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

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Published: Dec 31, 2019
DOI: https://doi.org/10.12681/cjp.21763
Keywords:
Holocaust medical education hierarchy power imbalance conscience formation conscientious objection bioethics education
Ashley K. Fernandes
The Ohio State University College of Medicine/Nationwide Children's Hospital
https://orcid.org/0000-0002-8376-0544
DiAnn Ecret
Jefferson College of Nursing
https://orcid.org/0000-0001-8145-0203
Abstract
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
References
Baron-Cohen, Simon. The Science of Evil. New York: Basic Books, 2017.
Baumslag, Naomi. Murderous Medicine: Nazi Doctors, Human Experimentation, and Typhus. Westport CT: Greenwood Publishing, 2005.
Benedict, Susan, and Jane M. Georges. “Nurses and the Sterilization Experiments of Auschwitz: A Postmodernist Perspective.” Nursing Inquiry 13, no. 4 (2006): 277-288.
Benedict, Susan. “Maria Stromberger: A Nurse in the Resistance in Auschwitz.” Nursing History Review 14, no. 1 (2006): 189-202.
Berlinger, Nancy, and Elizabeth Dietz. “Time-out: The Professional and Organizational Ethics of Speaking up in the OR.” American Medical Association Journal of Ethics 18, no. 9 (2016): 925-932.
Branch, William T. “Supporting the Moral Development of Medical Students.” Journal of General Internal Medicine 15, no. 7 (2000): 503-508.
Brown, Teresa. “Healing the hospital hierarchy.” New York Times, March 16, 2013. https://opinionator.blogs.nytimes.com/2013/03/16/healing-the-hospital-hierarchy/.
Bruns, Florian, and Tessa Chelouche. “Lectures on Inhumanity: Teaching Medical Ethics in German Medical Schools under Nazism.” Annals of Internal Medicine 166, no. 8 (2017): 591-596.
Caldicott, Catherine V., and Kathy Faber-Langendoen. “Deception, Discrimination, and Fear of Reprisal: Lessons in Ethics from Third-Year Medical Students.” Academic Medicine 80, no. 9 (2005): 866-873.
Cheng, Maria. “Belgium Investigates Doctors Who Euthanized Autistic Woman.” Associated Press News, November 27, 2018. https://www.apnews.com/249a8067af6740d2af22ed66fc9e1a90.
Christakis, Dimitri A., and Christopher Feudtner. “Ethics in a Short White Coat: The Ethical Dilemmas that Medical Students Confront.” Academic Medicine 68, no. 4 (1993): 249-254.
Colaianni, Alessandra. “A Long Shadow: Nazi Doctors, Moral Vulnerability and Contemporary Medical Culture.” Journal of Medical Ethics 38, no. 7 (2012): 435-438.
Crowe, Sophie, Nicholas Clarke, and Ruairi Brugha. “‘You Do Not Cross Them:’ Hierarchy and Emotion in Doctors’ Narratives of Power Relations in Specialist Training.” Social Science & Medicine 186 (2017): 70-77.
DiPalma, Carolyn. “Power at Work: Navigating Hierarchies, Teamwork and Webs.” Journal of Medical Humanities 25, no. 4 (2004): 291-308.
Dixon, D. P. “Informed Consent or Institutionalized Eugenics? How the Medical Profession Encourages Abortion of Fetuses with Down Syndrome.” Issues in Law and Medicine 24, no. 1 (2008): 3-59.
Donohue, J. J., and S. D. Levitt. “The Impact of Legalized Abortion on Crime.” The Quarterly Journal of Economics 116, no. 2 (2001): 379-420.
Dwyer, James, and Kathy Faber-Langendoen. “Speaking Up: An Ethical Action Exercise.” Academic Medicine 93, no. 4 (2018): 602-605.
Dwyer, James. “Primum non Tacere. An Ethics of Speaking Up.” Hastings Center Report 24, no. 1 (1994): 13-18.
Fenigstein, Allan. “Milgram’s Shock Experiments and the Nazi Perpetrators: A Contrarian Perspective on the Role of Obedience Pressures during the Holocaust.” Theory and Psychology 25, no. 5 (2015): 581-598.
