To this day there is a huge discrepancy between the real facts of life on our planet with respect to the enormous extent of evil which human beings do to one another, and our psychological knowledge of the readiness of human beings to do evil.

The subject of evil as such has not been strongly represented in the psychological literature.[1] Evil remains a term that is largely mistrusted by psychologists, perhaps as a relic of pre-scientific theology and philosophy, and in any case a 'judgmental' and 'moralistic' view of man and society which has no place in a 'scientific' discipline of psychology. The prevailing normative picture of human beings held up by our psychological professions still posits, for the most part, intelligent, expressive, creatures who can be expected to relate to and treat fellow human beings with basic empathy, kindliness, respect and decency. Certainly this is the expectation we have of all basically educated human beings, who themselves have not been emotionally brutalized, and who have not been socialized or inducted into any of the ideologies/societies which have as their norm exploitation, torture and destruction of others.

The outstanding exception to the dearth of scientific information about man's readiness to commit evil is the classic, brilliant series of studies by Stanley Milgram.[2] As is well known, Milgram himself conceptualized his work as a study of obedience to authority, but while obedience is a specific dynamic focus in his study, Milgram also studied, intentionally or not, the readiness of human beings to comply with, participate in and execute distinctly evil actions whose consequences could have caused serious damage and even the murder of fellow human beings! This is the real reason that Milgram's work catalyzed such profound emotional and intellectual responses, including strong controversy in the best professional quarters as to whether he should ever have conducted his 'Eichmann experiment' and forced on his subjects such powerful encounters with their readiness to harm others. Who can ever forget the labeling of the switches for administering shocks at progressively higher voltages identified both in voltage numbers and in words: 'Intense Shock' (255-300 volts); `Extreme Intensity Shock' (315-360 volts); `Danger: Severe Shock' (375-420 volts); and, finally, a provocative culmination to the continuum, 'xxx' (435-450 volts)?

For purposes of clarification, we will state that our basic definition of evil refers to taking away from other human beings the right to live out the fullest possible extent of their lives. In our way of thinking, evil refers first to destroying other human beings, and then also to destroying their opportunities to live out their lives free of unnecessary pain and privation. Slaughter, mass murder and genocide, torture and cruelty all qualify as forms of evil under our definition.[3]

The specific subject of euthanasia on which this study focuses raises perplexing questions for many well-intentioned people in modern society, but it should be clear at the outset that in this study there is no reference whatsoever to voluntary euthanasia, where a patient and/or the patient's family request termination of life-support measures beyond a certain point of suffering. In this study, the situation under consideration calls for mass, involuntary euthanasia, defined by a bureaucracy of health providers and administrators, on authorization of government, without patient or patient-family authorization, knowledge or consent; also where the timing of the decision to introduce euthanasia is not in terms of the patient's clearcut inability to enjoy remaining life, but a function of the health-service system's failing resources for dealing with patients who are severely disabled. The patients' lives are to be forcibly taken away from them by the authorities, without any consideration of their desires, or their relatives' desires, nor consideration of their actual capacity to enjoy remaining aspects of their lives.

The history of the Holocaust showed that delivering power to a bureaucracy to end the lives of the disabled and ill is to initiate nothing less than a program of mass murder, and that such mass murder in time opens the door to further demons of more extensive mass murder and genocide in that society. Amir, Chorover, Sachs and Wertham have described the infamous T-4 program, where the mentally defective and mentally ill were murdered systematically by German medical personnel, in the first program of mass executions by the Nazi regime.[4]

All historical and social science research indications are that although an ethical point of view would call for zero readiness to participate in policies of doing harm and certainly bringing death to groups of helpless people, in any unselected population of human beings, one must expect a certain percentage of people will be ready to do harm to others. On the other hand, following the Holocaust and given the prevailing humanistic traditions of helping professions one expects Jewish/Israeli students in the helping professions to represent more strongly the struggle of emergent respect for human life in our civilization. The population of subjects in this study was selected to accentuate on two counts a greater probability of choices to oppose any plan to authorize bureaucratic executions of the handicapped: the subjects are (a) Jewish/Israeli, and (b) student health professionals (there is also a secondary group of subjects who are interdisciplinary social science students).

 

The Jewish/Israeli tradition

 

In Jewish thought there is a powerful tradition of reverence for human life. The saving of life was held as a supreme fulfillment of godliness, and the protection of human life was made a cardinal part of Judaism without which many other religious directives lost meaning and coherence. Various other injunctions also called on Jews to relate to ‘the stranger’ in their midst as to their own people, and to provide care and charity for the sick and handicapped.

In addition, following the Holocaust, Jewish/lsraelis are expected to be aware of the terrible acts performed by medical personnel in the euthanasia program, and how this program led into the mass murders of the Holocaust. Armed with powerful historical knowledge of the dangers of authorized executions of people defined as severely and irretrievably ill by a medical bureaucracy, Jewish/Israeli student health professionals can be expected to be particularly vigilant and overwhelmingly opposed to any State bureaucratic plan to terminate the lives of any population of the ill and handicapped.

 

The health professional tradition

 

The first associations that come to mind when we think about physicians, social workers and psychologists are of care, warmth, humanity and concern for the suffering individual; people who are prepared to help the needy as far as possible, and who seek their welfare in all possible ways. Their professional ethics demand that they place the welfare of the individual under their care at the center of their concerns. The tradition of the health professions is best epitomized by the Hippocratic Oath of the physician who pledges protection of his patient from further injury or harm, to protect human life under all circumstances, even when the patient himself may request death, no matter what the circumstances.

The combination of Jewish/Israeli identity and being students of the health professions meant that the subjects in this study personified our civilization's hopes for the emergence of an ethos of the sacredness of human life.

