GOOD AND SCIENCE ARE ALWAYS AT WAR:

Bush vs. the Laureates: How Science Became a Partisan Issue (ANDREW C. REVKIN, 10/19/04, NY Times)

Why is science seemingly at war with President Bush?

For nearly four years, and with rising intensity, scientists in and out of government have criticized the Bush administration, saying it has selected or suppressed research findings to suit preset policies, skewed advisory panels or ignored unwelcome advice, and quashed discussion within federal research agencies.

Administration officials see some of the criticism as partisan, and some perhaps a function of unrealistic expectations on the part of scientists about their role in policy debates. [...]

Dr. Jesse H. Ausubel, an expert on energy and climate at Rockefeller University, said some of the bitterness expressed by other researchers could stem from their being excluded from policy circles that were open to them under previous administrations. "So these people who believe themselves important feel themselves belittled," he said.

Indeed, much of the criticism has come from private groups, like the Union of Concerned Scientists and many environmental organizations, with long records of opposing positions the administration favors.

The 20th Century gave us some considerable experience with allowing scientists to make public policy about science, Medical Science Under Dictatorship (Leo Alexander, M.D., July 14, 1949, The New England Journal of Medicine)

There is no doubt that in Germany itself the first and most effective step of propaganda within the medical profession was the propaganda barrage against the useless, incurably sick described above. Similar, even more subtle efforts were made in some of the occupied countries. It is to the everlasting honor of the medical profession of Holland that they recognized the earliest and most subtle phases of this attempt and rejected it. When Sciss-Inquart, Reich Commissar for the Occupied Netherlands Territories, wanted to draw the Dutch physicians into the orbit of the activities of the German medical profession, he did not tell them" You must send your chronic patients to death factories" or "You must give lethal injections at Government request in your offices," but he couched his order in most careful and superficially acceptable terms. One of the paragraphs in the order of the Reich Commissar of the Netherlands Territories concerning the Netherlands doctors of 19 December 1941 reads as follows: "It is the duty of the doctor, through advice and effort, conscientiously and to his best ability, to assist as helper the person entrusted to his care in the maintenance, improvement and re-establishment of his vitality, physical efficiency and health. The accomplishment of this duty is a public task." The physicians of Holland rejected this order unanimously because they saw what it actually meant—namely, the concentration of their efforts on mere rehabilitation of the sick for useful labor, and abolition of medical secrecy. Although on the surface the new order appeared not too grossly unacceptable, the Dutch physicians decided that it is the first, although slight, step away from principle that is the most important one. The Dutch physicians declared that they would not obey this order. When Sciss-Inquart threatened them with revocation of their licenses, they returned their licenses, removed their shingles and, while seeing their own patients secretly, no longer wrote death or birth certificates. Sciss-Inquart retraced his steps and tried to cajole them—still to no effect. Then he arrested 100 Dutch physicians and sent them to concentration camps. The medical profession remained adamant and quietly took care of their widows and orphans, but would not give in. Thus it came about that not a single euthanasia or non-therapeutic sterilization was recommended or participated in by any Dutch physician. They had the foresight to resist before the first step was taken, and they acted unanimously and won out in the end. It is obvious that if the medical profession of a small nation under the conqueror's heel could resist so effectively the German medical profession could likewise have resisted had they not taken the fatal first step. It is the first seemingly innocent step away from principle that frequently decides a career of crime. Corrosion begins in microscopic proportions.

The Situation in the United States

The question that this fact prompts is whether there are any danger signs that American physicians have also been infected with Hegelian, cold-blooded, utilitarian philosophy and whether early traces of it can be detected in their medical thinking that may make them vulnerable to departures of the type that occurred in Germany. Basic attitudes must be examined dispassionately. The original concept of medicine and nursing was not based on any rational or feasible likelihood that they could actually cure and restore but rather on an essentially maternal or religious idea. The Good Samaritan had no thought of nor did he actually care whether he could restore working capacity. He was merely motivated by the compassion in alleviating suffering. Bernal states that prior to the advent of scientific medicine, the physician's main function was to give hope to the patient and to relieve his relatives of responsibility. Gradually, in all civilized countries, medicine has moved away from this position, strangely enough in direct proportion to man's actual ability to perform feats that would have been plain miracles in days of old. However, with this increased efficiency based on scientific development went a subtle change in attitude. Physicians have become dangerously close to being mere technicians of rehabilitation. This essentially Hegelian rational attitude has led them to make certain distinctions in the handling of acute and chronic diseases. The patient with the latter carries an obvious stigma as the one less likely to be fully rehabilitable for social usefulness. In an increasingly utilitarian society these patients are being looked down upon with increasing definiteness as unwanted ballast. A certain amount of rather open contempt for the people who cannot be rehabilitated with present knowledge has developed. This is probably due to a good deal of unconscious hostility, because these people for whom there seem to be no effective remedies have become a threat to newly acquired delusions of omnipotence.

