Teaching Obedience
by Sarah van der Lely
I can say that I have always done my duty and have never done anything contrary to what was expected of me.
— Eduart Wirths, Chief SS doctor at Auschwitz
“The other day, I walked into the operation room. The patient, whom I had never met before, was already under general anesthesia and the gynecologist said, ‘Ah good, you’re here. Come do a vaginal examination to feel this massive polyp we’re about to remove.’”
This was stated by one of my fellow students during a so-called “medical ethics class.” Typically, in these classes, small groups of medical students discuss times when they had to make difficult ethical decisions. On paper, these classes should be an opportunity to talk about patient cases that were ethically challenging, and to review how these cases were handled by the medical team. In reality, however, most students use the class to confess instances when they had to bear witness to something—or were told to act in a way—that they felt was unethical.
In the aforementioned case, after weighing the pros and cons of doing the vaginal examination, the students in class unanimously felt that it was morally wrong to internally examine a patient who is unconscious and who had not given previous consent.
The teacher then asked: “So who would refuse to examine the patient?” A painful silence followed. No one raised their hand. Everyone was aware that they would rather act in a way they perceive as morally unacceptable than speak up to a supervising physician.
“There is probably no physician or medical student who has not seen or participated in callousness (or worse) in the treatment of patients in response to an order of a resident or an attending physician,” Eric J. Cassell, M.D. and professor, wrote in an article about the obedience experiments of Stanley Milgram.1,2
Multiple studies have found that up to 60% of students reported witnessing unethical treatment of a patient. Another study found that almost all of third- and fourth year medical students have witnessed physicians refer to patients in a demeaning manner.3,4Over two thirds of students felt inclined to participate in this behavior to “fit in” and experienced feelings of guilt afterwards.4-6
Other studies have found that the majority of students have encountered mistreatment at least once during their internships.7,8 As result, over three quarter of students have reportedly become more cynical about the medical profession and over a third have considered dropping out of medical school.8,9 Despite this discontent, mistreatment is only rarely reported to faculty due to fear of potential repercussions and the perception that mistreatment is simply part of the medical culture.8,10
To some extent, obedience is a requirement of medical training. But history shows how easily that requirement for obedience can lead educated and intelligent professionals to follow orders uncritically, or to passively accept dangerous, unjust, or immoral situations.
The eugenics movement, which first arose in the late 19th century, led to tens of thousands of involuntary sterilizations globally, prompted a “euthanasia” program in Nazi Germany in which “feebleminded” people—many of them children—were killed, and culminated in the murder of millions of people.11
In the wake of these mass murders, society was left to question how physicians could have been so deeply involved in such a barbaric movement.11 It has been estimated that more than half of German physicians joined the Nazi party.12 Physicians had a wide range of responsibilities with the regime: They decided which patients were “unworthy of life,” carried out lethal injections and involuntary sterilizations, performed experiments on prisoners, and selected people to be murdered in the gas chambers of the extermination camps. In the years since, many theories have emerged to explain how physicians could have drifted so far from the core values of medicine—compassion, healing, and the relief of suffering—and still consider themselves doctors.
In The Nazi Doctors, psychiatrist and scholar Robert Jay Lifton attempted to explain “the relative ease with which physicians—members of my own medical profession with its claim to healing—could be socialized to killing.”13 A large portion of his book focuses on the physicians at Auschwitz.
Perceived powerlessness
Many of the Auschwitz doctors described a feeling of powerlessness—of being “a tiny cog in someone else’s machine.”14 As a physician you had to carry out sterilizations “as it was simply ordered by the university which received its order from the state health offices,” one of Auschwitz’s doctors said in an interview with Lifton. In Auschwitz “you’re just there on the spot and helpless.” Another former Nazi doctor told Lifton that “it was a horrible thing but we couldn’t do anything [else].”14
Whether conscious or subconscious, this mode of thinking shifts the blame to the person giving orders, to the supervisor, or to the system. In the perception of these Nazi physicians, they were simply serving as agents. They believed they had no choice. By succeeding at being obedient, the doctors also, in their own minds, shed individual responsibility for their actions.