 

Health professionals in the Holocaust

 

Despite all that we hope will be true of helping professionals, we know that in Nazi Germany physicians participated actively in the killing of the Reich's unfit and in programs for the elimination of Jews and other peoples. The United Nations War Crimes Commissions which dealt with war crimes of physicians listed four areas of medical crime: (1) involuntary experiments on patients; (2) selections (for life or death) made by physicians, murder of prisoners by injection or through medical neglect; (3) euthanasia — 'mercy killing' of patients and mentally disturbed, and children of ‘inferior races’; (4) experiments on people in biological warfare research. [5]

In the Holocaust, physicians played decisive roles in the selection of millions of people for death. Lifton[6] has described the euphemistic reframing of these selections by medical professionals as their selection of those who were going to live and not die, hence as physicians they were continuing their time-honored roles as guardians of life. Physicians were also actual actors in the mass executions; the administration of the gas zyklon B was often the work of or to be supervised by physicians, and there were efforts to define the entire murder process euphemistically in medical terms as getting rid of a disease or a plague.

Only recently was it found by Vahakn Dadrian[7] that doctors and medical teams also played a central role in the process of the destruction of the Armenians by the Turks in the course of the Armenian Genocide. Turkish physicians testified in a military court to many instances of physicians poisoning Armenians, throwing them into the sea, slaughtering them, and performing medical experiments on them.

The history of the twentieth century is replete with instances of physicians torturing and murdering masses of human beings. Until the Gorbachev reforms in the Soviet Union, psychiatrists admitted to mental hospitals people who voiced protests against the regime, or were perceived as 'dangerous for the cultural level of society' and ‘treated' them with drugs, electric shocks, and other procedures that caused severe reactions. In Chile physicians participated in torture and murder committed by the police, and apparently also in Argentina.[8] In many instances physicians are described as the prime consultants to torture programs of governments around the world today.

The traditions of clinical psychology and social work are less clear in that they have not generated a concrete oath such as physicians take. However, insofar as members of these professions are often involved in the care of the sick in medical settings, it is also tacitly understood that the obligations of the physicians apply to them as well, let alone that both professions have strongly developed commitments to the protection of the welfare of their clients: In Israel, where this study was conducted, the Israeli Psychological Association and the Israel Association of Social Workers, like their counterparts in the United States, have explicit codes of ethics, and in any case the underlying historical and spiritual meanings of both professions clearly derive from a value position that eschews policies of injuring and murdering people.

The truth is that when we return to the Holocaust, we find that many members of both professions failed to live up to the expected ethical integrity. There are few data about psychologists as such, but it seems fair to see psychologists in what is known about the broader community of psychotherapists. Many psychotherapists in the Reich continued to practice as though nothing had happened after their Jewish colleagues were deported.[9] At the beginning of 1936, Henrich Göring (a cousin of Hermann Göring) founded an institute for psychological research and psychotherapy. The institute was supported by the Army, the SS and the Hitler Youth movements. In this institute there gathered many of the psychotherapists who remained after the flight or deportations of their colleagues. These psychotherapists assumed the function of guardians of the mental health and efficiency of the German nation. Psychiatrists participated in experiments on the mentally ill and those declared biological enemies: Members of the institute made evaluations of individuals for the SS, gave lectures to its members, and treated officers who were stressed by their participation in SS activities without raising any moral questions. Being members of the institute allowed the personnel to continue practicing psychotherapy as though nothing had changed with the coming of the Nazi regime, or the deportation or imprisonment of their Jewish colleagues.

As for social workers, in October 1933 there took place in Germany a conference of social workers who were entrusted with caring for ‘tramps’, ‘drunks’ and ‘peddlers’. The social workers complained of ‘exaggerated humanity’ and demanded severe treatment of their charges; in their opinion, tramps, drunks and beggars were not to be receiving welfare payments and there was need for a law to eliminate them.[10] Additional information in the roles of professionals as well as academicians in many fields in Germany in the Holocaust is available in the work by Friedlander and Milton, The Holocaust, Ideology, Bureaucracy and Genocide." [11]

 

PURPOSE OF THIS STUDY

 

It is hard to separate the activity of people in the caring professions from the recurrent question: How is it possible that human beings can do such terrible things to other human beings?[12] In regard to the caring professions, the question is more pointed because of the extreme change that takes place from the role of caretaker to that of murderer.

The aim of this research was to examine the readiness of students in the helping professions in Israel to participate in activities authorized by official instructions of the health bureaucracy not meant to fulfill care requirements, but on the contrary, to harm the clients or patients, and even bring about termination of their lives in a program of state- authorized involuntary mass euthanasia.

The general hypothesis of the study was that, in contradiction to all accepted positive values, a not-insignificant number of students of the caring professions would be prepared to obey official instructions blindly even if: (a) the purpose of the procedure ordered was unclear; (b) the purpose of the procedure would be to reduce and even eliminate active treatment of the disabled and hopelessly handicapped; (c) the health professional himself/ herself would be called in to execute the death of the patient.

 

 

METHOD OF STUDY

 

Subjects

 

The basic group of subjects were 60 student health professionals — 20 medical students, 20 clinical psychology students, and 20 social work students. An additional 32 subjects who were enrolled in an interdisciplinary behavioral sciences degree program were then also added, so that altogether 92 subjects were studied. The medical students were clinical externs at a hospital affiliated with Tel Aviv University Medical School from whom authorization had been received for the study. The students in clinical psychology included 17 majors in psychology at the B.A. level and 3 Masters students, and the study received the approval of the ethics committee of the Department of Psychology at Tel Aviv University. The social work students were drawn from a second year class in family therapy given by the senior author at the Bob Shapell School of Social Work at Tel Aviv University. The additional group of social sciences students were drawn from a social psychology class at Ben Gurion University.[13]

 

Administration of questionnaire

 

A questionnaire was designed for this study to investigate the readiness of students in the helping professions to comply with policy instructions by health authorities to engage in activities not intended to fulfill treatment needs but which, on the contrary, harm those being treated and even bring about their deaths.

