As piores práticas da indústria farmacêuticas

CIENCIAS (GENERAL) Las diez peores prácticas de la industria farmacéutica, según Ben Goldacre Antonio Martínez Ron domingo, 07/04/13 - 21:36 [ 27 ] El divulgador británico denuncia en su libro “Mala farma” las conductas irregulares de las farmacéuticas. La ocultación de los resultados negativos cuesta cada año muchas vidas, denuncia en su libro. Ben Goldacre, autor de "Mala Farma" -Foto: Iona Hodgson TemasCiencias (general) 1. El 90% de los ensayos clínicos publicados son patrocinados por la industria farmacéutica. Este es el principal motivo por el que todo el sistema de ensayos clínicos está alterado, según Goldacre, y por el que se producen el resto de problemas. 2. Los resultados negativos se ocultan sistemáticamente a la sociedad. "Estamos viendo los resultados positivos y perdiéndonos los negativos", escribe Goldacre. "Deberíamos comenzar un registro de todos los ensayos clínicos, pedir a la gente que registre su estudio antes de comenzar e insistir en que publiquen sus resultados al final". En muchos casos, denuncia el autor de "Mala Farma", las farmacéuticas se reservan el derecho de interrumpir un ensayo y si ven que no da el resultado esperado, lo detienen. Asimismo, obligan a los científicos que participan en estos estudios a mantener en secreto los resultados. Y esta práctica tiene de vez en cuando consecuencias dramáticas. En los años 90, por ejemplo, se realizó un ensayo con una sustancia creada contra las arritmias cardíacas llamada Lorcainida. Se selección a 100 pacientes y la mitad de ellos tomó un placebo. Entre quienes tomaron la sustancia hubo hasta 9 muertes (frente a 1 del otro grupo), pero los resultados nunca se publicaron porque la farmacéutica detuvo el proceso. Una década después, otra compañía tuvo la misma idea pero esta vez puso la Lorcainida en circulación. Según Goldacre, hasta 100.000 personas murieron innecesariamente antes de que alguien se diera cuenta de los efectos. Los investigadores que habían hecho el primero ensayo pidieron perdón a la comunidad científica por no haber sacado a la luz los resultados."Solo la mitad de los ensayos son publicados", escribe Goldacre, "y los que tienen resultados negativos tienen dos veces más posibilidades de perderse que los positivos. Esto significa que las pruebas en las que basamos nuestras decisiones en Medicina están sistemáticamente sesgadas para destacar los beneficios que un tratamiento proporciona".3. Las farmacéuticas manipulan o maquillan los resultados de los ensayos. En muchas ocasiones los propios ensayos están mal diseñados: se toma una muestra demasiado pequeña, por ejemplo, se alteran los resultados o se comparan con productos que no son beneficiosos para la salud. Goldacre enumera multitud de pequeñas trampas que se realizan de forma cotidiana para poner un medicamento en el mercado, como elegir los efectos de la sustancia en un subgrupo cuando no se han obtenido los resultados esperados en el grupo que se buscaba al comienzo.4. Los resultados no son replicables. Lo más preocupante para Goldacre es que en muchas ocasiones, no se puede replicar el resultado de los estudios que se publican. "En el año 2012", escribe Goldacre, "un grupo de investigadores informó en la revista Nature de su intento de replicar 53 estudios para el tratamiento temprano del cáncer: 47 de los 53 no pudieron ser replicados".5. Los comités de ética y los reguladores nos han fallado. Según Goldacre, las autoridades europeas y estadounidenses han tomado medidas ante las constantes denuncias, pero la inoperancia ha convertido estas medidas en falsas soluciones. Los reguladores se niegan a dar información a la sociedad con la excusa de que la gente fuera de la agencia podría hacer un mal uso o malinterpretar los datos. La inoperancia lleva a situaciones como la que ocurrió con el Rosiglitazone. Hacia el año 2011 la OMS y la empresa GSK tuvieron noticia de la posible relación de este medicamento y algunos problemas cardíacos, pero no lo hicieron público. En 2007 un cardiólogo descubrió que incrementaba el riesgo de problemas cardiacos un 43% y no se sacó del mercado hasta el 2010.6. Se prescriben a niños medicamentos que solo tienen autorización para adultos. Este fue el caso del antidepresivo Paroxetine. La compañía GSK, según Goldacre, supo de sus efectos adversos en menores y permitió que se siguiera recetando al no incluir ninguna advertencia. La empresa supo del aumento del número de suicidios entre los menores que la tomaban y no se hizo un aviso a la comunidad médica hasta el año 2003.7. Se realizan ensayos clínicos con los grupos más desfavorecidos. A menudo se ha descubierto a las farmacéuticas usando a vagabundos o inmigrantes ilegales para sus ensayos. Estamos creando una sociedad, escribe, donde los medicamentos solo se ensayan en los pobres. En EEUU, por ejemplo, los latinos se ofrecen como voluntarios hasta siete veces más para obtener cobertura médica y buena parte de los ensayos clínicos se están desplazando a países como China o India donde sale más barato. Un ensayo en EEUU cuesta 30.000 dólares por paciente, explica Goldacre, y en Rumanía sale por 3.000.8. Se producen conflictos de intereses: Muchos de los representantes de los pacientes pertenecen a organizaciones financiadas generosamente por las farmacéuticas. Algunos de los directivos de las agencias reguladoras terminan trabajando para las grandes farmacéuticas en una relación bastante oscura.9. La industria distorsiona las creencias de los médicos y sustituyen las pruebas por marketing. Las farmacéuticas, denuncia Goldacre, se gastan cada año miles de millones para cambiar las decisiones que toman los médicos a la hora de recetar un tratamiento. De hecho, las empresas gastan el doble en marketing y publicidad que en investigación y desarrollo, una distorsión que pagamos en el precio de las medicinas. Las tácticas van desde la conocida influencia de los visitadores médicos (con las invitaciones a viajes, congresos y lujosos hoteles) a técnicas más sibilinas como la publicación de ensayos clínicos cuyo único objetivo es dar a conocer el producto entre muchos médicos que participan en el proceso. Muchas de las asociaciones de pacientes que negocian en las instituciones para pedir regulaciones reciben generosas subvenciones de determinadas empresas farmacéuticas.10. Los criterios para aprobar medicamentos son un coladero. Los reguladores deberían requerir que un medicamento sea mejor que el mejor tratamiento disponible, pero lo que sucede, según Goldacre, es que la mayoría de las veces basta con que la empresa pruebe que es mejor que ningún tratamiento en absoluto. Un estudio de 2007 demostró que solo la mitad de los medicamentos aprobados entre 1999 y 2005 fueron comparados con otros medicamentos existentes. El mercado está inundado de medicamentos que no procuran ningún beneficio, según el autor de “Mala Farma”, o de versiones del mismo medicamento por otra compañía (las medicinas "Yo también) o versiones del mismo laboratorio cuando prescribe la patente (las medicinas "Yo otra vez"). En esta última categoría destaca el caso del protector estomacal Omeprazol, de AstraZeneca, que sacó al mercado un producto con efectos similares, Esomoprazol, pero diez veces más caro.

Como morrem os médicos

Sobre lucro assustador que indústria de assistência média aufere, prolongando a vida com aparelhos, à custa do sofrimento do paciente e familiares No blog Socialista Morena | Imagens: Quino Escritores octogenários que entrevistei coincidiram em dizer que o duro na vida não é envelhecer, mas enterrar os amigos, aguentar a saudade deles que fica. Você começa a encarar a morte de perto. Suponho que a isso se chame amadurecer. E dói. Dizem as estatísticas que a média de idade das pessoas subiu, mas a realidade ao lado da gente desmente a estatística. Cada vez que uma pessoa querida se vai, fico pensando na forma como nós encaramos a morte e como a medicina tradicional nos trata no final de nossas vidas. Será que não existe uma maneira menos sofrida? Pesquisando sobre o tema, encontrei, em um dos meus sites de jornalismo independente favoritos, o Alternet, um artigo do mês passado muito esclarecedor, que traduzi, adaptei e publico para vocês, sobre como os médicos norte-americanos planejam a própria morte. E a imensa maioria opta por não fazer os tratamentos invasivos que eles mesmos indicam a seus pacientes, preferindo cuidados paliativos. Os cuidados paliativos são um conceito em ascensão no mundo mas que engatinha no Brasil por desinteresse da classe médica. É chamado de hospice ou “casas para os que morrem”: centros voltados para a melhoria da qualidade de vida de pacientes diagnosticados com doenças incuráveis. Para que possam passar seus derradeiros momentos no mundo tranquilos, assistidos, da maneira menos dolorosa possível, cercado pelos familiares, em vez de tentando procedimentos invasivos –e inócuos– até o fim. (Há um bom artigo científico sobre o movimento hospice, inclusive no Brasil, aqui.) Esta reportagem aborda também o lucro que o prolongamento da vida com o uso de aparelhos dá à indústria da assistência médica, à custa do sofrimento do paciente e dos familiares. Leiam. Espero que seja útil para alguns de vocês. *** O segredo dos médicos para morrer direito –Por que médicos fazem escolhas diferentes que a maioria de nós no final da vida? Por Melinda Welsh, Sacramento News & Review O dr. Ken Murray escreveu um artigo para a revista online Zócalo Public Square pensando que, com sorte, atrairia algumas dúzias de leitores e um comentário ou dois. Em vez disso, o médico recebeu uma avalanche de respostas. Na verdade, o que ele escreveu o colocou no meio de um debate sobre a vida, a morte e médicos. O que ele revelou de tão avassalador? Revelou que a imensa maioria dos médicos faz escolhas para o fim da vida dramaticamente diferentes do resto de nós. Dito de uma forma simples, a maioria dos médicos escolhe conforto e calma em vez de intervenções ou tratamentos agressivos Visto de outra maneira, médicos rotineiramente ordenam procedimentos aos pacientes no fim da vida que eles não escolheriam para si mesmos. O que os médicos fazem e o resto de nós não? De acordo com Murray, os médicos veem as limitações da medicina moderna de perto e sabem que as tentativas de prolongar uma vida podem frequentemente levar a uma morte prolongada, sofrida. O livro de 2011 de Murray, How Doctors Die (Como Médicos Morrem), foi traduzido em vários idiomas e recebeu resenhas do The New York Times, The Wall Street Journal e The Washington Post. Milhares de pessoas comentaram nas páginas de leitores dos jornais e blogs que as reproduziram. Leitores falaram sobre “familiares à beira da morte sendo atacados por drogas tóxicas”, disse Murray, ofertas de “procedimentos dolorosos por nenhuma razão”. Entre as respostas estavam centenas de histórias de médicos e cuidadores profissionais que confirmavam a tese de Murray. “Muitas das histórias eram desoladoras”, disse. Dados que provam isso não são difíceis de encontrar. Murray cita o Johns Hopkins Precursors Study, uma das maiores pesquisas sobre envelhecer no mundo, que contém estatísticas de saúde em um grupo de aproximadamente 750 médicos que eram membros da Johns Hopkins University School of Medicine em Baltimore entre 1948 e 1964. Através dos anos, o estudo ajudou a pesquisa médica a relacionar, por exemplo, colesterol alto com ataques cardíacos. Mas 15 anos atrás –com seus participantes em seus 60, 70 e 80 anos– os pesquisadores começaram a perguntar sobre escolhas terminais. Dr. Joseph Gallo, diretor do Precursors Study, estava feliz de explicar como os dados mostram continuamente que médicos –por uma ampla maioria– fazem diferentes escolhas quando confrontados com diagnósticos desesperadores. Médicos que escolhem menos procedimentos também tendem a facilitar as chamadas “diretivas antecipadas de vontade”, uma importante parte da papelada que permite aos pacientes escolher um procurador e determinar antecipadamente que intervenções querem ou não em caso de acontecer um declínio em sua saúde. No Brasil isso ainda não é regulamentado (leia sobre o movimento pela regulamentação da Ordem de Não Reanimar aqui.) Em um cenário onde o grupo de estudo foi questionado sobre o que desejaria no caso de uma doença cerebral irreversível que os deixasse incapazes de reconhecer pessoas ou falar, “a maioria das pessoas quer tudo”, disse Gallo, enquanto 90% dos médicos disseram não à ventilação mecânica (aparelhos de respiração artificial) e à hemodiálise. Cerca de 80% dos médicos disseram também não a uma cirurgia de grande porte ou a um tubo de alimentação, disse. “Isto sugere que quanto mais familiar você é com intervenções, menos você quer”, Gallo disse, direto ao ponto. Murray crê que a culpa pela ruptura se deve a três fatores: má comunicação do médico com o paciente, expectativas irreais dos pacientes e suas famílias e um sistema de saúde que encoraja tratamento excessivo. (Nota: um quarto de todos os gastos com saúde ocorre no último ano de vida das pessoas.) ‘Não