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Research ethics

ESSAY

Research and complicity: the case of Julius Hallervorden

Franklin G Miller
Correspondence to Franklin G Miller, Department of Bioethics, National Institutes of Health, Building 10, Room 1C118, Bethesda, MD 20892-1156, USA; fmiller@nih.gov The opinions expressed are the views of the author and do not necessarily reect the policy of the National Institutes of Health, the Public Health Service, or the US Department of Health and Human Services. Received 8 April 2011 Revised 2 May 2011 Accepted 24 May 2011 Published Online First 21 June 2011

ABSTRACT The charge of complicity has been raised in debates over the ethics of fetal tissue transplantation and embryonic stem cell research. However, the applicability of the concept of complicity to these types of research is neither clear nor uncontroversial. This article discusses the historical case of Julius Hallervorden, a distinguished German neuropathologist who conducted research on brains of mentally handicapped patients killed in the context of the Nazi euthanasia programme. It is argued that this case constitutes a paradigm of complicity in research that is useful in assessing complicity in contemporary research ethics.

cases or types of research. Comparison of a type of research with the paradigm case can help in assessing whether the former qualies as complicity. To that end, I undertake here an ethical assessment of the post-mortem brain research conducted by Julius Hallervorden (1882e1965) during the Nazi era. After setting the stage with a brief account of the Nazi euthanasia programme and Hallervordens brain research, I explicate a strict conception of moral complicity on analogy with what it takes to be an accomplice in the law. This conception is then applied to Hallervordens research activities. The nal section sketches a framework for ethical analysis of research in which complicity is an issue.

Debates over controversial research involving human body parts or biological material, such as human fetal tissue transplantation during the 1990s and embryonic stem cell research today, have addressed the key issue of complicity.1 2 Some have argued that researchers who transplanted fetal tissue in the process of evaluating an experimental treatment were complicit with the wrongful abortions that supplied this fetal tissue. Likewise, it is claimed that embryonic stem cell research makes investigators complicit with the destruction of human embryos. Though not unethical in itself, this research is seen by some as unethical because of its connection with wrongdoing. Two basic conceptual problems hover over the bioethics literature with respect to these debates. First, there is no consensus on the ethical assessment of the activity that underlies the charge of complicity. Scholars and the public do not agree that abortion and destruction of embryos are wrong. Second, the contours of the concept of complicity are not well mapped. It is not clear when taking advantage of wrongdoing creates complicity with that wrongdoing. Writing about complicity in 1997, Lynn Gillam noted that It is not a common issue in bioethics, and there are no welldeveloped theoretical accounts of complicity generally accepted and used by bioethicists and moral philosophers3 (p 398). Although valuable conceptual work has been carried out since then, this statement remains true.4 5 One way to contribute to debates over complicity in certain types of current human research is to locate and characterise a clear case of complicity in research as a comparatordone that is clear both because everyone agrees that the activity with which an investigator is associated is evil and because the relationship to that activity qualies as complicity. Such a case can play the role of a paradigm case to be used in ethical analyses of other

