Oct. 8. 1993
Medical Reform and the Events Leading to The Holocaust: a comparison
By Anna Scherzer, M.D.
I can hardly be comprehensive. But I would like to address a few questions:
1. Who are the victims?
2. What are the methods?
3. What are the psychological states which permit or facilitate the process?
4. Is there anything which can be done?
The majority of us who are physicians share feelings of anger & resentment. I would dare say that the majority of us would classify ourselves as the victims. But victims of what? Victims of a wholesale disenfranchisement of the "American Dream" - of the "American Promise" itself.
Are we so different from the Jews of pre- World War II Germany, who felt that they were valued German Citizens? Citizens who had made and would continue to make significant contributions to what was considered one of the most advanced societies of Europe. How could anyone contemplate destroying such a valued Citizenry?
I bought into the "American Promise." If I worked hard... If I put forth my best effort... If I delayed my gratification... It didn't matter that I did not come from a monied class. It did not matter that I did not come from a family of influence. It didn't matter that I was first generation American, born of immigrant parents. I could achieve success.
And what was this success? Success was financial stability. Success was also a pride in accomplishment and a pride in identity. A joining of a respected group in American society, and contributing to that society. Success was also a sense of security and some degree of independence; autonomy.
One other thing we all did before becoming physicians was to take an oath. I did not take the Hippocratic Oath, but instead took the oath of Maimonides which dates back to the 13th century. Both oaths sanctified the relationship with our patient. We pledged to do our best to relieve an individual's suffering. We pledged to knowingly do no harm. I did not pledge to the State to satisfy its greater political or budgetary goal, but rather to do my best for the individual patient.
But what has been happening. The medical-political scene has changed since I took my oath. When I went to school, we were taught to deliver the best possible care. Ten years later, the physician was asked to deliver adequate care. Then we were asked to deliver fiscally responsible care, and finally we are now asked to manage covered lives. As physicians we are being saddled with the actuarial risk in the form of capitated contracts which are being imposed upon our relationship and treatment of our patients. What a progression. The patient is no longer the central individual around whom and for whom the art of healing was developed. Our function is to no longer primarily care for a person - we are now managing covered lives, ostensibly for some greater national or budgetary good.
Is this so different from what was demanded of physicians in Hitler's Germany? During that era it was with the help of the physicians that the efficiency of Nazi extermination was refined. Even before the establishment of systematic, massive killing machines, the scene had been set. Resources were scarce in the post World War I era. Germany was in a depression. The nation had been through terrible financial losses and country's morale was at a nadir.
After World War I in Germany, physicians were seen as servants of the State, rather than independent practitioners. Their primary allegiance was pledged to the government. At this same time, the chronically ill were viewed as an undesirable tremendous economic burden on the German society. The sickly, the impaired, the homosexual and the undesirable were seen as being maintained at the expense of precious and limited resources of the larger community, draining them and placing an undue stress on an already economically strapped nation. During that time of national crisis, pressures on the national economy and health care system were simply to be eliminated. Health Care was to be rationed. But how could this be made acceptable? By a simple technique which we are all well aware of today - reframing. These patients were viewed as having lesser valued lives, and eventually were considered an actual lower form of life. The concept of "lebensunwertes leben" was formulated. Translated, this means: Life not worthy of life itself. Such lives were not to be sustained. Such a philosophy permitted a clear psychological and emotional distancing between even the physician and patient. It discouraged the physicians and even the nation from any personal identification with the victim, and thereby facilitated the wholesale killing, or more properly stated, the elimination, of the victim, who was more popularly referred to as: "The Problem", or "The Jewish Problem". Even the human reference was eventually removed from popular Jargon.
Is this so different than our America today? By only a small step.