me entube’ Quando se considera o grande número de mortes que o Dr. James Gregor testemunhou em décadas como especialista em cuidados paliativos e em casas de repouso de Sacramento, é comovente vê-lo tomado pela emoção ao contar a história de Ella. Idosa diagnosticada com uma doença terminal, Ella (não é seu verdadeiro nome) tinha fortes convicções sobre não ter nenhuma intervenção médica quando estivesse próxima da morte. Ela preencheu a papelada com este efeito e oficializou tudo, com seu marido servindo como procurador no caso de se tornar incapaz de tomar suas próprias decisões. Logo veio o inevitável ponto em que Ella, presa numa cama de hospital e perto de morrer, começou a ter dificuldades de respirar. Um dos muitos médicos dela disse para seu marido: “Ela está se debatendo muito. O senhor não quer que a coloque num respirador?” Pensando que o médico sabia melhor, o marido consentiu e ela foi colocada no respirador artificial. Aquele momento de escolha virou sete longos dias de arrependimento. Apesar de seus desejos, Ella permaneceu semi-viva na unidade de terapia intensiva com “tubos em toda parte” e uma máquina respirando por ela durante uma semana. De acordo com McGregor, o marido então teve que tomar a responsabilidade por retirar a ajuda. “Ele estava devastado”, disse McGregor. “Ele sentiu que tinha traído sua mulher durante a última semana de vida dela… Você podia ver aquela dor.” McGregor, um especialista em hospices (que permitem a doentes terminais conforto em vez de tratamentos agressivos) e medicina paliativa (com foco em aliviar e prevenir sofrimento), disse que a experiência de Ella é mais comum do que se pensa. “Vi pacientes morrerem na UTI aos poucos e a família não podia nem chegar perto.” Além disso, apesar de a maioria das pessoas desejarem morrer em casa perto dos seres amados, 70% morrem no hospital ou na clínica após um longo embate contra um câncer avançado, falência cardíaca, doença incurável ou incapacidades múltiplas da velhice. Quando perguntados sobre a diferença e por que médicos não tendem a colocar a si mesmos em respiradores em UTIs no fim de suas vidas como aconteceu com Ella, McGregor foi sombrio. “Frequentemente a questão não é bem colocada”, disse McGregor, como: “Nós temos duas opções aqui: nós podemos tentar de tudo ou nós podemos administrar agressivamente seus sintomas e mantê-lo confortável. O que seria qualidade de vida para você?” Médicos, ele disse, tendem a escolher a opção 2, porque viram o que viram, e “sabem que uma intervenção pode gerar um efeito cascata.” Dr. Kevin Ryan, médico aposentado e escritor, coloca de uma forma diferente: “Médicos viram (morte e morrer) de todas as perspectivas, exceto acontecendo com eles.” “Quando você está perto do fogo, sabe como pode se queimar.” Medicina e hospitais existem para combater doença e morte, é assim que se pensa, então se o paciente morre, o médico falhou. McGregor lembra das aulas de habilidades clínicas que assistiu na faculdade de medicina com uma lista de passos que um médico deveria seguir, concluindo com as palavras: “Se o paciente morre, eu falhei”. “Espera-se de nós que façamos coisas, que consertemos coisas”, disse McGregor. “Médicos se sentem impotentes se não podem oferecer alguma coisa e é difícil para eles falar sobre opções que não sejam as agressivas ‘trazer sua saúde de volta’… Um médico pode sentir que falhou diante de um paciente ao dizer ‘Bem, você vai para um centro de cuidados paliativos’. ” Um informe publicado no ano passado no New England Journal of Medicine diz que 69% dos pacientes com câncer de pulmão e 81% dos pacientes com câncer colo-retal disseram não ter entendido de seus médicos que a quimioterapia não iria curar de todo seu câncer. Isto acontece por duas razões, diz McGregor. O paciente ou a família podem frequentemente vir com enormes expectativas não-realistas, algumas vezes reforçadas por crenças populares. Muitas veem a respiração artificial, por exemplo, como algo que salva vidas, mas na verdade ela raramente é eficaz. “Existe uma percepção equivocada que a medicina pode consertar tudo”, ele diz. “E há também um sentimento de ter direito a isso algumas vezes –’você deveria me dar tudo’.” Infelizmente, uma outra razão pelas quais médicos algumas vezes “fazem tudo” com pacientes terrivelmente enfermos é o medo de sofrer processos por má prática de medicina. “Acho que este é um fator”, disse McGregor. Os outros médicos entrevistados concordam. “Algumas vezes os médicos dizem ‘ok, nós lhe daremos tudo’, mesmo que saibamos que não irá ajudar, como um modo de não nos enredarmos numa ação legal de alguém da família que achou que deveria haver mais procedimentos”, disse. Para seu próprio desejo de fim da vida, se ele se encontra com uma doença terminal, seu desejo é morrer em casa sem intervenções e com a assistência de centros de cuidados paliativos. “Brinco que tenho ‘NMR’, ‘NTMR’ e ‘PMN’ tatuado no meu peito”, disse McGregor (não me ressuscite, não tente me ressuscitar e permita morte natural). “Simplesmente não me entube”, especifica. ‘De jeito nenhum farão isso comigo’ Dr. Michael GuntherMaher, diretor médico do Sacramento and Roseville Kaiser conta a história de Sophie. Mulher negra de 88 anos, Sophie (não é seu nome real) deu entrada no Kaiser poucos meses atrás com um histórico de rápida perda de peso e uma infecção chamada sepse, disse GuntherMaher. “Fizemos alguns testes e vimos que ela estava anêmica. Escaneamos seu abdômen… e achamos uma massa. Estava claro que tinha câncer”, disse. Já no começo Sophie falou que queria que os médicos fizessem todo o possível para salvar sua vida, disse GuntherMaher. Com a família insistindo fortemente, o hospital imediatamente começou com intervenções e remédios. “E esta mulher morreu lentamente na UTI com um tubo na garganta”, disse. “Finalmente a família disse: ‘tire-a da máquina’. Foi um difícil e prolongado final de vida quando não havia não havia nenhuma chance razoável de que isso fosse funcionar.” GuntherMaher, que tinha sido consultado sobre o caso de Sophie como um especialista em cuidados paliativos, refletiu que a mulher perdeu a chance de retornar a Oakland para morrer suavemente, em seu ambiente, “ao redor de amigos e família que queriam visitá-la e dizer adeus… Aquela oportunidade foi completamente perdida”. “Tenho um monte de histórias como essa. O hospital está cheio delas.” GuntherMaher vê o caso de Sophie como um exemplo do que ele chama de caos que acompanha muitos cenários de final da vida. “Um monte de mudanças na vida acontecem nos últimos anos, e as famílias não estão preparadas para a doença”, ele diz. “A doença existe. As pessoas entram e saem de hospitais ou casas de repouso. Eles estão nestes lugares mesmo apesar de estarem acostumados a pensar ‘eu nunca quero estar assim’. Mas eles estão. E isto é caótico.” Foi um desejo de colocar ordem nesta turbulência do final da vida que colocou GuntherMaher na rota do seu posto atual no Kaiser. “Acho que a maioria das pessoas… o que têm é medo”, ele disse. “Estão com medo. Estão confrontados. Há coisas a terminar. Eles não podem aceitar que irão chegar ao fim deste jeito porque estão pouco preparados.” Esse estado mental, diz, frequentemente pavimenta o caminho para que suas famílias aceitem todos os procedimentos oferecidos, não importa que sejam agressivos. GuntherMaher acredita que os pacientes deveriam estar aptos a escolher por eles mesmos se vão ou não ser submetidos a tratamentos perto do fim da vida. “Sou a favor que as pessoas escolham”, ele diz, “desde que isto seja informado.” Questionado por que médicos morrem de maneira diferente, como na tese de Murray, GuntherMaher respondeu: “Médicos são diferentes”. “Como grupo, tendemos a estar no final do espectro onde se acham as pessoas inteligentes, capazes. Então, se você pega gente assim e as expõe a estas complexidades e dificuldades uma e outra vez, elas irão levar em conta e processar isto. Outro aspecto que nós (médicos) somos capazes de fazer é conciliar aspectos psicológicos, a falência biológica, com os mais difíceis temas humanos. O que é a vida? O que é a morte? Do que se trata? Nos confrontamos com isso quase todo dia, como ninguém mais em nossa sociedade, exceto talvez pastores.” GuntherMaher disse que os médicos com quem se relaciona estão no hospital diariamente e “a maioria deles, quando externa sua opinião sobre (intervenções no final da vida), diz basicamente: ‘de jeito nenhum que farão isso comigo’.” Não foi surpresa descobrir que as escolhas de GuntherMaher sobre seu próprio final de vida ecoam as dos outros doutores no estudo da Johns Hopkins. Em realidade, meses atrás, ele reuniu os três filhos de 20 e poucos anos para falar sobre seus desejos. “Colocamos minha filha e meu genro no FaceTime do Ipad”, disse. GuntherMaher deu suas instruções e mostrou aos filhos um formulário POLST (ordens médicas para tratamento de vida assistida, na sigla em inglês), declaração sobre que tipo de tratamento médico doentes seriamente enfermos querem para si mesmos. “Acho que isso nos deu uma boa oportunidade para ser uma família e falar sobre coisas significativas juntos, praticar o saber ouvir e falar profundamente uns com os outros”, disse. “Fazer considerações, por um momento, sobre este período da vida é precioso.” Entre outras coisas, GuntherMaher lhes falou: “Não quero ser ressuscitado se meu coração parar. Não quero ser colocado em ventilação mecânica. E quando meu momento chegar, quero morrer em minha casa.” ‘Medicina não pode consertar tudo’ Dr. Jeffrey Yee está de frente a seus alunos –camisa cinza de botões, jaqueta e um pager de bolso– com todo o carisma amigável de um professor de ciências sociais. Mas ele é um médico que deixa por um tempo suas consultas particulares como clínico-geral para ensinar idosos e pacientes cronicamente doentes sobre as instruções e formulários POLST. O público de Yee no início de setembro consistia em 14 pacientes idosos –muitos deles pareciam lutar com doenças crônicas ou câncer. Yee, que testemunhou em 1997 a favor do POLST antes da aprovação no Estado, faz uma apresentação em PowerPoint para seus estudantes sobre as instruções e a importância de nomear um procurador para cuidados com a saúde. Ele e uma enfermeira inclusive encenam um pequeno esquete onde fazem o papel de dois irmãos com diferentes interpretações sobre o que o médico recomendou que deveria ser feito com uma mãe no caso de assistência à vida. “Tentamos fazer com que as pessoas considerem essa problemática, tenham conversas sobre isso”, Yee disse antes da aula. “Tentamos que as pessoas experimentem as tensões e os desafios que terão que enfrentar no futuro.” Yee não usa “final da vida” ou a palavra “morte” em seus seminários. Nem discute procedimentos específicos ou possíveis consequências. “Quando você reduz isto a uma conversa sobre ‘este procedimento dura tanto tempo’, isto realmente não proporciona um bom quadro”, ele diz. “Que número poderia representar ‘pequena chance de sucesso’?” Se você tem 95, você responderia esta questão de forma diferente do que se tem 30 e três filhos. Curiosamente, Yee –o mais novo dos médicos entrevistados– foi o único médico que não disse imediatamente que iria declinar de intervenções se ele mesmo se deparasse com uma doença terminal. “Depende da situação”, ele diz. “Não sei se eu poderia estabelecer isto tão especificamente agora”. Um outro programa que poderia resultar para reduzir o fosso entre médicos e o resto de nós nas escolhas de final da vida é chamado ROYL, sigla para “resto da sua vida” (em inglês). Dr. Philip Lisagor, cirurgião cardio-torácico aposentado e chefe médico do ROYL em Reno, Nevada, teve um estalo no final de sua carreira: “Me dei conta que ninguém estava falando com pacientes com doenças sérias sobre o que estava acontecendo”, disse. “Um jogo está sendo jogado aí”. Lisagor observa que o fator lucro não pode ser desprezado quando se discute por que este fosso existe, e por que tantos médicos frequentemente encorajam intervenções que eles mesmos não escolheriam. “A indústria da assistência médica faz muito dinheiro com os cuidados no fim da vida”, diz. De fato, cerca de 27% do orçamento anual de 327 bilhões de dólares do Medicare (seguro de saúde governamental nos EUA) são destinados a pacientes em seu último ano de vida. “Todo mundo no sistema lucra com mais procedimentos”, disse Lisagor, “incluindo médicos, hospitais, companhias farmacêuticas, centros de diagnósticos etc. É um problema enorme.” “Há uma mudança cultural acontecendo no país”, disse Murray, o médico do ensaio polêmico. “O tabu está acabando, as pessoas querem falar sobre isso… Demorará, mas acredito que está acontecendo.” Os médicos entrevistados para esta reportagem também concordaram que as coisas estão melhorando. “Sim”, disse McGregor. “As pessoas precisam entender que existe a possibilidade de ter uma morte confortável, de morrer cercado por seres queridos. As pessoas precisam entender que é uma opção real e viável.” “E necessitam entender que a medicina não pode consertar tudo.”

Experimentos com animais não provam nada.

