INTRODUCTION
This paper considers the quintessential control medical professionals and particularly doctors assert in the preservation or corruption of medical ethics. The primary resource of this study is entitled Medical Science Under Dictatorship, a report written in 1948 by Dr. Leo Alexander, “a psychiatrist and neurologist who wrote the Nuremberg Code after World War II, which established moral, ethical and legal principles for experiments on humans. A medical investigator for Secretary of War Robert P. Patterson and an aide to the chief counsel at the Nuremberg war crimes trials, Dr. Alexander wrote the code after studying the actions of German SS troops and concentration camp guards. Leo Alexander received his medical degree from the University of Vienna in 1929 and served his internship and residency in psychiatry at the University of Frankfurt, Germany. He came to the United States in 1933, holding positions at Worcester State Hospital, Boston City Hospital, Harvard Medical School and Boston State Hospital before becoming associate professor of neuropsychiatry at Duke Medical School in 1941.” [2] Dr. Alexander died of cancer in July 1985.
In his report Dr. Alexander describes two divergent responses of German and Dutch physicians to the threat of death by the Nazi regime if the pogrom was not implemented by the doctors. The German doctors Alexander refers to, for personal reasons, became willing participants in the Nazi health care system, an element of the larger ideology. Of the German doctors, Alexander said they were ”on the whole meek and over polite fellows who committed inhuman crimes because they found themselves suspect by their superiors.”[3] This claim will be investigated later for more detail. Alexander also writes of the courage of the Dutch physicians, who eruditely refused to cooperate with the Nazi directives, maintained their personal and professional integrity, served the population as best they could under terrible duress and were finally sent to concentration camps for their defense of the sick and infirmed. Parallels will then be shown between physicians who serve a nationalized bureaucratic health care system and physicians who uphold their Hippocratic Oath to do no harm no matter what the personal and professional outcome may be.
I. The Motivation to Commit Atrocities: Personal and Professional
Nearing the end of his article, Alexander concluded that the Nazi crimes “started from small beginnings.” He writes, “The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as life not worthy to be lived.”[4] The first of the “small beginnings” was the formal discussion of the responding to the idea that for some life was not worth living.
Acceptance of this paradigm shift away from the sanctity of life principle and the Hippocratic Oath is highlighted by Alexander was driven by a negative attitude toward those who could not be rehabilitated. He writes, “It is important to realize that the infinitely small wedged-in lever from which this entire trend of mind received its impetus was the attitude toward the nonrehabilitable sick.” “It is rather significant,” observed Alexander, “that the German people were considered by their Nazi leaders more ready to accept the exterminations of the sick than those for political reasons.” Not only did the physicians conclude that quality of life (QoL) was the criterion for a life worth living but the German population was perceived to generally accept this notion. Physician-Ethicist Edmund Pellegrino, writing in 1992, points that,
Seriously ill persons suffer commonly from alienation, guilt, and feelings of unworthiness. They often perceive themselves and are perceived by others, as economic, social, and emotional burdens. They are exquisitely susceptible to even the most subtle suggestion by physician, nurse, or family member that reinforces their guilt, shame, and sense of unworthiness. It takes as much courage to resist these subliminal confirmations of alienation as to withstand the physical ravages of the disease. Much of the suffering of dying patients comes from be subtly treated as nonpersons. The decision to seek euthanasia is often an indictment against those who treat or care for the patient.[5]
A life not worthy to live and nonrehabilitable where accepted principles of the physicians coupled with the public notion of the alienation of diminished QoL, made the extermination of life an acceptable practice. In the early stages of implementation only the severely and chronically sick were euthanized, but, as Alexander chronicled, “Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans.”
