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.”

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.

 

Medical errors and more medical errors

Last week the BMJ reported that annually, there are 251,000 hospital deaths due to preventable medical errors in the US. There’s some debate about the calculations that they used to arrive at that number, and about what exactly constitutes a medical error. However, rather than quibble over the fine points, let’s acknowledge that medical errors are an ethical problem that must be addressed. In this post I would like to widen the conversation beyond the hospital walls. Below is a sample of some deaths due to preventable medical errors that weren’t included in the BMJ calculations (most of these ones happen outside of hospitals); nevertheless, they too affect thousands of people annually. I will also attempt to provide a taxonomy of the relevant errors.

Deaths due to the inability of the patient to obtain medical care because they couldn’t afford the care or the insurance — unknown number. The medical error here is a systemic one, the rationing of health care on the basis of who can pay for it.

Deaths of patients due to their being the subjects of human research — unknown number. This is peculiarly prevalent among embryonic patients (as Jon Holmlund wrote about last week). The medical errors include the failure to extend to embryonic research subjects the protections enumerated in the Declaration of Helsinki. There is also a category error: classifying embryonic patients as something other than human beings.

Deaths of embryonic or fetal patients through elective induced abortion — 977,000 (2014 data). The same category error as previous comes into play here: the failure to recognize the humanity of the unborn human.

Deaths of patients from drugs prescribed by their physician for the purpose of suicide — the numbers data is incomplete. The number is relatively low but projected to grow as more jurisdictions legalize physician-assisted suicide. The errors here include a professionalism lapse (forgetting that the professional status of medicine was established, among other things, on the dictum that doctors do not give deadly drugs, even if asked to do so). There is also the error of hubris: the belief that doctors can decide that someone should be allowed to kill themselves.

Preventable medical errors, all.

A Modest Proposal to Solve the Physician-Assisted Suicide Debate

Yesterday’s Chicago Tribune carries an editorial by Steve Chapman entitled “The Case for the ‘right to die.'” Aside from missing the central point of the whole question, Chapman does a creditable job of marshalling arguments and bioethicists to support his support for physician-assisted suicide. However, he does neglect the central point, which, of course, is that doctors do not and should not kill — including not giving patients a deadly drug with the intent that the patient will use it to kill themselves. This has been a central tenet of medical ethics ever since there were medical ethics, and for good reason. Doctors are no more able to wisely and ethically deal out death than anyone else. I write as a physician, and I can assure you that a strong background in biochemistry, pathology, pharmacology, genetics, bioethics, etc., does not give me the wisdom and ethical discernment to make the decision to intentionally provide someone with the means to intentionally kill themselves.

Thus, the dilemma: Chapman and many others think that when it comes to killing themselves, patients should be able to get whatever they want, and that doctors should help them; and most of us doctors and our various societies say that we won’t help patients get everything they want if it means they want to kill themselves.

Allow me to propose a simple, yet elegant, solution: Eliminate the middle man (or woman).

Let me explain: Chapman et al. want to help patients kill themselves, but doctors have a problematic ethical code prohibiting them from doing such. Doctors have no more expertise than anyone else at dealing out death. So, eliminate the doctors from the equation: instead of Physician-Assisted Suicide, let’s establish Newspaper Editor-Assisted Suicide. And for those bioethicists who have jumped on the bandwagon, let’s have Bioethicist-Assisted Suicide. And to make it all easier for patients who don’t have easy access to an editor or bioethicist, we can add Plumber-Assisted Suicide, Bank Teller-Assisted Suicide, or Cable TV Guy-Assisted Suicide.

The advantages of this approach should be readily apparent. Patients get what they want, doctors don’t get what they don’t want, and Chapman et al. get to carry out their good intentions unencumbered by centuries of ethical tradition, thought, and wisdom.

How Far Can We Fall If There is No Bottom?