It’s official – the animal study literature is biased… but whose fault is it? By Roli Roberts Posted: July 16, 2013 Rating: +7 (from 9 votes) Testing a new drug on human subjects is expensive, risky and ethically complex, so the vast majority of potential treatments are first tried out on non-human animals. Unfortunately similar issues also constrain the size of animal studies, meaning that they have limited statistical power, and the scientific literature is littered with studies that are either uncertain in their outcomes or which appear to flatly contradict each other. Luckily statisticians have developed a workaround for this – the “meta-analysis”. To do this, scientists combine the data from a large number of published studies on the same treatment, ending up with a much more certain answer that’s tantamount to a super-study that uses the total number of animals from all the individual studies. Bingo! A much more solid basis for deciding on the merits of pursuing these treatments further. But a study just published in PLOS Biology by Konstantinos Tsilidis, John Ioannidis and colleagues at Stanford University shows that a meta-analysis is only as good as the scientific literature that it uses. That literature seems to be compromised by substantial bias in the reporting of animal studies and may be giving us a misleading picture of the chances that potential treatments will work in humans. You can read the excellent Synopsis by Jon Chase for how the authors set about doing their study, but the key take-home is that more than twice as many studies as expected appeared to have statistically significant conclusions – something known as excess significance bias. What’s the explanation for this anomaly? Rather than wilful fraud, the authors of the PLOS Biology study suggest that this excess significance comes from two main sources. The first is that scientists conducting an animal study might analyse their data in several different ways, but ultimately tend to pick the method that gives them the “better” result. The second arises because scientists usually want to publish in higher profile journals that tend to strongly prefer studies with positive, rather than negative, results. This can delay or even prevent publication, or relegate the study to a low-visibility journal, all of which reduce their chances of inclusion in a meta-analysis. The new work raises important questions about the way in which the scientific literature works, and it’s possible that the types of bias reported in the PLOS Biology paper have been responsible for the inappropriate movement of treatments from animal studies into human clinical trials. What do we do about it? Here are the authors’ suggestions: Animal studies should adhere to strict guidelines (such as the ARRIVE guidelines) as to study design and analysis. Availability of methodological details and raw data would make it easier for other scientists to verify published studies. Animal studies (like human clinical trials) should be pre-registered so that publication of the outcome, however negative, is ensured. Well, these are all excellent, but most people would also say that there are problems elsewhere in the system – in the high-profile journals’ desire to a have a cute story with well-defined conclusions, and in the forces exerted on authors by institutions and funding bodies to publish in those high-profile journals. So whose fault is it? The Institutions. Institutions (and funding bodies) feel driven to assess the “quality” of their employees’ work, and frankly, using the journal in which the work is published as a proxy for “quality” is an easy option – the peer reviewers and editors have already done the assessment job for them, and all they have to do is note down the impact factor. In this context, negative-result papers aren’t going to help the authors’ case. Even if they end up with the rosiest article-level metrics, they will end up tarred with a low impact factor. The Authors. Authors may have the best intentions, but ultimately writing and submitting (and re-submitting…) a paper takes a substantial number of person-hours. These are hours that could be better spent doing experiments, writing grant applications, teaching, etc. How can writing a negative-result paper that will end up in a “low-profile” journal compete? Ioannidis and colleagues point out that many negative studies end their days at this stage – a collection of data on a hard-drive with no prospect of seeing the light of day. And those that do get submitted may have had to wait until the authors have done umpteen other more pressing tasks. The Journals. There are some special journals out there, like PLOS ONE, that don’t make a judgement as to the importance of a study. In their eyes, positive- and negative-result papers should be published with equal probability. However, most journals, including PLOS Biology, make a call as to the perceived importance of a study. Some might disagree, but I would say that this is key to the “discoverability” of a paper, and that some flagging of important papers needs to occur, whether it’s pre-publication (as has happened traditionally) or post-publication (as some propose). Positive papers will almost always be seen as more important (with a few interesting exceptions), but what is essential is that the publication of negative results in a readily accessible journal is made as easy as possible; that publishers aren’t the barrier. Yes, the pre-registration of animal studies should help incentivise authors to write and submit negative papers, but: Institutions and funding bodies need to release themselves from the tyranny of the impact factor and view positive and negative results as equally valid contributions to the literature. Authors need to recognise that negative studies can contribute substantially to scientific knowledge, both via meta-analyses and by more informal means, and it is their duty to ensure that failure to submit these studies doesn’t bias the literature. Publishers need to ensure that there is an accessible home for sound papers that have negative results. Now here’s a question –would PLOS Biology have published this study if it showed that there was in fact no excess significance in animal studies? I doubt it, but at least we would’ve cordially pointed the authors in the direction of PLOS ONE, where their study could be published without substantial delay. Declaration of potential conflict of interest: I’m a PLOS Biology editor and an employee of PLOS. That said, these views are my own and don’t necessarily reflect those of PLOS. Konstantinos K. Tsilidis, Orestis A. Panagiotou, Emily S. Sena, Eleni Aretouli, Evangelos Evangelou, David W. Howells, Rustam Al-Shahi Salman, Malcolm R. Macleod, John P. A. Ioannidis (2013). Evaluation of Excess Significance Bias in Animal Studies of Neurological Diseases PLoS Biology, 11 (7) DOI: 10.1371/journal.pbio.1001609

Os anatomistas nazistas Parte II

1 “Sources of Material” In 1941, Charlotte Pommer graduated from medical school at the University of Berlin and went to work for Hermann Stieve, head of the school’s Institute of Anatomy. The daughter of a bookseller, Pommer had grown up in Germany’s capital city as Hitler rose to power. But she didn’t appreciate what the Nazis meant for her chosen field until Dec. 22, 1942. What she saw in Stieve’s laboratory that day changed the course of her life—and led her to a singular act of protest. Stieve got his “material,” as he called the bodies he used for research, from nearby Plötzensee Prison, where the courts sent defendants for execution after sentencing them to die. In the years following the war, Stieve would claim that he dissected the corpses of only “dangerous criminals.” But on that day, Pommer saw in his laboratory the bodies of political dissidents. She recognized these people. She knew them. Harro and Libertas Schulze-Boysen Courtesy of Kelisi/Creative Commons On one table lay Libertas Schulze-Boysen, granddaughter of a Prussian prince. She’d been raised in the family castle, gone to finishing school in Switzerland, and worked as the Berlin press officer for the Hollywood studio Metro-Goldwyn-Mayer. She joined the Nazi Party in 1933. On a hunting party, she flirted with Hermann Göring, commander of the Luftwaffe, the German air force. But in 1937 Schulze-Boysen joined the resistance with her husband, Harro, a Luftwaffe lieutenant. They helped form a small rebel group the Nazis called the Red Orchestra. When Libertas started working for Hitler’s movie empire in 1941, she gathered photos of atrocities from the front for a secret archive. Harro was transferred to Göring’s command center and with other dissidents started passing to the Soviets detailed information about Hitler’s plan to invade Russia. The Gestapo decoded their radio messages in 1942 and arrested Harro at the end of August. They came for Libertas eight days later. Both she and her husband were sentenced to death for espionage and treason. Now Harro’s body lay on another table in the lab. Pommer could see that he had been hanged and Libertas had been decapitated by guillotine. On a third table, Pommer identified Arvid Harnack, another member of the Red Orchestra who had been a key informant for the American Embassy as well as the Soviets. In the 1920s, Harnack had studied economics as a Rockefeller Fellow at the University of Wisconsin, where he wandered into a literature class by mistake and met a young American teaching assistant named Mildred Fish. They traded English and German lessons and got married on her brother’s farm. After the couple moved to Germany, Mildred also helped the resistance effort by carrying messages and trailing her husband to meetings to make sure he wasn’t being followed. They were caught in the same Gestapo operation that ensnared the Schulze-Boysens. "Can you remember Picnic Point, when we got engaged?” Arvid asked his wife in his final letter to her from prison. “And before that our first serious talk at lunch in a restaurant in State Street? That talk became my guiding star.” At the time, Mildred was serving a six-year sentence for her part in the Red Orchestra. Before he was executed, Arvid wrote to his family about his joy that her life had been spared. But Hitler refused to accept the sentence, and Mildred, too, would be beheaded on his order two months later.* “I was paralyzed,” Pommer later wrote of the sight of the bodies. “I could hardly perform my task as an assistant to Professor Stieve, who did his scientific study as always with the greatest diligence. I could barely follow.” Pommer was 28. Libertas Schulze-Boysen was 29 when she died. In her last letter to her mother, she said she’d asked for her body to go to her family. “Don’t fret about things that possibly could have been done, this or the other,” she wrote. “If you can, bury me in a beautiful place amid sunny nature.” Pommer stopped working for Stieve—and left the field of anatomy—because of what she saw that day in his laboratory. She went on to help resist the Nazis herself, by hiding the child of a man who participated in the “July Plot” to assassinate Hitler in 1944. In the spring of 1945, just before the war’s end, Pommer was herself sent to prison. By that time, German anatomists had accepted the bodies of thousands of people killed by Hitler’s regime. Beginning in 1933, all 31 anatomy departments in the territory the Third Reich occupied—including Poland, Austria, and the Czech Republic as well as Germany—accepted these corpses. “Charlotte Pommer is the only one we know of who left this work because of what she learned about the bodies,” says Sabine Hildebrandt, a historian and anatomist at Harvard Medical School. Unlike the research of Nazi scientists who became obsessed with racial typing and Aryan superiority, Stieve’s work didn’t end up in the dustbin of history. The tainted origins of this research—along with other studies and education that capitalized on the Nazi supply of human body parts—continue to haunt German and Austrian science, which is only now fully grappling with the implications. Some of the facts, amazingly, are still coming to light. And some German, Austrian, and Polish universities have yet to face up to the likely presence of the remains of Hitler’s victims—their cell and bone and tissue—in university collections that still exist today. This history matters for its own sake. It also matters for debates that remain unresolved—about how anatomists get bodies and what to do with research that is scientifically valuable but morally disturbing. Then there’s this eerie relevance: Stieve’s work was the source of an explosive controversy in the 2012 U.S. elections. It’s the basis for a claim that Republicans in Congress threw like a piece of dynamite into the abortion debate: The idea that women rarely or never get pregnant from rape. To take a step back for a moment, in one sense, the use of executed prisoners for science isn’t surprising. For centuries, anatomists around the globe