History’s clarion call is that some processes must never be initiated. Sadly, one of those conceptual doors already opened to the detriment of society at large is the favorable discussion of defining life by its quality (QoL).[6] The ideology that purports the lives of persons suffering from incurable diseases are not worth living may be a small step on paper but once put into practice has historical precedent endorse the killing all the government deems unwanted.[7] Once a category of “not worth living” is conceptually allowed to exist, social, ideological, racial and nationalistic qualifications can and will metastasize into the identification of classes of unwanted persons for elimination. [8]
Preceding the implementation of the plan to euthanize unwanted members of the population was the open and accepted discourse of the possibility of such action by physicians. Alexander writes that “Sterilization and euthanasia of persons with chronic mental illnesses was discussed at a meeting of Bavarian psychiatrists in 1931.[9] By 1936 extermination of the physically or socially unfit was so openly accepted that its practice was mentioned incidentally in an article published in an official German medical journal.”[10]
While the discussion of extermination was discussed openly among the medical elite, the vocabulary used to convey the plan’s implementation to the public according to Alexander was couched “in most careful and superficially acceptable terms.” Daryl Charles’ article “The Right to Die” gives modern expression to Alexander’s findings when he writes, “Euthanasia today depends on euphemisms. Orwellianisms such as ‘exit preference’, ‘death with dignity’ and a ‘right to die’ are absolutely critical to its cultural legitimation. Empowered by sentiment, euthanasia rhetoric is dependent on images and symbols.” [11]
The following examples list German government agencies that assigned pleasant titles to hideous practices. The Nazi “organization devoted exclusively to the killing of children was known by the similarly euphemistic name of ‘Realm’s Committee for Scientific Approach to Severe Illness Due to Heredity and Constitution.’ The ‘Charitable Transport Company for the Sick’ transported patients to the killing centers, and the ‘Charitable Foundation for Institutional Care’ was in charge of collecting the cost of the killings from the relatives, without, however, informing them what the charges were for; in the death certificates the cause of death was falsified.”[12]
The indispensable lesson to learn is that the naïve will be satisfied with what a thing is called possessing no inclination to look further to find out what the thing is. Words only have meaning to the degree they reflect reality. Prevarications and obfuscations must be recognized for what they are in light of the reality they are proposed to represent. Morality demands truth. If truth is absent immoral decisions will be made based on falsehoods. The continuing debate over when life begins illustrates the point.[13]
II. German Physicians
Alexander included the names to two German doctors that carried out Nazi directives, Drs. Karl Gebhardt and Sigmund Rascher.[14] The deciding factor to go forward with unspeakable human experimentation was the primal compulsion for self preservation. These two men consciously agreed that imposing unimaginable suffering on others was preferable to loosing their own lives. Gebhardt would have been killed if he did not perform “experiments to clear himself of the suspicion that he had been contributing to the death of SS General Reinhard (“The Hangman”) Heydrich, either negligently or deliberately, by failing to treat his wound infection with sulfonamides.” Rascher, after being suspected of having Communist sympathies was “ready to go all out and to do anything merely to regain acceptance by the Nazi party and the SS.” And, lest anyone think that only inhuman monsters would engage in the wanton torture and killing of fellow human beings, Alexander answers in familiar terms. Pointing to the essential aspects of fallen man he says, “These cases illustrate a method consciously and methodically used in the SS, an age-old method used by criminal gangs everywhere: that of making suspects of disloyalty clear themselves by participation in a crime that would definitely and irrevocably tie them to the organization…The important lesson here is that this motivation, with which one is familiar in ordinary crimes, applies also to war crimes and to ideologically conditioned crimes against humanity—namely, that fear and cowardice, especially fear of punishment or of ostracism by the group, are often more important motives than simple ferocity or aggressiveness.”