 

The questionnaire was organized around two dimensions:

1. Subjects' ethnic and geographic closeness to the patients in the study

Two target populations differing in their ethnic and geographic closeness to the subject were identified in the study. The first target population included the handicapped somewhere in a treatment institution in an African country; the second target population were patients in a well-known treatment institution in the heart of Israel. The combination of situations (Africa or Israel) tests whether there is a difference in the readiness of student health professionals to act in a way opposed to the welfare of their charges in populations varying in their closeness to the subject, namely the distant population of handicapped people in a country in Africa, as compared to the population at home of ill and handicapped fellow Jews in Israel itself. The effect tested here is that of the impact of distance on the dehumanizing attitude towards a group.

2. The extent of harm subjects agree to have done to the patients

The actions called for ranged along a continuum of the extent to which harm was to be done to the targeted groups of patients. The activities subjects were asked to perform in institutions for the sick and handicapped in Africa and Israel ranged from reducing treatment, to withholding treatment, to adopting a program of involuntary mass euthanasia, and finally to declaring one's own personal readiness actually to implement the patients’ deaths.

The questionnaire presented subjects with a progression of increasingly onerous tasks in order to test what severity of actions students in the helping professions are prepared to take (only the first task, classification and grading of patients, in itself did not explicitly convey doing harm to some patients). The actions which the subjects were called on to take were as follows:

1.     Classification and grading of patients when the purpose is to centralize treatment of the severe cases.

2.     Classification and identification of cases for the purpose of reducing care for the most severely handicapped.

3.     Stricter reclassification and greater reduction in care for the ‘weak’ and ‘most unproductive’ among the handicapped.

4.     Severe reduction of treatment and maintenance for the ‘most severely mentally ill and mentally retarded.’

5.     Agreement to participate in planning involuntary mass euthanasia of the ‘severely handicapped in order to end their suffering:’

6.     Readiness to participate personally in execution of the euthanasia.

All of the subjects in the study were administered the same standardized question­naire, but the 60 student health professionals were given their questionnaire individually, while the remaining 32 subjects from the behavioral sciences program were administered their questionnaires as a group. In the first instance, each subject sat alone with the researcher. The questionnaire was given to the subject to relate to as a written document, but personal interaction and open-ended verbalization and subjects' spontaneous comments were encouraged and welcomed. The questionnaire itself allows for open-ended replies to each of the situational problems developed. Given the nature of the questionnaire, there necessarily developed for many subjects a significant tension both for themselves and interpersonally with the researcher who was present.[14] The combination of responses to the open-ended questionnaire and recording of the spontaneous remarks of the subjects also made possible a series of content analyses of subjects' cognitive and affective reactions. It should always be noted that responses to a questionnaire are nonetheless not the equivalent of the actual actions subjects would have taken in real life. At the same time, it should also be noted that the questionnaire situation is open to expressions of disagreement and refusal to agree to participate in following orders described, without many of the pressures to conform and do what others are doing that are present in real-life situations.

Table 1 summarizes the sequence of experimental situations in both the Africa and Israel scenarios.

As indicated, the first part of the questionnaire deals with a population of patients somewhere in Africa. The subject is told that she/he has been invited as a physician/ psychologist/social worker to a country in Africa which has recently won independence in order to assist the health and welfare authorities in their organization of services since the country is still in the grips of a considerable disorganization following the period of revolution and civil war that preceded its independence. (There is a tradition in Israel of missions and tours of duty by many professions in developing African countries.) The health and welfare services are not functioning and there is a great shortage of resources.

In the first question, the subject is asked to participate in the examination and classification of patients whose functioning is limited in order to concentrate the most limited patients in a single center where it will be possible to maximize the organization of treatment resources for them. In the second question, because of scarcity of funds, the subject is asked to reduce treatment of the less hopeful cases. In the third question, because of drought (again the reference is to a condition that is extant in various parts of Africa for many years and is entirely realistic in the world knowledge of the Israeli student health professional), it is explained to the student that it is important to devote the limited economic resources to the most productive handicapped who are capable of working. The subject is now asked to do a re-evaluation and reclassification of the more 'productive' patients who will continue to receive full treatment as opposed to those who are not sufficiently productive, in whose treatment economies will be made.

In the fourth question, serious worsening of the economic situation is reported and the highest health authorities of the land — 'the Health Council in consultation with the Faculty of Medicine at the University' — decide on a drastic curtailment of treatment and maintenance for the most handicapped. The subject is now asked to classify the patients for purposes of assigning those who will be subject to drastic curtailment of all resources. In question five, because of ever-continuing deterioration of the national economy, the health authorities decide on euthanasia for the most severely handicapped. The subject is asked whether she/he will personally join a planning staff to suggest the most humane ways to implement the program. In the sixth and last question, the subject is told that in order to implement the euthanasia in the best and most humane ways, it is decided that the program will be carried out by professionals. The subject is now asked whether she/he will personally agree to participate in the execution of the euthanasia.

In the second scenario of the questionnaire, essentially the same sequence of steps is presented other than the first situation calling for a classification of patients in order to send them to a central treatment facility, but now with respect to patients 'in a well-known and respected institution' treating crippled, mentally retarded and mentally ill patients in the center of Israel. At the head of the institution are well-known and respected members of the professional community. Here, because of a severe economic depression and subsequently a war that breaks out, resources are again limited and the subjects are asked to take the same actions of classification, reduction of treatment and finally planning and

 

Table 1. Summary of experimental situations posed in questionnaire to student health professionals

(Abstracted and Translated from the Hebrew Questionnaire)

 

Questionnaire 2 Africa	Situation question	Task
You have been invited as a psychologist/physician/social worker to a country in Africa that has just gained its independence to assist the Ministry of Health & Welfare.	1	Identify the handicapped people in the general population in order to send them to a central treatment and rehabilitation village.
	2	Reduce treatment to the handicapped in order to conserve maximum resources for the general population.
	3	Favor the more 'productive' among the handicapped. Evaluate and classify patients according to who has a better chance of being helped by treatment and who has no such chance.
	4	The decision of the Health Council, in consultation with the Faculty of Medicine at the University, is to curtail drastically the treatment and maintenance for the most severely mentally ill and mentally retarded.
	5	The Health Council has decided to provide euthanasia treatment (mercy treatment) to the severely handicapped in order to end their suffering. You are asked to join a planning staff to suggest the most humane ways to implement the program.
	6	In order to implement the program in the best and most humane ways, the program will be carried out by professionals: You are asked to administer the mercy treatment to the most severely handicapped to end their continuing suffering.
Questionnaire 2 Israel	Situation question
You are working as a psychologist/physician/social worker in a distinguished institution in Israel) that treats the disabled, mentally retarded, and mentally ill. The leadership and staff of the institution include professionals who are well­ known and distinguished in Israel and internationally.	2	Same as 2 Africa.
	3	Same as 3 Africa.
	4	Same as 4 Africa.
	5	Same as 5 Africa.

