Faced with adversity, why are most of us mute? Why do those who prefer to remain dumb criticize those of us who dare to be outspoken in the face of almost certain failure in our gargantuan battle with the federal government? Are the problems confronting us unique?

Our organization - the AAPS - is 50 years old this year, and last April also marked the 50th anniversary of the uprising of the Warsaw Ghetto. Might the Holocaust hold any lessons for us? My answer is a resounding "Yes!" History should convince us that we have no recourse save action; that we cannot afford not to speak out. This message has been cast in concrete and steel in the form of the United Sates Holocaust Memorial Museum, which was recently dedicated in Washington, D.C. Allow me to read several words from a Washington Post Article, describing it:

"Jame's Freed's severe, demanding building...is a masterpiece. ...in the Holocaust Museum, the acute, unforgiving angles, the sharp, forced turns, are a powerful pedagogical device. This is the architecture of forced marches, of mechanized cruelty, of industrialized death. The building's texture of raw steel and brick and granite gives the feel of a factory, but its calculated irrationalities - cracked lines, dead ends, blotted windows, narrowing staircases - imply a machinery of derangement."¹

I would highly recommend that every American visit this museum. To do so is to immerse oneself in a thought-provoking emotional cauldron which is a testimony to a precious truth - that, in the final analysis, governments of men will not be judged on the merits of their economic productivity, but by the degree to which they promulgated and protected eternal human values - or failed to do so.

Several years ago, "Roundup," the monthly publication of the Maricopa County Medical Society, published an article of mine about this topic. I compared the demoralization of physicians resulting from growing governmental control and interference with the practice of Medicine to the psychological effects of repressive techniques used by the Nazi regime as it attempted to master a small segment of German society. Economic issues were central to that dark event in human history, just as they are in America's current "health care crisis."

Although this analogy may seem extreme at first glance, I would like to emphasize that I am only comparing the psychology and effects of the methods employed in these two situations - not the actual events themselves.

At the inception of the Holocaust, individual rights were slowly abridged; minor ones at first. As Pat Robertson writes in his book, "The New World order," "false propaganda, ridicule, and demeaning comments" were all heaped upon the Jews by the Nazi's in Hitler's Germany. "First they were ridiculed and blamed for the economic collapse of Germany. Then they were denied a few rights of citizenship. Then they were crowded into restricted ghettos. And finally their property and their lives were taken from them." As I wrote in Roundup in 1986: "The populace used denial to explain away and minimize the importance of successive incursions upon their Liberty and Freedom. As time wore on their dignity was slowly stripped away; they coped, and survived, for a time..."² Eventually, all will and determination were gone, and the controlling forces were easily able to shepherd the subdued masses. By implementing regimentation slowly, step by nefarious step, resistance had been effectively nullified.

It is all too clear that the federal government, in a forcefully determined and progressive fashion, is artificially fragmenting and dissolving the integrity of the medical profession.

Ever-burgeoning constraints are being levied upon American physicians as they attempt to practice their craft while the government steadfastly pursues its goal of the socialization of our unique profession. For a short while we were saddled with the "gag rule," which declared that a physician working for a federal health clinic was forbidden to even discuss the option of abortion. We have CLIA regulations proclaiming that a dermatologist may no longer interpret skin biopsies microscopically unless he pays a regulatory fee. We render legitimate service only to find that payment is denied retrospectively by third-party payors like Medicare. We are being handled as if we are an industry, but we are forbidden to unionize.

By passively permitting our government to arbitrarily abridge our professional rights to discuss interrelated scientific medical matters with our patients, or by allowing the government to constrain us from making full use of our professional abilities in any way, we are not only facilitating governmental control over the House of Medicine, we are running the risk of destroying the very basis of that profession. While physicians are well aware that the federal government has been incrementally restricting their ability to practice Medicine in a free market fashion, they have made no concerted effort to halt the process. Why? I believe the main reason can be explained by what I call "The Heinlein Principle," in deference to the late science fiction author, Robert A. Heinlein. In his inimitable way, he stated that "it is socially unacceptable to be right too early." Another (and better known) philosopher, George Santayana, stated that those who do not study history will be condemned to repeat it.

Education notwithstanding, history usually does repeat itself. I have formulated my "Heinlein Principle," a composite of the thoughts of these two men, in order to try to explain why this is so.