In Nazi Germany changes were clearly imposed upon the population through a dictatorship. But the population was systematically made ready and accepting of it. The populace supported the young and charismatic Adolph Hitler as a leader who spoke for the German people. A leader who captured the hopes and dreams of the common man. A leader who could rekindle the pride of being German. He was not of the elite political establishment. He was "down home". A little rough around the edges. But that could be forgiven. He embodied the nationalistic fervor. It was not hard to convince the people that greedy, corrupt and contaminating elements in their Great Society were acting as hindrances and threats which would undermine the strength of the Fatherland and the good hard working and deserving Aryan People. The German Parliament was in Gridlock because of private interest lobbyists and the elitist ruling establishment who were out of touch of the Manifest Destiny of the Great Aryan Nation and its future generations. The old ruling class had gotten the country into debt, had made expensive and unproductive decisions, was responsible for the unemployment and suffering of the populace, all the while being accused of trying to protect it's privileged life-style.
In our country similar conditions and changes appear more subtle although still insidiously and incrementally imposed. We might take a look back at the rhetoric of the last Presidential election. But I do not want to focus on that aspect of the process. However, in Clinton's recent televised speech on Wednesday 9/22/93, while introducing his health plan to the nation, he also spoke of greedy and corrupt forces within our nation, which hinder the efficient delivery of health care to the American people and are responsible for the rising costs, inadequacies and failures of the health care system. A striking parallel in presentation.
Is it so different now?
Changes are already afoot.
We are all aware that in administrative and business arenas we are no longer primarily identified as physicians. Let me remind you. We are now providers, sometimes even approved providers. We no longer have a name. We have a provider number. We now ask a bureaucratic reviewer, State [Medicare] or commercial, for a certification number for permission to provide a service, not to treat a person. We are not asked to aide, alleviate, cure, or help; but instead to manage covered lives and under budgetary constraints based on capitated rates devised and developed to assure an acceptable noninflationary low bid by the health care provider network. Yes there already is a cap on medical services. Although it may not be identified as a capped national medical budget, it is to a great degree already determined by contract bidding.
In state health plans such as proposed by Oregon, there is the recommendation that even in the case involving children who are unfortunate enough to be identified with a mental or nervous condition which may be chronic or bear a poor prognosis - despite the fact that their problems may be more serious and need greater apportionment of resources for a longer period of time - these children and their families are considered of lower priority in the delivery of health services than the more fortunate children who present with a time limited and good prognostic outcome condition. These proposals were meant to conserve precious resources for those who will have the best outcomes. A true triage system. Outright rationing of care. But what does this mean? It means that a child with autism, schizophrenia,or mental retardation, would be a lower priority for care, funds, and attention, than a child who has suffered a brief emotional stressor. Is this any different from the German "lebensunwertes leben"?
As a afterthought: what do we do with those who are low priority for services? What do we do with the families? How do we address the additional stress on these family units and loss of their economic productivity? It is not so easy. They don't just go away. They continue to create expenses. They continue to drain resources. These poor prognosis kids have both extensive and expensive ramifications. Unless they are somehow eliminated, of course.
How long can we ignore them? How do we rationalize that their treatments are not medically, ethically and morally necessary?
Allow me to focus for a few minutes on the medically necessary service: In my home state there was recent discussion on the governors, legislative and administrative levels regarding Medical Necessity. The Governor and the State Legislature wanted this whole issue to be clarified and boiled down to a simple definition. This was no longer an issue between a doctor and his patient. It was now an issue of government, policies and laws. So as to avoid administrative or legal difficulties the concept of medical necessity had to be administrated for the sake of clarification and development of a centralized policy. The definition of AHCCCS, the Medicare carrier, and the Department of Health Services, and the medical providers somehow had to be exactly the same. Even more worrisome, the definition of medical necessity was urged to be linked to covered service. Therefore, if a patient has a medical condition which requires a service which is not specifically covered by the State or Federally funded insurance carrier, it no longer could actually be medically necessary, by definition.
The practice of medicine is being managed by politicians, bureaucrats and attorneys.
In recently reviewing an AHCCCS physician provider contract in Arizona. I discovered that the statewide contracts delineate that a patient cannot be discharged from the care of a provider by that provider, without the expressed permission of the patient's case worker. This states that a doctor is not free to discharge a patient from his care, without the permission of a lower level State government worker, regardless of the problems between the doctor and the patient. It also stipulates that the State may add requirements to the provider that are not included in the original contract and the provider shall comply with the additional regulations, requirements, and added work load.