 

carrying out killing, just as in the African questionnaire. Obviously the second version of the questionnaire applies to a patient population drawn from the student health professionals' own people. It is clear that the institution is serving essentially Jewish patients — the possible presence of some Arab patients is a negligible factor in this context.

At the end of the questionnaire the subjects were asked to fill in a page of demographic particulars, and in addition, they were asked about the degree of their personal connection to the Holocaust, their acquaintance with other cases of genocide, and their overall political leanings.

For each of the 60 subjects who were seen individually, at the end of the questionnaire a brief interview was conducted. The subjects were asked about the feelings that they experienced in the course of the questionnaire, their associations in response to the various situations presented, and how they felt at the end. This final interview was also used to help the students release the emotional pressures that had built up for them in the course of the experimental sequence.

Questionnaires were scored for a variety of content criteria, and a sample of 18 questionnaires were submitted to the scoring of two additional judges in addition to the junior author with a resulting reliability of 88.5%.

 

Hypotheses

 

The main hypothesis of the study was that notwithstanding the accepted values of Western civilization in general, nor the specific values of Jewish/Israeli student health professionals who should be particularly sensitive to dangers of persecutory and genocidal societal processes, given an experimental situation concerning severely handicapped patients somewhere in Africa, as many as 40% of the subjects would be prepared to participate in a series of policies mandated by the health authorities to reduce treatment of the severely handicapped, as many as 15% would agree to participate in planning a program of involuntary mass euthanasia, and 2% would themselves even be prepared to participate in the execution of the euthanasia program.[15]

A second hypothesis of the study was that there would be a significant reduction in the numbers of Jewish/Israeli student health professionals who would agree to each of the above procedures in an experimental context which concerns Jewish patients in a hospital in Israel.

 

 

RESULTS

 

In both the Africa and Israel situations, a higher than expected rate of readiness to participate in activities injurious to patients in obedience to the policy prescriptions of the health authorities was found. In 11 of the 12 experimental situations, the difference was statistically significant.

The most shocking findings of the study relate to the readiness of the subjects to participate in the most severe actions. Contrary to the prediction that 15% would agree to cut down on food and medicines, 39% agreed to this step in Africa and 38% in Israel. It had been predicted that at most 5% of Jewish/Israeli students in the helping professions would be willing to participate in planning involuntary mass euthanasia. The findings were that 17.4% agreed to take part in planning involuntary mass euthanasia in Africa, and 12% agreed to take part in Israel. On the level of actual implementation, it had been predicted that at most 2% of the subjects would agree to implement the euthanasia. The actual results were that about 11% agreed to take part in the killing in Africa and 9% in Israel.

In order to test whether other senior professionals in medicine, psychology, and social work shared our view of the seriousness of agreement to execute the procedures called for in the three scenarios of curtailment of treatment and maintenance of the most handicapped, participating in planning mass involuntary euthanasia, and participation in actual execution of the euthanasia, we undertook an additional survey. Thirty clinical supervisors-trainers in the three professions (medicine, psychology, social work) were asked how they would react to a student who agreed to act in each of the scenarios. In the scenario of curtailing treatment and maintenance, 0% said they would not take any action, 27% said they would censure the student, 56% indicated they would put the student on probation, and 17% responded they would expel the student. In the scenario of planning mass involuntary euthanasia, again no supervisor indicated they would take no action, and none chose to censure the student, while 20% put the student on probation and 80% chose to expel the student, and the results were essentially the same regarding students who agreed to participate in actual execution of the euthanasia.

As expected, there was a greater inclination to participate in the less severe actions. The more severe the action, the lower the rate of readiness to participate. In Africa, 80% agreed to the original selection, 17% in planning the killing, and 11% in its implementation. In Israel, 90% agreed to the first withholding of treatment, 12% to planning the killing, and 9% to carrying it out.

Table 2 presents the above results for all 92 subjects. Table 3 presents the results for the original 60 subjects who were administered the questionnaire and interviewed individually. Table 4 presents the results for an additional group of 32 subjects who were administered a group form of the questionnaire in comparison with the original 60 subjects. Since no significant differences were found, the results for all 92 subjects were combined as presented in Table 2.

 

 

 

Table 2. Expected and actual numbers of total sample of 92 subjects agreeing to participate in each situation (N = 60 students administered questionnaire individually and 32 as group)

 

	Situation question	Expected agreement	Actual agreement	X2	P
Questionnaire 1 Africa	1 2 3 4 5 6	40%   (37)     40%   (37)     40%   (37)     15%   (14)       5%   (5)       2%   (2)	80%   (74)     82%   (75)     58%   (53)     39%   (36)     17%   (16)     11%   (10)	31.38     33.28       5.78     18.53       7.08       6.0	0.001 0.001 0.02 0.001 0.01 0.02
Questionnaire 2 Israel	2 3 4 5 6	40%   (37)     40%   (37)     15%   (14)       5%   (5)       2%   (2)	90%   (83)     57%   (53)     38%   (35)     12%   (11)       9%   (8)	51.0      5.78      9.21      2.86      4.08	0.001 0.02 0.01 N.S. 0.05

 

Table 3. Expected and actual numbers of 60 subjects agreeing to participate in each situation (N = 60 students administered questionnaire individually)

 

	Situation question	Expected agreement	Actual agreement	X2	P
Questionnaire 1 Africa	1 2 3 4 5 6	40%   (24)     40%   (24)     40%   (24)     15%   (9)       5%   (3)       2%   (1)	80%   (48)     77%   (46)     58%   (35)     38%   (23)     18%   (11)     12%   (7)	20     21.5       4.04       8.69       5.16       4.4	0.001 0.01 0.05 0.01 0.05 0.05
Questionnaire 2 Israel	2 3 4 5 6	40%   (24)     40%   (24)     15%   (9)       5%   (3)       2%   (1)	90%   (54)     57%   (34)     37%   (22)     13%   (8)     10%   (6)	32.9       3.34       7.99       2.6       3.48	0.001 N.S. 0.01 N.S. N.S.

