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Holocaust studies foster discussion of medical ethics

Yale Medicine Magazine, 2012 - Spring

As medical student Jonathan Levin stood on the grounds of the former Nazi concentration camp at Birkenau, Germany, on a wet and cold summer day in 2011, he was unprepared for what he saw and felt.

“The camp was absolutely enormous, and it was unbelievable that it could have been built—that it wasn’t somehow stopped,” said Levin. What made it even worse was the knowledge that doctors had played a role in the atrocities that took place there. “Where were they standing?” he recalled asking himself, trying to come to grips with the idea that physicians, professionals supposedly dedicated to healing, could have had a hand in unspeakable acts. Nazi doctors performed guinea pig-like experimentation—poisonings, surgeries without anesthesia, and exposure to extreme cold or hot temperatures—on Jews, Roma, and people with disabilities. Ultimately became active participants in horrific acts of genocide.

Levin made the journey to Auschwitz-Birkenau to participate in a new program that uses the Holocaust as a backdrop for discussions of contemporary ethics.

“We focus a great deal on medical professionalism in medical school. Yet one of the greatest evils that has ever been perpetrated on humankind could not have occurred without the participation of physicians—the very professionals who should have been the major bulwarks against it,” said Thomas P. Duffy, M.D., professor of medicine and director of the Program for Humanities in Medicine. “Instead, leaders of the medical and legal professions played a decisive role in enabling, designing, and executing what happened during the Holocaust.”

Duffy, along with Nancy R. Angoff, M.P.H. ’81, M.D. ’90, HS ’93, associate dean for student affairs, and other faculty at the School of Medicine launched the Fellowships at Auschwitz for the Study of Professional Ethics (FASPE) in 2010, in collaboration with staff from the Museum of Jewish Heritage and other professional schools. Levin is one of 34 medical students selected to take part since the program began. Initially geared towards medical and law students, it has expanded to include those in divinity and journalism programs nationwide. So far, 126 students in all four fields have taken part.

The 10-day fellowship begins in mid-June with an introductory session at the Museum of Jewish Heritage in New York City. Then students attend seminars with leading scholars and visit such sites as the House of the Wannsee Conference in Berlin, where Nazi leaders drew up plans for the “Final Solution”; the Deportation Memorial “Track 17,” one of the train platforms where Berlin’s Jews were forced to board trains heading to concentration camps; and Auschwitz-Birkenau, where more than one million people perished. During the final days of the trip, fellows tackle such contemporary ethical issues as end-of-life decisions and the provision of health care with limited dollars.

“With the advent of technology and the speed at which we do things, it’s not clear how we even frame ethical questions to keep pace with such change,” said David Goldman, J.D., a lawyer in New York who approached Duffy, a social acquaintance, with the program concept. “This program allows us to take a step back and talk about ethical issues and doing it at Auschwitz makes it a life-changing experience.”

Angoff noted that doctors make countless ethical decisions every day. “It need not be Auschwitz or Abu Ghraib or Rwanda—there are things that are done daily where physicians need to be aware of the power that we have and the ability to go off track,” she said. It is important, she said, for students to think about a situation “where our profession not only didn’t behave ethically, but behaved unethically.”

FASPE’s medical curriculum was designed by Duffy and John S. Hughes, M.D., HS ’76, professor of medicine, Mark R. Mercurio, M.D., HS ’85, professor of pediatrics, and Mark D. Siegel, M.D., FW ’95, associate professor of medicine (pulmonary), in partnership with FASPE staff. Mercurio and Hughes have also served as ethics discussants on the trip. The program’s goal, and hope, is that students will serve as catalysts for discussions on medical ethics after returning to their respective institutions. Faculty and students agree that the most memorable conversations emerge when students across disciplines share the ways in which FASPE has affected their thinking. Students express their thoughts through photographic exhibits, poetry, video, and personal reflections that they present at a meeting in the January following the trip.

By all accounts, the program seems to be making an impact. “One student chose to create a film on human and health rights in Uganda for his medical thesis,” said Duffy. “I can’t help but believe that he was influenced by this journey and used problems that arose in the past to look at the problems that exist now (that carry) important health and health delivery implications.”

The trip continues to inspire Levin.

“It takes time to digest and reflect upon the powerful emotions,” he said. “But it serves as a poignant reminder to always be aware of our intuitions and ethical hunches and act the right way.”

The trip also underscores, he said, the importance of caring for each patient as an individual.

“There was such extreme dehumanization of individuals during the Holocaust,” Levin explained. “As doctors, we have to treat each person as an individual. It’s when the individuality of the person in front of you is lost that bad things can happen. For all the good we do, we have this dark history and we need to be aware of it.”

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Four Yale medical students were selected for the 2012 FASPE Medical Program and are traveling in New York, Berlin, and Krakow, Poland, between June 16 and June 28. The students, Dhruv Khullar, Michael Peluso, Avital Perry, and Daniel Weisberg, will send occasional blogs and photos from the trip, which will be posted here.