The "long version" of the Heinlein Principle states: History usually repeats itself because those who would otherwise take appropriate action and preventive measures in a timely fashion are restrained by the knowledge that they would be stigmatized due to the perception of the public and their peers that such actions were at least premature - if not entirely inappropriate. Or, to sum this up more succinctly: History usually repeats itself because precocious prevention is scorned.

Passivity, coupled with the use of denial, is the characteristic and expected response to the slow but steady abridgment of freedom we are experiencing - this, even in the face of death itself.

Thinking that I had indeed pushed an analogy to its limits when I published my own article, it was most interesting to read a paper in the April 25, 1990 Journal of the American Medical Association bringing up the same historical issues during a discussion about the possibility of active euthanasia in America in the near future. Allow me to quote from the JAMA publication, which reflects on the infamy of the Holocaust as it discusses what it considers to be a growing threat to the longevity of our nation's elderly:

"Not only has there been a movement to discriminate against patients in a persistent vegetative state, but evidence of discrimination against the aged in our population is becoming apparent. It has been suggested that after a person has lived most of his or her natural life span, medical care should not be oriented to resisting death...

The greatest aberration of the physician occurred in Nazi Germany, with direct medical killing and systematic genocide. How could a physician be transformed into a being capable of such heinous actions? First, there was the concept of lebensunwertes leben ("a life unworthy of life"). Soon the unworthy life came to be anyone considered undesirable or useless. Second, physicians were no longer caretakers of an individual patient, but rather promoters of the general health of the German people. Physicians were servants of the state rather than independent practitioners [italics, ed.]. These [undesirable] people were [deemed to be] a tremendous economic burden on society, [and] there was a distancing of the killer from the victim.

The beginnings [of those crimes perpetuated during the Holocaust] at first were merely a subtle shift in emphasis of the basic attitude of the physicians."

[You may find what I am next about to tell you unbelievable - it may seem that I have made it up - but the next few words are all too frighteningly true. The following statement appears in the manifesto of the Arizona Affordable Health Care Coalition, the group of citizens and corporations - including Cigna, Intergroup, Blue Cross and Blue Shield - which is designing my own state's managed care plan. I doubt these people fully realize how closely one of their main policies mimics the paradigm shift in medicine which occurred in Nazi Germany. Their so-called (confidential) "Vision Statement" maintains that (and I quote):

"The physician gradually will need to accept a necessary change of ethical focus from the biomedical mode (intervention without regard to cost if there be any chance of success) to a biosocial model that considers not only the health needs of individuals, but also the health needs of populations, including those members of the population who do not seek medical care."

As the saying goes, ideas do have consequences.

This same manifesto goes on to insist that "health care quality and patient safety will never be compromised"!]

Joseph Goebbels, Hitler's propaganda minister, stated that if you make the lie big enough it will be believable.

According to the 1990 JAMA article, "The parallels of what happened in Germany and what is currently occurring in this country...are striking. Physicians [are] becoming more concerned with societal needs as opposed to the needs of an individual patient as scarce resources decrease."³

I agree with JAMA about these changes and the parallels it draws, but I maintain that the engine governing the new road along which medical care is being guided is the federal government rather than society per se, and this attitudinal shift is being driven solely by the economic concerns of Bureaucracy and Big Business - the "wealthy elite," as William Greidner says in his book, "Who Will Tell the People". Societal and physician attitudes are being molded by the approach which the government and the managed care plans it has been fostering have decided to take. Doctors are being straightjacketed, their autonomy and creativity throttled. The methodology being used to successfully turn doctors into servants of the state is designed to substantially decrease, if not destroy, the ethical incentives intrinsic to the proper practice of Medicine.

The subtleties of these ongoing events and their noxious consequences should not be dismissed, and it must be appreciated that it is in the government's fiscal interests to breach the wall of physician advocacy. The physician's championship of his patient, a key ingredient in the practice of Medicine, is the most substantial - and critical - barrier to the goals of statist medicine.

As the article in JAMA stated, ..."American medicine must realize where it stands in its fundamental premises. There can be no doubt that in a subtle way the Hegelian premise of "what is useful is right" has infected society, including the medical portion. Physicians must return to the older premises, which were the emotional foundation and driving force of an amazingly successful quest to increase powers of healing and which are bound to carry them still farther if they are not held down to earth by the pernicious attitudes of an overdone practical realism."

As you know too well, the attitude of many of our colleagues is: "It is useless. There are too few of us with the will to resist."