 

 

Table 4. Comparison of responses of 60 subjects given questionnaire individually and 32 subjects given group questionnaire (number of subjects who agreed to participate in each situation)

 

	Situation question	Individual questionnaires N = 60	Group questionnaire N = 32	Difference
Questionnaire 1 Africa	1 2 3 4 5 6	80%   (48)     77%   (46)     58%   (35)     38%   (23)     18%   (11)     12%   (7)	81%   (26)     91%   (29)     56%   (18)     41%   (13)     16%   (5)       9%   (3)	N.S.     N.S.     N.S.     N.S.     N.S.     N.S.
Questionnaire 2 Israel	2 3 4 5 6	90%   (54)     57%   (34)     37%   (22)     13%   (8)     10%   (6)	91%   (29)     59%   (19)     41%   (13)       9%   (3)       6%   (2)	N.S.     N.S.     N.S.     N.S.     N.S.

 

 

Comparison of results in the Africa and Israel contexts

It was hypothesized that there would be a greater readiness to undertake activities which are harmful to the disabled in a country that was far removed both geographically and from the ethnic identity of the subjects than in the subjects' home country with patients of their own ethnic background. As seen above, the results show that there were no essential differences between the responses of subjects to the situation described in Africa and to the situation described in Israel. Remarkably, the lessened psychological distance from the patient population in the second questionnaire which involves Jewish patients like the subjects themselves, and where treatment is being conducted 'at a well-known treatment institution' in the heart of Israel, with its implications of a standard of professional excellence and integrity, were not reflected in any significant differences in the responses of subjects to the two situations. There was a close similarity between the replies about the actions mandated by the health authorities whether these took place in Israel or in Africa. The percentages of subjects who agreed to a drastic curtailment of treatment were 39% and 38%, respectively. Although there is some trend towards lower figures in Israel with regard to planning euthanasia (17% and 12%) and executing the policy (11% and 9%), the differences are not significant.

These results are more remarkable when one takes into account the fact that by the time the subjects were into the second questionnaire (Israel), they were fully aware of the progression of the situations described and the lengths to which the study goes. One might have expected that once the subjects knew what they were going to be asked and saw that the development of the situations in the second questionnaire paralleled the first, they would have been that much more aware of the serious consequences to which they were being taken and would have backed off and refused that much more to participate in the mandated procedures.

Remarkably, very few subjects even commented on the difference between the two geographical and ethnic settings; if anything there were some comments on the fact that the subject would react the same as she/he did in the previous situation.

One student observed how the difference between Africa and Israel enabled her to agree with the severe measures in the former thus: ‘In a deprived country such as Africa it is much easier because the condition of the patients is far more severe.’ In another instance, a student who refused to curtail treatment in Africa and agreed to curtail treatment in Israel explained the unusual reply thus: ‘My decision [in Israel] is this despite the fact that it seems to be a very unethical and unjust position but it may be necessary in times of extreme collective need, and I am able to give this reply because this is my country, its security problems and needs are understood by me and important to me.'

 

Content analysis of subjects who agreed to participate in the planning of involuntary mass euthanasia and those who refused

 

In an effort to generate beginning 'profiles' of the predominant ideation and attitudes of subjects who agreed and refused to participate in drastic curtailment of treatment and in planning and executing a program of involuntary mass euthanasia, content analyses of the response of the original 60 subjects were prepared.

Among the justifications for agreeing to curtail treatment and maintenance, one student said: ‘The mentally-ill and retarded are also human beings, but if the situation is really so critical, that's the alternative.’ A number of students gave the reason for their agreement as that of no alternative. ‘When difficult decisions have to be made, it should be done with maximum deliberation and caution, but it has to be done.’

Among those who agreed to participate in the planning of the involuntary mass euthanasia, there were often painful misgivings. One student said: ‘I will do it only if there is nobody else to do it instead of me.’ Another said: ‘It's possible that l would join the team in order to make sure that the ways chosen to implement the program are the most humane.’ Figure 1 shows a classification of the contents of responses of subjects who agreed to participate in planning involuntary mass euthanasia in the first questionnaire. Figure 2

 

 

N= 11 out of 60 subjects who agree

 

Fig. 1. Classification of reasons given by subjects who agree to participate in planning involuntary mass euthanasia.

 

 

shows a classification of the contents of responses of subjects who refused to agree to participate in planning such a program. Among the 11 subjects (who constituted 18% of 60 subjects) who agreed to participate in the planning of involuntary mass euthanasia, three content groupings were identified: ‘Good Children,’ ‘Killers Out of Mercy’', and ‘Obedient to Orders without Question’. Since the absolute number of subjects who agree to plan the euthanasia is nonetheless small, the distribution of responses into these three groups involves only a handful of subjects, and the comparison of ‘percentages’ of each can be misleading. Nonetheless, the analysis of the contents of the responses of all those who did agree to involuntary mercy killing are important.

Five subjects were characterized as ‘good children’ or people who do what they are told to do even though it is difficult for them. The good children say they are decidedly unhappy about what they must do, but they tell you that they are trapped and that they have no choice. They don't want to be held morally responsible for their actions. One subject said: ‘I won't agree to carry out the classification by myself but only as part of a

 

N = 49 out of 60 subjects who refuse

 

Fig. 2. Classification of reasons given by subjects who refuse to participate in planning involuntary mass euthanasia.

