How to make Nazi doctors

Most people who go into medicine have as at least part of their motivation the desire to help other people. I’m sure this was as true in 1930’s Germany as anywhere else. So how did a cadre of Nazi doctors come not only to commit crimes against humanity, but also to defend the moral correctness of their conduct when placed on trial for those crimes? The answer is complex, but one way was through the teaching of medical ethics.

An article in the April 18th Annals of Internal Medicine tells a cautionary tale for teachers and learners of bioethics. Entitled “Lectures on Inhumanity: Teaching Medical Ethics in German Medical Schools Under Nazism,” the article details how the Nazi party developed a curriculum for teaching ethics in medical schools that “was intended to explicitly create a ‘new type of physician’ . . . trained to internalize and then implement the Nazi biomedical vision . . . shifting the focus of ethical concern and medical care away from the individual patient and toward the general welfare of society or the people.” The curriculum included lectures in racial hygiene, the science of heredity, population policy, military medicine, and the history of medicine. Only long-standing members of the Nazi party were appointed lecturers. The lecturer at Berlin University, Rudolf Ramm, wrote the ethics textbook used in the curriculum, which emphasized physician paternalism in practicing their moral obligation to rid society of certain groups, and asserted that every (Aryan) person in Germany had a moral duty to stay healthy.

The article’s authors write, “The Nazis neither ignored nor abandoned medical ethics. Instead, they implemented their own version of it in order to substantiate their health policies and secure physicians’ allegiance. . .  an ethic that turned away from the individual and instead emphasized the well-being of the community. . . [They] reinterpreted the Hippocratic Oath for their purposes . . . [drawing] an analogy between the German people and a sick patient . . . so that the Hippocratic Oath seemed to fit with Nazi medical ethics: Exterminating Jewish persons, disabled persons, or patients with hereditary diseases was acceptable in order to heal the organism of the German people.”

The article’s authors draw the conclusion that “we should not rely on the existence of ‘eternal’ or ‘universal’ values in medicine because it is not the medical profession alone that determines the medical ethos but also the moral climate in society, the system of government, and its political goals.” However, this seems to me backwards; it is precisely because society, government, and politics are so fickle that it is vitally important that the practitioners of this art cling tenaciously to the universal values stated so simply and starkly in the Hippocratic Oath: I will not kill, whether in the womb or out of it. I will protect patient privacy.  I will treat everyone with the same regard, regardless of their status. Real Hippocratism should have been a resistance movement against Nazism; it should be again now against the forces that are threatening to deform the medical ethos. If we do not hold fast to these values and teach subsequent generations of doctors to do the same, we will find — we are finding — that we are playing variations on a Nazi theme: for the eugenic ideals inherent in Nazism, the idea that it is morally acceptable to kill some (unborn) people to benefit others, and the belief that there are lives which are not worth living, ideas which have “laid the groundwork for medico-ethical transgressions in the past, remain in play across time.”

Apologies and Outcomes

What if a study shows that the course of action we know to be right doesn’t “work”? Or that it may even place us at a disadvantage?

When bad things happen to patients in the course of medical treatment, doctors traditionally have avoided apologizing or even expressing sympathy to patients, for fear that such expressions would be used against them in malpractice court as an admission of guilt. So multiple states have passed “apology laws” excluding such expressions from trials, in order to encourage doctors to make apologies. The underlying idea is that the act of apologizing helps to enhance communication between patients and physicians and to assuage some of the anger that leads people to sue their doctor, thereby reducing the likelihood of a malpractice suit.

However, a recent extensive study found that in states where apology laws are on the books, doctors’ risk of malpractice suits actually increased, as did the average payment to settle a claim.

Assuming for the sake of argument that the results of the study are valid, what conclusions are we to draw from them? It seems like a right, normal, ethical, human thing to do to apologize when we have harmed someone. Should doctors avoid apologizing to patients if it will increase their risk of a malpractice suit? More generally, how much do we allow outcomes (a major buzzword in medicine these days) to influence our moral reasoning and acting? Take, for instance, the opposite scenario: What if a wrong action is shown to have a beneficial result? For example, what if a study showed that a stem-cell therapy that relied on destroying embryos would effectively cure diabetes, or Alzheimer’s? Should such a compelling good outcome sway our moral reasoning and acting?