THE NAZI EUTHANASIA PROGRAMME

In late 1939, at the beginning of World War II, Adolph Hitler authorised the systematic killing of institutionalised handicapped patients.6 A group of medical experts planned the secret T-4 programme, selected patients for extermination, and supervised the killing operation. This euthanasia programme was inspired by the racial hygiene ideology prominent within German medicine, especially psychiatry.7 Particularly inuential was a 1920 publication by Karl Binding and Alfred Hoche, respectively professors of law and psychiatry, entitled Authorization for the Destruction of Life Unworthy of Life. Historian Michael Burleigh observed that Binding and Hoche deliberately conated the issue of voluntary euthanasia with the non-consensual killing of idiots and the mentally ill8 (p 215). The Nazis enthusiastically embraced this ideology and radically put it into practice, beginning with compulsory sterilisation of those regarded as unt, followed by killing more than 100 000 handicapped patients, and ending with the nal solutiondmassive extermination of Jews in the concentration camps.6 Selection of handicapped patients proceeded on the basis of written information in response to a questionnaire sent to psychiatric hospitals and other institutions throughout Germany. On the basis of very limited diagnostic information supplied on these forms, medical advisors to the T-4 programme rapidly selected those to be killed. Selected patients were transported from their institutions to designated killing centres. They were processed and shortly after arrival were escorted to extermination chambers disguised as shower rooms. Death was caused by carbon monoxide poisoning, after which the victims bodies were cremated. Young physicians were recruited to oversee the killing and to fabricate natural causes of death, which were reported to family members of the victims.
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Research ethics
HALLERVORDENS BRAIN RESEARCH
Born in 1882, Julius Hallervorden became a distinguished psychiatrist and neuropathologist. In 1938 he was appointed chair of neuropathology at the Kaiser Wilhelm Institute for Brain Research, located in Berlin-Buch. Hallervorden took advantage of the T-4 programme as an opportunity to obtain post-mortem brains for scientic research.6 9e11 He collaborated with Hans Heinze, a child psychiatrist who headed the large state psychiatric hospital at Gorden and was one of the planners and supervisors of the T-4 programme. Hallervorden visited the killing centres at Brandenburg and Bernburg, where he arranged to obtain brains from victims after gassing. On at least one occasion he extracted brains from newly killed individuals.12 At both of these facilities, he collaborated with Heinrich Bunke, a young physician overseeing the killing operation. Hallervorden instructed Bunke in methods of extracting brains during a 4-week period in which Bunke was on leave from the killing centre and was posted at Hallervordens laboratory at Berlin-Buch. Hallervorden communicated a remarkably frank account of his brain research related to the T-4 programme in a June 1945 interview with Leo Alexander, a psychiatrist in the US Army, who was a member of the Ofce of the Chief of War Crimes at Nuremberg. Asked about his involvement with the T-4 killing centres, Hallervorden responded:
I heard that they were going to do that, and so I went up to them and told them Look here now, boys, if you are going to kill all these people, at least take the brains out so that the material could be utilised. They asked me: How many can you examine? and so I told them: an unlimited number e the more the better . I gave them xatives, jars and boxes, and instructions for removing and xing the brains, and then they came bringing them in like a delivery van. There was wonderful material among those brains, beautiful mental-defectives, mal-formations and early infantile diseases. I accepted these brains of course. Where they came from and how they came to me was really none of my business.9 (p 119)

Hallervorden subsequently published several scientic articles based on the examination of these brains.12 After the war, Hallervorden was never a subject of legal proceedings or formally investigated regarding his role in the euthanasia programme. Hallervordens research activities did not place him in the same moral position as the physician planners of the T-4 programme or the physicians on site in the killing centres who opened the gas valves and falsied death certicates. But his research brought him into very close contact with the wrongful deaths of patients. Hallervorden lamely attempted to whitewash his involvement by telling Alexander that it was really none of my business where the brains came from or how they came to me. However, he made it his business to procure these brainsdsometimes extracting them himself as well as instructing others in how to remove and preserve them for research. Was Hallervorden complicit in the murder of handicapped patients? On a broad sense of complicity, in which any wrongful taking advantage of wrongdoing counts as complicity, the answer is obvious. Hallervorden was closely associated with the killing operation, which he opportunistically exploited for his scientic research. I shall argue that Hallervorden was complicit in the killing of handicapped patients on a strict conception of complicity, tied to being an accomplice in wrongdoing.