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June 28, 2012
New Haven

by Michael Peluso
Now that FASPE is over, I’ve been reflecting on the experience and trying to determine the impact that I think it will have on me. From the outside, FASPE might appear to be a free trip to Europe. Indeed, traveling is an important part of the trip, but it is a means to an end rather than an end itself. FASPE is first about people—interesting people from interesting backgrounds with interesting ideas and a willingness to express those ideas and also hear the ideas of others. There is a real focus on making the participants feel like individuals whose opinions and ideas matter. And because the participants feel empowered by this, FASPE is also about discussion—between different individuals, different groups, medical students, doctors, historians, priests, rabbis, ministers. FASPE has a huge formal curriculum, but its informal curriculum is just as, if not more, valuable. The structured time gave us a place to start discussions; the “free” time was a rarely free—it was a place to continue them. And that’s where the traveling comes in. Sure, all of the discussions that we had on FASPE could have taken place in the classrooms in the Museum of Jewish Heritage. But if they were, an important stimulus would be lost. What makes FASPE such a salient experience is the opportunity to think through problems in places of such great consequence, where those before us have done the same, with disastrous consequences. FASPE rarely felt like an exercise.

What will I take away from FASPE? First, the importance of perspective. The bad guys usually think that they are the good guys, and without being able to see things from a broader perspective, we all run the risk of falling into the same trap on large and small scales. It’s important that we try to assess our decisions from others’ perspectives, and to think about how these decisions fit together with our professional responsibility as physicians. The value of self-awareness and an awareness of where our decisions fit within the context of history cannot be overstated. Second, the value of structured argument in discussing issues of moral controversy. We are living in a time in which emotional arguments carry the same weight (or more) than logical ones. People know what is right because it is what they “feel.” Being able to conceptualize controversial issues within an ethical framework is valuable, as is realizing that what you come up with as the “right” thing to do won’t necessary be what you actually do. And this may be okay, as long as you have thought about it and know why you are deciding to do what is “wrong.” Third, the value of interdisciplinary discourse. Physicians may be experts in medicine, but it would be foolish to think that this expertise extends more broadly than it does. Participation in FASPE has made me much more likely to seek others’ opinions when dealing with difficult situations—this might mean with experts in health or ethics, with other health professionals or an ethics board. But it also should mean with those who might be experts in people—social workers, counselors, advocates. After this experience, I’ll be surprised if I don’t have the hospital chaplain on speed dial. Finally, the value of time. Medical school is busy, residency will be busier, and it will just get harder after that with patient care, research, and teaching responsibilities. Being busy is good, but it’s not always good. To be able to spend the time answering a question, pursuing an idea, exploring something of interest, is so important. I hope that I will be able to find time in my career to do these things.

My most important recommendation to future FASPE participants is to just focus on being there. Ignore emails and phone calls, and give the experience your full mental participation. There’s not really such a thing as down time on FASPE, as even the unstructured time ends up being filled with valuable discussions between fellows and with faculty. You can really learn something during every moment on FASPE, so it’s important to be there mentally when these opportunities arise.

June 27, 2012
Krakow, Poland
Moral Status

By Michael Peluso
Today we left Oswiecim and returned to Krakow, where we spent our last sessions addressing the question that seems to permeate everything in American life: abortion. I have to say, I was very unenthusiastic about this session up front but the way that Mark Mercurio, M.D., framed it was spectacular and really demonstrated how this debate can have educational rather than ideological value. It was a discussion of moral status, with a focus on how this may change for a fetus throughout pregnancy, and for a baby after birth. It was framed through the Holocaust with the discussion of whether moral status can differ for different groups of people or different individuals within the same group. Those in our discussion, for the most part, showed an incredible amount of restraint and we were actually able to talk through an ethical framework for arguing these issues. It made me wish that this could happen in the real world—intelligent discussions about emotional issues are not impossible, even when you have individuals with differing opinions.

We ended our sessions with a discussion titled “What do we owe our patients?” Here we came up with a list: honesty, humility, compassion, our attention, competent care, empathy, respect, dignity, information. We discussed the mantra “cure sometimes, relieve often, comfort always” and the Kantian idea that no person should be made to serve solely as a means to someone else’s ends. Mercurio concluded the section by asking us to always reflect in the following way: “by your actions and your in actions, what are you becoming?”

For the remainder of the day, we were able to explore Krakow one last time. We went to Wawel Castle and explored the area near the river, where they have a stone dragon that breathes fire, in the spirit of the story of the founding of Krakow. It was nice to just hang out, relax, and decompress there. We had an amazing group dinner with speeches (or speeches with dinner might be a more appropriate description). Gratitude was expressed by everyone to everyone—the FASPE coordinators, the medical and seminary faculty, the fellows. It again underscored the crucial community aspect of FASPE, which is what, beyond anything else, made this trip special for us. This was our third “final” dinner and I think that it’s appropriate that the process of winding down the trip takes place over such a long period of time. These are amazing people that I hope I continue to have relationships with for the rest of my career and life, and it would be too hard to do that if the trip ended abruptly. It makes it easier when none of the goodbyes feel like the last.

