Patient Dignity 16: From Mother Theresa to Dr. Mengele

I know that this title seems inflammatory, but this series of posts is all about AND from the view of (victim) patients. What is inflammatory are the cases of  Justina Pelletier and Dr. Stanley Bo-Shui Chung. These are but two of the thousands of examples of physicians betrayal and abuse of patients.

Patients who have had their dignity victimized often describe their experiences liking them to the indignities suffered by the survivors of the concentration camps. More than once I have heard providers referred to as Dr. Mengele. One common attribute that they share is the fallout in their lives after the event, namely PTSD.

That all humans are capable of evil is the foundational truth of Christian civilisation. This insight — known as “original sin” — has been around for at least 2,000 years. It has been repeatedly underwritten by the crimes of history. Yet, mysteriously, people still find it shocking.

What is more dangerous is the denial by the healthcare system that their practitioners ARE capable of doing such things, AND that human dignity commonly ignored. There are some instances that outright abuse, torture, and assault occur. I wish that I could say these were rare occurrences, but they have become all to common. 

So many people claim to go into healthcare for altruistic reasons but come out seemingly lacking any compassion or empathy. Patients are objectified, an entitlement to the patients' bodies permeates, and dignity and self-determination is sacrificed for efficiency, paternalism, and arrogance. Some providers are even worse.....

This has prompted me to look closer look at Nazi doctors in the concentration camps. If these physicians could abandon all ethics. Perhaps this can shed some insight to providers today.

Perhaps the most large-scale, infamous misappropriation and misapplication of medical personnel and practices and widespread perversion of medical research occurred in the Holocaust. As Lifton [Lifton RJ: The Nazi Doctors: Medical KillIng and the Psychology of Genocide.] recounts in his monumental study, The Nazi Doctors, the Nazi ‘biomedical vision’ seized on the metaphor of healing the racially diseased body of the German nation. 

In this context, killing those who constituted the disease was a therapeutic venture, much as the excision of a malignant growth. “The Nazis based their justification for direct medical killing on the simple concept of ‘life unworthy of life’ (lebensunwertes Leben) … Of the five identifiable steps by which the Nazis carried out the principle of ‘life unworthy of life,’ coercive sterilization was the first. There followed the killing of ‘impaired’ children in hospitals; and then the killing of ‘impaired’ adults, mostly collected from mental hospitals, in centers especially equipped with carbon monoxide gas. This project was extended (in the same killing centers) to ‘impaired’ inmates of concentration and extermination camps and finally, to mass killings, mostly of Jews, in the extermination camps.” [Lifton RJ: The Nazi Doctors: Medical KillIng and the Psychology of Genocide.] 

Lifton [Lifton RJ: The Nazi Doctors: Medical KillIng and the Psychology of Genocide.] quotes Martin Borman, “The Fuhrer holds the cleansing of the medical profession far more important than, for example, that of the bureaucracy, since in his opinion the duty of the physician is or should be one of racial leadership.” In the camps, Jewish doctors among the inmates on occasion were forced into assuming various roles in the Nazis' projects.

Lifton [Lifton RJ: The Nazi Doctors: Medical KillIng and the Psychology of Genocide.] found that many of the Nazi doctors coped with the tension between their usual selves and values and the roles that they had in the camps by ‘doubling,’ i.e., by forming a self that could tolerate and adapt to the total perversion of traditional medical values. “In sum, doubling is the psychological means by which one invokes the evil potential of the self. That evil is neither inherent in the self nor foreign to it. To live out the doubling and call forth the evil is a moral choice for which one is responsible, whatever the level of consciousness involved.” [Lifton RJ: The Nazi Doctors: Medical KillIng and the Psychology of Genocide.]

Even more disturbing than the mass killings of the concentration camps was how the prisoners were routinely stripped of all human dignity. The camps and the killing was all about efficiency. Having prisoners naked added to the efficiency and made them more compliant.

Within 90 minutes of arrival at the camps, after being stripped of possessions, clothes and all human dignity, prisoners were prodded naked down what the SS laughingly called Himmelstrasse  -  "the road to heaven"  -  to the "showers." 

They complied because the guards were authority figures and the purpose of undressing was for "hygiene" and "medical" reasons. The medical aspect was to choose the which prisoners were to be used for slave labor and medical experiments, the rest were sent to the gas chambers. 

Medicalization of the killing process was one of the many deceptions the Nazis used. It was partly for the victims so that they can be rendered non-resisting as much as possible, and for the Nazis, so they can see themselves as some way caring out a legitimate medical procedure. 