 

 

 

larger staff that will be able to establish with much greater reliability the condition of the patients.’ They do wish that it were all different and themselves try to look for alternative solutions, but alas unsuccessfully. When the die is cast, and the situation is grave, they tell you that what must be must be. One student commented that the whole conception ‘violated the principles of the physicians’ oath,’ nonetheless he added that if the situation really were one of ‘patients who had no chance of getting well, such as defectives or chronic mental patients, I would agree.’ Not surprisingly, these subjects expressed a great deal of difficulty and pressure at the end of the experiment.

A second group of subjects was characterized as people who do their killing ‘out of mercy.’ These subjects tell themselves and the experimenter that they are trying to do the most humane thing possible for the patients, and they make ‘profound’ statements about the valuelessness of life for people who are disabled.

Two subjects were characterized as totally obedient people who showed no hesitation whatsoever in agreeing to involuntary mass mercy killing. They have no questions and follow orders blindly. Their world is flat, absolute, without complications.

When it came to actual execution of the patients, some of those who agreed to take part had reservations or needed to minimize the significance of the actions, and others needed to try to place their actions in a humanitarian light. One student said: ‘I participate only if there is no one else to do it.’ I don't know how I could do it, maybe only in a critical situation.' Another student said: ‘It's a good idea; but the implementation is problematic, perhaps the best way is by stopping all treatment, unless it is possible to pass a law which legitimizes killing the patients.’ One student decided to join the team ‘in order to make sure that a humanitarian method is chosen.’

Among those who refused to participate in planning the involuntary mass euthanasia, four groups were identified: ‘Refuse and Oppose Vehemently,’ ‘Reject on Moral Grounds,’ ‘'Favor Euthanasia but Not By State,’ and ‘Leave the Situation.’

The largest number of subjects who refused to participate in the planning of involuntary mass euthanasia (46%) were absolutely clearcut in their refusal and in their protest. They were adamant in their opposition: ‘This is an inhuman idea.’ Or ‘When we do a selection and they tell us that the mental patient is at the bottom of the ladder of humanity, the evil that is done is not only to the patient but also to us as human beings.’

Many characterized the mercy killing as plain murder. An example of the latter is a statement by a subject: ‘This is an immoral decision of the most outrageous sort; whoever participates in it actively or passively takes full responsibility for committing murder.’ A smaller number of subjects (21%) also expressed opposition on the basis of ethical considerations but were less resolute about taking personal action against the program. Altogether, there were 33 out of 60 subjects (55%) who were clear in their moral conviction that involuntary mass mercy killing was untenable.

Ten subjects (20%) found the pressure of the situation described in the experiment so difficult, that along with their refusal to participate in the planning of the mercy killing they answered that they would have to get away from the situation such as by leaving the country, because they felt they would have no way of effectively opposing the government authorities who were running the health services.

Finally, a small group of those who opposed the mercy killing (13%) made a point of expressing their approval of voluntary euthanasia for individuals but were opposed to mandating involuntary euthanasia by any authority or government.

Those who refused to participate were much clearer as to the meanings of their positions than those who agreed to participate. Among the almost 50% who indicated they would protest with all their strength, one heard clear comparisons to Hitler and Nazism. For example: ‘This is the way Hitler began and it is possible to be drawn into the process without feeling it. At a certain point you have to know and set your boundary.’

 

Results according to the students’ disciplines

 

Curiosity at least requires that we also present the results from the point of view of comparisons between three disciplines represented among the original 60 student health professionals. Table 5 shows that somewhat fewer psychology students were agreeable to some of the earlier procedures which called for diagnosis and rediagnosis of patients for purposes of reducing treatment procedures, but somewhat more were agreeable to participating in planning program of involuntary mass euthanasia in the situation in Africa (30% psychology students as compared to 15% students in medicine and 10% in social work). This difference did not hold in the situation in Israel. Moreover, the difference is not

 

Table 5. Comparison of responses of 60 student health professionals in psychology, medicine and social work (Number of subjects who agreed to participate)

 

	Situation question	Psychology N = 20	Medical N = 20	Social Work N = 20
Questionnaire 1 Africa	1 2 3 4 5 6	11      (55%)     16      (80%)       8      (40%)       7      (35%)       6      (30%)       3      (15%)	19      (95%)     16      (80%)     12      (60%)       8      (40%)       3      (15%)       3      (15%)	18      (90%)     14      (80%)     15      (75%)       8      (40%)       2      (10%)       1      (5%)
Questionnaire 2 Israel	2 3 4 5 6	19      (95%)       7      (35%)       5      (25%)       3      (15%)       1      (5%)	18      (90%)     10      (50%)       9      (45%)       3      (15%)       3      (15%)	17      (85%)     17      (85%)       8      (40%)       2      (10%)       2      (10%)

 

 

present between psychology students and medical students when it comes to readiness to participate in actual execution of patients (15% for each). It can also be observed that a smaller number of social work students than any of the other disciplines were agreeable either to the planning (10% versus 15% in medicine and 30% in psychology) or the execution (5% social work versus 15% both medical and psychology students). Again, however, the difference does not hold up in the same direction when it comes to the patients in the Israel situation. It must also be noted that no differences between the different professions proved statistically significant.

No significant differences were found on any other variable including sex, country of origin, or relationship to the Holocaust (children of survivors).

 

 

DISCUSSION

 

Legitimate ‘triage’ or outright evil?

 

What might be the most extenuating considerations that can be raised with regard to the almost 40% who are prepared to curtail the treatment and maintenance of the handicapped, the almost 20% who are prepared to participate in planning involuntary mass euthanasia, and the 10% who themselves are prepared to participate in actual execution of the handicapped?