Outcomes need to be taken into account, but they must not be the only or the overriding factor in making ethical decisions. Just as a potentially good outcome does not make it more right to destroy an embryonic human, a potentially bad outcome does not make it less right to apologize to a fellow person when we have done them harm.

Excuse Me, Doctor, What Exactly Do You Profess?

The late Edmund Pellegrino, M.D., revered medical educator, ethicist, and physician, often made the point that a professional professes something. Merriam-Webster  confirms that the etymology of the word, profession, includes the Latin for “public declaration.”

The Hippocratic Oath, probably penned by members of the Pythagorean sect, according to Ludwig Edelstein (see Ancient Medicine: Selected Papers of Ludwig Edelstein. Baltimore: Johns Hopkins University Press, 1987), has for centuries been accepted as the gold standard for the practice of medicine. Nigel M. deS. Cameron (The New Medicine: Life and Death After Hippocrates. Chicago: Bioethics Press, 2001)
 explicates the Hippocratic Oath as containing four parts:

1.   Covenant with Apollo and others

2.   Duties to teacher

                            Regard teacher as equal to parent

                            Treat him as a partner in livelihood

                            Share money with him when needed

                            Consider his children as siblings

                            Teach medicine to own children, children of teacher, and pupils who take the oath

3.  Duties to patients

                            Use treatment to help the sick, never to injure or wrong them

                            Give no poison to anyone though asked to do so, nor suggest such a plan

                            Give no pessary to cause abortion

                            In purity and in holiness to guard the practitioner’s life and art

                            Use no knife on “sufferers from stone,” but allow others trained to do so

                            Enter houses to help the sick, not to participate in wrong doing or harm

                            Keep oneself from fornication with woman or man, slave or free

                            Not to divulge, but guard as holy secrets those things that are heard by the practitioner

4.  Sanction

Oath-taking by medical students has increased in the last 50 years, as reported by Neil Chesanow, in “Is it time to retire the Hippocratic Oath?” Medscape, 25 Jan 2017.  The form of oath taken by medical students has also changed. Many schools have re-written the oath in “updated” language, and a good number of students craft their own.

Do they swear not to have sex with their patients? Do the medical students or newly minted physicians now swear not to give poisons or pessaries? What oaths are taken in those states where physician-assisted suicide has been made legal? It would be good for the public to know. Perhaps it is time for physicians to post on their walls (actual and virtual) exactly what it is they profess to be and to do.

 

— D. Joy Riley, M.D., M.A., is executive director of The Tennessee Center for Bioethics & Culture.

 

“The Enormity of the Moral Mission of Medicine”

As I write, Paul Kalanithi’s book When Breath Becomes Air sits atop the New York Times Bestseller List. I highly recommend it. It is beautiful.

This book was written by a dying man. All books are, I suppose, but this author knew with more certainty than most that his time was short. Paul Kalanithi was finishing a grueling neurosurgery residency and on the cusp of a brilliant career when he discovered he had advanced lung cancer. In this book, written during the last months of his short life, he tells his story, a story of his search for meaning. He initially looked for meaning in the study of words, as he collected degrees in English and history and philosophy. But he discovered that meaning is not just read about, but lived, lived in relationships with others. As he thought about relationships, words, minds, and the brains through which words and minds are expressed, he writes that he “couldn’t let go of the question: Where did biology, morality, literature, and philosophy intersect?” The answer wasn’t to be found, for him, in the classroom: “. . . I found myself increasingly often arguing that direct experience of life-and-death questions was essential to generating substantial moral opinions about them. Words began to feel as weightless as the breath that carried them. . . It was only in practicing medicine that I could pursue a serious biological philosophy. Moral speculation was puny compared to moral action.”

And this illustrates one of the great strengths of the book: the profound understanding that medicine is at its heart a moral practice. Kalanithi writes of “The enormity of the moral mission of medicine . . .” He pursued one of the most technical of specialties, neurosurgery, yet he did not let the technical aspects obscure the moral core of medicine, the patient-physician relationship. As he writes, “When there’s no place for the scalpel, words are the surgeon’s only tool.”