June 26, 2012
Auschwitz I
No Man’s Land
By Michael Peluso
We had class with Mark Mercurio, M.D., this morning, focused on questions of pediatric ethics. First was the question over whether we resuscitate a 23-week-old premature newborn. The discussion was wide-ranging, and hit on a number of key points focused on the quality of evidence, our ability to understand quality of life and predict prognosis, and the values and opinions of the parents. We discussed the spectrum of decisions in pediatric ethics—from impermissible, to permissible, to advisable, to obligatory. With the first and the last of these, physicians do not need to struggle to reach the ethical decision because it is pretty clear cut. But with permissible interventions, the parents should be consulted. This was a useful framework for considering several cases, including those of premature twins, but things got complicated when we began to talk about what we would do in a case where a parent decided to abort a premature fetus based upon its sex or their vacation plans. I’m not sure we came to a resolution by the end of the session.

This afternoon we were given the option of returning to either Auschwitz or Birkenau for self-guided tours. I decided to go to Auschwitz, even though I would rather have gone to Birkenau. I didn’t want to return there in the afternoon because it gets really crowded and I wanted to preserve in my head the images from yesterday when we were there alone, of a gray, isolated, lonely space not filled with tourists. So I went back to Auschwitz. I began by making a wrong turn and somehow getting between the two layers of the double barbed wire fence running around the camp. I kept following the path, walking within the no-man’s land between the fences, and made my way slowly around the camp. The view was strange—there were little flowers sprouting up in between the pieces of gravel (it seems like people rarely walk here) and my view of the camp was through the barbed wire. I felt trapped and it was honestly a little frightening. It reminded me of the memorial in Berlin, as a followed a path unsure of when it would end. I walked around the entire perimeter of the camp until I reached the main gate and realized that I was stuck and probably should not have been there.

After I made my way back out, I went to some of the country-specific exhibits that we had skipped the other day. There were a few notable points here. First was the video of the liberation of Auschwitz, which showed the prisoners walking between the fences when they were freed, the exact same way that I had been moments before. Second was a video in the Hungary pavilion which was one of the most disturbing I have seen—piles of corpses, close-ups of dead, swollen faces, individuals worn down to skin and bones—it was sickening and very difficult to watch. I went to the Netherlands pavilion, which showed a video of Jews boarding trains for Auschwitz—they were dressed well, smiling, waving out the windows, chatting amongst themselves and with their captors. Very strange, especially when juxtaposed with the videos in the Hungary building. I also visited the buildings for Austria (which has a disclaimer saying that the exhibit is biased toward portraying Austrians as victims and not perpetrators, and does not reflect the modern understanding of their involvement), Czechoslovakia (which had a long ramp leading up to a statue of the 10 Commandments—very strange), Poland, and the Roma/Sinti (Gypsy) groups. On the first day here, Thorin Tritter, FASPE’s managing director, said that he felt that with all the visitors and the exhibits, Auschwitz had begun to look and feel a bit like Disney World. Today, I couldn’t help but think of a perverse version of Epcot, with pavilions showing not the best of what each country has to show, but the worst, saddest, most devastating.

Finally, I returned to the gas chamber and spent some quiet time alone in there. It was nice to be there without a crowd, if not a bit terrifying to experience it again. I tried to take it in by touching the walls, the floors, and the ovens in the crematorium, but there is still something about that place that is intangible. As enlightening as it was to see the camps, I don’t think I ever want to go back again.

Tonight at the hotel we had dinner followed by a bonfire. It was a lot of fun and a nice way to end our time here on a more positive note. I don’t need to continue to write about the sense of community that FASPE fosters, or the value of combining medical and seminary students, but it was a great time. And best of all, the trip is not over. We have one more day in Krakow, which will be a happier end than we could have in Oswiecim.

June 25, 2012
Efficiency and Inefficiency
By Michael Peluso
In many ways, Birkenau was what I expected from Auschwitz. We were extremely lucky that the FASPE program decided to send us in the morning, before the crowds arrived. We had the entire camp to ourselves for the first three hours. This was an amazing opportunity to experience it for ourselves without dealing with throngs of teenagers and tourists.

We began by heading to the set of tracks about a kilometer from the camp, the initial ramp and selection area before the rail lines were extended directly into the camp. There is a train car there but not much else. Interestingly there are homes just a few dozen feet from the track—it must be strange to live there. There was a small girl in the window and I couldn’t help but wonder how her parents explained to her the abandoned train tracks outside the house. We walked across the fields from the first set of tracks to another that led up to and through the infamous gate into the camp. One set of tracks enters and splits into three, all of which terminate abruptly at the back of the camp. This was interesting after seeing Track 17 in Berlin, where so many journeys began—this was the end of the line. As a map in Auschwitz I yesterday indicated, all rails led to Auschwitz.

The sky was gray when we entered Birkenau, and despite the grass, the camp lacked color except for brown and gray. Massive numbers of buildings stretched in every direction from the center of the camp—Birkenau dwarfs Auschwitz I. Rows of barbed wire stretch to all ends of the camp, and we walked across the broken, uneven paths to the right side of the camp. It was a long walk, passing ruin after ruin of the barracks on both sides. When we got to the end, our guide explained what each sub-camp was for—political prisoners, Poles, Jews, Gypsies. She pointed out where Mengele conducted many of his experiments, especially those involving twins. She also pointed to another fence, across another set of wire from the camp where we stood. As though Birkenau were not large enough, the Nazis were expanding the camp at the end of the war. This area—dubbed “Mexico” by the Birkenau prisoners because the inhabitants, without clothes, covered themselves in blankets that looked from a distance like ponchos—would have doubled the camp in size.

