by Craig Klugman, Ph.D.
The world of the life sciences and medicine is being changed radically in 2017. The proposed Trump budget cuts funding for the CDC, NIH, NSF, NEH, NEA, EPA, and PHS will radically change how science is done, how much science is done and by whom. The US is withdrawing from the Paris Climate Treaty. Cuts to social security that traditionally pays for medical residents have also been proposed. The American Health Care Act will take affordable health insurance away from 23 million people. For the rest of us, the AHCA means higher premiums and less coverage. At the same time, we live in an era of “fake news,” “leaks,” incendiary tweets, and loyalty as the sign of someone’s worth. What might be the impact on medicine, the life sciences and bioethics in the Trumpian era? Will the dominant political ideology affect the practice of science and medicine in more ways than economics? Can ethics help steer a course around ideology?
One change that has already occurred under Trump is an anecdotal decrease in the number of immigrants (documented and undocumented) who are seeking medical care under concern that they will be deported if they show up to hospitals and doctor’s offices. In one case, a woman was forcibly removed the hospital where she was to be treated for a brain tumor and brought to a detention center.
Certainly, there is a U.S. history of medicine following the ideology of the government. Forced sterilization, the Tuskegee Syphilis study, the US radiation experiments and the Guatemala Syphilis studies were all government financed research created to prove a particular ideology: In these cases, species-level differences between the races and that a nuclear war was “winnable.” Even today, medicine can be co-opted by politics: Consider that evolution is now taught as questionable hypothesis in many states rather than as proven by science. Several states (Arizona, Kansas, South Dakota and Texas) require that women who seek an abortion be given factually incorrect information to make the risks seem much higher than they are.
History provides some sad tales and warnings. Pediatrician Harmut M. Hanauske-Abel describes how by 1933, German medicine had largely become taken over by Nazi ideology. The life sciences “scientifically proved” (mostly based on US work) the superiority of the Aryan race, breeding programs, scientific experiments, as well as the Final Solution for extermination the lesser beings (Jews, Roma, Catholics, Gays, and more). The author discusses the two major theories for how this happened: (1) a slippery slope where medicine slowly succumbed to the bias and beliefs of those in power. After all, the doctors “conceiv[ed] of the ‘Jewish problem” as a ‘medical problem,’” and discussions of how to deal with them appeared in medical journals. (2) Sudden subversion where the leadership of the medical profession was forcibly taken over by the Nazi party. His response to these ideas is a third, what he considers the more likely scenario, that medicine chose to align with the Nazis: “The evidence presented here, however, strongly suggests that the German medical community set its own course in 1933. In some respects this course even outpaced the new government, which had to rein in the professions’ eager pursuit of enforced eugenic sterilisations. In 1933, the convergence of political, scientific and economic forces dramatically changed the relationship between the medical community and the government.”
Some might argue that we can learn from the past. After all, a good number of medical schools have required and elective bioethics curriculum that teach about decision-making and the mistakes of the past. Can bioethics save us from political and economic pressures in the life sciences? A new paper in the Annals of Internal Medicine shows that German medical schools in the Nazi era had required ethics curriculum and faculty to teach it: “The appointed lecturers were mostly early members of the Nazi Party and imparted Nazi political and moral values in their teaching. These values included the unequal worth of human beings, the moral imperative of preserving a pure Aryan people, the authoritarian role of the physician, the individual’s obligation to stay healthy, and the priority of public health over individual-patient care.” Given that almost anyone can call him or herself a “bioethicist” it is not an impossible scenario that teaching in modern medical schools be done by people with certain political leanings. For example, during more than one interview for a bioethics position at a medical school I was asked about my beliefs. One med school asked if I supported an emphasis on social justice in teaching bioethics (I do). Another asked if I was okay with not teaching certain subjects that might contradict religious belief (I was not and immediately withdrew from that search). Is teaching medical ethics toward a more extreme ideology that far a step?
Can medicine and bioethics withstand the potential pressures to teach toward the government beliefs? History also provides some hope in this area. Consider that doctors in Holland resisted the Nazis once their country was invaded. In the U.S. physicians were involved with the Civil Rights Movement. The AMA did support the Affordable Care Act and has come out against the ACHA.
Critics of bioethics have often pointed out its lack of advocacy for social justice and for protesting egregious abuses of power. As a field that began fighting the power of the medical establishment, we have become settled as part of the white coat bureaucracy. Are bioethicists willing to use their social capital to help resist an abuse of the life sciences to support ideology? I think we may be too comfortable in our positions (or in the case of ASBH, in not taking positions) to be on the frontline. Besides, if medical schools were ordered to or decided to replace their bioethics faculty with members of the ruling party, we would have no way to stop them.
The life sciences, medicine and bioethics have choices to make in this new political environment and the fearful future that seems to be unfolding. They can slowly find themselves accepting the new reality and make small changes that someday will be a big step from how things have been (slippery slope). They may find new leaders and who are more likely to have influence with the new administration and Congress, people who are likely to be donors and hold similar beliefs to those in government (sudden subversion). They may face new rules and regulations that dictate practicing. The life sciences may choose to willingly choose to be an instrument of the state (alignment). Given the scientifically false statements that some states require in regards to abortion counseling, recent history suggests this is the most likely path.
Or they can choose to be brave, to maintain the traditional values of compassion, beneficence, nonmaleficence, and justice (resistance). Can bioethics and the life sciences stand up to political authority and ideological dictates if it comes to that? Can we put our patients and the public first before our own safety and preservation?
As Hanauske -Abel said in his 2005 paper and is even more true today, “The same convergence is occurring again and must be approached with great caution if medicine is to remain focus on the preservation of physical and medical integrity.”