Fenigstein, Allan. “Were Obedience Pressures a Factor in the Holocaust?” Analyse & Kritik 20, no. 1 (1998): 54-73.
Fernandes, Ashley K. “Nazi Medicine and the Holocaust: Implications for Bioethics Education and Professionalism.” In Nazi Law: From Nuremberg to Nuremberg, edited by John J. Michalczyk, 149-153 (London: Bloomsbury Press, 2017).
Fernandes, Ashley K., et al. “Integrating Simulated Patients in TBL: A Strategy for Success in Medical Education.” Medical Science Educator 29, no. 2 (2019): 383-387.
Fiala, Christian, and Joyce H. Arthur. “‘Dishonourable Disobedience’ – Why Refusal to Treat in Reproductive Healthcare is not Conscientious Objection.” Woman – Psychosomatic Gynaecology and Obstetrics 1 (2014): 12-23.
Gergerich, Erika, Daubney Boland, and Mary Alice Scott. “Hierarchies in Interprofessional Training.” Journal of Interprofessional Care 33, no. 5 (2019): 528-535.
Ginsburg, Liane, and Lorna Bain. “The Evaluation of a Multifaceted Intervention to Promote ‘Speaking Up’ and Strengthen Interprofessional Teamwork Climate Perceptions.” Journal of Interprofessional Care 31, no 2 (2017): 207-217.
Haeberle, Bennet. “Former Mount Carmel Doctor Pleads not Guilty to 25 Counts of Murder; Bond Set at $1 million.” Columbus Dispatch, accessed on October 22, 2019. https://www.10tv.com/article/former-mount-carmel-doctor-pleads-not-guilty-25-counts-murder-bond-set-1-million-2019-jul.
Hall, Wayne, and Malcom Parker. “The Need to Exercise Caution in Accepting Addiction as a Reason for Performing Euthanasia.” Addiction 113, no. 7 (2017): 1178-1180.
Heylens, G., et al. “Transgender Persons Applying for Euthanasia in Belgium: A Case Report and Implications for Assessment and Treatment.” Journal of Psychiatry 19, no. 1 (2016): 347-348.
Kuntz, K. “Euthanasia Doctors Seek Existential Answers at Auschwitz.” Spiegel Online, November 21, 2014. http://www.spiegel.de/international/zeitgeist/belgian-euthanasia-doctors-seek-answers-at-auschwitz-a-1003441.html.
Lagerwey, Mary Deane. “The Third Reich, Nursing, and AJN.” American Journal of Nursing 109, no. 8 (2009): 45-48.
Lempp, Heidi, and Clive Seale. “The Hidden Curriculum in Undergraduate Medical Education: Qualitative Study of Medical Students’ Perceptions of Teaching.” British Medical Journal 329, no. 7469 (2004): 770-773.
Levi, Primo. Survival in Auschwitz: The Nazi Assault on Humanity. Translated by Stuart Woolf. New York: First Collier Books, 1993.
Lifton, Robert J. The Nazi Doctors: Medical Killing and the Psychology of Genocide. New York: Basic Books, 2000.
Malloy, David, et al. “Culture and Organizational Climate: Nurses’ Insights into their Relationship with Physicians.” Nursing Ethics 16, no. 6 (2009): 719-733.
Maritain, Jacques. The Person and the Common Good. Translated by John J. Fitzgerald. South Bend: University of Notre Dame Press, 1985.
Martinez, William, et al. “Speaking Up about Traditional and Professionalism-related Patient Safety Threats: A National Survey of Interns and Residents.” British Medical Journal Quality and Safety 26, no. 11 (2017): 869-880.
Martinez, William, Sigall K. Bell, Jason M. Etchegaray, and Lisa S. Lehmann. “Measuring Moral Courage for Interns and Residents: Scale Development and Initial Psychometrics.” Academic Medicine 91, no. 10 (2016): 1431-1438.
McKie, Andrew. “‘The Demolition of A Man:’ Lessons From Holocaust Literature For The Teaching Of Nursing Ethics.” Nursing Ethics 11, no. 2 (2004): 138-149.