A May 26th post in the Bioethics Forum of The Hastings Center asks “Are we reaching a tipping point in the debate over physician aid in dying?” The author cited the case of a Cornell psychologist who opted to commit suicide with physician assistance before Alzheimer’s caused her to lose “all quality of life” and “meaning.”

Cases such as these are compelling, because aging, infirmity, and dying are so. Each instance causes distress, and to remove distress seems to be the ultimate humanitarian act.

We must ask, however, why Hippocrates thought it necessary so long ago to include in the physician’s oath the injunction against assisting suicide. What was it he saw that made it necessary to draw this bright line? Certainly suffering was at least as common then, as physicians did not have nearly as many tools to alleviate it. For Hippocrates to draw this line in the face of suffering, he would have had to see how far physicians could go in willfully causing their patients’ deaths, and the consequences of such actions on the profession, the community, and the relationship between them. We don’t see such problems today, as we are still living off the fruit of that ethical standard.

In ethics we ought to consider the importance and value of clear lines such as those written into the Hippocratic Oath. They do not guarantee that nothing undesirable will happen. They do, however, serve as a floor, guaranteeing that professional conduct will only fall so far. If removed, what then becomes the insurance that we will not step lower and lower?

Many years ago I spoke with the head of a large shelter for the homeless. He had an impressive background, retiring from the Army where he had served in the Rangers. Driven by the imperative of his Christian faith to aid his fellow man in need, he had become a nurse and eventually in charge of this shelter in a Georgia city. I asked him what was it that he saw that worried him the most. He said, “Youth today have no bottom.” After I asked him to explain, he said that many youth so lacked any moral foundation that there was no depths of depravity to which they couldn’t fall. A few months later was Colombine.

We could debate in detail each of the author’s premises, such as claims as to what is “quality of life,” or “meaning,” or the role of physicians. One thing we must recognize, however, is that line drawn so long ago by Hippocrates has served as a “bottom,” preventing physicians from plumbing the depths of increasingly abhorrent acts. In discussions of PAS, proponents of it extract the positive feelings and leave the scene before the unpleasant consequences emerge. Hippocrates must have known those full well, and with that knowledge wrote his oath. I fear that we will soon regain that knowledge…the hard way.

“Grace” as a principle for the medical profession

The other day I was speaking to another physician about grace. This was at church, not surprisingly, but later I wondered why such discussions don’t occur in the hospital. When I recall the more remarkable physician-patient encounters I have seen, the word that comes to mind as the common theme is grace.

We can see it in the physician calmly and pleasantly treating the irascible and demanding patient in the darkest, bone-wearying moments of a long shift. We can see it in the compassionate but direct explanation of the direst of news to a frightened patient. We can see it in the happy celebration of a beautiful newborn to a relieved and exhausted mother. And we can see it in the bedside comfort given to a dying patient in those quiet moments when time slows down.

If one agrees that grace exists, then he ought to ponder from where we get it. For me it is clear: grace is God’s gift of Himself to us. We can speak theologically about godliness, but grace is a more specific and tangible manifestation of what that is. In medical ethics we have the well-known and practical principles of beneficence, non-maleficence, justice, and autonomy. But these describe the nature of what we should do. It is time, I propose, to speak of what we should be.

If we don’t speak of such things, then we ought to hope that they are at least manifest in our comportment, words, and deeds. Yet in our postmodern age, when society has abandoned such discussions, the mere mention of grace, something deeply profound, might strike that raw nerve in every man that fires the memory of something far greater than we’ve actually become. Or for many, want to become. And if the field of medical ethics is to move beyond an artful sophistry that produces philosophical justifications for our basest needs; if the profession of medicine is going to regain the moral standing in society for which it was created, then our medical schools must teach the highest principles. Like the magnificent blessing of grace we have received, that speaks to more than the nature of our acts, but to the nature of our being.

