Adapted from The New Eugenics in Medicine: Two Novellas About Power, Science, and the Future of Human Worth.
My recent article in The Pharos, “Eugenics Is Having a Quiet Revival, and Medicine Must Respond,” began with a premise that is easy to state but harder to live by: Eugenics should not be treated as a safely quarantined historical episode. Its most dangerous legacy is not a particular vocabulary or political movement but a way of thinking: assigning differential value to human lives and allowing medicine, science, law, or policy to legitimize that hierarchy.
Shortly after the essay was published, I received an email from a recently retired physician and longtime medical educator. Each year, he returns to his undergraduate college to teach medical ethics. This year, he was asked to speak about physicians and the Holocaust. For him, the subject is personal. His father, a Jewish American medical student, studied at the University of Freiburg in Germany in 1932-33 before transferring to Basel. His surviving textbooks and notes document the eugenic assumptions circulating in medicine at the time.
My colleague told me he planned to conclude his lecture with a discussion he called “Red Flags for Today,” noting that certain habits of thought that once enabled physicians to participate in profound injustice can reappear in different forms. That was one of the points I tried to make in The Pharos: The danger is not necessarily a return to forced sterilization statutes but the normalization of selective protection, stratified empathy, and judgments about whose lives deserve greater investment.
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Here are the red flags my colleague and I worry about:
1. When race moves from clinical context to human classification
Medicine has good reasons to confront racial disparities, diversify its workforce, and understand why some patients may feel greater trust or comfort with clinicians who share aspects of their background. But an important distinction exists between recognizing those realities and treating race as a determinant of who should care for whom.
The warning light flashes when race ceases to be a relevant social factor and instead functions as a sorting mechanism. The history of eugenics teaches us how dangerous supposedly scientific categories become when institutions harden them into rules. Physicians should reject biological essentialism and be especially cautious about treating race as a genetically coherent clinical category.
2. When equity becomes indistinguishable from preferential worth
Efforts to correct health disparities are not eugenics. Neither is directing resources to populations that bear disproportionate burdens of illness. But medicine should continually ask which principle justifies differential treatment. Are we trying to overcome an identifiable disadvantage, or have we begun to decide that membership in one group confers a greater claim to care than membership in another? These are not the same. The ethical goal should be to remove unjust barriers rather than create a new hierarchy of deservingness.
3. When professional formation becomes ideological conformity
My correspondent was particularly troubled by mandatory leadership programs and institutional expectations, which, in his view, sometimes blur the line between education and ideological formation. I would draw the line cautiously here. Leadership education is not inherently sinister; physicians desperately need better leadership skills. The red flag is when a medical institution begins defining the “good physician” not by professional conduct, competence, compassion, and ethical reasoning, but by conformity to an approved set of social or political beliefs. Medical education should teach students to think ethically, not dictate every conclusion they must reach.
4. When medical ethics simply mirrors prevailing social values
This may be the most important warning of all. My colleague recalled an ethicist who suggested that physicians’ ethics should reflect their society’s dominant ethical norms. History offers a devastating rebuttal.
If medical ethics follows the majority sentiment, it stops functioning as ethics precisely when it is needed most. Physicians sometimes have an obligation to stand against popular opinion, political authority, institutional pressure, and even the law.
A timely example comes from critical care physician David Oxman, MD, who recently challenged medical school deans to speak out when government health officials contradict established scientific evidence, arguing that institutional caution can reach a point where “silence feels like assent.” The vulnerable patient needs medicine to maintain a moral center that a referendum cannot alter.
5. When public health begins valuing populations instead of protecting them
Public health policy inherently requires population-level allocation decisions that entail stark trade-offs. During COVID-19, elevated mortality among vulnerable groups, such as older adults and medically compromised individuals, was at times accepted as a risk of competing societal priorities. Because policies can generate inequities without explicit discriminatory intent, predictable disparate harm always warrants ethical scrutiny. The crucial question is not merely “Does this policy improve aggregate outcomes?” It is also “Who bears the cost?”
6. When control of payment becomes control of professional legitimacy
Government and corporations inevitably play major roles in financing American health care. The warning arises when economic power is used to exclude disfavored physicians, treatments, or patient populations for reasons unrelated to legitimate clinical evidence or stewardship. Whoever controls payment holds enormous influence over what medicine can do. Physicians should therefore remain alert whenever financial mechanisms quietly become moral gatekeepers.
7. When some lives are discussed primarily in terms of burden or cost
Assisted dying, prenatal genetic testing, disability rights, and reproductive choice invite heated moral debate. They cannot be responsibly conflated with Nazi euthanasia programs, which involved coercion and murder. We shouldn’t dismiss the underlying concern.
The red flag appears when discussions of suffering shift toward social utility; when cost containment influences judgments about whether a life is worth sustaining; or when technological efforts to prevent disability subtly become cultural judgments about the value of people living with that disability. Modern genetics makes these issues increasingly urgent. Therapy seeks to alleviate pathology, whereas enhancement and selection can move toward optimization according to socially constructed notions of desirability.
Red flags signal the need to examine what lies ahead. None of them proves that medicine is descending into eugenics. Taken together, however, they remind us how easily ethical drift can occur when discrimination, institutional conformity, economic pressure, and judgments about human worth are normalized. Medicine’s task is not to see Nazis everywhere. It is to recognize dangerous patterns early so history does not dictate their course again.
Arthur Lazarus is a physician-author whose work spans narrative medicine, physician leadership, artificial intelligence, health care ethics, medical culture, and fiction. He has published more than 500 articles and essays across scientific journals, professional publications, and online platforms.
He is the author of numerous books on narrative medicine, AI in medicine, career development, and the changing moral landscape of health care, as well as fictional series including Rounds Never End, Sick and Systemic, and Real Medicine, Unreal Stories. His writing explores the forces reshaping modern medicine while preserving a central commitment to story, meaning, judgment, and the human relationship at the heart of care.
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