Neumann, Melanie, et al. “Empathy Decline and Its Reasons: A Systematic Review of Studies with Medical Students and Residents.” Academic Medicine 86, no. 8 (2011): 996-1009.
Numminen, Olivia, Hanna Repo, and Helena Leino-Kilpi. “Moral Courage in Nursing: A Concept Analysis.” Nursing Ethics 24, no. 8 (2016): 878-891.
Pellegrino, Edmund D. “The Nazi Doctors and Nuremberg: Some Moral Lessons Revisited.” Annals of Internal Medicine 127, no. 4 (1997): 307-308.
Proctor, Robert N. Racial Hygiene: Medicine under the Nazis. Cambridge, Massachusetts: Harvard University Press, 1988.
Radlicz, Christopher M., and Ashley M. Fernandes. “Physician Conscience and Patient Autonomy: Are They Competing Interests?” Linacre Quarterly 86, no. 1 (2019): 139-141.
Reis, Shmuel, Hedy Wald, and Paul Weindling. “The Holocaust, Medicine and Becoming a Physician: The Crucial Role of Education.” Israel Journal of Health Policy Research 8, no. 1 (2019): 1-5.
Runciman, Bill, Merry Allen, and Merrilyn Walton. Safely and Ethics in Healthcare: A Guide to Getting it Right. Burlington, Vermont: Ashgate Publishing, 2007.
Russell, Nestar, and Robert Gregory. “Making the Undoable Doable: Milgram, the Holocaust, and Modern Government.” The American Review of Public Administration 35, no. 4 (2005): 327-349.
Savulescu, Julian, and Udo Schuklenk. “Doctors Have No Right to Refuse Medical Assistance in Dying, Abortion or Contraception.” Bioethics 31, no. 3 (2017): 162-170.
Scott, H., Kim, J., Y. Raymond De Vries, and John R Peteet. “Euthanasia and Assisted Suicide of Patients with Psychiatric Disorders in the Netherlands 2011 to 2014.” Journal of the American Medical Association Psychiatry 73, no. 4 (2016): 362-368.
Sheldon, Tony. “Dutch Approve Euthanasia for Patient with Alzheimer’s Disease.” British Medical Journal 330, no. 7499 (2005): 1041.
Shields, Linda, and Thomas Foth. “Setting the Scene.” In Nurses and Midwives in Nazi Germany: The “Euthanasia Programs,” edited by Susan Benedict and Linda Shields, 1-12. New York: Routledge, 2014.
Shipman, Alexa R. “The German Experiment: Health Care without Female or Jewish Doctors.” International Journal of Women’s Dermatology 3, no. 1 (2015): 108-110.
Stahl, Ronit Y., and Ezekiel J. Emmanuel. “Physicians, Not Conscripts – Conscientious Objection in Healthcare.” New England Journal of Medicine 376, no. 14 (2017): 1380-1385.
Sulmasy, Daniel P. “What is Conscience and Why is Respect for It So Important?” Theoretical Medicine and Bioethics 29, no. 3 (2008): 135-149.
ten Have, Henk. Vulnerability: Challenging Bioethics. New York: Routledge, 2016.
The Nobel Prize. “Otto Loewi: Biographical.” https://www.nobelprize.org/prizes/medicine/1936/loewi/biographical/.
Vidal, Edison, et al. “Why Medical Schools are Tolerant of Unethical Behavior.” Annals of Family Medicine 13, no. 2 (2005): 176-180.
von Cranach, Michael. “Ethics in Psychiatry: The Lessons we Learn from Nazi Psychiatry.” European Archives of Psychiatry and Clinical Neuroscience 260, no. S2 (2010): 152-156.
Western Galilee College. “The Galilee Declaration.” http://english.wgalil.ac.il/category/Declaration.
Wynia, M. K., W. S. Silvers, and J. A. Lazarus. “How do U.S. and Canadian Medical Schools Teach about the Role of Physicians in the Holocaust?” Academic Medicine 9, no. 6 (2015): 699-700.