its relevance for one’s professional identity formation; 2) describing how resistance and resilience stories resonated with one’s own sense of moral courage within challenging contemporary healthcare; and 3) reflecting on what participants were taking forward from the experience.
Post-trip interviews were conducted with 13 of the 19 student participants between July and October 2022. Interview prompts elicited narrative responses about a range of aspects of the trip, including the general experience, personal and professional impacts of the trip, and what they most wanted to share with others about the experience.
Analysis
Deidentified interview transcripts (n = 13) and reflective writings (n = 52) were analyzed using techniques derived from grounded theory.Footnote 15, Footnote 16 This process initially involved an initial line-by-line coding first done independently by ML and RS and then synthesized. After this iterative coding process, like codes were raised to categories. Themes were identified by observing patterns and connections across categories.
Results
Analysis of the interview transcripts and reflective writings yielded four core themes:
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1. Gaining a greater understanding of the relationship of bioethics and the atrocities of the Holocaust
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2. Recognizing moral courage and social awareness as part of professional identity formation, particularly in light of the concern that such atrocities could happen again
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3. Developing a deeper appreciation for the roles played by dehumanization and medical power during the Holocaust and their contemporary manifestations
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4. The power of presence and experiential learning for bioethics and humanism education and professional identity formation
Each of these themes is explicated below, including constituent codes or categories (which are italicized in each subsection) and representative quotes.
Theme 1: Gaining a greater understanding of the relationship of bioethics and the atrocities of the Holocaust
In-depth exposure to the history of the Holocaust and of medicine during the Holocaust deepened students’ bioethics understanding. Often repeated codes under this theme centered on principles of medical ethics such as autonomy, nonmaleficence, and beneficence, as well as the immorality of Nazi physicians, and the central role of dehumanization in catalyzing their moral atrocities.
Predominantly, the students felt the study trip served as a transformative experience that provided an opportunity to delve into the genesis of bioethics in atrocities of Nazi medicine. This included reckoning with forced medical experimentation, eugenics, and involuntary euthanasia, among other egregious violations of principles such as beneficence and nonmaleficence. In addition to deepening knowledge and acquiring historical context for their general bioethics curriculum in the standard OUWB curriculum, students reported an increased consciousness about their personal responsibility to uphold basic ethics principles and moral standards as they enter practice. As one student wrote in a reflective writing:
We are constantly reminded of the values and norms of the profession we are soon entering and how critical it is not only to uphold them but to embody and live them in all aspects of our lives. This foundation has made it especially challenging to attempt to comprehend the moral failings of physicians during the Holocaust. I can only believe that the physicians who made the choice to become perpetrators never held these values and beliefs of the profession to the highest regard, as it is even more terrifying of a thought to wonder if the Nazi regime was able to chip away at their morals until nothing remained.
Students acknowledged that the centrality of the health of the state justified coercive experimentation and even murder for the greater good in the beliefs of Nazi physicians, particularly when coupled with the belief in the fundamental inferiority of their victims. As another student said in an interview:
I was thinking a lot about how Nazi scientists wanted to do good by doing experimentation, but they were doing it at the cost of other humans that they felt were inferior. So, I believe there’s a boundary between wanting to advance science and caring about people… you need to make sure that in caring about people, you’re also respecting their autonomy and their wishes.
Throughout the interviews and reflective writings, students generally reported a more nuanced perspective of both the origins of bioethics and the necessity of its core principles, particularly as safeguards for patients.
Theme 2: Recognizing moral courage and social awareness as part of professional identity formation, particularly in light of the concern that such atrocities could happen again
Students commonly discussed developing a greater appreciation for the importance of physician moral courage, often offering examples of physician role models such as Dr Adélaïde Hautval, a non-Jewish physician imprisoned at Auschwitz who cared for other prisoners and refused to cooperate with performing heinous gynecological experiments. As one student remarked in a reflective writing:
She was strong in what she believed was right. She stood by it, without question. I tend to think about whether the Holocaust still could have happened if everyone lived like this. Would Hitler be able to recruit people? Would doctors have assisted? I also think about how in order to stand your moral ground you must first have concrete morals that you intend to live by.
