The Tragedy of Bioethics

At last week’s CBHD conference, a few of us were treated to a unique “Drinking-from-a-firehose” experience.  Jerome Wernow gave a talk with the eyesplitting title, “Bioethics:  Facing a Philosophical Theology of Tragedy and Mystery.”  Intrigued at the title in the conference brochure, but having no idea at all what it might refer to, I slid into a seat in the classroom where Dr. Wernow was to speak, prepared to be befuddled.  Instead, in the space of about about twenty minutes, those of us in the room were given an alluring glimpse into a poignantly beautiful picture for doing bioethics that alters what I see when I look at a patient.

I will attempt to present gleanings from the rich feast that was Dr. Wernow’s talk.  The early 20th Century Russian philosopher Nicloas Berdyaev wrote,  “There can be no moral life without freedom in evil, and this renders moral life a tragedy and makes ethics a philosophy of tragedy.”  As anybody who has witnessed the anguish of those who seek an ethics consult can attest, as anybody haunted by the dark questions our modern technology raises would agree, in bioethics all decisions are fraught with tragedy;  ethics consultants are actors in one-act medical dramas that are tragedies.  And tragedy is neither lessened nor assuaged when good and evil alone are used in bioethics’ calculus.  Our knowledge of good and evil is damaged, the product of a lie (“your eyes shall be opened, and ye shall be as gods, knowing good and evil“); it was in the very act of grasping for the tree of that knowledge that we were banished from the tree of life.  When we approach people whose stories have taken a catastrophic turn and we wield only the calculus of good and evil, our bioethics is left lifeless, empty, and tragic.  According to Wernow, to address tragedy we must turn to mystery, to “Mystery-revealed:” Christ, in whom is Life.  The question we ask as Christians doing bioethics is not just, “What is good?” but “How do I bring eternal life into this tragedy?  How do I bring the mystery of Life into the abyss?”

There was an amazed silence in the little classroom when Dr. Wernow finished.  Unfortunately, that is all I can leave the reader with.  I am not even sure that in my pathetic summary I presented Dr. Wernow’s vision remotely accurately;  his ideas poured out quickly and passionately, I could take only skeleton notes, and he has not as yet published an article or book that sets out the implications of the “Philosophical Theology of Tragedy and Mystery.”  But I sure love his vision of bioethics-as-drama instead of as sterile philosophical specimen;  and I can embrace the quest to bring the Mystery of Life into tragedy as a robustly and profoundly Christian way to engage and immerse myself in the tragedies of a fallen world.

 

STEPS in the wrong direction

One of the major tasks of bioethics since its inception has been to ensure the ethical conduct of scientific experiments involving human subjects.  One of the cornerstones of ethical experimentation (indeed of all medical treatment that respects the human dignity of the patient) is the concept of informed consent:  the study participant should know up front the purpose, potential benefits, and potential risks of participating in the study.

In the 1990’s, Parke-Davis, the manufacturer of the anti-epileptic medication Neurontin (generic name: gabapentin), conducted a trial called Study of Neurontin:  Titrate to Efficacy, Profile of Safety (STEPS).  This was a Phase 4 trial (performed after the medication was already on the market) whose professed objective was to study the efficacy, safety, tolerability, and quality of life among gabapentin users as the drug’s dose was increased.  Parke-Davis recruited physicians to enroll patients into the trial;  in all, 772 physician-investigators enrolled a total of 2759 patients into the trial.  The study resulted in two published papers.

It all sounds innocuous enough, no?

Recently, through legal action, all of Parke-Davis’s internal and external documentation relating to STEPS became available for review.  In these documents, a different picture of the trial’s objective comes to light.  A few quotes from the company’s internal memos:

– “Some indicators of [the study’s] success include 20% increase in new patients’ starts in March and a 3% market share in new prescriptions. . .”

– “STEPS is the best tool we have for Neurontin and we should be using it wherever we can.”

– “. . .at the very least, we should be looking to place as many managed-care patients as feasible in [STEPS] to prevent Lamictal [a competitor’s drug] starts.”

– Multiple strategic planning documents cite the STEPS trial itself, not the trial’s findings, as a key marketing tool for gabapentin.

– Parke-Davis monitored and analyzed the physician-investigators’ prescribing habits, finding increased prescribing of gabapentin among STEPS participants compared to a control group of non-participants.