the killing of handicapped patients, Hallervorden wrongfully engaged in post-mortem brain research because he failed to obtain ethically proper authorisation for examination of the victims brains. Regardless of any possible legal authorisation, Hallervorden did not obtain the consent of the victims or surrogates deciding on their behalf. Although by itself this makes the research unethical by current standards, it is only a relatively minor element in the ethical assessment of Hallervordens activities. This point can be illustrated by contrasting Hallervordens research with the following hypothetical case. Imagine that a neuropathologist investigator illicitly obtained brains of patients who were residents of a neurological institution and who died naturally. Their bodies were to be cremated in light of decisions by the patients or their family members. The brains were obtained before cremation by arrangement with the undertaker without authorisation by patients or family members. This would constitute unethical research, but not complicity. It was Hallervordens close connection with the killing programme, not the unauthorised use of brains for research, that gives rise to the charge of complicity and the moral turpitude associated with his case. This point also is important in using the Hallervorden case as a comparator for assessing complicity in other forms of research, such as human fetal tissue transplantation. In itself, there is nothing wrong in transplanting this tissue obtained with valid consent of the donor for the purpose of evaluating an experimental treatment. Rather, it is the connection between the use of the tissue for research and the abortions that make it possible, especially the tendency of the research to encourage abortions that would otherwise not occur, that raises moral concerns about complicity. Clearly, complicity does not involve any instance in which an agent takes advantage of an activity regarded as evil. In discussing complicity in the context of human fetal tissue transplantation research, commentators have pointed out that some relationships between agents and evil activities raise no moral concerns. In particular, surgeons may procure organs for transplantation from donors who were victims of violent crimes that rendered them brain dead.1 2 No one would regard this organ procurement as complicity with criminal violence. What sort of relationship between an agent and a wrongful activity gives rise to a legitimate charge of complicity? One way of mapping the contours of complicity as a moral category is to build on the established legal conception of complicitydthat is, what it takes to be an accomplice in crime. Christopher Kutz explicates this as follows:
The basic requirements are deeply rooted in common law, but have been formalised in the UK in the Accessories and Abettors Act of 1861 (amended by the Criminal Law Act of 1977): Whosoever shall aid, abet, counsel, or procure the commission of any indictable offence . shall be liable to be tried, indicted and punished as a principal offender. And in the US, in the Model Penal Code x2.06: (3) A person is an accomplice of another person in the commission of an offense if: (a) with the purpose of promoting or facilitating the commission of the offense, he (i) solicits such other person to commit it, or (ii) aids or agrees or attempts to aid such other person in planning or committing it, or (iii) having a legal duty to prevent the commission of the offense, fails to make proper effort so to do.5 (p 293) J Med Ethics 2012;38:53e56. doi:10.1136/jme.2011.044586

