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.

  • The abuse has already occurred yrs ago. Whether the info is used or buried does not alleviate the unjust suffering which occurred in that era. Better to put the information to good use as a final 🖕to those whose judgement was so impaired by their ideology. The crowning blow would occur if the beneficiary were Jewish. Rest easy Dr MacKinnon

    • Dr. Brewer – Wondering how you might address “Nazi data” with respect to “reproducibility”. Or are you prepared to accept “the information” and “put it to good use” without relying on this commonly accepted sine qua non used to validate the conclusions of “research” (see citation below). If the data can neither be validated nor reproduced I think it ought to be tossed. And who is going to volunteer to be a subject in reproducing data obtained by torture? None of the people who have expressed their approval of using this type of “research” have volunteered to participate in the reproducibility studies. There is a reason that we don’t do “Nazi research” in this country and we don’t cite “Nazi research” in our publications. It involves a moral code.

      Reproducibility and Research Integrity
      David B. Resnik, JD, PhD and Adil E. Shamoo, PhD
      Author information Copyright and License information Disclaimer
      The publisher’s final edited version of this article is available at Account Res
      See other articles in PMC that cite the published article.

      Reproducibility—the ability of independent researchers to obtain the same (or similar) results when repeating an experiment or test—is one of the hallmarks of good science (Popper 1959). Reproducibility provides scientists with evidence that research results are objective and reliable and not due to bias or chance (Rooney et al 2016). Irreproducibility, by contrast, may indicate a problem with any of the steps involved in the research such as, but not limited to, the experimental design, variability of biological materials (such as cells, tissues or animal or human subjects), data quality or integrity, statistical analysis, or study description (Landis et al 2012, Shamoo and Resnik 2015).

    • @mitchell
      In this particular case (anatomical depictions), regardless of any of our feelings about the rest of Nazi ‘research’ or experimentation, your argument about reproducibility in research is absolutely flawed.

      It doesn’t have to be torture to reproduce; any cadaver from a legal and willing body donor can verify the information meticulously collected and produced by the Pernkopf illustrations. I’m not saying this is a proof for one side or the other of the morality of using Nazi medical literature; I’m simply saying that at least in this case, the data is reproducible, and has been proven many times. Were it not, it would not even be worth arguing about, and wouldn’t have helped Dr. MacKinnon in her surgery.

  • This is political correctness gone wild. Facts are facts no matter where they come from and when a patient is at risk any and all measures should be used. As my old med school professor used to say “St. Peter don’t check ids”. LS.

  • I agree that scientifically accurate information should be used, for the purpose of alleviating sufference and helping our patients.
    The issue with Nazi medicine, on top of being unethical, is that it was biased to prove their twisted wiev of world and their ardent racism.
    Personally, I believe the biggest embarrassment should belong to the modern science, for being unable to produce better sources in the past 75 plus years.

    • I am surprised that so many people have responded that it’s OK to use “Nazi research”; if one can even call it “research”. None of the respondents seem to be willing to volunteer as subjects for “torture research” and I find that hypocritical in the extreme. As a surgeon myself, I’d like ot point out something else about the article. It is disturbing that this “expert surgeon” should bring her patient to the OR without thoroughly reviewing the case BEFORE the day of surgery. Does this happen to other professors of surgery? f I were having an operation I think I’d feel uncomfortable seeing my doctor googling “the anatomy of the coronary vessels” IN THE OR while I’m on the table. I never saw it as a medical student, a house officer or in practice. This point isn’t about “Nazi research” but about preparing for a case before taking your patient to the OR (assuming the story hasn’t been dramatized for effect). I wonder how often Dr. DeBakey did his cases like that.

    • @mitchell
      I write my personal opinion, pure and simple. May be agreeable to some or not to others. I respect both.
      I also use my full real name. If you wish to take the discussion to the personal level, please do the same.
      Respectfully
      Seref Bornovali MD

    • Dr. Bornovali – I am reading the instructions above: “Leave a Comment”. Are you thinking that in some way “a comment” is more valid if it is accompanied by “a full real name”? While I “respect” the opinions written here, it is unfathomable to me that even physicians are prepared to legitimize data (if one can call it data) obtained through torture and murder. I can only guess that the people leaving that sort of comment are so far removed from that reality that they are unable to “feel” what it must be like to be the victim, or the family of the victims, of what passes for “Nazi research”. So far, I see not one of the people who have commented willing to volunteer themselves or their family members to be subjects in experiments that involve torture and murder. To me, this introduces an element of hypocrisy. For your amusement, I send you an article regarding research ethics committees in Turkey that appeared in the BMJ. It appears that you attended medical school before 1993, the year Turkey first implemented “legal regulation of research on human beings” (see article). One would think that “legal regulations” would be unnecessary in our profession but sadly, even some doctors seem to be willing to cross the line of what most of us consider “ethical human behavior”. Hence, regulations. For the same reasons we need “regulations”, we ought to have regulations about justifying, and thereby encouraging, unethical research practices. Using “Nazi research” would be the poster child for the reason we need to reject the results of data obtained using torture.

