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January 21, 2014

Doctors, the Holocaust, and the Oath of Hippocrates

The mastery of fire was the first seminal moment in human history, which makes the Holocaust the second seminal moment in human history. A century ago, Germany was a highly-evolved society with a strong intellectual tradition. Its universities and its medical community were the flowers of Europe. Doctors from all over the world travelled to Germany to learn the latest and best techniques. It thus begs the question: How, then, did one of the most sophisticated societies and medical communities in the world beget a killing machine?

To answer that question, one must reflect upon the Kaiser’s vision of nationalized health care, the notorious discipline of the German people and their natural affinity for strong leaders, economic catastrophe, and war. One must also reflect upon the birth of social Darwinism and the burgeoning eugenics movement in the West at that time. Against this backdrop, and practicing in the climate of fear that fascists always create, many German physicians perceived a duty to treat the body politic as well as the bodies of their patients.

Some of these physicians likely recognized this paradigm shift as an assault on the Hippocratic tradition, which places the individual patient, not the collective, at the rightful focus of a doctor’s attention. Any doctor who has taken the 2500 year-old Oath of Hippocrates has vowed to honor his teachers, to teach the next generation of physicians, to do his best for his patients, to do no harm, to never assist with suicide or abortion, to eschew procedures that he is not trained to do, to avoid sexual contact with patients, and to respect patient confidentiality. There is nothing in the Oath about taking care of society, or managing scarce resources.

To care for their nation, to purge it of its ills, German physicians were induced to pursue progressively brutal programs that betrayed the Hippocratic tradition. It started with the sterilization of those deemed unworthy to reproduce, spread to euthanasia of the crippled, the sick, and the mentally ill- those deemed as having a life not worth living (“lebensunwertes Leben”), continued as the outright murder of healthy individuals who were a political problem, and culminated in genocide, primarily the Jews of Europe. Doctors, trained in the traditions of Hippocrates, were central characters in the entire process. Only recently did the German Medical Association admit to and apologize for physician complicity in the Holocaust.

How could this happen in an advanced society? How could such highly-educated, cultured men have done such a thing? Books have been written about this topic, and one can read about the doctor trials at Nuremberg. It is a big topic, but one can say a few things about physicians and the Oath they have taken at the risk of trivializing the Holocaust.

Bad things happen when fear silences the individual conscience. One can almost hear the discussions among groups of German doctors as they gazed upon a crippled child, weighing whether or not his was a life worth living, considering the precious resources needed by soldiers at the front. And so on and so forth. Whether it came from group-think or from the climate of the times, the first mistake, the first rupture of the Hippocratic tradition, was doctors treating society as the patient, and the silence of individual doctors.

Today, we are also at war, and we are also in debt. Physicians are told that we have dwindling resources, and that we must make hard choices. We are reminded that much of the Medicare budget is consumed in the last thirty days of life. We are told by our professional societies and the government that it is our solemn duty to allocate resources wisely and to take care of the health care system and the country. We hear questions like: “Are these patients worth treating, and is this a life worth living? And all the while we are asked to "maintain our professionalism,” as if we have forgotten the Oath.

Physician-assisted “suicide” is the now the law in some states, and it is becoming increasingly common in “advanced” Western societies. The inevitable contraction of Medicare and Medicaid will not lead to outright medical killing. It may not lead to more medically-assisted suicides, or even to large doses of morphine given quietly at night to very sick patients. But it will certainly lead to the rationing of care. Be certain the politicians will figure out a way to force doctors to do that rationing. If history serves, many doctors will comply. If interest rates suddenly rise and America suffers an acute currency crisis, the healthcare system will collapse and people will begin to die as they did for millennia. Fortunately, morphine is cheap.

It is simply a fact that cancer patients who live in countries with socialized medicine and drug rationing die at higher rates than they do in America. It is simply a fact that elderly patients with renal failure who live in those countries are denied dialysis and are left to die. This is not medical killing, but people are dying and these systems force physicians to confront the Oath that they have taken. Professional medical societies can blabber all they want about professionalism and doctors’ responsibilities, but, in the end, all that matters is the Oath and whether or not individual doctors take it seriously. It is all right there, in simple black and white.

Physicians cannot do all things for all people, and it is not their responsibility to treat society. In fact, to treat society as the patient is a violation of the Hippocratic Oath. While caring for their patients, physicians have confronted limited resources for centuries yet somehow muddled through with their reputations intact. Why? Because the most powerful drug to treat human suffering is cheaper than morphine and that drug is love. If a patient perceives that his physician is withholding care to protect “the system” economically, to manage scarce resources for “society,” the physician and his profession will not only lose all credibility, they will evaporate. The patients, who are All of Us, will be the ultimate victims.

The primary lesson of physician involvement in the Holocaust is that physicians should never take marching orders from the government or from politicians. And in an era when doctors are increasingly employed by hospitals, they should not take marching orders from hospital bureaucrats either. They should work only for their patients, and they should only be paid by their patients. They should remember their Oath. How quickly we forget.

Early in my career, I was asked by a senior surgeon to sterilize a retarded teenager while he was having an orthopedic procedure. How can you object to this family’s reasonable request, I was asked; he might get someone pregnant. People frequently find themselves tongue-tied when receiving an unexpected call. At the time, I did not make any cogent philosophical arguments, nor did I deflect with any delaying tactics- let me talk to a lawyer, etc. I simply said “no,” or at least my gut said “no,” while my mind sketched out. I was berated for it. Fortunately, young surgeons are used to being berated.

Somewhat conversely, I was asked years later to see a young man who had suffered a severe head injury and brain death. His body yet thrived, otherwise healthy, on a ventilator. His grieving wife, wishing to cling to her husband in the form of a child, asked that I harvest her husband’s sperm. Rather than refuse, as was my gut reaction given that I did not know her husband’s wishes, I cowardly deferred the decision to the next morning and to my partner, muttering something about my being a pediatric urologist, merely holding down the fort overnight for adult patients.

As I reflect on that night, I wonder if my colleagues and I, now confronted with an assault on the fortress of our profession and our individual responsibilities to our individual patients, will listen to our guts, remember our Oath, and not be cowards.

Pray for us.

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