Medicine has always demanded trust: the willingness to be vulnerable in front of a stranger who has sworn to act only in your interest. Under Europe's twentieth-century totalitarian regimes, that promise was tested, and in many cases, broken. This essay examines how a profession built on individual care came to serve the state, and what it took for some physicians to refuse.
Whose patient?
Few professions occupy a place of greater trust than medicine. The physician enters moments of human vulnerability, suffering and dependence. The relationship between doctor and patient rests upon a seemingly simple premise: that medical knowledge is exercised in the service of the individual who seeks care. This premise proved fragile.
Across Europe's totalitarian regimes, medicine became entangled with projects that extended far beyond the treatment of illness. Doctors participated in programmes of racial purification, compulsory sterilisation, human experimentation and political repression. In some cases, they abandoned their patients in the name of the state. The historical record of such crimes is well documented. The more unsettling question is how a fundamental ethical principle became negotiable: to whom does a physician ultimately owe loyalty, the patient standing before them, or the political order in whose name they are asked to act?
Physicians do not operate in isolation. They are educated by states, regulated by institutions, funded by public systems and embedded within broader political cultures. Medicine therefore occupies a complex position: it serves individual patients, but it also serves communities; it protects personal health, yet it is equally concerned with public health. For much of modern history, these obligations appeared complementary. The emergence of public health systems in the nineteenth century, advances in epidemiology and the expansion of preventive medicine reinforced the conviction that individual and collective interests could be reconciled.
The twentieth century exposed the fragility of that assumption. Medicine did not become entangled with totalitarian projects despite its commitment to science and rationality. In many cases, it was precisely through scientific language and medical reasoning that such projects acquired legitimacy. The ethical transformation that made atrocities possible developed directly out of medicine's scientific aspirations, rather than representing a departure from them.
Thinking in populations
The intellectual ground for medicine's reorientation was prepared not by totalitarian ideologues, but by physicians and public health advocates working entirely within legitimate scientific discourse.
Throughout the late nineteenth and early twentieth centuries, medicine expanded its field of vision beyond the individual body. Advances in bacteriology, epidemiology and public health encouraged physicians to think not only about individual patients but about populations. Disease could be studied statistically. Health could be measured collectively. Prevention became as important as treatment. These developments were genuine medical advances, and they also created new intellectual possibilities.
The central question was simple: if medicine could improve the health of society, what should be done about those perceived to weaken it? Across Europe and North America, eugenics emerged as one influential answer. Often presented as a progressive, scientifically grounded movement, eugenics sought to apply biological knowledge to the improvement of human populations.
Eugenics circulated widely, attracting physicians, social reformers, academics and politicians who believed that science could reduce suffering and improve the human condition. If disease could be prevented, proponents asked, why should hereditary disease be treated differently? The same logic that justified eradicating epidemics seemed, to many contemporaries, to justify reducing the transmission of inherited disabilities as well.
Among the most influential figures in the German-speaking world was the physician Alfred Ploetz, who in 1895 introduced the concept of Rassenhygiene, racial hygiene. Borrowing the language and prestige of modern hygiene, Ploetz proposed that hereditary characteristics could be managed and improved much as public health authorities sought to control infectious disease. The metaphor gained influence precisely because it was embedded in legitimate scientific discourse.
Once medicine relocated its primary concern to the population, a different logic took hold. Statistical averages began to outweigh personal circumstances; biological categories began to outweigh individual biographies. The question was no longer simply how to help a particular patient, but how to optimise the health of the collective. Some lives came to appear worthy of investment and protection; others, gradually, came to be regarded as burdens. The patient ceased to be an end in themselves and became, instead, a variable in a calculus concerned with the biological future of the nation.
What disappeared in this process was medical compassion's object, not compassion itself. Compassion was redirected from the person in front of the physician to an abstraction standing behind them. Society became the patient. The nation became the patient.
Aktion T4
If eugenics marked the moment medicine began to think in populations, Aktion T4 marked the moment that shift acquired institutional form: state policy embedded directly in medical practice.
