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The Nazi analogy on bioethics.

The Analogy in Bioethnics

Commentary by

Nat Hentoff

The Nazi Analogy in Bioethics

To say that certain contemporary bioethicists and members of the laity sometimes approach the solving of life-or-death problems as the Nazis did in no way means they are Nazis. It is possible, however, with the very best of intentions, to think and plan in a way that would bring about results that were also the goals of the Nazis--from different motivations.

For instance, beginning in 1933, the Germans began killing "defectives" of various kinds, in part because they were unproductive ("useless eaters") and therefore were costly to the society. The pragmatic, cost-benefit dimension to the murders was illustrated in the widely used high school mathematics text cited by Dr. Leo Alexander. The text, Mathematics in the Service of National Political Education, included such problems, Alexander noted, as "how many new housing units could be built and how many marriage-allowance loans could be given to newly wedded couples for the amount of money it cost the state to care for the 'crippled, the criminal and insane,'" ("Medical Science Under Dictatorship," New England Journal of Medicine, July 14, 1949).

Daniel Callahan readily admits that he wrote Setting Limits because of the acute and inexorably increasing problem of medical care costs, particularly with regard to the elderly. He does not advocate euthanasia for people past a certain age; but by having the state--through Medicare--refuse to pay for certain expensive life-extending procedures such as coronary bypass operations once that age has been reached, the result of his design is to shorten lives. For all that he talks about alleviating their pain and suffering and getting the society to provide them with decent home care or nursing home care, he is saying that the lives of the elderly are worth less--in terms of prolonging them--than other lives.

This is a variation, as I see it, of the Nazis' lebensunwertes Leben, "life unworthy of life" In this case, life unworthy of being extended, according to cost-benefit analysis, by procedures he believes ought to be more available to others in the society.

When Callahan is asked whether there is not a certain injustice in sorting out people by age as to whether they can get certain treatment--not counting the elderly who can afford whatever they want and do not depend on the government to stay alive--he admits there is an unfair economic bias to his plan. But, he adds, the resulting "injustice would not be for a very long time." A very long time by whose measure?

The comment, and cost-benefit designs for dying by others, recall something said by Milton Himmelfarb:

[I]s there not an argument that could be made...about a general coarsening of regard for life? There exists ... a certain kind of accountant's mentality or an engineer's mentality in dealing with the questions of life.... While it has nothing to do necessarily with the specifics of Nazism, yet the Nazis too did not have the bias of awe toward life and dealt with life (certain kinds of life at any rate) as if they were dealing with mere things ("Biomedical Ethics and the Shadow of Nazism," Hastings Center Report, August 1976, Special Supplement).

In the Spring 1988 Concern for Dying newsletter, Dr. Ronald Cranford (Neurology Department, Hennepin County Medical Center, Minneapolis) is quoted as proposing that in the future, some instances of artificially shortening life--a most gentle euphemism--be exempted from charges of homicide. If someone, he adds, were in an irreversible persistent vegetative state, there is no "personhood." Without personhood, there could be no act of murder.

Aside from whether physicians are invariably correct in their diagnoses of "irreversibility," Cranford has gotten to the basic question in the similarities, if any, between some current physicians and ethicists and the Nazi doctors. Rosemary Anton puts it quite clearly in the March 18, 1988 National Catholic Reporter.

Fundamental to most bioethical problems are the questions: What does it mean to be a human being? Whom shall we admit into human society on an equal basis with ourselves, protected by the same rights, entitled to the same opportunities?

And who shall decide these irreversible matters? Will the decisions be subject to independent due process procedures?

Should someone in a persistent vegetative state be killed because a "person" is no longer there? The Nazis had no compunction about that solution. In this country, more and more bioethicists, and an increasing number of state courts, agree that it is permissible to end the feeding and hydration of permanently unconscious people. Is that not murder? Or is it okay because "personhood" has presumably disappeared?

