Chapter XVII: Do We Treat All Patients, or May We Refuse to Help Some of Them?

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Mount Taigetos. In Sparta all newborn children had to be presented to the Ephors of State, who selected the ones they considered robust and healthy. All other children were left on the slopes of Mount Taigetos as prey for wild dogs and predatory birds. The mothers were not allowed to display grief. (108)

The Physician on the Rocks of Taigetos. I use the term "Taigetian mentality" to denote the philosophy of life claiming that society should free itself of its weak and "useless" members. This philosophy is often called "social Darwinism," which, however, misrepresents the views of Darwin and the genuine social Darwinists. Darwin described natural selection and the "survival of the fittest" as the way blind nature operates; he never proposed that society consciously regulate human affairs in that manner. The original social Darwinists, William G. Sumner, Herbert Spencer, and Walter Bagehot, did indeed postulate survival of the best adapted as a principle of social organization, but exclusively on the socio-economic level. The proposition to exterminate the biologically weak, and to entrust doctors with the task, has its source in later writers, especially Ernst Haeckel, Karl Binding, and Alfred Hoche. (109) With these reservations, I will be using the terms "social Darwinism," "Taigetian mentality," and "biological cleansing" interchangeably.

Dr. Isaac van der Sluis traced the history of biological social Darwinism in his excellent book. (110) I will limit myself to manifestations of this mentality with which I was confronted in the last twenty years of my medical practice.

* A young woman doctor opposes the implantation of a pacemaker in a 75 year old patient suffering from heart block, and states that, as a matter of principle, she is against the implantation of pacemakers in people over 75 and that society should not be burdened with keeping the elderly alive.

* A team of anesthesiologists at a university hospital decide to refuse to provide anesthesia and thereby to prevent surgery for congenital heart disease in children with Down syndrome.

* In Rotterdam, a cook in a hospital kitchen is suffering from progressive kidney failure. An internist at that same hospital refuses to make use of renal dialysis and allows the patient to die because the patient is a bachelor and has no immediate family.

* A family physician sends our hospital in Den Bosch two women patients, both suffering from pulmonary edema (a buildup of fluid in the lungs due to heart failure: this is a sudden and life-threatening condition, but one which usually can be quickly relieved), and, in both cases, stipulates by phone that these women were "too old" and should be refused treatment. In the second of these two cases, the doctor even demanded that the woman be refused admission to the hospital.

* When transferring a patient with acute myocardial infarction and pulmonary edema to me, an internist colleague warns me "not to make overly vigorous attempts to save this man since he is a widower and without family."

* Another doctor tells me that "as a family physician" he opposes the implantation of a pacemaker to his patient since she is 86 years old. The woman had fainted due to a heart block, striking her head on the kitchen stove as she fell, and was found on the floor in a puddle of blood.

To form an idea of how widespread this attitude is, and how many sick people are refused treatment, one has to multiply these observations made by a single specialist by several thousand.

Holland is not the only country infected with Taigetian attitudes; the specter seems to loom over the part of the world around the North Sea. In the early seventies, I heard the opinion that pacemakers should be denied to older people, expressed by a doctor in Aalborg, Denmark (the view was found inadmissible by the head of cardiology). In Copenhagen, doctors at the only hospital doing the coronary bypass surgery at that time refused to do it in patients over 60, not because of less favorable results expected in them, but on principle, as a self-conceived rationing. …