The conceptual groundwork was laid well before the Nazi state came to power. In 1920, the jurist Karl Binding and the psychiatrist Alfred Hoche published Die Freigabe der Vernichtung lebensunwerten Lebens (Permitting the Destruction of Life Unworthy of Life), a text that remains among the most influential and controversial in the history of modern medical ethics. Binding and Hoche argued that individuals with profound intellectual disabilities or severe psychiatric illness could be regarded as existing outside the sphere of meaningful social value. Their proposal drew on the language of rationality, utility and compassion rather than open hostility. Human value was now assessed from the perspective of the community observing a life, rather than the life being lived.
After 1933, these ideas acquired unprecedented political force. The National Socialist regime built on existing eugenic thought, integrating it into state institutions with a consistency and radicalism unmatched elsewhere. Public campaigns, educational materials, medical journals and propaganda films portrayed people with disabilities as burdens upon the national body. Intellectual argument was systematically translated into administrative structure and public consciousness.
Hitler's secret authorisation of October 1939, backdated to coincide with the outbreak of war, functioned less as a rupture than as a logical culmination of these developments. It empowered designated physicians to grant what was euphemistically called a Gnadentod, a "merciful death," to patients deemed incurably ill. The terminology itself reveals the transformation at work: killing reframed as treatment, death reframed as a therapeutic intervention.
The mechanism by which this became possible in practice deserves particular attention. Thousands of questionnaires were sent to psychiatric hospitals and care institutions across the Reich. Patients were reduced to diagnoses, files, coded categories. The physicians deciding their fate frequently never saw them in person; expert panels reviewed paperwork, marking forms with coloured symbols denoting life or death. The encounter between doctor and patient, the ethical foundation of medicine since antiquity, was replaced by administrative evaluation carried out at a distance.
There were forms to complete, committees to convene, procedures to follow, reports to file. As Zygmunt Bauman later argued, some of the most radical violence of the twentieth century became possible through the efficiency of rational organisation, not its collapse.
During the programme's official phase, an estimated 70,000 patients were murdered at six killing centres, among them Grafeneck, Hadamar and Hartheim.¹ Later, decentralised phases extended the toll considerably: historians estimate that between 200,000 and 300,000 people with disabilities and psychiatric illness ultimately died as a result of Nazi euthanasia policy.
The historical significance of Aktion T4 extends beyond these numbers. It formed a bridge between eugenic theory and genocide: its killing techniques, administrative procedures and even personnel would later reappear in the extermination camps of occupied Poland. More fundamentally, T4 demonstrated that medicine could become an instrument of exclusion without ever abandoning the language of care. In its place stood an abstraction: the biological future of the nation.
The camp as laboratory
The transformation that began with Aktion T4 found its fullest expression in the concentration camp, where scientific inquiry, administrative authority and ideological objective converged in ways that removed almost every ethical constraint traditionally governing medical practice.
The history of Nazi medical experimentation is usually told as a catalogue of atrocities: high-altitude experiments at Dachau, sterilisation procedures at Auschwitz, studies of twins, infectious disease, hypothermia, chemical agents. Cataloguing cruelty, however, misses a more fundamental question: how the concentration camp came to be recognised, by physicians and research institutions alike, as a legitimate space for scientific inquiry in the first place.
The answer lies in what the camps uniquely offered: absolute administrative control, unrestricted access to captive populations, the suspension of legal protection, and the ability to organise human beings into categories defined entirely by the state. From the SS administration's perspective, prisoners were a population that could be observed, classified, transferred and used with a freedom unavailable anywhere else.
Those who conducted camp research did not see themselves as stepping outside medicine. Many remained connected to universities, research centres, military medical services and professional organisations. Their work responded to questions considered legitimate within contemporary medical discourse: the physiological effects of extreme altitude, the human response to hypothermia, methods of combating infectious disease. The camp did not require doctors to abandon science. It required them to stop asking whom that science was for.
Once medicine took responsibility for the biological future of the national community, the individual patient's moral claim on the physician weakened. A prisoner's status as a source of biological data or a representative of a racial category increasingly outweighed their status as a person in need of care. The collapse of medical ethics in the camps was not a collapse of scientific rigour: observations were recorded systematically, results analysed, reports written to contemporary standards. What changed was the ethical frame around that rigour. Human beings were no longer owed anything simply for being human, and their welfare no longer imposed an automatic obligation on the physician observing them.
