Oaths I Never Swore

There’s a common misconception around the manner in which doctors graduate. All sorts of people assume that when we go to graduate, there is a sacred swearing of oaths, particularly the Hippocratic Oath. And every time someone mentions this to me, I break out in a slight cold sweat and wonder if I missed the all important tribal council meeting. The one where all potential medical graduates have to wrestle a snake and tie it in knots around a staff to win immunity and walk away carrying the rod of Asclepius. Unless they want to be psychiatrists in which case they get inside the serpent’s head, make it examine its life at length and eventually have it realise that twisting around a staff represents self-actualisation.

Actually, quite glad snake handling wasn’t part of the qualification. [via m.inmagine.com]

The Ethical Doctor

The thing is, I never took any sort of oath like that. I think the last time I swore an oath was probably when I was a scout learning to tie knots and shave cats (not in a bad way, really). Taking the Hippocratic Oath (or a modern version) is very common in the US graduation rituals, but not such a feature in the Antipodes. Which is not to say we didn’t get lots of coaching in medical ethics, with some of Hippocrates’ bon mots still in there. Just no secret handshaking solemn oath-swearing rituals.

If I’m reflecting on how doctors develop their understanding of ethics, and whether that’s changed over time, it’s because I recently read the most astonishing article I’ve seen in a long time, by Emily Bazelon and appearing in Slate. It details a history I’d not heard of regarding the anatomists working throughout the period of Nazi rule and their acceptance of the bodies of those executed by the regime. Acceptance and even cooperation. More than this it poses big but essential questions. How do we judge historical practices by modern norms? Should we build off knowledge gained in horrifying circumstances? How far would ethical practitioners go when surrounded by a drifting crowd? And what happens when knowledge gained in such a manner is distorted further?

Different Times

At a time when bodies for advancing anatomy were hard to come by, it was common practice to use the bodies of the executed. When the Nazi regime started executing much larger numbers of prisoners, including women, the question of whether to study those bodies seems not to have been considered. And so it was that Hermann Stieve suddenly had access to the bodies of women executed who had lived with the stress of being condemned to death.

Stieve established that stress alters the female reproductive cycle. Fast forward a few decades, and the idea that stress makes it impossible to fall pregnant makes it way into the suggestion that a woman can’t conceive in cases of “legitimate rape” (*shudder* and no link to that drivel). The ills of that ridiculous statement are for another post (and probably another writer). To conduct the research that led to this, Stieve accepted many more bodies than he would require, and coordinated execution times with prison authorities. Is his conduct that of the pragmatist operating by the ethics of the time seeking to understand the world around him, or someone colluding with a terrible regime without due regard for human life? There are arguments both ways, but there would have  to be a certain degree of callousness to proceed in the manner he did.

One of a Crowd

The article makes it clear though that Stieve was hardly alone in this practice. Around half of the doctors in Germany at the time joined the Nazi party. Many terrible experiments were conducted at the time. Were they the product of a prevailing lack of ethical considerations, or the result of a drift in morality starting at the top, allowing behaviour that would never usually be condoned?

There are of course other studies that have been done over the years which hint at the extent to which individuals will adopt the morality conditioning of the situation built around them. The famous Milgram experiment where subjects were asked to deliver shocks to help “teach” an individual in a memory exercise revealed 65% of participants would deliver (false) electric shocks right up to a dangerous level. The Stanford Prison experiment is another example of research showing the powerful effect of situation on the behaviour of individuals (although the conduct of the study was itself questionable ethically).

After the war, only a few hundred doctors were deemed to have been involved in crimes, although the implication is that no serious effort was made to investigate initially. Follow-up work by Milgram indicated that even having a single other participant involved in delivering the shocks was enough to drop the rates of completion to the full shock range, as strength was gained when the other showed disquiet. So was the concept of ethics so different at the time that there weren’t more voices being raised to dispute what was happening, or was the silence evidence of the fear created by the regime if you did object?

Standing on Tainted Ground

One of the factoids I remember from my studies was that a commonly used drug in anaesthesia, pethidine, was explored as a potential nerve agent by Nazi scientists as it has atropine-like effects similar to some toxins. It stuck for obvious reasons although I struggle to find corroboration now. It may be that as it came out of the infamous IG Farben labs (the company responsible for much of the machinery that allowed for the operation of the gas chambers), it has been tainted by association even if it wasn’t part of the primary research by that company.

It came back to me when reading the source article – how much of what I know or rely on in my day to day work has its origins in research tainted by how it was conducted? What do you do if that information bears stains? Is it unethical to use that knowledge, or more unethical to not apply that knowledge to achieve good things?

Arthur Caplan, a bioethicist at New York University, is quoted providing some suggestions for how to deal with tainted data which could apply to medicine or science generally. His approach amounts to:

* Use it when there’s no other choice (the life-saving situation or very important stuff).

* Admit where it came from (this, of course, supposes that you know those details).

* Don’t give credit to the individual who did the tainted research by name.

Is this enough to perfume the stench though? Is it even realistic to think that most practitioners know the deep history informing their everyday practice?

Where now?

There is knowledge that has been uncovered over centuries in ways that would be considered unacceptable now. To discard all that knowledge would be impractical and ultimately self-defeating, as there is much of it that couldn’t be established again. Perhaps Caplan is right in that removing the individual researchers from the history but allowing good to come of the knowledge is the best way to provide redress.

In the meantime, these stories are a stark reminder of the need to constantly wrestle with the ethical principles that underpin modern medical practice. And I probably don’t need to swear an oath to Greek deities to remind me of the importance of that. Part of me wants to go and wrestle a snake now though.