72 The Southwest Respiratory and Critical Care Chronicles 2023;11(46):72–74 Letter Comparisons between health care practices in Nazi Germany and the current United States Gilbert Berdine MD Corresponding author: Gilbert Berdine Contact Information: Gilbert.Berdine@ttuhsc.edu DOI: 10.12746/swrccc.v11i46.1135 In the commentary Revisiting Psychiatric Support for the National Socialist Agenda in Germany: Impli­ cations for medical and residency training,1 the authors note similarities between horrible practices in Nazi Germany and what seems to be creeping up on us in the United States. I agree with many of the points made by the authors. I disagree that our current system is more enlightened than what was in place in Nazi Germany, though we are not as bad–yet–and I further disagree with implications that if we went further away from a private health care system toward a more social- ized system that the problems would disappear. The authors correctly point out that undesirable groups were considered to be “useless eaters” by the Nazi party, which justified the ill treatment, includ- ing murder, of these undesirables. The authors also correctly point out that blind faith in ideology leads to rationalization of terrible practices. However, undesir- ables are not limited by utilitarian concerns. Just as Jews were considered by Nazis to be undesirables, irrespective of their economic productivity, unvac- cinated people during the COVID pandemic were considered by western elites to be undesirables irrespective of their economic productivity. Medical “experts” such as the New England Journal of Medicine demanded that if the population would not voluntarily be vaccinated, then vaccination would be mandated by loss of employment, or in some cases incarcera- tion.2 “One option for increasing vaccine uptake is to require it.”2 “In addition, state mandates should not be structured as compulsory vaccination (absolute requirements); instead, noncompliance should incur a penalty. Nevertheless, because of the infectiousness and dangerousness of the virus, relatively substan- tive penalties could be justified, including employment suspension or stay-at-home orders for persons in des- ignated high-priority groups who refuse vaccination.”2 In Australia, the unvaccinated were literally herded up like cattle and put into internment camps. Unlike, the Nazis, the Western World did not murder millions of people, but we hardly behaved like the shining city on the hill we claim to be. The authors correctly point out that the economic burden of the disabled, mentally ill, elderly, and incapac- itated people is more noticeable during depressions, recessions, or hard times. This does, indeed, make more people consider these groups to be “useless eaters.” However, recognition of the sentimental value of human lives does not make the economic burden go away. There are people who represent a net drain on economic resources. The ideology of “useless eaters” blinds people to the sentimental value these people have. However, the ideology of “human life is priceless” or “health care is a human right” blinds peo- ple to the very real resource burden of unproductive people. On whom should the burden of care fall? The sentimental value of individuals is greatest for family members, next greatest for neighbors, next greatest for members of the same tribe, and so on. As unpro- ductive individuals become more and more removed from other productive individuals, the productive indi- viduals become less enthusiastic about continued support of the unproductive. At some point, everyone walks away from further responsibility. On leaving my local movie theater a few years ago, I saw a man stumble and fall to the ground. I went to his assistance, helped him to his feet, and assisted him to a bench to rest. Another woman aided my efforts. After some effort, we were able to contact a family member to come pick him up. I asked the woman if she could stay with him until help arrived, as I had to leave. Should I have stayed? If the man required a trip to the hospital, should I have trans- ported him? If he was unable to pay for the hospital, should I have made good on any debt? If he needed 73 Comparisons Between Health Care Practices in Nazi Germany and the Current United States Berdine The Southwest Respiratory and Critical Care Chronicles 2023;11(46):72–74 expensive surgery, should I have guaranteed pay- ment? At what point does one walk away from a com- plete stranger in need? Different people will draw the line at different places. The same person will draw the line at a different place depending on current financial status. There is no correct answer to the question. The question and answer are subjective. It is ideology for a leader to believe that one’s personal belief repre- sents some Universal Truth. Costs must be paid. Even if costs are socialized, the costs still must be paid. According to the Medicare Trustees, the Medicare program is officially insolvent. Socialized systems have ever increasing costs with ever decreasing quality of service. The US pretends that we can just print money to cover the cost. Modern Monetary Theory (MMT) is just another ideology. The Canadian system solves its cost problem by making people wait a long time so that many will cross the border and get care in the US. The Mexican system encourages