Apparently, contrary to the trial’s stated objective, the purpose of STEPS was not science, but marketing;  the true subjects of the trial were not the patients, but the physicians.  The most important measured outcome of the trial was not the safety or efficacy of gabapentin, but whether and how much doctors changed their prescribing behavior as a result of participating in the trial.

Is this an ethical trial?  Some might say, sure, there was nondisclosure of the true intent of the trial, but c’mon, it wan’t Tuskegee, right?  I mean, nobody was hurt (unless you count the 11 patients who died, the 73 who experienced serious adverse events, and the 997 who experienced less serious adverse effects).

No, this was an unethical trial.  There could not be informed consent, as the true purpose of the trial was not revealed to physicians, patients, or IRBs.  In addition, using any human being in such a deceptive manner for monetary ends is inconsistent with respect for human dignity.

 

An article that reviewed STEPS and provided the quotes above appeared in the June 27 Archives of Internal Medicine;  the abstract can be accessed here.

 

Sleepless in Afghanistan

In the June 22/29 JAMA, Dr. Joshua Alley, a surgeon with the 452nd Combat Support Hospital in Khost, Afghanistan, writes eloquently in an essay entitled “Sleepless” of staying up all night treating an enemy combatant severely wounded in a firefight with US troops.  Despite the fact that this patient “wouldn’t hesitate to slit my throat if he could,” the team of doctors works heroically to save his life.  Dr. Alley asks, “Why do we go to such trouble to treat our enemies?  Automatic action?  a trained response?  fear of bad publicity, echoing Abu Ghraib?  the Geneva Conventions looming over our heads?  some Pollyanna notion that when we nurse him back to health, he’ll fall down sobbing and ask for forgiveness for his actions?  a desire for “actionable intelligence” that he might give our interrogators once he’s off the ventilator and talking?

 

“Maybe some of these thoughts enter my mind, but the reason I went nearly sleepless that night is so that I can sleep all the other nights . . .”

 

He goes on to write, “One mark of a civilized people is our response to wounded enemies.  Cultural refinements like art, music, architecture, and technology don’t make us civilized.  Some of the most barbaric monsters in human history have been avid subscribers of such refinements.  How we relate to our wounded enemies, though, is our moment of truth. . . ‘Do good to those who hate you,’ we read in Matthew’s gospel.  And tonight, I can sleep, because last night I didn’t.”

 

It seems that underlying Dr. Alley’s treatment of this bloodthirsty enemy is a recognition that (even if he doesn’t put it in these words) this person, like all others, is a human being, with the dignity that all human beings — even our enemies — possess, the dignity that merits the best treatment he knows how to offer.

 

I encourage you to read the essay in full, if you can get your hands on a copy of the journal or your institution has online access.  There is powerful truth in what Dr. Alley writes.  Our actions in situations like the one he details do demonstrate what sort of civilization we have, what sort of people we are, what sort of bioethics we espouse, whether we really believe in human dignity, whether we take Jesus’ words seriously.  There are other situations as well that reveal those qualities in us:  for instance, how we treat the poor among us, how we treat the alien, the widow, the defenseless and vulnerable.  As a society, we may do well measured by how we treat our wounded enemies.  But what about the undocumented foreigner who needs basic health care?  Or who is more defenseless and vulnerable than a “disabled” child developing in a womb — or worse, in a Petri dish?  Measured by how we relate to these, we live in the Darkest of Dark Ages, employing a thin veneer of cultural refinements to convince ourselves we are a civilized society.  What an opportunity to be salt and light!  What an opportunity for Christians to make a difference!  (And coincidentally, next week’s CBHD conference will explore the Christian influence in bioethics!  I hope to see you there.)

Abortion Prevention

Nigel Cameron wrote that it is important to see elective abortion as a symptom, not the disease.  Because this is true, if Roe v. Wade were overturned tomorrow, and some states started to outlaw abortion, the abortion problem would not end;  because even if Roe v. Wade goes away, all of the reasons that women have abortions will still exist.  What will those of us who call ourselves Pro-Life do to address some of those underlying causes?  What are we doing to address those underlying causes?  (Do we even think about what the underlying causes are?)  What are we doing to promote a social and cultural environment that is less inimical to the raising of and providing for children?  What are we doing to help those who do choose to carry their babies to term, particularly among the poor in whom abortion is so prevalent?  What are we doing to support them in feeding and housing and providing a safe environment and medical care to their children?  (Why are Pro-Lifers so heavily represented among those who are most vocally opposed to health care reform and gun control?)

