Saturday, 24 November 2012

From Healthcare to Holocaust

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It all started modestly enough. Hoping to stem the rising tide of socialism in the late 19th century, German Chancellor Otto von Bismarck decided to institute a welfare state, the theory being that finding a middle ground between laissez-faire capitalism and full-blown socialism would blunt the popularity of the latter without unduly interfering with the former. Bismarck convinced the Reichstag to create four programs: accident insurance, old-age pensions, disability insurance, and compulsory health insurance.

The health insurance bill, passed in 1883, provided for cash payments to those temporarily unable to work because of illness and in-kind benefits for their medical treatment. Employers paid one-third of the cost of the program; employees paid the rest. According to Wikipedia, “The program was considered the least important [of the four] from Bismarck’s point of view.” But as we shall see, it had perhaps the most pernicious effects of all.

Darwinism in Theory and Practice

Around the same time as socialism was on the ascent, so was another controversial idea: the pseudoscience of eugenics. Charles Darwin’s theory of evolution, introduced in 1859, posited that creatures with survival advantages would pass those advantages on to the next generation, thereby creating stronger and better versions of their kinds. While Darwin was loath to follow his theory to its logical conclusion — that selective breeding of “superior” humans and prevention of that of “inferior” ones would aid natural selection in producing a “master race” — others were not. Indeed, by seemingly obviating the need for a creator and ultimate lawgiver, Darwin’s theory freed those desiring to artificially accelerate the process of human evolution from the moral constraints that might otherwise have stood in their way.

Throughout the world, but especially in the West, where it was presented as “scientific” and “progressive,” eugenics quickly took hold. Governments began passing laws designed to prevent allegedly inferior humans from reproducing. Persons deemed mentally unfit were prohibited from marrying, as were mixed-race couples. Worse still, individuals were sterilized against their will. America, to its great shame, was in many ways the vanguard of the movement: 31 states passed compulsory sterilization laws in the early 1900s; over 62,000 individuals were sterilized before these practices ended in the 1970s.

In Germany, of course, the idea of building a master race captured the imagination of a young painter who, at the age of 43, would ascend to the same post formerly held by Bismarck. And what the Iron Chancellor had created to prevent the socialists from coming to power would be used by National Socialist dictator Adolf Hitler to exterminate a vast swath of humanity.

From Patients’ Partners to Hitler’s Handmaidens

Like most government programs, Bismarck’s compulsory health insurance program started out small, covering only a portion of the German workforce and primarily giving them sick pay; and, like most government programs, it grew rapidly, covering more and more individuals and changing its focus from sick pay to in-kind benefits. Naturally, whoever is paying the piper calls the tune, and so “by the time of Weimar, German doctors had become accustomed to cooperating with the government in the provision of medical care,” Dr. Marc S. Micozzi wrote in a 1993 article for the Freeman. Micozzi continued:

The reforms of the Weimar Republic following the medical crises of World War I included government policies to provide health care services to all citizens. Socially minded physicians placed great hope in a new health care system, calling for a single state agency to overcome fragmentation and the lack of influence of individual practitioners and local services. The focus of medicine shifted from private practice to public health and from treating disease to preventable health care....

Medical concerns which had largely been in the private domain in the nineteenth century increasingly became a concern of the state. The physician began to be transformed into a functionary of state-initiated laws and policies. Doctors slowly began to see themselves as more responsible for the public health of the nation than for the individual health of the patient.

While this led, at least for a short time, to improved public health, “in connection with these reforms the doctor’s role changed from that of advocate, adviser, and partner of the patient to a partner of the state,” Micozzi explained. “Where traditional individual ethics and Christian charity had once stood, the reformers posited a collective ethic for the benefit of the general population.”

As present events demonstrate, welfare states, feeding off the productivity of the private sector, do not fare well during bad economic times; and so when depression struck, “health care became primarily a question of cost-benefit analysis,” observed Micozzi. “Under the socialist policies of the period, this analysis was necessarily applied to the selection of strong persons, deemed worthy of support, and the elimination of weak and ‘unproductive’ people.” Thus, “by the time the National Socialist Party came to power in Germany, the mentally ill and the mentally retarded had begun to be sterilized and to be subjected to euthanasia in large numbers in German government institutions.”

