Why Medical Ethics?

When I lecture to audiences about the Jewish approach to medical ethics, one issue always lurks below the surface: Why medical ethics? And why particularly Jewish medical ethics? Isn't it sufficient to allow the medical field to police itself? Aren't physicians moral people?

Today the world is filled with institutional review boards and hospital ethics committees. Most, if not all, medical schools in the United States now have curricula in medical ethics, a phenomenon that was not true even 15 years ago. Why is this so and what events brought about this increased interest in teaching ethics to doctors?

When we look back at the past hundred years, we face the uncomfortable reality that the scientific community, and the medical community in particular, have been the impetus for some of the most barbaric and immoral programs of the 20th century. It becomes painfully apparent that secular, scientific and medical credentials do not imply moral rectitude. In fact, an immoral person with credentials is granted latitude that would not otherwise be bestowed upon the average person.1

The ability to trample the rights of fellow human beings without compunction is rooted in a belief that the needs of society outweigh the needs of the individual.

If we exclude those individuals who consciously choose to act unethically, we must still ask what motivates people who are ostensibly dedicated to helping mankind to perpetrate injustice. The answer is often simpler than we might imagine. Most major medical ethical lapses this century can be traced back to a single flawed philosophy. The ability to trample the rights of fellow human beings without compunction is rooted in a belief that the needs of society outweigh the needs of the individual.

While at face value, the concept of the needs of the many outweighing the needs of the individual may sound reasonable, this idea is fraught with danger. Let me illustrate this point by examining some vignettes from the 20th century that deal with ethical lapses.

The following description of a lecture appeared in a certain magazine in 1968:

[The speaker] inferred that 'we cannot continue to regard all human life as sacred'. The idea that every person has a soul and that his life must be saved at all costs should not be allowed; instead the status of life and death should be reconsidered. If, for example, a child were to be considered legally born when two days old, it could be examined to see whether it was an 'acceptable member of human society'. It might also be desirable to define a person as legally dead when he was past the age of 80 or 85, and then expensive medical equipment should be forbidden to him . . .

If new biological advances demand a continuous readjustment of ethical ideas, how are people to be persuaded to adapt to the situation? Clearly by education, and [the speaker] did not think it right that religious instruction should be given to young children. Instead they should be taught the modern scientific view of man's place in the universe, in the world and in society, and the nature of scientific truth. Not only traditional religious values must be re-examined, but also what might be called liberal views about society. It is obvious that not all men are born equal and it is by no means clear that all races are equally gifted.

While the magazine states that the speaker "made it clear that he was not advocating them as such, but was merely concerned to indicate the kind of ways in which society may be forced to reconsider conventional ethics," the speaker clearly feels that his suggestions are among the acceptable alternatives to "conventional ethics."

Who might the speaker be? What is he advocating?

First, he believes that ethics are completely relative. We can redefine life and death. Life begins at two days if we say that it does. Life ends at 80 or 85 if we say that it does. It is not murder to kill someone, so long as we have redefined him or her as no longer human.

His suggestions are also clearly racist. In fact, his theoretical approach rejects many of the common beliefs that modern Western society have accepted as core values. Interestingly, he also wisely recognizes that the impediment to instituting his plan is religious education, a force that traditionally advocates for morality. He frames his battle well, as Judaism in particular has always been a voice for morality even in a world gone mad. One of Adolf Hitler's accusations against the Jews was that they corrupted society by introducing the concept of conscience.2

The ideas of the speaker may resemble those of Adolf Hitler or David Duke, but the speaker is neither of them. If the speaker were an avowed racist, part of a fringe movement, we could more easily dismiss him. While this passage may sound like a quote from Mein Kampf, it is really a quote from the November 2, 1968 issue of "Nature," the prestigious science periodical.3

Why was there no outcry from the scientific world? Because the speaker was also a Nobel laureate.

Why was there no outcry from the scientific world? Even if the speaker himself did not necessarily advocate these views, why was there no outcry that such ideas should even be considered in an ethical society?

Because the speaker, while clearly espousing immoral and racist ideas, was also a Nobel laureate. Who was he? Francis Crick, the English scientist who shared the 1962 Nobel Prize in medicine and physiology for establishing the function and double helix structure of DNA, the key substance in the transmission of hereditary characteristics. The aura of the messenger's scientific credentials blinds us to the insidious nature of the message. So much for scientific credentials bestowing moral rectitude!