This United States was founded on the concepts of individual freedom. We fought the Civil War defending these freedoms for people of all color. We engaged in foreign battles carrying similar ideals. However, in our own land of freedom we are clearly not engaging in a free economy and with an expansive sweep we are quickly eliminating personal freedoms.
While an undergraduate student at the University of Pennsylvania, I learned basic Galbraith economics. I was taught the economies of guns and butter. Relative values were determined by the Law of Supply and Demand. The concept is always modified, however, by the psychology of perceived value, perceived need and entitlement to service. In this game of values the Federal Government has a powerful trump card: the concept of Eminent Domain.
I first thought this applied primarily to physical property. The government can seize private property in the name of the good of the nation as a whole with compensation to the citizen at a Federally determined rate of exchange. Our Manifest Destiny could easily be viewed as a expansionist derivative of the concept of Eminent Domain. But it was not until recently that the cruel reality of ownership of or infringement upon my skills as a physician or of my work product also came under that doctrine of national expansion, Eminent Domain, known better as the Resource Based Relative Value Scale [RBRVS]. Like the German physicians of WWII, I am being asked to serve and pledge loyalty to the Good of the Nation as a Whole.
Again, I go back to the President's speech of 9/22 regarding the Health Plan. When the President spoke of relieving the doctor from the burden of paperwork, he did not suggest that the doctor could or should use that time for enhancement of knowledge or skills, or improvement of patient care. He suggested instead, that more patients could be seen. This same production line mentality to medicine for optimal operational efficiency, had been seen in pre-World War II Germany. The value of the doctor is not primarily gauged by the quality of care, but by the quantity. There will be, however, reviews of both quantity and quality. These reviews will be made public. But, if the public will have choices only from the health plan panels, what is the point of disseminating this knowledge? I propose that these monitors will be extensively used by government, agencies and large insurance blocks. Under the guise of QI there will be a physician report card. The doctor's liability to the system will be noted. The doctors will have their own professional issues of "lebensunwertes leben". As we know, these types of statistics can be very misleading, especially for the higher risk subspecialists.
Here is a curious turn of events: during a time when insurance carriers will no longer be permitted to exclude high risk or high utilizer patients, there is a mechanism being developed for maintaining a central review of the doctor's "pre-existings," a review of their outcomes and their fiscal efficiency. The national data bank of disciplinary actions by the Board of Medical Examiners, the malpractice carriers, and hospitals have provided insufficient oversight or supervision of the medical provider, at least, from a financial standpoint.
So what if doctors finally say: "I refuse! I wont work under these rules!"?
Pre-World War II Germany had workshops and camps where essential goods and products were produced under strict quotas. If the quotas were not met, there were clear reprisals on not only the working personnel, but also the managers of the shops and their families.
You are aware that there is movement afoot for an expansion of the doctor draft. Quite curious to establish a template for a forced conscription of physicians at a time of a volunteer military. Can you imagine a medical work-camp? I just wonder at which time the loss of independence crosses the line to indenture or slavery? But I am neither a constitutional expert, politician, nor attorney.
As American physicians, do we identify primarily with the German medical establishment or with the larger group of Holocaust victims? I feel that we can identify with both. As a group of physicians we are being herded into the a similar crisis mind-set as pre World War II Germany. Why is this happening? We are threatened with the so-called "Truth" - that we have a "Crisis". We are told that the system which delivers the highest quality of care and which has contributed the most towards the advancement of medical science is "Broken". If we continue with our old values, we will no longer be able to exist financially or professionally. So if we want to survive the medical Holocaust we need to join the March. Somehow, that's what we had been hearing from our A.M.A. It was not until just the last a few weeks that even they voiced formal objections to the Clinton Health Plan. Too little. Too late.
After all, how many of us have the luxury of living our conscience? How many of us have our own personal obligations, families, to protect, mortgages, children in college. We say to ourselves:
"I can personally adjust."
"I'll just go on day to day."
"This is better than nothing."
"Just a short while before I can retire from the whole thing." "After all, it couldn't be all that bad."
"I do support many of those ideals."
"The Devil is in the Details", I've heard said.