Doubling
Lifton also described a phenomenon he termed “doubling,” which he described as “the division of the self into two functioning wholes, so that a part self acts as an entire self.”
The other self “is created on behalf of what one perceives as one’s own healing or survival,” he continued. And in “avoidance of guilt: the second self tends to be the one performing the ‘dirty work.’”15
Professionals, in particular, may have a special capacity for doubling, Lifton argued. In them, a professional self can be joined to a prior self. In physicians, for instance, a “medical self” is almost a necessity. The “medical self” enables the physician to be compassionate (original self) but also to keep a professional distance (medical self). The medical self can be relatively unmoved by pain and grief, inured to death, and carry out challenging medical procedures that demand a certain distance.16
But doubling has a downside: it creates a self through which physicians can easily and quickly distance themselves from something they feel is unethical or unacceptable. The student from the above example, who was ordered to perform a vaginal examination on an unconscious patient without previous consent, would never do so as their prior self. Even if there is inner reluctance from the prior self, the medical self steps in and performs the examination because it believes it has to, thereby freeing the prior self from the moral conscience and responsibility.
Lifton argued that the danger of this “opposing self” is that it can become “unrestrained, as it did in the Nazi doctors.”17
“The way in which the doubling allowed Nazi doctors to avoid guilt was not by the elimination of conscience but by what can be called the transfer of conscience,” he wrote.
Rudolph Höss, commander of Auschwitz, listed the options: “Either to become cruel, to become heartless and no longer to respect human life [that is, to develop a highly functional Auschwitz self] or to be weak and to get to the point of a nervous breakdown [that is, to hold onto one’s prior self, which in Auschwitz was nonfunctional].” 20
Groupthink
At Auschwitz,doubling became not just an individual method but a shared psychological process and group norm. Irving Janis, psychologist and scholar, called this phenomenon “groupthink.”21
When a young doctor at Auschwitz was
first taken to one of the selections, he was shocked. He reportedly said that he “didn’t want to be
in a slaughterhouse…[and that] as a doctor his task is to help people and not
to kill them.”22 Another physician later told Lifton that this
argument was never used at Auschwitz, because “it would have been completely
pointless.” If one of the doctors were to question the morality of his own
actions, then he would implicitly be judging those of his colleagues. The young
doctor was subsequently reassured by the camp commander, mentored by another
doctor, and he participated in the selections without further incident.
The doctor…if not living in a moral situation…where limits are very clear…is very dangerous.
– Auschwitz survivor23
In light of these and other dark pages in medical history, there is an obligation for physicians to constantly reconsider their practices. Although standard medical training today is in no way comparable to the practices of doctors at Auschwitz, some of the psychological mechanisms Lifton described are disturbingly familiar to medical students.
In their essay on professionalism, then-medical students Andrew Brainard and Heather Brislen painted the unsettling picture that most students “seem to adopt an implicit set of rules that place hospital etiquette, adherence to academic hierarchy, and subservience to authority above patient centered virtues.”
“Students become ‘professional’ and ‘ethical’ chameleons because it is the only way to navigate the minefield of an unprofessional medical school or hospital culture,”24 they wrote. Students are molded into obedience, and learn that they get better grades in professionalism, when compromising their ethical standards and “mimicking the unprofessional behavior of their educators.”25
Many students witness unethical acts for which the physicians in question are not held accountable, as they are protected by the hierarchy of authority.26-28 Because reporting or questioning these acts is regarded as disruptive and therefore unprofessional behavior, many students will very quickly learn to simply conform.29 As a result students feel “mute” in morally distressing situations and complicit as bystanders to their superiors’ actions, which causes them to feel powerless and “trapped in a hierarchy.”24,29,30 This is a way for students to distance themselves from their inaction or immoral actions by shifting the blame to the system or supervisor and explaining to themselves that they have no choice.