Multiple students commented on the heroic actions of a Jewish OBGYN physician, Dr Gisela Perl, who helped save the lives of Jewish women by hiding them from the Nazis. One student wrote: “I think about Dr. Gisela Perl and how her form of resistance was to help the women she cared for at Auschwitz.” Another student reinforced the powerful sentiment behind her resistance and elaborated on how the actions of Dr Perl inspired them to one day become the physician who acts within their own moral agency regardless of immoral, systematic rules. This student wrote in their reflection:
One of the stories we heard was of an OBGYN, [Dr. Gisela Perl]… The reason that stood out to me was because it showed how a physician truly should act with their moral compass. After hearing so many stories about doctors who used their positions in harmful ways, it felt powerful to hear the story. This story helps me find my voice because it shows that even in times where society has completely failed to show humanism, there is always the ability to take moral agency. As a future physician, I know that it is my job to treat patients in an ethical and humanistic way. Even if society decides one way is right and I know that is morally not right, I must find a way to follow my own moral compass.
This concept of moral courage was often coupled with articulation of the importance of resilience and political activism amid the contextual pressures that are faced by physicians. One student offered this commentary in their written reflection:
One conclusion I do have… is that physicians must be involved in politics – not because we need to endorse a certain party (which in fact, I think we as physicians should not do since we are not all the same), but because we need to stand firmly by our moral values, and moral code which we must establish. We may not agree on everything, but there are some fundamental values I feel we must all see and stand by… that in the event of something stepping on those values, we will have the courage, strength and unity as a body of healers to do what is right, good, and just.
In addition, moral courage and professional virtues were described as being part of a physician’s professional identity, which transcend the workplace and must be embodied by physicians at all times. One student wrote the following:
This experience has highlighted the importance of constant vigilance towards these echoes [of the Holocaust], with the need not only to notice, but to act to correct them. I’m taking forward the need for constant reflection on these issues, and why my own moral compass is the most imperative tool for developing one’s sense of moral courage… We are obligated, not only to do no harm, but to also set the standard for good. This is not limited to the field of medicine, as the professional identity of a physician is not left at the clinic door when they head home at the end of the day. I feel inspired to live these values and ethics that we have reflected on to the absolute fullest, which I know will in turn aid my work as a physician.
Importantly, both personal and socially conscious orientations toward moral courage and professional practice manifested in narratives related to this theme. In essence, students reflected both on their own moral commitments and on the need to develop their personal capacity for moral courage, as well as how they might direct such efforts outward, not only for patients but also for society at large.
Students also commonly expressed concern regarding the potential for atrocities resembling those of the Holocaust to happen again. Narratives reflected a deepened sense of obligation to acquire greater social awareness and consciousness about what is transpiring in the world and to advocate against discrimination and injustice. As mentioned, this was often coupled with a sense of responsibility for personal growth and development in this area. As one student described in a written reflection:
I can look back in time and think ‘how did the world turn a blind eye’ during the time of the Holocaust? How did people do nothing? But then I think of myself. Right now… How much do I know about what’s going on in Ukraine?… How can I be the moral person that I want to be without exposing myself to current events and knowledge? I can’t… I’m learning that in morality, it’s not just as easy as making game-time decisions. Morality takes exploration, learning, exposure, vulnerabilities, willingness to admit love, and the time and patience to commit to all of these things… Morality is a full immersive experience.
Such narratives focused on the need for both awareness about injustices in the world around them, and for personal accountability and conscientiousness of one’s own actions within medical hierarchies, including potential for abuse of power. One student wrote the following in a reflection:
In order to honor the lives lost during the Holocaust, I feel a responsibility to stop not only such extreme atrocities but any lapse in morality that I may find…to sit with the discomfort… provides the greatest opportunity for growth.
