The surgeon needed to call a time-out. She had already cut into the patient’s knee for what she thought would be a technically challenging but straightforward operation: freeing a nerve that had gotten so badly pinched after several knee replacements that it was causing unbearable pain. If the surgery didn’t work, the 50-year-old patient told Dr. Susan Mackinnon of Washington University in St. Louis, she wanted her leg amputated.

But now Mackinnon, one of the country’s most renowned nerve surgeons, was stumped. She couldn’t trace the saphenous nerve and its branches. To figure out where the nerve wends its way between and around and under muscle and connective tissue and free it, she needed to consult the best anatomical maps of peripheral nerves ever created. So she asked her colleague, Andrew Yee, to dash into her office, grab the Pernkopf Topographic Anatomy of Man, photograph the right illustration with his iPhone, and email it to her in the OR.

Yee did. Mackinnon projected the image on a screen, figured out where the nerve was, and successfully completed the surgery.

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But soon after this 2014 operation, she began worrying whether she had done the right thing. The meticulous, four-color paintings in the Pernkopf book, which she had received as a gift upon graduating from medical school in 1982, were created by Viennese medical illustrators who were such ardent Nazis they included swastikas and lightning-bolt SS symbols in their signatures. The drawings were compiled by an Austrian medical school dean who fired all his Jewish professors after the Anschluss (Nazi Germany’s annexation of Austria in 1938), and were based in part on the bodies of people executed by the Nazis. The first of the two volumes was published in 1937, the second in 1941.

Knowing the book’s history, which came to light in the mid-1980s, Mackinnon and Yee wondered, is it ethical to use the Pernkopf illustrations? They reached out to some of the nation’s leading historians of Nazi medicine, bioethicists, and experts on Jewish law to discuss whether Mackinnon acted ethically, as they describe in the May issue of the journal Surgery.

Anatomy text comparison
Anatomic illustrations from Netter’s Atlas of Human Anatomy (left) and Pernkopf’s Topographical Anatomy of Man — which is more detailed and precise. Screen capture from SURGERY May 2019

The book’s horrific provenance “has been known for a while,” said Yee, who films Mackinnon’s surgeries and founded an online program so others can learn expert techniques. “The publisher stopped reprinting it in 1994,” soon after the University of Vienna (where Nazi Eduard Pernkopf became rector in 1943) traced many of its images to people executed by the Nazis. Investigators were unable to identify the specific people used by Pernkopf’s artists, however, or even determine how he procured most of the bodies. But the investigators found no evidence that any came from concentration camps, and concluded that many were people executed in the city for resistance to the Nazis.

The moral dilemma for surgeons is that, even now, the Pernkopf illustrations are unsurpassed in their accuracy and detail, especially their depiction of peripheral nerves. “I hate to say it, but the illustrations are beyond spectacular,” said bioethicist and Rabbi Joseph Polak of Boston University, whom the Washington University team consulted. “They are really world-class.”

Other anatomy atlases pale by comparison, Yee said, and although a few journal papers may have an equally good, single illustration, finding the right paper takes time that Mackinnon did not have as she stood over her patient. The surgical team had no doubts at the time that they were doing the right thing, but after a visiting scholar gave a talk about the Pernkopf atlas, she and Yee “wanted counsel from respected experts” on the proper way to use it in both education and clinical practice, he recalled.

Scholars and physicians have long debated the use of Nazi medical data, in particular from experiments on hypothermia and phosgene gas (data collected by exposing Jewish prisoners to freezing and poisoning). The U.S. military even redesigned Army flak jackets based on Nazi data so downed airmen had a better chance of surviving the cold, said Dr. Michael Grodin of Boston University School of Public Health, an expert on Nazi medicine and co-author of the Surgery paper.