In the beginning of the deportation, Jews, peasants, Gypsies went voluntarily to the camps. After all, they were work camps. There was overcrowding in the cities and ghettos. Life had gotten so bad. Their ways of life had "broken down". They were promised apartments, food, work. No one believed that there could be such a plan as to eliminate them, a plan to make Europe "Judenrein", clean of Jews. Many, once they knew that the sick and weak were killed, still did not protest. They didn't feel strong enough. They didn't feel powerful enough. They didn't think their single voice would make a difference. It was not in their teaching. It was not in their culture. They were told that they were needed. They told themselves that they were needed. If they could prove their importance. If they could prove their function. If they can prove their contribution, even to the German war machine, their lives might be spared, or at least prolonged. They were often desperate in their efforts. They could not show they were weak, sick, or vulnerable. Their lives had to have been worthwhile. They had to have "Lebenswertes"; a worthiness to their lives.
How many of you remember the image of the President holding up the Universal Health card during his Speech on Wednesday night, September 22? He used it as a symbol of Health Care for all. The Universal Insurance Card. What a potentially powerful and decisive instrument. All our medical records in the hands of the Bureaucrats, without any guarantee or promise of confidentiality. How simple it would be for one person to decide if we march to the Left and be excluded from care, or march to the Right.
In the Holocaust Memorial Museum there is a computer system made of punch cards. It is the German prototype of the Universal Health Card. Yes, they thought of it first. Each German citizen would have a card which reflected a centralized health record. [The field trials were on the Jewish segment of society.] Every medical problem or condition for which a patient either had a history of or had received some type of treatment for was recorded on the individuals central and comprehensive health record. In that manner the Nazi government was not only aware of the costs incurred upon the Aryan People and the Fatherland, but who specifically incurred these costs. The Fatherland could than calculate the financial risk to its resources by any one individual and could therefore calculate the value, the likely productivity, or the liability of any individual to the State. In short the lebenswertes of any one person.
The history provided by our own proposed Universal Insurance card may very easily become an important factor for a medical reviewer or fiduciary agent in deciding whether to release or authorize funds for a given service; whether it is medically warranted. The data from that card may also find its way to other nonmedical entities and used in decision making for anything from job advancement to college admissions.
What about the "lebenswertes" of the physicians? How often have you heard physicians say: "They can't run a hospital without us." "They need us." Let us not get too smug. My colleagues, we are replaceable. There are physician extenders - social workers, nurses, psychologists and paramedics waiting to be given the privilege of doing what we do. They are lobbying for such opportunities. With the strike of the legislative pen, they can easily replace us. And they will do it cheaper, although, I am certain, not better. Just like the workers in the concentration camps. If there weren't enough Jews, there were always the Gypsies, or the Intelligencia, or the clergy, or the Partisans, or the Catholics to take their place.
There are always new physicians coming through the pipelines. There is a glut of physicians in Europe. We are not secure. The truth is, if we are looking at an industrialization mentality where the product is more valued than the service and quality is difficult to judge by the lay user, it is very easy to show how we as physicians, and the way we practice may falsely appear, at a superficial first glance, as an extravagance.
If we identify with the massacred millions, we also need to understand how they survived the continuous and ongoing stressors.
The Germans were quite calculating in the progression of limitations and restrictions which they placed on the Jewish people in the ghettos. There was a steady abridgement of freedoms. There was finally dehumanization and death.
Yehuda Nir: a survivor of the Holocaust states in his book, The lost Childhood:
"We could see the pattern developing. Every month or so, the Gestapo took 10% to 15% of the city's Jewish population for extermination. It seemed that at this rate, even if we were the last to go, we had no more than a year to live. Strange though, we were not in despair; without any good reason, we felt that we would survive."
"Between the 'actions' life was bizarrely normal in its abnormality. We learned to live from crisis to crisis, from one life-threatening situation to the next. The days in between seemed isolated from what happened before or after."
