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In the lessons of medical-scientific methodologies of the medical faculty at the Sapienza University of Rome, basic notions on the ethical and deontologic aspects characterizing the history of the medical profession are provided, including the formulation and application of bioethical principles to clinics and biomedical research. Within such framework, an educational project has been initiated on the historical origin of the current normative and juridic dispositions in the regulation of experimental biomedical research and the relationship between health operators and patients, with particular attention tothe procedure, the meaning the value either professional or deontologic, of ethics and the legality of the informed consensus. Emphasis is put on medical and experimental abuses that occurred in Germany during the naziregime.
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                                                                                                        Review article


From Nuremberg to bioethics: an educational project
for students of dentistry and dental prosthesis




                                                                                             li
                                                                                          na
Silvia Marinozzi, PhD1                                        Eugenic theories in Europe in the XVIII
Gilberto Corbellini, PhD2                                     and XIX century




                                                                                       io
Livia Ottolenghi, MD, DDS3
Francesca Ripari, PhD, DDS3                                   The diffusion of the Hippocratic oath formed the basis of
Antonio Pizzuti, PhD4                                         the principles of medical deontology, morally constraining
Marcello Pezzetti, MA5                                        the doctors to follow specific norms and forbidding atti-




                                                                                    az
Fabio Gaj, MD6                                                tudes and practices that would violate the “purity of art”.
                                                              Deontology, as a set of norms regulating the professions,
                                                              reflects principles and models of the general moral of a
1
    Department of Molecular Medicine, “Sapienza”              given culture and society, but also builds the foundations




                                                                      n
    University of Rome, Italy                                 and reinforces an internal culture characterizing socially
2
    Department of Medical and Surgical Sciences and           and legally the main self commitment (mandate) of each




                                                                   er
    Biotechnology, “Sapienza” University of Rome, Italy       profession.
3
    Department of Oral and MaxilloFacial Sciences,            The care of patients as primary goal of the doctor, primum
    “Sapienza” University of Rome, Italy                      non nocere, a guide principle of the medical behaviour, to
4



5

6
    University of Rome, Italy
                                           nt
    Department of Sperimental Medicine, “Sapienza”

    Director of the Museum of Shoah of Rome, Italy
    Department of General Surgery, Surgical Specialties
                                                              equally care for all humans without discrimination, are val-
                                                              ues sanctioned in the hippocratic code, confirmed by all
                                                              authors, both doctors and non doctors, that in the course
                                                              of the centuries have dealt with ethical and deontological
                                         iI
    and Transplants, “Sapienza” University of Rome, Italy     aspects of the medical profession never put in discussion
                                                              or denied in the medical communities of the XVIII and XIX
                                                              century
                                       on

                                                              However, in the course of the XIX century, experimental
Corresponding author:                                         research in biology and medicine started to develop,
Silvia Marinozzi, PhD                                         while anthropological studies validating the biological the-
Department Molecular Medicine                                 ories proposed classifications of human races that be-
                              i


“Sapienza” University of Rome                                 came the presupposition of the doctrine constituting the
                           iz


Viale dell’Università 34/A                                    ideologic basis of the politics of “racial hygiene” and eu-
00185 Rome, Italy                                             genetics in nazi Germany.
Phone: +39 06 64451721                                        The cruel and lethal medical experiments carried out on
              Ed




E-mail: silvia.marinozzi@uniroma1.it                          the jewish and other prisoners used as human guinea
                                                              pigs in the concentration camp, provides the core of the
                                                              debate that from after the Nuremberg trials has deter-
                                                              mined that there is the need of an univocal normative lim-
Summary                                                       iting the biomedical research within the boundaries of
In the lessons of medical-scientific methodologies of
                                                              moral and ethical lawfulness.
 IC




the medical faculty at the Sapienza University of Rome,
basic notions on the ethical and deontologic aspects
characterizing the history of the medical profession are
                                                              “Racial hygiene” in the nazi Germany
provided, including the formulation and application of
C




bioethical principles to clinics and biomedical research.
Within such framework, an educational project has been        The programme of “racial hygiene”, proposed and per-
initiated on the historical origin of the current normative   formed by Hitler, freely interpreted and misinterpreted
and juridic dispositions in the regulation of experimen-      the idea of the eugenics started in 1883 by the English sci-
                                                              entist Francis Galton, cousin of Charles Darwin, who
©