Many students suggested that experiences during the trip accelerated their personal and professional growth with respect to a sense of duty for fighting against injustice and intolerance now and onward. More specifically, many students expressed that the inherent power of physicians amplifies their responsibility to advocate for the rights of their patients, strive to dismantle systemic injustices, and promote inclusivity.
Theme 3: Developing deeper appreciation for the roles played by dehumanization and medical power during the Holocaust and their contemporary manifestations
Central to the atrocities of the Holocaust was the idea that some groups of people were less than human or some kinds of lives were not worth living. In reflecting on their experiences, students articulated a deeper appreciation for the role that dehumanization played, but also for how it interacted with medical power in ways that amplified the horrors of Nazi medicine. As one student succinctly reflected, “I believe that when humans lose sight of this love for others, it is easy to dehumanize, to dissociate, to harm those around you.” Another pointed out that dehumanizing behavior does not always have to emerge from a particular anthropological view, but can be implicit in everyday behavior, “Acting without intention, or acting by simply following orders, whether or not they harm the patient, is dehumanizing.”
Students often referred to the many ways in which the Nazis dehumanized concentration camp prisoners. Although not equivalent, echoes of this dynamic resonated in relation to dehumanizing practices in healthcare today. One student verbalized the following during an interview:
… one of the things I kept thinking about when I was there was how the Nazis dehumanized and deindividualized the victims… by taking away their belongings, making them shave their hair, taking away their clothes, and giving them a number – not a name… So, I want to talk about that in my project, because I think it’s something we might still do with patients today… we make them put on a hospital gown and not their street clothes, we give them a barcode on their wrist instead of… asking them their name every time, we just scan it. I think there are traces of…deindividualizing patients in the hospital.
In addition to lessons on modern-day patient care, other students drew the analogy to treatment of persons experiencing homelessness. One student wrote about a specific conversation with a homeless individual that reflected the dehumanization of the homeless population:
Throughout the trip, one thing I have been drawn to is the notion that Nazis, particularly the doctors, were able to do these things, because they viewed the Jews and other populations as less than human. There was a societal structure and systematic teaching that made them think of the Jews as less. This gave them the loophole to treat those populations, maliciously and not follow their ethical standards and morals. In today’s society, I believe the homeless population echoes some of those same notions. We have a society that tries to keep us separate from homeless people… I remember once I heard a homeless person say, “the worst part is people just ignoring you, walking past you, as if you aren’t there; you aren’t a person.”
Students often drew parallels under the umbrella of dehumanization to modern-day phenomena, including racism, antisemitism, sexism, and discrimination against minority communities in the United States. They coupled their reflections on Nazi dehumanization practices with thoughts about the treatment of Jewish, Muslim, LGBTQIA+, and indigenous individuals, as well as frequently reflecting on the situation in Ukraine. While they recognized that such social injustices are not analogous to the Holocaust, the notion of dehumanization provided a context for promoting critical reflection on such contemporary social problems.
Theme 4: The power of presence and experiential learning for bioethics and humanism education and professional identity formation
Although various methods exist for Holocaust and medicine education (including, for example, readings, lectures, and seminars), students asserted that the experience of visiting important historical sites, including and especially, immersion of the environment, engagement of the senses, perceiving the gravity of events, and standing in the physical spaces at Auschwitz where many of the most infamous medical atrocities occurred, was profoundly impactful and often described as an irreplaceable learning experience. During an interview, one student commented:
I can’t picture how the trip would be successfully run virtually, because you can get that… knowledge and content… through the modules, but it doesn’t compare to being in person walking through a concentration camp in person or walking through the city of Krakow or Auschwitz to understand the severity of what’s happened there… That’s only something that you can get from… talking to survivors, in person, and building that conversation while being fully immersed in that sort of experience.
