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 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 from 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 other

wise, 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 worthwhile 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 and which are bound to carry them still farther 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 Toynbee18 has convincingly confirmed— namely, that there is a logical sequence from Koros to Hybris to Ate, 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.

Fortunately, there are developments in this democratic society that counteract these trends. Notable among them are the societies of patients afflicted with various

chronic diseases that have sprung up and are dedicating themselves to guidance and information for their fellow sufferers and for the support and stimulation of medical research. Among the earliest was the mental hygiene movement, founded by a former patient with mental disease. Then came the National Foundation for Infantile Paralysis, the tuberculosis societies, the American Epilepsy League, the National Association to Control Epilepsy, the American Cancer Society, The American Heart Association, "Alcoholics Anonymous" and, most recently the National Multiple Sclerosis Society. All these societies, which are coordinated with special medical societies and which received inspiration and guidance from outstanding physicians, are having an extremely wholesome effect in introducing fresh motivating power into the ivory towers of academic medicine. It is indeed interesting and an assertion of democratic vitality that these societies are activated by and for people suffering from illnesses who, under certain dictatorships, would have been slated for euthanasia.

It is thus that these new societies have taken over one of the ancient functions of medicine-namely, to give hope to the patient and to relieve his relatives. These societies need the wholehearted support of the medical profession. Unfortunately, this support is by no means yet unanimous. A distinguished physician, investigator and teacher at an outstanding university recently told me that he was opposed to these

special societies and clinics because they had nothing to offer to the patient. It would be better to wait until someone made a discovery accidentally and then start clinics. It is my opinion, however, that one cannot wait for that. The stimulus supplied by these societies is necessary to give stimulus both to public demand and to academic medicine, which at times grows stale and unproductive even in its most outstanding centers, and whose existence did nothing to prevent the executioner from having logic on his side in Germany.

Another element of this free democratic society and enterprise that has been a stimulus to new developments is the pharmaceutical industry, which, with great vision, has invested considerable effort in the sponsorship of new research.

Dictatorships can be indeed defined as systems in which there is a prevalence of thinking in destructive, rather than in ameliorative terms in dealing with social problems. The ease with which destruction of life is advocated for those considered either socially useless or socially disturbing instead of educational or ameliorative measures may be the first danger sign of loss of creative liberty in thinking, which is the hallmark of democratic society. All destructiveness ultimately leads to self-destruction; the fate of the SS and of Nazi Germany is an eloquent example. The destructive principle, once unleashed, is bound to engulf the whole personality and to occupy all its relationships. Destructive urges and destructive concepts

arising therefrom cannot remain limited or focused upon one subject or several subjects alone, but must inevitably spread and be directed against one's entire surrounding world, including one's own group and ultimately the self. The ameliorative point of view maintained in relation to all others is the only real means of self-preservation.

A most important need in this country is for the development of active and alert hospital centers for the treatment of chronic illnesses. They must have active staffs similar to those of the hospitals for acute illnesses, and these hospitals must be fundamentally different from the custodial repositories for derelicts, of which there are too many in existence today. Only thus can one give the right answer to divine scrutiny: Yes, we are our brothers' keepers.

REFERENCES

1 Bumke, O. Discussion of Faltlhauser, K. Zur Frage der Sterilisierung geistig Abnormer. Allg. Ztschr. f. Psychiat., 96:372, 1932.

2 Dierichs, R. Beitrag zur psychischen Anstaltsbehandlung Tuberkuloser. Ztschr. f. Tuberk., 74:21-8, 1936.

der

3 Dorner, A. Mathematik in Dienste Nationalpolitischen Erziehung: Ein Handbuch fur Lehrer, herausgegeben in Auftrage des Reichsverbandes Deutscher mathematischer Gesellschaften und Vereine. Moritz Diesterweg, Frankfurt, 1935, pp. 1-118. Second edition (revised). 1936, pp. 1-118, Third edition (revised).

4 Alexander, L. Public Mental Health Practices in Germany, Sterilization and Execution of Patients Suffering from Nervous or Mental Disease. Combined Intelligence Objectives Subcommittee, Item No. 24, File No. XXVIII-50, Aug. 1945, pp. 1-173.

5

Neuropathology and Neurophysiology, Including Electro-Encephalography in War-time Germany. Combined Intelligence Objectives Subcommittee, Item No. 24, File No. XXVII-1, July 1945, pp. 1-65.

6

German Military Neuropsychiatry and Neurosurgery. Combined Intelligence Objectives Subcommittee, Item No. 24, File No. XXVIII-49, Aug. 1945, pp. 1-138.

7

Sociopsychologic Structure of SS: Psychiatric Report of Nurnberg Trials for War Crimes. Arch. Neurol. & Psychiat., 59: 622-34, 1948.

8

9

War Crimes: Their Social-Psychological Aspects. Amer. J. Psychiat., 105:170-7, 1948. War Crimes and Their Motivation: Socio-Psychological Structure of SS and Criminalization of Society. J. Crim. Law & Criminol., 39:298-326, 1948.

10 Madaus, G., and Koch, F. Tierexperimentelle Studien zur Frage der Medikamentosen Sterilisierung (durch Caladium seguinum) (Dieffenbachia seguina). Ztschr. f. d. ges. exper. Med., 109:68-87, 1941.

11 Madaus, G. Zauberpflanzen im Lichte experimenteller Forschung, Das SchweigrohrCaladium seguinum. Umschau, 24:600-2, 1941.

12 Alexander, L. Miscellaneous Aviation Medical Matters. Combined Intelligence Objectives Subcommittee, Item No. 24, File No. XXIX-21, Aug. 1945, pp. 1-163.

13 Document 1971 a PS.

14 Document NO 220.

15 Alexander, L. Treatment of Shock from Prolonged Exposure to Cold, Especially in Water. Combined Intelligence Objectives Subcommittee, Item No. 24, File No. XXVI-37, July 1945, pp. 1-228.

16 Seiss-Inquart. Order of the Reich Commissar for the Occupied Netherlands Territories Concerning the Netherlands Doctors. (Gazette containing the orders for the Occupied Netherlands Territories), Dec. 1941, pp. 1004-26.

17 Bernal, J. D. The Social Function of Science. George Routledge & Sons, London, 1946, 482 pp. Sixth edition.

18 Toynbee, A. J. A Study of History, Abridgement of Vol. I-VI. By D. C. Somervell. Oxford Univ. Press, New York and London, 1947, 617 pp.

Editor's Comment:

His stark experience as an official American medical expert at the Nuremberg Trials of German physicianexecutioners of Nazi medical atrocities clearly had a profound effect on A. The experience impelled him to record the insidious progression of corrosive medical thinking which led to the degradation of the German medical profession and to warn his American colleagues with startling prophetic insight and foresight that what happened there could happen here.

It must be remembered that in the decades preceding World War II, German medicine was preeminent. Germany was the leading world center for post-graduate medical studies. As the United States is to the world of medicine today, Germany was then. To see this great giant topple not only shocked the medical world but raised for the reflective the crucial question of how the giant's downfall came about.

A's answer has great simplicity—a simplicity that gets to the heart of the matter: that the moment German medicine forgot that cure etymologically derives from care and deviated from

medicine's prime end of healing, it began its inexorable road to doom. These are his words:

Whatever proportions these crimes finally assumed, it became evident to all who investigated them that they had started from small beginnings. The beginnings at first were merely a subtle shift in emphasis in the basic attitude of physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as life not worthy to be lived.

He adds,

This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans. But it is important to realize that the infinitely small wedged-in lever from which this en