Medicine After the Holocaust (contd) • Election and assassination of John F. Kennedy • Ask not what your country can do for you… • Rice Stadium moon speech • Election and resignation of Lyndon Johnson • Civil Rights Act of 1964 • Medicare and Medicaid 1965 • The War in Vietnam • Kennedy Center for Bioethics 1971 • Roe v Wade 1973 • Gertrude Potsma found guilty of mercy killing 1973
Medicine After the Holocaust (contd) • (Unconstrained) Rights: The story behind the term “rights” is the story of social contract. The myth postulates free and independent if highly vulnerable beings who voluntarily trade a portion of their autonomy for a measure of collective security. The myth makes the collective arrangement the product of individual choice and thus secondary to the individual. “Rights” are the fundamental category because it is the normative category which most nearly approximates that which is the source of the legitimacy of everything else. Rights are traded for collective security.
Medicine After the Holocaust (contd) • (Constrained) Duty: The basic myth of Judaism is obligation or mitzvot. It, too, is intrinsically bound up in a myth—the myth of Sinai. Just as the myth of social contract is essentially a myth of autonomy, so the myth of Sinai is essentially a myth of heteronomy (subjection to something else). Sinai is a collective—indeed, a corporate—experience. The experience at Sinai is not chosen. • There is no Hebrew word for “right” in the modern sense of “I am entitled to it.”
Medicine After the Holocaust (contd) • The right to an abortion • The right to die • The right to a (medical) education • The right to medical care • The right to health insurance • Animal rights • Gay rights • Women’s rights
Medicine After the Holocaust (contd) • Beauchamp & Childress: Principles of Biomedical Ethics 1979 includes the four clusters of Basic Principles: • Respect for autonomy (a norm of respecting the decisonmaking capacities of autonomous persons) • Nonmaleficence (a norm of avoiding the causation of harm) • Beneficence (a group of norms for providing benefits and balancing benefits against risks and costs) • Justice (a group of norms for distributing benefits, risks, and costs fairly)
Medicine After the Holocaust (contd) • From Roe v Wade, Decided January 22, 1973 by a 7 to 2 majority: “ The principal thrust of appellant's attack on the Texas statutes is that they improperly invade a right, said to be possessed by the pregnant woman, to choose to terminate her pregnancy. Appellant would discover this right in the concept of personal ‘liberty’ embodied in the Fourteenth Amendment's Due Process Clause; or in personal, marital, familial, and sexual privacy said to be protected by the Bill of Rights or its penumbras; or among those rights reserved to the people by the Ninth Amendment.”
Medicine After the Holocaust (contd) • “Before addressing this claim, we feel it desirable briefly to survey, in several aspects, the history of abortion, for such insight as that history may afford us, and then to examine the state purposes and interests behind the criminal abortion laws.” • “Ancient religion did not bar abortion.” • “Why did not the authority of Hippocrates dissuade abortion practice in his time and that of Rome?”
Medicine After the Holocaust (contd) • “The late Dr. Edelstein provides us with a theory: The Oath was not uncontested even in Hippocrates' day; only the Pythagorean school of philosophers frowned upon the related act of suicide. Most Greek thinkers, on the other hand, commended abortion, at least prior to viability. See Plato, Republic, V, 461; Aristotle, Politics, VII, 1335b 25. For the Pythagoreans, however, it was a matter of dogma. For them the embryo was animate from the moment of conception, and abortion meant destruction of a living being.”
Medicine After the Holocaust (contd) • “The abortion clause of the Oath, therefore, ‘echoes Pythagorean doctrines,’ and ‘in no other stratum of Greek opinion were such views held or proposed in the same spirit of uncompromising austerity.’” • “Dr. Edelstein then concludes that the Oath originated in a group representing only a small segment of Greek opinion and that it certainly was not accepted by all ancient physicians. He points out that medical writings down to Galen (A. D. 130-200) ‘give evidence of the violation of almost every one of its injunctions.’”
Medicine After the Holocaust (contd) • “But with the end of antiquity a decided change took place. Resistance against suicide and against abortion became common. The Oath came to be popular. The emerging teachings of Christianity were in agreement with the Pythagorean ethic. The Oath ‘became the nucleus of all medical ethics’ and ‘was applauded as the embodiment of truth.’ Thus, suggests Dr. Edelstein, it is ‘a Pythagorean manifesto and not the expression of an absolute standard of medical conduct.’”
Medicine After the Holocaust (contd) • “This, it seems to us, is a satisfactory and acceptable explanation of the Hippocratic Oath's apparent rigidity. It enables us to understand, in historical context, a long-accepted and revered statement of medical ethics.”