Physician-assisted suicide, torture, and Hippocrates: He may be old, but (let’s hope) he ain’t dead yet

A recent op-ed piece in the Chicago Tribune avers that Hippocratism is dead; and since Hippocrates’ oath is all that stands in the way of that particular exercise of compassion and patient autonomy known as physician-assisted suicide (PAS), let’s just acknowledge the oath’s irrelevance and wash our hands of it so doctors can get back to the business of killing patients. The oath has “marginal relevance” today, it is a “flimsy shield” which cannot withstand “the drumbeat of change.” “Since medicine has already discarded the vast majority of the Hippocratic oath why adhere to” the bit about not killing patients?

I have not time or space to address all of the specious arguments put forth in the editorial. But in light of the recent Senate report on CIA torture tactics, which revealed the collusion of physicians in planning and carrying out that torture (as publicized by Atul Gawande on Twitter), we had better hope that the op-editors are wrong about Hippocrates’ demise. Because if society needed a shield like the Oath to protect it from the powers of its physicians back in Hippocrates’ day, it needs it even more desperately now, when the powers of medicine to perform evil have increased as immensely as its powers to perform good. I do not know what motivations were behind the actions of the physicians who worked for the CIA: Patriotism?  The desire to protect loved ones from terrorists? Whatever they were, it is clear that even good motivations — compassion (in the case of PAS), patriotism (in the case of torture) — can lead physicians to perform unethical acts, acts whose effect is to knowingly cause harm those under their “care.” The Oath’s power to protect patients comes because the Oath doesn’t appeal to elastic concepts like “compassion,” “dignity,” or even “sanctity of life”; instead, it simply says, “I will not kill. In the course of my work I will do what is best for my patients” — not what’s best for me, or my country, or my family, but my patients.

So instead of euthanizing Hippocrates, we should be doing everything to reinvigorate the ethical values associated with his name. Because if the op-editors’ dream ever comes true — if Hippocratism dies out — then we are all in trouble; because any one of us may find ourselves at the mercy of an unrestrained, powerful techno-medicine, especially if somebody thinks we are too old, or too sick, or too weak, or too poor, or too disabled, or too inconvenient, or too suspicious-looking. . .

Please don’t allow me to kill people: an open letter to Scott Adams

(Last Saturday, Scott Adams, the creator of the brilliant comic strip “Dilbert,” wrote in his blog a raw piece about physician-assisted suicide, which has created something of a stir. If you wish to read it, it is here; but I warn you, it is not pleasant reading, and it is full of profanity.)

Mr. Adams,

My deepest, deepest condolences. I don’t know you, but I am a Family Physician, and I have stood more times than I can count at the bedsides of people going through situations similar to your father’s. I have sat in too many rooms with families as their loved ones have withered away; too many times, I have been unable to offer healing, but only comfort, support, presence, and respect for the dying and his or her family.

Please don’t ask me to offer more than that. I know your blog post was written in the midst of “hideous unpleasantness,” and I can pardon your wish for me to die a slow, horrible death because I am opposed to using my power to kill people. But such extreme frustration, grief, and anger as you are experiencing is not in itself an argument for giving one class of people the right to kill others.

A long time ago, we doctors did kill people. We with the power to heal have always had the power to kill, and at one time we were allowed to use both powers indiscriminately. We were salesmen, technicians, offering whatever the customer wanted, whatever the market would bear.

But then someone, or maybe it was a group of people, who assumed the name “Hippocrates,” came out and said, “No more. We will not use our power to kill people. We know that Power can be used for good. But Power by its very existence begs to be used, and it knows no distinction between good and bad uses. We are well-meaning, but we know we are flawed. Therefore, we will place the most stringent restraints we know on our Power: we will not use our Power for killing.” And it was at that moment that we stopped being technicians and became Professionals.