As he explores the moral practice of medicine, Kalanithi writes insightfully of informed consent, not as “a juridical exercise in naming all the risks as quickly as possible . . . but an opportunity to forge a covenant with a suffering compatriot.” As a neurosurgeon he writes of the experience of life and death from the bedside. He learns that “the physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.”   Then he receives his own terminal diagnosis, and writes eloquently of his experience of life and impending death from the patient’s bed. The ending of the book, along with his wife’s epilogue, is deeply, deeply moving, but not maudlin.

(Quotes from pp. 32, 43, 44, 87, 88, and 166)

 

Good Ethics Requires Bad News

Some bad news took me by surprise this week, taking the form of an article in the Annals of Family Medicine entitled, “Why Medical Schools Are Tolerant of Unethical Behavior.”  The authors described a medical school graduation ceremony in which the speaker thanked professors and healthcare professionals not just for competent and humane care, but for providing examples of “pure unethical behavior.”

I wondered if my surprise at these circumstances was a bit of bad news in itself. Either I was blessed to be away from such an environment, or ignorant of similar problems around me. To some relief I found (after looking quickly) that the authors were from Brazil, but a book by an American author is but the most recent reminder that the problem resides between our shores as well.

The authors themselves seemed surprised by the audience’s lack of unease or objection to the allegation, and concluded that the professional environment must be tolerant of the behaviors. They asked why, and described these possible reasons:

  1. Barriers to reporting, due to fear of retaliation, lack of anonymity, and complaining seen as a sign of weakness;
  2. Leaders turning a blind eye to problems;
  3. “Systemic disrespect,” that is, widespread problems of the healthcare system that produce long waiting times for patients, excessive staff workloads, and a culture where mistakes are not acknowledged and apologies not made;
  4. Lack of accountability by accrediting organizations for ethical behavior.

They go on to discuss conflicts between explicit and implicit values, with the implicit ones being “culturally appropriate” yet far from admitted publicly. Such conflicts produce a systemic delusion, as well as cynicism in the young and developing healthcare professional.

That such a situation exists merely highlights how critical the truth is to ethical behavior. Organizational dishonesty, in whatever form, corrodes the integrity of individuals and provides fertile ground for unethical behavior. Integrity requires a willingness both to hear bad news and to give it. Values greater than one’s personal image, comfort, or success must be paramount, or else bad news becomes a problem unto itself, as opposed to a useful and necessary tool for ferreting out problems and making organizations better.

We can’t find such integrity from purely utilitarian arguments. The authors cite, unfortunately, only utilitarian arguments for building a professional ethic (increased costs, medical errors, etc.), reminding me how the language of virtues has long ago faded from modern societies. They do note utilitarianism’s inadequacies in the problem of “administrative evil,” in which “standard operational procedures within an organization inflict harm or suffering on individuals by blindly following a cold bureaucratic rationality committed for the ends but not the means to those ends.”

It is virtue ethics that is required to fight the corrosive effect of pure utilitarian thinking, for it reminds us that one of the ends produced when disregarding means is that one becomes the sort of person who uses those means. This requires an understanding of virtues and the central nature of the character of man to any ethical system.

I am not confident that modern society is ready to recover the lost language of virtue. Virtue, it seems, must not be spoken of, lest the speaker be subject to the vitriol as experienced in the strident denunciations of Christianity we hear more and more about. To escape our mean state, however, we must venture to do so.

To discuss virtues, in turn, requires that we articulate a robust vision of the telos—the purpose and ends—of the practice of medicine. A description of a state of being greater than our common existence, greater than mathematical calculations of gains and losses, would give direction and meaning to our efforts. It would enable us to see beyond self-interest, to make the necessary sacrifices for the truth, to move ourselves and our organizations along the road to that greater goal. For such a journey, bad news becomes not an impenetrable wall or obstacle to avoid, but merely a stepping-stone.

Mediation

A short while ago I was asked to be part of a delegation to meet this fall with leaders of a seminary in Kyiv, Ukraine, in which my church seeks to deepen a partnership. Perhaps in hopes that the glorifying of God is best accomplished when His foot soldiers (me, in particular) don’t commit ridiculous and embarrassing cultural missteps, I was given loan of the book, The Meeting of the Waters: 7 Global Currents that Will Propel the Future Church, by Fritz Kling. It is both highly readable and deeply challenging.