We walked back toward a forest on the grounds of Birkenau, not a few trees, literally a forest. This area served as an undressing area for prisoners en route to the gas chambers, but its primary purpose was to shield the prisoners from the truth of what was happening on the other side. Photos of prisoners in the forest, among the trees—it was eerie to stand there and to think of those who had stood there before, awaiting their fate. Behind the forest were the ruins of the gas chambers IV and V, both reduced to a pile of rubble. By looking at the foundations you could decipher the floor plan of the buildings and see just how small a space everyone was crammed into. Also in the back of the camp is the registration center, which is basically an assembly line of activities—undressing, shaving, showering, tattooing—set around oven-like chambers for the disinfection of clothing with steam or hot air. The final room of this building housed photographs found in the luggage of the prisoners.

The memorial area at Birkenau is flanked by gas chambers II and III, piles of brick and twisted metal whose floor plans show how they were designed for efficiency—enter and undress, head into the chamber, breathe in the zyklon B, die, have any valuables (gold teeth, etc.) removed, and get thrown into the cremation ovens. Another assembly line. In both corners at the back of the camps are graves filled with the ashes of the people who were murdered there. They look like innocent fields of grass.

Half of the barracks at Birkenau are brick, the other half wood. The brick barracks have been preserved and show just how awful the living conditions must have been—tri-level bunks, each of which accommodated multiple individuals, and no insulation other than a single layer of brick between the prisoners and the outside walls. I was surprised that the builders had been considerate enough to budget for windows. The wooden barracks were even worse—smaller beds, almost no space to move, no windows at all.

The last thing we saw at Birkenau was the view from the guard tower, which shows just how expansive the camp was. There is a photo in the tower of a selection occurring in the central area of Birkenau, directly in front. It was strange to look up from the photo at the exact space where this occurred (you can tell from a change in the angle of the tracks) and try to imagine it. For me, the most difficult thing to get a sense of is how Birkenau sounded. I can visualize it, I can imagine what it smelled like (especially after seeing the reconstructed bathroom facilities), but I’m not sure what I would hear. Did people have the energy to speak? Were they too tired, too depressed, too scared? In a place that seems to have been designed to move prisoners from the trains to the ovens as efficiently as possible, was there even anything to talk about?

In the afternoon, we had seminars at the Center for Dialogue and Prayer. Our first was an excellent joint session with the seminarians with the provocative title “Where was God during the Holocaust?” We divided into small groups to discuss this topic in general, and how we can help those we serve as doctors or chaplains deal with something horrific. Again we were able to discuss this from medical, Jewish, and Christian approaches and the results were very interesting. We came to the conclusion that it is impossible to provide a uniform answer, and even to understand “why” in these situations since we do not have the perspective of God. The worst response in these situations would be to try to explain to someone why they are suffering—instead we should give them room to be angry, ask questions, and experience emotions. It is our responsibility to help them think about what comes next—we don’t know why they’re suffering, but we know what we can do now. We discussed how it would be wrong to use our over-education and experience to try to “rate” a patient’s empathy, and instead should allow them to determine just how severe their suffering is and try to be what they need us to be for them. We also had an extensive discussion of empathy, including how it is taught, learned, practiced, and demonstrated. One of the seminarians brought up the insightful point that if we think about efficiency as the defining feature of the concentration camps, empathy could be defined as the willingness to be inefficient.

One thing I thought about a lot today is the idea of ruins. I’ve seen ruins on a number of continents now, ruins in Thailand and in England, in Mexico and Uganda. All of these carry a sense of seriousness, but are fundamentally happy places. They are notable for good reasons—for ancient civilizations and ancient mysteries. They inspire wonder and curiosity. The ruins are Birkenau are different. They are ruins of misery and suffering and death, and there are and can be no good feelings there. Auschwitz and Birkenau feel like black holes, where you can do nothing by twist your face in disbelief. One of the seminary students asked today whether people were able to pray at Birkenau. I don’t think I could.

The evening ended with another group dinner at the hotel, and a recap of the day. Tomorrow is a more academic day but we do have the opportunity to go back to Auschwitz one last time if we wish.

June 25, 2012
Auschwitz 1
By Michael Peluso

We departed for Oswiecim this morning and arrived at our hotel after a drive through the Polish countryside. We began the afternoon with a walking tour of Oswiecim, the town closest to Auschwitz and from which the camp got its German name. Oswiecim is used to describe the town, not the camp; Auschwitz is used to describe the camp, never the town. Maybe that is one reason why people can still live here. We visited the site of the old synagogue, destroyed by the Nazis, and the Jewish center, which has a functional synagogue.

When we arrived at Auschwitz, one of the seminary students asked that we take a moment before we went into the camp to discuss what we were about to do and be supportive of each other. This turned out to have been one of the best things we’ve done as a group on this trip. Several seminarians shared moving thoughts and prayers with the group, and this really served to strengthen our bonds as a community of students and faculty. It was a powerful moment that set the right tone for our day at Auschwitz. Then it was through the visitor center and through the infamous gate, past the barbed wire, and into the camp.