But our record isn’t perfect. As recently as the middle of the last century some of our number in Germany thought we could safely use our Power to kill for beneficial purposes. And more recently, our colleagues in a few European countries — and now a few of our own states — have been given the go-ahead to use our Power (oh, so much greater now than in Hippocrates’ time) for just the purpose you advocate: to actively end a person’s life. And I must gently dispute your assertion that such policies are working “with little problems.” On the contrary, the problems those policies are facing are huge ones.

So please, don’t ask the government to give me the power to kill. I am human, like you, and, even with the best of intentions, I can’t properly handle such power. You can ask me not to abandon my dying patients. You can ask me to sit at my dying patients’ bedsides and weep at their funerals. You can ask me to do whatever I can to help their families. You can ask me to stop using unwelcome powers of healing that serve no other purpose to keep bodily functions going, and I will gladly comply; and I will use every bit of power within my reach to help alleviate pain, short of killing the sufferer. I will do it all in “com + passion,” which literally means “suffering with.”

But please don’t ask me to end suffering by using my Power to do away with the sufferer. Because there are just some things a Doctor shouldn’t do.

 

Toward Reasserting the Ends of Medicine: A tentative beginning, with some historical considerations

Recent posts (Here and here) on this blog referred to the “ends” of medicine, and last week Dr. Holmlund challenged us to explore more systematically just what those ends are. As I have considered that challenge, I have been stymied by the herculean magnitude and complexity of the task, especially given my limited knowledge of, and reading in, the relevant philosophical, theological, sociological, and historical disciplines. However, having been a practicing physician for about twenty years, I will tentatively start on the project, based more on my experience than on any great learning or reading; I hope that those who have the advantage of the learning and reading will make up for and (gently) correct my deficiencies.

One of the hurdles to overcome in defining the ends of medicine is that there are many views held by different groups of people, and they have changed over time. So the question becomes more focussed: What are the proper or correct ends of medicine? Is this something we can discover, or must we merely define it? If so, on what basis? Also, what do we mean by medicine? Are we talking just about the actions of physicians? Or does it include the actions of, say, hospital boards? Biomedical researchers? Public health departments? Medicare utilization reviewers?

My impression of the history of this subject is that the ends of medicine were originally narrowly defined in regard to physicians, and their goal was to help the sick. The Oath of Hippocrates, from around the 5th century BC, speaks of dealing with “the sick” and “sufferers.” There seems to be no reference to preventive medicine or promoting health. This view of medicine’s ends was taken up by the Christian medical tradition: “Care of the sick, grounded in the compassionate sharing of the sufferer’s pain and seeking ways of alleviating and perhaps curing it, is a witness to God’s work of redemption in Jesus Christ.”*

As modern science developed, its founding fathers such as Francis Bacon and René Descartes thought that by gaining power over nature, people could go beyond treating disease to preventing disease and preserving health. Measures to prevent disease were of course known from antiquity, as the health regulations in the Pentateuch demonstrate; and magic charms to ward off disease have probably always been widespread. But somewhere along the way, this idea of not just treating disease but preventing it, and in so doing promoting health, was taken from the priest’s job description and inserted into the physician’s. Thus, the physician’s ends expand to become, “Caring for the sick, preventing disease, and promoting health.” A Tall Order indeed. And one that adds umpteen layers of ethical considerations, such as, What does it mean to “Do no harm”? What is “health”? And many others that I can’t begin to mention in a 500-word post. But in future posts I will attempt to chart a course through this maze , and with Jon Holmlund I invite fellow bloggers and commenters to help us along the way.

 

*Robert Song, Human Genetics, 13.

Why Dr. Kevorkian Was No Hero…and I Often Am

Admittedly that title is provocative. In a sense, both the late Dr. Jack Kevorkian and I could be considered to be in the business of euthanasia (though I hope I will someday be remembered for far more), but the species of our patients differs. And that, as they say, makes all the difference in the world.

