Pulse: A Message from Dean Edward C. Halperin

Let us assume that Dr. John Doe, a graduate of the University of Louisville School of Medicine, has practiced for many years as a primary-care physician in a small town in Western Kentucky. The town has a three-member police force including Officer Bob Brown, who is well known around town as a "tough guy" who doesn't mind using "a little muscle" when he thinks it serves his ends.

One evening Dr. Doe is called to the police station. The police have taken into custody an 18-year-old high school senior named Robby Blue. Blue is also well known around town. He's not a very good student and is the high school's "trouble maker." He has already been arrested twice since he got his driver's license and been charged with various traffic offenses. Now he's been pulled over by Officer Brown for driving while impaired.

When Dr. Doe gets to the jail, he finds that Blue has multiple bruises around the head and shoulders and is complaining about abdominal pain. Officer Brown is in the process of pushing Blue up against the wall, shouting at him and "roughing him up." The officer turns to Dr. Doe and says, "I'm glad you're here, doctor. Take a look at this boy. We going to knock some sense into him, and I want to have a doctor on the premises to tell me how much he can stand."

What is Dr. Doe to do?

Let us assume that Dr. Mary Smith, a graduate of the University of Louisville School of Medicine, had been practicing medicine for many years in Louisville. She has many friends in high places including senior members of the local and state government and the police department. She also is a leader of the Greater Louisville Medical Society.

Dr. Smith is roused out of bed by an urgent phone call at 4 a.m. The police chief, at the other end of the phone, asks her to rush to police headquarters.

On arrival, Dr. Smith is met by representatives of the police department, FBI, Federal Bureau of Alcohol, Tobacco and Firearms, and the U.S. Postal Inspection Service. They brief her rapidly: There is credible evidence that a dirty nuclear bomb has been placed in a mailbox somewhere in downtown Louisville. This bomb, a combination of radioactive material and dynamite, will explode and scatter radioactive particles over the Louisville metropolitan area. There may be several hundred immediate deaths, several thousand people at risk for long-term health problems, including cancer as a result of the radioactive fall out, and the clean up will cost hundreds of billions of dollars. The police have a suspect in custody: a man for whom there is very credible evidence that he is related to the planting of the bomb. Indeed, he has proudly confessed that he has planted the bomb as part of God's will and refuses to give any other information. Law enforcement officers believe that the bomb is scheduled to go off at the height of downtown rush hour in about three hours.

Unable to extract information from the suspect through conventional means, the authorities intend to begin a series of "graded interrogation techniques" including physical and verbal abuse, water boarding and psychological techniques. They need a physician present to make sure they "push this man as far as possible to get information out of him but don't kill him, for if that happens he will be useless to us."

What should Dr. Smith do?

It would be nice if we lived in a world where such scenarios were completely hypothetical and devoid of any connection to reality. Unfortunately, this is not the case. We know that physicians have been involved in interrogation that either borders on or crosses the line into torture at the Abu Ghraib Prison in Iraq and at the Military Detention Facility at Guantanamo Bay, Cuba. We also know that, in the midst of the war on terror, problems such as those portrayed in the second story are, it is sad to say, chillingly possible. American physicians must be prepared to grapple with the desperate ethical problems engendered by the war on terror. On the one hand, physicians appreciate their responsibility to heal. On the other hand, physicians understand the age-old lesson of the Midrash: He who is merciful to the cruel will, in the end, be cruel to the merciful. How far should a physician go to help law enforcement prevent the explosion of a dirty nuclear weapon in downtown Louisville?

A recent study by a group of physicians from Harvard Medical School involved a questionnaire filled out by more than 1,700 U.S. medical students. Not surprisingly, the study demonstrated that less than 5 percent of U.S. medical students understand there are laws on the books which permit the federal government to rapidly reinstitute the doctor draft in times of national emergency. Approximately one-third of U.S. medical students do not have a rudimentary understanding of the rules regarding medical treatment of prisoners under the Geneva Conventions.

I was recently asked to think seriously about medical ethics and the war on terror during a conference in Cleveland. I was invited as a guest of the U.S. government to attend this meeting, hosted by The Cleveland Clinic and sponsored by the U.S. Holocaust Museum. The museum, in 2004, had an exhibit called "Deadly Medicine."I traveled to Washington, D.C., that year to see it. It is now in Cleveland.

The "Deadly Medicine" exhibit describes the origins of eugenics in the United States in the 19th century. Many physicians, impressed by the teachings of Social Darwinism, felt that "survival of the fittest" also applied to issues related to disease, culture and race. These physicians felt that there were some groups in society who "really shouldn't procreate." At one end of the spectrum, some physicians favored actively discouraging individuals with mental illness, epilepsy, lower IQ or various medical disorders from fathering or bearing children. At another end of the spectrum, more than 20 states in the United States and many countries in Europe created a system of forced sterilizations for adolescents and adults. Tens of thousands of these sterilizations took place in the United States.

Eventually, in Germany, the concepts of eugenics morphed into the idea of "life unworthy of life." This led to hundreds of thousands of forced sterilizations. Ultimately, it led to the incarceration of children with a variety of illnesses, the mentally ill and the mentally retarded. Deeming these individuals a burden on the state, children and adults were executed by starvation, lethal injection and gas chambers. When the Nazis launched large-scale extermination programs directed against political opponents, Jews, gypsies and homosexuals, the lessons learned by the slaughter of these innocents were applied on a large scale. The gas chambers of European concentration camps were originally developed by physicians working in the eugenics program.

Would the story of medicine's role in the origins of the Holocaust be a useful instructional tale for modern American medical students? This was one of the questions that my colleagues and I explored at the meeting in Cleveland. History is useful in modern medical education in that it teaches us several things: (a) Humility. Whenever, in medicine, you think you are facing a problem for the first time, study medical history. You will generally find that previous generations have faced analogous problems. (b) Guidance. By studying how your predecessors handled a problem, you can gain valuable insight into the appropriate course of action in your time and place. (c) Distance. History offers perspective. One can see how decisions played out over time and were viewed by subsequent generations.

In the next two years, the medical school curriculum at the University of Louisville will incorporate new courses designed to help the physicians of the future cope with problems posed by the war on terror. Courses in medical ethics, theological medical ethics, medical history, and medicine and literature should offer our young physicians-in-training a broad-based approach to deciding upon the right course of action when faced with complex problems. As the dean of your medical school, I am not in a position to dogmatically tell young people what is right and what is wrong. I am, however, responsible for giving young physicians-in-training the skills and tools necessary to think about the ethical problems of the present and future, and make informed decisions about the right course of action.

I believe that the alumni of the School of Medicine should expect nothing less from the leadership of their school.

Edward C. Halperin, M.D., M.A.
Dean, School of Medicine