tal biomedical research and the relationship between
health operators and patients, with particular attention to   considered that the progress of the human race de-
the procedure, the meaning the value either professional      pended on the improvement of selective transmission of
or deontologic, of ethics and the legality of the informed    heritable traits in the population to future generations. In
consensus. Emphasis is put on medical and experimen-          Germany, the eugenics movement was already very ac-
tal abuses that occurred in Germany during the nazi           tive in the XIX century and the work of their founders Wil-
regime.                                                       helm Schallmayer and Alfred Ploetz had distorted its
                                                              meaning; in 1908 in the period when Germany had
Key words: history of bioethics, dentistry in the nazi        colonies in South West Africa, all mixed marriages were
Germany.                                                      annulled and the germans involved in mixed marriages

138                                                                             Annali di Stomatologia 2013; IV (1): 138-141
From Nuremberg to bioethics: an educational project for students of dentistry and dental prosthesis


were deprived of their civil rights. After 1933, when the        ment had given the license to marry to persons with oral
nazis came to power, the eugenic ideas became ripe for           schisis or with a anamnestic positive family history only if
political purposes that aimed through euthanasia, sterili-       sterilized, subsequently forbade the union of a healthy
zation and selectivity of marriages to reach the ambitious       person with a person pre-emptively sterilized, on the as-
goal of creating a “superior race”.                              sumption that the goal of the marriage is mainly the pro-




                                                                                                li
                                                                 duction of healthy offspring for the Nation. The attempts
                                                                 to avoid such dictates were eluded by the certainty that




                                                                                             na
“Useless lives”: the T4 experience                               the “sick” subjects would have survived as stowaway for
                                                                 their entire life, since the Ministry of Public Instruction
Hitler put in charge some hierarchs to extend medical au-        banned access to schools to the children or access to any
thority to evaluate those persons considered beyond cure         public job to the adults, thus excluding them from any so-




                                                                                          io
after accurate diagnostic evaluations, to whom a “merci-         cial contact.
ful death” would be allowed. The “Reich Committee for the        The atrocity judged at the Nuremberg process were part
scientific research of serious diseases of heritable origin”     of a global system that had been encouraged by eugenic
had prepared the registration forms to record useful infor-      euthanasia, such as the obligatory sterilization, the selec-




                                                                                       az
mation to select the persons “worthy of help” from those         tive marriages on the basis of the genetic health and
considered “useless lives” and the distribution of such          racial hygiene, among which also the subjects with oro-
questionnaires was carried out in the long stay hospitals,       maxillofacial malformations were included.
the sanatoria and in the madhouses. The directional cen-




                                                                         n
ter for the “euthanasia” operation had its residence in
Berlin in a house at n. 4 of Tiergartenstrasse. All men-         Racial hygiene and oro-maxillo facial district




                                                                      er
tioned questionnaires were sent to this address where
each case was examined by a doctor; the selected pa-             As all professionals in the medical field, dentists were
tients were then transported and killed in one of the five       obliged to report about all patients affected by congenital


4 operation.                                 nt
centers for euthanasia in Germany or in the one in Aus-
tria (Linz). This procedure went down in history as the T-

There are not reliable data on the number of people killed
                                                                 malformations.
                                                                 The racial health became an obligatory subject in all stu-
                                                                 dent classes of medicine and dentistry and the scientific
                                                                 literature on the same topic was very prolific in the 30s,
                                           iI
by “euthanasia”; it is said between 120.000 and 275.000          as it can be deduced from the proclamations with racial
cases and that only 15% of the mentally ill people of            content. Among them, the “Neue Grundlagen der Rassen-
Germany survived the program of the third Reich.                 forschung” states that the movements of mastication of
                                         on