What I found most disturbing about Auschwitz was how pretty it is. The lawns are well-manicured, the trees evenly spaced, and the buildings that were formerly barracks and prisons are beautiful weathered brick structures spaced evenly along wide gravel roads. Once you disappear past the gates and the barbed wire, you might as well be in a suburb or summer camp or vacation resort. That Auschwitz is at once visually appealing and emotionally disturbing makes me feel conflicted inside.

Auschwitz I is mostly a museum, with each building converted into a museum related to a specific topic. We had a great tour guide who explained the camp and each building to us, and gave us a good mix of overview and free time to explore on our own. To recount everything I saw would take far too long, but I will mention a few things that stood out. The first was the room with hair—an enormous glass case, an entire wall long and perhaps 15 feet deep, filled with the hair of the murdered victims of Auschwitz recovered after the liberation. This was powerful because it represented something from a person—no matter how many shoes or pots and pans or glasses you see piled up, hair really is at once shocking and tangible and gives you a sense of the scale of what was done, and how much of a violation of humanity it was. The second was the room with the suitcases. These too did not feel like simple objects, perhaps because they were not anonymous; each case had some information—a name, an address—that made it very personal. Next were the prison cells, more specifically the “standing cells.” These were extremely narrow prison cells that would be used as a form of punishment (but really torture). Someone who spent 12 hours a day working would return home to be locked into one of these cells, where they were unable to sit all night; this would repeat for as many as 12 nights. This struck me because I don’t think most people would be capable of designing something like that, even though it seems so simple. The gas chamber was as eerie as I expected it to be—even though I have seen photos before, it was different in person. A room like that can clearly be for nothing good, and you have to wonder what people who were corralled into the room were thinking when the door was locked behind them. The cremation ovens were much smaller than I expected, emphasizing that this was really the killing of a group of 6 million, but rather of 6 million individuals. They could be killed in groups, but they had to be cremated one by one.

What I had the most trouble wrapping my head around was the behavior and actions of other visitors to the camp. I don’t understand why anyone would want to pose in front of the barracks, or the gate, or the gas chamber smiling, waving, with their thumbs up. I can see why someone might want to show that they were physically there, especially if they had family who were involved. But I don’t understand why a tourist would want a photo like that. Similarly, I couldn’t believe what some parents were allowing their children to do. Remembering what happened at Auschwitz is more than just being there, it’s being mindful of what happened there and respectful to those who died. It makes me sad that some people can be so far off.

It was great to talk with everyone, both the medical and seminary students, after the trip, to hear their thoughts and reactions, and to decompress as a group. We did this again after dinner. I think that tomorrow at Birkenau will be even harder, but has the potential to be even more powerful than today was.

June 22, 2012–June 23, 2012
“Condemned to Choose”
By Michael Peluso

Krakow is an amazing, vibrant city. According to legend, the city was once covered by a river and inhabited by a gigantic dragon with a taste for the females of the kingdom. The king promised his daughter to any knight who could slay the dragon, and many tried and failed. One day, a farm boy named Krak came up with a plan to slay the dragon—he filled a sheep with sulfur and when the dragon ate it, it became so thirsty and drank so much water that it drained most of the river and uncovered the land that would become the city. As he drank and drank, his stomach filled and eventually exploded, killing the dragon and liberating the land from its terror. The farm boy married the king’s daughter and the land was named Krakow.

We arrived on Friday morning and immediately took a walking tour of the city. Thorston Wagner, the European director of FASPE, pointed out the major sites in the Market Square, most notably St. Mary’s Church, a large Catholic church, where a trumpeter’s song is cut short abruptly each hour to represent the killing of the trumpeter sounding the warning call of invasion many years ago. We saw Jagiellonian University and went to the Jewish Quarter, where Thorin Tritter, the managing director of FASPE, led us on a tour of important areas of Kazimierz, home to Krakow’s Jewish community, and two synagogues, before we headed to the Galicia Museum. Here we discussed the stories of a number of Poles who hid and protected Jews during the Holocaust, and discussed the motivations and justifications for doing so, as well as their applications to modern ethical dilemmas that require individual risk or sacrifice. Afterwards we headed back to the hotel for a seminar on rationing in health care, with a focus on the classic “trolley problem.” (A runaway trolley is racing down a hill. It will kill five people clustered at the bottom of the hill, unless you throw a switch that will divert it to another track, but it will kill one person standing there. What do you do?)

Saturday morning we had a tour of the former Jewish Ghetto, including the monument outside, which is designed as a number of empty chairs scattered throughout a plaza. We went to Schindler’s factory, one of the most impressive and successful museum exhibits I have ever seen. The museum traces the history of Krakow in the 1900s, with a focus on the social and political forces at play in the city rather than the Holocaust alone. It also has exhibits focused on Schindler and his efforts to provide safe haven for the Jews during the Nazi occupation. Afterwards we went to a traditional Polish restaurant called Jadtodajnia, for soup and “Russian” perogies, with potato and onion.