Well, resistance movements are generally never large. There are very potent obstacles in the way of a large scale, concerted physician rebellion against governmental control, especially vis a vis Medicare: threats of civil and criminal penalties - for example, fines of up to $10,000 a day for not completing certain paperwork requirements. The government is quite an intimidating opponent. Additionally, there is no question that doctors are constantly in jeopardy of a severe public backlash at the merest mention of the word "fees." (Any doctor realizes that "fee" is really a four-letter word.) Knowing this, it is particularly clever of the government to force physicians to ration care by means of fee constraints. Our government is quite cognizant of how difficult it is for doctors to win any points if this subject is debated, and we realize that private contracts are of paramount importance to the physician-patient relationship. Ironically, while our government pompously declares health care a "Right" it attempts to forbid Medicare patients from purchasing this "Right" with their very own funds!

According to a 1992 issue of AAPS News, in 1949 Melchior Palyi said - "In democracies the Welfare Sate is the beginning and the Police State the end. The two merge sooner or later, in all experience, and for obvious reasons...All modern dictators have at least one thing in common. They all believe in social security, especially into coercing people into governmentalized medicine."⁴

Was Ayn Rand correct when she wrote that the difference between a welfare state and a totalitarian state is only a matter of time? If we allow ourselves an open mind to examine the issues raised here, the parallels with Communism and all its pitfalls should be obvious.

There are frighteningly accurate predictions of the present government and corporate rape of Medicine in Ayn Rand's Atlas Shrugged. In the novel, the government decides to control a new, lightweight and exceedingly strong metal- symbolic of the metal of one's mind, one's soul - one's productivity - and enacts laws making ownership of Rearden Metal a virtual right. Then, in order to determine what constitutes a fair share of this valuable commodity, the government hires the equivalent of our own Dr. Hsaio. Finally, Rearden is informed that he must sell his metal to the government - that he has no choice. His response is noteworthy:

"A sale," said Rearden, slowly, "requires the seller's consent." He got up and walked to the window. "I'll tell you what you can do."

He pointed to the siding where ingots of Rearden Metal were being loaded onto freight cars. "There's Rearden Metal. Drive down there with your trucks - like any other looter, but without his risk, because I won't shoot you, as you know I can't - take as much of the Metal as you wish and go. Don't try to send me payment. I won't accept it. Don't print out a check to me. It won't be cashed. If you want that Metal, you have the guns to seize it. Go ahead...You need my help to make it look like a sale - like a safe, just, moral transaction. I will not help you." ⁵

"...looters believe it is safe to rob defenseless men, once they've passed a law to disarm them. But their loot becomes the magnet for other looters, who get it from them as they got it. Then the race goes, not to the ablest at production, but to those most ruthless at brutality. When force is the standard, the murderer wins over the pickpocket. And then that society vanishes, in a spread of ruins and slaughter."

"When you see that trading is done, not by consent, but by compulsion - when you see that in order to produce, you need to obtain permission from men who produce nothing - when you see that money is flowing to those who deal, not in goods but in favors - when you see that men get richer by graft and by pull than by work, and your laws don't protect you against them, but protect them against you - when you see corruption being rewarded and honesty becoming a self-sacrifice - you may know that your society is doomed."

"Do not expect [men] to produce, when production is punished and looting rewarded."

"If it is now believed that my fellow men may sacrifice me in any manner they please for the sake of whatever they deem to be their own good, if they believe they can seize my property simply because they need it - well, so does any burglar. There is only this difference: the burglar does not ask me to sanction his act."⁶

Later in the novel, the State's new policy's result in internal strife and decay. The leadership decides it must take drastic action in order to safeguard the recently implemented new order (I will be quoting several pages here, interjecting comments along the way):

"The picture now is this," said Wesley Mouch. "The economic condition of the country was better the year before last than it was last year, and last year it was better than it is at present. It's obvious that we would not be able to survive another year of the same progression. Therefore, our sole objective must now be to hold the line. To stand still in order to catch our stride. To achieve total stability. Freedom has been given a chance and has failed. Therefore, more stringent controls are necessary. Since men are unwilling and unable to solve their problems voluntarily, they must be forced to do it."⁷

"In the name of the general welfare," read Wesley Mouch, "to protect the people's security, to achieve full equality and total stability, it is decreed for the duration of the national emergency that -"

"Point One. All workers, wage earners and employees of any kind whatsoever shall henceforth be attached to their jobs and shall not leave nor be dismissed nor change employment, under penalty of a term in jail..." [When Canadian doctors threatened to strike they were threatened with imprisonment. Our own government has just established a protocol for a large scale doctor draft even though general conscription ended long ago - ed.]