III. The Physicians of the Netherlands
Against the backdrop of the German occupation of the Netherlands and the ideological pogrom intended for all but the German people, the Dutch physicians bravely disobeyed the German high command, maintaining their high principles as physicians to do no harm. The attempt to pull them into the alignment with their German counterparts began on December 19, 1941, when Sciss-Inquart, Reich Commissar for the Occupied Netherlands Territories, sent orders of the Reich Commissar of the Netherlands Territories concerning the Netherlands doctors which reads in part: “It is the duty of the doctor, through advice and effort, conscientiously and to his best ability, to assist as helper the person entrusted to his care in the maintenance, improvement and re-establishment of his vitality, physical efficiency and health. The accomplishment of this duty is a public task.”[15]
While this directive does not sound overly obtrusive to modern readership, the Dutch doctors understood they were reading orders sent down from a government that never said what it really meant. The words were permeated with the ideology of death. No matter what was written, the result was the advancement of the regime’s tyrannical ideology. Therefore, the Dutch physicians refused the order because properly rendered; “the concentration of their efforts on mere rehabilitation of the sick for useful labor” meant they were to provide labor for concentration camps. Alexander lauds these physicians saying, “They had the foresight to resist before the first step was taken, and they acted unanimously and won out in the end. It is obvious that if the medical profession of a small nation under the conqueror’s heel could resist so effectively the German medical profession could likewise have resisted had they not taken the fatal first step. It is the first seemingly innocent step away from principle that frequently decides a career of crime. Corrosion begins in microscopic proportions.”
When threatened them with revocation of their medical licenses, the doctors voluntarily returned their credentials, closed their offices and began to see people secretly. For their resistance to Nazi tyranny Sciss-Inquart “arrested 100 Dutch physicians and sent them to concentration camps.” Praising the physicians in the Netherlands Alexander recorded that the “medical profession remained adamant and quietly took care of their widows and orphans, but would not give in. Thus, it came about that not a single euthanasia or non-therapeutic sterilization was recommended or participated in by any Dutch physician.”
The single most important point is that for physicians to violate their oath to do no harm is the step, whether innocent or not, that initiates the slippery ideological slope that engages the health care profession in the killing of the governments unwanted people. Only when doctors remain true to their oath to care for all people, whether they can be rehabilitated or not, can the profession be preserved from governmental tyranny.
IV. Noted Parallels between the 1949 Report and 2009
The parallels between the Nazi program as described by Dr. Alexander and the modern governmental trajectory is striking. America’s Affordable Health Choices Act of 2009 HR 3200 and Veteran’s Administration literature challenge the imagination. Note the similarities. The first quote is by Dr. Alexander (A), the second by the fitting government document (B):
(1) The Five Year Stipulation: A. “All state institutions were required to report on patients who had been ill five years or more” – B. HR 3200: “Advance care planning consultation means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning… the individual involved has not had such a consultation within the last 5 years.[16]
(2) The Personal Questionnaire Stipulation: A. “who were unable to work, by filling out questionnaires giving name, race, marital status, nationality, next of kin, whether regularly visited and by whom, who bore financial responsibility and so forth” – B. Veteran’s Administration: “My situation causes severe emotional burden for my family (such as feeling worried and stressed all the time); “I am a severe financial burden to my family.”[17]
(3) The Quality of Life Stipulation: A. “The decision regarding which patients should be killed was made entirely on the basis of this brief information by expert consultants, most of whom were professors of psychiatry in the key universities.” — B. HR 3200: “An advanced care planning consultation with respect to an individual may be conducted more frequently that provided under paragraph (1) if there is significant change in the health condition of the individual, including diagnosis of a chronic, progressive, life-limiting disease, a life-threatening or terminal injury, or upon admission to a skilled nursing facility, a long-term care facility (as defined by the Secretary), of a hospice program.”[18]
(4) Euphemisms: A. “Realm’s Committee for Scientific Approach to Severe Illness Due to Heredity and Constitution”; “The ‘Charitable Transport Company for the Sick”; “Charitable Foundation for Institutional Care.” — B. American Recovery and Reinvestment Act of 2009; America’s Affordable Health Choices Act of 2009; “exit preference,” “death with dignity,” “right to die.”
