Nursing in WWII Europe: lessons from history for today’s nurses

It’s said that those who ignore the lessons of history are doomed to repeat them and, certainly, our understanding of nurses’ roles in war crimes can help them respond to practice challenges today. 

'The nurses using social media in 2012 did not question their manipulation of technology to kill the patient any more than those nurses involved in Nazi Germany’s killing programs.'

In the early 1990s, Hilde Steppe, a courageous German nurse, began publishing on the role that nurses played in Nazi-era Europe. Why was this nurse courageous? Because she was the first to publicly acknowledge the complicity of nurses in some of the worst crimes in history.

Steppe’s various publications, available in German and English, expose the role that nurses played in crimes against humanity – those carried out under the aegis of the Nazi regime in the 1930s and 1940s.

Many of the Nazi-era crimes occurred in hospitals, psychiatric institutions, asylums and in concentration camp hospitals. After World War II, when doctors were called to account for their work in such places, the profession of medicine addressed its role in these crimes against humanity. It fostered a body of scholarship and research, the German Medical Association made an official apology to victims and their families and, worldwide, principles and processes were developed to guide ethical research involving human beings. These principles form the basis of research practice today.

What seems surprising is that whilst doctors’ roles were investigated at length, nurses’ complicity in facilitating these crimes received less attention. This seems surprising because, just as they do today, nurses made up the largest proportion of hospital workforces in Europe during the 1930s and 1940s. In our forthcoming book on the subject of nurses in Nazi-era Europe, Susan Benedict and I argue that many more nurses than doctors actively killed their patients, yet only a tiny proportion of them were held accountable. Few nurses were tried and even fewer were punished. A trial in 1960 of 14 nurses concluded that each was guilty, yet within months, all were acquitted.

We ask why was this so? What made nursing so invisible and, as a profession, so unaccountable? Was it because nursing was predominantly a female occupation and the world could not countenance the idea that women could participate in mass killing? Was it because nurses were (and still are) considered one of the most trusted professions in society and to associate them with crimes on this scale would be unthinkable? Was it because of nursing’s lack of professional status at the time?

Without a doubt, nurses played a role in the killing sites that hospitals and institutions became, but nurses today find this evidence unpalatable. When we present it at conferences some of the feedback we receive expresses disbelief – “Nurses would never do those things” – or it is discounted: “It was long ago, it’s irrelevant now.” But we argue that it is a foolhardy profession that thinks this way. We also contend that examining the role of nurses in Nazi-era war crimes has benefits for nurses today.

Why is it so important that nurses learn about what their professional forebears did some 65-plus years ago? Because, as a profession, nursing has much to learn from its history. Taking one example, many of us who trained as nursing apprentices in hospitals recall that obedience was par for the course. Obedience was (and is still in some countries) a foundational ethos of nurses’ professional behaviour. A dictum that all nurses followed orders was drummed into new recruits and couched in terms of unquestioning respect for doctors, sisters, matrons or anyone considered more senior than the newest nurse. Even if we felt uncomfortable about something in practice, nurses were not permitted to remove dressings that a patient had complained of or question other practitioners’ care, because these tasks were considered the doctor’s domain. Disobedience brought censure and exclusion.

In many cases associated with Nazi Germany, it was obedience to their seniors that led nurses to actively kill their patients. As Benedict and I argue, some of the nurses brought to criminal trial in 1960 justified their actions in killing patients simply on the basis that they were “obeying orders” from superiors. This justification collapses when one examines the moral and ethical principles that ought to underlie all of one’s actions in life – particularly the principle that killing can never be an acceptable part of a nurse’s scope of practice.

Of course this example is an extreme case and because such crimes are so far removed from us in time, it is easier to contemplate nurses’ complicity in them and to imagine that it could not happen now. But even this end of the spectrum in nursing history can help nurses today question their own moral and ethical stances, before they become involved in questionable practices.