It is interesting to note that those that constituted the        the arian men are horizontally oriented to allow mastica-
program of so-called euthanasia were not ignorant, nor           tion with closed mouth, while in men of different race, as
mentally insane, but doctors, hospital nurses and bu-            in animals, the movements of mastication are perpendi-
reaucrats seduced by the idea of a “pure” nation in which        cular, to let them chew with an open mouth; moreover,
                                i


chronic disease and disability were considered an unjus-         while the canines of an arian man are not higher than the
                             iz


tifiable burden. Among them famous scientists as C. H.           other teeth, in the other races they are in general higher,
Schroeder, pioneer in the etiology and mechanisms of             round and large, as in animals.
heritable transmission of oral schisis, who in 1931 recom-       Since the beginning, the german dentists and their scien-
              Ed




mended to carry out the eugenic measures for those in-           tific and professional organizations were involved in the
dividuals affected stating that the prevalence of this           consequences of the power achieved by the nazis in
pathology was increased because the surgical interven-           1933.
tion contrasted natural selection.                               In the same year, Ernstt Stuck became Reichzah-
The law for the Prevention of birth of persons affected by       narztefuehrer (i.e. head doctor of the Reich) and decided
heritable disease of 14 July 1933 envisages the obligatory       that each dentist working in private had to complete a
 IC




sterilization, thus making explicit the concept already ex-      course of ideologic and military education over eight
pressed by Hitler in Mein Kampf to systematically prevent        weeks in order to get access to funds from social welfare;
all unhealthy individuals to generate diseased and in-           in his opinion, each dentist should become a national-so-
sane offspring, as a “compassionate action”, that would          cialist, trust the Fuehrer and follow him faithfully in his
C




spare undeserved suffering and improve the health of the         progress to contribute to reach the victory. The results was
race on the whole. Also in this case, the tribunals in           that during the first months of the war 6000 dentists en-
charge of the selection of the subjects were composed by         rolled in the german army.
a qualified commission represented by a lawyer, a fam-           Still in 1933, a law was approved forbidding the Jewish
©




ily doctor, and a doctor specialist in hygiene; they had the     dentists to exert their profession in favour of the funds of
duty to select the risky categories, including deafness,         social welfare, until in 1939 the profession was finally
acute alcoholism, epilexy, blindness, but also physical          completely forbidden to them, so that the number of jew-
malformations such as oral schisis and all doubtful cases        ish dentists went down from 1064 (on a total of 11.332
of cranio-facial malformations such as the simple open           surgeon dentists) in 1934, to 372 in 1939.
bite, which in the uncertainty were anyway sterilized.           In this period, especially following the promulgation of the
The program that planned to “protect the german honour           racial laws of Nuremberg, the health policy included the
and blood” was even more ambitious, therefore the “law           ban of marriage among german citizens “pure” and jew-
for the prevention of heritable diseases”, that in a first mo-   ish, and afterwards, simple “impure” individuals, with the

Annali di Stomatologia 2013; IV (1): 138-141                                                                             139
S. Marinozzi et al.


defense of the arian species the pillar of the measures of        due to well defined racial characteristic and that it would
public hygiene, so that the medical and health prevention         be possible to differentiate the various ethnic groups from
coincided with the idea of racial hygiene and prevention.         the study of the mandible. Combining his interest for the
Among the numerous scientific works aimed at demon-               facial development and the experiments conducted in
strating the dangerousness and the risks of contamination         genetics by professor Otmar Freiherr von Verschuer of the




                                                                                                   li
coming from uncontrolled marriage unions and to give              prestigious Goethe University of Frankfurt am Main, to
suppert to the ban of reproduction not only for those that        whom he was committed, Mengele, was concerned that




                                                                                                na
could actually transmit heritable pathologies, but also so-       the progress in the surgical treatment of oral schisis
matic and genetic stigmata judged as incongruous and              would not have decreased the incidence of these congen-
antithetic to the selection of the pure race, there are also      ital malformations genetically transmitted. He carried out
studies concerning the connection between maxillo-den-            a study on 17 families of 110 patients affected by both




                                                                                             io
tal anomalies and some psychiatric pathologies, such as           labial and palatal schisis resident in Frankfurt: the results
the frequency of prognatism and of an ogival palate               suggested that 47% (a higher proportion than that re-
among the mentally ill patients. The basic idea, in absolute      ported in previous studies) had a heritable component.
coherence with the phrenology doctrines of the time, was          Moreover, Mengele found an association between “cleft