What Yehuda Nir is describing is the psychological defenses of denial, repression, isolation of affect, and dissociation. Without the ability to do this, human beings could not survive ongoing periods of stress. We see it now in Yugoslavia. We see it in Israel and Lebanon. It is a human strength. It does not allow us to give up life. But this same defense can also be the ruin of a people. It can hold them back from needed action. What survives, however, is the despair, the hopelessness the despondency and passive victimization. These responses are the hallmark of Type II post traumatic stress syndrome, which occurs as a result of continuous victimization and threats to one's safety and life. It is characterized by a chronic and longstanding anxious depressive state, a heightened reactivity, a chronic tense vigilance, a decrease in concentration and productivity, and an active avoidance of dealing with the distressing topic directly. But there remains a haunting of memories: flashbacks, unwanted, distressing and intrusive reminders. There is loss of hope or vision of a future. The pattern may facilitate ongoing victimization, especially when the future is than only seen through the eyes of the persecutor, when the victim begins to doubt their own known truths, and the persecutors truth predominates.
I daresay, many of our colleagues have suffered and still suffer from these symptoms. As we all know being pro-active helps counteract the victimization. Having group support also helps counteract the sense of individual helplessness. And so here we all are.
But how did we get to this point? To the point that we are making analogies with the Holocaust?
Similar to the effect of the gradual Nazi infringement on the lives and limitation of the rights of the Jewish population of Europe, the American physician has adapted to the progressive changes and abuses with defenses of accommodation, denial, minimization and repression. The Germans calculated that eventually all willful opposition would be quelled, or at least easily controlled. Similarly our governmental agencies and large business interests are quite confident that they can not only shape, but redefine the mind-set and the function of the physician away from the traditional biomedical model to a social model. They admit that it might take a generation of medical students who are taught different attitudes through their medical training to complete the transition. You see the doctor must be taught a different creed in medical school. [This is already happening.]
But there is no doubt that it will eventually be accomplished. Both governments, ours and the German Reich, used similar psychological and educational techniques.
While physicians have long been aware that the federal government has been incrementally restricting their ability to practice Medicine in a free market fashion, there have been few and faltering concerted efforts to halt the process. Even in the face of international examples of boondoggle and failure.
Our own A.M.A. has chosen to act like the older Vichy Government of France. It had chosen to appease, to work with the Administration. The Clinton administration has viewed this lack of organized objection as a measure of support and validation of the President's Health Plan.
In Germany and pre World War II Europe, there were many intellectuals, leaders, scholars and youth who warned of the Holocaust. But they were largely ignored. How could this type of atrocity could not happen in such a civilized nation? Instead of confronting the problem head-on, the popular leaders, with too much to lose if a radical approach was not successful, believed that appeasement would suffice. Remember Chamberlain.
"There will be less trouble."
"Fewer will suffer."
"There will be less reprisal."
"We might even find a way to benefit."
Radical surgical ablatement was eventually was the only approach which was effective; to use a medical metaphor.
How can I summarize a comparison between the Germany's Holocaust and the current situation in the United States?
As I previously stated, Germany was in the throes of a severe depression. Labor was oppressed. Masses were out of work. The people were demoralized from World War I. They felt stripped of their dignity. The old political guard was unable to maintain a majority party. Old leaders and old political machines were slow and ineffective. They were not seen as sufficiently responsive in bringing about the change that the disenfranchised workers needed and demanded. The old politicians were felt to come from an elitist group which were no longer in touch with the majority of the people. A young dynamic Hitler brought a new element of vitality, spirit, pride and hope. He was able to play on the anger, frustrations and old fears of a people who felt stripped of their old pride. He found scapegoats onto which to displace blame. These scapegoats: foreigners, Jews, Catholics intellectuals, were identified as controlling and limiting the poor innocent German worker and needed to be wiped out so that the German Aryans Nation could flourish and get what rightfully they were entitled to and deserved. The abilities, skills and wealth that these non-Aryans had were the property and the right of the German nation, and thereby could be used and disposed of by the Fatherland as it saw fit. That which did not support the Aryan state, was a threat to the Aryan state and had to be eliminated. That which did not directly contribute to the growth of the Aryan State, but instead was a drain on the resources, or could potentially distract from the development of a single and controlled culture was a "lebensunwertes leben".
There would be some expected sacrifice in the beginning for the better life, but as time went on , the blame for the sacrifice was displaced onto all those negative non-Aryan elements.