Medicine After the Holocaust (contd) • America’s circumstances today are eerily similar to those of Germany in the early 1930s. American biomedical science is now the most advanced in the world. The Human Genome Project has revitalized a universal interest in biological determinism and eugenics. Patient autonomy and patient rights have become orthodox thinking in the highest circles of academic medicine, government, and philanthropy throughout America and the rest of the Western world. Economic and political power in medicine is concentrated in a strong, centralized American government.
Medicine After the Holocaust (contd) • The placement of autonomy, patient rights, and law above other ethical principles, the doctor-patient relationship, and religious moral values is, in part, a consequence of our secular bioethics that originated in the Nuremberg Code. Lisa Eckenwiler and Felicia Cohn, citing bioethicist Jonathan Moreno, describe the danger of the dominance of autonomy over other values this way: “When it comes to America in the mid-twentieth century, the creation stories are often summarized in a word—“Nuremberg,” “Tuskeegee,” “Willowbrook,” and
Medicine After the Holocaust (contd) more. All of these stand for part of but not the whole story. In its foundational beliefs in individual autonomy, bioethics had a distinctly American cast. In warning against American ‘bioethics imperialism,’ however, Moreno cites the experience of Weimar Germany in the early 1930s when a few physicians created a journal called Ethics to discuss varioustheories of eugenics, then the dominant social philosophy of medicine. Moreno calls the devolution of this journal into a Nazi tract for racial purification, a warning that an intellectual movement can slide into disaster.”
Medicine After the Holocaust (contd) eugenics nonmaleficence beneficence justice EUGENICS nonmaleficence beneficence JUSTICE AUTONOMY nonmaleficence beneficence JUSTICE LIFE nonmaleficence beneficence JUSTICE
Medicine After the Holocaust (contd) • In Judaism, the value of human life is supreme; nearly all Biblical laws are waived to save a life. This approach contrasts with the secular ethical view, which considers human life to be one of many values and often gives greater weight to “the quality of life.” Nonetheless, the value of human life in Judaism is not absolute and, in certain rare and well-defined circumstances, other values may prevail. • We neglect 3,000 years of empirical data and analysis from Jewish medical ethics or bioethics at our peril.
Medicine After the Holocaust (contd) • During the Third Reich, eugenics triumphed over the Jewish medical values of the supreme value of all human life and the sanctity of the human body. • In America today, autonomy and rights have experienced a similar triumph. • A society that believes in the supreme value of all human life will legalize neither abortion on demand nor the right to die. • A society that believes in the sanctity of the human body would treat it with respect both during and after life.
Medicine After the Holocaust (contd) • Singer, speciiesism, PETA and “holocaust on your plate,” partial birth abortion, infanticide • Diversity trumps competence (Major Hassan) • Homemade eugenics via Preimplantation genetic diagnosis (PGD): • Down Syndrome (Sarah Palin) • Creating a donor for a sibling (My Sister’s Keeper) • Gender “selection” in about 50% of IVF clinics • A focus on the “perfect baby” that makes us less tolerant of people with disabilities (Human Genome) • Fifty million abortions in America since Roe v. Wade
Medicine After the Holocaust (contd) • “In 1989, the Oregon Legislature created the Health Services Commission and directed it to develop a prioritized list of health services ranked in order of importance to the entire population to be covered.” • “Individual condition/treatment pairs are prioritized according to impact on health, effectiveness and (as a tie-breaker) cost.” • “The resulting prioritized list is used by the Legislature to allocate funding for Medicaid and SCHIP, but the Legislature cannot change the priorities set by the independent Commission.”
Medicine After the Holocaust (contd) • In “1997 Oregon enacted the Death with Dignity Act (the Act) which allows terminally-ill Oregonians to end their lives through the voluntary self-administration of lethal medications, expressly prescribed by a physician for that purpose.” • “The law states that…a patient must be: 1) 18 years of age or older, 2) a resident of Oregon, 3) capable of making and communicating health care decisions for him/herself, and 4) diagnosed with a terminal illness that will lead to death within six (6) months.”
Medicine After the Holocaust (contd) • According to DerekHumphry, the founder of the Hemlock Society in Freedom to Die, “A rational argument can be made for allowing PAS [physician-assisted-suicide] in order to offset the amount society and family spend on the ill, as long as it is the voluntary wish of the mentally competent terminally and incurably ill adult. There will likely come a time when PAS becomes a commonplace occurrence for individuals who want to die and feel it is the right thing to do by their loved ones. There is no contradicting the fact that since the largest medical
Medicine After the Holocaust (contd) expenses are incurred in the final days and weeks of life, the hastened demise of people with only a short time left would free resources for others. Hundreds of billions of dollars could benefit those patients who not only can be but who want to live.” [Emphasis in the text.] • In July 2008 Barbara Wagner and Randy Strop asked Medicaid to cover their chemotherapy. Each received a letter from the OHP administrator refusing to cover chemotherapy but offering to pay for their assisted suicide or “comfort care.”