                                                                                          az
to nosologically embed some physiognomics for the diag-           lip with/without palatal schisis” and other conditions such
nosis of mental diseases thought to be congenital, to             as hernia, hemangioma, phimosis, foot malformation,
prevent heritable transmission through the sterilization of       polydactyly and syndactyly, scoliosis, hydrocefalon and
the subjects.                                                     spina bifida. Therefore, he hypothesised a link between




                                                                           n
From the association of ogival palate-prognatism with             oral schisis and mental retardation, deafness, strabis-
heritable diseases, it was concluded that all people pre-         mus and the delayed closure of the cranial sutures, ex-




                                                                        er
senting this kind of malocclusion were carriers of congen-        plaining in this way the pathogenesis of the oral schisis as
ital mental disability and therefore had to be included in        a “global perturbation of the fetal development” with dif-
the categories to be sterilised.                                  ferent degrees of seriousness.


                                             nt
In this respect, the concerns for some oro-maxillo-facial
anomalies, was that the knowledge on the transmission
patterns of the labio-palatal-schisis in 1930 was very lim-
ited. The different authors, among which included
                                                                  As known by now, the nazi dentists did the extraction of
                                                                  golden teeth at the beginning only from the mouth of the
                                                                  cadavers in the lager, then also from live prisoners in or-
                                                                  der to reutilize the metal in various ways. Xavier Rioux in
                                           iI
Schroeder, observed that oral schisis were present with           his works on the history of dentistry in Germany during the
an incidence of 40.5% among the offspring of affected in-         nazi period highlighted how the general order or the den-
dividuals, that the transmission patterns were multiple           tal treatment of the prisoners in the concentration camps
                                         on

even if the recessive heredity seemed prevalent in 75%            was to reduce at the minimum the medical care and to
of cases, that in 64.3% of cases the affected individuals         avoid the use of anesthesia during operations, considered
were males and that in particular the labial schisis mani-        by Dr. H. Pock, head dentist of all concentration camps,
fested with a higher frequency in the left lip and was not        a practice “too human”for individuals thought to be “less
                                i


necessarily associated to palatoschisis. The results pro-         human” (2).
                             iz


vided scientific support to the obligatory sterilization of the
adults and to the euthanasia of children affected by oral
schisis. They hypothesised a correlation between the              From Nuremberg to modern bioethics
              Ed




oral pathology and other malformations manifested by the
same individual or in kins, such as bifid tongue, poly-           The elimination and the forced sterilization of the “impure”
dactyly, malformations of the foot fingers, hydrocephalon,        Germans, or those not matching the biological “arian”
stiff neck, and some ocular pathologies.                          ideal, the planning of a “final solution” of the Jewish ques-
The social anathema imposed to the subjects with oral             tion, the total elimination of a whole people, and the per-
schisis was clearly described by Beatty in 1936. Referring        formance of medical experimentations carried out on the
 IC




to subjects who were surgically treated to solve the oral         prisoners of the concentration camps used as human
schisis, he affirmed that if operated early, both the lan-        cavias, constitute the core of the debate that after the
guage and the aesthetics seemed to improve sufficiently           Nuremberg trial there was a need for a univocal norma-
to prevent pain and the sense of repulsion from the oth-          tive that would limit the biomedical research into the
C




ers. Moreover, since the aesthetic defects of the                 boundaries of moral and ethical lawfulness.
palatoschisis were enhanced by the simultaneous pres-             The Nuremberg code of 1947, promulgated just a few
ence of the cleft lip, the psychological effects of such          days before the end of the process to the nazi officials and
pathology on the children should not be overlooked, risk-         health people, underlines the indispensability of the re-
©




ing to hamper the natural process of socio-cultural growth        spect of the integrity and the dignity of individuals, and rat-
rendering the subject, even if healthy, insecure and with         ifies on one side the priority of a voluntary consensus of
excessive educational and mental delays.                          the patients and of the individuals under experimental pro-
Also Mengele dedicated his studies to the oro-maxillofa-          tocols, while on the other side the sense of ethical respon-
cial malformations, obtaining his degree with a thesis en-        sibility, professionality and legality required of the doctor
titled “Morphologic racial research on the inferior part of       whenever an experimental research would result harmful
the maxilla of four racial groups” in which he made com-          to the individual. The “voluntary consensus” becomes an
plex measurements of the alveolar region of the mandible.         “essential” prerequisite for a morally acceptable conduct
He concluded that the variation in measurements were              of the experiments on humans.