The Hastings Center's 1987 Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying say that in certain circumstances, nutrition and hydration can be "discontinued." (An accountant's or an engineer's way of saying "cut off" or "denied.")

German physicians who went along because of their peers--rather than out of intoxicating ideology--found that they were soon on the very definition of a slippery slope. And in dissenting from the food-and-water section and other parts of the Hastings' Guidelines, Leslie Steven Rothenberg warned of other slopes, American slopes:

I fear these Guidelines, if widely endorsed, may be used to give a moral "imprimatur" to undertreating or failing to treat persons with disabilities, unconscious persons for whom accurate prognoses are not yet obtainable, elderly patients with severe dementia, and others whose treatment is not believed (to use the language [of another part of the report]) "costworthy."

No Nazis participated in that Hastings project, but the majority, overwhelmingly, decided that patients with certain conditions no longer had lives worth living and for their benefit--as well as that of our caring society--should leave us. If the Hastings Guidelines had been available at the time and I had been a defense attorney for the Nazi doctors at Nuremberg, I would have welcomed them.

With what has become nearly a rush to endorse the removal of nutrition and hydration for certain patients, the opposition of organizations of the handicapped--the Association for Retarded Citizens, the Association for Persons with Severe Handicaps, and the United Handicapped Federation--has been largely ignored.

What could they possibly fear anyway? The compassionate elimination of the handicapped for the good of the rest of society can't happen here.

Commentary by

Daniel Callahan

Nat Hentoff has had a distinguished career as a civil libertarian and defender of the freedom of speech under the First Amendment to the Constitution. As he well knows, that freedom allows a wide range of invective and innuendo as a part of public debate. Its victims have no recourse to the courts, only to the forum of public opinion. That is as it should be. But articles of the kind Hentoff has written raise some serious questions about how we as a people are going to discuss the increasingly hard issues of life and death, rationing and allocation, in a way that does honor to no less valuable traditions of civility. I hope we do not go too far in the rhetorical direction Hentoff is pioneering.

What way should we go? It is necessary and appropriate for those of us who write the kinds of things that offend Hentoff to consider the possibility he is right. Our sense of personal hurt should not keep us from that self-examination. The problem, of course, is that it is hard for someone like myself to know whether, in his words, my writings will end with "results that were also the goals of the Nazis." If so, I would surely be sorry, but I simply do not know how to predict that in advance or guard against it. It would strike me as more helpful in this respect (as a recent consumer of a great deal of invective) to be shown where my arguments have gone wrong, what some alternative possibilities are, and how my critics and I could work toward some reconciliation. That is the spirit I think we are going to need in the years ahead. The issues are hard, and they are hazardous, and no one side in these debates has a monopoly in the running of dangers.

The argument of my book Setting Limits is that the combination of steady medical progress and the growing number of elderly should force us to think health care to the elderly. It is a book primarily addressed to those (like myself) who are not yet old, and it asks that we be willing to restrain our health demands upon each other, and younger are groups, when we become old. The threefold premise of the book is that the present bias of Medicare in the direction of acute care medicine should be replaced by an emphasis on the daily needs of the elderly and on good long-term and home care; that we should be prepared to see a limit set on our entitlement to life-extending high technology medical care; and that we should do so not because the elderly are burdensome or unproductive (irrelevant to my argument), but because we need to devise a just health care system that is fair to all age groups. This is not a cost-benefit argument and it has nothing to do with the idea of a "life unworthy of life." The real target of my book is not the elderly, but the idea that we can afford constant and expensive medial progress for the elderly, and do so without hurting other age groups or other social needs. The desire for constant progress is the real issue. I do not think that possible, at least in the long run, and that is why "setting limits" becomes necessary. Only in America, the land of unbounded desire, could the idea of setting limits to what is now an open-ended entitlement program shared by no other age group be seen as proto-Nazism.

