The Left Atrium · De l'Oreille Gauche

CMAJ 2000;162:1594-7

• Death's accomplices
• Remarking the unremarkable
• One thousand words
• Illness and the hero's journey: still ourselves and more?

Nurses in Nazi Germany: moral choice in history
Bronwyn Rebekah McFarland-Icke
Princeton University Press, Princeton; 1999
343 pp. US$35 (cloth) ISBN 0-691-00665-2

In her meticulously researched and disturbing study, Nurses in Nazi Germany: Moral Choice in History, McFarland-Icke draws on a variety of primary sources to understand the mentality of Nazi nurses. She gains insight into their training through the window of a psychiatric nursing journal, Die Irrenpflege, published from 1896 on, which instructed psychiatric nurses through articles written by psychiatrists, nurses, social welfare workers and members of the clergy. She examines personnel records from two psychiatric institutions to reconstruct the atmosphere created by administrative policies. Finally, she scrutinizes the postwar trial testimonies of nurses accused of involvement with the "euthanasia" measures employed by the Nazis between 1939 and 1945.

McFarland-Icke describes the developments in psychiatry that led to the "euthanasia" program and the role nurses played in the killing of mentally and physically handicapped people in Germany between 1939 and 1945. Indeed, the techniques deployed against the Jews were first tested on Germany's disabled citizens. She focuses on two areas, the professional morality of psychiatric nurses and the realities of institutional life, and sets the evolution of psychiatry and psychiatric nursing against the backdrop of World War I, the Weimar Republic, the emergence of National Socialism and, finally, World War II. Changes in psychiatry and psychiatric nursing contributed to a changing view of the psychiatric patient. The roots of this change lie in World War I and the emerging concept of the Volk, "the people," to which individuals ideally subordinated themselves through sacrifice. During the economic hardships of the thirties, the moral value of "the people" superseded that of the individual, thus contributing to a situation in which the patient receded from view as an object of moral concern for nurses.

Psychiatric nurses in Nazi Germany generally came from working- or lower-middle-class backgrounds and had only a rudimentary education. Formal nursing training did not exist; some nurses were promoted into psychiatric practice from housekeeping or the kitchen. The group examined by McFarland-Icke was very different from the professional nurses of today. That being said, psychiatric institutions in Nazi Germany did not differ greatly from psychiatric institutions around the globe at the time. Although administrative policy paid lip service to the notion of nurses' training, it became increasingly difficult to obtain qualified nursing staff during the National Socialist years. The characteristics that governed the profession, however, remained the same. As members of a respectable calling, nurses were expected to exercise moral abstinence, confidentiality, patience, economy and self-control.

It was within a changing institutional and political climate that nurses became supporters of the National Socialist euthanasia program. As McFarland-Icke notes, "formal changes and rituals designed to promote National Socialist ideals cultivated an acceptance of structured authority, a readiness to contribute to a collective effort, and the habit of taking orders from superiors without asking for reasons" (p. 202). In psychiatric institutions nurses were discouraged from establishing friendships with their patients, felt powerless to influence or make decisions and were surrounded by the probing eyes and ears of potential denunciators. Was this how their moral deliberation and sense of responsibility were destroyed? For McFarland-Icke, "the National Socialist regime's most devastating power lay not in its ability to mobilize people against its victims through propaganda but rather in its ability to deploy propaganda in conjunction with specific physical, discursive, and hierarchical arrangements so that the desire for psychological comfort would prevail over courage" (p. 264).

Nazi nurses did not see the violence and blood associated with the deaths of patients, who were sent away in buses, "fell asleep" following an injection administered by a nurse, or simply wasted away from hunger. The author concludes that these "ordinary" nurses, previously trained to care for patients, became mass murderers for complex reasons that cannot be reduced simply to their willingness to follow orders. Among these were fear of reprisals, isolation from one another and their patients, a sense of powerlessness and an enforced moral paralysis. Some had an "unpleasant feeling" but did not act upon it. One nurse testified that she suffered unbearable conflicts of conscience but did not feel guilty about her assistance in the murder of adults because she was not directly involved (p. 255). A troubling comment indeed.

This research poses the unanswerable question: How would we behave in similar circumstances? The distance between Nazi nurses and nurses in Canada may not be as great as we would wish to imagine. The first nursing school in Canada opened with the motto, "I see and am Silent." At what point do obedience and professional detachment become dangerous? McFarland-Icke identifies 1933 as the year in which "strategies of eugenic management suddenly became the cornerstone of a new authoritarian regime" (p. 130). The result was the passage of the Law for the Prevention of Hereditarily Diseased Progeny. Alberta's Sexual Sterilization Act came into effect in 1928, and nurses played a significant role in its execution. Do nurses continue to remain silent today when they ought to speak out?

I thank Carolee Pollock for her comments on a draft of this review.