 

I hope and pray that some day Roe v. Wade is overturned.  But I believe that we as a Christian community must work more energetically to show that being Pro-Life means more than picketing and praying.  At the very least, it means making sacrifices to help women and families with children.  It means getting more involved in the messy lives of those around us.  If we can address some of the reasons so many women feel that abortion is their best or only option, maybe we can go a long way towards accomplishing what we can never accomplish merely by overturning a Supreme Court decision.

 

Breaking News: Insurance Coverage Affects Access to Health Care!!

 

Okay, so maybe it’s not breaking news:  the type of insurance you have may affect whether or not you can get in to see a doctor.  In particular, if you have Medicaid-Chidren’s Health Insurance Program (CHIP) insurance (sometimes called “Public Aid”), you might have trouble finding a doctor who will see you.

In a study published in the June 16th New England Journal of Medicine, women posing as mothers of children with common health conditions called 273 pediatric specialist clinics throughout Cook County, Illinois.  They made two calls, one month apart, to each clinic, trying to get appointments for their purported children.  The calls were identical, except that one time the callers said they had Medicaid-CHIP insurance;  the other time, they said they had Blue Cross Blue Shield, a “good” private insurance.  The results are unsurprising but sobering:  66% of the callers reporting Medicaid-CHIP coverage were denied an appointment, compared with 11% of those reporting private insurance coverage.  For those Medicaid-CHIP patients who did get appointments, the average wait for the appointment was 42 days, compared to 20 days for the privately insured.

On the surface, one might attribute these inequalities to a bunch of bad, greedy doctors.  The reality, however, is more complex.  In Illinois, Medicaid-CHIP pays about 20 cents on the dollar (when it finally gets around to paying, which is sometimes six months after the fact).  Because of this, physicians may actually be spending more money than they take in for each Medicaid patient they see.  One can only  do that for so long and still keep the doors open and the lights on.  No, the inequalities do not merely stem from the behaviors of individual, money-hungry doctors;  the inequalities are built into a disastrously flawed system.

I am looking forward greatly to the upcoming CBHD conference examining the “Scandal” of Christian influence on bioethics.  Christians are perceived as being very concerned about issues like abortion, physician-assisted suicide, and embryonic stem cell research, which threaten human dignity by estimating a person’s worth based on their age, appearance, or utility to society.  But it seems that we are perceived as being less concerned about the structural, systemic factors built into our health care “system” which daily lead to insults to human dignity by estimating a person’s worth based on their pre-existing conditions, income, or occupation (i.e., their ability to get insurance).  I wonder, if we Christians really stood out in society because of our concern for the latter as well as for our concern for the former, whether we might not have a greater hearing and make a greater difference in all areas of bioethics.  (Remember Mother Theresa?)

Hope to see you at the Conference!

First Day in the ICU

As I write this I am sitting in an ICU family waiting room.  I have often sat in rooms like this, comforting families and explaining to them what is happening to their loved one or discussing treatment options. Today, it is my family I am sitting with, and my family member in neurosurgery.  The ten of us are sitting in a circle.  The comfort of being together is inexpressible.  We sit and talk alternately of trivialities and of life and death.  One knits, another is on the laptop posting updates to Facebook, I am writing a blog entry.  The surgeon figured it would take three hours.  That was over four hours ago.

This was in none of our plans for the weekend.

***

The surgeon finally came out.  It was worse than he anticipated.  He was trying to be positive, but let slip words like “heroic measures” and “if she makes it.”

It is all very surreal.  Someone says, “I feel like I’m watching a movie.”  The whole gamut of emotions pours out, opposites juxtaposed incongruously:  shocked looks, tears, laughter at a suddenly resurrected old joke.  We pray.

***

The surgeon just came back out, a few minutes later.  A terse, hurried report this time:  the post-op CT scan shows swelling, and they need to do emergency surgery now to relieve it.  Silence, everybody together but alone with their own thoughts.  Someone passes out snacks.

***

I hate being a doctor and knowing what’s going on.  Or maybe I just hate what’s going on.  Is it more terrifying to hear cryptic references to “dilated pupils” and “midline shift” and have no idea what they mean, or to know exactly what they mean, and their implications, and get a queasy feeling of impending doom?