It may very well be that, in order to adapt, students feel inclined to double and form a “medical self” that will act in the way that is expected of them. However, as Lifton and Rank described, the risk is that this medical self may ultimately replace the prior self.
The consequences of this cycle of hierarchic and social pressure, moral compromise, and consequent habituation are many.Most importantly, this can lead to an erosion in professional and academic integrity, as exhibited in a study showing that first year students were more likely than more advanced students to identify case scenarios describing academic dishonesty as being unacceptable.
Furthermore, a larger proportion of the more advanced students indicated that they had or would engage in such dishonest behavior.34 The erosion of professional integrity was also evident in a survey that asked medical students in different years of their education about their experience with and attitudes towards cheating. In their first year, 97 to 100% of students said they expected not to cheat in medical school, but by their fourth year, up to a quarter of all students reported having cheated in activities directly related to patient care.35 These actions, such as lying about having ordered a test, reporting findings elicited by others, and recording tasks not performed, were often motivated by fear or “the pressure to appear as if [one] knew everything.”35 One respondent noted that she was actually advised by a resident that she “would come off better if [she] lied a little.”35
If upcoming physicians have to create medical doubles for themselves to “survive medical school,” then it’s conceivable that, by the time students become residents, their medical selves will have replaced their prior selves, and will teach or oblige new students to double as well. The “see one, do one, teach one” approach in medicine only exaggerates this phenomenon through groupthink.1 Brainard and Brislen argued that “students’ professionalism has been questioned when they disagree with a team.”24 Or, as one student was told by his clerkship director: “the most important professional virtue is getting along with your superiors.”24
Perceived powerlessness, doubling, and “groupthink” seem to be an essential part of the hidden curriculum that focuses on maintaining the hierarchy of authority.29,36 Physicians need to reexamine the structural mechanisms in medical training that can lead to future doctors valuing the obedience above all else, and that lead to their self-perception as a tiny cog in someone else’s machine.
We might simply feel bad, and let it go at that, when patients are mistreated because of undue obedience on the part of health care personnel, if it weren’t for other findings of Milgram’s research. For not everybody obeyed…Appropriate disobedience can be taught.
— Eric J. Cassell1
The issues of mistreatment of medical students and misuse of power by physicians have been known for decades. Yet policies and educational courses have failed to eradicate this structural mistreatment.37 Researchers have suggested that the hidden curriculum might be inhibiting change.29,37
Interventions such as courses on how to handle sexual harassment, mistreatment or unfair feedback do not address social pressures and institutional forces that lead to misuse of power.38,39 By teaching the students how to function in this broken system, educators confirm the status quo and encourage students to adapt and double in order to create a more resilient medical self. In some of these classes, students will be told that they can do better once they’ve become physicians, which creates the unfair expectation that individual students alone should initiate change of such institutional problems and incites feelings of guilt when students can’t live up to these expectations. Brainard and Brislen concluded that “the current structure of professionalism education and evaluation does more to harm students' virtue, confidence, and ethics than is generally acknowledged” and leaves students “feeling persecuted, unfairly judged, and genuinely and tragically confused.”24
Talk about power
Instead of teaching students how to endure maltreatment during their internships, education should focus on how to responsibly handle the power that comes with being a physician. Through their career most students will come to accept the status quo, partly because they adjust, but most importantly because the higher they climb in the hierarchy, the more privileges they will experience as result of it. Because the hidden curriculum teaches students not to speak up, physicians are hardly ever criticized.
One of the ways to address this is to have students grade their educators. This would serve the dual purpose of creating a system to put a check on power, while also rewarding positive models.