Auschwitz was not just an extermination camp, it was the clearest example of German doctors betrayal of all their ethical training. For the first time physicians could implement death into their medical research. Buchenwald was the first camp to use prisoners for medical experiments, but it was not the only one.

Doctors had been the largest professional group to join the SS. Their crimes were so great, that a separate trial took place in Germany for them. The object of their experiments was not how to rescue or cure, but to destroy and kill.

Read more about the key role that SS physicians played in the concentration camps here:

Even TodayThe United States Military, CIA Compelled Physicians to Abuse Detainees at Gitmo

Defense Department and CIA interrogation policies after 9/11 forced medical professionals to abandon their ethical obligations to "do no harm" to those in their care and some prohibited practices, including force-feeding of hunger strikers, continue today, a report issued Monday alleges.

The report, Ethics Abandoned: Medical Professionalism and Detainee Abuse in the War on Terror, was carried out by a 19-member task force of Columbia University's Institute on Medicine as a Profession and the Open Society Foundations. The researchers spent two years examining public records of medical professionals' involvement in military and intelligence interrogations and treatment of detainees.

It accuses the counter-terrorism operations of having "improperly demanded that U.S. military and intelligence agency health professionals collaborate in intelligence gathering and security practices in a way that inflicted severe harm on detainees in U.S. custody." (Source: LA Times, November 4, 2013)

The "restraint chair" used to immobilize and force-feed detainees on hunger strike in the prison hospital at Guantanamo Bay, Cuba. A report issued Monday said doctors and other medical professionals have been forced by the Pentagon and the CIA to take part in abusive practices that violate their ethical commitments. (Joe Raedle / Getty Images)

Even more:

A piece in the medical journal Tropical Medicine and International Health is raising questions about possible medical abuse at the prison facility because of the use of a controversial anti-malaria drug connected to serious side effects, including depression, anxiety, panic attacks, nausea, vomiting, sores and suicidal thoughts and behavior. (Source: Mintpress News, August 30, 2012)

How to explain the "Mother Theresa to Mengele" Phenomenon 

There are two famous experiments that can explain the transformation that takes place among medical providers as they go through their training. They are the "Stanford Prison Experiment" and the "Milgram Experiments."

The results of these experiments was so traumatic to the participants that the Stanford Prison Experiment was stopped in less than half the time it was planned. Some have deemed these experiments unethical and should never be repeated.

The Stanford Prison Experiment

Stanford University ran an experiment that was to become famous. Known as the Stanford Prison Experiment, 24 participations were arbitrarily split into two groups, with 12 role-playing prisoners and 12 role-playing guards. The experiment was to last 2 weeks and was going to investigate the mental and emotional changes that a person goes through when they are a prisoner.

The experiment is explained in great detail in the book The Lucifer Effect by Philip Zimbardo. It is a rather harrowing read; in very little time what started out as role-playing became real life. The guards took to their new positions with brutality and mental and physical abuse was rife. The prisoners became insular and it was like an accelerated course in learned helplessness. They either became robots blindly following the guard’s requests or began to rebel – trying to escape or going on a hunger strike.

The experiment was meant to last for two weeks but was stopped after six days when three prisoners had been released early due to mental breakdowns.

All participants, whether they ended up being prisoners or guards, considered themselves pacifists and non-violent types, your quintessential hippies. But the setting and the situation changed all of this in a very short space of time. The book goes on to review the situation at Abu Ghraib prison, where prisoners were tortured and photos were taken showing the depraved behaviour. It was like history repeating itself but without someone pulling the plug after six days.

During the summer of 1971, an unprecedented experiment was conducted by Stanford University psychology professor Philip Zimbardo, involving a mockup of a prison built in the basement of the university’s Psychology Department. 24 undergraduate students were paid $15 a day to participate in what was intended to be a two-week experiement. They were either assigned a role as a prison guard or as a prisoner, and the guards were told to run the ‘prison’ as they saw fit with the one condition that they were not to use violence.  

The students who were assigned roles as prisoners were ‘arrested’ by Palo Alto police officers who escorted them to the prison, fingerprinted them, after which the prisoners were given ill-fitting smocks and rubber sandals with their given ‘numbers’ sewn. Some prisoners were forced to be naked as a method of degradation.