The Nazis built upon this existing philosophy and practice. “An influential manual by Rudolf Ramm of the medical faculty of the University of Berlin proposed that each doctor was to be no longer merely a caretaker of the sick but was to become a ‘cultivator of the genes,’ a ‘physician to the Volk [German people],’ and a ‘biological soldier,’” Robert Jay Lifton wrote in The Nazi Doctors: Medical Killing and the Psychology of Genocide.

Ramm … discussed the virtues of sterilization and labeled “erroneous” the widespread belief that a doctor should under no circumstances take a patient’s life, since for the incurably sick and insane, “euthanasia” was the most “merciful treatment” and “an obligation to the Volk.” That obligation was always central. The physician was to be concerned with the health of the Volk even more than with individual disease and was to teach them to overcome the old individualistic principle of “the right to one’s own body” and to embrace instead the “duty to be healthy.”

Although many doctors were more than willing to accept these notions — six percent of them had already joined the National Socialist Physicians’ League by 1933, and eventually almost half would sign on — some still held to the idea that everyone, even the weak and dying, was deserving of medical treatment. According to Lifton, the Nazis soon found a way to overcome these objections:

They mounted a consistent attack upon what they viewed as exaggerated Christian compassion for the weak individual instead of tending to the health of the group, of the Volk. This partly Nietzschean position, as articulated by Ramm, included a rejection of the Christian principle of caritas or charity, and of the Church’s “commandment to attend to the incurably ill person and render him medical aid unto his death.” … The matter was put strongly by Dr. Arthur Guett, a high-ranking health official, who declared that “the ill-conceived ‘love of thy neighbor’ has to disappear.... It is the supreme duty of the … state to grant life and livelihood only to the healthy and hereditarily sound portion of the population in order to secure … a hereditarily sound and racially pure folk [Volk] for all eternity.” He added the visionary-idealistic principle that “the life of the individual has meaning only in the light of that ultimate aim.” The doctor, like everyone else in Nazi Germany, was expected to become “hardened,” to adopt what Hitler himself called the “ice-cold logic” of the necessary.

The Un-birth of a Nation

One of the first laws passed under the Nazi regime was the 1933 Law for the Prevention of Genetically Diseased Offspring. Originally drafted during the Weimar Republic — again demonstrating the essential continuity between Weimar and Nazi public-health policy — the law called for the sterilization of any “hereditarily diseased” person, with that phrase defined as anyone suffering from mental retardation, schizophrenia, manic depression, hereditary epilepsy, Huntington’s disease, hereditary blindness or deafness, “any severe hereditary deformity,” or even alcoholism.

The law created numerous “Genetic Health Courts” to decide who would be sterilized. Each was composed of three men — two physicians and a judge — at least two of whom were closely tied to the Nazi Party. “All physicians,” penned Lifton, “were legally required to report to health officers anyone they encountered in their practice or elsewhere who fell into any of the preceding categories for sterilization, and also to give testimony on such matters unrestricted by the principle of patient-doctor confidentiality.” Doctors prosecuted the candidates for sterilization and performed the surgeries on those found unfit to reproduce. Not surprisingly, over 90 percent of those brought before the courts were sterilized, and the sham appeals courts overturned less than five percent of appealed decisions.

As broad as the law’s original definition of “hereditarily diseased” was, it was inevitable that it would be stretched even further than its Weimar-era authors could have imagined. After all, just about anything could be classified as mental retardation, or “feeblemindedness.” And woe betide the doctor whose patient bore an imperfect child; better to sterilize too many individuals than too few. Moreover, noted Lifton:

Inevitably, too, political considerations affected diagnoses and decisions — as was made clear by a directive from Martin Bormann, Hitler’s private secretary and close associate, instructing that the moral and political behavior of a person be considered in making a diagnosis of feeblemindedness. The clear implication was that one could be quick to label “feebleminded” a person seen as hostile to the Nazis, but that one should be cautious indeed about so labeling an ideologically enthusiastic Party member.

In the end, anywhere from 300,000 to 400,000 persons were sterilized, about 5,000 of whom died as a result. For those who somehow escaped the government’s notice before conceiving, there was also the option to force them to abort their potentially unfit offspring. For those deemed fit to conceive, on the other hand, abortion was strictly forbidden, and the Genetic Health Courts could even deny their requests for voluntary sterilization. The perfection of the master race, after all, could only be advanced by increasing its numbers. Not without reason, therefore, did Lifton declare that “sterilization was the medical fulcrum of the Nazi biocracy.”

