thing as life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually, the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans. But it is important to realize that the infinitely small wedged-in lever from which this entire trend of mind received its impetus was the attitude toward the non-rehabilitable sick.18
Alexander is a cogent proponent of the slippery slope argument, but his explanation should challenge those of us who live in the world after Nuremberg not to throw out the slope altogether in fear of our sliding
uncontrollably down but rather to remember the relative ease with which commitments to “care” and to “heal” were betrayed due to a failure on the part of medical professionals to recognize and act upon their own moral agency. As one German nurse wrote, “I sensed that the killings were wrong […] I carried out the deeds as prescribed, because I viewed it as my duty, inasmuch as my superior told me to.”19 The small, incremental steps towards the commitment of atrocities, taken unwaveringly in the name of “duty” to their profession, are among the biggest reminders to me of the dangers of dogmatic, unreflective adherence to the guidelines and protocols that underpin the modern medical profession. Even principles as wholesome and routinely unquestioned as patient autonomy, informed consent, and patient-centered care can become harmful if we stop evaluating whether our actions in service to these principles are causing good or harm.
One of the key personal responsibilities impressed upon me as a new physician is the development of powers of discernment and judgment regarding aligning my actions and interventions as a medical professional with
medicine’s overarching goals. In the intensive care setting, Hippocrates’ enjoinder—to “cure sometimes, treat often, comfort always”—becomes especially salient. Through thoughtful, continuous evaluation of our actions as moral agents, we can begin to understand how our backgrounds both inform and obscure our values and beliefs about life, death and dying, as well as our role as doctors to care and heal even in the face of terminal illness.
Pragmatically, the current medical education system needs to improve by adequately preparing physicians to lead compassionate and effective end-of-life conversations. Medical education needs to treat this skill like any other core competency, such as placing a central line or choosing appropriate sedation.20 On a wider policy level, we need to develop standards for patient-physician communication about end-of-life preferences that are actionable, scalable, and evidence-based and to establish the structures necessary to support whatever decisions are made.21
During my second week of working in the ICU, my patient, the former English professor, died. His wife and children were present. On the wall above his hospital bed, someone had taped a quote from his favorite poet, Rabindranath Tagore: “clouds come floating into my life, no longer to carry rain or usher storm, but to add color to my sunset sky.”
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Yuntong Ma was a 2017 FASPE Medical Fellow. She is currently an assistant professor at the University of California San Francisco and a staff physician at the San Francisco VA Medical Center. She graduated from Washington University School of Medicine in St. Louis in 2017.
17 Leah Rosenberg and David Doolittle, Learn and Live?: Understanding the Cultural Focus on Nonbeneficial Cardiopulmonary Resuscitation (CPR) as a Response to Existential Distress About Death and Dying, “American Journal of Bioethics”, 17(2) (2017): 54-55.
22
Block 10, Auschwitz I where medical experiments took place.