imagine—naked—nothing burns. How does one manage to [burn] this?”5. It seems absurd to ponder the best way to burn dead bodies instead of asking why people had to die, but this is partly how these physicians coped with the overwhelming guilt and psychological torment of participating in such heinous crimes. They evaded ethical considerations by treating them as purely technical and pragmatic concerns.
A similar phenomenon occurred among Nazi doctors who were hungry for surgical experience. In the name of mastering technical skills, they operated on prisoners suffering from their conditions of interest. Ethics aside, they felt that they had found an ideal surgical laboratory, constituting a Faustian bargain that marked their regression into automatons, ready to apply their skills to any operation regardless of its morality.
While certainly in no way equivalent to the conditions under which surgeons normally find themselves, the tendency to focus on technique alone, even at Auschwitz, can nevertheless serve as a cautionary tale.
It is a common tendency in modern surgery to focus too much on the technical aspects. Some degree of this may be inevitable for trainee doctors so that they might master certain skills. But doing so can also lead to a lack of ethical awareness, which only comes into view when the surgeon or surgeon-in-training bears in mind the greater context. Without awareness of the purpose and goals of a procedure, one cannot ascertain if a procedure is being used to heal or harm. One runs the risk of merely being a technician on autopilot. As physicians, we hold the responsibility of safeguarding our patients’ and communities’ well-being. A part of that responsibility is always ensuring a meaningful application of our skills.
Anesthesia
Patients whom I cared for in the OR were usually under strong anesthesia. I found this surprisingly comforting. Not only did it mitigate my fear of causing pain during procedures, but it also shielded me from the unnerving prospect of making a mistake that, in the case of conscious patients, would lead to increased suffering for them and shame for me. It also liberated the medical staff to discuss topics, even humorous or inappropriate ones, which were unrelated to the operation, instead of worrying about how our talk would be received by the patient. In other words, we could act as if the patient were not there at all.
Studies have noted how surgeons’ speech, behavior, and even teaching methods can drastically change when patients are under anesthesia6. In an article in the American Journal of Surgery, Claire Smith and fellow researchers, for example, have proposed surgeon-patient communication guidelines to balance patient comfort with teaching and operative efficacy7. I was not aware of how much I relied on anesthesia to shield me from the psychological stress of being around fully conscious patients until I interacted with waking patients during minimally invasive procedures. Even when it came to innocuous chores, such as washing a patient’s body, I found I experienced a substantially greater degree of empathy with awake patients and frequently felt compelled to ask them how they were doing. In contrast to working with anaesthetized patients, for example, I always made sure to use warm water to scrub their bodies so that they would not feel cold. I shaved more cautiously to avoid razor burns. Instead of joking with my coworkers, I had conversations with the patients themselves. This led me to realize that knowing that I was dealing with a human body was not enough to arouse empathy in me. Rather, my empathy seemed to vary significantly depending on the degree of patient awareness.
Anesthesia diminishes patient sensation, but, just as potently, it can reduce physician empathy. At Auschwitz, physicians found reassurance in and strongly adhered to the false belief that Zyklon-B that contained hydrogen cyanide, caused a painless death. Rudolf Höss, the commandant of Auschwitz, remarked that “[t]he doctors explained to me that the prussic acid [Zyklon-B] had a paralyzing effect on the lungs […] that was so quick and strong that death came before the convulsions could set in” and cause a terrible choking sensation8. The physicians rejected the alternative method of killing— extermination by shooting—because it would surely cause greater suffering. In retrospect, it is chilling to consider how one method of killing could be deemed more permissible simply because it caused less pain. After all, the “painless” method resulted in perhaps the most horrendous genocide in mankind’s history.
In surgery, most procedures take place when the patient is under anesthesia. Being aware of how that influences the way we practice is critical. Being aware of someone else’s pain is one of the strongest forms of empathy. It holds us accountable for our actions and challenges us to be better. While anesthesia is necessary in modern surgery, we should aim to treat the anaesthetized body as if it still could perceive sensations, because physical harm can occur even if the patient is not feeling pain. To take the extreme example of Nazi physicians’ behavior, a painless death, after all, does not change the fact that a murder has occurred.
Conclusion
I do not mean to suggest that surgery is unethical by nature. Modern surgery is undeniably a miraculous process that offers alleviation and hope to patients. Nor can I pretend to summarize in such a short paper the complex psychological shift that enabled doctors to participate in genocide under the Nazi regime. But in discussing some of the ethical pitfalls of the OR and citing some of the experiences of physician prisoners in concentration camps, I do hope to point to the importance of remembering that a procedure must reside within an ethical framework and that a simple awareness of the larger context of one’s actions is at times all that separates a life-saving act from a potentially harmful one. Developing and refining an ethical framework need not be complicated in a perioperative setting—at times, consciously acknowledging that the patient is in a vulnerable position or reminding oneself why certain acts are important in the context of patient care can imbue our work with greater meaning and positively influence those around us. These considerations ought to supplement our current perioperative ethical guidelines.
Surgeons are doers. Our hands are eager to pick up the scalpel and address the immediate surgical issue before our minds have fully processed why. True healing, however, can occur at the level of thought. We must reason out why a patient needs a particular lifesaving procedure well before our hands are red and our blades wet.
======
Jason Han was a 2016 FASPE Medicine Fellow. He is currently a cardiac surgeon at Cooper University Hospital.
=====
1 American College of Surgeons, “Statement on Principles Underlying Perioperative Responsibility,” Bulletin of the American College of Surgeons 81 (1996): 39-40.
2 Robert Jay Lifton, “The Nazi Doctors: Medical Killing and the Psychology of Genocide” (New York: Basic Books, 2000), 165.
3 Miklos Nyiszli, Auschwitz: A Doctor’s Eyewitness Account (New York: Arcade Publishing, 2011), 23.
4 Lifton, 178.
5 Lifton, 157.
6 Anonymous, “Our Family Secrets,” Annals of Internal Medicine 163 (2015): 321.
7 Claire Smith, et al., “Surgeon-Patient Communication During Awake Procedures,” American Journal of Surgery (July 29, 2016): 30369-5.
8 Lifton, 162.
22