Physicians were deeply involved not only in Hitler’s forced sterilization program but also in his earliest measures aimed at preventing the commingling of “Aryan” and Jewish genes. The 1935 Nuremberg Laws prohibited marriage and sexual relations between Jews and non-Jews; later laws forced couples to undergo medical examinations to ensure they were not violating the Nuremberg Laws. “The Nuremberg laws were considered public health measures and were administered primarily by physicians, who profited financially as instruments of racist Nazi policies,” Sheldon Rubenfeld wrote in Medicine Magazine.

Sterile Logic
Leads to “Final Solution”

Despite all these attempts to prevent future generations of the “unfit,” there still remained the problem of those “unfit” persons whose births had preceded the Weimar-cum-Nazi programs. For this the Führer devised another solution — the one that ultimately became the “Final Solution.” Rubenfeld recounted:

In May of 1939, Hitler implemented the concept of “extermination of lives not worth living” when he instructed his personal physician, Karl Brandt, to appoint a committee to prepare for the secret “mercy killings” of deformed and retarded children. Jewish children were originally excluded from this program on the grounds that they did not deserve the “merciful act” of euthanasia. Doctors were required to register any child born with congenital deformities — the reporting requirement was eventually extended to cover children up to 17 years old — with local health authorities. After the reports were filed, physicians on the Committee for the Scientific Treatment of Severe, Genetically Determined Illness sorted the infants and children for possible “selection,” a euphemism for death by medical means.

The killings occurred in 28 institutions, including some of Germany’s most prestigious hospitals, administered by pediatricians and medical authorities. The head of the euthanasia program of Brandenburg Hospital emphasized that only physicians should perform euthanasia, saying, “The needle belongs in the hand of the doctor.” Children were killed by a variety of methods, including morphine injections and gassing with cyanide or chemical warfare agents. Some institutions starved the infants and children to death so that they died of “natural causes.”
… More than 5,000 children were killed in the child euthanasia program.

Then came the “T4” program (named for the address of Hitler’s Chancellery, Tiergarten 4), which demanded the “mercy killing” of those deemed incurable. Physicians again made the determination as to who lived and who died, primarily on the basis of a questionnaire. Having decided who would die, physicians proceeded to kill them with poison injections or gas chambers; then they falsified the death certificates. The program was terminated in August 1941, by which time doctors had put to death some 70,000 adults.

Even after T4 had officially ended, Rubenfeld explained, “doctors were encouraged, if not directed by the regime, to act on their own initiative to exterminate ‘lives not worth living.’ The killings continued until, and in some cases even beyond, the demise of the Nazi regime.”

Meanwhile, gas chambers began to be used in concentration camps, where they were used to murder all those unwilling or unable to work — and, of course, anyone even suspected of being Jewish.

The first commandant of Ausch­witz, Rudolf Höss, noted in his autobiography the first large-scale use of a gas chamber in his camp, where 900 Russians were killed:

The Russians were ordered to undress in an anteroom; they then quietly entered the mortuary, for they had been told they were to be deloused. The whole transport exactly filled the mortuary to capacity. The doors were sealed and the gas shaken down through holes in the roof. I do not know how long this killing took. For a little while a humming sound could be heard. When the powder was thrown in, there were cries of “Gas!” then a great bellowing and the trapped prisoners hurled themselves against both doors. But the doors held. They were opened several hours later, so that the place might be aired. It was then that I saw, for the first time, gassed bodies in the mass.... I must even admit that this gassing calmed me, for the mass extermination of the Jews had to start soon, and at that time neither Eichmann nor I had any idea how these killings were to be carried out in the expected mass.... Now we had discovered the gas and also the method.

Shortly thereafter, according to the book Auschwitz Chronicle, which provides a log of daily happenings in the camp, based on official records and the eyewitness testimony of thousands of individuals, Jews were killed en masse. When a transport of Jewish prisoners — often containing in excess of a thousand men, women, and children — entered the camp, after “selection,” fewer than one-third were still left alive to be tattooed with an identification number. (Even entry to the camp didn’t mean safety; most prisoners at Auschwitz would be dead from disease, malnutrition, overwork, or brutality within six months of their arrival.)

In the main, doctors selected which prisoners would be sent to the gas chambers immediately and which would first be worked until they were near death or used for medical experiments that often ended in death.

The most infamous of these doctors was Auschwitz’s Josef Mengele, who more than earned the appellation “the Angel of Death” for his flamboyant prisoner selection method and the grisly experiments he performed on his chosen prisoners, including children and pregnant women.