Much of those data are considered scientifically unreliable (“they’re not worth anything,” Grodin said) and therefore easier to reject 75 years after the Holocaust. Not so with the Pernkopf. Even in 2019, it is considered unsurpassed in comprehensiveness and precision, said Dr. Sabine Hildebrandt, an anatomy lecturer at Harvard Medical School whom the Washington University surgeons also consulted. In part, that’s because anatomy is viewed as 19th-century medicine, and no one has an incentive to put much effort into trying to improve on the classic texts.

Hildebrandt does not use the book in her anatomy lectures, she said, and asks that colleagues who do explain its horrific origins and acknowledge the sacrifice and suffering of the people whose bodies it is based on.

But that didn’t provide much guidance to Mackinnon. When she posed the dilemma to Grodin and Polak, they produced what has become a definitive work on when it is morally acceptable to use the Pernkopf and other knowledge rooted in Nazi medicine. “It relates to the old question, can you derive good from evil?” Grodin said.

The highest value in Jewish law is life. If the illustrations in Pernkopf can save a life or alleviate suffering, Grodin said, “most rabbis would not just permit using it but say it was mandatory” — as long as physicians and educators remember its origins and pay respect to those who were killed to create it. “Every time someone uses one of these pictures, they need to say where it came from,” said Polak, who survived the Bergen-Belsen concentration camp as a child.

Scholars not involved in Mackinnon’s case agree. “Not every utilization of Nazi-generated data or information is morally out of bounds,” bioethicist Arthur Caplan of New York University wrote in a commentary on the Surgery paper. “This case makes clear that at least a narrow use of tertiary information — paintings of bodies — is morally defensible. If direct, immediate, and substantial patient benefit is being sought from the use of existing information, and if there is no better resource available, then the demands of beneficence create a presumption of use.”

That does not settle the debate over the Pernkopf atlas, however. After a series of corporate takeovers, the plates now belong to scientific publisher Elsevier. When Hildebrandt visited its Munich headquarters in March, and was shown many of the originals, she asked the company to let the Medical University of Vienna display them as part of an exhibition on the Nazi horrors and their lasting influence in medicine. Elsevier is still considering that request, but “lawyers are involved,” Polak said. Elsevier spokesman Tom Reller told STAT, however, that “we’ve decided the pictures should not be published further or lent or donated.”

As for Mackinnon’s patient, she recovered fully and was pain-free for the first time in years. During the usual preoperative discussions about the risks of surgery, Mackinnon didn’t think to ask how the patient would feel if her surgeons consulted a work of Nazi medicine to help them, nor did the surgeon tell the patient afterward that she had consulted Pernkopf. The outside scholars weren’t asked whether it is morally imperative to do so.

“We never thought about it,” said Grodin, who has studied survivors of Dr. Josef Mengele’s experiments at Auschwitz. But informing patients, he said, is a logical next step as scholars continue to grapple with the Nazis’ medical legacy.

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  • I find this example and questions insulting. My parents were both concentration camp survivors. Shocking that nobody mentioned the the Nurnberg code (not the trials but the code): https://en.wikipedia.org/wiki/Nuremberg_Code
    Nothing good can come out of something evil. Ethics is the moral principles that govern a person’s behavior or the conducting of an activity, to tell right from wrong. It is unethical to use data and information from unethical experiments.

  • Dr.Suzan McKinnon did a marvellous job ,relieving sufferings of a human beings.We as a physician learn many things from others experiences and writings. If humanity benefits from this knowledge ,we have fulfilled our mission.

    • My response:
      Those who feel it’s OK to torture and/or kill people provided that “humanity benefits from the knowledge”; who feel that their “mission has been fulfilled” “if humanity will benefit”, ought to have no problem volunteering to be subjects in those types of studies. With all due respect, I can’t imagine anything more hypocritical than to volunteer “Jews or other sub-humans” as subjects to be tortured, exposed to lethal doses of radiation, hypothermia, etc., so “we as physicians” can “learn many things” and from which, ultimately “humanity will benefit”. I don’t know where you grew up, but my moral code simply does not justify or condone the malevolent treatment of humans, (or even of animals,) because humanity “benefits”. Almost every culture contains some version of “the Golden rule”; treat others as you would want to be treated”. If you’re not volunteering yourself and your family as subjects then don’t “volunteer” any humans as subjects. Using “data” tainted by “the height of immorality” condones and justifies future collections of data using these same methods. We ought to be sending a message to any future “scientists” that humans don’t consider this “research” and that “research” will never see the light of day.