"Point Two. all industrial, commercial, manufacturing and business establishments of any nature whatsoever shall henceforth remain in operation, and the owners of such establishments shall not quit nor leave nor retire, nor close, sell or transfer their business, under penalty of the nationalization of their establishment and of any and all of their property."

"Point Three. All patents and copyrights, pertaining to any devices, inventions, formulas processes and works of any nature whatsoever, shall be turned over to the nation as a patriotic emergency gift by means of Gift Certificates to be signed voluntarily by the owners of such patents and copyrights. The Unification Board shall then license the use of such patents and copyrights to all applicants, equally and without discrimination, for the purpose of eliminating monopolistic practices, discarding obsolete products and making the best available to the whole nation. Every formerly patented product shall be known by a new name and sold by all manufacturers under the same name, such name to be selected by the Unification Board. All private trademarks and brand names are hereby abolished." [As you know, our government is planning a nationwide "formulary" of "approved" pharmaceuticals for our medical care, and new laws have shortened the duration of pharmaceutical patents - ed.]

"Point Four. No new devices, inventions, products, or goods of any nature whatsoever, not now on the market, shall be produced, invented, manufactured or sold after the date of this directive. The Office of Patents and Copyrights is hereby suspended." [It is financially beneficial for the government to restrict the number of physicians - especially the more learned specialists - in order to limit medical expenditures as well as technological and pharmaceutical progress. The stage has been set - ed.]

"Point Five. Every establishment, concern, corporation or person engaged in production of any nature whatsoever shall henceforth produce the same amount of goods per year as it, they or he produced during the Basic Year, no more and no less. The year to be known as the Basic or Yardstick Year is to be the year ending on the date of this directive. Over or underproduction shall be fined, such fines to be determined by the Unification Board." [ Ponder the concept of "Volume Performance Standards" and realize that Gail Wilensky, the former director of HCFA in the Bush administration, was quoted as saying that "conservative" doctors would be rewarded under the RBRVS, the implication being a doctor will be paid more per piece if he generates less piecework - ed.]

"Point Six. Every person of any age, sex, class or income, shall henceforth spend the same amount of money on the purchase of goods per year as he or she spent during the Basic Year, no more and no less. Over or underpurchasing shall be fined, such fines to be determined by the Unification Board." [Contemplate the position HCFA is taking with respect to the private purchase of medical services by Medicare recipients and think about the restrictive possibilities inherent in the nebulous phrase, "Global Budgets." The abolition of balance billing, coupled with the universal institution of price controls, has been spelled out quite frankly in the Clinton Health Plan - ed.]

"Point Seven. All wages, prices, salaries, dividends, profits, interest rates and forms of income of any nature whatsoever, shall be frozen at their present figures, as of the date of this directive." [Governments repeatedly utilize price controls as a "quick fix," even though they are proven failures, and Clinton is about to try them again in spite of verbal denials -ed.]

"Point Eight. All cases arising from and rules not specifically provided for in this directive, shall be settled and determined by the Unification Board, whose decisions will be final."⁸ As you know, our government is establishing a "national health care board" which would control all medical services and expenditures, both public and private, and Clinton's plan explicitly states that its directives are final, and not open to discussion - ed.]

"We have the right to do it!" cried Taggart suddenly..."We need it"..."We'll be safe for the first time in centuries."⁹

I wish that I could read Ayn Rand's words and dismiss them as sheer paranoid invention - but they were truly prophetic. It is clear that the federal government has already injected policies into the Medicare program which are all too evocative of the image of the totalitarian state painted in Atlas Shrugged. Clinton has converted Rand's nightmarish scenario into deadly serious reality.

Radical changes are in store for American Medicine, which our government is manipulating in a manner all too redolent of the actions taken by Rand's fictitious Unification Board. One might almost believe the federal government is using her book as a template for its "health care reform" program. It is patently absurd to believe that our government is primarily concerned about the quality of medical care. We know it - but we must tell the public.

We physicians realize that American politics are threatening medical science, our profession, and the very quality of life in our country.

