The Effect of Hierarchy on Moral Silence in Healthcare: What Can the Holocaust Teach Us?

Published: Dec 31, 2019
Holocaust medical education hierarchy power imbalance conscience formation conscientious objection bioethics education
Ashley K. Fernandes
DiAnn Ecret
Physicians, nurses, and healthcare professional students openly (and in many cases, eagerly) participated in the medical atrocities of the Shoah. In this paper, a physician-bioethicist and nurse-bioethicist examine the role of hierarchical power imbalances in medical education, which often occur because trainees are instructed ‘to do so’ by their superiors during medical education and clinical care. We will first examine the nature of medical and nursing education under National Socialism: were there cultural, educational, moral and legal pressures which entrenched professional hierarchies and thereby commanded obedience in the face of an ever-diminishing individual and collective conscience? We will then outline relevant parallel features in modern medical education, including the effects of hierarchy in shaping ethical decision making and conscience formation. We then propose several solutions for the prevention of the negative effects of hierarchical power imbalances in medical education: (1) universal Holocaust education in medical and nursing schools; (2) formative and experiential ethics instruction, which teaches students to ‘speak up’ when ethical issues arise; (3) acceptance of, and adherence to, a personalistic philosophical anthropology in healthcare; (4) support for rigorous conscience protection laws for minority ethical views that respect the role of integrity without compromising patient care.
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Author Biographies
Ashley K. Fernandes, The Ohio State University College of Medicine/Nationwide Children's Hospital
Dr. Ashley K. Fernandes, MD, PhD is the Director of the Professionalism Competency, the Associate Director of the Center for Bioethics, and Associate Professor of Pediatrics at The Ohio State University College of Medicine and Nationwide Children's Hospital.
DiAnn Ecret, Jefferson College of Nursing
DiAnn Ecret, PhD, MSN, RN, MA, is an assistant professor of Nursing in the Jefferson College of Nursing, Philadelphia, PA
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