Comments on Inhumanity in the Name of Medicine: Old Cases and New Voices for Responsible Medical Ethics from Japan and China

- - Ole Doering, Ph.D.

Eubios Journal of Asian and International Bioethics 11 (2001), 44-47.
The renewed debate about unethical experiments in the name of medicine and nationalism during the wartime governments of Japan and Germany, as initiated by Takashi Tsuchiya (2000), should be greeted with enthusiasm! From a perspective of medical ethics and a genuine concern about the East Asian situation, it is even more encouraging to witness, how this issue is now stimulating scholars to speak up and call for a general debate, confronting the impact of a silenced past, for societies and future relationships in this region, and for medical ethics. Thanks to Eubios Ethics Institute and EJAIB for providing the necessary forum for such an overdue debate. First of all, thanks to the authors, especially Takashi Tsuchiya, Jingbao Nie and Masahiro Morioka, and others, who are well aware of the great task in front of them. The way is long, the mountains are high, and wanderings are plenty. A challenge for medical ethics, indeed! This paper intends to confirm sympathy with this engagement from a German perspective and to set a sign of solidarity. However, I shall not try to assess the domestic parts of the intricate problems. This is well in the hands of our prudent and courageous colleagues in Japan and China, and forthcoming debates.

Some views in light of the German experience

Whereas some aspects of these horrible crimes in the name of medicine are unique as committed by violent political systems, others reveal issues of continuous concern, on grounds of both, social history and medical ethics (1). Some of the mechanisms that helped many German criminal physicians escape legal punishment and go on with their careers after the war seem to have applied in other countries as well. On a deeper level, medicine itself may constitute a problem because it combines original medical purposes with a great power over people's lives and imaginations, and it is naturally on the edge to abuse by secondary interests of research, fame and gain. It is important to acknowledge that, in trying to learn from our past, many German physicians and even more social scientists, especially among the younger generations and after the 1970s, have done great work to show that there in fact are continuing threads combining Nazi medicine and our current medicine (2). Some problems have been solved, as a matter of fact, by time, while others prevail.

I am frequently asking myself, how shall we take precautions to the effect that similar crimes can never happen again, especially in the name of medicine. I believe that the answer should acknowledge the ways we use to think about our bodies and ourselves as well as the ways we organize our medical and health care systems. For countries that are beginning to change and re-organize these systems, facing these problems should be on top of the agenda, so as to avoid building potentially harmful flaws into the new system. One of the major structural reasons for the very possibility of these crimes to happen on a large, industrial-like scale as well as hidden in labs and hospitals, is that alliances have been formed, (either formal or informal), between politics and medical sciences/medical practice. The common rationale was public health and population control, two probably legitimate purposes, but likely to be abused as pretexts for bio-engineering, eugenics, euthanasia, enforced sterilization and "medical experiments", without the correcting role of a functioning public. Currently, since the beginning of the "biotechnological revolution", the impact of the structural dimensions is even more pressing, although it may appear less obvious. Alliances between medicine and economy are global, societies are brainwashed and manipulated to adopt the interests developed by bio-engineering, (sometimes even in the alleged name of autonomy); politics are trying to control and repair the damage. At the same time we support advancement in biosciences we frequently fail to comprehend on a social and long-term level. Genuine medical purposes are challenged by economic rationality, utility and bio-reduction of medicine. There is a host of literature about this field in international literature, much from Germany. It would be of good use for the discussions in Japan and China if some of this material could be translated and publicized in a systematic way. By learning from the history of humankind how gross inhumane medical conduct became reality we might infer how to prevent similar things to happen again.

Although the Allies punished more German criminals of war than their Japanese brothers, in fact, the Allies let a lot of "physicians" and other criminals of war from Germany go free, either they let them escape to South America, like Joseph Mengele, the "monster from Auschwitz", or even supported their further careers, as scientists, lawyers, judges, doctors, and so on. There seems to be a difference in degree. The real difference, however, is that Japan has continued to live with the taboos and the lie longer than Germany. We have learned that revealing and talking is very painful (3), and it does not clean up the mess instantly. But it allows us to honestly believe in the dignity of the fundaments of our society. It has been a constant puzzle to my own generation, how could those people clear their conscience of what they have done, and how can they stand it to look into the mirror, or, to speak to a patient or a child? This painful inquiry should never stop. (4)

From a philosophical standpoint, the dimension of language ought to be part of such an inquiry. There are many ways to use euphemistic language in order to de-humanize humans, including improper application of "objective" scientific terminology, such as "medspeak" (5), and we should better not proceed on such a basis ourselves. This is very important. We used to say that "das alltaegliche Grauen," the trivial horror of the real ways the crimes were performed as part of everyday routine, is vital in demystifying and explaining the "medical" experiments and other atrocities. We should better be aware that we are on the edge to unethical action all the time. Therein lies a very strong ethical imperative to continuously learn and care.