***

Some of us eat snacks.  Some read waiting room magazines.  Every once in a while an attempt at small talk, an attempt at normalcy.  Mostly quiet.  I’m glad we’re all together.

***

It’s been another hour, and no word.  That can’t be a good sign.

***

Hurry up and wait.  Another half hour has passed.  We’re a little more lively group now, laughing and kidding each other.  It’s hard to maintain that serious aspect through the long, anxious watch.

***

 

At last — the surgeon has come back.  He is guardedly optimistic.  He looks weary.  I walk out with him for a doctor-to-doctor talk out of everybody else’s earshot.  He is more frank about how he feels;  in some way, we can understand each other.  When I return to the group, the atmosphere is much more relaxed.  Not that the news is that great, but at least the uncertain waiting is over.  One round of waiting, that is;  everything depends now on how she will wake up, and how she does over the next couple of weeks.

***

 

The next moment of truth;  the nurse has just come out, and told us that in about ten minutes the family can come in to see her, two at a time.  Deep breaths:  we’re about to dive in, and God only knows what the water will feel like.

***

Psalm 121.   I lift up my eyes to the hills — where does my help come from?   My help comes from the LORD, the Maker of heaven and earth.   He will not let your foot slip — he who watches over you will not slumber;   indeed, he who watches over Israel will neither slumber nor sleep.   The LORD watches over you — the LORD is your shade at your right hand;   the sun will not harm you by day, nor the moon by night.   The LORD will keep you from all harm — he will watch over your life;   the LORD will watch over your coming and going both now and forevermore. (NIV)

***

Just back from visiting her room.  The ICU smell!  Intubated, sedated, tubes everywhere, the Darth-Vader hiss of the ventilator, monitors, drips, her head wrapped with a little blood seeping through the right side of the bandage . . . I talk to her as if she can hear, I kiss her on the side where she still has cranium.  I come back to the waiting room and I am trembling.

***

Exhaustion.  I was tired before this started;  I am almost numb and staring now.  If this were a novel, I would have to fight turning to the last page to find out how it ends.  It is a little like a novel, or a movie.  Sometimes I want life to have a plot.  Well, it does today:  suspense, unexpected turns, hope and despair and snatches from the jaws of death, heroic actions, a beautiful damsel in mortal peril.  God knew what he was doing when he made life full of more routine than plot.  I don’t think we could take too much of plot.

***

***

It is too easy as a busy physician to forget in the rush that all patients have stories, have families.  It is all too easy to objectify people, to think of them as their disease, to fall into thinking of “the asthmatic in room 39” instead of “Mr. Brown, who is a forester with a wife and three children and who has just been laid off and is here because his asthma is worse.”  Or to say, “The drunk is back” instead of “Mrs. Smith, who desperately wants to stop drinking but her daughter came over with a bottle and she couldn’t resist so she is back here looking for help and does she ever feel awful.”  It is a good reminder, this being on the other side of medical care.  I have cried (and laughed) a little bit more readily with my patients this last week.  I don’t think that’s a bad thing.

Physicians, Technicians, Clinicians, and Providers

A few weeks ago I had lunch with two doctors who are currently in a residency training program.  In a moment of candor, both of them remarked, “I feel like I’m being trained as a technician.”

This comment struck me as tremendously important (and not just because I am heavily involved in their training and their words highlight my failure as a teacher!).  Because if their perception is correct — if we are indeed instilling in future physicians the ethos of the technician — then we had best be prepared for the inevitable results.  “To a man with a hammer, everything looks like a nail;”  to a technician, every problem looks like a technical problem, one which needs to be solved by a technique or technology.  The dizzying upward spiral of health care costs is driven largely by the increasing use of increasingly expensive technologies;  training a technician workforce can only exacerbate the problem.  The technical bias towards the automatic, unreflective use of technology simply because it exists will lead to more of the inappropriate use of technological interventions that are the bread-and-butter of hospital ethics consultations.

But more importantly, not all problems in medicine are technical problems;  some are singularly resistant to simplistic, technical solutions.  For some conditions, the doctor is the best drug:  his or her human, caring, and compassionate presence, just being with the patient.  Yet to the technical mindset, this simply attending to the patient (from which we get the expression “Attending Physician”) is discounted in favor of doing things to patients;  and while both the being and the doing are necessary for the practice of good medicine, the standardization, mechanization, and industrialization of medicine in our day has heavily favored the latter at the expense of the former.  More often than our technical mindset acknowledges, it is better not to do something to the patient;  but this option is not in the purview of the technical mindset.  We always feel we must do something, and medical caring  often suffers as a result.  The central economy of medicine, the physician-patient relationship, is lost in the technical mindset.