Diana Mansell
Faculty of Nursing
University of Calgary

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"I have measured out my life with coffee spoons" T.S. Eliot, The Love Song of J. Alfred Prufrock

Poor J. Alfred, caught in that awkward modernist moment when the manners of polite society had become hollow and the monotony of life paralysed the soul. But now that we are thoroughly postmodern, banality has apparently become something to celebrate.

Exhibit A: Canadian artist Kelly Mark, whose latest solo show was recently mounted at Vancouver's Contemporary Art Gallery. Since 1991 Mark has been attracting notice as a young conceptualist to watch. Her work engages with utilitarian objects and materials, which she subjects to compulsive orderliness and quirky forms of stress testing. White Jars (1994) is an arrangement of 144 Mason jars containing white substances; Black Jars (1995) repeats the exercise with black items. 1000 Hemlock Hits (1994) consists of two wooden beams that have been struck together 1000 times; Split Axes (1995) is a row of wooden axe handles that have been split by an axehead and repaired. Object Carried for One Year (1996–1997) is an aluminum bar carried in the artist's back pocket for the stated period. These pieces bluntly declare the effort of producing them, which may invite the viewer to reassess the nature of our engagement, through work and repetitive action, with the material world. They also constitute a mimicry of modern, industrialized consumption: 1000 Watts and 1000 Hours (1997) are displays of illuminated lightbulbs that offer, as one reviewer notes, "a conceptually eloquent, home-hardware meditation on entropy and hope, vigilance and excess."¹ The consumption necessary for art is also enacted by a series of pencil drawings from 1997, which singlemindedly records the scribbling of graphite on paper: when the pencil runs out, the drawing is finished.

In some of her more recent works, however, a sense of human agency relieves the materialist weight of Mark's brand of minimalism. A grid of photographs entitled Broken Meter documents notes found on dysfunctional parking meters, giving us a gratifying sense of talking back to mute authority. Placed records adaptive responses to a mundane, repetitive environment with photographs of styrofoam cups, crumpled pieces of paper and other detritus that has been tucked into odd corners rather than being relegated to the pure randomness of litter. Origami Transfer is an arrangement of bus transfers folded by fidgety travellers into interesting shapes. With these iterations Mark's study of materials inches into a study of behaviours and a kind of sociologic voyeurism.

Kelly Mark, 1999. Broken meter (detail). Photographs, 4" × 6" each.	Kelly Mark, 1999. Placed (detail). Photograph, 4" × 6".

Reading commentaries on Mark's work, it struck me how readily interpretation rushes into the vacuum of the banal. What is self-evidently dull suddenly demands our attention by being singled out and manipulated by the artist, who thereby exerts a kind of intellectual and moral authority, directing us as to what phenomena in life we should remark.

Which brings us to Exhibit B, the Journal of Mundane Behavior, whose inaugural issue was recently published on the Web (www.mundanebehavior.org). In "A Mundane Manifesto," contributor Wayne Brekhus declares that "in failing to take the ordinary as seriously as the extraordinary, social science has produced a distorted picture of the social world." Drawing on structuralist linguistics, he invokes the categories of the "marked" and "unmarked." The "marked" is the exotic, extraordinary or extreme, which in being studied and written about takes on the status of the exemplary and instructive. The "unmarked" is our "epistemological blind spot" and consists of those things too typical to attract our notice, but which by virtue of their pervasiveness are far more significant than the "marked." The journal's first issue offers studies on shaving, how people behave on elevators in Japan, and the spatial organization of libraries.

Brekhus argues that our notion of what is newsworthy or deserving of study must be turned on its head. He describes the old order as follows: "For a scholarly or journalistic article to be regarded as interesting it generally has to [be] ... factually interesting (i.e. statistically unusual or extraordinary); 2) ... morally interesting (i.e. politically important); or 3) ... analytically interesting (i.e. counterintuitive or theoretically interesting)."² These criteria distinguish the figure that stands out from the ground of the unmarked. Brekhus' project is to reverse figure and ground or, ultimately, to "mark" everything.

Considering Brekhus' critique of "interestingness," I wondered how medical publishing fits in. Are not the new, the politically relevant and the unexpected the sort of findings a medical journal ought to report? But then I began to ponder how much truck medical research has with the "unmarked" anyhow. In searching for therapies that will work for most people most of the time, are medical researchers not looking for the normative, the predictable, the replicable, the generalizable, the reliable, the algorithmical? Perhaps they have been less guilty than sociologists of reifying the remarkable. Besides, Brekhus' manifesto is intended to improve ethnographic methodology. In medicine, ethnography is only just beginning to make inroads into the levelling of experience brought about by statistical studies fixated on narrow questions and standard deviations from the mean. For now, I reckon, we are safe from Brekhus' challenge. Medicine is already banal enough.

References

1. Allen J. Every Day [exhibition catalogue]. Sydney, Australia: Art Gallery of New South Wales; 1998.
2. Brekhus W. A mundane manifesto. J Mundane Behav 2000;1(1). Available: www.mundanebehavior.org/issues/v1n1/brekhus.htm

Anne Marie Todkill
CMAJ

[Contents]

Sterilizing milk cans. No date.