What drives Dr. Crick to advocate such a horrendous model for the future? Before answering, let us examine another quote, from Dr. Michael Thaler's article,4 "The Art and Science of Killing Children and Other Undesirable Beings," published in the journal, California Pediatrician, Fall 1992:

Physicians in Hitler's Reich participated in programs designed by other physicians to kill their chronically ill patients, to destroy infants with inherited disorders and congenital malformations and to sterilize thousands of victims against their will. By the time the Third Reich lay in ruins, German doctors had sterilized at least 460,000 men and women diagnosed as unfit or disturbed . . . dispatched 250,000 to 300,000 chronically ill patients by means of starvation, gas inhalation, prolonged sedation and toxic injections; gassed and cremated more than 10,000 infants and children with disorders ranging from congenital heart disease to epilepsy." In his book, Hitler's Doctors, Kater has shown that nearly 50% of all German physicians were active in the Nazi party by 1939. The true extent of their commitment to Nazi doctrine is seen particularly clearly in the context of German society at large: by 1937, more than 7% of all German doctors had been inducted into the SS, a rate 14 times above that of the general population.4

It is important to understand that this passage is dealing with German physicians killing their own Aryan countrymen. The eugenics program of the German medical community, dating back to the 19th century, formed the underpinning of its assault on its own people, and was the forerunner to the much greater Holocaust that followed. The Nazi Party merely borrowed the philosophy of the physicians and used their own totalitarian tactics to carry them to their logical conclusion. How could physicians have been so willing to participate in the killing of their own neighbors, not to mention their participation in the Holocaust?

It is because they were willing to subvert the rights of the individual to the needs of the state. The needs of the Reich were made paramount, with all individuals deriving value only with respect to their contribution to society. The continued support of those who provided no benefit to the Fatherland, or even worse those who were a "drain on society," could not be justified from an "ethical" standpoint. Is this not a familiar theme in the world today? (See "Should Terri Schiavo live or die?")

One may object that the events in Nazi Germany were an aberration, not indicative of anything. But were they?

In 1924, Adolf Hitler wrote the first volume of his manifesto, Mein Kampf, clearly laying out his world view, a view that only had room for the master race. In 1927, ten years prior to Hitler's election as chancellor, and almost 15 years before the formulation of the Final Solution, the following words were penned in the United States:

We have seen more than once that the public welfare may call upon the best citizens for their lives. It would be strange if it could not call upon those who already sap the strength of the state for these lesser sacrifices . . . It is better for the world, if instead of waiting to execute degenerate offspring for crime, or let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind. The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes. Three generations of imbeciles are enough.

Like the quote from Dr. Crick, this quote closely mirrors Nazi doctrine. Just as Hitler claimed that the Jews and other undesirables at home in Germany had sapped the strength of the great Aryan army and caused their defeat in WWI, this author claimed that "degenerate offspring" were sapping the strength of the United States. But the author is not a Nazi. The author is not a totalitarian dictator. The author is Oliver Wendell Holmes, Jr., associate justice of the United States Supreme Court, from his majority opinion in the 1927 case of Buck versus Bell.5 This United States Supreme Court decision was based on the testimony of medical professionals. Mr. Holmes' opinion was not an aberration, but reflected the mainstream view of eugenics in the early 20th century.

The noted evolutionary biologist, Stephen J. Gould, researched this unbelievable case and discovered a terrible tale.6 A perfectly normal girl was involuntarily sterilized merely because she became an unwed mother after being abused. To guarantee that the court would uphold the right of the state to involuntarily sterilize those citizens whom it found unfit, doctors and nurses were utilized to create false documentation of retardation in the baby, the baby's mother, and the baby's grandmother.

Mr. Holmes opened his Supreme Court decision with the words: "Carrie Buck is a feeble-minded white woman who was committed to the State Colony… She is the daughter of a feeble-minded mother in the same institution, and the mother of an illegitimate feeble-minded child."

Hence, at the end of the opinion we arrive at the famous statement of one of our greatest jurists: "Three generations of imbeciles are enough."

It would be a grave error to assume that the medical professionals who testified in that landmark court case were just "bad apples." The United States, and the medical profession in particular, had a long history of extensive involvement in eugenics programs. In fact, eugenics was widely practiced in the United States prior to WWII. Eugenics, as a concept, was very popular until the Nazis just carried it "too far" and gave it a "bad name."

To understand the full depth of depravity of the United States eugenics movement (a movement equally embraced by other "civilized" nations), you need only contemplate the following model sterilization bill, written by Harry Laughlin, superintendent of the United States Eugenics Office in 1922,7 and used as the basis for most of the more than 30 states that passed eugenics bills by the 1930's.

"….to prevent the procreation of persons socially inadequate from defective inheritance, by authorizing and providing for eugenical sterilization of certain potential parents carrying degenerate hereditary qualities."