The ongoing industrialization of medicine is reflected in and driven by the terms we use to describe doctors.  In the May 25th JAMA, the authors of an essay entitled “Dear Provider” wrote of the replacement of the title “clinician” with “provider.”  The authors believe that this semantic change could be subliminally altering professional self-concept and behavior, “shifting the clinical encounter from patient-centered to task-oriented.  Nowadays, patients are quickly ‘plugged in’ to templated workups;  progress notes have become computerized inventories of completed tasks;  and when we ask residents on teaching rounds ‘What do you think?’ we often hear ‘I think I want to get an MRI.’  It appears that the time and effort spent by providers packaging patients through the system is displacing most other clinical activities.”

Packaging patients through the system. Sounds like a technician’s handiwork to me.  How did we get to this?  Do we turn back or go on?

 

Your pharmaceutical company care$ about you (No, really, they do)

An editorial in the May 5th issue of the New England Journal of Medicine (NEJM) recounts the tale of Makena.  It starts back in 2003, when a landmark study funded by the NIH showed a decrease in preterm births for certain high-risk women who receive treatment with 17 alpha-hydroxyprogesterone caproate (17OHP).  17OHP is the only medication ever to have shown benefit for this problem;  therefore, on the basis of this study, it was used widely.  It was not a commercially available medication, but could be obtained from certain compounding pharmacies for about $15-$20 per weekly dose.

 

Many groups, hoping for a more easily obtainable and standardized drug, welcomed the FDA’s decision this past February to grant exclusive rights to Ther-Rx and KV Pharmaceutical Company to manufacture 17OHP under the name Makena.  Their welcome turned into astonishment when Ther-Rx announced that Makena would be priced at $1500 per dose.

 

Gregory J. Divis Jr., the pharmaceutical company’s chief executive, attempted to defend the indefensible by saying that Makena could help offset some of the costs associated with preterm birth, and that “These moms deserve the opportunity to have the benefits of an FDA-approved Makena.”  (The NEJM article estimates the total annual preventable medical costs associated with preterm births in this country to be $519 million.  At $15 per dose of 17OHP compounded in the local pharmacy, it would cost $41.7 million to attain those savings.  At $1500 per dose of 17OHP marketed as Makena, it would cost $4.0 billion to save that $519 million.)

 

The plot thickens.  On March 30th, the FDA issued a statement that it does “not intend to take enforcement action against pharmacies that compound 17OHP” when a valid prescription is written.  In other words, the FDA granted Ther-Rx a patent on the medication;  but when they saw the grievous abuse of that patent, they in essence revoked it!  (Was that an unethical reneging on a promise, or an ethically justified intervention to thwart pharmaceutical highway robbery?)  Ther-Rx generously reduced the price to a mere $650 per dose, and my OB colleagues inform me that Ther-Rx’s representatives have contacted many physicians’ offices and suggested that patients no longer have the option of using compounding pharmacies, but must instead use Makena.

 

It is not just Ther-X’s rapacity that is so breathtaking, but their audacity as well.  Has our society become so cozy with the idea of medicine as industry that a company actually has reason to believe it can commit such profligacy in broad daylight?  What part should the profit motive play in providing medical care?  Where’s the line between reasonable return on investment and unscrupulous opportunism?  Maybe it’s like what Supreme Court Justice Potter Stewart said about pornography:  I can’t define where the line is, but I know it when I see it.

 

I visited the Makena website, and read an online brochure that asserted, “Ther-Rx cares about you and your baby.”  I don’t doubt that they care;  I just wonder if they would still care if it weren’t so darned lucrative.