Secondary vs. Primary Virtues and Problems of "Asian Values"

Reading references to "Asian Values" in this context, as explanations for the Japanese doctors' crimes, makes me quite unhappy and uneasy, too. The issue of "German virtues", or the "Spirit of Prussia" as responsible for Nazi violence has been discussed at length in Germany since the later 1960s. We have, in Germany, had a bitter debate about "secondary virtues versus primary virtues"; it was argued that with the former it would be possible to lead a concentration camp etc.. Even our former chancellor, Helmut Schmidt, was accused of adhering to these secondary virtues in the 1980s, by Oskar Lafontaine (who in 1998 became minister of finances in the government of his own Social Democratic Party). The values in question here are hardly "Asian" in any reasonable sense. You can find an almost identical set of values in the ideology of German Prussia and in many other "well ordered superior states with a superior mission". To me, the case of Japan appears much more as a lesson in fascism and chauvinistic nationalism and its internal structures and mechanisms if they ally with advanced economic and scientific and technological powers of their time. Harmony and authority have the most crucial psychological and propagandistic functions in such a state. This is true in old Japan as well as in other authoritarian states. It is no surprise that countries like the People's Republic of China, Malaysia and Singapore have been among the most active proponents of secondary virtues as "Asian" or "Confucian" values. This is instrumental for political interests but flawed in terms of historical truth and ethics.

If medicine tends to reduce the human being to biomedical features, this may be fair as long as it serves the patient who is more than the sum of scientific data. If ethics sometimes tends to reduce cultures and norms to national or regional borderlines, this will hardly serve any good purpose but distort reality. If we look at Asia, with its cultural diversity and its political reson d'etat, in comparison with other regions, it ironically turns out that appealing to relativistic values is a universal political trick. The categories of the compass can not inform the categories of ethics. Medical ethics should respect this fact in the concepts and languages we use. All the diverse official traditions, invented or real, have much state interest as well as that of other powerful interest groups', but little ethical and social life tradition \ and they are far from grounding any ethical concept. If we use their framework we give up the free horizons of ethics.

This is also true, and maybe more obviously so, in the so-called "Western" part of relativists globes. As regards medical ethics, "the Western one" does not exist. Even inside Europe we have at least three very different bioethical traditions, namely the secular schools of consequential nominalism, the deontological essentialists and a beehive of Christian metaphysics. The current debates are very hot and it seems easier sometimes for a German to agree with a Chinese than with an Englishman. It is utterly impossible for Europeans in many cases to go along with US American bioethics. There are regular attempts to violently attack US or Australian bioethicists especially in Germany (ask Peter Singer, Helga Kuhse, or H. Tristram Engelhardt Jr. about their experiences!). The degree of inner-"Western" antagonism in bioethics is pretty high; if we ever achieve a European consensus on controversial issues of bioethics, it is doomed to be either extremely ambiguous or only representing minority positions. If we are using the terminology of East versus West, and the related conceptual framework, (which is in fact not a conceptual framework but a map of our Globe), we are going to continue to use exactly one of the schemes which have brought so much pain and confusion over humanity since the early 20th century! East and West, in terms of ethics, has not even the least substantial thing to tell us! It is nothing but a dead end in ethics, in both senses. The real lines of demarcation between ethical systems lie elsewhere. Their whereabouts are among the most fascinating topics of research. It sure has much to do with the ways ethical concepts are generated and discussed over the years or ages. I sincerely hope that with the help from the fresh discussion of inhumane "medicine" in Japan and China, (and I agree that Korea must be included as well as other countries in that region), we will find out much more about the connection of cultures and ethics. We are naturally not uniform moral entities, neither as individuals nor as communities, such as cultures and nations. Our diversity, however, can only be protected on the basis of some commonly agreed meta-principles that do not have anything to do with where we come from. If we appreciate the "right" differences between our moral persons and their expressions, we can reject the arbitrary differences, because they simply inhibit us from ethical improvement. This will help us to get rid of the esoteric war-prone babble of East and West.

Can "Tradition" be regarded as a moral or immoral subject?