COMPLICITY
In an ethical assessment of Hallervordens role in the Nazi euthanasia programme, it is important to separate for analysis two aspects of his brain research. Aside from his connection with
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Research ethics
Kutz adds that The fundamental point is that accomplice liability is a basis of liability for another s substantive crime, not a crime in its own right. Once a defendants liability as an accomplice is established, he is thereby treated as a principald that is, as if he had committed the actus reus of the crime itself. Summarising these points, Kutz observes, And here common law and code, UK, and US, agree that there are two basic categories for complicity-generating behaviour: rendering assistance to another planning to or already engaged in committing a crime; or encouraging that other to commit the crime, without necessarily assisting in its commission5 (pp 293e4). Following this legal paradigm, moral complicity, in a strict sense, can be seen as being an accomplice in wrong-doing. If B solicits or encourages A to do a wrongful act, aids A in doing it without directly committing the wrongful act, or fails to prevent A from doing it when B is in a position to do so, then B is complicit with A in the wrongdoing. An agent who is complicit morally becomes, to some degree, responsible for the wrong committed by another. If Hallervorden was complicit in this sense of being an accomplice in the Nazi euthanasia programme, then he bore moral responsibility, to some extent, for the killing. 228). The evidence, however, appears circumstantial; and Peiffer added that In any event, I found no notes or written agreements in the patients les that would support this judgement. Did Hallervordens research activities encourage those directly involved in the killing operation? Robert J Lifton interviewed physicians who participated in the Nazi extermination programme in the context of his research on medicalised killing.14 15 One of the interviewees was a psychiatrist employed at one of the killing centres for handicapped patients, given the pseudonym Horst D (to protect condentiality). The reported details indicate that this was Heinrich Bunke, who collaborated with Hallervorden. Lifton argued that the scientic signicance of Dr D s work helped him adapt to his role in the killing. The opportunity to serve science occurred with the appearance of a leading German neuropathologist at the killing centre to obtain brains for dissection15 (p 106). Though not identied in the text, this undoubtedly was Hallervorden. Horst D reported that he studied the medical histories of patients at the killing centre and tried to nd those whose brains might eventually be of interest to the neuropathologist. Lifton interpreted what he learnt in this interview as follows: Horst D had, in other words, found a way to connect the killing work with medical research and to feel he was doing his duty as dened both by his immediate group and by science. Or to put things another way, a new sense of serving medicine and science enabled him, psychologically, to go on with the killing15 (p 106). If Lifton is correct, then Hallervorden encouraged Bunke in his role of supervising the killing of patients and thus was complicit in that activity. The fact that Hallervorden trained Bunke in techniques of brain extraction strongly suggests that he knew, or should have known, that he was encouraging Bunke in the killing operation. Although not explicitly commenting on Bunkes motivations, Friedlander expressed scepticism about Liftons account of why young physicians participated in the killing operation.6 He stated that Career considerations and personal prot seem to have motivated these young physicians6 (p 225). Owing to wartime, Bunke received an emergency medical licence before completing his training and joined the Wehrmacht. When the opportunity to become part of the T-4 programme emerged, he found it preferable to being a military physician. Certainly, Hallervorden had nothing to do with Bunkes initial employment in the T-4 programme. It is reasonable, however, to infer that Hallervordens scientic interest in brains extracted from the victims encouraged Bunke, especially since Bunke had the opportunity to take leave from the killing centre to spend time in Hallervordens laboratory. Just as participation in the T-4 programme was voluntary, doctors employed in it were free to leave.6 Collaboration with Hallervorden may have motivated Bunke to persist in the job. (In 1987 a Frankfurt court sentenced Bunke to 4 years in prison based on his role in the T-4 programme.16) I conclude, on the basis of the balance of evidence, that Hallervorden was complicit with the Nazi euthanasia programme by virtue of his probable role in the selection of some patients to be killed and his likely encouragement of a young physician who played a direct role in the killing operation. In other words, Hallervorden arguably was an accomplice in the murder of handicapped patients such that he bore moral responsibility, to some extent, for their unjust deaths. To be sure, if Hallervorden was not strictly speaking an accomplice in the Nazi killing operation, his research activities would still make him responsible for wrongfully taking advantage of the euthanasia programme and thus complicit in a broader sense. The virtue of adopting such a strict conception of complicity lies in its implications for moral responsibility for grave
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HALLERVORDEN AND COMPLICITY