The whole thing went out of hand relatively quickly, despite the fact that both the guards and the prisoners knew that they were participating in an experiment. A riot ensued on the second day; the prison quickly became filthy and unsanitary. Prisoners began to show severe acute emotional disturbances even within the first few days, forcing the prison ’superintendent’, Zibargo himself, to intervene on behalf of two prisoners who were eventually ‘released’ from the experiment. The guards also became progressively more sadistic, denying food to unruly prisoners, forcing them to spend time in isolation, and even making them clean the bathrooms with their bare hands. The experiment ended after six days, when it became clear that the situation was spiralling out of control in its eerie realism. 

"The Stanford prison was a very benign prison situation and it still caused guards to become sadistic, prisoners to become hysterical… it promoted everything a normal prison promotes … sadism, confusion and shame. " 

The following is a 29-minute long BBC documentary on the experiment:

It’s disturbing to note how people, irrelevant of personality or character, are able to impose authority, or on the other hand submit meekly without questioning, and furthermore to assume roles that are entirely made up. One must realize that an experiment of its kind, for its unethical nature, will probably never be reproduced again.

Yet, this is repeated thousands upon thousands of times each day in the U.S. healthcare system where dignity is trampled upon, building trust is not done, and authoritarianism is used in the name of entitlement (to patient's bodies), efficiency, and paternalism.

The Milgram Experiments

In the post Holocaust era, the question of how normal people could commit such horrid acts to one another haunted the American psyche.  Stanley Milgram decided to investigate this occurrence, in what turned out to be one of the most famous modern psychology experiments in history.

Milgram wanted to see if normal people would comply if authority figures told them to do inhuman acts.  To do this, he set up a scenario where his subjects would think that they were giving escalating shocks to a person to the point where it could be lethal.  The only prodding these subjects would receive to continue giving higher voltage shocks was from an authority figure in a white lab coat telling them that they must continue with the experiment.

The results of his experiment (which are summarized here:) were disturbing, because the majority of subjects did continue to “shock” someone until the lethal levels when prodded by the authority figure.
Two slips of paper marked "teacher" were handed to the subject and to the co-subject. The co-subject was actually an actor who, in posing as a subject to the experiment, subsequently claimed that his slip said "learner" such that the unknowing subject was inevitably led to believe that his role as "teacher" had been chosen randomly.
Both learner and teacher were then given a sample 45-volt electric shock from an apparatus attached to a chair into which the "actor-learner" was to be strapped. The fictitious story given to the "teachers" was that the experiment was intended to explore the effects of punishment for incorrect responses on learning behavior.

A succession of unknowing subjects in their roles as teacher were given simple memory tasks in the form of reading lists of two word pairs and asking the "learner" to read them back and were instructed to administer a shock by pressing a button each time the learner made a mistake. It was understood that the electric shocks were to be of increased by 15 volts in intensity for each mistake the "learner" made during the experiment.

The shock generator that the "teacher" was told to operate had 30 switches in 15 volt increments, each switch was labeled with a voltage ranging from 15 up to 450 volts. Each switch also had a rating, ranging from "slight shock" to "danger: severe shock". The final two switches being labelled "XXX".
The experiment was conducted in a scenario where the "learner" was in another room but the "teacher" was made aware of the "actor-learner's" discomfort by poundings on the wall.

No further shocks were actually delivered - the "teacher" was not aware that the "learner" in the study was actually an actor who was intended, by the requirements of the experiment, to use his talents to indicate increasing levels of discomfort as the "teacher" administered increasingly severe electric shocks in response to the mistakes made by the "learner".

The experimenter was present in the same room as the "teacher" and whenever "teachers" asked whether increased shocks should be given he or she was verbally encouraged by the experimenter to continue.

These encouragements were, in fact, pre-scripted by the research team and followed this pattern:-

Prod 1: Please continue or Please go on.
Prod 2: The experiment requires that you continue.
Prod 3: It is absolutely essential that you continue.
Prod 4: You have no other choice, you must go on.

These Prods were to be deployed successively by the researchers - a higher number Prod could only be used if a lower number one had proved unsuccessful.

Each experimental session was terminated whenever Prod 4 failed to induce the "teacher" to continue administering electric shocks. In this scenario 65% of the "teachers" obeyed orders to punish the learner to the very end of the 450-volt scale! No subject stopped before reaching 300 volts!

At times, the worried "teachers" questioned the experimenter, asking who was responsible for any harmful effects resulting from shocking the learner at such a high level. Upon receiving the answer that the experimenter assumed full responsibility, teachers seemed to accept the response and continue shocking, even though some were obviously extremely uncomfortable in doing so.

How does this Happen to Physicians?