In the afternoon we had two great sessions—the first on human experimentation and the second on modern issues in euthanasia. In the former, we discussed the ethics of using data generated from Nazi experiments in the concentration camps. We talked about this in three contexts: data revealing a cure for Alzheimer’s disease, general data of unknown utility, and preserved organs from the concentration camps. People fell on different sides of different issues, but the general consensus of our group was that we would use the Alzheimer’s cure and the general data, but not the organs. We reached this point by analyzing and applying many of the arguments in the background reading. From a pure cost-benefit standpoint, we thought that not using data that would be outright beneficial to thousands with Alzheimer’s could not be justified, with the stipulation that there should be full disclosure to patients (not just physicians or journal readership) regarding where this potential treatment came from. With regard to the data, we decided that it was justifiable to use previously collected data with the same stipulation of full disclosure. However, many thought that it was not justifiable to use the organs to generate new data; we felt that this was fundamentally different from using previously collected data and would constitute a continuation of the Nazi experiments. The second session was an interdisciplinary discussion on euthanasia using specific case examples: one based on the decisions made regarding evacuation during Katrina, and two on hastening death in geriatric and pediatric patients. My small group included Catholic and Jewish seminarians as well as medical students, and we really struggled with our assigned case (the pediatric euthanasia case). We discussed the case from the perspectives of Catholic, Jewish, and lay law, as well as the Hippocratic oath, and the values of autonomy, beneficence, non-maleficence, and justice. We ultimately decided that we would not hasten the death of a dying newborn on request from the parents, with the justification that there was no evidence that the baby was suffering and that, although we were sympathetic to the parents, we could not justify providing a treatment to the child that was meant not to relieve symptoms but only to hasten death.

After these discussions, we headed to Jagiellonian for a lecture on Poland during the first half of the 20th century by Barbara Klich-Kluczewska, a professor of history. This is an interesting and often misunderstood story, because the story of the Jews during the Holocaust is different from that of the Poles. The way the Holocaust is discussed and understood in Eastern Europe is different and focuses on the troubled history of Poland, first divided by Austria, Germany, and the Soviet Union, then as an independent state for 20 years, then under Nazi occupation, and then Soviet rule. The extent of the suffering of the Poles is often not fully recognized, and I was less aware of it than I thought I was.

We had dinner (more soup and more perogies—meat this time) at a restaurant called Nostalgy. It’s great to see how much bonding has occurred within our group within just a week, and this made it clear why we save Auschwitz for the end of the trip. A group of medical students and seminarians went out to socialize after dinner, and it was great to get to know people from both groups even better—one of the best things about FASPE is that it connects medical students from different institutions, and medical students with seminarians who they would be unlikely to interact with otherwise. I wish we had more of this in our regular lives. It’s still amazing to me how much overlap we have in our interests and life experiences, and it makes me happy to know that we’ll be working on the same team in the future.

We ended the night with a walk back to Kazimierz, where we indulged in Zapiekanka, a Polish tradition. This is a half-baguette topped with vegetables, cheese, and a sauce that is somewhere between tomato and barbecue. I’d take perogies any day, but it was a nice end to the night. It’s great to be a part of the community of FASPE, and this sense of community will be even more important tomorrow when we arrive at Auschwitz.

June 20, 2012
Track 17, House of the Wansee Conference
Beauty and Tragedy

By Michael Peluso
Berlin feels more natural in the rain. It was drizzling when we woke up this morning and continued throughout the early afternoon. Our first stop today was the "Track 17" memorial in Grunewald, which commemorates the deportation of Jews from Berlin to the camps. Thorston, the FASPE European director, discussed the history of the station and the controversies surrounding the memorial. One of the running themes with all of these memorials is the conflict in the 1980s between East and West Berlin, resolution of this conflict, and changed plans in the 1990s, and the divide between grassroots groups and government-based advocacy for the design of memorials. This is very true at Track 17, which consists of three separate monuments. The first is a simple set of railroad ties in a garden of birch trees transplanted from Birkenau. The second is a stone wall into which are carved abstract human figures, another example of the use of negative space in commemorating the Holocaust. The third is a set of railroad tracks lined with the dates and number of Jews for each deportation. The tracks extend past the platform and into a grove of trees, which grow around, in between, and on top of the steel rails, perhaps representing that such tracks are never to be used again. This was another powerful memorial that provides both information and an opportunity for interpretation.

After Track 17, we headed to the house where the Wansee Conference occurred. This was the conference where prominent Nazis, led by SS officers Reinhard Heydrich and Adolf Eichmann, were able to consolidate administrative power and begin to plan the logistics behind the massive deportation and murder of European Jews. The House itself is beautiful, with pretty gardens and a view of the lake—why is it that the places with the most troubled history are always so beautiful? The house has some fascinating documents that record the meeting, indicating the statistics of how many Jews remain in Europe and how forced labor will lead to death for many of them. The strongest and fittest will have to be murdered afterwards in a perversion of natural selection. We spent the afternoon eating a hilarious lunch (why are sandwiches outside of the U.S. so disappointing?) and reviewing some documents from professionals during the Holocaust. While we didn’t have as much time as we would have liked for heated conversations today, tomorrow will be mostly that and I think we are looking forward to thinking about and discussing a bit more critically the important questions that arose through the activities of the Nazi doctors and how we can learn from their misdoings today.