struggled to find an adequate supply of bodies. The need was keen—without corpses, there could be no dissection for research and medical training. In France, the bodies of poor people who died in hospitals were used widely in the 1700s. An 1832 law in Britain permitted access to the unclaimed bodies of anyone who died in a prison or workhouse. In the United States, medical students robbed graves, often of African-Americans. ‘‘In Baltimore the bodies of colored people exclusively are taken for dissection because the whites do not like it, and the colored people cannot resist,’’ a British travel writer observed in 1838. When paupers were the target of body snatching, the practice was justified by their poverty. “Why would those who have made war on society or have been a burden to it be permitted to say what shall be done with their remains?” the Washington Post asked in an 1877 editorial. “Why should they not be compelled to be of some use after death, having failed to be of value to the world during life?” Plötzensee Prison in 2012 Courtesy of Ahle, Fischer & Co. Bau GmbH/Creative Commons Before Hitler, German anatomists had complained to the government for decades about the lack of supply. They had the right to claim the bodies of the executed, but few death sentences were carried out. That changed as the Nazi courts ordered dozens and then hundreds of civilian executions each year, for an estimated total of 12,000 to 16,000 from 1933 to 1945. (The 6 million who were killed in concentration camps are counted separately, as are the many millions more who were otherwise mass-murdered.) Plötzensee and other prisons delivered to anatomists a sudden abundance. In the mid-1930s, British anatomists described with envy the “valuable sources of material” their German counterparts had. The “sources of material” included many people the Nazis sentenced to death for minor crimes, such as looting, and many convicted for political crimes that particularly incensed the regime, ranging from treason to the vague offense of “defeatism.” The victims included political protesters like the Schulze-Boysens and the Harnacks, who would one day be seen as heroes. By refusing them graves, anatomists such as Stieve humiliated the victims’ families and disturbed the peace of the dead. A few of these anatomists followed the Nazis further down their twisted path: They committed or acceded to acts of mass killing, in the name of science and from inside the halls of academe. 2 Dr. Stieve and “Legitimate Rape” Stieve had a taste for the theatrical: He liked to wear his long black academic robe to give lectures. At the age of 35, he became the youngest doctor to chair a German medical department. That was in 1921, soon after Stieve backed a coup that would have knocked out the Weimar Republic in favor of authoritarian rule. Stieve was a nationalist about language, too: He supported a drive to replace Anglified words like April and Mai with Germanic alternatives. Stieve welcomed Hitler for his promise to restore the country’s pride, although he did not join the Nazi Party. Like most academics, Stieve did not protest when the Nazis began to expel Jews from universities in 1933. Charlotte Pommer is the only one we know of who left this work because of what she learned about the bodies. Sabine Hildebrandt Stieve’s main research interest, throughout his career, was the effect of stress and other environmental conditions on the female reproductive system. He studied whether hens would lay eggs with a caged fox nearby, and he set up conditions of stress for newts. Stieve studied human uteruses and ovaries when he could get them from accident victims or from gynecologists who’d removed the organs in the course of an operation. Before the Nazis, the access that German anatomists had to the bodies of executed prisoners was of less use to Stieve. During the Weimar Republic, no women received death sentences. The Third Reich and the war changed that. At Plötzensee alone the Nazis executed 3,000 people. Stieve agreed to take all these bodies off the hands of the prison officials—many more than he needed for his research. By accommodating Plötzensee, he won concessions that aided his work on the “unprecedented number of women” now available to him, as the German anatomist and historian Andreas Winkelmann puts it. In 1942, when the prison shifted the time of executions to the evening, Stieve visited the prison and got the time moved back to the morning so he could continue to process organs and tissues on the same day. He also got details of the women’s medical histories before they died, including information about their menstrual cycles, their reactions to the prison environment, and the impact of receiving a death sentence. We know this because Stieve kept a list. The official record of the bodies he received was lost when the Institute of Anatomy’s registry was destroyed in 1945, either deliberately or in a bombing. But a Protestant minister who tended to the Plötzensee prisoners during the war helped search for and record information about them afterward. He reported that in 1946, Stieve handed him a typed list of names—the people whose bodies he had used. It was located decades later in German government archives, with handwritten additions. There were 182 names: 174 women and eight men. Their ages ranged from 18 to 68, with most of reproductive age. Two of the women were pregnant when they were killed. The majority were executed for political reasons. They came from Germany, for the most part, and seven other countries. Libertas Schulze-Boysen is No. 37 on Stieve’s list. Mildred Harnack is No. 87. Mildred Harnack's Red Orchestra Counterintelligence Corps file, circa 1947 Courtesy of National Archives, College Park, Md. Stieve published 230 anatomical papers. With the data he gathered pre-execution, as well as the tissues and organs he harvested and studied, he could chart the effect of an impending execution on ovulation. Stieve found that women living with a looming death sentence ovulated less predictably and sometimes experienced what he called “shock bleedings.” In a book published after the war, Stieve included an illustration of the left ovary of a 22-year-old woman, noting that she “had not menstruated for 157 days due to nervous agitation.” Stieve drew two conclusions that continue to be cited (for the most part, uncritically). He figured out that the rhythm method doesn’t effectively prevent pregnancy. (He got the physiological details wrong but the conclusion right.) And he discovered that chronic stress—awaiting execution—affects the female reproductive system. In August 2012, then–Rep. Todd Akin of Missouri said that women can prevent themselves from getting pregnant after a “legitimate rape.” Following an uproar, Akin lost his bid for a Senate seat.* Still, a few other Republicans have followed along, arguing that rape rarely results in pregnancy, to explain why they oppose an exception for rape victims in laws that restrict access to abortion. Whether they know it or not, Stieve’s work is the source for their discredited claim. The American College of Obstetricians and Gynecologists warned that saying rape victims rarely get pregnant was “medically inaccurate, offensive, and dangerous.” But the anti-abortion doctor Jack Willke, former head of the National Right to Life Committee, insisted otherwise. "This goes back 30 and 40 years,” he told the Los Angeles Times in the midst of the Akin furor. “When a woman is assaulted and raped, there's a tremendous amount of emotional upset within her body." Willke has written that "one of the most important reasons why a rape victim rarely gets pregnant” is “physical trauma." Where did he get this idea? In 1972, another anti-abortion doctor, Fred Mecklenburg, wrote an essay in a book financed by the group Americans United for Life in which he asserted that women rarely get pregnant from rape. Mecklenburg said that: The Nazis tested the hypothesis that stress inhibits ovulation by selecting women who were about to ovulate and sending them to the gas chambers, only to bring them back after their realistic mock killing, to see what effects this had on their ovulatory pattern. An extremely high percentage of these women did not ovulate. Mecklenburg got his facts wrong. Plötzensee Prison wasn’t the gas chamber. And the prolonged trauma of anticipating execution isn’t the same as the shock of rape. But when Hildebrandt, the Harvard historian and anatomist, read about Mecklenburg’s rationale after I wrote about it for the New York Times Magazine and Slate, she recognized the handiwork of Stieve. Mecklenburg had quoted a presentation on a “Nazi experiment” by another obstetrician, from Georgetown University, at a 1967 Washington, D.C., conference on abortion. That doctor had to be talking about Stieve, Hildebrandt says, since “there is no other ‘Nazi experiment’ like this.” It was another link in the chain from Stieve to Mecklenburg to Willke to today’s anti-abortion Republicans. Hildebrandt wrote to me about Stieve, and that’s how I learned about her work. She is 55 and was born in Germany; her parents were children during the Third Reich. “It was always around us,” she said. “I had no Jewish neighbors. I went to an elementary school named after a member of the German resistance.” Hildebrandt came to live in the United States in 2002. Her interest in the history of anatomy is recent. “In many ways it was helpful for me to formulate my first ideas all by myself, with physical distance from Germany,” she said. “I didn’t have to worry about treading on anyone’s toes. I’m not a brave person.” Hermann Stieve lecturing on anatomy, 1943 Courtesy of Privatbesitz/Creative Commons By contrast, Hildebrandt says that Stieve “never doubted himself.” She thinks he refused to see that the ethics of how he procured bodies shifted under the Nazis. “He knew better, but he didn’t want to realize it, because this was a great opportunity for him,” she says. “He really could do the work that he always wanted to do.” When I asked to learn more about Stieve, Hildebrandt sent me to Winkelmann, the German doctor and lecturer in anatomy at Charité, the major university hospital in Berlin. Born in 1963, Winkelmann is also of the “grandchildren generation,” as he put it when we spoke by phone. I asked him how he got interested in Stieve, and he said, “Stieve was a Berlin anatomist like me. He is part of my history. He worked in the same building that we work in today.” Winkelmann has helped make the ethical case against Stieve. “His research cannot be validated without justifying, at least to some extent, the entire Nazi justice system, which was instead one of injustice,” he argued in a 2009 article, co-written with Udo Schagen, a medical historian at Charité. Stieve abetted the Nazis with his willingness to accept far more bodies than he needed for research, and he kept his supply line quiet. And Winkelmann pointed out that Stieve’s “use of the terror of death row as a sober scientific variable is undoubtedly callous.” But Winkelmann has also pleaded for a kind of mercy for Stieve—or at least for nuance. “People tend to forget that it was only in the 1950s and ’60s that body donation programs were invented,” he said. “Stieve thought using the bodies of executed prisoners was something normal to do. He didn’t do research to prove some people were subhuman, as some doctors did. I don’t think that vindicates what he did, but you could say, at least he didn’t do that.” In 1944, Stieve dissected one of his own friends. Winkelmann has also pushed back against two allegations that turn Stieve into a monster. William Seidelman, a University of Toronto medical professor who has written extensively on medicine in the Third Reich, thinks Stieve allowed SS officers to rape women on his list before they were executed, so he could study the migration of sperm. Seidelman’s allegation is based on a 1997 letter from a former student of Stieve. Winkelmann’s co-author, Schagen, spoke to the former student, and they think he was repeating a rumor or misinterpreting Stieve’s remarks about his work. None of Stieve’s papers discuss sperm migration. The former student has since died, and Seidelman stands by his accusation. Winkelmann calls it “far-fetched.” But he adds, “I can understand how Seidelman would think it’s true, because whenever you look into Nazi medicine, you find that the very worst things—they have happened.” Case in point: There is a rumor that Stieve’s lab made soap from the remains of the victims. Winkelmann has refuted that one, too. “But another anatomist named Spanner did make bodies into soap,” he told me. Rudolf Spanner was director of the Danzig Anatomical Institute. He didn’t go into mass production—“Professor Spanner’s Soap Factory” is a myth. But the remains of 147 unidentified people were found in Spanner’s institute after the war, and “during several interrogations Spanner conceded the production of small amounts of soap for anatomical purposes but was not prosecuted,” Hildebrandt writes. After the war, Stieve falsely insisted that he hadn’t conducted research with the bodies of political prisoners. The anatomist, he argued, “only tries to retrieve results from those incidents that belong to the saddest experiences known in the history of mankind.” He continued to see himself as a man of science. “In no way do I need to be ashamed of the fact that I was able to reveal new data from the bodies of the executed, facts that were unknown before and are now recognized by the whole world.” Like almost every other anatomist of his time, Stieve was never professionally penalized or prosecuted for conducting research on the corpses of murdered prisoners. He continued to direct his university’s Institute of Anatomy until his death from a stroke in 1952. Stieve’s obituaries didn’t describe his negotiations with Plötzensee Prison over the timing of executions to ensure the daily delivery of fresh bodies. They lauded him as a highly respected scientist who loved hunting and mountaineering. Winkelmann told me a strange story that supports his interpretation of Stieve as blinded by science, not ideology. In 1944, Stieve dissected one of his own friends. Walter Arndt was a doctor and zoologist who converted to Judaism in 1931. He was executed after being convicted for criticizing the Nazis. “Stieve took out his heart and kept it,” Winkelmann told me. “Stieve wanted to donate his own body to science when he died,” he continued. “But his wife objected. So in the end, he was buried.” 