(Photo courtesy of the National Archives of Canada / PA-048688)

[Contents]

When Queen Medb of Connacht launched a great cattle-raid against Conchobor the king of Ulster, all the men of that region of Ireland were ill with something resembling labour pains. This was a curse that had been put on them because they had mistreated a pregnant woman. Who would defend Ulster? Luckily, one man was exempted from the illness: a young warrior named Cuchulain. In the story, Cuchulain defends Ulster single-handedly against Queen Medb's armies until the men of Ulster recover and rout Medb in battle. He is the hero of the eighth-century Irish epic, the Tain Bo Cuailnge.¹ Like most heroes, he is wounded physically and forced to give up things he holds dear in order to come through the experience. Like other heroes, his experiences are less history than metaphors for how to live, and his story is one of many examples in mythology of the hero's journey.² We probably live these journeys in the most mundane aspects of our daily lives,³ but I wonder if the heroic perspective is not particularly relevant when we become ill with chronic and life-threatening illnesses.

According to Jung, myths are the deep code of the human psyche.⁴ The hero myth has a series of predictable sequences.² First, there is the call to a new experience. This might appear like good news (a promotion) or bad news (a medical diagnosis), but in either case the call may be resisted. However, sooner or later, if they are to fulfil their destinies, heroes accept the call and cross the first threshold. They accept the new job, start the chemotherapy or go for the first dialysis treatment. There follows an interesting gestation period sometimes described as "the belly of the whale." Heroes find that their old identity and sense of themselves are not adequate to their new situation. Their world is in chaos. They feel alone and under attack from unfamiliar enemies, such as a crisis in the company for which they are now responsible, complications of disease or treatment, loss of employment or financial difficulties resulting from illness. They need to dig deep to find unused talents and attributes that are helpful in the new situation. Old expectations, such as always having someone to pass the buck to, or being free of disease, have to be relinquished. Then follows the path of trials. The new identity needs to be tested, tried out and practised against adversity before it is solid enough to be functional in the day-to-day world. Finally, when the hero is ready, there is the return to the normal world with a new perspective and new riches to share. As a man with a kidney transplant put it, "Someone once asked me why little things don't bother me anymore. I told them to go get a transplant."⁵

The hero myth is a template, perhaps the template for human growth and development. It bears a strong relationship to other models that have been proposed to describe how people deal with illness and life crises. For instance, Kubler-Ross's stages of denial, anger, bargaining, depression and acceptance in patients who are dying⁶ focus on the first stages in the hero's journey: the call, refusal of the call and crossing of the first threshold. Another model,⁷ based on qualitative interviews with patients receiving hemodialysis treatment, suggests that these patients have three main questions: Who is this new me with kidney failure? What is this disease that I have? What supports do I have? These questions appear entirely appropriate for someone in the middle of a hero's journey. Virginia Satir's growth model, in which the person moves through the stages of old status quo, introduction of a foreign element, chaos, new options and integration, implementation and new status quo,⁸ is very close to the full hero myth.

These modern formulations confirm that our thinking has not changed, but do they have the same power as heroic stories to galvanize the human spirit? If illness is a story that we tell about our experience with disease,⁹ then perhaps the hero's journey is the most appropriate structure to transform that story into a meaningful experience. Are patients then to be called heroes? This does not fit with the common conception that the term "hero" is only applicable to an extraordinary person who changes the world. But, as Christopher Reeve says in his autobiography Still Me,¹⁰ perhaps a hero is also "an ordinary individual who finds the strength to persevere and endure in spite of overwhelming obstacles." Is it a new idea to apply the hero label to people suffering from disease? Don't forget that it was the illness of the men of Ulster that made a hero of Cuchulain.

References

1. Kinsella T, translator. The Tain. London: Oxford University Press; 1970.
2. Campbell J. The hero with a thousand faces. Princeton (NJ): Princeton University Press; 1973.
3. Joyce J. Ulysses. New York: Random House; 1992.
4. Campbell J, editor. The portable Jung. New York: Penguin Books; 1971.
5. Philips D, editor. Heroes: 100 stories of living with kidney failure. Montreal: Grosvenor House Press; 1998.
6. Kubler-Ross E. On death and dying. New York: Macmillan; 1970.
7. Gregory DM, Way CY, Hutchinson TA, Barrett BJ, Parfrey PS. Patients' perceptions of their experience with ESRD and hemodialysis treatment. Qual Health Res 1998;8:764-83.
8. Satir V, Banmen J, Gerber J, Gomori M. The Satir model: family therapy and beyond. Palo Alto (CA): Science and Behaviour Books; 1991.
9. Kleinman A. The illness narratives: suffering, healing and the human condition. New York: Basic Books; 1988.
10. Reeve C. Still me. New York: Random House; 1998.

Tom A. Hutchinson
Departments of Medicine and of
  Epidemiology and Biostatistics
McGill University, Montreal

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