Second, the evaluation system used to assess student performance can also be an important factor in the balance of power. Compared to a pass-fail approach, an A-F grading scheme promotes peer competition and anxiety rather than collaborative learning.40 Students have cited grades as one of the reasons to compromise their ethical standards.3 A pass-fail evaluation could help students feel less anxious about grades and more secure in their moral perspectives. In this system failing a student would have to be an extraordinary measure that is only taken in the case of irrefutable misbehavior. This would therefore protect the students from being subjectively punished with low grades for not “mimicking the unprofessional behavior of their educators.”
A third approach was taken by Yale School of Medicine almost two decades ago. During the school’s annual “Power Day” medical students would “define and analyze power dynamics within the medical hierarchy and hidden curriculum, using literature, guest speakers, and small groups.”29 As a result, some units at select hospitals held weekly meetings, called “Power Hours,” in which staff and students discussed power within their departments. Instead of simply talking to students about power, the physicians (those in the position of power) were frequently reminded of their power in the hierarchical structure of medical practice—and of the consequences of their day-to-day actions. It's unclear whether these sessions led to structural change so far, but the aim is to positively reshape the hidden curriculum for future healthcare professionals.
Appropriate disobedience
In order to support the development of physicians who value altruism, integrity, and accountability above the hierarchy of authority, we have to stop regarding conformity as professional behavior.
Medical history should be incorporated into all medical schools’ curricula, with special attention to mechanisms that lead physicians to become subservient and numb to ethical responsibility. The values of critical pedagogy, which aim to awaken a critical consciousness, would be a welcome addition to the curriculum.41
Furthermore, students should be encouraged to be critical of institutions and to think regularly about their ethical responsibility. When students are disobedient in order to remain true to their moral standards, they should be applauded, not punished.
Recent articles have urged physicians to
speak out against social injustice and unethical policies.42,43 But
how will students ever become physicians who meet these demands when they’re
taught to be obedient, compromise their values, and quietly do what is expected
of them? A critical examination and an open discussion of the power structures
embedded in the hidden curriculum is urgent and essential to make future
physicians morally conscious, courageous and—when necessary—disobedient.
Sarah van der Lely was a 2019 Medical Fellow. She will be graduating from medical school at the University of Amsterdam in April 2020, where she is currently working with faculty to bring a focus on power dynamics in medicine into the curriculum.
Notes
1. Cassell, E.J. (2005). Consent or Obedience? Power and Authority in Medicine, New England Journal of Medicine, 352;4, 328-330.
2. Milgram, S. (1963). Behavioral Study of obedience. The Journal of Abnormal and Social Psychology, 67(4), 371-378.
3. Dyrbye, L.N. (2005). Medical Student Distress: Causes, Consequences, and Proposed Solutions, Mayo Clinic Proceedings, 80 (12), 1613-1622.
4. Feudtner C (1994). Do clinical clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development. Academic medicine, 69:670-679.
5. Christakis, D.A. (1993). Ethics in a short white coat: the ethical dilemmas that medical students confront.Academic Medicine, 68:249-254.
6. Hundert E.M. (1996). Characteristics of the informal curriculum and trainees’ ethical choices. Academic Medicine, 71:624-642.
7. Cook A.F. (2014). The prevalence of medical student mistreatment and its association with burnout. Academic Medicine, 89(5):749-54.
8. Harnett Sheehan, K. (1990). A Pilot Study of Medical Student 'Abuse': Student Perceptions of Mistreatment and Misconduct in Medical School. JAMA, 263(4):533-537.
9. Chung, M.P. (2018). Exploring medical students' barriers to reporting mistreatment during clerkships: a qualitative study. Medical Education Online, 23(1):1478170.
10. Elnicki D.M. (2002). Medical students’ perspectives on and responses to abuse during the internal medicine clerkship. Teaching and Learning Medicine, 14:92-97.
11. Barondess, J.A. (1998). Care of the medical ethos: Reflections on Social Darwinism, Racial Hygiene, and the Holocaust. Annals of Internal Medicine, 129: 891-898.