The ethical stances of nurses are challenged every day at the bedside. Comparing and contrasting what others have done in similar situations in the past can teach us how to approach complex issues in healthcare. I believe that we can, and should, use examples from nursing’s history to teach nurses how to make choices and decisions in everyday practice.

Taking an example of contemporary practice, some countries still have capital punishment, a process in which nurses are known to assist despite the strong stance of the International Council of Nurses against the death penalty. It is easy to pass judgement on a nurse for being present and attending to a prisoner at an execution, and to prescribe how a moral stance can be made against it. But there are other areas that are not so black and white. Maternal-foetal screening services (prenatal diagnosis or pregnancy choice services) are now commonplace. In some cases where a foetus is deformed or carries an inherited disease, parents may be offered termination of the pregnancy. Whilst some of these foetuses may carry features that are incompatible with life, others may have non-life-threatening conditions, such as cleft lip and palate or be missing a limb. In these circumstances a nurse may ask what the difference is between killing children with disabilities after they are born (as was done by nurses in Nazi Germany) and killing babies with disabilities before they are born, as is permitted by law in Australia?

Taking a health system approach, rationing of limited healthcare resources is now high on the agenda and presents nurses with ethical dilemmas that are not so far removed from Nazi-era Europe. As they face escalating healthcare and technology costs, hospitals and other services have to balance what patients and clients expect against what can be delivered within budgets. In the United States, this dilemma has been highlighted by tensions over President Obama’s funding reforms under the Affordable Care Act (Obamacare). In the UK, the National Health Service is collapsing under the weight of what is a laudable intention – providing equitable and good healthcare, free, at point of delivery, to the British people.

Nurses and midwives are caught up in this. Those attending at the bedside face increasing pressure from managers and policymakers to work within financial constraints.

Nor is Australia immune from healthcare rationing, with staff numbers and services being cut as governments attempt to balance their budgets, a situation likely to continue. We also hear frequently about the looming burden as people age.

For nurses and midwives in 2014, the financial climate may present ethical dilemmas about rationing patient care, and understanding the history of nursing during the Nazi era can guide moral and ethical decisions about practice when it comes to nurses’ involvement in legally permitted, voluntary euthanasia. Rationing of health services in Nazi Germany meant that people were killed if they were considered a burden on the state. One could argue that there is a world of difference between euthanasia today, often described as “mercy killing”, and the euthanasia practised by the Nazis, which was anything but voluntary or merciful. Our intention here is not to judge what is involved in that world of difference, but to highlight the role of history in bringing this and other challenging episodes to the attention of nurses today so that they can weigh up the rights and wrongs of choices they make in practice every day.

Similarities can be drawn between past and present. A conversation observed in social media in 2012 illustrates how moral choices and ethical stances can be abrogated by modern nurses just as they have been in the past. We thank our colleague from the University of Texas Health Science Centre at Houston, Dr Cathy Rozmus, for permission to share the accompanying exchange, in which a student nurse caring for a patient in an intensive care unit during a clinical placement discussed the patient’s management with several registered nurses.

What makes us uncomfortable about this conversation? Does it matter that nurses and nursing students would discuss an individual’s care in such an open forum? What about the tone of the conversation and the ethical stance of those participating in it? What relevance to nursing in Nazi Germany does this exchange have?

The nurses in Nazi Germany, of course, would not have encountered a patient on a ventilator, yet their regard for patients was similarly low. The nurses using social media in 2012 did not question their manipulation of technology to kill the patient any more than those nurses involved in Nazi Germany’s killing programs. Perhaps most striking is that the nurses using social media seemed unconcerned that their proposal to kill a patient by their actions alone runs counter to every human principle as well as the primary principle of all healthcare – “First, do no harm”.

Benedict and I believe that lessons from unpalatable episodes in our profession’s history, such as from Nazi-era Europe, have much to teach us about how we practise as nurses today: how we make decisions and respond to practice challenges. By using history to inform practice we can be advocates for patients’ human rights. By critically examining and discussing our profession’s past we can be confident that we are doing our best to prevent a progression along the slippery slope that manifested in nurses’ complicity in crimes against humanity.