Interestingly, but perhaps not so surprisingly, the politics of late twentieth century America are not so very different from what they were when our nation was founded. The parallels between America's past and present political climate are truly astounding. A couple of years ago I discovered a book about life in pre-Revolutionary New York by Edward Countryman. It revealed that the political rhetoric of that era and the complaints about New York's elected officials at that time were rife with modern similarities. Some of the 200 year old quotations in this book are particularly relevant to our own time. The comparisons are so strong that some of the words might just as well have been written by any one of today's political commentators. For "New York," simply substitute "America:"

"The provincial political structure began to weaken in the mid-1760's...Its problems came from its own internal contradictions and corruption... As its power weakened, the government itself became the subject of ridicule and criticism that questioned not only the propriety of its actions but the rightfulness of power's remaining any longer with the men and the institutions that held it."¹⁰

"The real rulers of provincial New York believed that they held their power virtually as a matter of right. But how, and in whose interests, did they exercise that power?...the old order was filled with contradictions. From those contradictions much else flowed, for they had a significant part in the way that the conjuncture of imperial issues and postwar depression generated a massive internal political crisis for New York itself."

"...once in office, the provincial assemblymen could be as imperious as any royal placeman...political commentators were vilifying the assembly, rather than the British, as the greatest single threat to New York's well- being."¹¹

"...though many factors stimulated the voters' interest, there was no real popular control over politicians in office. Electors were invited to think about issues and to choose among competing candidates, but they were choosing among men who saw their task in terms of ruling the public, not in terms of serving its wishes."¹²

"Officials and men in positions of social and political privilege regularly employed the public machinery to achieve their private ends, sometimes with disastrous public results. Many officials considered their office as their private possession, that they held for their own good rather than for the service of either king or country...."

"Lesser officials, too, considered office as private property. [The] corrupt provincial treasurers Abraham De Peyster and John Watts showed it by the way they diverted public funds to their private businesses."¹³

..."the contradiction between a rhetoric of involvement, virtue, and public liberty and a reality of exclusion [and] corruption...was becoming increasingly visible."¹⁴

Some words by a gentleman named Justice Livingston are especially poignant: ""It is well known," he said, "that every Man and Body of Men, are desirous of Power; this is natural to humanity, for none fear the abuse of Power in their own Hands." He described how the Commons took more and more power to itself, until "at last, we find the Commons assuming all Power, turning the Government into what was called a Common Wealth, though it was a real Tyranny.""¹⁵

"New Yorkers were as worried about uncontrolled power in 1775 as they had been in 1765. But in 1765 their intellectuals had been telling them that the danger posed by power came from outside, from the British government [read "Russia" - ed.]....By 1775, in contrast, the assembly had been exposed to years of blistering criticism. The men who made it up, the things they did, the ways they did them, and the principles on which they operated had been analyzed, mocked, and held up as inimical to New York's welfare....New Yorkers were being told that liberty's best defense was no longer to be found in a virtuous elite operating as the people's representatives. Rather, it lay in the people's taking as direct a part in politics as they could."

"The power of the old order decayed. [B]y 1774 and 1775 the old institutions had very little moral claim to authority, their power rest[ing] on little more than whatever physical force they could command."¹⁶

"The problem... sprang from contradictions that were inherent in the political structure and the political culture of provincial New York. Those contradictions came to a head during the imperial crisis, as the opposition writers of that decade realized and explained. Their maturation meant that independence would require both angry conflict among New Yorkers and a sharp change from the old ways."¹⁷

There is but one conclusion to be drawn from all this. We must study history, learn from it, and then act upon our knowledge. To do otherwise is to deny the heritage of our great country and its magnificent Constitution. We physicians must take the lead. There is no one else to turn to. We must fight for the survival of private practice and our autonomy. To lose this battle is to lose the fight for the profession of Medicine itself. We must educate our public, our politicians, and our peers. Tell them about Medical Savings accounts, inform them of organizations like the AAPS that are fighting for their preservation, and urge them to join - to be pro-active. Convince them that government domination of the medical profession will spell disaster for all concerned. Tell them that if medical care has to be limited due to costs - and it does - that it is preferable for the patient rather than the state or federal government to be the arbiter of decisions related to medical expenditures. Listen to what former Arizona Senator Barry Goldwater has to say about socialism and socialized medicine:

"I'm not afraid of my country losing its freedom to any force from the outside. What I am afraid of is that we are losing our freedom because of the politics of men who don't know and men who don't care. And that's a very evil combination. [S]ocialized medicine is a step toward the downfall of a free government." It is clear that our government knows full well what it is up to, but at the same time it may not realize all the consequences of its manipulation of our profession. As I wrote in my poem, "Cancer Ward,"

May God grant us the will to persist.