3 “A Few Perverted Psychopaths” With the war’s end came an early chance for investigation. The occupying military governments operating after the war tried to find the bodies of political dissidents and foreign nationals. And families looking for their loved ones started visiting Germany’s anatomical institutes. The procurement of bodies had been an open secret. “Thus, anatomists were asked about the identity and fate of the bodies remaining in their institutes’ storage spaces,” Hildebrandt writes. Often, however, identification was out of reach—documents had been lost, dissected bodies rendered unrecognizable. At the Nuremberg trials, 23 doctors faced charges. But those few charged with crimes were the physicians at the Nazi forefront: the ones who experimented on live subjects in the concentration camps, not the much larger number of academics who stayed in the universities. “Many people in the medical profession who played leading roles during the Third Reich retained power after the war—especially in the academy,” Seidelman told me. “They were able to keep the lid on things.” Exhibition entitled “Physical and Emotional Appearance of the Jews,” which opened at the Museum of Natural History in Vienna in 1939 Courtesy of the Museum of Natural History in Vienna Half of Germany’s doctors had joined the Nazi Party. Despite the denazification that followed the war, almost all of them continued practicing. “People didn’t want to know,” said Arthur Caplan, a New York University bioethicist and author of When Medicine Went Mad: Bioethics and the Holocaust. “Who would be the doctors if not the doctors from before the war? Who else would staff the universities? The German establishment wasn’t looking to weed out all the doctors who’d done bad things.” So it was expedient when an influential German physician, asked to study the matter, declared at a 1948 national meeting that among the country’s 90,000 doctors, only 300 to 400 had been involved in Nazi crimes. Other doctors quickly adopted this assessment, “as it conveniently allowed them to declare that the National Socialist medical atrocities were committed by only a few perverted psychopaths,” Hildebrandt writes. Caplan emphasizes that this is a trap. He argues for the importance of seeing the doctors who took advantage of Nazi immorality to benefit their research not as “kooks,” but instead as typical and conventional for their time and place. “One of the great challenges in all of ethics is, how do mainstream, legitimate people do evil things?” he said. “It’s not like we can necessarily stop it. But to understand how it happened—that is our best shot.” The more perspective gained, perhaps, the more this kind of far-reaching inquiry becomes possible. In the years after the war, though, when the horrors of the camps were fresh, punishing the worst of the worst doctors took precedence. The single German anatomist who went to prison was one of them. Johann Paul Kremer at the "trial of 40 German butchers of Auschwitz camp," Nov. 25, 1947 Courtesy of the National Archives and Records Administration Johann Paul Kremer was an SS officer as well as an anatomist at the University of Münster. There he had conducted animal experiments on hunger. Detailed to Auschwitz, he continued his research on humans. He would observe prisoners, he said later, “and when one of them interested me because of a highly advanced state of starvation, I commanded the orderly to reserve that patient for me, and inform me of when that patient would be killed with the help of an injection.” Kremer often witnessed the killings. He collected tissue and sent it back to Münster. In another facet of his job, Kremer selected 10,717 prisoners for death on the train ramp in Auschwitz. For that, he was sentenced to death in Poland in 1948. He served 10 years before he was released and returned to Münster. Other anatomists ensconced in the academy, meanwhile, got away with terrible crimes even when the Allies had direct knowledge of them. In June 1945, a Boston neurologist named Leo Alexander, a consultant for the United States secretary of war, visited Julius Hallervorden, a doctor and member of the Nazi Party who in 1938 became head of the neuropathology department of the Kaiser Wilhelm Institute for Brain Research (one of the world’s pre-eminent psychiatric research centers, with a building financed in the 1920s by the Rockefeller Foundation). Hallervorden showed Alexander a collection of 110,000 brain samples from 2,800 people. Hallervorden said that with the director of his institute, Hugo Spatz, he had harvested the brains of victims of the T-4 killings—the Nazi program to gas psychiatric patients at six “euthanasia” centers in Germany and Austria. “Hallervorden was present at the time of the killings and removed brains from the murdered victims,” Seidelman writes. Alexander reported what he learned, but no one took action against Hallervorden and Spatz. They were allowed to help relocate the Kaiser Wilhelm institute to Frankfurt, Germany, where it was renamed the Max Planck Institute for Brain Research. They continued to be recognized for their signature scientific accomplishment: In 1922, Hallervorden and Spatz had discovered a degenerative brain disease that was named after them. The two neuropathologists finished their careers and died in the 1960s. In 1982, Hallervorden was honored by a German university; the citation called him “the grand old man of German and international neuropathology.” Now, because of Hallervorden and Spatz’s later methods, the disease they discovered is called something else. That is the right decision, NYU’s Caplan says. While he does not think science has to throw out Hallervorden and Spatz’s findings, he also has rules for dealing with tainted data. “If you use it, you had better be sure you don’t have any choice,” he said. “The purpose should be life-saving or very, very important. And you have to admit you are using it, but without giving credit to the person who gave you the tainted experiments. You say, ‘This came from a prominent German scientist under the Nazis.’ But you don’t recognize them by name.” That is fitting. But it took a long time to get there. 4 “Dirtying the Nest” By the 1980s, the doctors and scientists of the World War II generation no longer ran Germany’s medical schools and anatomical institutes. They’d passed the baton to their pupils. But this second generation was hardly more eager to dig into the past. When German medical students and a few researchers, Seidelman among them, started asking questions about the conduct of anatomists under Hitler—and the status of the slides and tissue samples they’d left behind as teaching materials—their queries mostly ran into a wall of denial. The professors rebuked the new generation of students for demanding more information, scolding them for being Nestbeschmutzer, for “dirtying the nest.” The wall of denial began to crack, though, when a German historian and journalist, Götz Aly, persisted in applying for access to the Max Planck Institute’s specimen collection. Once he got inside, Aly identified some of the T-4 euthanasia victims and started pushing for the burial of the specimens. It was a novel idea. The Max Planck Society admitted that its collection contained the tissue of euthanasia victims—including 700 children. The director of the Max Planck Institute resisted, contesting Aly’s claims. But Aly had solid evidence. In small groups, German medical students began taking up the same cause. At the University of Heidelberg, where Gerrit Hohendorf (now a professor at the Technical University of Munich) was a student, “They didn’t want an independent inquiry or students to deal with these things,” he told me. “We organized a student lecture series on our own with no support by the medical faculty or teachers of medicine. We heard something about children being euthanized at the Heidelberg psychiatric hospital, so we went into the hospital and asked the professors.” The new wave of attention crested at the University of Tübingen in 1989, when student demand for an inquiry sparked national press attention. TV and print stories spotlighted the continuing use of Nazi-era specimens for research and teaching. Demonstrators protested outside the German Embassy in Israel, and the Israeli minister of religion demanded that Chancellor Helmut Kohl return the remains of all Nazi victims for proper burial. Aly added fuel to the fire with an article quoting Hallervorden saying “the more the better” about the brains he’d acquired. “I have not heard of one German anatomist who after the war repudiated Nazi practices and buried his ill-gotten collection,” Aly wrote. Two important books appeared—Doctors Under Hitler, by York University historian Michael Kater, and Oxford Brookes historian Paul Weindling’s volume on health, race, and German politics. Caplan held the first conference on medicine and science during the Nazi era in Minnesota. A proposal to boycott German data collected under Hitler was a major topic. The University of Tübingen issued a public apology and set up a commission to investigate that served as a model for other schools. And the Max Planck Society admitted that its collection contained the tissue of euthanasia victims—including 700 children. The Max Planck Society buried these remains in a May 1990 memorial service. It was the demand Aly had been making. But it wasn’t enough, in the view of Seidelman and Caplan, who’d begun to play a leading activist role among Western researchers. Seidelman protested the disposal of the human specimens in a mass grave, without uncovering “who these people were, how they died,” and how their remains had been used for almost half a century. He and Caplan called for an international commemoration and bioethical inquiry. It didn’t happen. “They weren’t ready,” Seidelman says. In 1992, the German government ordered all state universities to investigate their anatomical collections. Some followed Tübingen. Others followed the Max Planck example of mass disposal. “The victims’ bodies were seen as ‘polluting’ German universities,” Weindling, the British historian, writes. And some universities brushed off the government’s order or claimed they couldn’t comply because their buildings had been bombed during the war. The effort to carry out a full national inquiry foundered at a time of momentous distraction: The Berlin Wall fell in November 1989, and the Soviet Union soon collapsed. Amid the upheaval, indifference won out. As one anatomy professor said two decades later, at the age of 96, when he was interviewed about the use of the bodies of the executed at his Vienna institute: “Nobody cared, and why should we have cared?” A 77-year-old colleague echoed him: “Nobody cared.” Illustration from Eduard Pernkopf's Atlas of Topographical and Applied Human Anatomy Pernkopf atlas/Urban & Schwarzenberg. Scans via Codex99. The two men were talking about a controversy that flared up at their own institute. It concerned a work of lasting scientific importance, one that occupies its own niche and is used by doctors and researchers around the world: the Pernkopf atlas. Eduard Pernkopf toiled over his four-volume atlas in Vienna for more than 20 years beginning in 1933. “He put in 18-hour days dissecting human bodies and supervising a team of artists who painted what he revealed in intricate detail,” Heather Pringle explains in Science. The New England Journal of Medicine called the atlas “an outstanding book of great