    • Again, you are making personal comments, even making accusations, and I still do not know who I am talking to. I would appreciate your real name, the same way you know mine. My comments are not directed to you, but to the article

  • Re: SHARON BEGLEY (MAY 30, 2019)”The surgeon had a dilemma only a Nazi medical text could resolve. Was it ethical to use it?” The Boston Globe.

    To the editor of the Boston Globe.

    The surgeon’s awareness of Pernkopf illustrations origins is a thoughtful response to previous experiments and practices that have fueled sources of medical knowledge. Throughout history, scientific information has been gathered in multiple experiments on people, animals, and plants – that modern thought now considers unethical. In times gone by, bodies have been exhumed in the night for dissection, marginalized populations have been infected and observed, animals have been tortured, land has been ravaged. Yet, I am convinced that two conflicting truths can exist simultaneously: the pain inflicted on innocents is reprehensible, and the knowledge gained is decidedly good.
    Future generations will look back on our time and see clearly the immoral and unconscionable pain we continuously inflict on our environment, animals, and each other – and judge us. If they have courage, their ethicists will call out our bad behaviors, and challenge their contemporaries to follow a higher moral path.

  • The US Army’s Environmental laboratory faced a similar ethical dilemma. Part of their researches was aimed at helping US service people survive and fight in cold weather environments and treat them for frostbite and hypothermia.

    However, the single best source of information on how the human body reacts to cold environments was obtained by the Nazis, experimenting on Jewish concentration camp prisoners. Prisoners were tied to poles in freezing environments and their vital signs meticulously monitored as they were allowed to freeze to death.

    • Understandably, it’s difficult to get people to volunteer to be subjects in “experiments” like this. Do you have any suggestions? How about one of those “survivor shows”? We have four contestants and the last survivor wins $50,000 while the other three die trying. Do you think this sort of thing might generate enough data, and save enough lives, to justify doing it?

  • This information should go into medical “public domain”. No publisher or distributor should make one red cent from it and every person that downloads the information must be made aware of the sacrifice and/or tortuous (sic) methods used to obtain the information. It is a far stretch from what I learned in Hebrew school; Jewish law and tradition support the living. It respects the dead. If the sacrifice of the dead can save the life of a living person, so be it. [Then light a candle or plant a tree with respect.]

    • I think the word “sacrifice” might require some further definition. If someone (not you) decides to take your life “for the good of someone else, perhaps take your beating heart against your will, to save his own child, I don’t think the word “sacrifice” applies. If you disagree, please send me contact information so we’ll know where to find body parts for transplant of heart, kidneys, lungs, etc. I am sorry I am not making my point clearly. Once one legitimizes this sort of “research” the door is open to justify almost anything “for the sake of …”, including torture and murder. Who among us thinks that’s a good idea “for themselves and for their own families to be the experimental subjects”? Please think about it.

    • Mitchell: You are carrying the issue to an extreme. This is not a ‘leads to human sacrifice’ issue.

      The information is there. The information can be used to help somebody. Not using that information will harm that person.

      This is the ethical issue here. How much harm are you willing to accept in order to have a ban on information that was gained through illegitimate means?

      And I don’t really get your reasoning that assumes that using this information will result in humans being harvested for parts. You have a ‘part A’ and then a ‘Part Z’ – but no explanation as to what the progression from a to z was.

    • I totally agree with CS but add the alternative of monies obtained from the sale of the literature go to an appropriate charity.

  • It does not matter whether you are a physician or not. This article is addressing the idea of ethics based on morals. Not based on whether it makes you feel bad or uncomfortable. When it comes time for you to make that decision on your parameters and on your patient, then you can choose to amputate or rescue.

    But let us review why this whole ordeal is even worth being concerned about.

    The concerned doctor in this article did the deed in 2014. Years later a scholar gives a talk about the text in some forum which must have had many practicing professionals attending. This sparked the cognitive thinking to determine if past practice of it was of proper practice.

    To use the resource of what is now considered villainous and obtainable only from unethical practice is the agenda at hand.

    But remember this: this is privelaged information that the enemy possessed and most likely did not intend to share. At least not for some world saving ideology.

    To use it today can be justifiable if its factual information cannot be rebuked. Imagine if the Nazis had some agricultural mechanism they designed to make harvesting fields 47% efficient. It reduced the amount of manpower needed to manage related tasks. Would we refuse such technological ingenuity today because of what it was used to support?

    Before you answer any of my points, remember that things produced for the good of mankind can be utilized for evil deeds. Sometimes a person of evil intent can even improve it and make it work better.

    Progress towards the betterment of our future comes at cost and not all of it can be planned out.