12. Kater M.H. (1979). Hitlerjugend und Schule im Dritten Reich. Historische Zeitschrift, 228: 609-10.
13. Robert Jay Lifton, The Nazi Doctors (New York: Basic Books, 2017 [1986]), Preface to the 2017 edition.,vii.
14. Lifton, The Nazi Doctors [13]. Page 450-451.
15. Lifton, The Nazi Doctors [13]. Page 418-419.
16. Lifton, The Nazi Doctors [13]. Page 427.
17. Lifton, The Nazi Doctors [13]. Page 425.
18. Otto Rank, The double: A Psychoanalytic Study (Chaper Hill: University of North Carolina Press, 1971 [1925]).
19. --
20. Rudolph Höss quoted by Karl Buchheim, “Command and Compliance” in Helmut Krausnick et al. Anatomy of the SS State, (New York: Walker, 1968 [1965]) Page 374.
21. Irving L. Janis. Groupthink: A Psychological study of Foreign-Policy Decisions and Fiascos (Boston: Houghton Mifflin, 1972).
22. Lifton, The Nazi Doctors [13]. Page 310-311
23. Lifton, The Nazi Doctors [13]. Page 430.
24. Brainard, A.H. (2005). Learning Professionalism: A View from the Trenches. Academic Medicine. 82(11):1010-1014.
25. Kassebaum, D.G. (1998). On the culture of student abuse in medical school. Academic Medicine, 73:1149–1158.
26. Weber, D.O. (2004). Poll results: doctors’ disruptive behavior disturbs physician leaders. Physician Executive, 30:6–14.
27. Shrank, W.H. (2004). Fostering professionalism in medical education: a call for improved assessment and meaningful incentives. Journal of General Internal Medicine, 19:887–892.
28. Frase-Blunt, M. (2007). Rude medicine. New Physician, 56:12–18.
29. Angoff, N.R. (2016). Power Day: Addressing the Use and Abuse of Power in Medical Training. Bioethical Inquiry, 13:203–213.
30. Robins, L.S. (2002). Using the American Board of Internal Medicine’s “Elements of Professionalism” for undergraduate ethics education. Academic Medicine, 77(6): 523–531.
31. Woloschuk, W. (2004). Attitude change during medical school: a cohort study. Medical Education, 38:522-534.
32. Hojat, M. (2004). An empirical study of decline in empathy in medical school. Medical Education, 38:934-941.
33. Crandall SJ, Volk RJ, Loemker V. Medical students’ attitudes toward providing care for the underserved: are we training socially responsible physicians? JAMA. 1993;269:2519-2523.
34. Rennie, S.C. (2003). Differences in medical students’ attitudes to academic misconduct and reported behavior across the years—a questionnaire study. Journal of Medical Ethics, 29:97-102.
35. Dans, P.E. (1996). Self-reported cheating by students at one medical school. Academic Medicine. 71(1): S70–2.
36. Gaufberg, E.H. (2010). The hidden curriculum: What can we learn from third-year medical student narrative reflections? Academic Medicine 85(11): 1709–1716.
37. Fried, J.M. (2012). Eradicating medical student mistreatment: a longitudinal study of one institution's efforts. Academic Medicine, 87(9):1191-8.
38. Tsevat, R.K., (2015). Bringing home the health humanities: Narrative humility, structural competency, and engaged pedagogy. Academic Medicine, 9(11): 1462–1465.
39. Metzl, J.M. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science and Medicine, 103: 126–133.
40. Robins, L.S. (1995). The effect of pass/fail grading and weekly quizzes on first-year students’ performances and satisfaction. Academic Medicine, 70:327-329.
41. Paulo Freire, Pedagogy of the Oppressed (New York: Continuum, 1968).
42. Talbot, S.G. (2018). “Physicians aren’t ‘burning out.’ They’re suffering from moral injury” in Stat (2018).
43. Eric Topol. “Why doctors should organize” in The New Yorker (New York, August 5, 2019).