Pernicious: Highly injurious or destructive: deadly. Causing irreparable or deadly injury.

When considering the subject of health care reform it is important to understand what the words really mean. The term "health care” (which is really disease care), has become a catch phrase for medical insurance. "Health care reform” is a code name for changing means by which individuals are insured for medical expenses and the manner in which physicians, hospitals, and other entities within the disease care industry are paid for the services they provide.

I have repeatedly heard the statement, "Forty-six million Americans are without health care!” This is simply not true. What is really being stated is that 46 million Americans are not currently insured for the medical expenses they may incur.

When it is understood that "health care” is a euphemism for "disease insurance”, the call for reform is understandable. The cost for businesses to provide medical insurance to their employees has risen 92 % since 2000. The average employee contribution to medical insurance costs has jumped 155 % over that same period, during which the cumulative rate of inflation was 44 % and wages rose only 29 %. Medical insurance costs now exceed profits for many companies, and they played a major role in bringing about the bankruptcies of Chrysler and General Motors.

Clearly, the way medical services are purchased should be reformed. Unfortunately, the health care reforms currently before congress do not do so. They do not propose to bring costs in line by placing the primary responsibility for payment of medical services directly in the hands of the individuals purchasing them. This could be accomplished simply by changing from a system that provides nearly first dollar coverage to a system that provides an umbrella of high-deductible insurance policies that protect individuals from the burden of catastrophic medical expenses.

Today’s proposed health care reforms are not about changing the system of payment; they are about redefining who controls the system. They are not about making changes that will rapidly result in a reduction in the cost of medical services; they are about giving governmental agencies the power to determine who will receive treatment and when they will receive it. They are about giving the federal government the authority to decide who will live and who will die.

There is a dark and sinister philosophy that is driving the current health care reform effort. It is not a new philosophy; it has been used to guide decisions about the provision of medical services in the past with horrifying results.

On July 14, 1949 an article of historic significance appeared in the New England Journal of Medicine. It was written by Leo Alexander, M.D. Dr. Alexander was a renowned psychiatrist who was on the faculty of Tufts College of Medicine. His academic position, however, was not relevant. What qualified him to write the article was his experience as consultant to the secretary of war, on duty with the Office of the Chief Counsel for War Crimes, Nuremberg, United States Zone of Germany, 1946-1947. The article was titled Medical Science Under Dictatorship.

Dr. Alexander had been shocked by what he had learned about medical practices in Nazi Germany and in the countries occupied by the Nazis prior to and during World War II. By skillfully using discussions at medical meetings, films, and textbooks to prepare the medical profession and the public at large to accept the coming changes, medical science rapidly deteriorated from a system devoted to providing care and comfort to hurting people to an efficient system for culling undesirables from society. The change was so complete that Alexander coined the term "ktenology” meaning "the science of killing” to describe the state of the medical profession under the auspices of the Third Reich.

The article details many of the barbaric procedures and gruesome experiments that were conducted in the name of medical science during the Nazi regime. Detailing these was not the primary focus of the article, however. Dr. Alexander wrote the article to answer two questions:

1) What caused physicians in countries under Nazi control to abandon their traditional role of caring for the sick and injured and willingly identify and refer patients with chronic mental or physical illnesses to governmental agencies charged with their extermination?

2) Could a similar shift occur in the United States?

Alexander found the answer to the first question in the philosophy of Georg Wilhelm Friedrich Hegel. Hegel was a strong proponent of rationalism. In many ways he was a model for Mr. Spock of Star Trek fame. Mr. Spock, you may recall, was often at odds with Dr. McCoy who allowed emotion to affect his judgment. One of the elements of Hegelian philosophy is the principle that "what is useful is good”.

Economic rationalism argues that what serves the greatest segment of society is good. One of the techniques used by the Nazis to teach this principle was to present it in the form of math questions in textbooks. For example, one problem asked high school students to determine how many new housing units could be built and how many marriage-allowance loans could be given to newlyweds for the amount of money spent caring for the crippled, the criminal, and the insane.