If one thinks of emergency-room and disaster situations where there are a huge number of casualties, such as after a terrorist attack or a train wreck, medical personnel actually are trained to make rapid assessments of whose lives can be saved and therefore will benefit the most from the immediate application of the team's resources as opposed to those who are judged to be beyond help. Whether we like the concept of triage or not, it is an organized societal response that has been around from the dawn of civilization, is understood as close to the evolutionary law of selection of the fittest which is inherent in nature, and can be argued as serving moral purpose.

Can it be said that the young student health professionals in this study were acting out of such a moral paradigm of triage? We think not, since nowhere in the structuring of the experimental situation was there any hint whatsoever of any kind of emergency-room or disaster conditions in which immediacy of health service to patients was an issue.

The more cruel concepts of triage involve policies of elimination of the weakest such as the terminally and irremediably ill and handicapped, or — depending on the classification employed by any given group — human beings who are no longer seen as able to be productive workers, or those who constitute a long-term needy population that will drain societal resources such as the aged and handicapped children. The definitions are, of course, selected and legitimated by any given society. It has been argued that at least some of these definitions should be treated with respect for their possible appropriateness to the realities of a given people and ecology, as well as for the fact that the application of a principle of selection of the fittest also deserves to be judged on the basis of its closeness to nature's lawfulness and should not be dismissed summarily as a fascist, totalitarian or evil way of organizing life.[16] This being the case, one could argue that the agreements of student health professionals to undertake drastic measures in this study were not necessarily statements of a readiness for evil.

Still, it is certainly clear that the overwhelming consensus of western society and Judeo-Christian thought adamantly rejects any such concepts of elimination of groups of the indigent, weak, chronically needy, or seriously ill. The only argument for willful termination of a sick person's life that has achieved some credence in Western society involves voluntary, individual euthanasia for a patient who requests it, or whose closest relatives request it when the patient is beyond being able to make such a judgment and request, and when objective medical opinion confirms that the patient is entirely beyond hope. Moreover, this concept of euthanasia is most often intended to eliminate suffering by way of removing heroic life-support measures when the patient is on the edge of final clinical death, and only more rarely is it defended for patients who are still capable of enjoying a regular regimen of everyday life activities.

What has become clear in history — whether in the template of the Holocaust which was the implicit background information which we expected our Jewish/lsraeli students to be most aware of, or in countless other histories such as Stalinist Russia[17] — is that authorization of any elite, authority or government to eliminate any group of people inevitably opens the door to heinous cruelty in the conduct of the authorized executions. This, then, leads to a progressive extension of the 'right' to exterminate a given group to more and more broadly defined groups.[18] To agree to a plan for involuntary euthanasia of a group of patients as called for in this study is to authorize health professionals, acting as agents of legitimated government policy, to define the boundaries of handicap and disability which will justify extermination. It is also to endow health authorities with the right to make summary judgments, since nowhere in the experimental description was there any provision for critical review, second opinions, or appeal.

Even if it is argued that the 40% of the subjects who agreed to curtail treatment and maintenance were responding sincerely to the definiteness of the experimental description of severe limitations of resources and were choosing to maximize the use of resources to benefit others who had a chance to live, the subjects' responses to the last two experimental situations which called for planning of actual involuntary mass euthanasia and then participation in the actual executions violate every principle of the civilized world and constitute clear-cut murder by a state-authorized professional elite.

The fact that the student health professionals in this study are relatively young and were drawn in suggestively by the power and authority of the rhetoric of the research questionnaire does not `excuse' the subjects from their choices of evil, but simply underscores some of the dynamic pathways through which otherwise not-at-all-evil-people are available to be drawn into the worst roles. This is the point that Arendt made in her famous formulation of the ‘banality of evil.’[19]

In an earlier review of the individual and group dynamics through which genocide comes to be executed by broad segments of the population; the senior author Charny presented the same conclusion: ‘Dare we really listen inside ourselves . . . The bedrock capacity and urge to kill are present latently in all human beings . . .’, and concluded further, ‘We need a psychology of how it is possible for normal everyday people to end up destructive when they did not intend to become so.’[20] Eric Fromm wrote, ‘no wonder it has taken us so long to understand the nature of evil because good and bad were so inextricably mixed that we couldn't make them out . . . The paradox is that evil comes from man's urge to heroic victory over evil.’[21]

The present study provides new evidence for the potential Nazi in all of us in the sense that there will always be significant numbers of human beings, in all ethnic and religious groups, at all levels of society, and under a great variety of structural conditions, who will be ready to do what they are told, or what the situation calls for, or to obey explicit orders to kill others.[22] Although the classic Milgram study has been deservedly studied at great lengths, few if any have observed that the situation around which the study was built was inherently trivial — the nonsense of learning new words — so that the fact that so meaningless a situation could be taken as justification for possibly killing others makes the results infinitely more frightening and important.

As indicated earlier, the overwhelming opinions of a group of 30 fellow Israeli clinical supervisors-trainers in medicine, psychology, and social work was that students who express a readiness to curtail treatment and maintenance of the handicapped, participate in planning mass involuntary euthanasia, or participate in executing the actual euthanasia should be dealt with severely — 17% of the trainers opted to expel the students who agreed to curtail treatment and maintenance from further training and 56% said they would put the student on probation, while 80% of the trainers were ready to expel outright the students who were ready to plan or participate in mass involuntary euthanasia.

During the Holocaust, Polish underground member Jan Karski went into the Warsaw Ghetto and then the Betzec death camp to see what was being done to the Jews. He observed an Estonian guard at Betzec thus:

 

‘I looked at his heavy, rather good-natured face and wondered how the war had come to develop such cruel habits in him. From what I had seen he seemed to be a simple average man, not particularly good or bad. His hands were the calloused but supple hands of a good farmer. In normal times that was what he probably had been, and a good father, a family man, and a church goer. Now . . . with everyone about him engaged in a grisly competition that knew no limits, he had been changed into a professional butcher of human beings.’[23]

 

Dynamics of the readiness to harm and kill patients

 

Considerable advances in social science research and thinking of the last twenty years, much of it clearly in the wake of the Holocaust and the nuclear bombings at the end of World War II, give us the following concepts which can help to explain the results of this study:

1.    Obedience to authority, conformity, and suggestibility.

2.    Blind participation in ongoing collective process, denial of personal responsibility for policy, and self-serving fulfillment of one's ambition.