  • @Mitchell let me start off by saying I am thankful that you were able and willing to share with us the contents and personal connection with this story through your family’s history with Aushwitz. It is never easy to talk about the horrors, and yet it is necessary to continue to do so lest we forget what humans are capable of. In my case, generations of my family were wiped out by a country that still today denies that a genocide even happened. I understand your frustration and pain.

    One thing that we all should keep in mind is the spectrum of what we each feel is ok. Personal beliefs are powerful and can stray us one way or the other depending on our emotions. Some may find the historical accounts of digging up dead bodies for anatomical study against the will of the deceased or their family as egregious, and yet we celebrate these anatomists today. Clearly, experiments on the living are far worse. That was simply an example to showcase that our profession has a long history of doing things in the pursuit of “knowledge”, and we each land on different locations within the spectrum of what constitutes acceptable behavior in this pursuit.

    It’s easy to limit our view to only German atrocities, but we should keep in mind if the way we practice today is related to other such atrocities throughout human history. To be sure, we have been doing experiments on our fellow man for thousands of years. We Americans have also been found guilty of testing unwilling and unsuspecting individuals in the name of science (cough, cough- American doctors infecting fellow Americans with syphilis).

    To add a little depth to the conversation, we can expand the information to include non-human experiments.

    Let us not forget that towards the end of the war, Americans and Russians raced to reach German doctors and scientists first for this “tainted information” the Germans had been producing. One instance is Wernher Von Braun, architect of the V2 rocket. He held the rank of Major in the famed SS branch, earning numerous accolades. He joined the SS in 1933, well before the war atrocities occurred, but well after he understood what the group stood for. Per a BBC documentary, the V2 rocket that he helped design resulted in the deaths of an estimated 9,000 civilians/military, and a further 12,000 forced laborers and concentration camp prisoners due forced participation in the production of the rockets.

    You would imagine that someone like this might have had their life ended by hanging in the Nuremberg trials. Wrong. Wernher was secretly flown to the USA where he lived comfortably and helped our fledgling space program (NASA) reach the goal of manned space flight. He even earned the USA’s National Medical of Science. He died of natural causes and is buried in Alexandria, Virginia. Similar internal conflicts can be produced if one reads about the historical involvement of Mercedes-Benz and BMW. There are countless ways America has benefited from war crimes that should cause goosebumps. Do we toss this valuable knowledge away, or is there a responsible way of using it?

    As angry as I get knowing that people can do bad things and walk away unscathed, I find solace in the idea that society is better off because of the contributions from those who suffered. In my opinion, the real insult to those who gave their lives unwillingly would be to prevent this information from being used in order to stave of someone else’s demise. We do not celebrate the monsters of these situations, only the victims.

    If I knew it was my relative who suffered these experiments, I would be saddened to think that it was all for nothing if the information doesn’t help future sufferers. But this is my opinion on the spectrum of beliefs. No one is right, and no one is wrong.

    Lastly, I’m pretty sure this surgeon knows her anatomy and doesn’t need to refer to texts intraoperatively on routine cases. This patient had multiple surgeries leading up to this surgery. Typically, people are referred up the chain of expertise as things become more complex. It’s hard to say where you fall in the echelon of care, but those at the top don’t get there by allowing their hubris to stand in the way of opening a book when the going gets tough. You can prepare all you want, but if new clues during surgery require you to seek information, then that’s what you do.

    Great article and great discussion!