The Hastings Center's Guidelines on the Termination of Treatment would not have made, I am afraid, an ideal defense document for the Nazi doctors at Nuremberg. The Guidelines stress four fundamental values: the wellbeing of patients, the right of patient self-determination, the integrity of health care professionals, and justice. They specifically say that medicine should "refuse to abandon patients and hasten death to save money." It is perfectly true the Guidelines permit, under some circumstances, the cessation of artificially provided nutrition and hydration. Well before the courts sanctioned such termination, it was imbedded in some conservative religious traditions as a form of "extraordinary care," which could be stopped when judged burdensome or useless for patients. Perhaps it is unwise to terminate such forms of care, but to call it "murder" is not a helpful description of the reasoning or motive behind support of that possibility.

Commentary by

Gary E. Crum

In bioethical policy debates one party sometimes charges that his or her opponents are embracing a Nazi-like position. The opponent usually audibly groans in disbelief that such an inflammatory accusation would be used in serious debate. Meanwhile, sympathizers nod in agreement with the charge, seeing it as the ultimate blow to their opponents.

The problem with using the Nazi analogy in public policy debates is that in the Western world there is a form of anti-Nazi "bigotry" that sees Nazis as almost mythically evil beings. Nazis are monstrous figures in our literature and history books and we have come to view them with such a pure prejudice that we are incapable of discerning the socioethical pathways that could lead us to adopt the same erroneous public policies ourselves.

I believe we should strive to see Nazis as individual persons such as ourselves; persons whose rationales and actions were sometimes despicable, but not always so. We should make an effort to stop using the experience of Nazism as a metaphor for "The Cosmic Evil" and instead try to read it like a warning label on a bottle under our own kitchen sinks.

Closely related to our unfortunate tendency to draw Nazi analogies in mythological terms is our habit of drawing them on too broad a scale. Firsthand knowledge of our own culture makes it virtually impossible to equate Nazi society with our own. The official racism of Germany, its military mentality, the stresses of war, and the presence of a dictator instead of a democratic system make Nazi Germany in the 1940s obviously different in ethically important ways from America in the 1980s. Like the myth of the Nazi as the personification of evil, a macrocultural analysis distorts our view of the many lessons to be learned; on one hand we experience the blindness of sensory deprivation and on the other that of sensory overload.

Given these qualifications, how can the Nazi analogy best be used? Certainly we must reduce our analysis to reasonable dimensions, and we must be willing to study the Nazi experience with unbiased methods. An instructive approach is to analyze specific policies and/or specific policymakers within the Third Reich. The Nazis were famous for recording chains of command, policies, procedures, histories, and biographies so that even after the chaos of war much remains to document these specifics.

As an obvious example, Germany's failures can be analyzed on an understandable scale in the case of the Nazi policy to use prisoners for involuntary and often fatal human experimentation. The lessons learned from that policy helped the Western world to develop formal safeguards for human subjects research in the form of the Nuremberg Code. Human experiments can be tested against the code to see if they meet basic requirements of respect for autonomy and respect for life, a test that allows more precision in comparing current policies to those of Nazi Germany.

Studying an individual Nazi policymaker can also permit us to see the errors of Nazism in human dimensions. A likely candidate is the Third Reich's chief medical officer, Dr. Karl Brandt (Gary E. Crum, "Nazi Bioethics and a Doctor's Defense," Human Life Review 8 [1982], 55-69, 123-25).

Brandt was trained as an emergency room physician and early in his career had an indelible experience with a chronically suffering patient. His compassion for the chronically ill made him anxious to help patients find what he called "a peaceful end." He became Germany's top public health administrator during the war and was placed at the head of the modern world's first national euthanasia program. On the witness stand at Nuremberg he proved to be familiar with ethical concepts and an articulate advocate both for himself and for Nazi medicine. He claimed to be unaware of the atrocities of human experimentation in death camps and maintained all the way to the gallows that it was his deep sympathy for the sick that led him to support the Nazi euthanasia program that developed new death technologies, including the first gas chambers in which tens of thousands of hospital patients were killed.