3.    Destruction in the name of ideology and ‘double-think’, removal of the boundary between healing and killing so that evil or doing harm to others is relabeled as merciful, and also the blindness of needing to remain consistent with oneself — having begun to harm people, one continues to do so.

This is not the place to elaborate on each of the above. Sources to which the reader is referred in regard to the above include several preeminently classic works: Milgram[24] on obedience and conformity; Asch's[25] study of suggestibility; Kelman's[26] award-winning essay on sanctioned massacres including the dynamics of legitimation; the field research of Jones[27] in creating a collective Nazi-type process in a high school classroom; Zimbardo's[28] work on the recourse to cruel power of students elected to be jailers in a study simulating a prison, and Lifton's[29] sterling work on the dissolution of the boundary between healing and killing in the physicians in the Nazi concentration camps, and what he terms the 'healing-killing paradox'. Reference is also made to a little-known experiment at the University of Hawaii by Mansson[30] in which an overwhelming majority of subjects agreed to a 'final solution' of executing the retarded; a little-known study by Olson and Christianson[31] of pacifists doing a simulation of non-violence which ended when those playing the roles of an occupying power turned to ‘actual killing’ of the non-violent resistors; and to a forthcoming essay on the double-think and double-talk of the language of extermination by Smith and Hirsch.[32]

Earlier survey-essays describing many of the dynamics of collective massacre will be found in works by Charny and Rappaport.[33] A forthcoming summary of the dynamics of destructiveness by Charny and Fromer[34] develops the concept of clusters of dynamics as a series of doors or pathways through which people are variously drawn into sequences of evil, and then co-opted by the pyramiding momentums and complications of interlocking mechanisms acting synergistically on one another. Charny[35] has recently proposed that actual doing harm to others, or increasing readiness to do so, be viewed as psychopathological, and as the other side of the coin of hurting one's own life and opportunity to live out life fully. See also Pilisuk and Ober[36] for a statement of genocide as a public health problem.

Finally, for a definitive text describing the widespread phenomenon of genocide in the twentieth century, see Kuper[37]; and for a description of fictionalized scenarios based on the realities of past events transformed into generic templates or scripts of how genocides can develop under different societal and historical conditions, see Fein.[38]

 

The lack of difference between responses to the experimental situations in Africa and Israel

 

The most surprising result of this study was the failure to demonstrate any meaningful differences in the responses of the Jewish/lsraeli student health professionals to situations of patients in Africa and Israel. We believe these results may reflect, much more than we anticipated, people's needs to be consistent with themselves. Once subjects chose to harm patients in the Africa scenarios, the need to continue in whatever policy direction one initially chose may have been responsible for their going on with the same destructive choices when the target population of patients became members of their own ethnic nationality. If true, this finding is of course consistent with the well-established concept that people eschew cognitive dissonance, and it is also suggestively important evidence for a speculation offered by the senior author some years ago that 'once human beings allow themselves to be drawn seriously into genocidal events . . . there also come into play powerful experience-denying mechanisms. Otherwise it would be unbearable to experi­ence the humanity of the victims destroyed.'[39] Charny arid Fromer[40] recently studied the attitudes of Israelis, who were going to see a film about the Holocaust, towards the statement by a soldier who had been convicted of massacring innocent Arabs 30 years earlier, and now stated that he was only doing his duty and would, do the same again. (See also Bar-On and Chamy[41] for a study of how the children of victimizers in the Holocaust in most cases cannot deal fully with their parents' roles as victimizers.) The likelihood that the subjects who already committed themselves to euthanasia in the Africa situation in this study were then unable to reverse their roles in the second experimental situation taking place in Israel is supported by the fact that of the 8 subjects who approved euthanasia in Israel, 7 had previously opted for euthanasia in the Africa context. Similarly, of the 6 who were available personally to terminate patients' lives in Israel, 5 already took the same position in Africa.

 

Further research

 

The surprising finding that there were essentially no differences between the experimental situations in Africa and then in Israel suggests the desirability of conducting the same study using the reverse sequence of ethnic/geographical closeness, in other words placing the Israel context first and the Africa context second, to see if introducing policy instructions to reduce treatment and plan involuntary euthanasia of one's own ethnic family at the outset will bring less agreement in regard to one's own people.

This study could also bear comparisons with using students from other disciplines as subjects although the experimental situations will have to be varied when there no longer is the same logical context of turning to the subjects as future health providers. Comparisons between student health professionals, as in this study, and practicing health professionals of varying experience are also called for. It would also be meaningful to develop comparative studies where the patient-handicapped populations are varied — the elderly, seriously handicapped children, mentally retarded, psychotic adults, psychotic children, criminally insane adults, patients with AIDS, and others. This study also lends itself to the possibilities of introducing experimentally preventive and corrective measures designed to bring health professionals into contact with the needs and humanity of their patients on the one hand, and to the ethics and values of their professions on the other hand, e.g. a pre- and post-study of subjects where the professionals have been taken to visit a health facility for the chronically ill, or where they are exposed to a lecture on values in medical care, or after subjects are exposed to a lecture on the history of health professionals in the Holocaust.

 

SUMMARY AND CONCLUSION

The present study is seen as contributing to emerging knowledge of the widespread availability of human beings to undertake policies and actions which harm, hurt, and kill other human beings, when told to do so on the basis of a policy directive by a person, or a system, and/or when placed in a situation where the power to assign and determine the fate of other human beings is entrusted to their hands. The present study derives its special significance from the combinations of contexts of using subjects who are Jewish/ Israeli and are students of health professions. Notwithstanding the powerful combinations of traditions and the images of each of these traditions that call for identification with the sacredness of life and the privilege and obligation to protect handicapped people who need care, a large number of subjects agreed to participate in procedures which would lead to the deaths of patients in their care.

 

 

 

NOTES