Two questions are directly relevant to determining whether Hallervorden was (morally) complicit in the strict sense of being an accomplice in the murder of handicapped patients. First, did he select or participate in the selecting of patients to be killed? Second, did he encourage others to engage or persist in the killing operation? On the basis of my review of English language literature relating to the Nazi euthanasia programme and Hallervordens research, I believe that an afrmative answer can be provided for both of these questions; however, the verdict falls short of proof beyond a reasonable doubt. As noted above, Hallervorden collaborated with Heinze in brain research. In addition to being a planner of the T-4 programme and head of the Gorden psychiatric hospital, Heinze was chief of a T-4 research centre located at Gorden. In his comprehensive history of the killing of handicapped individuals, Henry Friedlander stated that Research on the brains removed from subjects did not take place at Gorden. The brains were transferred to Julius Hallervorden6 (p 129). Friedlander proceeded to note that During the rst 9 months of 1942, for example, 56 male and 41 female patients suffering from retardation, epilepsy or brain injuries were delivered to Gorden as subjects for research. The subjects were observed and tested at Gorden; eventually they were killed and their brains were removed and studied, with particular attention to a comparison between the anatomical ndings and the data collected earlier. Friedlander did not state that Hallervorden was part of this particular research venture at Gorden, but it can be reasonably inferred that he was the neuropathologist who examined the brains. If so, then he was a knowing participant in research that involved selecting particular patients for investigation followed by their being killed and using their brains for neuropathological research. This would make him a participant in the selection process leading to the murder of these patients and thus, arguably, an accomplice to murder. Jurgen Peiffer, who wrote extensively about the euthanasia programme and Hallervordens involvement stated that There is a question whether Hallervorden, in the course of his close cooperation with Heinze, expressed a desire that certain patients with especially interesting diseases be killed so he could remove the brain for scientic examination. The answer to this question of a death on demand must with high probability be positive13 (p
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Research ethics
wrongdoing by virtue of being an accomplice in that wrongdoing. A looser sense of complicity that is not strictly tied to being an accomplice in wrongdoing does not necessarily permit such implications for responsibility. For example, suppose that in the 1950s a German neuropathologist at the Max Planck Institute for Brain Research (the successor to the Kaiser Wilhelm Institute) examined brains in Hallervordens collection in order to undertake scientic research. If this investigator knew that the brains were derived from victims of the euthanasia programme and published ndings based on this research, he might be considered complicit in accordance with a looser conception of that concept. Such research might well be regarded as unethical, but the researcher would never be regarded as an accomplice to murder. While a wider conception of complicity may play a useful role in ethical assessment of research, it is important to be clear about what it does, and does not, imply regarding moral responsibility for the evil activity that gives rise to the charge of complicity. disagreement about the evil of killing handicapped patients for the purpose of racial hygiene. As noted above, Hallervorden obtained his research material without ethically appropriate authorisation. In contrast with some of the scientically slipshod Nazi concentration camp experiments,17 Hallervorden was a distinguished neuropathologist who conducted scientically valid and potentially valuable research.9 Without question, Hallervordens research relationship with the Nazi euthanasia programme was deeply morally problematic. Moreover, it arguably constituted complicity in the strict sense. It is doubtful that progress in brain research relating to rare neurological conditions required examination of brains from this source. Accordingly, the social consequences of forgoing the scientic opportunity to investigate this potential research material appear to be minimal. Application of these considerations to human fetal tissue transplantation and embryonic stem cell research is more complex and apt to be contested. Particularly with respect to complicity, commentators disagree about the moral assessment of abortion and destroying human embryos and about whether research connected with these activities makes the researchers accomplices. In working through ethical assessment of these, and other, research contexts, comparison and contrast with the case of Hallervordens post-mortem brain research can shed light on the appropriateness of appealing to complicity in the ethical assessment of research.
Acknowledgements Thanks to Paul Lombardo, Joseph Millum, Seema Shah and Alan Wertheimer for helpful comments on previous drafts of this paper. Funding This research was supported by the Intramural Research Program of the Clinical Center, NIH. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.