The camp system was the logical endpoint of a process that had begun long before the first prisoner arrived at Auschwitz or Dachau. Once the patient stopped being the unquestioned centre of medical concern, the line between treatment, selection and experimentation became progressively easier to erase.
Beyond Nazi Germany
The ethical transformation of medicine under Nazism had parallels elsewhere. Nazi Germany developed an unparalleled system of racial medicine, culminating in organised murder and human experimentation, but other totalitarian regimes subordinated medical expertise to political ends through different means.
The Soviet Union offers an instructive comparison. Soviet medical policy was not organised around racial hygiene or biological engineering; there was no equivalent search for hereditary threats to a national body. Instead, Soviet authorities increasingly used medicine, psychiatry above all, as an instrument of political control.
Under the Moscow School of Psychiatry, led by Andrei Snezhnevsky, a diagnostic category known as vyalotekushchaya shizofreniya ("sluggish schizophrenia") made it possible to reinterpret political nonconformity as a symptom.² Individuals who criticised the Soviet system openly could be diagnosed with a disorder characterised by outwardly normal behaviour combined with supposedly pathological "reformist delusions": an exaggerated, clinically suspect commitment to justice and truth. Once political disagreement had been translated into medical terminology, involuntary hospitalisation could be presented as treatment rather than punishment.
The differences between the two systems matter and should not be flattened. Nazi medicine pursued an explicitly biological project: racial purification, hereditary selection, the construction of a supposedly healthy national organism. Soviet medicine was concerned with political orthodoxy rather than ancestry. It sought to redefine dissent as pathology, not to eliminate the biologically "undesirable."
A common mechanism nonetheless underlies both cases. In each, medical expertise gained its power to harm by placing scientific language in the service of political authority, rather than by abandoning that language. Diagnosis became a means of classification. Treatment became a means of exclusion. Professional expertise stopped functioning primarily as a safeguard for the individual patient, and began serving objectives defined far outside the clinical encounter.
The twentieth century demonstrated, more than once, that medicine becomes vulnerable whenever physicians are encouraged to see themselves as guardians of a political or ideological project before they see themselves as guardians of the individual patient. The forms of coercion differ. The underlying structure does not.
The ethical choice
The history of medicine under totalitarian regimes need not be told as a history of inevitability. Even within systems designed to subordinate medicine to ideology, individual physicians made consequential ethical choices, demonstrating that the outcome was never structurally guaranteed.
Deprived of medicines, equipment, legal protection and institutional autonomy, many nonetheless refused to abandon the principles that had traditionally defined their profession. What united them was a shared understanding of medicine as a relationship grounded in responsibility toward another human being, rather than political affiliation, nationality or place of work. Where totalitarian systems encouraged doctors to classify people by biological, political or economic value, these physicians chose instead to keep the patient as medicine's central moral subject.
Resistance, in this context, rarely resembled conventional political opposition. More often it took the form of a simple, repeated refusal to stop practising medicine on its own terms: concealing patients from persecution, falsifying records to prevent deportation, obtaining medicines through clandestine networks, running improvised hospitals under conditions that made functioning hospitals nearly impossible.
In the Warsaw Ghetto, physicians such as Ludwik Hirszfeld documented the medical consequences of starvation while simultaneously organising education, clinical care and public health initiatives under catastrophic conditions. Similar acts of professional resistance emerged in underground medical services, clandestine hospitals and the concentration camps themselves, where doctors and nurses repeatedly risked their own lives to protect the people in their care.
Among them was Dr Stefania Perzanowska, who organised and led the prisoners' hospital at Majdanek. In early 1943, as typhus swept through the camp, she persuaded the SS that the epidemic endangered guards as much as prisoners, and won permission to open a women's infirmary that the camp's own logic should not have allowed to exist. Working with almost no medicines, equipment or sanitary facilities, she treated it as a hospital to be run rather than a concession to be managed, insisting on that word even as the camp's administrative language offered her a narrower one: Revier. The distinction went beyond terminology. By continuing to call the sick "patients" rather than "inmates," and by wearing, without complaint, the same armband that identified her only as camp staff, Perzanowska held onto the one thing the system most wanted to take from her: the idea that every person in her care remained worth treating, regardless of what the regime had decided about their worth.
