Time flies ....

To what extent are doctors agents of the state and does it matter? At a recent meeting organised by the Human Values and Health Care Forum, Professor Michael Burleigh presented historical data on the role of doctors—mainly psychiatrists and paediatricians—in the execution of the so called euthanasia policy, pursued and legalised in Nazi Germany in 1933. A contemporary account of the complexities of doctors’ involvement in state business was provided by a forensic psychiatrist who explored the ways that doctors are involved—with varying degrees of intimacy—in the punishment of those who offend against the state.

Burleigh’s paper contained material both fascinating and awful. It is clear from his research that most doctors were not coerced into murdering their patients, but rather volunteered for a course of action with which they were in political sympathy. Such behaviour is a nice example of distinction between the doctor as a medical scientist, and the doctor as a citizen, or, perhaps more clearly, as a political animal. Clearly people can be citizens, or political agitators, and can also be doctors. Their political and professional identities coexist; there are several such sitting in parliament. Equally, however, it must be possible for people to become doctors, and then use that medical knowledge or technical experience in the furtherance of political ends—that is, the clinical identity is used for the purposes of the political identity.

Should we contemplate excluding some types of people from being doctors?

Burleigh’s research makes plain the potential negative consequences of this confusion of identities. Doctors who were Nazi party members—45% of the medical population at one time—used their knowledge and clinical power to carry out Nazi policy. Doctors have cherished eugenicist beliefs on a variety of grounds, ranging from the religious to the quasiclinical, much like today. Such beliefs could be subsumed under the rubric of “clinical activity” to make it morally possible to act as a doctor while also serving political views.

Of course, this situation does not apply only to eugenics. Other political arenas in which doctors or citizens may hold strong views include policies about immigration and ethnicity, and the use of torture to control dissidents. Doctors have been active in the promotion of apartheid in South Africa; they participate in torture; and may be involved to a greater or lesser degree in judicial executions. In these situations, the political identity clashes with the professional one and seems to supersede it.

One response from doctors is often to say “Let’s separate our identities completely. One’s political identity is discrete from, and irrelevant to, one’s identity as a doctor.” This separation is particularly acute given the positive moral identity often attributed to doctors; you must be virtuous because you’re a doctor. There are very few physicians who are depicted in the popular media as morally flawed. Even if they can be gruff, irritable, or even traumatised, they are still basically good guys.

And sometimes, there are good guys in medicine. It may even be that doctors are more often good guys when they elide their two identities for good purposes. Dr Aneez Esmail and Dr Sam Everington have used their medical identities and experience to expose racism in medicine in several articles (BMJ 1997;314:1619; BMJ 1998;316:193-5); painful as their findings have been to acknowledge, theirs is valuable work for which we should all be grateful. The name of Albert Schweitzer used to be a byword for someone who used medicine and medical practice to improve the general health of disadvantaged people. Individuals’ political agendas can take medicine forward, not just backward: can illuminate and develop the professional identity.

So it seems unlikely that we could, or should, separate out doctors’ political identities from their professional ones. Perhaps the key issue is to know which hat one is wearing, at any one time, and be able to be upfront about it. Danger seems to lie in those situations where political and ethical agendas are hidden under the guise of clinical material; and then separated or excluded from the public domain. We also have to think seriously about who we train as doctors. Should we contemplate excluding some types of people from being doctors; from working with the vulnerable? Civil service post applicants often undergo rigorous psychological testing. Are there medical graduates who, although technically highly competent and even scientifically brilliant, should be identified and excluded from ever being with patients, because of their beliefs about other people?

Although 60 years may seem a long time ago, not much historical time separates us from our counterparts who worked in Nazi Germany. I wonder if time went by quickly or slowly for the doctors and nurses who actively participated in killing their patients. Even if the present is very different from the past, as Burleigh is keen to emphasise, it cannot be assumed that those doctors and nurses were completely different from doctors today. Evil is not in the past, it is a state of mind that anyone can enter. External vigilance and professional self reflection are important safeguards for the future.

Figure.

BARNABY’S PICTURE LIBRARY

At one time 45% of German doctors were members of the Nazi party