V. Conclusion
The crux of saving the health care system is the moral fiber of the American people. The least the community can do for the physicians who care for them, those we hold in the highest regard for their compassion, intellect, and expertise, is to reciprocate that care by creating and sustaining a societal context that believes and practices that life is precious above all other things because it is endowed by our Creator. The local church, both pulpit and people are the key to creating a context based on the Truth of God’s Word thereby aiding the community and physician with the matters of conscience dealt with daily. [19]
BIBLIOGRAPHY
Alexander, Leo. “Medical Science under Dictatorship.” New England Journal of Medicine. 241: 39–47. 1949.
Bumke, O. Discussion of Faltlhauser, K. Zur Frage der Sterilisierung geistig Abnormer, Allg. Zischr. J. Psychiat. 96:372. 1932.
Cameron, Nigel “The Christian Stake in Bioethics,” Bioethics and the Future of Medicine: A Christian Appraisal. John F. Kilner, Nigel M de S. Cameron, David L. Schiedermayer, eds. Grand Rapids: William B. Eerdmans Publishing Co. 1995
Daryl Charles, “The ‘Right to Die’,” Bioethics and the Future of Medicine: A Christian Appraisal. John F. Kilner, Nigel M de S. Cameron, David L. Schiedermayer, eds. Grand Rapids: William B. Eerdmans Publishing Co. 1995.
Dierichs, R. Beitrag zur psychischen Anstaltsbehandlung Tuberkuloser. Zischr. f. Tuberk. 74:24-28. 1936.
The Hippocratic Oath. translated by Michael North, National Library of Medicine. 2002.
Mitchell, Ben. “Bioethics and the Church,” Bioethics and the Future of Medicine: A Christian Appraisal. John F. Kilner, Nigel M de S. Cameron, David L. Schiedermayer, eds. Grand Rapids: William B. Eerdmans Publishing Co. 1995.
Pearlman, Robert, et al. Your Health, Your Choices. U. S. Veteran’s Administration. nd.
U.S. Congress. House. American Recovery and Reinvestment Act of 2009. to accompanyHR 1. 111th Cong., 1st sess. (February 12, 2009)
America’s Affordable Health Choices Act of 2009. HR 3200. 111th Cong., 1st sess. (July 14, 2009)
[1] The Hippocratic Oath, translated by Michael North, National Library of Medicine, 2002. http://www.nlm.nih.gov/hmd/greek/greek_oath.html, (accessed Sept. 3, 2009).
[2] Leo Alexander, “Medical Science under Dictatorship,” New England Journal of Medicine, 241: 39–47. http://www.nytimes.com/1985/07/24/us/dr-leo-alexander-79-nuremberg-trial-aide.html?sec=health. (Accessed Sept. 3, 2009).
[3] http://www.nytimes.com/1985/07/24/us/dr-leo-alexander-79-nuremberg-trial-aide.html?sec=health. (accessed Sept. 3, 2009)
[4] Nigel Cameron, “The Christian Stake in Bioethics,” Bioethics and the Future of Medicine: A Christian Appraisal, John F. Kilner, Nigel M de S. Cameron, David L. Schiedermayer, eds. (Grand Rapids: William B. Eerdmans Publishing Co., 1995), 5. Cameron asks, ‘Is the pursuit of the good life to be understood in terms of a flight from suffering? Is suffering in itself such a disbenefit as to outweigh the good of life itself? Is a life of suffering a life ‘not worth living’?” Alexander’s observations of euthanasia are not based on suffering but on the concept that some lives have been determined not worth living, not because of infirmity, but according to the world-view of the political regime.
[5] Ben Mitchell, “Bioethics and the Church,” Bioethics and the Future of Medicine: A Christian Appraisal, John F. Kilner, Nigel M de S. Cameron, David L. Schiedermayer, eds. (Grand Rapids: William B. Eerdmans Publishing Co., 1995), 133. Mitchell is quoting Edmund D. Pellegrino, “Doctors Must Not Kill,” The Journal of Clinical Ethics 3 (summer 1992), 96-97. Pellegrino’s findings are especially applicable in light of the present push for nationalized health care and end of life counseling.