The student went on to further describe a particularly impactful moment made possible by place-based learning:
… while touring the concentration camps, there’s a very long path that led from the gates of the concentration camp to the gas chambers… we walked that path… And for me, the “aha! Moment” was just imagining so many people, children, adults, who had no idea what was going on or what was to come walking down this road horrified for minutes… accumulating only to be murdered… That path was very chilling to me and I kept looking back as I was walking to see just how long the road was and how long that experience of fear was for everyone who was involved… that moment showed how gruesome the Holocaust was,… how merciless the people were who committed the atrocities… that’s one of those things that you could never get through a virtual experience… to be there walking that path helped to really see the gravity of the situation.
The students often contrasted bioethics and humanism content taught in more traditional formats with this place-based learning experience, with the former feeling comparatively abstract. Witnessing the remnants of concentration camps, feeling the stark malice of the barracks, hearing the personal testimonies, and understanding the brutal intentionality of the camps evoked a more robust level of connection to engaging with bioethics and humanism concepts and the violation of fundamental moral precepts.
Some points of discomfort were also mentioned, such as how surprisingly pristine and aesthetic the Auschwitz and Birkenau camps were juxtaposed to the historical atrocities that occurred in those places. The strong imagery of some installations, including displays of piles of shoes and hair, elicited intense emotions not often evoked in reading or watching lectures. These more immersive experiences enabled the participants to connect on a visceral level. As one student noted in an interview:
Nothing compares to actually being there… we read people’s testimonies as we went to different parts of the concentration camp… there’s so much weight to that… it really sticks with you to see where this was happening… I think it was completely necessary and so helpful to get immersed in it… being there seeing the grounds, seeing where pictures were taken and… putting the pieces together like this is where people waited in their final moments… it just sticks with you.
Relatedly, the situatedness and emotional weight of the trip created a bonding experience among the students. During the trip, the students were provided an outlet to share their thoughts and feelings in the form of reflective writings and facilitated open discussions with one another. A student stated similar sentiments in an interview:
So, at the end of the day, it was a good opportunity to unpack everything that we had seen and learned. And I loved listening to people bring up things that I had never even thought about… I thought that that was the main time where we were able to learn from the trip honestly. Just because you’re seeing so much throughout the day and learning so much. The take-home points are really emphasized in the reflective writings, and when other people would share them.
Opportunities for exchange of candid thoughts within small group discussions allowed for decompression and emotional processing after the heavy content of the tours. Many students described these reflection opportunities within the study trip as quite valuable and impactful for character development, with reports of deriving insights from their peers’ reflections, along with a heightened sense of comradery.
Discussion
The above themes elucidate the value of reflective, place-based pedagogy for bioethics and humanism education, and in general, an “identity enriching” experience for future physicians within their professional identity formation.Footnote 17 All student participants had completed the standard bioethics curriculum for first-year OUWB students, which included numerous lectures, small group and large group discussions, and multiple assignments involving many of the bioethics and humanism concepts. They often referenced concepts from these sessions and the pre-trip curriculum during their interviews and reflective writings, including principles of bioethics, problems of dehumanization and objectification, dilemmas of “otherness,” and moral courage. Their reflections on the study trip, however, highlight the value added by such an immersive experience. In particular, this included a deepening sense of personal connection to those concepts, a capacity to reflect on the meaning of moral courage in the context of their own lives and responsibilities as future physicians, a greater awareness of social injustices both in society at large and in medicine specifically, and a strengthened commitment to activism. Ultimately, our analysis revealed how this experience impacted the depth of their knowledge and their bioethical imaginationFootnote 18 and contributed in an impactful way to their process of professional identity formation.
With respect to engagement with core concepts of bioethics and humanism, it is notable that students began connecting abstract bioethics principles to real and stark moral failings. The visceral experience of the death camps appears to have cultivated a stronger sense that concepts such as autonomy and nonmaleficence are not simply philosophical constructs, but rather ideally represent protections against abuses of actual persons. The personalized and emotionally laden tone with which the students spoke about these formerly abstract principles suggests this experience deepened their appreciation for the significance and practical necessity of ethics in medicine. Additionally, the students’ voices reflected a more sophisticated understanding of the relationship between humanism (or in this case, dehumanization) and ethical obligation, often noting in various ways that any moral system can be fundamentally undercut when one views another as less than human and, thus, not deemed worthy of being included in the moral analysis at all.