 

From Eugenics to Genocide (A Short Walk)

Last week I wrote about the practice of eugenics in modern American obstetrics:  induced abortion performed because prenatal testing shows a potential chromosomal abnormality or birth defect.  This past week, the BBC News Online ran a series of stories under the headline “India’s unwanted girls.”  These stories tell of the practice in India of induced abortion performed because prenatal testing shows a particular unwanted chromosomal “abnormality”:  the presence of the XX chromosome pair, i.e., aborting a baby simply because she is female.  Because of long-standing prejudices and practices, in many parts of Indian society a female child is considered undesirable.  There is widespread availability of prenatal ultrasound clinics for sex determination, and so many parents  avail themselves of  these clinics’ services to guide abortion decisions that in some areas of India there are less than 840 female children for every 1000 male children.  Some Indian activists use the word “genocide” to describe this selective killing of girls.  Lest anyone suspect that Indian families thought up this novel use of medical technology on their own, the following quote from the story provides chilling evidence to the contrary:  “In 1974, Delhi’s prestigious All India Institute of Medical Sciences came out with a study which said sex-determination tests were a boon for Indian women.  It said they no longer needed to produce endless children to have the right number of sons, and it encouraged the determination and elimination of female foetuses as an effective tool of population control.”

Three observations:  First, given the rationalizations for the unfettered right to abortion that pro-choice advocates have promulgated in this country, they would be have to be mute in the face of sex-selective abortion.  They cannot say that it is wrong to abort girls, because if it is wrong to abort girls, then it is wrong to abort boys.  If they admit that it is wrong to distinguish — and extinguish — foetuses on the basis of an arbitrary criterion such as gender, then they would have to admit that it is wrong to do so on the basis of any arbitrary criterion — such as the presence of a disability.

Second, the term “genocide” used by certain Indian activists seems extreme, but it may not be such a long walk from eugenics to genocide.  The justification used to commit foeticide on the basis of gender can be employed to commit foeticide, say, on the basis of  a genetic predisposition to obesity (A 1993 March of Dimes poll found that 11% of parents said they would abort a  fetus whose genome was predisposed to obesity), and is not far from the justification used to commit murder on the basis of whether one belongs to the Hutu or Tutsi tribe.

Third, this tragic story shows yet again what happens when medicine abandons its Hippocratic ethos of commitment to the patient and instead uses its considerable power to pursue goals such as “population control,” social stability — or eugenics.

 

Confession of a Eugenicist

 

I have a confession to make:  I am a eugenicist.

 

I am a family physician who provides obstetrical care.  I love taking care of moms and babies.

It has insidiously become the Standard of Care to offer to all pregnant women testing that will inform them whether there is an increased risk that their unborn children have certain genetic abnormalities or birth defects.  If I do not offer these tests to all pregnant women, I am considered to have provided substandard care, and the wrath of a society that tolerates Nothing But The Best will descend quickly upon me.  If I do offer these tests, I am practicing “Good Medicine” — and eugenics.

 

How did eugenics become Good Medicine again?

 

I don’t want to practice eugenics.  Yet I am compelled to by the Standard of Care;  and the Standard of Care is shaped by the existence and marketing of these tests.  It’s the old story in our technophilic society:  we are constrained to use a technology merely because the technnology exists.

 

Why were such tests even developed in the first place?  Was it only for diagnostic purposes,  simply to provide information to prospective parents?  Of course not.  Clearly these tests were developed to help guide therapy;  and because the primary “therapeutic” option is induced abortion of fetuses who are not up to snuff, it seems equally clear that eugenic considerations drove their development.  So, the eugenic ideal drives development of eugenic technology, which, marketed and disseminated, drives the Standard of Care, which drives what I do in my office and provides the ammunition for the licensing board — and malpractice lawyers — who are looking over my shoulder.

 

Thus am I an unwilling eugenicist.  Thus am I compelled to do the dirty work for the eugenicists of our society.

(This is not to say that all parents who opt to undergo this testing do so for eugenic purposes.  I realize that some do so solely for diagnosis.  I am writing here about the development and mandatory offering of such tests.)

 

Maybe the time has come for a new  medical association.  Instead of the AMA, perhaps we should inaugurate the HMA:  the Hippocratic Medical Association, the members of which will adhere to a different Standard, who will pledge to uphold the ideals behind the Hippocratic Oath.  The members of this association would return to the ethos of that Oath which, according to anthropologist Margaret Mead,  marked one of the great turning-points in the history of the human race, because, “For the first time in our tradition, there was a complete separation between killing and curing . . . One profession . . were to be dedicated completely to life under all circumstances, regardless of rank, age, or intellect–the life of a slave, the life of the Emperor, the life of a foreign man, the life of a defective child . . .”