value” in 1990. “If you’re a serious anatomist like I am, you still look at the thing, because it has more detail than anything else,” Hildebrandt says. “And some of the images pop up in later anatomy books.” Pernkopf was a Nazi. As dean of the medical school at the University of Vienna, he expelled Jews from the faculty faster than any university official in the Third Reich. Nazi insignia appear in his atlas, woven into the signatures of the artists. A Columbia professor of dentistry, Howard Israel, started asking about the insignia in 1994. “His wife gave him the atlas as a gift when he was in dental school,” Seidelman says. “He used it every day.” Seidelman brought Israel’s concerns to Yad Vashem, the Holocaust museum in Jerusalem. One of the men portrayed in the atlas had a shaved head—was he a Jewish concentration camp victim? Letters started flying back and forth between Yad Vashem and Vienna. Austrian officials at first denied that any illustrations in the atlas came from the Nazi era. The hair of all cadavers was shaved at the institute, they said. When informed consent is not the rule, the people whose bodies and tissues go to medicine have been overwhelmingly the poor and the marginalized. “We pointed out why they were wrong,” Seidelman says. At a 1999 University of Vienna symposium called Medicine Under Scrutiny, the rector of the university announced a committee of investigation. “He said he’d turned to the faculty of medicine, and he realized they’d lied,” recalls Seidelman, who also spoke at the symposium. “For him to stand up in public and say that—it was risky. It was a big deal.” The investigating committee documented the delivery of 1,377 bodies to the university from the execution chambers of the regional Vienna court. The images in the Pernkopf atlas could not be traced to individual victims, but the historians I talked to think there is a great likelihood that the drawings depict people executed by the Nazis. And there was more: a link between university scientists and Heinrich Gross, the doctor who headed the infants’ ward of Spiegelgrund, the children’s wing of the Vienna Psychiatric Hospital, during the war. Gross did painful experiments on living children there, some of whom died as a result. One child who survived said the children called Gross “the Scythe”; another remembered that his arrival on the ward “was like a cold wind coming.” All told, 772 children were killed at Spiegelgrund, about half of them from Gross’ ward. In 1948, he was charged with murder. But the penal code he was prosecuted under did not define murder to include disabled people because they were “not capable of reasoning.” He was found guilty only of manslaughter, and when Gross appealed and won, the prosecutor chose not to retry him. Memorial for the children murdered by the National Socialist Euthanasia Program at Spiegelgrund from 1940-45 in Vienna Courtesy of Haeferl/Creative Commons Gross returned to Spiegelgrund (it had been renamed) and continued his research using brain specimens from the children who had been killed there. He published 35 papers, some written with University of Vienna faculty. He also testified as a psychiatric expert in thousands of cases in the Austrian court. In 1975, he was awarded the Austrian Cross of Honor for Science and Art. As the University of Vienna committee brought renewed attention to this history, evidence against Gross also surfaced in the files of the Stasi, the East German secret police. In 1999, he was indicted for murder again. But Gross’ lawyers said he had Alzheimer’s and could not understand the proceedings against him. The court accepted this defense. But Seidelman does not believe it. “Do you know what Gross did?” he asked. “He smiled and went off to a coffee shop with his friends and family to celebrate.” Gross lived for six more years, until the age of 90. In 2002, the wartime human specimens at the University of Vienna were buried in the city’s Jewish cemetery, and the brains of the Spiegelgrund children were placed in the main graveyard. The Austrian Cross was stripped from Gross the following year. 5 The Henrietta Lacks Problem The long-buried history of Nazi-era anatomy is surfacing now because of a burst of investigation by the third postwar generation. These scholars also want to memorialize the victims. “I never expected to see this reckoning in my lifetime,” Seidelman told me. Still, it is “just a beginning,” Hildebrandt wrote last year with Christoph Redies, director of the anatomy department at Germany’s Jena University and another leader in the new history, following the first public symposium on anatomy during the Third Reich, held by Germany’s prestigious international anatomical society, Anatomische Gesellschaft, founded in 1886. Hildebrandt has tracked down evidence showing that after World War II, during the Allied occupation, the Allies questioned anatomists at 11 of the 31 anatomical institutes at universities in Germany, Austria, Poland, and the rest of the territory occupied by the Third Reich. Since 1992, when the German government ordered the universities to investigate their anatomical collections and their wartime histories, only 14 of the 31 universities have done full-fledged and thorough examinations. The other 17 conducted preliminary investigations or none at all. This means they still have a giant Henrietta Lacks problem. For example, at Jena, which opened its collections to outside inspection in 2005, more than a dozen paraffin blocks with histological specimens, taken from four people executed under Hitler, have been found in the past three years. It’s impossible to say what lies in the collections of the schools that have not undertaken this kind of inquiry. In Rebecca Skloot’s 2010 best-seller about Lacks, whose cervical cancer produced a fast-growing cell line that became the basis for decades of scientific advances, the author raises deep ethical questions about the use of Lacks’ cells: After all, she and her family never consented to any of the research done with her tissue. Harro Schulze-Boysen, 1930s Courtesy of I.M. Bondarenko Archive/Creative Commons Informed consent is the moral difference between the fate of the bodies of Libertas and Harro Schulze-Boysen and of voluntary donors. Anatomists and medical students do need cadavers. Science does need bones and tissue. The utilitarian case for using the bodies of the executed or people who die in public institutions and whose corpses go unclaimed is that the scientific benefit is greater than the moral harm. And the deceased will never know. When informed consent is not the rule, the people whose bodies and tissues go to medicine have been overwhelmingly the poor and the marginalized. In an article in Clinical Anatomy published last year, bioethicist Gareth Jones and anatomist Maja Whitaker, both from New Zealand, called for an international standard of informed consent. “Anatomists should cease using unclaimed bodies,” they write. That would change the ongoing practice in some African countries and also in Bangladesh, India, and Brazil, Jones and Whitaker say, where bequests are rare or nonexistent. It would also require the law to change in parts of the United States. “Maryland, Pennsylvania, North Carolina, Michigan, and Texas, automatically pass on unclaimed bodies to state anatomy boards,” the authors write. There are concerns, too, about the use of bodies of the executed in China. In an email, Jones told me he sees the state laws that still allow for the use of unclaimed bodies as “a historic hangover.” It’s time for these statutes to go. Countries without a tradition of body donation pose a greater dilemma, but Jones thinks cadavers could be sent from places where there is a good supply to those where there is not. “We have not seriously begun to consider this,” he wrote. “Bodies are bequeathed where there are good relations between those requiring bodies (anatomy departments) and those able to provide the bodies (ordinary people in the community). This requires mutual trust and understanding, something that is built up over many years. In my estimation this side of bequeathing has been seriously overlooked and downplayed by anatomists.” The same can apply to organ donation. As Jones and Whitaker write, “There will always be tension between obtaining a satisfactory range of acceptable human material both for teaching and research, and abiding by demanding ethical standards.” The field of anatomy has long failed to get the balance right. That helps explain what went so wrong among the anatomists of Nazi Germany. “It is deeply unfortunate that they belonged to a discipline that at that time gave little thought to ethics (a criticism that applied for many years after the 1940s in any country),” Jones wrote to me. “Consequently they were operating in an ethos that allowed for appallingly unethical behavior. This in no way justifies any of their practices, but if anatomy as a discipline had been radically different, at least some of the horrors of this corner of Nazi atrocities may not have taken place.” 6 Attending to the Victims August Hirt (1898–1945) Courtesy of Hans-Joachim Lang In 2001, Hubert Markl, president of the Max Planck Society, gave a landmark speech about the wartime culpability of the society’s doctors and scientists. Markl acknowledged that Josef Mengele, the notorious Nazi doctor who selected people for life or death at Auschwitz, did his perverse research on twins with his mentor, an anthropologist at the Kaiser Wilhelm Institute, the precursor to the Max Planck Society. In attendance were a few survivors of Mengele’s experiments. Markl apologized to them personally. “It is a painful way to meet the past when one personally stands face to face with the victims of these crimes,” he said. “I beg you, the surviving victims, from the bottom of my heart to forgive those who, no matter what their reasons, failed to ask you themselves.” This is the latest stage of reckoning: Trying to attend to the victims and to their memory. The most startling breakthrough comes from German journalist and Tübingen culture professor Hans-Joachim Lang. He has identified all of the Jews selected for gassing by August Hirt, director of the anatomical institute in Strasbourg who had a singularly ghoulish plan for their remains. Hirt was interested in adding to a collection of skulls at the University of Strasbourg. “Although extensive skulls collections existed from nearly all races and peoples,” the Jews were missing, he wrote to the director of an SS research group established to prove Aryan superiority. “From the Jewish-Bolshevik commissars, who embody a disgusting, but characteristic type of subhuman, we have the opportunity to acquire a tangible scientific document by securing their skulls.” As I wrote this piece and lived with its horrors, the photographs of the women and men at its center held me close. Hirt was essentially competing with the Natural History Museum in Vienna, which procured Jewish skulls from another anatomist, Hermann Voss. In consultation with the staff of Heinrich Himmler, Hirt received permission to go ahead. Two staff members were sent to Auschwitz to separate out a group of Jews, 30 women and 79 men. They were examined according to the standards for racial typing of the time: Their skin, hair, and eye color were noted and coded using special tables, and the shapes of their heads, foreheads, noses, mouths, and ears measured. Fifty-seven of the men and 29 of the women were chosen. They were gassed in a special chamber and their bodies delivered to Hirt at his anatomical institute. Hirt stored the bodies in the basement. In the end, he didn’t work on them—he lacked the equipment during the course of the war. At the war’s end, Himmler ordered the bodies destroyed. But in January 1945, after the liberation of Strasbourg, the London Daily Mail reported their discovery in the anatomical institute. Accused as a fanatic, Hirt pointed out that bodies could be found in every anatomical institute. The corpses, he wrote, “are the usual cadavers for dissection training.” Frank Sachnowitz (1925–1943) Courtesy of Hans-Joachim Lang Hirt went into hiding in April of that year and committed suicide two months later. It turned out that Himmler’s order had been partially followed: The heads of 70 of the bodies had been removed and cremated. The French military, which controlled Strasbourg, gave up trying to identify them and buried the bodies in the local Jewish cemetery in a mass grave. But the French left behind documents showing that Hirt’s lab workers had forgotten to remove the concentration camp numbers on some of the bodies. And one of those workers revealed at the Nuremberg doctors’ trials that he had written the numbers down without knowing what they were. He kept the piece of paper. After a long search, Lang found a copy of it in the U.S. Holocaust Memorial Museum. He translated the numbers back into names. He found pictures of a few of the victims. He learned their cities of origin. One