SKETCH OF AN ETHICAL FRAMEWORK

The case of Hallervorden has been examined both for its intrinsic ethical interest and as offering a potentially useful comparator for assessing the ethics of human fetal tissue transplantation research and embryonic stem cell research. It is not my intention to contribute here to debates over these types of research. However, in service of ethical evaluation of research in which complicity is an issue, I suggest the following framework consisting of six sets of ethical considerations. The rst and the fourth considerations, relating respectively to the evil with which research is connected and the relationship of the research to that evil, are central to determining whether the research involves complicity. The other four considerations consist of more general issues of research ethics that deserve attention with respect to the use of human biological material connected with an activity purported to be wrongful. It is presented as a sketch, because the relevant considerations are merely outlined and deserve further explication. First, the charge of complicity is grounded in a purportedly evil source (eg, abortion, destruction of embryos) with which the research is connected. This gives rise to the question of whether the source is evil, or whether there is ethical controversy or debate about this. Second, the research involves deriving scientically valuable material from this source. Has the investigator obtained proper authorisation for use of this material? Third, as in all health-related research, the target of the research is generalisable knowledge relevant to the diagnosis, treatment or prevention of disease. In different research scenarios, the potential that knowledge can be obtained that will lead to improvements in health will vary. This is a function both of the clinical value and scientic validity of the research. Fourth, what is the relationship of the investigator to the source of research material? Does it constitute complicity in the strict sense of making the investigator an accomplice in wrongdoing? Is the relationship otherwise morally problematic in a way that might ground a charge of complicity in a broader sense? Fifth, it is important to assess whether alternatives exist for deriving valuable knowledge with respect to the research questions under investigation without a problematic relationship between the investigator and the source of research material. Finally, the social consequences of permitting or prohibiting the research in question are ethically relevant. Can the end of health-related knowledge generation justify the use of material from the allegedly evil source? In the case of Hallervordens research, there are relatively straightforward answers to these questions. Today there is no
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REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Childress JF. Ethics, public policy, and human fetal tissue transplantation research. In: Childress JF, ed. Practical Reasoning in Bioethics. Bloomington, IN: Indiana University Press, 1997:301e28. Devolder K. Complicity in stem cell research: the case of induced pluripotent stem cells. Hum Reprod 2010;25:2175e80. Gillam L. Arguing by analogy in the fetal tissue debate. Bioethics 1997;11: 397e412. Gardner J. Complicity and causality. Crim Law and Philos 2007;1:127e41. Kutz C. Causeless complicity. Crim Law and Philos 2007;1:289e305. Friedlander H. The Origin of the Nazi Genocide: From Euthanasia to the Final Solution. Chapel Hill, NC: University of North Carolina Press, 1995. Proctor RN. Racial Hygiene: Medicine Under the Nazis. Cambridge, Mass: Harvard University Press, 1988. Burleigh M. Psychiatry, German society, and the Nazi euthanasia programme. Soc Hist Med 1994;7:213e28. Hughes JT. Neuropathology in Germany during World War II: Julius Hallervorden (1882e1965) and the Nazi programme of euthanasia. J Med Biogr 2007;15:116e22. Shevell MI, Peiffer J. Julius Hallervordens wartime activities: implications for science under dictatorship. Pediatr Neurol 2001;25:162e5. Shevell M. Racial hygiene, active euthanasia, and Julius Hallervorden. Neurology 1992;42:2214e19. Peiffer J. Assessing neuropathological research carried out on victims of the euthanasia programme. With two lists of publications from Institutes in Berlin, Munich and Hamburg. Medizinhist J 1999;34:339e56. Peiffer J. Phases in the postwar German reception of the Euthanasia Program (1939e1945) involving the killing of the mentally disabled and its exploitation by neuroscientists. J Hist Neurosci 2006;15:210e44. Lifton RJ. Medicalized killing in Auschwitz. Psychiatry 1982;45:283e97. Lifton RJ. The Nazi Doctors: Medical Killing and the Psychology of Genocide. New York: Basic Books, 1986. Times Wire Services. Doctors in Nazi mercy killings get 4-yr. terms. Los Angeles Times 1987 May 18. http://articles.latimes.com/1987-05-18/news/mn598_1_mercy-killings (accessed 30 Mar 2011). Berger RL. Nazi sciencedthe Dachau hypothermia experiments. N Engl J Med 1990;322:1435e40.

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Research and complicity: the case of Julius Hallervorden

Franklin G Miller J Med Ethics 2012 38: 53-56 originally published online June 21, 2011

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