More equal than others?

When I called to discuss my bill for a few lab tests for my medical practice, the on-hold recording included an advertisement for a “noninvasive prenatal screen.” The lab company’s website elaborated that the “timely information about your fetus’ chromosomal makeup ... can help you make decisions with your healthcare provider.”

What sort of decisions would those be?

In his landmark 1986 work The Nazi Doctors, Robert Jay Lifton explored how the dog-bites-man story of tyrants murdering citizens turned into the man-bites-dog story of doctors being the ones who killed. He summarizes at the outset: “Prior to Auschwitz and the other death camps, the Nazis established a policy of direct medical killing: that is, killing arranged within medical channels, by means of medical decisions, and carried out by doctors and their assistants.” Even as the murder moved to the Holocaust’s industrial scale, doctors researched, designed, and supervised the systems that performed it.

Lifton traces that sordid history to “mercy” killing, then to the notion that people deemed defective were subhuman; he quotes Alfred Hoche, a professor of psychiatry from the University of Freiburg, stating in 1920 that killing them “is not to be equated with other types of killing … but [is] an allowable, useful act.” His reasoning focused on “the tremendous economic burden such people cause society to bear; especially those who are young, mentally deficient, and otherwise healthy.” The list of those deemed “life unworthy of life” soon grew to entire races—but the idea that physicians weren’t killing as much as curing, at least at a national level, remained.

Modern America adds its own twist: Perhaps the disease to be cured belongs not to the unborn baby but to her mother, and isn’t so much physical as emotional, or even financial. A baby complicates life and restricts parents’ freedom—and isn’t stress bad for one’s mental health? Moreover, if a society can stomach Hoche’s attitude toward the “economic burden” of sick babies, how can it not carry that same attitude over to paying for diapers and caregivers for healthy ones? Cue the “I can’t afford a baby,” often from people whose lifestyle otherwise shows little sign of financial desperation. And, for a ready answer to that perceived economic crunch, cue Hoche’s subhuman people—the ones whose murder seems “useful.”

Whether the illness is real or perceived, physical or emotional, the question remains: To paraphrase Animal Farm, are some people more equal than others? Can sickness, poverty, or simply being unwanted—before or after birth—render us “life unworthy of life”? And will we as a society learn from Holocaust scholar Raul Hilberg, whom Lifton cites as “examining ‘tens of thousands’ of Nazi documents without once encountering the word ‘killing,’ until, after many years he did finally discover the word—in reference to an edict concerning dogs”?

Living in ‘this state’

What if we don’t fight until the bitter end? In With the End in Mind (Little, Brown, 2018), British physician Kathryn Mannix gently introduces readers to hospice—a field focused on symptom relief and quality of life for patients in their waning months and days. One might expect a doctor whose patients all die to be downbeat, but Mannix strikes a strongly life-affirming note in her book. She profiles one patient who fled the Netherlands for England to escape constant suggestions that “many people would prefer not to live in this state,” and records his brilliant response: “[He] agreed that he did not wish to live in that state: this was not his choice. But if the only way to live was in that state …”

Mannix does not argue directly against euthanasia as a solution to end-of-life suffering. But then, she might not have to: Showing readers her infinitely better solution is its own rebuke to the death-as-cure idea.

The book contains occasional profanity and realistic descriptions of death. —C.H.