Andreas Killen, PhD

When Leo Alexander, the psychiatrist who served as advisor  at the Nuremberg doctors’ trial, helped draft the articles of the Nuremberg  code, his attention was drawn to two earlier episodes in German medical history.  One of these occurred in 1931, when, following the deaths of 75 children in  Lbeck by means of a contaminated TB vaccine, the Reich Health Council issued  guidelines spelling out the principle of voluntary consent.

Galvanized by the Lbeck affair and others like it,  prominent physician Julius Moses had publicly condemned the “experimental  mania” in German medicine, and by the time it met to discuss Moses’ charges,  the Health Council was responding to considerable public outrage. Noting  widespread popular belief that experimentation served the interests of  scientific knowledge rather than those of healing, Council members agreed on  the necessity of clearly defining the boundaries of permissible human  experimentation. Yet these boundaries were by no means self-evident to the  Council.

In an effort to clarify the issue, Council member Alfons  Stauder suggested that the distinction between experiments for therapeutic  purposes and those purely for research purposes could be illustrated by  reference to the practice of hypnosis. In the hands of a trained physician this  method of treatment was invaluable, although it exercised such a “profound  influence over the patient’s mental life” that it could only be used with due  caution. Very different, Stauder continued, was the use of hypnosis by  lay-practitioners, whether for the purpose of healing or for the sake of  gratifying public interest in mysterious or unconscious forces. He stressed the  danger such experiments posed and the disrepute such practices could bring to medicine.

On the face of it, Stauder’s illustration of the general  problem addressed in this session by reference to hypnosis seems surprising,  even bizarre. Why did hypnosis appear in these deliberations? And why was it  seen as so transgressive? Closer examination shows that, however seemingly  tangential to the controversies surrounding the Lbeck affair, Stauder’s  comments allude to a wider history of debates concerning the ethical and  professional boundaries of medicine, in which hypnosis figured as a recurring  theme.

Another key moment in this history concerns an earlier  scandal that erupted in 1898, when several people experimentally injected with  serum from a syphilitic patient contracted the disease. One participant in the  resulting controversy was Albert Moll, a specialist in neurology and hypnosis,  whose book 

 (1902) Leo  Alexander cited as a key source. Moll argued that this case was not an isolated  one but indicative of wider abuses, including frequent instances of  experimentation on patients in public hospitals. He identified several possible  causes of such lapses: medical overspecialization and the resulting narrowness  of doctors’ outlook; the growing knowledge-gap between doctors and patients as  medicine was revolutionized by the natural scientific method; the greater  prestige accorded research over treatment. He also suggested that physicians’  social status blinded them to the power differential between them and their  often poor, under-age, or mentally handicapped patients. To prevent abuses,  Moll suggested the need for a contract between physician and subject-patient  spelling out, among other key issues, the principle of voluntary informed  consent.

Not surprisingly, given his own professional interests, Moll  referred often to hypnosis in his discussion of medical ethics. Indeed it is  quite central to his treatment of the doctor-patient relationship. The opening  pages of his text included a warning concerning the dangers of hypnosis at the  hands of lay practitioners, illustrating these dangers by citing the case of a  woman who had to be institutionalized following treatment by a Hungarian  hypnotist. Though he regarded such occurrences as unusual, Moll conceded in his  text 

 (1898) that the  hypnotized subject was in fact “completely devoid of a will of his own,” and  reiterated this view in his book on medical ethics. In Moll’s eyes, the  hypnotic procedure carried clear risks, involving not just its apparent ability  to penetrate deeply into the subject-patient’s psyche, but, in effect, to turn  the subject into an object. A corollary to this was the great power it placed  in the doctor’s hands.

Hypnosis thus raised significant issues concerning the  doctor-patient relationship. A precondition for the contract between doctor and  patient, he wrote, was the existence of a relationship of trust: a consent  given by the patient or patient’s guardian. This was precisely what hypnosis,  by disabling the will and thus the very basis of voluntary consent, called into  question. This special feature of the hypnotic procedure, therefore, was  symptomatic of a larger problem plaguing modern medicine: that patients all too  often were treated as objects -- a fact raising questions about “the so-called  voluntary nature of the consent that patient-subjects gave their  physician-researchers.” In touching here on the issue of physicians’ treatment  of their patients, Moll linked the problem of ethical violations to larger  questions of public trust. Absence of trust harmed hopes of medical progress  both by hindering public health policies and by strengthening the popularity of  alternative medicine.

