Ethical dilemmas regarding allocation of medical resources

Luba Bielicka Blum

Luba Bielicka Blum studied and qualified at the nursing school in Warsaw, becoming its director at the outbreak of war. Blum obtained permission from the Nazis for the nursing school in the ghetto to continue to function. When the Nazis imposed mass deportations on the ghetto, including those of nurses, she had to make heart-rending decisions as to who would stay and who would go. She based her decisions on examination grades. Later, just before the ghetto uprising, Blum and her children, using her connections with Polish nurses, managed to escape from the Ghetto after the Nazis had killed the patients and most of her nurses at the hospital.11 Her story was related by the Surgeon General at her grave (figure 2).

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Figure 2

Surgeon General, Israel Defense Force, relating Luba Blum's story at her grave.

Through these cases, we see how despite impossible conditions some medical practitioners continued with forbidden education, research and patient care, while facing hunger, disease and impending annihilation for themselves and their families.4

These cases illustrate principles of medical ethics as related to distributive justice and ethical triage3 and stimulated discussion of these principles.

The medical oath and Nazi medical practice

Traditionally, the Hippocratic Oath was sworn by the physician as the moral and ethical basis for his/her life's work. State licences allow the physician to practice medicine but the physician makes his oath voluntarily, to all humanity and not to any State. If State actions are not compatible with the oath, the physician must resist the demands of the State.12 In 1931 ‘Guidelines for New Therapy and Human experimentation’, formulated by a Jewish German doctor and politician Dr Julius Moses, including 14 measures to prevent medical malpractice, was published in Germany. Under Nazi influence, the German medical profession willingly disregarded these principles, as well as the Hippocratic Oath, respecting instead the perceptions and priorities of the Third Reich. The Nazis even changed the terminology, replacing the idea of ‘healthcare’ with ‘health leadership’—doctors no longer owing a duty to their patients as individuals but to the State.13 Legislation on human experimentation was rescinded.5 14 Nazi doctors carried out forced sterilisations and implemented the Nuremberg laws medicalising Nazi social policies.5 They carried out a policy of euthanasia of the disabled and mentally ill and participated in mass exterminations and genocide, as well as sadistic experiments in the name of science.

One example was Dr Joseph Mengele and his inhuman method of containing spotted fever (typhus) and other infectious diseases in Auschwitz, as well as his infamous participation in selections. The group was told how one case of rubella in a certain inmate block led him to send 600 inmates of the ‘infected’ block and its adjacent blocks to their deaths in the gas-chambers in order to contain the epidemic.15

The Nazi doctors medicalised killing by using controlled technology to kill a large number of people, as well as maintaining distance between killer and victim. This was important in enabling the Einsatzgruppen troops to carry out their ghastly work.16 Nazis disregarded the right to life, autonomy and dignity, as well as many other medical ethical principles. As far as military medical ethics were concerned, they showed gross disregard to non-combatants and prisoners, who were denied medical care, tortured and killed. The Nazis clearly showed moral complicity.

Nazi pseudo-research and sadistic experiments

Nazi pseudo-research and sadistic experiments were related to the group in the punishment block in Auschwitz, near Block 10 where many of these deeds took place. Hypothermic and hypobaric research that had taken place in Dachau, Germany, was described. Personal testimony was given by an officer whose grandmother had been repeatedly raped as part of a fertility and sterilisation pseudo-experiment at this very site.

One of the experimentation programmes that was studied at greater length was human hypothermic research in which Nazi physicians exploited concentration camp inmates. Their aim was to understand the consequences to German pilots downed over the North Sea, and how protection and medical treatment could be improved. The Nazis disregarded major principles of medical ethics, including voluntary and informed consent in human experimentation, as well as the right to life and dignity. Although many felt that the data were not of any real scientific value, others disagreed. Unfortunately and unethically, some used their findings after the war. The group discussed experimentation in general and human experimentation in particular. The discussion included guidelines for experimentation and the dilemmas in the rejection of unethical research.2

Courage of medical professionals

Janusz Korczak was a paediatrician and principal of an orphanage in the Warsaw ghetto. Rather than escaping to the Aryan side of Warsaw, he chose to accompany his deported charges to the concentration camp and ultimate death. The scene outside the orphanage was later recalled by Berman.15 19 The group received a lecture on this subject and visited a monument dedicated to Dr Korczak.

Tadeusz Pankiewicz was a Christian pharmacist. The group visited the site of his pharmacy, Apteka Pod Orleo (The Pharmacy Under the Eagle), strategically positioned on the border of the ghetto in Krakow. A pharmacist in the group related how the site allowed him to smuggle Jews, food and medication in and out of the ghetto. Although he was not Jewish, he had risked death by his efforts.20

In the previous sections, supererogatory acts have been described that may initially seem of doubtful relevance to quotidian moral behaviour. However, they provide lessons in survival and functioning when faced with extreme situations and impossible choices. Similar dilemmas could be faced by military physicians and we discussed the pressure on physicians who stayed true to their humanity and vocation, remaining resolutely professional and compassionate.

Inmate doctors

Gisella Perl was a gynaecologist from Hungary. She was deported to the Auschwitz-Birkenau concentration camp in 1944 and was made to work as an inmate doctor in the infirmary, which was nothing more than an unconverted former horse stable. There was little in the way of treatment and often none at all. Perl describes how she tried her best to help the prisoners, despite the primitive conditions and without anaesthetics. She assisted at births and carried out abortions21 since being pregnant in the concentration camp was a death sentence. Her actions and her moral dilemmas regarding abortions to save the mothers were discussed in an AVP.22 These are well expressed by Meyerhoff ‘[She]risked death and eternal damnation…and came to be hailed on behalf of ‘simple humanity’ at the price of thousands of lives which might have been, but never were and never will be. [She]was right in being what she was by committing this enormous wrong.’

Aliza Baruch was deported as a girl to Auschwitz from Saloniki, Greece. She was ordered to be sterilised by Dr Mengele as a part of a brutal human experiment on sterilisations. The surgery was performed by a Jewish doctor under the watchful eye of a Polish doctor in the infamous medical Block 10. After the war, although she believed that she had been rendered infertile, she became pregnant. The Jewish doctor had pretended to sterilise her while the Polish doctor was distracted during an air raid. The Jewish doctor was later put to death. His actions were discussed in an AVP.23

Ceremonies

Great importance was placed on military ceremonies performed by the participants at concentration camps and other places of mass slaughter, to honour the victims. The ceremonies were performed in full dress uniform. Eulogies and psalms were read. Kaddish, the traditional Jewish prayer for the dead, was recited and the Last Post was sounded. Two ceremonies were of special note. The first, on the bleak site of the Treblinka concentration camp, where 13 doctors read the names of 13 of the doctors among the hundreds who were killed at this camp. The names included that of Janusz Korczak and other doctors discussed during the programme. Another moving ceremony took place at the British military cemetery in Krakow. Standing among the graves the group was told how British Prisoners of War (POWs) did all in their power to stop Jewish POWS being separated from the rest of the troops by the Nazis. Wilson described how in one group of POWs, when the Jews were instructed to take three steps forward every single soldier in the unit took three steps forward.24 British troops showed morals and ethics not often seen in other armies.

The ceremonies illustrated military ethics, showing honour and respect, while visiting the British graves illustrated loyalty, duty and personal courage.