man, Frank Sachnowitz, came from Norway. His brother, who survived Auschwitz, wrote in a memoir that his father had planted an apple tree—a tree of life—for himself, his wife, and each of their eight children in the family garden. Before the war. In 2005, a memorial stone with the names of the victims was added to their grave. Lang created a website about them. “Remembrance of their fates … does not, as is often said, return dignity to the victims,” he wrote this year in an article in Annals of Anatomy. “It is not the victims who lost their dignity, but rather those who had persecuted them. The perpetrators should not be allowed to have the final word.” Erna, Elfriede, and Erich Remarque during their childhood Courtesy of the Erich Maria Remarque Peace Center Osnabrück Hildebrandt also sees this as her mission: “to turn numbers back into names,” as she puts it. She has publicized Stieve’s list, giving the BBC photographs and details of some of the women and helping Slate with this piece. She opens one of her articles with a 1946 quote: The difficulty is, you see, that our imaginations cannot count ... And if I say one died—a man I have made you know and understand ... then perhaps I have told you something that you should know about the Nazis. The words come from a man who knew the power of narrative: Erich Maria Remarque. He wrote All Quiet on the Western Front, the classic novel about World War I. Remarque served in a World War I battle with Hitler. But the Nazis banned and burned his book. He left Germany for Switzerland in the 1930s. His sister, Elfriede Scholz, remained in the country with her husband and two children. She was found guilty of “undermining morale” in 1943 for saying she thought the war was lost. "Your brother is unfortunately beyond our reach—you, however, will not escape us,” the judge said when he gave Scholz a death sentence. Like Libertas Schulze-Boysen and Mildred Harnack, she was executed in Plötzensee Prison, and her body was given to Stieve. Hildebrandt has counted about 2,000 execution victims of Nazi-era anatomy who have been individually identified. She points out that still, “existing memorials rarely name individuals.” Weindling has been trying to identify the victims of all Nazi-era medical experiments, including those from the T-4 euthanasia killings. He has been blocked by the rules for German archives, which dictate that the names may not be released for privacy reasons because they were once psychiatric patients. Arvid and Mildred Harnack Courtesy of the German Resistance Memorial Center* And yet, so many years have passed—is privacy really the reigning concern? As I wrote this piece and lived with its horrors, the photographs of the women and men at its center held me close. They are young. They are full of life. They are wearing the hats and clothing of my grandparents’ generation. I learn little from the faces of the anatomists. But I could look forever at Libertas and Harro Schulze-Boysen, and Arvid and Mildred Harnack, and Frank Sachnowitz. I could not find a photograph of Charlotte Pommer. She never married or had children. She died in a retirement home near Munich in 2004 and donated her body to anatomy. Correction, Nov. 6, 2013: This article originally misstated the date of Mildred Harnack's death. She was executed two months after her husband, not 15 months. (Return.) This article also stated that former Missouri Rep. Todd Akin lost a bid for re-election to his House seat. He lost a bid for the Senate. (Return.)

Os anatomistas nazistas Parte I

The Nazi Anatomists How the corpses of Hitler's victims are still haunting modern science—and American abortion politics. By Emily Bazelon 1 “Sources of Material” In 1941, Charlotte Pommer graduated from medical school at the University of Berlin and went to work for Hermann Stieve, head of the school’s Institute of Anatomy. The daughter of a bookseller, Pommer had grown up in Germany’s capital city as Hitler rose to power. But she didn’t appreciate what the Nazis meant for her chosen field until Dec. 22, 1942. What she saw in Stieve’s laboratory that day changed the course of her life—and led her to a singular act of protest. Stieve got his “material,” as he called the bodies he used for research, from nearby Plötzensee Prison, where the courts sent defendants for execution after sentencing them to die. In the years following the war, Stieve would claim that he dissected the corpses of only “dangerous criminals.” But on that day, Pommer saw in his laboratory the bodies of political dissidents. She recognized these people. She knew them. Harro and Libertas Schulze-Boysen Courtesy of Kelisi/Creative Commons On one table lay Libertas Schulze-Boysen, granddaughter of a Prussian prince. She’d been raised in the family castle, gone to finishing school in Switzerland, and worked as the Berlin press officer for the Hollywood studio Metro-Goldwyn-Mayer. She joined the Nazi Party in 1933. On a hunting party, she flirted with Hermann Göring, commander of the Luftwaffe, the German air force. But in 1937 Schulze-Boysen joined the resistance with her husband, Harro, a Luftwaffe lieutenant. They helped form a small rebel group the Nazis called the Red Orchestra. When Libertas started working for Hitler’s movie empire in 1941, she gathered photos of atrocities from the front for a secret archive. Harro was transferred to Göring’s command center and with other dissidents started passing to the Soviets detailed information about Hitler’s plan to invade Russia. The Gestapo decoded their radio messages in 1942 and arrested Harro at the end of August. They came for Libertas eight days later. Both she and her husband were sentenced to death for espionage and treason. Now Harro’s body lay on another table in the lab. Pommer could see that he had been hanged and Libertas had been decapitated by guillotine. On a third table, Pommer identified Arvid Harnack, another member of the Red Orchestra who had been a key informant for the American Embassy as well as the Soviets. In the 1920s, Harnack had studied economics as a Rockefeller Fellow at the University of Wisconsin, where he wandered into a literature class by mistake and met a young American teaching assistant named Mildred Fish. They traded English and German lessons and got married on her brother’s farm. After the couple moved to Germany, Mildred also helped the resistance effort by carrying messages and trailing her husband to meetings to make sure he wasn’t being followed. They were caught in the same Gestapo operation that ensnared the Schulze-Boysens. "Can you remember Picnic Point, when we got engaged?” Arvid asked his wife in his final letter to her from prison. “And before that our first serious talk at lunch in a restaurant in State Street? That talk became my guiding star.” At the time, Mildred was serving a six-year sentence for her part in the Red Orchestra. Before he was executed, Arvid wrote to his family about his joy that her life had been spared. But Hitler refused to accept the sentence, and Mildred, too, would be beheaded on his order two months later.* “I was paralyzed,” Pommer later wrote of the sight of the bodies. “I could hardly perform my task as an assistant to Professor Stieve, who did his scientific study as always with the greatest diligence. I could barely follow.” Pommer was 28. Libertas Schulze-Boysen was 29 when she died. In her last letter to her mother, she said she’d asked for her body to go to her family. “Don’t fret about things that possibly could have been done, this or the other,” she wrote. “If you can, bury me in a beautiful place amid sunny nature.” Pommer stopped working for Stieve—and left the field of anatomy—because of what she saw that day in his laboratory. She went on to help resist the Nazis herself, by hiding the child of a man who participated in the “July Plot” to assassinate Hitler in 1944. In the spring of 1945, just before the war’s end, Pommer was herself sent to prison. By that time, German anatomists had accepted the bodies of thousands of people killed by Hitler’s regime. Beginning in 1933, all 31 anatomy departments in the territory the Third Reich occupied—including Poland, Austria, and the Czech Republic as well as Germany—accepted these corpses. “Charlotte Pommer is the only one we know of who left this work because of what she learned about the bodies,” says Sabine Hildebrandt, a historian and anatomist at Harvard Medical School. Unlike the research of Nazi scientists who became obsessed with racial typing and Aryan superiority, Stieve’s work didn’t end up in the dustbin of history. The tainted origins of this research—along with other studies and education that capitalized on the Nazi supply of human body parts—continue to haunt German and Austrian science, which is only now fully grappling with the implications. Some of the facts, amazingly, are still coming to light. And some German, Austrian, and Polish universities have yet to face up to the likely presence of the remains of Hitler’s victims—their cell and bone and tissue—in university collections that still exist today. This history matters for its own sake. It also matters for debates that remain unresolved—about how anatomists get bodies and what to do with research that is scientifically valuable but morally disturbing. Then there’s this eerie relevance: Stieve’s work was the source of an explosive controversy in the 2012 U.S. elections. It’s the basis for a claim that Republicans in Congress threw like a piece of dynamite into the abortion debate: The idea that women rarely or never get pregnant from rape. To take a step back for a moment, in one sense, the use of executed prisoners for science isn’t surprising. For centuries, anatomists around the globe struggled to find an adequate supply of bodies. The need was keen—without corpses, there could be no dissection for research and medical training. In France, the bodies of poor people who died in hospitals were used widely in the 1700s. An 1832 law in Britain permitted access to the unclaimed bodies of anyone who died in a prison or workhouse. In the United States, medical students robbed graves, often of African-Americans. ‘‘In Baltimore the bodies of colored people exclusively are taken for dissection because the whites do not like it, and the colored people cannot resist,’’ a British travel writer observed in 1838. When paupers were the target of body snatching, the practice was justified by their poverty. “Why would those who have made war on society or have been a burden to it be permitted to say what shall be done with their remains?” the Washington Post asked in an 1877 editorial. “Why should they not be compelled to be of some use after death, having failed to be of value to the world during life?” Plötzensee Prison in 2012 Courtesy of Ahle, Fischer & Co. Bau GmbH/Creative Commons Before Hitler, German anatomists had complained to the government for decades about the lack of supply. They had the right to claim the bodies of the executed, but few death sentences were carried out. That changed as the Nazi courts ordered dozens and then hundreds of civilian executions each year, for an estimated total of 12,000 to 16,000 from 1933 to 1945. (The 6 million who were killed in concentration camps are counted separately, as are the many millions more who were otherwise mass-murdered.) Plötzensee and other prisons delivered to anatomists a sudden abundance. In the mid-1930s, British anatomists described with envy the “valuable sources of material” their German counterparts had. The “sources of material” included many people the Nazis sentenced to death for minor crimes, such as looting, and many convicted for political crimes that particularly incensed the regime, ranging from treason to the vague offense of “defeatism.” The victims included political protesters like the Schulze-Boysens and the Harnacks, who would one day be seen as heroes. By refusing them graves, anatomists such as Stieve humiliated the victims’ families and disturbed the peace of the dead. A few of these anatomists followed the Nazis further down their twisted path: They committed or acceded to acts of mass killing, in the name of science and from inside the halls of academe. 