    • Wow – there’s a lot there. I was aware of the Tuskegee study, a blatantly racist and immoral act that proved nothing and provided no new information. The Oslo Study, performed half a century earlier, when no treatment for syphilis was available, (and hence “no treatment” was not immoral at that time,) already provided the same information as Tuskegee. This is a horrible blot on American medical research however it does not compare in magnitude to the torture and killing of innocent people “just to see what happens”. The Nazi atrocities are without parallel in terms of the magnitude of the horrors they perpetrated.
      The melodrama of suggesting that not a single anatomy book, since the time of Hippocrates, could describe the course of the saphenous nerve; and that only an eleventh hour reference to this one text, while the patient was on the table in the OR, might save a person’s life (or save her from a lifetime of pain,) is simply not credible. It reminds me of the “trolley problems” presented to first-year law students with the purpose of “proving to them” that there is no such thing as “right” or “wrong”. Well, there is such a thing as “right and wrong” and it may be difficult to provide a better example than the one presented in this article.
      The surgeon ought to prepare herself for surgery before going to the OR – not when the patient is on the table. The anatomy of the nerves of the leg have been illustrated in medical texts for millenia without the need to refer to “Nazi data” or Nazi methods.
      To dramatize a “worst-case scenario”, in which “nothing except Nazi ‘research’ can save a life”, is what the Nazis, the people who relished the opportunity to torture and humiliate humans before they put them to death, would like you to believe. That all they were doing was “trying to make the world better”. Well, what they did wasn’t research as we understand it but torture masquerading under the name “research”. Let’s send a message to anyone who wants to emulate those monsters that civilized society does not accept their methods as “research”. No one will publish their papers. No one will read their papers. Any other approach gives these monsters “hope” that “someday” they will be recognized as “scientists” instead of as the monsters they are.
      P.S. Using the results of Nazi experiments does not “honor the victims”. To suggest that the victime were tortured, humiliated and killed “to serve a higher cause”; that “lives can now be saved” as a result of what they went through; does not “honor” the victims. It simply adds insult to injury.

  • This is a thoughtful and thought-provoking analysis. Dr. McKinnon demonstrates why she is so respected both as a surgeon and a human being. The best way we can honor the tragedy that was so heavily borne by so many individuals and their families is to always remember and respectfully acknowledge their pain and sacrifice and never allow that misfortune to visit any individual ever again.
    VP

  • @MITCHELL Sir or madam, could it be possible that you have living family members? Spouse? Children? Parents? Whoever they might be, get the idea that they are all going to die unless a certain medical procedure is performed, and that procedure requires employing some knowledge gained from the dreaded and despised Nazi experiments. There is no other known data or technology that will help. Your children, your spouse, your entire family is going to die, unless you open that book and employ that tainted data. And of course, you are going to tell your family members, your children, that they are all going to die and although you could save them, you have refused to use that tainted knowledge so they must simply die. Of course they will instantly agree, curl up into foetal positions, and promptly pass away while you watch, confident and pleased that you’ve done the right thing. Oh please, really, Mitchell, grow up!

    • The depiction that “Nazi data is the ONLY way to save a life” is melodrama to the extreme. Most “Nazi data” has been tossed because it is not usable; for scientific reasons, not moral ones. So which “Nazi data” will be elevated to “usable”; which Nazi tortures justified “to obtain helpful information”? I say toss the whole lot.
      Now add to the melodrama that “the patient’s on the table in the OR”. I perform surgery on patients. And I don’t wait until the patient’s on the table to start thinking about how I’m going to do my case. Is that what Cooley and DeBakey did? Call for an anatomy book when they get to the OR because they can’t remember the anatomy of the coronary arteries?
      I hope that other surgeons will reply with stories about how they couldn’t remember “the anatomy” and called for a textbook while the patient was on the table. I don’t even think that happens in the movies; much less so in real life.
      I’d love to hear from other doctors, doctors who actually saved patients’ lives, about how many times “only Nazi data saved their patients” because peer-reviewed studies, performed by “real scientists”, just couldn’t provide useful information.
      You can keep your “grow up” comment. It’s offensive.

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