The Nazis rarely gave direct orders requiring physicians to send chronically ill patients to death camps or to follow governmental directives to give lethal injections in their offices. To advance their vision of a society unfettered by individuals who consumed more resources than they could produce the Nazis approached physicians in a manner that appeared harmless. For example, upon occupation of the Netherlands Dutch physicians were asked to sign the following statement:

"It is the duty of the doctor, through advice and effort, conscientiously and to his best ability, to assist as helper the person entrusted to his care in the maintenance, improvement, and rehabilitation of his vitality, physical efficiency, and health. The accomplishment of this duty is a public task.”

The physicians of Holland unanimously refused to comply. They realized that it is the first step away from the established path that is the most significant. Had they accepted that their task was to restore their patients’ to full vitality and efficiency they would have been simultaneously accepting that it was a waste of their time and resources to provide care to anyone who could not be restored to their full potential.

When they refused to accept the order the physicians were threatened with loss of licensure. Rather than give in they returned their licenses, continued to see their patients secretly, and no longer submitted birth or death certificates. One hundred of them were arrested and sent to concentration camps, but the others still held firm. It is noteworthy that not a single instance of euthanasia or involuntary sterilization took place in the Netherlands during the occupation.

Dr. Alexander answered the first question by suggesting that adopting an attitude that medical care must involve a reasonable chance of full recovery to be worthwhile inevitably leads to the conclusion that individuals who are not worth treating are leading lives that are not worth living. The first step, which sounds so reasonable on the surface, is the most deadly for it leads progressively deeper into a dark, unforgiving chasm of hopelessness.

Addressing the second question, "Could it happen here?” Dr. Alexander pointed to the formation of foundations for the support of patients with chronic diseases and the development of new pharmaceutical agents to treat chronic disease as trends that could counter the development of a utilitarian approach to medicine in the United States. He issued these words of caution, however:

"Physicians have become dangerously close to being mere technicians of rehabilitation. This essentially Hegelian rational attitude has led them to make certain distinctions in the handling of acute and chronic diseases. The patient with the latter carries an obvious stigma as the one less likely to be fully rehabilitable for social usefulness. In an 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 be no effective remedies have become a threat to newly acquired delusions of omnipotence.”

I have seen this attitude first hand. A prime example is the "fibromyalgia expert” concluded his lecture by stating, "These people can take up a lot of your time and resources. Your job is to get them out of your office as quickly and cheaply as possible.”

We now know the answer to the second question with certainty. Not only could a shift to a Hegelian approach to medical care occur in the United States, it has occurred and the degree to which it is affecting decisions regarding medical treatment is rapidly increasing.

It is astounding how quickly lessons learned by one generation can be forgotten by the next. After standing so strongly against the practice of euthanasia during the Nazi occupation, the Netherlands became the first country in the post-WWII world to legalize the practice.

In 1948 the medical societies of the world met in Geneva, Switzerland to determine how to avoid a repeat of the atrocities committed under Nazi rule. The result was the adoption of an updated version of the Hippocratic Oath called The Declaration of Geneva.

The principles agreed upon as foundational to the ethical practice of medicine by the delegates to the Geneva conference remained in place for less than 25 years. When I graduated from medical school in 1972 my classmates and I were told that omitting the phrase "from the time of conception” in regard to maintaining the utmost respect for human life was acceptable. It has since been removed from the Declaration. While the 1948 Declaration asked physicians to commit to the tenet that "The health and life of my patient will be my first consideration”, the current version is eerily reminiscent of that required of doctors in Nazi occupied countries. It simply states, "The health of my patient will be my primary consideration.”

Hegelian philosophy has guided the Medicare program for many years. When I was still involved in the care of hospitalized patients I was under constant pressure to transfer those who were not showing signs of rapid improvement to progressively lower levels of care. The current legislation, however, is intended to take this practice to a new level.

Contained within the so-called stimulus package was a clause limiting the availability of medical treatment. In effect, the cost of a medical treatment is to be divided by the number of "Quality Years" the patient is likely to experience, based upon average life expectancy. If the annualized cost is too high, the available treatment is to be withheld.

I have not personally read the voluminous bills before the House and Senate, but Dr. Betsy McCaughey, a health policy expert and a former New York Lieutenant Governor has done so. She discusses many of the provisions on her website, http://www.defendyourhealthcare.us/. One of the cost-cutting elements of the program is a requirement that seniors attend counseling sessions on limiting end-of-life care at five year intervals with an additional session should they develop a life-threatening illness in the intervening time period.