140                                                                                  Annali di Stomatologia 2013; IV (1): 138-141
From Nuremberg to bioethics: an educational project for students of dentistry and dental prosthesis


In 1948 the World Medical Association approved the             integrating the classes of Medical Deontology and Applied
Geneve Declaration, updated the Hippocratic oath and           Bioethics through the historical reconstruction of the con-
committed doctors not to use their knowledge against hu-       siderations that have been developing from the Nurem-
man rights “even under obligation”. The debate and the         berg Code in the medical and scientific community of the
discussions in the medical community that followed post-       western countries. The goal is to offer an educational con-




                                                                                                li
Nuremberg, and the issue of normatives always being            tribution on the history of medical bioethics through the re-
more oriented towards the free consensus of the pa-            construction of the historical-cultural prerequisites of the




                                                                                             na
tients and/or subjects under experimental research, de-        race doctrine, the systems adopted in Germany to carry
lineate the historical origins of the current bioethics ap-    out “racial hygiene”, from the elimination of disabled to the
plied in the medical and clinical field. The Helsinki          discrimination of the impure races, the experiments con-
declaration (1964) confirms and reinforces the principle of    ducted on human beings in the extermination camps un-




                                                                                          io
free and voluntary consensus, which must also be explicit,     til the successive response of the international community,
thus highlighting the need of a normative procedure that       from the Nuremberg Code of 1947 to the Belmont Report,
further supports the right of autodetermination of the in-     and to the definition of bioethical “codes” in current med-
dividuals, the guarantee of the welfare of the individual,     icine, with particular relevance to the concept, the history




                                                                                       az
but also the terms by which the consensus of the patient       and the worthiness of the “informed consensus” (1).
can be valid (major age, psychical conditions, etc.).
In 1971 the American oncologist Van Rensselaer Potter
published “Bioethics: a bridge to the future”, and pro-        Acknowledgements




                                                                        n
posed the term “bioethic” as explicitation of an ideal proj-
ect where the medical ethical problems are inserted in         We thank Prof. Antonella Polimeni, Director of the Depart-




                                                                     er
those more general of an “environmental” ethic, integrat-      ment of Oral and MaxilloFacial Sciences of “Sapienza”
ing the new biological knowledge with the human values,        University of Rome, and Prof. Ersilia Barbato, Responsi-
centered on the problems of the demographic develop-           ble of the Advenced Degree Course in Dentistry and


                                             nt
ment, ecological degradation, and for an adjustment of the
technologic and scientific progresses to the moral refer-
ence values (global bioethics). In a more strict medical
field, in 1978 the National Commission for the protection
                                                               Dental Implants, to having allowed this didactical and
                                                               educational project.
                                           iI
of Human Subjects in the Biomedical and Behavioural Re-        References
search of USA, drew up the document “Ethical Principles
and Guidelines for the Protection of Human Subjects of         1.   Conforti M, Corbellini G, Gazzaniga V. Dalla cura alla
                                         on

Research” (known as Belmont Report), in which the three             scienza. Malattia, salute e società nel mondo occidentale.
fundamental principles of the current medical bioethics are         Varese: Encyclomedia 2011.
                                                               2.   Riaud X. Story of three SS dentists during World War II: Pr
ratified: beneficence and non-maleficence; equity and jus-
                                                                    Hugo Blaschke, Dr Hermann pook and Dr Willy Frank.
tice; respect of the decisional autonomy of the patient.
                                                                    Vesalius. 2006 Dec; 12 (2): 79-93; Three tragic destinies of
                                i


The relevance of the treated themes in bioethical consid-           surgeon-dentists: Bernard Holstein, Danielle Casanova and
                             iz


erations induced institutionalisation of an educational             Dr Rene Maheu during World War II. Vesalius. 2005 Dec; 11
route for the students of the Courses of the Medical Fac-           (2): 88-97; The German army dental corps in World War II”
ulties of the Sapienza University of Rome, with seminars            Vesalius. 2005 Jun; 11 (1): 38-47.
              Ed
 IC
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©




Annali di Stomatologia 2013; IV (1): 138-141                                                                               141