June 19, 2012
Deja Vu

By Michael Peluso
We arrived exhausted but excited, and ready to make up for lost time. After checking into our hotel, Thorston Wagner, the European director of FASPE, took us on a walking tour of the city. This was a much-abbreviated version of what we were actually supposed to do (since we arrived so late), but it was good to get at least some of the activities in. We visited a few important sites around Berlin. One of the most interesting was a simple parking lot that turns out to be the area under which Hitler’s infamous bunker was located. The site was never specifically located or commemorated until recently because there was concern that it would become a pilgrimage site for neo-Nazis; similar to the United States’ fear that burying Osama bin Laden would cause the same problem.

We then walked to the Holocaust memorial, or rather the "Memorial to the Murdered Jews of Europe." I first visited this memorial in winter 2008, when I came to Berlin for the first few days of spring break. I visited the memorial when it was snowing, and it was mostly empty except for a handful of little children playing tag between the stones. Their giggling and singing as they ran in and out of sight made the visit a very eerie experience, but perfectly captured a certain sentiment of loneliness and innocence that I thought made the memorial very effective. I wasn’t sure that my second visit to the memorial would be very different from my first, but it certainly was.

The most striking thing about the memorial is the sense of escalation, and then isolation, that one feels upon entering. At first, the columns are short and you can see right over them—it’s underwhelming. As you enter further, the columns grow and everything else disappears—anything in your peripheral vision is replaced by the towering monoliths, the sky becomes small and distant, it gets dark, and all that remains in front of you is a single path, rising and falling, extending into the distance. There’s no one path through the stones, and so you weave in and out, changing direction, going forwards and backwards, taking different paths, feeling lonely and overwhelmed, and on some level increasingly desperate to get out. The unique thing about this visit to the memorial was that I was with 40 other people that I now know. Although we all entered and navigated through the forest of stones alone, occasionally two paths would cross or you would catch a glimpse of someone as they passed to the side or in front of you. Sometimes they didn’t know you were there, sometimes they’d make eye contact, sometimes you’d turn to look and they’d be gone and you’d wonder if they had been there in the first place and whether you’d see them again. This was a powerful experience and entirely different from my first time at the memorial. I still feel that it is one of the best memorials to which I have been because different people experience and interpret their time between the stones differently. It’s not a memorial about hand-holding or presenting facts; instead in embraces the abstract and subjective and has the viewer apply his pre-existing knowledge to the present experience. I think that any memorial that can get people to have a discussion about the event that it is meant to memorialize in an effort that requires personal thought and introspection is unusually successful.

From the memorial, we went to see other parts of past and current Germany: Brandenburg Gate, the Soviet Embassy, Humboldt University, the site of book burnings. We ended up near Museum Isle and at Nolle, which turns out to be the same restaurant I went to for dinner in Berlin five years ago. It was strange to be back there again, and to think of how much has happened in the intervening time.

June 18, 2012
Museum of Jewish Heritage,
New York

"It all began with the notion that some lives were not worth living…"
-NEJM, 1947

By Michael Peluso
We had two teaching sessions today, one with Mark Mercurio, M.D., on professionalism and one with Thomas P. Duffy, M.D., on medical education. The one with Mercurio was excellent and I feel that every medical student should have it during the first week of medical school. He absolutely nailed what professionalism is and what it means to be a professional—this will obviously be fundamental to our discussions about the behavior of professionals on FASPE. We discussed fiduciary duty and ethics, virtue ethics and practical wisdom. This session made me think a lot about how loosely the term "professional" is used these days, and how true professionals need to make sure that the term is not co-opted by everyone else and diluted in the process. We discussed how the perfect and the good are often not the same thing, and that sometimes the best we can do is not perfect, and maybe not even good, but is rather the best we have available to us. I think it’s easy to forget this in the context of being a medical student, resident, attending, etc. It forces us to ask the question, "even if what I am about to do isn’t perfect, is it the best that I can do, and is it worth doing?" I think this applies to some of the tough questions in medicine and makes it easier to justify things that we might otherwise have trouble with, for better or worse. This is how we can justify learning a procedure on a patient for the first time, but it is also how we can justify something like racial profiling. Neither is ideal, but both may be the best we can do right now. If we waited to act until we knew that the action was perfect, we would never act.

Duffy spoke about the Flexner report and the principles of German medical education that permeated U.S. medical education in the 1900s (and still today). Flexner went along with Billroth’s (of the Billroth I and II procedures) idea that a "medical professor is a superior being dealing with inferiors" and created a system that overemphasized knowledge and underemphasized service. It’s interesting to think about this, especially in the context of the shift toward an emphasis by modern medical schools on empathy, humanism, and service. Sure, Flexner created the concept of the modern medical school, but in creating his educational ideal, forgot the service aspect of the profession. This is apparently something that he later regretted. The key principles that Duffy arrived at by examining the slippery slope of the involvement of medical professionals in the Holocaust were, of course, "first, do no harm," but perhaps more importantly, "second, do not be silent." We would be wise not to forget the latter.