Physician control is at the heart of health care reform. I attend the annual scientific assembly of the Oklahoma Academy of Family physicians annually. In recent years a new incentivized practice format – the Patient-Centered Medical Home – has been promoted. What’s the big deal? I wondered when the concept was initially presented. For over 25 years my practice provided a medical home for thousands of individuals. My partners and I were available 24/7 to answer any and all calls and deliver any needed care. I cannot begin to count the times I met someone at the office after hours to save them the expense of an emergency room visit. Clearly something was afoot.

I now know why primary physicians are being pushed to have their practices officially certified as Patient-Centered Medical Homes (PCMH). One of the core features of a Patient-Centered Medical Home is the incorporation of Health Information Technology. According to the American Academy of Family Physicians member website, "HIT is not just an electronic health record (EHR). A patient-centered medical home automates business and clinical processes, depends on clinical decision support tools, and is connected to patients and other members of the health care team. It is the central nervous system of the practice.” (Italics mine.)

Once again we are dealing with something that sounds extremely practical and beneficial to physicians and patients alike. Unfortunately, the "clinical decision making support tools” upon which a PCMH relies are an extremely effective vehicle for ensuring physician compliance with governmental directives. In fact, another clause in the stimulus package that received almost no discussion and of which most people are unaware mandated the implementation of computer technology that will guide physician decisions about what treatments are "cost-effective”. Beginning in 2014 physicians and hospitals that are not "meaningful users” of the system will face stiff penalties from federal programs. (It is likely that private insurers, if they still exist, will follow the government’s lead, as they have consistently done so in the past.)

One might like to believe that I have developed a severe case of paranoia or that I am being an alarmist. Unfortunately, the government’s intent has been stated clearly, in writing, by its chief architects.

The term Nazi was a nickname for the National Socialist German Workers Party. The Nazis were socialists, politicians who believed in governmental ownership and control. The current health care reform effort is being driven by politicians who, like the National Socialists of the past, believe in governmental control.

The individual named to be the national coordinator of health care technology by Barack Obama is David Blumenthal, who is a professor at Harvard Medical School. Dr. Blumenthal has written extensively that governmental limits on the availability of medical treatment should be established. He has openly stated that his position is not simply about putting machinery in doctor’s offices. It is clear that he believes that his position is about creating the environment necessary to control physician activities. It is all about control.

Another key player in the health reform effort is Dr. Ezekiel Emanuel, who just happens to be the brother of Rahm Emanuel, the White House Chief of Staff. Dr. Emanuel has been appointed health-policy adviser at the Office of Management and Budget and he has also been named as a member of the Federal Council on Comparative Effectiveness Research.

Dr. Emanuel has written that meaningful health care changes will only be accomplished by changing the way doctors view patients. He has suggested that doctors take the Hippocratic Oath too seriously and in so doing do not adequately consider the cost of the care they are providing. He believes that it is essential that physicians reject the model of valuing each individual life as of ultimate importance and adopt "communitarianism”, which would reserve medical care for the non-disabled. In the Hastings Center Report of November/December 1996 he wrote that medical care should not be given to people "who are irreversibly prevented from being or becoming participating citizens . . . An obvious example is not guaranteeing health services to patients with dementia.” He has also written that it is acceptable to withhold medical treatment on the basis of a person’s age:

"Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years.”

The Health Information Technology section of the stimulus package and the Patient Protection and Affordable Care Act (ObamaCare) as envisioned by those charged with their implementation stand in stark opposition to the principles upon which the United States of America was founded. In declaring their independence the revolutionary leaders proclaimed that all people are endowed by their Creator with the right to life, liberty and the pursuit of happiness. They believed those rights to be unalienable – unable to be taken away by those governing the people.

Because of their love of liberty and their fellow men many have voluntarily given their lives so that others could live. Unfortunately, the combined effects of the 2008 "Stimulus Package" and the 2010 "Patient Protection and Affordable Care Act" will ensure that many will be denied care by faceless bureaucrats who feel they have the right to decide who shall live and who shall die for what they deem the best interest of society. The philosophy that guided medical practice under National Socialism has once again reared its ugly head. I fear for the future of our nation.