As I have tried to point out, I agree with Jingbao Nie that moral traditions in Asia do not inevitably lead to Japanese doctors' factories of death. Of course, there is an influence of moral beliefs on good and bad conduct of societies. However, to use "tradition" as a subject that could "lead" to something is an utterly flawed assumption. What can lead to these things is the interpretation of tradition etc. by human beings as acting subjects, even if they may hide behind institutions or behind "the name of" something great. I straightforwardly deny that any tradition, (whatever exactly "tradition" means), can ever causally lead anyone to kill or torture another human being. This expression might be figuratively tolerable tentative language. However, given the many cases such a language has been and is still being abused for guiding cultural relativism and cultural essentialism, etc., ethicists may not be careless in this regard. If we accept freedom and responsibility as inalienable, we must identify personally, who has behaved wrong; these are always individuals in the first place. Only on the basis of individual accountability can collective guilt be assessed. Together with Nie, I believe that "Japanese doctors' human experiments are not only violating against Western morality, but against the common sense of humanity, and this includes that it is directed against Asian moral principles and ethical ideals."

In this light, cultural identity is important, but it is different from tradition. Tradition is a process of transformation of one situation of identity to another, sometimes allowing different identities to co-exist. Sometimes, the meaning of identity becomes entirely opaque. Ethically, it is most important now, in our times, to build up good medical and health care systems for Asian, Japanese, and Chinese people, wherever they live. The actual points of origin of the guiding concepts in such a system building process are matters of historical and sociological interest. In terms of medical ethics, they are not really significant.

Therefore I acknowledge with delight that Jingbao Nie has argued in another article that the way of depicting "the" Western morality as individualistic vs. "the" Eastern ethics as authoritarian or communitarian has seriously simplified and even distorted the reality and moral traditions in both the West and the East (6). This clarification can help us to settle global medical ethics on a solid conceptual starting point. It also helps us to understand the deep impact of Tsuchiya's paper much better, without associating morality and relativism.

Another myth should be discussed, namely the alleged character of an individual right as a Western value in a relativistic sense. In the first place, a positive individual right is not an ethical right but a socio-political right. As such, it has been introduced, shaped and phrased under special socio-economic and political conditions, in the name of the ethical imperative to respect the freedom of the other human and to forbid his abuse as a mere tool. It would be a simple confusion of categories and levels if one would claim that these applications and implementations of the ethical model are themselves a universal model again! This does not withstand that we are well advised to learn from the ways other societies have tried to implement this ethical imperative in their respective context, so as to learn from their failures and to profit from their achievements. Herein lies another fundamentally important distinction with systematic implications for the overall design of medical ethics. We might not need to refer to any particular given form of the individual right if we wish to condemn the mass murder of Japanese doctors. We may as well either refer to another related model, or assess the ethical principle directly.

Given the highly elaborated concepts of Confucian ethics, the Western moral traditions are not the only resources for us to draw from. If we, for instance, would be able to integrate the Confucian concept of Shu (moral reciprocity), into medical research and practice, we would thereby include a practical maxim, which helps us to contextualize the cardinal principle of Ren (humaneness). This would guide the individual agent morally and, at the same time, become a part of the foundations of global medical ethics, hence serving as an equivalent of the "Golden rule" in a different language, with different "stories" as connotations, enriching the ethical discourse. No physician who has been educated on the basis of Shu would be capable of abusing humans. Interestingly, Shu has not become very prominent in the so-called real Confucian tradition, although the Lunyu explicitly calls it "a single word, which, because of its nature, can be practised for all one's life" in realizing humaneness (7). Without an autonomous ethical act of approval, informed by Shu, or equivalent concepts, the meaning of inter-personal relationship, benevolence and righteousness would have to remain incomprehensible and unpractical. (The denial of a reason-guided personal approval has obviously resulted in making it easy for non-ethical interests with power to instrumentalize, e.g. the value of inter-personal relations). It is also impossible to blame Confucianism for ethically approving of the killing of people or the torturing of innocent human beings by moral obedience to their seniors, authorities or "scientific progress". We should better look for the moral obligations we have according to ethical tradition of mankind/humanity. This includes that the just aspects of Confucianism, Buddhism, Daoism, and others must be integrated into the conceptual language and the stories of medical ethics.