Kling finds the seven currents, alliteratively enough, to be “mercy, mutuality, migration, monoculture, machines, mediation, and memory.” All are intriguing, all are highly-relevant, all should provide enough knowledge to keep me from committing an international incident when abroad. But a few of his provocative assertions seemed especially winsome. He described “monoculture,” which is indeed different from “multiculturalism.” Whatever the merits (or lack thereof) of multiculturalism, where cultural differences are celebrated, monoculture erases those differences through the use of common technology and media. This was seen in the United States in the 1950s onward, in relatively miniature form, when disparate cultures like Minnesota iron miners, Texas schoolteachers and Boston investment bankers began to share a common cultural experience through television. Each group watched the same shows every week, and summarily began to laugh at the same jokes and use the same “catch-phrases.” Today the internet and smart phone technology make the entire world a much smaller place, with many more shared experiences and media that exude common, not diverse, messages.

The product of monoculture, surprising to some but not others, is reflected in increased fear emanating from threatened cultures. What is radical Islam but a reaction to a perceived threat from a monoculture that oozes modern Western vice? The reaction to monoculture is polarization. Traditionalists and multiculturalists alike have little reason for cheer as the vanilla of monoculture threatens each. Is it any wonder that we live in a country where roughly half the country loves the president and roughly half detests him (stats that could apply to the previous occupant of the office as well as the current one)? Is it a surprise that little common ground can be found as we address bioethical issues? We use language in the form of smokescreens (for we must relate to monoculture) with terminology that is intellectually nonsensical, like “pro-life,” however noble its intent, or shamefully deceptive, like “women’s health,” which never seems to address anything but abortion rights. People who disagree are not just in disagreement, but are morally bankrupt. I am unconvinced that Red and Blue State Americans could successfully find consensus to run a successful lemonade stand together, despite a more homogenous media-driven culture.

And it isn’t as though I crave consensus. I am increasingly convinced my positions are right, whether a product of growing intellectual sophistication or the curmudgeonly effects of aging. Apparently either one affects a lot of us. But the ironic polarization that has resulted from monoculture leads Kling to discuss another great global current: mediation. Polarization requires mediation, lest we get nothing accomplished or (worse) begin to kill each other via drone or jihad or intellectual shunning at universities.

And this next associated concept especially pricks my ears: he calls for us within the Church to engage in “philosophical mediation.” Here he specifically speaks of the increasingly strident nature of atheism that seeks to corner and bait orthodox Christian thought into a corner where it responds in a way that lacks grace and love, which ought to be its distinctive, and fights the battle on atheism’s home turf. I would also extend that argument to our task as Christ-following bioethicists. We can scream our differences with others from the mountaintops, but who besides us will actually hear them? Those who hold a high view of human life and the dignity of human beings in all their stages of development and until their final moments of life have scored victories, to be sure. But there have been setbacks as well, and there is always a fear that such a stance on certain issues will eventually be discarded altogether as irrelevancies in a rapidly-evolving world. I, for one, do not want my philosophical and moral views to be lumped under the category of “quaint anachronisms,” primarily because I think they are right. Perhaps our best options are to be philosophical mediators, maybe because so few on any side appear to be willing to do it. But how do we serve as mediators, which many that hold other views seem openly disdainful of doing, while maintaining what we contend is distinctive?

The apostle Paul pinned his brilliant Mars Hill speech on an appeal to the commonality between himself and his audience, not in the polar opposites that these worldviews represented. He was a philosophical mediator. His overall message never wavered. He found common ground, common language, and demonstrated a willingness to reach out. It seemed he was fighting on their turf; in fact, he brought them onto his own. Some ignored him, but many were drawn in.

I don’t have great answers here for how to do it. I do propose we agree to elaborate upon, and summarily discard, much of our smokescreen language, on both sides. It has to be a two-way street. I also propose that we be the ones to do the reaching out. That is not a position of weakness, but one buttressed by strength of the underlying argument. It is also the way to be heard in a world that desperately needs grace. Yes, we can offer a prophetic voice in a wilderness that seems to embrace ethical horrors with every news cycle, but repentance and healing are a part of the prophetic message as well. I need it as much as the person with whom I disagree.