Students were noted to frequently grapple with questions about who they wish to become, both personally and professionally, and articulated how the trip contributed to this. Such critical reflection, or “living the questions” as the poet Rainer Maria Rilke has described, is a key component of the transformative process of professional identity formation.Footnote 19 This finding as well as the recognition of “power of place” in educationFootnote 20 aligns with Madelin S. Riesen and colleagues’Footnote 21 report on the impact of a similar curriculum for German medical and psychology students, including supporting the generalizability of these findings. The curriculum and study trip grounded the students’ historical knowledge, but went beyond this with their narratives, highlighting the great deal of thought and insight about the way the echoes of the Holocaust can inform both medicine and broader social engagement today. The insights students derived from their experience are germane to a range of issues, including persistent dehumanization in healthcare bureaucracies, health and healthcare inequalities, the marginalization of disadvantaged groups from important social resources, antisemitism and racism, and issues related to diversity, equity, inclusion, and belonging. In general, using immersive experiences centered on this history can help catalyze and foster the process of ethical professional identity formation within socially accountable health professional education.Footnote 22
Although this study evidences the value of critically reflective, place-based learning, several limitations exist. First, it reports findings from only one institution, which may or may not generalize to other schools with different curricula, admissions standards, and academic priorities. Relatedly, the participants in this study were self-selected, in that they opted to apply for the trip, suggesting some level of predisposed sensitivity to, and interest in, the subject matter. As with all qualitative approaches, data coding and conceptualization may be affected by the predispositions of the coders, though the effect of this is mitigated by appropriate reflexivity and transparently presenting the constituent codes and categories around which each theme crystallized, along with representative quotations.
Finally, this study reports on a program involving the time and financial commitment of our university and the medical school, which may not be easily replicable at other institutions. The program also requires a commitment from students who engage in both pre- and post-study trip activities in addition to rigorous medical school requirements, along with the week-long study trip in the summer, which may potentially pose conflicts with other educational opportunities. Interest in promoting Holocaust and medicine studies in medical education is, however, increasing as exemplified by the Lancet Commission on medicine, Nazism, and the HolocaustFootnote 23 as well as the AAMC annual webinars on this topicFootnote 24 for International Holocaust Remembrance Day. Moreover, even if there are significant barriers to creating a program as comprehensive as the one described here, the insights from our experiences may nonetheless be informative for development of any number of other kinds of place-based educational programs.
Conclusion
The transformative impact of the study trip provides evidence about the impact of Holocaust and medicine education in medical curricula and validates calls for greater inclusion of this content in all health professions education.Footnote 25 Integrating critical reflection on this history appears to deepen students’ appreciation of ethical dimensions of medicine and healthcare. Moreover, exposing students to the atrocities of the Holocaust as well as exemplars of moral courage can help foster a sense of responsibility, empathy, and moral commitment in the next generation of healthcare professionals. Dedicating time in the curriculum for delving into this history in the humanities helps to transition bioethics, medical humanism, and professional identity formation from the abstract and theoretical to a personally meaningful and potentially activating experience. These findings also suggest the potential value of reflective, place-based learning involving other histories and topics related to ethics and humanism that should be explored in future research.
The challenges of instituting robust and effective curricula in ethics and humanism are well documented, including insufficient time focused on these topics or adequately addressing ethical dilemmas that can create moral distress for students and residents.Footnote 26, Footnote 27 The OUWB Study Trip to Auschwitz highlights the potential for reflective, place-based education related to the history of the Holocaust and medicine to deepen understanding and personal connections to bioethics and medical humanism and promote reflective, ethically grounded professional identity formation.
Disclosures
Hedy S. Wald, PhD, is a commissioner of the Lancet Commission on medicine, Nazism, and the Holocaust. The views presented in this article do not necessarily represent the views of the other members of the Lancet Commission on medicine, Nazism, and the Holocaust, but rather of the authors only.
Competing interest
The authors declare none.
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