    • I think those of you who would like to be “volunteers” for the types of experiments performed by Nazi monsters like Mengele ought to be free to sign up. Have your beating heart cut out, for instance, “just to possibly learn something from it”. Or maybe you’d like to volunteer your children and your siblings “for the good of mankind”. Who knows what discoveries might be made? I am not “just a physician who actually does take care of people”, but also the son of an Auschwitz survivor. Auschwitz, maybe you’ve heard of it, where my grandparents, aunts and uncles were gassed and burned; perhaps after being placed in cold water for hours “just to see how long it would take for them to die”. It appears that many people still have no idea what happens when you open the door to this kind of “research”. Let me know when you;’d like to personally volunteer and we can see what can be arranged. Possibly not here in the USA but I understand there are places in South America where former Nazis and their friends might still be looking for new subjects. I simply can’t believe this issue is even on the table for discussion. Unless you’d like yourself or your family tortured, under the “umbrella” of “scientific research”, you ought to emphatically say, “No, Never”! On the other hand, if you say, “Go ahead and recruit subjects, not for yourself of course, but for sub-humans, like Jews or other undesirables,” the case is even worse.

    • https://www.nejm.org/doi/full/10.1056/NEJM199005173222011?query=recirc_inIssue_bottom_article

      Above see New England Journal of Medicine editorial that explains, more eloquently than I can, the reasons we don’t support “unethical research”, either by publishing it or ” by spreading the word” about “advances purported to ‘save lives’ or reduce human suffering”. The whole idea is so distasteful; it gives me the creeps. I am shocked by some of the “reasons” given here. (Especially the person who thinks “Nazi research” (read torture) saved “millions of lives”.) The idea that someone believes this is almost as scary as the acts themselves.

  • I am a physician. I totally disagree with the use of Nazi “research” as appropriate under any circumstances. Imagine the potential for harm if we justify this kind of research in any way.

    • And how many lives are you willing to sacrifice for this principle? In this article the surgeon needed it to properly repair somebody’s knee. Should she have simply allowed her patient to be crippled?

      People seem to think that the bad stuff from history should be buried. It shouldn’t. We need to acknowledge what happened, but accept any good that may have come from the tragedy.

      And what you fear is not something we have to worry about in our culture.

    • To disregard the medical breakthroughs of tragedy and mad men would set modern science back decades. Adolf Hitler was an early proponent of a vegetarian diet and the nazi physicians recognized the importance of vitamins, minerals, whole foods and fibre in their diet The first article on Asperger syndrome was a product of eugenics and the vile experimental work at Auschwitz. Hundreds of people lost their lives at the hands of Hans Reiter (Reiter’s arthritis experiments at Buchenwald). While from a poisonous tree, the fruits of Nazi Medicine have contributed to saving millions of lives since the end of the war.
      Probably the most important outgrowth of the Nazi horrors was, as Alan Well said, physicians must ” treat every person equally, without regard to race or ethnic background.”

    • Responding to the comments below. It amazes me that some people are unable to see beyond a single case to the horrible implications of permitting, or even encouraging, this sort of “research”. Colin, do you really believe that “Nazi research” was “the only way to help this person”? What’s next, human sacrifice (with you being the next victim)? One needs to be careful before opening some doors. This is a very slippery slope.

    • Was it the ‘only’ way? I don’t know. But it appears to have been the best of that doctor’s options.

      And using the information does not justify what they did. Information is not good nor evil – it is simply information. And I do not see a ‘slippery slope’ here. This debate we are having is evidence that we do have limits on what we are willing to do.

  • My grandparents were actively protecting Jewish people in the Underground in WWII, and they shared their horific and heroic experiences in the positive light of preventing another Holocaust. The origins of the specimens used by Pernkopf is very disturbing, but if many lives can be saved through the precise anatomical illustrations derived from the victims, then those victims in a way get immortalized. That is what they deserve, and this can be accomplished in clarified, outspoken respect for the human study subjects. Just skip the author’s name as much as possible ……

  • Hippocrates said that ‘war is the only proper school for a surgeon’. The unfortunate reality is that enormous tragedy often gives rise to medical breakthroughs. World War One saw advancements in orthopedics, neurosurgery and psychiatry; the use of mobile laboratories, tetanus antitoxin, and typhoid vaccination to stem the spread of infectious disease. The Korean and Vietnam wars were goldmines for future trauma care. Even now researchers are re-examining the antiseptic properties of several plant medicines used by the Confederacy as they show tremendous promise in the treatment of antibiotic resistant bacterial infections.
    We can’t change history, but we must not forget history. Remembering the mistakes of the past goes a long way in preventing the mistakes of the future. This patient will live to tell those stories!

    • “war is the only proper school for a surgeon” addresses the heroic life-SAVING attempts to put mangled bodies back together. It’s about putting people “back together”. And the surgeon learns anatomy and technique. Don’t confuse “war” with what the Nazis did – torturing and killing millions “for their pleasure”. Calling that “research” is more than perverse. Imagine putting a pillow over your child’s nose and mouth until they die and then reporting how many seconds it took to do that? And then calling it “research”? Check out a photo from Babi Yar or one of thousands of other mass graves. They killed with relish. Read Eric Goldhagen’s book, “Hitler’s Willing Executioners”. Are we now going to call that “research”? This isn’t “research”.

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