How good a mediator will I remain when my philosophy is mocked and persecuted? History has shown great volumes of mockery and martyrdom, and yet the gospel marches on. I pray that we are the voices that seek philosophical mediation in the challenging global context we will face, for in that we truly model the Great Mediator who gave everything to bring us back to our Father God.

Ethical Bullies, Part I

To the degree that there are any public sins anymore, particularly among the young, “bullying” may be the chief among them, wed as it is to the cardinal vice (in our culture, at least) of intolerance. The bullies of yesteryear, with their lunch-money-stealing, “uncle”-extorting bluster, are now replaced by the sophisticated “cyber-bully,” and with those who replace brawn with “hate-speech.”

Don’t read me wrong here—I think that a focus on the devastation that can come from cruelty from one person or group to potentially weaker individuals is well overdue. Many of us bear more scars from emotional cruelty than physical, and it is right to recognize that cruelty ought not to be regarded as normative, as a rite of passage, that must be endured to toughen us up.

That said, it seems fascinating that two recent issues that directly confront ethical choices seem to have bullying at their core. The first is perhaps more personal to me than the second, the second more consequential than the first.

The Boy Scouts of America (BSA), who count my 10-year old son as a member and me as a den leader, concluded a very public year of angst over the status of their ban on openly gay and lesbian scouts and adult leaders with an announcement last month that such individuals would be accepted (largely on the basis of “orientation”) as scouts, but not as adult leaders. This decision, of course, had the effect of making no-one entirely happy, though some were less unhappy than others.

I could spend countless words on the merits or lack thereof of such a decision. I could spend a lot of time on the issue of homosexuality itself, where the evangelical church has fallen so short of wrestling well with an issue that is deeply complex, that involves behavior springing from desire that vanishingly few feel can be chosen or denied, and where too many seem to declare that an entire group of human beings are not created in the image of God, but are marks of a very broken image. This view, in my mind, has little to support its theology. I have close friends and colleagues who struggle with their faith and their desires, and others who see a Christ presented to them that couldn’t possibly be seen as loving, one who will love sinners who gamble or are drug-addicted or engage in the heterosexual hook-up culture or plunge into materialism wholeheartedly, but not them. On the other hand, we live in a society of sexual entitlement, where full acceptance of anything that affirms our well-being in the pursuit of sexual desire must be embraced. The Jesus who told us to sell everything to buy the pearl of greatest price surely didn’t mean that we remain celibate inside an old-fashioned social construct.

Okay, so I spent some words on that. But none of those things directly address my concern with the position of the Boy Scouts. This decision, in reality, has little to do with the Scouts tackling the ethics of their policy, whatever its faults or merits. Their choice was based on the effective use of a much-shunned, quietly-devastating campaign of bullying by vociferous critics of the long-standing position. While the official words from the BSA reflect a clear sensitivity, the proponents of change spent many hours and much treasure threatening the Scouts, from loss of financial support from businesses that would face boycotts to overt efforts to thwart enrollment of new Cub Scouts. Every scouting manual, from Tiger Cub to Boy Scout, teaches young men to abandon bullying and to help each other stand up in defiance of it. In their national meeting in Grapevine, Texas, in 2013, the leadership of the Boy Scouts of America, facing shrinking enrollment and corporate abandonment, collapsed under the weight of sophisticated bullies, teaching their youth everything and nothing.

There is no small irony here. People who have faced historically awful levels of bullying in the gay and lesbian communities were successful with those same methods. More troubling, the BSA took an ethical position because they were backed into a corner when the numbers stopped adding up. Maybe I am naïve, but it seems that, even with wildly-different ethical groundings, people once brought their best ethical arguments to the table and then worked through them. Today, in a system marked by moral relativism, we are left with the ethical imperative that one choice is wrong because it is not on the “right side of history.” Only in a world that understands ethics and morality poorly, and history even more poorly, could such a weak appeal be made.

The ridiculous and anachronistic feudal system of czarist Russia was replaced by the regimes of Lenin and Stalin. Who was on the “right side of history” there? History may be a better a judge of ethical and moral choices than opinion polls, but the fact that something replaces an antecedent is a rotten marker of its moral worth, however untenable the system it may have replaced. Is this really the best we can bring to ethical conversation today? It is unsurprising, but is disappointing.