How are we doing in the United States? The Vietnam era has left a long and painful legacy, and I would say that we are not yet fully recovered. The Gulf War was at first considered a success, but upon second look, did not accomplish what the American people had hoped for. Somalia and Bosnia are certainly unsatisfying international ventures. The input which we had in Russia and the destabilization there is cause for consternation. We are in a stagnant economy. Many of us would call it a recession if not an actual depression. There are ongoing jobs lost in private industry, in the military establishment, and even more proposed within the federal government, positively couched in the administration's proposal to "reinvent government". There is the fear that NAFTA will accelerate the loss of jobs. The development of a disenfranchised working class is clear.
Who is at fault? An old government establishment which had a history of gridlock and inaction? A leadership which was ineffective and out of touch with the people, only looking out for the interests of the elite? Whomever stands in the way of what this administration views as good for the country is represented as a sabotaging and dangerous agent. Oh, those conservative Republicans!
For many years, the message to the American people has been that those rich doctors are getting richer from your sorrows and miseries. Mr. and Mrs. average America, you deserve more! You deserve better! You are entitled to... education, retraining, housing, health-care, jobs, health-care. Don't worry. You'll only have to make small sacrifices so that you and your children have the future you deserve. We'll take the money from the rich, from the employers, from the doctors, from all those that wouldn't benefit from the help we would give them anyway. These are hard times folks, we've only got limited resources. Don't want to leave that debt to your children. But you, Mr. and Mrs. America are entitled and deserving.
Of course, to get these benefits and make them equitable, there will have to be protocols, standards, supervision. Both you and your health care providers will have to have identification numbers. Patients wear blue arm bands. The insignia on the arm bands will indicate their diseases or their state of health. Providers will wear arm bands. The colors and insignias will indicate their affiliations and subspecialties. Production and quality guidelines will be expected to be followed or arm bands will be recalled. There will be a penalty for not wearing or displaying your arm bands. Regulations will be posted at predetermined intervals and will be enforced upon posting. It is the responsibility of every citizen of the State to familiarize themselves with all regulations. So as not to overburden our court system which is concerned with more important matters, all hearings regarding infringements will be handled by a State Health Arbitrator of the People. So as not to show any bias, this health arbitrator will be prohibited from having any affiliation or knowledge of the practice of medicine. Cost for services of the health arbitrator will be financed by confiscation of all property and licenses of the accused medical provider. The provider will have the right to a defense attorney at his own expense. If found to be in non-compliance of regulation, the medical provider will continue to provide services to the people of the State without compensation.
Oh, dear. I must be getting carried away.
We can learn from history. In countries where nationalization and full control of medicine was all the rage over the last few decades, [Germany, England, Israel], there is again privatization. Why? The people demanded it. When possible, they valued themselves highly enough to want the best possible care. Supporting the State was fine, but if they could afford it they wanted to be treated special, like an individual. An elitist concept, I guess? Additionally, giving everyone care became very expensive and care got very mediocre, uninspired. The populace realized this, of course, before the governments officially admitted it.
The human condition does maintain resistance and the will to survive. There was resistance in Europe to the Nazi's. The maintenance of a quasi normal life was not merely a psychological defense, but also a psychological war. During the worst times of World War II, during starvation, disease and persecution, Jewish children continued to learn about their heritage with pride. Our American heritage is the commitment to Individual Freedoms. The Constitution and the Bill of Rights still stands as our guide. But we must also maintaining the hope that there will be a survivor. And that survivor, whomever he or she may be, will have the responsibility of continuing an honored tradition. The tradition of learning, healing, helping, of having social conscious and maintaining the dignity of man. I reaffirm the Oath of Maimonides that I took upon becoming a physician:
If doctors wiser than me seek to help me understand, grant me the desire to learn from them, for the knowledge of healing is boundless. But when fools deride me, give me fortitude! Let my love for my profession strengthen me resolve to withstand the decision even of men of high station. Illuminate the way for me, for any lapse in my knowledge can bring illness and death upon your creations. I beseech you, merciful and gracious G-d, strengthen me in body and soul, and instill within me a perfect spirit.