The significance of these examples lies less in individual moral heroism, though courage they certainly required, than in what they reveal about medicine itself: its ethical character does not depend solely on scientific knowledge, technology or institutional structure. These shape what medicine can do, but they cannot, by themselves, determine what medicine is for. Medicine remains an ethical profession because it asks physicians to recognise another person's vulnerability and respond to it with care. Wherever that recognition survives, medicine retains its integrity, even where healing has become almost impossible.
That such physicians existed also carries a less comfortable implication: medical collaboration with totalitarianism was not inevitable. It was chosen, by individual practitioners, by institutions, by professional cultures. This makes the history of collaboration more troubling, not less. It cannot be explained away as the mere product of coercion or institutional pressure.
The patient remains the question
Throughout this essay, medicine has appeared as a moral practice rather than simply a scientific discipline, one that keeps returning to a single, basic question: who is the patient?
At first glance, the answer seems self-evident: a patient is the individual seeking care. The history of the twentieth century, however, shows how far that definition can be stretched, and eventually broken. Once medicine places the interests of the state, the nation or an ideological project above the person standing in front of the physician, the patient gradually disappears from the ethical centre of medical practice, not all at once, but one small administrative step at a time.
The lesson of this history is not simply that medicine can be abused by totalitarian regimes. The more significant lesson is that medicine is never ethically neutral to begin with. Scientific knowledge, professional expertise and technological innovation cannot, on their own, determine what medicine ought to serve. Every practitioner, every institution, every generation has to answer the question again: who deserves care, whose suffering is recognised, and what does medicine owe to the person in front of it?
These are not only historical questions. Contemporary medicine faces dilemmas that look very different from the ones examined here, yet they still require decisions about vulnerability, responsibility and the value of individual lives. The technologies have changed. The question has not.
The history of medicine under totalitarianism is therefore not simply an archive of twentieth-century crimes. It is a standing challenge to medical practice itself: a test of whether physicians will define themselves first as instruments of the state, or as guardians of the vulnerable. That choice is made daily, not once, and it depends less on institutional structure than on the moral commitments of the practitioners living inside it.
This history cannot be reduced either to the crimes of the physicians who complied or to the heroism of those who resisted. It is, instead, a history of two competing visions of medicine. One treated medicine as an instrument of the state, capable of classifying, excluding and managing populations in pursuit of political goals. The other insisted that medicine begins with the encounter between physician and patient, and draws its legitimacy from an unwavering commitment to the dignity of the person in front of it.
Perhaps that is the most enduring legacy of the twentieth century. The future of medicine will be shaped not only by the knowledge it acquires or the technologies it develops, but by the answer it keeps giving to the question this essay opened with.
Who is the patient?
Notes:
- Estimates of victims at the six main killing centres vary somewhat between historians (see Friedlander, 1995; Burleigh, 1994); the figure given here follows the range most widely cited in standard historiography.
- On the diagnostic category and its political use, see Bloch & Reddaway, Russia's Political Hospitals (1977), on which the discussion of Snezhnevsky's school in this section draws.
References:
- Bauman, Z. Modernity and the Holocaust. Cornell University Press, 1989.
- Bloch, S., & Reddaway, P. Russia's Political Hospitals. Gollancz, 1977.
- Binding, K., & Hoche, A. Die Freigabe der Vernichtung lebensunwerten Lebens [Permitting the Destruction of Life Unworthy of Life]. Meiner Verlag, 1920.
- Burleigh, M. Death and Deliverance: 'Euthanasia' in Germany 1900–1945. Cambridge University Press, 1994.
- Friedlander, H. The Origins of Nazi Genocide: From Euthanasia to the Final Solution. University of North Carolina Press, 1995.
- Lifton, R. J. The Nazi Doctors: Medical Killing and the Psychology of Genocide. Basic Books, 1986.
- Ploetz, A. Grundlinien einer Rassenhygiene [Outline of Racial Hygiene]. Grundmann, 1895.
- Proctor, R. N. Racial Hygiene: Medicine Under the Nazis. Harvard University Press, 1988.
- Weindling, P. Health, Race and German Politics Between National Unification and Nazism, 1870–1945. Cambridge University Press, 1989.