What were the "degenerate hereditary qualities" for which the US Eugenics Office recommended involuntary sterilization? Mr. Laughlin's proposed list included the "blind, including those with seriously impaired vision; deaf, including those with seriously impaired hearing; and dependent, including orphans, ne'er-do-wells, the homeless, tramps, and paupers." While most states did not go as far as Mr. Laughlin suggested, as Dr. Gould describes in his article, by 1935, approximately 20,000 forced "eugenic" sterilizations had been performed in the United States, nearly half in California.

Unfortunately, while America only sterilized tens of thousands of people, the Nazis, led by the medical profession who developed and supported the Nazi eugenics program, carried out Mr. Laughlin's program with a vengeance, sterilizing hundreds of thousands of people, most for "congenital feeble-mindedness" and nearly 4,000 merely for blindness and deafness.

One of the most egregious examples of the mentality that leads otherwise normal people to create laws permitting involuntary sterilization and eugenics can be seen from the United States Public Health Service Tuskegee Syphilis Experiment, which began in the 1930's. As James Jones describes in his book Bad Blood,⁸ poor, uneducated Black men were observed to see the effects of untreated tertiary syphilis and were barred from receiving treatment even after penicillin was discovered to be efficacious for curing syphilis. The so-called experiment ran until 1972, with multiple articles published along the way presenting the findings in prestigious medical journals. The damage that this one experiment has caused with respect to erosion of faith in the medical profession within the Black community cannot be measured. ⁹

So much for the medical profession policing itself.

What is the common thread in all of the historical cases that I have described? What shared philosophy binds Francis Crick's lecture, Nazi Germany's physicians, Oliver Wendell Holmes' Supreme Court decision, American eugenics programs, and the infamous Tuskegee Syphilis experiment?

The responsible parties were all individuals dedicated to helping mankind. The common denominator was the belief that caring for society takes precedence over caring for the individual. In every case, society became the patient and the individual became unimportant. It is exactly the desire to help mankind at the expense of each man that leads to moral bankruptcy.

It is for this reason that ethics must be taught to medical students and doctors, that hospitals need institutional review boards and ethics committees. When the medical profession strays from its mandate to protect health and life and enters into the realm of social policy, it risks aligning itself with immoral forces that may pervert it beyond recognition.

However, various ethical perspectives vie for acceptance in our society. This is why the Jewish approach to medical ethics is so important. We have a great deal to contribute to the societal debate.

In my next article, I will explain the structure of the Jewish approach to medical ethics, how it differs from the secular approach, and how it might prevent such abuses as I have described above.

Notes

1. The Milgram experiment was a scientific experiment of social psychology performed by Yale University psychologist Stanley Milgram which was intended to measure the willingness of a subject to obey and authority who instructs the subject to do something that may conflict with the subject's personal conscience. Dr. Milgram demonstrated that average people would perform sadistic acts to innocent people if they were instructed to do so by someone in a "white coat." See Milgram, S. (1974), Obedience to Authority; An Experimental View.

2. "Conscience is a Jewish invention. It is a blemish, like circumcision.... There is no such thing as truth, either in the moral or in the scientific sense. The new man would be the antithesis of the Jew." Herman Rauschning, Hitler Speaks, p. 220

3. Nature, November 2, 1968

4. Thaler, Michael "The Art and Science of Killing Children and Other Undesirable Beings," California Pediatrician, Fall 1992

5. BUCK v. BELL, 274 U.S. 200 (1927)

6. Gould, Stephen J., The Flamingo's Smile: Reflections on Natural History, W.W. Norton & Company, Chapter 20: Carrie Buck's Daughter.

7. See "Eugenic Sterilization Laws" by Paul Lombardo, University of Virginia.

8. Jones, James, Bad Blood: the Tuskegee Syphilis Experiment, New York Free Press, 1993

9. see Giselle Corbie-Smith, et. al, "Distrust, Race, and Research," Archives of Internal Medicine. 2002;162:2458-2463. The authors investigated the issue of distrust of research and the medical community which impedes successful recruitment of African Americans into clinical research. They examined possible differences in distrust by race and wanted to determine to what extent other socio-demographic factors explain any racial differences in distrust. They found that African American respondents were more likely than white respondents not to trust that their physicians would fully explain research participation and to state that they believed their physicians exposed them to unnecessary risks. After controlling for other socio-demographic variables, race remained strongly associated with a higher distrust score. They concluded that "even after controlling for markers of social class, African Americans were less trusting than white Americans. Racial differences in distrust have important implications for investigators as they engage African Americans in research."