After lunch, we met with a Holocaust survivor from Poland. No matter how many books you read, it’s different to hear a survivor talk about her experience, in her own words, in person. I felt like I was sitting there with my jaw on the floor—the details of her story were unbelievable and you have to wonder just how lucky someone has to be to fall on the right side of each node at the branch points between life and death. Her stories of separation from her family, running, hiding, being a head of household at 11, and eventually ending up at Auschwitz were powerful enough, but were followed with harrowing memories of her interactions with Mengele, first defying his wave to the gas chambers and years later begging him for her life as bombs fell near Auschwitz. She attributed his mercy to nothing but cowardice. The way that she described him was truly terrifying. I was surprised by how large the tattooed numbers on her arm were - in the movies they are always smaller, neater, and straighter.

Later, we arrived at the airport to find that our 5:30 p.m. flight was delayed until at least 2 a.m. Somehow it is hard to be upset about this after spending the afternoon with a Holocaust survivor. We spent the evening in a hotel near JFK and at 1a.m., the shuttle that was supposed to take us to the airport did not show. We ended up cramming all 37 of us into a mini-bus meant for 15 people and driving that to the airport. I don’t think the irony was lost on anyone.

June 17, 2012
Museum of Jewish Heritage,
New York

By Michael Peluso
FASPE began last night with a mixer at a bar in the financial district. It’s funny that even though I lived in New York for four years, I barely spent any time in the financial district and absolutely no time in Battery Park. This area of Manhattan is beautiful, and it’s amazing to think of its significance per square foot. We are staying in the shadow of the World Trade Center, in view of the Statue of Liberty; it’s beautiful and overwhelming and all right here. Even for a New Yorker, it’s easy to be taken by where we are and what we’re about to experience.

The other fellows seem great—I am excited that there are non-Yale medical students here, and even more excited about the seminarians, who are much different than I anticipated. They are certainly less outwardly pious than I expected and all have told great stories about their current and past life experiences. I think it will be fun to spend time with them, and I am glad the trip is so well-integrated. This is one of the most impressive groups of people of which I have ever been a part. Staying at the Ritz-Carlton, for the first and probably the only time in my life, is also a nice perk.

This morning we went to the Museum of Jewish Heritage for the official start of the program. We began with breakfast and an introduction from Thorin Tritter, the managing director of FASPE. Thorin is an entertaining guy and a bit of a comedian; he will be great to have on the trip to defuse tense situations. His background is in American history and he has a recent Ph.D. from Columbia. We also met David Goldman, who is the founder of FASPE. He led us in an interesting exercise about car racing. The concept of the exercise was that we had a racing team and were participating in a race; if we won we would receive $1 million. The catch was that our car had an unreliable gasket that didn’t function well at low temperatures, and it was a cold morning. We would lose our contract with our sponsor (worth $500,000) if we blew the gasket during the race. Each group had a few minutes to decide on whether or not they would race that day. We decided to race because "we are racers and racing is what we do." Many groups decided not to race because they thought it didn’t make financial sense, or for other reasons. It turns out that this exercise was really an adaptation of the decision that was made to launch the Challenger space shuttle in 1986; the gasket was supposed to represent the O-rings and the blown gasket was the Challenger exploding.

Obviously this was not a great analogy and many groups felt conned because they didn’t realize that human lives were at stake if a gasket blew. However, the exercise did a good job of introducing the point of professional responsibility, and was therefore very useful. The engineers from the Thiakol company were the only professionals involved with the launch, and it was their recommendation not to go ahead with it—they had the expertise and knew that it was a bad idea. However, NASA and the managerial staff, even though they were the ones to make the decision, would not go against the engineers’ recommendations and therefore were trying to persuade the engineers to go along with their desire to launch. In the end, the engineers caved and the rest is history (and tragedy).

I thought that the most interesting part of this was a quote that came when someone from NASA instructed the Thiakol representative to "take off his engineer hat and put on his management hat." This really struck me as fundamentally flawed—a professional should be put in a leadership role because of his expertise, not in spite of it. The idea that there are two hats, two individuals, that exist in different realms is unfair to the professional and ultimately was unfair to those astronauts. The lesson to be learned here is that our professional knowledge should inform our decisions, and that we should think carefully about making decisions that contradict our professional knowledge.

Afterwards we had a lecture by Andres Sofair, M.D., from Yale, on eugenics, which traced back the history of the movement using articles from the New England Journal of Medicine and the Journal of the American Medical Association. This was fascinating work and provided great insight into what was going on in the minds of American physicians in the 1930s. The discussion was animated. We had lunch and went on a tour of the Museum, which is divided into floors on Jewish history, the Holocaust, and post-Holocaust Judaism. It’s a well-done exhibit that focuses primarily on the Jewish identity and community rather than on the specific events of the Holocaust. We did long-form introductions of the group, which was a good start in the process of getting to know each other. I was very impressed by the others in the group, but I think it’s true that we represent a very specific "type" of medical student. There is certainly a selection bias, for better or worse.

We watched a movie called Engineering Evil that focused on the process of building the concentration camps and systematically isolating and destroying the Jews. What impressed me most was how mundane many of the decisions were from a professional perspective. For example, in designing the camps, one engineer was able to solve the problem of Zyklon B gas only working at 79F by re-routing the heat from the cremation ovens to the asphyxiation chambers. This was solution to a problem that the engineer worked out on his own time at home, a mundane engineering problem that had a solution facilitating the deaths of six million people.

After dinner and some drinks, we headed back to our hotels. Tomorrow should be a long and exhausting day.