In conclusion

I would like to conclude by emphasizing that we must learn from history, keeping ourselves alert about the contingency of "humanity". But we must not reduce medical ethics to the historical dimensions. A practical suggestion is to organize related international conferences with Chinese and Japanese participants in Ravensbrueck and Dachau, two of the most notorious places of Nazi-medicine in Germany. It would be a perfect arrangement if we could organize an entire series of international meetings with participants from Asia, Europe and America in other significant places, such as Pinfang where Unit 731 was located and the "raped" Nanjing. And we should share in the solid work that has been done by historians and sociologists in this field to date, without receiving much public attention in East Asia.

The most important starting point for preventing these crimes from happening again, in one way or another and on a macro or a micro level, seems to be in our minds. Old ethical insights should be taught, respected and improved. And we could explore with much more effort than in the past, why it is so difficult to live according to these simple and plain lessons. A key to all of this might be an open and well-informed public debate, and in particular a responsible medical ethics discourse that stimulates and appreciates the contributions from China and Japan.


It is my pleasure to acknowledge the substantial support by Dr. Jingbao Nie who encouraged me to write this paper.


1) E.g. Stefan K_hl (Kuehl), The Nazi Connection. Eugenics, American Racism, and German National Socialism, New York/Oxford 1994; Cf. Heide Berndt, "'Wertfreie' Sozialmedizin? Hans Schaefers Einflu_ auf die akademische Sozialmedizin nach dem II. Weltkrieg, in Naturwissenschaften und Eugenik (Sozialhygiene und Public Health Bd.1), by H. Kaupen-Haas and Chr. Rothmaler (ed.), Frankfurt/M, 1994: 83-111. Also cf. Moral, Biomedizin und Bevoelkerungskontrolle (Sozialhygiene und Public Health Bd. 5), by H. Kaupen-Haas and Chr. Rothmaler (ed.), Frankfurt/M, 1997.

2) The most comprehensive study about the history of eugenics in Germany, with a special focus on wartime crimes, is Rasse, Blut und Gene. Geschichte der Eugenik und Rassenhygiene in Deutschland (Race, Blood and Genes), by Peter Weingart, J_rgen Kroll and Kurt Bayertz, Frankfurt/M. 1988, especially: 562-622. See also Ludger Wess (ed.), Die Tr_ume der Genetik. Gentechnische Utopien vom sozialen Fortschritt (Genetics' Dreams); Frankfurt/M., 2nd edition 1998.

3) A classic in this regard is Hans Jonas, Das Prinzip Verantwortung. Versuch einer Ethik fuer die technologische Zivilisation, Frankfurt/M., 1979. See also Wolfgang van den Daele, Mensch nach Mass, Munich 1985. Glenn McGee, in his edition of Pragmatic Bioethics, (Vanderbilt UP, Nashville 1999) has collected a number of essays introducing this dimension of medicine to the English speaking world in an unbiased manner, (though with little reference to German sources). E.g. cf. Herman J. Saatkamp, Jr., "Genetics and Pragmatism", in McGee: 152-167. I fully agree with Jingbao' Nie s remark in personal communication, saying, "It seems that the real danger is not the technologies themselves, but those who control them, such as the international companies, pharmacy industries, etc. Since the late nineteenth century, medicine has (...become...) a power system, an industry, an ideology, no long simple and innocent."

4) The first book that brought this issue to the attention of a greater public was Medizin ohne Menschlichkeit (Medicine without humanity. Documents of the Nuremberg Trial against physicians), edited and commented by Alexander Mitscherlich and Fred Mielke, Frankfurt/M. 1960. An earlier version of this report had been distributed exclusively among members of the Chambers of Physicians of Western Germany, in 1948. See also Arthur L. Caplan, When Medicine Went Mad: Bioethics and the Holocaust; Totowa 1992.

5) Cf. William E Seidelman, "'Medspeak' for Murder: The Nazi Experience and the Culture of Medicine"; in: Caplan, a.a.o.: 271-279. The suggestive power of language is obvious in the distinction between human experiments and experimentations. The meaning is slightly different, but has huge ethical impact: experiments are more neutral, there can be a good way of making them; experimentations, however, indicate an attitude of a powerful researcher who treats a powerless specimen as a mere object of his curiosity, without any human relation. This attitude must be rejected in any ethical language, particularly in the language of medical ethics.

6) Nie, JB. "The Plurality of Chinese and American Medical Moralities: Toward an Interpretative Cross-Cultural Bioethics", Kennedy Institute of Ethics Journal 10: 239-260, 2000.

7) Lunyu 15.24. Cf. Heiner Roetz, Confucian Ethics of the Axial Age, New York, 1993: 133-148.

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