TEACHING
OBEDIENCE
Sarah van der Lely, FASPE
I can say that I have always done my duty and have never done anything contrary to what was expected of me.
— Eduart Wirths, Chief SS doctor at Auschwitz.
“The other day, I walked into the operation room. The patient, whom I had never met before, was already under general anesthesia and the gynecologist said, ‘Ah good, you’re here. Come do a vaginal examination to feel this massive polyp we’re about to remove.’”
This was stated by one of my fellow students during a so-called “medical ethics class.” Typically, in these classes, small groups of medical students discuss times when they had to make difficult ethical decisions. On paper, these classes should be an opportunity to talk about patient cases that were ethically challenging and to review how these cases were handled by the medical team. In reality, however, most students use the class to confess instances when they had to bear witness to something—or were told to act in a way—that they felt was unethical.
In the aforementioned case, after weighing the pros and cons of doing the vaginal examination, the students in class unanimously felt that it was morally wrong to internally examine a patient who is unconscious and who had not previously given consent.
The teacher then asked: “So, who would refuse to examine the patient?” A painful silence followed. No one raised their hand. Everyone was aware that they would rather act in a way they perceive as morally unacceptable than speak up to a supervising physician.
“There is probably no physician or medical student who has not seen or participated in callousness (or worse) in the treatment of patients in response to an order of a resident or an attending physician,” Eric J. Cassell, M.D. and professor, writes in an article about the obedience experiments of Stanley Milgram.
Multiple studies have found that up to 60% of students reported witnessing unethical treatment of a patient. Another study found that almost all of third- and fourth year medical students have witnessed physicians refer to patients in a demeaning manner. Over two thirds of students felt inclined to participate in this behavior to “fit in” and experienced feelings of guilt afterwards.
Other studies have found that the majority of students have encountered mistreatment at least once during their internships. As result, over three quarters of students have reportedly become more cynical about the medical profession and over a third have considered dropping out of medical school. Despite this discontent, mistreatment is only rarely reported to faculty due to fear of potential repercussions and the perception that mistreatment is simply part of medical culture.
To some extent, obedience is a requirement of medical training. But history shows how easily that requirement for obedience can lead educated and intelligent professionals to follow orders uncritically or to passively accept dangerous, unjust, or immoral situations.
The eugenics movement, which first arose in the late-nineteenth century, led to tens of thousands of involuntary sterilizations globally, prompted a “euthanasia” program in Nazi Germany in which “feebleminded” people—many of them children—were killed, and culminated in the murder of millions of people.
In the wake of these mass murders, society was left to question how physicians could have been so deeply involved in such a barbaric movement. It has been estimated that more than half of German physicians joined the Nazi party. Physicians had a wide range of responsibilities under the regime: they decided which patients were “unworthy of life,” carried out lethal injections and involuntary sterilizations, performed experiments on prisoners, and selected people to be murdered in the gas chambers of the extermination camps. In the years since, many theories have emerged to explain how physicians could have drifted so far from the core values of medicine—compassion, healing, and the relief of suffering—and still consider themselves doctors.
In The Nazi Doctors, psychiatrist and scholar Robert Jay Lifton attempts to explain “the
Fellowships at Auschwitz for the Study of Professional Ethics (FASPE) promotes ethical leadership for today’s professionals through annual fellowships, ethical leadership trainings, and symposia, among other means. Each year, FASPE awards 80 to 90 fellowships to graduate students and early-career professionals in six fields: Business, Clergy, Design & Technology, Journalism, Law, and Medicine. Fellowships begin with immersive, site-specific study in Germany and Poland, including at Auschwitz and other historically significant sites associated with Nazi-era professionals. While there, fellows study Nazi-era professionals’ surprisingly mundane and familiar motivations and decision-making as a reflection-based framework to apply to ethical pitfalls in their own lives. We find that the power of place translates history into the present, creating urgency in ethical reflection.
Each month one of our fellows publishes a piece in Memoria. Their work reflects FASPE’s unique approach to professional ethics and highlights the need for thoughtful ethical reflection today.
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