2 Dr. Stieve and “Legitimate Rape” Stieve had a taste for the theatrical: He liked to wear his long black academic robe to give lectures. At the age of 35, he became the youngest doctor to chair a German medical department. That was in 1921, soon after Stieve backed a coup that would have knocked out the Weimar Republic in favor of authoritarian rule. Stieve was a nationalist about language, too: He supported a drive to replace Anglified words like April and Mai with Germanic alternatives. Stieve welcomed Hitler for his promise to restore the country’s pride, although he did not join the Nazi Party. Like most academics, Stieve did not protest when the Nazis began to expel Jews from universities in 1933. Charlotte Pommer is the only one we know of who left this work because of what she learned about the bodies. Sabine Hildebrandt Stieve’s main research interest, throughout his career, was the effect of stress and other environmental conditions on the female reproductive system. He studied whether hens would lay eggs with a caged fox nearby, and he set up conditions of stress for newts. Stieve studied human uteruses and ovaries when he could get them from accident victims or from gynecologists who’d removed the organs in the course of an operation. Before the Nazis, the access that German anatomists had to the bodies of executed prisoners was of less use to Stieve. During the Weimar Republic, no women received death sentences. The Third Reich and the war changed that. At Plötzensee alone the Nazis executed 3,000 people. Stieve agreed to take all these bodies off the hands of the prison officials—many more than he needed for his research. By accommodating Plötzensee, he won concessions that aided his work on the “unprecedented number of women” now available to him, as the German anatomist and historian Andreas Winkelmann puts it. In 1942, when the prison shifted the time of executions to the evening, Stieve visited the prison and got the time moved back to the morning so he could continue to process organs and tissues on the same day. He also got details of the women’s medical histories before they died, including information about their menstrual cycles, their reactions to the prison environment, and the impact of receiving a death sentence. We know this because Stieve kept a list. The official record of the bodies he received was lost when the Institute of Anatomy’s registry was destroyed in 1945, either deliberately or in a bombing. But a Protestant minister who tended to the Plötzensee prisoners during the war helped search for and record information about them afterward. He reported that in 1946, Stieve handed him a typed list of names—the people whose bodies he had used. It was located decades later in German government archives, with handwritten additions. There were 182 names: 174 women and eight men. Their ages ranged from 18 to 68, with most of reproductive age. Two of the women were pregnant when they were killed. The majority were executed for political reasons. They came from Germany, for the most part, and seven other countries. Libertas Schulze-Boysen is No. 37 on Stieve’s list. Mildred Harnack is No. 87. Mildred Harnack's Red Orchestra Counterintelligence Corps file, circa 1947 Courtesy of National Archives, College Park, Md. Stieve published 230 anatomical papers. With the data he gathered pre-execution, as well as the tissues and organs he harvested and studied, he could chart the effect of an impending execution on ovulation. Stieve found that women living with a looming death sentence ovulated less predictably and sometimes experienced what he called “shock bleedings.” In a book published after the war, Stieve included an illustration of the left ovary of a 22-year-old woman, noting that she “had not menstruated for 157 days due to nervous agitation.” Stieve drew two conclusions that continue to be cited (for the most part, uncritically). He figured out that the rhythm method doesn’t effectively prevent pregnancy. (He got the physiological details wrong but the conclusion right.) And he discovered that chronic stress—awaiting execution—affects the female reproductive system. In August 2012, then–Rep. Todd Akin of Missouri said that women can prevent themselves from getting pregnant after a “legitimate rape.” Following an uproar, Akin lost his bid for a Senate seat.* Still, a few other Republicans have followed along, arguing that rape rarely results in pregnancy, to explain why they oppose an exception for rape victims in laws that restrict access to abortion. Whether they know it or not, Stieve’s work is the source for their discredited claim. The American College of Obstetricians and Gynecologists warned that saying rape victims rarely get pregnant was “medically inaccurate, offensive, and dangerous.” But the anti-abortion doctor Jack Willke, former head of the National Right to Life Committee, insisted otherwise. "This goes back 30 and 40 years,” he told the Los Angeles Times in the midst of the Akin furor. “When a woman is assaulted and raped, there's a tremendous amount of emotional upset within her body." Willke has written that "one of the most important reasons why a rape victim rarely gets pregnant” is “physical trauma." Where did he get this idea? In 1972, another anti-abortion doctor, Fred Mecklenburg, wrote an essay in a book financed by the group Americans United for Life in which he asserted that women rarely get pregnant from rape. Mecklenburg said that: The Nazis tested the hypothesis that stress inhibits ovulation by selecting women who were about to ovulate and sending them to the gas chambers, only to bring them back after their realistic mock killing, to see what effects this had on their ovulatory pattern. An extremely high percentage of these women did not ovulate. Mecklenburg got his facts wrong. Plötzensee Prison wasn’t the gas chamber. And the prolonged trauma of anticipating execution isn’t the same as the shock of rape. But when Hildebrandt, the Harvard historian and anatomist, read about Mecklenburg’s rationale after I wrote about it for the New York Times Magazine and Slate, she recognized the handiwork of Stieve. Mecklenburg had quoted a presentation on a “Nazi experiment” by another obstetrician, from Georgetown University, at a 1967 Washington, D.C., conference on abortion. That doctor had to be talking about Stieve, Hildebrandt says, since “there is no other ‘Nazi experiment’ like this.” It was another link in the chain from Stieve to Mecklenburg to Willke to today’s anti-abortion Republicans. Hildebrandt wrote to me about Stieve, and that’s how I learned about her work. She is 55 and was born in Germany; her parents were children during the Third Reich. “It was always around us,” she said. “I had no Jewish neighbors. I went to an elementary school named after a member of the German resistance.” Hildebrandt came to live in the United States in 2002. Her interest in the history of anatomy is recent. “In many ways it was helpful for me to formulate my first ideas all by myself, with physical distance from Germany,” she said. “I didn’t have to worry about treading on anyone’s toes. I’m not a brave person.” Hermann Stieve lecturing on anatomy, 1943 Courtesy of Privatbesitz/Creative Commons By contrast, Hildebrandt says that Stieve “never doubted himself.” She thinks he refused to see that the ethics of how he procured bodies shifted under the Nazis. “He knew better, but he didn’t want to realize it, because this was a great opportunity for him,” she says. “He really could do the work that he always wanted to do.” When I asked to learn more about Stieve, Hildebrandt sent me to Winkelmann, the German doctor and lecturer in anatomy at Charité, the major university hospital in Berlin. Born in 1963, Winkelmann is also of the “grandchildren generation,” as he put it when we spoke by phone. I asked him how he got interested in Stieve, and he said, “Stieve was a Berlin anatomist like me. He is part of my history. He worked in the same building that we work in today.” Winkelmann has helped make the ethical case against Stieve. “His research cannot be validated without justifying, at least to some extent, the entire Nazi justice system, which was instead one of injustice,” he argued in a 2009 article, co-written with Udo Schagen, a medical historian at Charité. Stieve abetted the Nazis with his willingness to accept far more bodies than he needed for research, and he kept his supply line quiet. And Winkelmann pointed out that Stieve’s “use of the terror of death row as a sober scientific variable is undoubtedly callous.” But Winkelmann has also pleaded for a kind of mercy for Stieve—or at least for nuance. “People tend to forget that it was only in the 1950s and ’60s that body donation programs were invented,” he said. “Stieve thought using the bodies of executed prisoners was something normal to do. He didn’t do research to prove some people were subhuman, as some doctors did. I don’t think that vindicates what he did, but you could say, at least he didn’t do that.” In 1944, Stieve dissected one of his own friends. Winkelmann has also pushed back against two allegations that turn Stieve into a monster. William Seidelman, a University of Toronto medical professor who has written extensively on medicine in the Third Reich, thinks Stieve allowed SS officers to rape women on his list before they were executed, so he could study the migration of sperm. Seidelman’s allegation is based on a 1997 letter from a former student of Stieve. Winkelmann’s co-author, Schagen, spoke to the former student, and they think he was repeating a rumor or misinterpreting Stieve’s remarks about his work. None of Stieve’s papers discuss sperm migration. The former student has since died, and Seidelman stands by his accusation. Winkelmann calls it “far-fetched.” But he adds, “I can understand how Seidelman would think it’s true, because whenever you look into Nazi medicine, you find that the very worst things—they have happened.” Case in point: There is a rumor that Stieve’s lab made soap from the remains of the victims. Winkelmann has refuted that one, too. “But another anatomist named Spanner did make bodies into soap,” he told me. Rudolf Spanner was director of the Danzig Anatomical Institute. He didn’t go into mass production—“Professor Spanner’s Soap Factory” is a myth. But the remains of 147 unidentified people were found in Spanner’s institute after the war, and “during several interrogations Spanner conceded the production of small amounts of soap for anatomical purposes but was not prosecuted,” Hildebrandt writes. After the war, Stieve falsely insisted that he hadn’t conducted research with the bodies of political prisoners. The anatomist, he argued, “only tries to retrieve results from those incidents that belong to the saddest experiences known in the history of mankind.” He continued to see himself as a man of science. “In no way do I need to be ashamed of the fact that I was able to reveal new data from the bodies of the executed, facts that were unknown before and are now recognized by the whole world.” Like almost every other anatomist of his time, Stieve was never professionally penalized or prosecuted for conducting research on the corpses of murdered prisoners. He continued to direct his university’s Institute of Anatomy until his death from a stroke in 1952. Stieve’s obituaries didn’t describe his negotiations with Plötzensee Prison over the timing of executions to ensure the daily delivery of fresh bodies. They lauded him as a highly respected scientist who loved hunting and mountaineering. Winkelmann told me a strange story that supports his interpretation of Stieve as blinded by science, not ideology. In 1944, Stieve dissected one of his own friends. Walter Arndt was a doctor and zoologist who converted to Judaism in 1931. He was executed after being convicted for criticizing the Nazis. “Stieve took out his heart and kept it,” Winkelmann told me. “Stieve wanted to donate his own body to science when he died,” he continued. “But his wife objected. So in the end, he was buried.” 3 “A Few Perverted Psychopaths” With the war’s end came an early chance for investigation. The occupying military governments operating after the war tried to find the bodies of political dissidents and foreign nationals. And families looking for their loved ones started visiting Germany’s anatomical institutes. The procurement of bodies had been an open secret. “Thus, anatomists were asked about the identity and fate of the bodies remaining in their institutes’ storage spaces,” Hildebrandt writes. Often, however, identification was out of reach—documents had been lost, dissected bodies rendered unrecognizable. At the Nuremberg trials, 23 doctors faced charges. But those few charged with crimes were the physicians at the Nazi forefront: the ones who experimented on live subjects in the concentration camps, not the much larger number of academics who stayed in the universities. “Many people in the medical profession who played leading roles during the Third Reich retained power after the war—especially in the academy,” Seidelman told me. “They were able to keep the lid on things.” Exhibition entitled “Physical and Emotional Appearance of the Jews,” which opened at the Museum of Natural History in Vienna in 1939 Courtesy of the Museum of Natural History in Vienna Half of Germany’s doctors had joined the Nazi Party. Despite the denazification that followed the war, almost all of them continued practicing. “People didn’t want to know,” said Arthur Caplan, a New York University bioethicist and author of When Medicine Went Mad: Bioethics and the Holocaust. “Who would be the doctors if not the doctors from before the war? Who else would staff the universities? The German establishment wasn’t looking to weed out all the doctors who’d done bad things.”