In the end, up to 17 million people, as many as six million of them Jews, perished at the hands of the Nazis and the physicians who assisted them every step of the way — most of them quite willingly. “No profession in Germany became so numerically attached to National Socialism in both its leadership and membership as was the medical profession,” noted Micozzi. Doctors, having been transformed into agents of the state by Bismarck’s health insurance program, put the state’s interests before those of their patients: Anyone seen as a burden on the state because of existing or potential health problems was marked for death. All this took place under the rubric of science as physicians tried to goose the process of human evolution.

The Lethal Elixir of
State Healthcare and the Culture of Death

In the 67 years since the destruction of the Nazi regime, few doctors in the free world have allowed themselves to be put in the service of such a monstrous cause. During that same period, Western governments have assumed an increasing role in the medical systems of their countries, from the single-payer approach of Great Britain and Canada to the heavily regulated public-private approach of the United States. Meanwhile, the culture of death has metastasized, and its proponents have grown ever bolder.

Abortion-on-demand has been legal in much of the West for dec­ades. In the United States alone, it has prevented well over 50 million people from ever seeing the light of day. Medical ethicists have argued that this is acceptable because unborn children are nonpersons who therefore have no right to life. Some have even extended this reasoning to newborns.

Princeton University bioethics professor Peter Singer has stated that since infants lack “rationality, autonomy, and self-consciousness,” “killing a newborn baby is never equivalent to killing a person, that is, a being who wants to go on living.”

Earlier this year Francesca Minerva of the University of Melbourne and Alberto Giubilini of the University of Milan published a paper called “After-birth abortion: why should the baby live?” in the Journal of Medical Ethics. “Merely being human,” they averred, “is not in itself a reason for ascribing someone a right to life.” In order to be considered deserving of life, they claimed, a person must be able to attribute value to his own existence. Since neither pre-born nor newly born infants possess this ability, they are by definition fair game for extermination, the professors concluded.

Furthermore, they argued that babies born with conditions requiring expensive, long-term care, such as Down syndrome, ought to be first in line for death by doctor. “Such children might be an unbearable burden on the family and on society as a whole, when the state economically provides for their care.”

This argument was all too familiar to Germans under the Third Reich. One Nazi propaganda poster, for example, featured a kindly looking physician supporting a man with physical deformities. “60000 RM [Reichsmark]” it screamed. “This is what this person suffering from hereditary defects costs the community of Germans during his lifetime. Fellow citizen, that is your money, too.” The implication was clear: The man depicted in the poster should be put to death for the good of both the nation and the individual taxpayer. In fact, he should never have been allowed to enter the world in the first place.

While those in charge of state-run or state-subsidized healthcare today are not generally as blunt in their explanations of why certain patients must be denied care, their thought processes are similar to those of the National Socialists. Caring for individuals with chronic conditions can cost vast sums of money — money that the state simply doesn’t have. Thus, these individuals must be sacrificed for the greater good of keeping socialized medicine afloat.

Of course, such sacrifices are often couched in the language of compassion. Hitler called his euthanasia program “mercy killing.” In 2012 Great Britain, it’s called the Liverpool Care Pathway (LCP). Originally created to help cancer sufferers during their last days, the LCP, which withholds lifesaving care from heavily sedated patients, has been expanded well beyond its inventors’ intentions. According to British neurologist Dr. Patrick Pullicino, today 130,000 National Health Service (NHS) patients, many of whom are far from death, are shown to an early grave each year via the LCP; 29 percent of all deaths under NHS care can be attributed to euthanasia.

Likewise, the Netherlands, with its ObamaCare-style short-term care and Bismarck-style long-term care systems, has some of the most liberal abortion and euthanasia laws on the planet, including one allowing physicians to euthanize “suffering” infants with their parents’ consent. By contrast, in 1944, when the state had relatively little involvement in healthcare, every single Dutch doctor refused to comply with Nazi orders to treat his patients as German doctors were then treating theirs, even under pain of being shipped off to a concentration camp, as 100 Dutch physicians were.

“Politicized medicine is not a sufficient cause of the mass extermination of human beings,” argued Micozzi, “but it seems to be a necessary cause.”

Given the 21st century’s combination of government-controlled medicine, with its inevitable rationing, and the culture of death, with its convenient rationalizations for denying care to the most vulnerable, might that sufficient cause be on the horizon?

Photo: Children with "hereditary defects" such as Down syndrome were among the first victims of the Nazi euthanasia program, which killed those deemed "unworthy of life."

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