William S. Silvers
Physician, "The Skiers Nose"

Holocaust ‘Bioethics’ vs. Medical Ethics in decision-making today

How do lessons from the Holocaust influence ethical decision-making in medicine during the pandemic today?

Today’s pandemic is a crisis of a virulent virus, but not a Holocaust of man’s own making- we do have choice in how to respond individually, as a community, as a country, and as a global society.  We are not being dictated to by an authoritarian tyrant bent on genocide, but we wish not to make the mistake again of perverting science to promote an ideology.

There are many differences in how physicians and healthcare workers are approaching decision making during the COVID crisis today given the failures of the medical profession during the Holocaust. No longer are the disabled intentionally targeted for killing to lessen the burden on the rest of society. In fact, advocates for the disabled sit at the table helping to give justice to the system as lifesaving care needs to be prioritized.  This is just one striking example.

We value the physician advocating for their patient, the sanctity of the lives of all individuals. We now adhere to the four basic principles of medical ethics: personal autonomy, beneficence, non-maleficence (first “do no harm”), and justice. Treat everyone equally up front. When looking at policies,” the first thing you have to commit to is that you won’t discriminate”, says Arthur Caplan, author of When Medicine Went Mad, now Professor of Bioethics at NYU Langone School of Medicine.

We think seriously about resources available but do not resort easily to “rationing”, “racializing”, or discriminating against those with disabilities be they physical or intellectual/cognitive.  We place in context age, pre-existing chronic conditions, and debate about the weight of one’s “social worth”.  Everyone agrees that race, religion and wealth should not matter when it comes to doling out care. But what factors should matter? Should youth take priority over old age?

These were not the principles of the Nazi regime, which promoted eugenics, the Aryan master race, and the health of the state over the lives of those they devalued.  Physicians caring for patients at the bedside today are not donning white coats to make life/death decisions at the head of train tracks or at the entrance to the emergency rooms.  “That job should go to an independent group of clinicians who are blind to the patient’s race or religious background and whether they’re disabled, homeless or a major hospital donor. The people making the triage decisions should not even have access to that information,” says Dr. Matthew Wynia, Director of the University of Colorado Center for Bioethics and Humanities, who is an advisor to the Colorado Governor’s Expert Emergency Epidemic Response Committee, a team of doctors helping finalize guidelines for patient care if supplies and ICU beds become in short supply.

In catastrophic circumstances, doctors should try to save as many lives as possible. But equally important is protecting the country’s social fabric and preserving confidence in institutions, which can erode when people feel as if the lives of certain citizens are valued more than others. “We need to be able to look back and say we made those decisions in a way that maintains the trust of the community, that maintains social cohesion, and allows us to heal,” Dr. Wynia says.

Factors clinically or ethically irrelevant to the triage process (e.g. race, ethnicity, ability to pay, disability status, national origin, primary language, immigration status, sexual orientation, gender identity, HIV status, religion, veteran status, “VIP” status, or criminal history) SHOULD NOT be used to make Crisis Standards of Care triage decisions.

As Mark Levine, chair of the Lessons Learned group of the Holocaust Genocide Contemporary Bioethics Program in Colorado, elaborated in addressing how the medical profession approached the Holocaust in contrast to the present response to the COVID crisis- “both were social responses based in fear of perceived existential threat.  The response to COVID-19 is, hopefully, reasoned, inclusive across society and collaborative.  The Nazi approach was obviously quite different, being exclusionary and based in emotion and irrational ideology.”

The mistakes and shortcomings of medicine during the Holocaust are background to our decision-making in medical ethics during today’s pandemic. May we merit pursuing truth in science and humanity, always dedicated to “pikuach nefesh” (“saving a life”), the principle in Jewish law that the preservation of human life overrides virtually any other rule.

About the Author
Clinical Professor of Medicine, Allergy & Immunology, University of Colorado School of Medicine. Faculty Affiliate, CU Center for Bioethics and Humanities & founder of its “Holocaust Contemporary Bioethics Program”. Son of Holocaust survivors.
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