Hospitals like to limit themselves to the care of patients who can be fully rehabilitated, and the patient whose full rehabilitation is unlikely finds himself, at least in the best and most advanced centers of healing, as a second-class patient faced with a reluctance on the part of both the visiting and the house staff to suggest and apply therapeutic procedures that are not likely to bring about immediately striking results in terms of recovery. I wish to emphasize that this point of view did not arise primarily within the medical profession, which has always been outstanding in a highly competitive economic society for giving freely and unstintingly of its time and efforts, but was imposed by the shortage of funds available, both private and public. From the attitude of easing patients with chronic diseases away from the doors of the best types of treatment facilities available to the actual dispatching of such patients to killing centers is a long but nevertheless logical step. Resources for the so-called incurable patient have recently become practically unavailable.

There has never in history been a shortage of money for the development and manufacture of weapons of war; there is and should be none now. The disproportion of monetary support for war and that available for healing and care is an anachronism in an era that has been described as the "enlightened age of the common man" by some observers. The comparable cost of jet planes and hospital beds is too obvious for any excuse to be found for a shortage of the latter. I trust that these remarks will not be misunderstood. I believe that armament, including jet planes, is vital for the security of the republic, but adequate maintenance of standards of health and alleviation of suffering are equally vital, both from a practical point of view and form that of morale. All who took part in induction-board examinations during the war realize that the maintenance and development of national health is of as vital importance as the maintenance and development of armament.

The trend of development in the facilities available for the chronically ill outlined above will not necessarily be altered by public or state medicine. With provision of public funds in any setting of public activity the question is bound to come up, "Is it worth while to spend a certain amount of effort to restore a certain type of patient?" This rationalistic point of view has insidiously crept into the motivation of medical effort, supplanting the old Hippocratic point of view. In emergency situations, military or otherwise, such grading of effort may be pardonable. But doctors must beware lest such attitudes creep into the civilian public administration of medicine entirely outside emergency situations, because once such considerations are at all admitted, the more often and the more definitely the question is going to be asked, "Is it worth while to do this or that for this type of patient?" Evidence of the existence of such an attitude stared at me from a report on the activities of a leading public hospital unit, which stated rather proudly that certain treatments were given only when they appeared promising: "Our facilities are such that a case load of 20 patients is regularly carried . . .in selecting cases for treatment careful consideration is given to the prognostic criteria, and in no instance have we instituted treatment merely to satisfy relatives or our own consciences." If only those whose treatment is worth while in terms of prognosis are to be treated, what about the other ones? The doubtful patients are the ones whose recovery appears unlikely, but frequently if treated energetically, they surprise the best prognosticators. And what shall be done during that long time lag after the disease has been called incurable and the time of death and autopsy? It is that period during which it is most difficult to find hospitals and other therapeutic organizations for the welfare and alleviation of suffering of the patient.

Under all forms of dictatorship the dictating bodies or individuals claim that all that is done is being done for the best of the people as a whole, and that for that reason they look at health merely in terms of utility, efficiency and productivity. It is natural in such a setting that eventually Hegel's principle that "what is useful is good" wins out completely. The killing center is the reductio ad absurdum of all health planning based only on rational principles and economy and not on humane compassion and divine law. To be sure, American physicians are still far from the point of thinking of killing centers, but they have arrived at a danger point in thinking, at which likelihood of full rehabilitation is considered a factor that should determine the amount of time, effort and cost to be devoted to a particular type of patient on the part of the social body upon which this decision rests. At this point Americans should remember that the enormity of a euthanasia movement is present in their own midst. To the psychiatrist it is obvious that this represents the eruption of unconscious aggression on the part of certain administrators alluded to above, as well as on the part of relatives who have been understandably frustrated by the tragedy of illness in its close interaction upon their own lives. The hostility of a father erupting against his feebleminded son is understandable and should be considered from the psychiatric point of view, but it certainly should not influence social thinking. The development of effective analgesics and pain-relieving operations has taken even the last rationalization away from the supporters of euthanasia.

The case, therefore, that I should like to make is that American medicine must realize where it stands in its fundamental premises. There can be no doubt that in a subtle way the Hegelian premise of "what is useful is right" has infected society, including the medical portion. Physicians must return to the older premises, which were the emotional foundation and driving force of an amazingly successful quest to increase powers of healing if they are not held down to earth by the pernicious attitudes of an overdone practical realism.

What occurred in Germany may have been the inexorable historic progression that the Greek historians have described as the law of the fall of civilizations and that Toynbee has convincingly confirmed—namely, that there is a logical sequence from Koros to Hybris to Atc, which means from surfeit to disdainful arrogance to disaster, the surfeit being increased scientific and practical accomplishments, which, however, brought about an inclination to throw away the old motivations and values by disdainful arrogant pride in practical efficiency. Moral and physical disaster is the inevitable consequence.

Science is always a partisan issue. Senator Kerry believes, along with the Science establishment, that: "what is useful is right." Republicans oppose such mere utilitarianism.

Posted by Orrin Judd at October 19, 2004 2:19 PM