Ethics and law are taught in nursing courses everywhere, but the history of nursing and midwifery (from which these subjects draw their cases) has been dispensed with, notionally because of crowded curriculums. But we believe this is to the detriment of the critical thinking skills that come from learning about nursing’s history. Critical thinking and reflection is an invaluable skill that applies every day, at every bedside, in every aspect of nursing. Lobbying for the return of history as a permanent component of the curriculum for nurses and midwives should be high on the agenda for 2014. Nurses, midwives and historians can take courage from the example of Hilde Steppe, the German nurse who first exposed the role of her predecessors in crimes against humanity. Steppe died in 1999. Her work and that of others in recording the history of nursing, warts and all, lives on.

A slippery slope

Day 1

Student Nurse: Ugh, had a brain dead patient today … whose family should have been prepared for discussions about pulling life support out … Brain stem involvement anyone? … he’s not running a BP of infinity over a zillion because he has a history of hypertension, it’s because he’s doing his best to die.

Registered Nurse 1: The neuro doc should have been more upfront. I’m surprised your organ donation group wasn’t already involved.

SN: He’s not a candidate – he tested positive for PCP, opioids and pot on his ER toxicology screen but we’re supposed to call organ procurement anyway because his Glasgow score is 3. The patient coded on the CT table 2 days ago.

RN2: 6 extra ICU days are not cheap. The family deserves honesty, not false hope.

SN: That’s my thought. I’m all for hope when it’s appropriate, but they still think he’s going to walk out of the hospital, despite the doctors telling them the dude is brain dead. Of course, I was the one stuck dragging the code bag down and back up.

RN 2: Hell, you could have been pushing the enormous code carts we have here. LOL. That is why I plan on telling everyone I care about healthcare (POA) power of attorney. LOL.

SN: No cart, because we had to minimise metal J Couldn’t even have leads on him during the MRI, which was terrifying. We had to watch his pulse ox and hope it’s worked.

RN 2: Well, he’s brain dead, so “all the way” dead isn’t that far off.

SN: I don’t doubt that my nurse would have done a slow code if she thought she could have gotten away with it. But it was pretty late in the shift so it would have been extra paperwork.

RN 2: You can’t understand unless you’ve been there.

RN 3: This is so depressing.

Day 2

SN: Brain dead guy or mostly brain dead was still on the unit today, while his family tries to find another hospital that will stimulate his brain. Wouldn’t have a functioning brain stem be a pre-req. for that?

RN 4: Grief and logic do not go hand in hand. L

RN 5: Welcome to futile care. I participate in it often.

SN: You might be participating in this guy’s … they really don’t understand that their options are “Pull life support” or “Peg and trach him and send him to an LTAC to live like this”.

RN 6: I doubt our NICU would take him. Maybe as an organ donor. J

SN: Hah. Would be if it wasn’t for the pot, opiates and PCP in his system in the ER.

RN 5: We can clear that out with dialysis hahaha minor details, the transplant numbers are more important for our hospital.

SN: Good luck with dialysis, his SR-frequent PVCs and PACs turned into SVT during today’s dialysis session. I got to play with drips so I thought it was fun.

RN 6:  You could totally put him into arrest and then really make him dead-dead, do it, do it!!

SN: We keep trying. Like he coded on the CT table early last week so we took him to MRI late last week where patients aren’t monitored at all and he behaved himself.

RN 6: Accidentally turn off the drips to change the bags and wait for the BP to disappear. It’s a necessary thing to change bags, he just couldn’t handle it.

SN: I have to tell them to do that during his next dialysis. His pressure was going pretty low even with the drips.

Linda Shields is professor of nursing tropical health, tropical health research unit, James Cook University and Townsville Hospital and Health Service.

She is also an honorary professor, department of paediatrics and child health, University of Queensland.

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