So what in the world does this have to do with bioethics? The second of the two issues, that of Internal Revenue Service shenanigans, which I hope to address next week, speaks directly to a concern that ethical choices will sublimate to forces of bullying. The Boy Scouts of America did not succumb to a superior ethical argument, but to an ethic of bullying by stronger cultural forces. When the government is involved, particularly the division assigned to implement our health care policy going forward, things ratchet up a bit, and we will all be wise to take notice.

The New Realities of the Public Square

Today’s public presidential inauguration festivities were reported with as strenuous a level of polarization as has characterized our politics these past years. Several, representing both the gleeful and despondent that represent our poles, have evaluated the benediction delivered by Luis Levon. Whatever his flaws or merits as a “benediction-giver”, much has been made over the fact that he is not Louis Giglio, the Atlanta pastor of Passion City Church. Most know that Giglio was initially chosen to give the benediction as a result of his substantive work in the name of justice, particularly toward the recognition and elimination of human trafficking, and that he withdrew his name after a sermon from over two decades ago, critical of homosexual activity, became impossible to reconcile with a presidential speech that linked Seneca Falls, Selma, and Stonewall. It is not my interest to elaborate on this issue, though evangelical thinkers are neither monolithic nor graceless on the matter. This is part of a larger wind, one that already sends a January chill through many who think that the Bible is not a quaint historic book filled with a mix of arcane thought and unreal sublimities, but a legitimate directive on how to live a moral life, and who question their place in the public dialogue.

It was on the “Huffington Post” site, of all places, that the headline jumped out: “After Louie Giglio Bows Out, Some Ask If Conservative Evangelicals Are Welcome in The Public Square.” Lured in, I found no lamentation inside the text for the loss of these voices. Especially for the “H.P.” (and the internet in general, where nuance is replaced by red meat) I found this piece curiously dispassionate. It didn’t blast the bigoted and hateful voices of conservative evangelicalism (that was left to the comments section), but it didn’t speak of the diversity of view that will go missing in the public square without them. It closed with a bland request to offer some names that could replace Giglio.

As someone with a bunch of convictions on all kinds of issues, many of which relate to issues of bioethics, I fear this attitude more than open disdain. I see evangelical Christians engage in solid scholarship, made all the more real by its connection to heartfelt spiritual conviction. I can bear seeing their work refuted, for they often serve as modern prophets to academia, and prophets have never been the popular kids in school. What is worse is to see an entire community dismissed as utterly irrelevant and hardly troublesome to the status quo.

A couple of things should be said about this. First, we knew it was coming, but it sure came fast—the biblical worldview espoused by many evangelicals is no longer welcome in the public square. Speech will increasingly be offered by invitation only, and we won’t be invited. I agree with the premise that a liberal democracy will allow all viewpoints to be presented on whatever basis—religious or secular—the presenter chooses, a Nicholas Wolterstorff view. I just can’t see that happening, when the public square for such arguments is limited to the insular world of faith-based websites and still-protected pulpits and not the wider avenues that reach our culture. The invitations will be fewer to public debate, except to serve as caricatures or foils to the flow of popular sentiment. Christian bioethicists that can’t make cogent arguments to secularists will find themselves as intellectual circus curiosities, as anachronistic as the Amish, but without the charm. If someone who gathers 60,000 people at one time to speak boldly against human slavery can be quickly disinvited by the president, should we assume a seat at the table?

Second, what is the role of a blog site like this, or even of Bioethics program like that Trinity offers? Last week, Chris Ralston and, before him, Joe Gibes, more eloquently (and, indeed, more briefly) than me addressed the sweeping secularization of bioethics as an opportunity, not an obstacle. I do not think what we do here to be an inside game, a list of “house rules” that impact nobody outside our circle. The error of an evangelicalism that strays from biblical conviction is that it has no anchor; it can, at best, supplement an existing secular argument, but not serve as a prophetic voice that to some offers conviction and to others, the sweet aroma of life that Christ provides. If we don’t know our stuff, in its fundamental form, then we have nothing to offer for the increasingly rare opportunities we have to address the public square.