There are lessons to be learned from the life of Karl Brandt and the Nazi euthanasia program. An effective government euthanasia program can be designed and efficiently administered, which once established will tend to expand until thousands of patients annually are given "release by death," and will generate new medical research aimed at producing better and cheaper death "treatment" procedures. Such a program can effectively be tied to ethical arguments based on medical compassion even though it may have a subsidiary agenda of medical cost-containment. And finally, the most long-lasting ethical opponents of public policy euthanasia will probably be organized religion rather than organized medicine.

In looking at individual Nazis, however, it is important to differentiate between the unilateral actions of unethical persons and the actions of professional policymakers who have official rationales and sanctions for their unethical decisions, a point that Brandt himself made on the stand at Nuremberg. It is those in authority who provide the most telling ethical lessons. The individual who takes an unethical step unilaterally may be a product of an unethical national value system, but until such actions take the form of public policy it is difficult to link the unethical behavior directly to the national value system.

In summary, Nazi analogies can be effectively drawn and do have a place in contemporary debates on ethics policy. They must be drawn narrowly, however, analyzing specific policies and the rationales of specific policymakers. To say that the Nazi experience is today irrelevant is to claim we have nothing to learn from Nazi mistakes. This obviously will make it all the more likely that we will take some of the same immoral paths that they so self-confidently took less than fifty years ago.

Commentary by

Cynthia B. Cohen

The analogy of the Nazis permeates bioethics. Ironically, it is sometimes used to attack diametrically opposed positions. Those who would withdraw treatment from critically ill patients and those who would extend their lives for as long as possible are each accused of emulating the Nazis. Such haphazard use of the analogy endangers rational communication and reflective moral choice. Is the analogy apt in discussions of bioethics? My focus is on the withdrawal of disproportionately burdensome treatment, but my conclusions will have implications for the use of the analogy in other areas of bioethics. First, however, we must get clear what the Nazis did and why.

Mass murders by the Nazis began when children with congenital malformations, other physical deficits, or mental retardation were marked for "treatment"--a euphemism for killing. Soon this so-called "euthanasia" program engulfed "incurable" adults with diseases such as schizophrenia, epilepsy, syphilis, encephalitis, and Huntington's disease. Next, the handicapped, "asocial" persons, Jews, Gypsies, Poles, Catholic and Protestant dissenters, Soviet prisoners of war, patients with typhus, and the insane became victims of the "euthanasia" program. Ultimately, some 6,000,000 Jews and 4,000,000 others were murdered by the Nazis.

Physicians were responsible for the planning and supervision of these murders. They selected individuals for death, sent children and adults to the gas chambers they organized and ran, killed some with lethal injections, starved others to death, and falsified death certificates. Nurses assisted in these acts and were, in some instances, also perpetrators of killings. The role of health care professionals as state executioners was central to National Socialist ideology.

The Nazis viewed their program as a form of biomedical engineering that could only be carried out by health care professionals. Life involved an ongoing struggle against those who threatened the health and survival of the Volk, the "people"--the ultimate source and criterion of value. Hitler conceived of this Volk as a creative, primordial being, a boundless, expanding force that incorporated the Aryan racial type. It, above all others, was entitled to live and to rule the world. The survival of the Volk was threatened by mentally and physically impaired Aryans, who were a danger to the gene pool, and by those of the "lower" races, such as Jews and Gypsies, who were poisoning Aryan blood. Doctors were to serve as "alert biological soldiers" charged with healing the wounded social organism by killing all who attacked it.

An analogy will fail if its components are too dissimilar or if the moral principles by which the analogues are informed are misunderstood or confounded with each other. A major difference between the Nazi program and the position of those who would withdraw burdensome medical treatment involves their radically disparate views of the value of individual human beings. Individuals were killed by the Nazis because they were considered devoid of social worth. Their value was strictly functional--unless they could further the purposes of the Volk, they were expendable.