Moll’s effort to find a middle ground between the patient’s  interests and those of science initially found little resonance. Meanwhile, the  critique of the natural scientific orientation in medicine spawned a lively  medical counter-culture of alternative and esoteric healing, against which  German doctors campaigned vigorously. This proved, however, no easy task, and  became less so as a result of subsequent developments. During World War I,  thousands of shell-shocked soldiers were treated with hypnosis. German military  doctors’ discovery of its therapeutic properties gave hypnosis new validity. At  the same time, the war amplified many of the issues that had surfaced in earlier  debates. In some hands, the hypnotic treatment took on authoritarian features,  making the patient’s submission to the physician’s absolute authority a part of  the cure, and leading to conflicts between medical authorities and soldiers.  Such conflicts were re-enacted in postwar films like 

 (1919),  which portrayed the hypnotist as a figure of intense fear and fascination.

During the 1920s, debates about hypnosis  proceeded along several tracks. On the one hand, many doctors incorporated it  into their clinical practice. On the other, controversies persisted concerning  its still poorly understood workings, benefits, and risks. Malpractice charges  were not infrequently filed against the many unlicensed hypnotists who  flourished in the war’s aftermath. The campaign against lay medicine, or  quackery, continued throughout the Weimar period. At the same time, in the  polarized political climate of this era, many politically conservative  physicians cultivated an image of themselves as charismatic leaders, claiming  the right to administer ambitious, and sometimes radical, solutions to many  social problems. Moreover, doctors continued to resist encroachment on their  prerogatives, resisting efforts to impose stricter guidelines on experimentation,  claiming that - as opposed to the problem of quackery, where intervention was  justified – prospects for scientific progress demanded complete freedom.

It was in this context that Julius Moses launched his  attacks on the “experimental mania” in German medicine. In referring  polemically to the Lbeck case as an instance of “medical quackery,” Moses  challenged the claims of physicians like Alfons Stauder, the doctor who brought  hypnosis into the 1930 Health Council deliberations, that German medicine stood  on solid scientific foundations. Stauder was the head of two leading medical  associations who had long used his position of influence to campaign against  lay-healers. Convinced that his profession had adequate safeguards in place,  Stauder argued that the worst abuses occurred in natural medicine circles.  Nevertheless, in the outcry following the Lbeck affair, the Health Council  issued new guidelines spelling out the limits of permissible experimentation  and the principle of voluntary informed consent. These guidelines, however, had  limited impact before the Nazis repudiated them in 1933. With the passage of  laws legalizing involuntary sterilization of the mentally handicapped, the  systematic violation of patient’s rights became institutionalized under the  rapidly Nazified medical profession.

What conclusions may be drawn from this story about hypnosis  and its place in the history of debates about medical ethics? Though the issues  surrounding hypnosis do not warrant comparison with the Lbeck case or the  crimes tried at Nuremberg, the persistence with which German doctors wrestled  with them over a period of decades suggests that these issues touched a deep  nerve in the medical community. Hypnosis represented a special category, one  that threw several problems confronting the profession into relief. Debates  about hypnosis exposed a general lack of clarity surrounding the boundaries  between treatment and experiment, as well as the boundaries between science and  non-science, in other areas of medicine. Perhaps more importantly, hypnosis  raised significant questions concerning the relationship between doctor and  patient. Efforts to establish this relationship, and the wider relation between  medicine and public, on the basis of the principle of voluntary, informed  consent proved, in the deeply fractured political climate of the early 1930s,  short-lived. It would take the verdict of the Nuremberg doctors’ trial, and the  subsequent efforts of the psychiatrist Leo Alexander, to establish this  principle at the center of modern medical ethics.

Articles

When Leo Alexander, the psychiatrist who served as advisor at the Nuremberg doctors’ trial, helped draft the articles of the Nuremberg code, his attention was drawn to two earlier episodes in German medical history.

Author | Andreas Killen, PhD

Articles

Hypnosis and Medical Ethics in Germany