A few weeks ago, I reflected upon how euthanasia of my animal patients offers a glimpse into the debate over human euthanasia, and what trends may be portended by this ethically-accepted practice for animals if starts to become more widely-accepted when applied to humans. But why the distinction? Why do we look at this difficult but necessary part of a veterinarian’s work as a genuinely humane way to end animal pain and suffering but have such qualms about applying it to people? Perhaps it could be found in Leon Kass’s “moral wisdom of repugnance” or good old natural law? A few of my thoughts.

First, even the most strident of animal rights advocates could find that the technological and logical capabilities of human beings compel them to exert some superiority over non-human animals, if only to relieve pain when we see it. If animals have rights, others (specifically humans, who have the wherewithal to act upon them) have responsibilities to those animals. Even those like me, who find little practical use in using the language of rights for animals, can recognize the awesome powers human beings have for good and evil over the natural world, and thereby derive a responsibility to tend to the pain of those animals that cannot provide for themselves. Intellectually we have a hard time believing that we can legally take the lives of healthy animals for food or clothing (even if vegetarians dislike its practice) and yet have no authority to euthanize the gravely ill and dying. While the acceptable criteria for animal euthanasia may well differ (some veterinarians will not euthanize pets that have behavioral problems but are otherwise healthy, for example, whereas others will do so if a pet owner is just “tired of” their pet—that’s a subject for another time), it is well-respected as part of the veterinarian’s principal duty to “relieve animal suffering” as our oath states, and appears well within the ethical bounds of being a good and moral person. I read a piece by another veterinarian today that felt like our oath should well be extended to state “relief of animal AND HUMAN suffering,” as the process of slow pet death can be so poisonous to the human family enduring it. There is a certain restoration of wholeness that comes from the removal of that pain and perceived suffering in a creature that cannot understand it nor benefit from it (see my comments below). When people are given the freedom to address their pet’s AND their family’s quality of life issues, the relief is palpable. Though not ultimately my decision, I can ethically apply the “best interests” standard to both my patients and the human family and recommend euthanasia based on all applicable factors. For a physician to apply those same standards would be alarming.

Second, and obviously, I am not a “people doctor.” The medicine certainly overlaps substantially, but I have heard no one who realistically wishes to merge the professions. I’ve mentioned before that the Hippocratic Oath is primarily focused on healing disease, not relieving suffering, and euthanasia directly violates that. It is a primary reason (though not the only one) that the Oath is under such assault now. Whether we look at the Judeo-Christian view of anthropology as humanity made in the image of God or the secular idea that our species is distinguished by higher capacities than other species, there is an inarguable “otherness” to human beings. We have courts to help ensure justice, but certainly do not expect even brainy animals like dolphins and chimpanzees to do the same. Our fearsome capabilities to exert justice on one another limit, in civilized society at least, the role for taking the lives of other human beings to the domain of the state. As a veterinarian, I don’t need the courts to help me decide if the patient’s “time” has come, because I am acting entirely within ethical bounds and my own professional oath. For a physician, charged with doing all she can to heal disease in a patient, to usurp the role that legitimately belongs to the government and work to end a life is a horror, regardless of whether or not it is carried out in the name of compassion.

Third, the “otherness” of humans carries into the dying process itself. While facing the approach of death can, perhaps counter-intuitively, be a time of growth and transformation for human beings, a time to heal relationships and face eternity, there is nothing to suggest that such things happen in animals. I can find no redemptive purpose in prolongation of life in a moribund pet for the animal itself, but have observed that very thing in the death of a relative of mine, albeit a rather distant relative and as viewed via Facebook, as he very slowly died from cancer. His bad days were bad indeed, but his good days offered him and his family great joy as they treasured the sunsets and the breezes, enjoying the few days left on this Earth and gathering in what it meant for life after death. The privilege of dying with his family surrounding him, to themselves be able to impute his brave submission to a death that they might someday face, would have disappeared had a physician helped to sacrifice his life on an altar of compassion. That’s part of why our oaths are different, and why I can be a hero and why Dr. Kevorkian was decidedly not, even as we ostensibly carry out the same task.