[6] Jerome R. Wernow, “Saying the Unsaid: Quality of Life Criteria in a Sanctity of Life Position,” Bioethics, 93. “Patient’s experiences with pain, suffering, indignity, and financial burdens have forced the medical community to reconsider sustaining life at all costs. Currently, this reconsideration has resulted in the acceptance of quality of life criteria (QoL) over the sanctity of life principle (SLP) in the majority of medical literature guidelines and praxis studies which address life-sustaining care in the United States.”
[7] “In Germany the exterminations included the mentally defective, psychotics (particularly schizophrenics),epileptics and patients suffering from infirmities of old age and from various organic neurologic disorders such as infantile paralysis, Parkinsonism, multiple sclerosis and brain tumors.”
[8] http://www.foxnews.com/politics/2009/07/21/obamas-science-czar-considered-forced-abortions-sterilization-population-growth/. “President Obama’s ‘science czar,’ John Holdren, once floated the idea of forced abortions, “compulsory sterilization,” and the creation of a ‘Planetary Regime’ that would oversee human population levels and control all natural resources as a means of protecting the planet — controversial ideas his critics say should have been brought up in his Senate confirmation hearings. Holdren, who has degrees from MIT and Stanford and headed a science policy program at Harvard’s Kennedy School of Government for the past 13 years, won the unanimous approval of the Senate as the president’s chief science adviser. He was confirmed with little fanfare on March 19 as director of the White House’s Office of Science and Technology Policy, a 50-person directorate that advises the president on scientific affairs, focusing on energy independence and global warming.”
[9] Alexnder citing Bumke, O. Discussion of Faltlhauser, K. Zur Frage der Sterilisierung geistig Abnormer, Allg. Zischr. J. Psychiat., 96:372, 1932.
[10] Dierichs, R. Beitrag zur psychischen Anstaltsbehandlung Tuberkuloser, Zischr. f. Tuberk., 74:24-28, 1936.
[11] Daryl Charles, “The ‘Right to Die’,” Bioethics, 271.
[12] “According to the records, 275,000 people were put to death in these killing centers.”
[13] http://www.cnsnews.com/news/article/51676. “The fetus, given the opportunity to develop properly before birth, and given the essential early socializing experiences and sufficient nourishing food during the crucial early years after birth, will ultimately develop into a human being,” John P. Holdren, director of the White House Office of Science and Technology Policy, wrote in “Human Ecology: Problems and Solutions.”
[14] Nazi physicians performed “‘terminal human experiments,’ a term introduced by Dr. Rascher to denote an experiment so designed that its successful conclusion depended upon the test person’s being put to death.”
[15] Seiss-Inquart. Order of the Reich Commissar for the Occupied Netherlands Territories Concerning the Netherlands Doctors. (Gazette containing the orders for the Occupied Netherlands Territories), pp. 1001-1026, December, 1941.
[16] America’s Affordable Health Choices Act of 2009, HR 3200, 111th Cong., 1st sess. (July 14, 2009), 424.
[17] Pearlman, Robert, et al. Your Health, Your Choices. U. S. Veteran’s Administration. nd.
[18] HR 3200, 428. According to the American Recovery and Reinvestment Act of 2009, to accompanyHR 1, 111th Cong., 1st sess. (February 12, 2009), 142, bureaucrats will determine the definition of “life-limiting disease” or a life not worth living because it is beyond rehabilitation.
[19] http://www.theamericandissident.org/PoemNiemoller.htm The entry is thought to be the original sequence of persecutions in Niemöller’s famous statement about the Nazis. Many variants and derivatives have arisen, causing a great deal of confusion about the original, but most agree that the original statement began with mention of the Communists.
“When the Nazis arrested the Communists,
I said nothing; after all, I was not a Communist.
When they locked up the Social Democrats,
I said nothing; after all, I was not a Social Democrat.
When they arrested the trade unionists,
I said nothing; after all, I was not a trade unionist.
When they arrested the Jews, I said nothing; after all, I was not a Jew.
When they arrested me, there was no longer anyone who could protest”