Proponents of the withdrawal of burdensome treatment, in contrast, consider individual human beings to be of great worth. Some see their value as connected to their distinctive power of choice and intention, their capacity for relations with others and with God, and their ability to engage in first-person reflection. Individual humans do not become "unworthy of life" when they can no longer function fully, but are owed increased care. They are entitled to fulfill their basic needs, to claim their rights, and to shape their futures. This entails that they or their surrogates be allowed to judge when the burdens of treatment outweigh its benefits, assessed in terms of their needs, values, and beliefs and the basic ethical norms of the community.

A second difference between the analogues concerns how death comes about. The Nazis deliberately murdered. Their killings had nothing to do with the literal meaning of "euthanasia" as a good death, or even with its current sense of killing the terminally ill to spare them a painful death. In contrast, when treatment is not provided to patients because it is disproportionately burdensome, physicians do not deliberately bring about their deaths. They allow them to die.

But isn't stopping treatment also a form of killing? Won't the withdrawal of a respirator cause a patient's death? Not necessarily. Two identical physical movements can exemplify different actions, depending on the larger context in which they are performed. In this context, the underlying disease that creates the patient's difficulty in breathing kills, not the physician. Were it not for medical technology, she would succumb to the disease. When use of this technology is judged severely burdensome to the patient, its withdrawal allows death to result from the disease process. The difference between this and Nazi practices is between no longer attempting to prevent death and bringing death about, which embodies an important moral distinction. Our moral responsibility for what we produce, as opposed to what we allow, is greater, even though the outcome of each may be the same. Those who withdraw disproportionately burdensome medical treatment to allow death do not kill and do no moral wrong.

The analogy fails also in relation to long-standing professional and moral ideals. Doctors and nurses who actively cooperated with the "euthanasia" program of the Third Reich were seduced by a political ideology to perform heinous acts. They transformed their very ways of moral reasoning and evaluation and betrayed their professional and moral standards. Physicians today who withdraw burdensome treatment, in contrast, continue a long professional tradition. The Hippocratic corpus requires physicians not only to alleviate the symptoms of disease and to lessen the suffering of patients, but also to refrain from treating aggressively those whose illnesses medicine cannot reverse. There is no obligation simply to prolong life. The withdrawal of burdensome treatment is also supported by the long-standing medicomoral corpus, which declares that there is no obligation to provide "extraordinary"--or disproportionately burdensome--treatment.

On balance, the Nazi practice of exterminating those they deemed "unworthy of life" is sufficiently unlike the practice of withdrawing disproportionately burdensome treatment that it is not justifiable to draw a parallel between them. Should we then abandon the analogy with the Nazis? Why do thoughtful people continue to draw it? There are respects in which we stand in danger--wittingly or unwittingly--of repeating the terrible acts of the Third Reich. We may misjudge what treatments would be disproportionately burdensome for those who cannot speak for themselves. We may impose our views of the value of life on patients who live according to different perceptions. We may allow ourselves to be pressured by forces extraneous to patient care to withdraw treatment from those for whom it would be beneficial. To avoid these moral errors, we must continue to ask ourselves whether we are stumbling toward a practice that is reminiscent of the Nazis.

Yet our use of the analogy with the Nazis must be critical. Making facile generalizations, slurring moral distinctions, and using Nazi euphemisms literally will lead to disregard for the terrible significance of the Nazi movement and trivialize the suffering of its victims. The lessons of history will be rendered meaningless if they are used indiscriminately.

Nat Hentoff is a columnist for The Village Voice and the Washington Post, and a staff writer for The Writer Yorker.

Daniel Callahan is director of The Hastings Center.

Gary E. Crum is associate professor of health services administration, The George Washington University, Washington, D.C.

Cynthia B. Cohen is a philosopher and lawwer who teaches at Villanova University and is an adjunct associate of The Hastings Center.
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Title Annotation:includes commentaries
Author:Hentoff, Nat; Callahan, Daniel; Crum, Gary E.; Cohen, Cynthia B.
Publication:The Hastings Center Report
Date:Aug 1, 1988
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