Medicine After the Holocaust (contd) • America has a unique Judeo-Christian foundation and remains one of the most religious countries in the world. • One (constrained) segment of America accepts, “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty, and the pursuit of Happiness.”
Medicine After the Holocaust (contd) • A survey of Baby Boomers in 1996, when we were turning fifty, asked them the age at which they thought that old age begins. • The median response was 79.5 years. • The average life span was 76.1 years. • Another (unconstrained) segment of America may believe, “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Quality of Life, Autonomy, and Happiness.”
Medicine After the Holocaust (contd) • The transformation of “Life, liberty, and the pursuit of happiness” into “Quality of life, autonomy, and happiness” has profound implications for the medical profession in the area of clinical medicine. • Consider a story about the namesake of the building in which we are today, Michael DeBakey, a story that highlights the differences between an IRB to evaluate human subjects research applications and an Ethics Committee to evaluate clinical decision-making.
Medicine After the Holocaust (contd) • Science or reason and religion or faith can work together to solve many thorny problems. • For example, consider the respirator, a great technical achievement that has brought with it fundamental questions about the definition of death. • Physicians initially utilized respirators to save lives but quickly realized that, in many cases, they were simply delaying an inevitable death. What to do? • Avraham Steinberg and timers on respirators.
Medicine After the Holocaust (contd) • A new king arose over Egypt, who did not know of Joseph. • “Behold! The people, the Children of Israel are more numerous and stronger than we.” • The king of Egypt said to the midwives of the Hebrews, “When you deliver the Hebrew women, and you see them on the birthstool, if it is a son, you are to kill him, and if it is a daughter, she shall live.” • “But the midwives feared God and they did not do as the king of Egypt spoke to them, and they caused the boys to live.”
Medicine After the Holocaust (contd) • The King of Egypt summoned the midwives and said to them, “Why have you done this thing that you have caused the boys to live!” • The midwives said to Pharaoh, “Because the Hebrew women are unlike the Egyptian women, for they are experts; before the midwives come to them, they have given birth.” • God benefited the midwives—and the people increased and became very strong. And it was because the midwives feared God that he made them houses.”
Eugenics in Germany (contd) • This image from controversial German anatomist Gunther von Hagens’ Body Worlds recalls the Glass Man. • It also recalls images from Eduard Pernkopf’s infamous Atlas of Topographical and Applied Human Anatomy, whichhas been hailed as one of the most important anatomical atlases since the work of Vesalius. • Pernkopf used the murdered bodies of men, women, and children from the Holocaust for his atlas of anatomy.
Eugenics in Germany (contd) • While Pernkopf was a successful anatomist, he was also a fervent believer in National Socialism. He joined the Nazi party in 1933. Soon after Hitler invaded Austria in 1938, Pernkopf was chosen as Dean of the Vienna Medical School. His first assignment included purging the medical school faculty of all Jews and undesirables. This resulted in the loss of 153 of the 197 faculty members, including 3 Nobel Laureates.
Medicine After the Holocaust • How do we explain the willing participation of the medical profession in the most egregious and well-documented violations of medical ethics ever? • Three necessary but insufficient conditions must be present: • A centralized government. • A dominant philosophy of medicine. • Economic distress. • Proctor identifies six reasons why doctors eagerly served as Hitler’s henchmen:
Greco-Roman values meet Judeo-Christian values • The unconstrained (Greco-Roman or, in this case, Irish) but beautiful cop meets the constrained but holy (Jewish) religious leader in a case of a missing person in 1992’s A Stranger Among Us directed by Sidney Lumet and starring Melanie Griffith.
Eugenics (contd) • First see intro to Haas/Greenberg to note conflict between religion and science. • Compare French revolution and American revolution in terms of a conflict of visions i.e. see Sowell
Cruelty to humans implies cruelty to animals • Cruelty to animals implies cruelty to people • Kindness to humans implies kindness to animals • Kindness to animals tells us nothing about how people will treat people e.g. think PETA, which compares eating chickens to “Holocaust on a plate” i.e. they will lower the value of people and treat them less kindly • Hitler forbade vivisection of animals (and opposed smoking) but demanded vivisection of humans • See cartoon with animals saluting Hitler
Include slides which say 1)Why it happened it Germany the way it happened i.e. Fred’s friend 8 ethics violations and Proctor’s six explanations plus central government; 2) what was similar and what was different about Germany and America; 3) why it happened there and not here; 4) what’s good about America