The process of becoming a doctor is so extremely challenging to most physicians cannot help but feel their survival is threatened from time to time. So behaviors/attitudes get driven into their mental programming as a Survival Mechanism. Physicians learn them at a deep subconscious level and can’t turn them off.

So what are these learned behaviors? Here are some. Some of the following learned behaviors desexualize the human body but also lead to abuses of human dignity:

• being a workaholic
• looking professional
• hide emotions/feelings
• being a "loner"
• use scientific, technical language
• focus on getting the task done
• using a chaperone
• objectifying the patient
• using power to control and/or intimidate patients to do what they’re told

No instructors, professors or attendings has ever tried to "brainwash" physicians consciously and on purpose. The expectations and attitudes that create this subconscious programming are built into nearly every facet of their medical education as NORMAL and "the way things have always been done around here".  [Have we heard that before?]

To most physicians in private practice the programming is invisible and unrecognized and the automatic behaviors it produces are dysfunctional and baffling. This “brainwashing” virtually guarantees physician burnout in their 40’s and 50’s AND for abuses of patient dignity to occur.

How deeply are physicians brainwashed?

Basic training in the military is 8 weeks. In that time they can condition an 18 year old to take a bullet on command. Medical education is a minimum of 7 years, for some physicians it could be 12 years.  I believe there is no more thorough conditioning program on the planet than becoming a doctor.

Conclusions:

Is there a Mr. Hyde hiding in the good Dr. Jekyll?

What is the good of saving a life if the quality of that life is not worth living (PTSD)? Just because "that was the way you were taught" OR "that is the way it is done here" does NOT mean that that is the correct and most dignified way to perform a procedure. The protocols for many procedures 25 years ago would NEVER be acceptable today.

This is how some patients feel during a procedure:

Don't believe me, OR are you lying to yourself?

Consider Peter Ubel, M.D., author of Critical Decisions and Free Market, and a post he made on Psychology Today:

I felt a woman’s uterus without her permission. How this happened, and why I thought I had done the right thing at the time, tells us something important about medical education and shows us why doctor/patient interactions often play out like conversations between earthlings and aliens.  

To understand my inappropriate actions, you need to know something about the physical exams that we physicians conduct on our patients. More specifically, about the pelvic exams we perform to assess whether a woman’s uterus or ovaries are potentially diseased... 

...But we know that we must overcome our nerves and practice. I certainly knew of my need to practice when I walked into the operating room that day, in 1987, gowned and gloved and prepared to assist the surgeon in any way possible... 

“Student, come over here right now,” the surgeon said. “We need to start the operation, but you need to examine the patient first.”  

“Come over and feel her uterus,” she told me. “She has a large uterine mass. You need to know how to recognize this kind of mass on a pelvic exam.”

“Don’t worry,” the surgeon continued. “She’s anesthetized and won’t feel a thing. Plus, her muscles are totally relaxed from the anesthetics, so you will have a much easier time feeling the anatomy.” 

I inserted two fingers from my right hand into her vagina, pressed gently on her abdomen with my left, her uterus now squeezed between my two hands. Yep.  Definite mass. My physical examination skills were now inching towards expertise. My surgical supervisor had helped me develop as a physician. 

But of course, she’d also shaped my moral development. I had examined the woman, after all, without her permission. How could the surgeon and I have thought that it was acceptable to do this?  I could only speak for myself. To begin with, I was frantically obsessed with learning my new trade.  In addition, I wanted to impress the surgeon and get a good grade on the rotation. So when I stood there in the O.R. that day, presumably facing a moral dilemma, I barely gave the situation a second thought. 

The result of that was that I began thinking that this kind of action was ok. The surgeon, after all, was a wonderful person, committed to medical education and patient care. And I knew that I had nothing but good intentions in examining this patient. There was nothing prurient in my behavior.  I simply wanted to become a better clinician. 

But I’m sure if we had woken up that woman and told her what happened, she would have been horrified. The women I have surveyed on this topic say that, while they’d be willing to give permission for medical students to practice pelvic examinations on them, they would feel violated if such practice occurred without their permission.  

Moral attitudes are often a function more of our experience than of our training. When some colleagues and I surveyed medical students and asked them how important it was to ask permission before conducting a pelvic exam on an anesthetized woman, brand new medical students almost universally stated that permission was vital but by the time the students finished their OB/GYN rotations three years later, they didn’t see permission as being important anymore (see paper here). 

Despite the lectures they’d received about “informed consent” during the first two years of medical school, six weeks of an OB/GYN rotation was enough to change their moral attitudes.

 Are you Medical or a Monster??? 

What would your patients say?

How do you know???

--Banterings