Healthcare Ethical Obligations Triumph Over Authoritarian Control
When a governing body impedes the provision of medical assistance, those in caregiving roles are forced to operate covertly. A timely directive from U.S. psychiatrist Leo Alexander in 1949 resonates with the health workers in the United States at present: under an oppressive rule, science becomes a tool for the inherent ideology of the oppressors. Alexander’s caution was based on his observation of how medical professionals, rather than opposing tyrannical regimes, sometimes became willing instigators. At that time, nearly half of all German doctors pledged allegiance to the Nazi Party, a rate twice as high as any other profession.
When the establishment or health care system prevents the fulfillment of ethical obligations, principled medical practitioners devise methods to offer care in violation of the law and beyond institutional confines. In the 1943 Netherlands, nearly all Dutch doctors, amounting to 97% of the profession, disdained Nazi-imposed orders to register with the Chamber of Physicians. This registry was a ploy to compel physicians to assist in racial, ableist screenings, mass deportations, sterilizations, and euthanasia policies. In defiance, the doctors resigned en masse and shut down hospitals for weeks, safeguarding their professional integrity and refusing to collaborate in Nazi atrocities.
Many doctors relinquished their licenses while numerous others endured arrests, and 100 Dutch physicians were incarcerated in concentration camps. The Nazis finally relented when the prospect of potential epidemics became overwhelming. It was a rare and pivotal instance of care ethics triumphing over fascist oppression.
Elsewhere, in Rome, the medical team at Fatebenefratelli Hospital devised an ingenious plan to safeguard Jews and anti-fascist rebels. They conceived of a nonexistent disease, K Syndrome, and admitted the threatened individuals under the pretense of this being a communicable disorder. When subjected to a Nazi inspection, the patients enacted coughing fits while the lead physician dramatically outlined the devastating effects of this invented illness. The strategem strategically exploited the Nazis’ fear of contagion and succeeded in leaving the hospital undisturbed.
For years, the series of events that unfolded at Fatebenefratelli Hospital remained largely unknown. Building on the phrase coined by bioethicist Robert Macauley in 2005, this can be termed as ‘the Hippocratic underground’, a mostly unheard-of practice acknowledging the perennial duty of care that extends beyond concerns of legal and professional risks.
Doctors, at times, might find themselves altering a patient’s medical history or diagnosis to secure insurance coverage or necessary financial aid for a disabled patient. Some of such actions indeed flout the law and contravene employer and professional organization regulations.
In such circumstances, the fulfillment of ethical obligations necessitates allocation of risk to protect the most vulnerable. This often implies resisting unjust mandates and instructions. Case in point is Pinochet’s Chile, where, while some doctors engaged in state-sponsored torture programs, others defied the government to provide secret care for the victims and maintain confidential accounts of their injuries, which could later be used as substantiating evidence.
In recent times, drawing from, and building on, these historical learnings has taken on a sense of urgency. The past six months have seen the previous administration’s policies morph medicine into a tool for authoritarian control. The policies are specifically centered around groups that the administration perceives as a threat to society: trans individuals, people with autism, and others living with disabilities.
Currently, the most lethal implications of the previous administration’s policies have been indirectly manifested through the removal of health and social welfare services. However, a significant part of the administration’s brutal actions are also implemented through direct violence. Over the past half a year, the policies have increasingly skewed medicine towards being an instrument of authoritarian imposition.
As the prior regime manipulated laws and federal funding against the underprivileged and the sick, and as the hierarchy complied, US medical practitioners ought to revisit history for strategic insights and moral fortitude. When laws and medical institutions become instruments of exclusion and cruelty, health workers bear the responsibility to defy, dissent, and sabotage regardless of the opinions of their superiors and peers.
How each individual contributes to the Hippocratic underground is largely determined by prior knowledge, abilities, status, and geographical location. Those with relative safety or institutional protection bear a particular onus to act bravely and shield their colleagues, students, and patients. Those in greater danger should generally limit their action to providing behind-the-scenes support. But overall, there lies power in unity. A sustainable system for effective care requires collective, coordinated action, not solitary acts of bravery.
Reflecting upon the enduring Hippocratic tradition in the context of present times, it is clear that our obligation to provide care persists, more so when the law undermines the provision of it.