people to illegally cross the border into the US, have anchor babies, and welcome the entire family to Medicare/Medicaid. The United Kingdom system decreases costs by caring for people in hall- ways and with too few health care workers. Recently the UK nurses went on strike.3 The authors correctly point out that private health insurance is motivated by profit. However, Medicare is also motivated by cost containment. My experience with bureaucrats from both systems is that trying to get something done is like having a conversation with a fencepost. A big problem in the US is that “insur- ance” has become a cost subsidy rather than pool- ing risk. Health care costs in the US are about 1/6 of the Gross National Product. How high a number is “correct?” Once again, the question and answer are subjective. It is ideology to believe that there is an objectively correct “fair share.” The authors correctly point out that many physi- cians in Nazi Germany “absolved themselves of their complicity by claiming they were merely following orders.” Nobody wanted to draw attention to them- selves with dissent. Single payer systems make it very easy to coerce practitioners. Practitioners who perform hospital or expensive outpatient procedures cannot perform these procedures without meeting Medicare requirements for both practitioners and care facilities. If Medicare demands that patients get tossed out in the snow as depicted in Dr. Zhivago, the physicians will rationalize the decision to toss patients out in the snow. We are already seeing mission creep in terms of “pay for performance.” The authors correctly point out that, “A health care predominantly profit-driven system driven by increas- ing health care costs and profit margins can be sus- ceptible to extreme utilitarian, impersonal, cost-benefit analyses that were employed in Nazi medicine and ultimately that resulted in policies of eliminating people deemed worthless due to chronic illnesses or disabil- ities.” I hate to point out that ALL charity comes from profit rather than from Santa Claus. Without profit, there is NO charity. The virtue of private charity is the providers are aware of a budget and have incentives to perform the greatest good for the lowest cost. Public charities are cesspools of corruption. The cost of a thoracentesis tray is about $150. I can charge Medicare only $100 for performing the procedure thereby losing money. I can, however, admit the patient to the hospital for a few days, attach the procedure to an unneces- sary CT scan and generate about $25,000 in Medicare payments after all the participants get their cuts. Public charity has a delusion of unlimited resources, so the sky is the limit, and everyone wants to maximize how much is spent. When the resources run out, however, good luck on arguing that Medicare is more deserving of tax dollars than Raytheon. The authors correctly point out that the current US health care system is plagued by divided loyalty. Do physicians serve patients? Or do physicians serve the people who pay the fees? The Biblical version of the Golden Rule was, “And as ye would that men should do to you, do ye also to them likewise.”4 The modern version of the Golden Rule is, “Whoever has the gold makes the rules.”5 Physicians are under increasing pressure to serve the person who writes the check. It does not matter whether physicians serve a corpo- rate master or a Medicare master, the patient gets the short end of the stick. I agree with the authors that medical students should learn the horrors of medical practice in Nazi Germany. 74 Berdine Comparisons Between Health Care Practices in Nazi Germany and the Current United States The Southwest Respiratory and Critical Care Chronicles 2023;11(46):72–74 “Those who do not learn history are doomed to repeat it.” George Santayana It does not matter whether authoritarian policies come from authority on the left or the right. “Clowns to the left of me! Jokers to the right! Here I am stuck in the middle with you.” Bob Dylan However, we should not believe that we are either enlightened or immune to the dark path of ideology. “The line separating good and evil passes not through states, nor between classes, nor between political parties either–but right through every human heart– and through all human hearts.” Aleksandr Solzhenitsyn. Article citation: Berdine G. Comparisons between health care practices in Nazi Germany and the current United States (Letter). The Southwest Respiratory and Critical Care Chronicles 2023;11(46):72–74 From: Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas Submitted: 1/8/2023 Accepted: 1/9/2023 Conflicts of interest: none This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License. RefeRences 1. McMahon T, Ali H, Baronia R, McGovern T. Revisiting psy- chiatric support for the National Socialist Agenda in Germany: Implications for medical and residency training. The South- west Respiratory and Critical Care Chronicles. 2023;11(46): 1–10. 2. Mello MM, Silverman RD, Omer SB, et al. Ensuring uptake of vaccines against SARS-CoV-2. N Engl J Med. 2020;383: 1296–1299. 3. Picheta R. British nurses launch historic strike, as pay and staffing crises threaten the NHS. https://www.cnn.com/2022/ 12/15/business/uk-nurses-strike-thursday-nhs-gbr-intl/index. html 4. Luke 6:31 KJV Bible. https://www.biblestudytools.com › kjv › luke › 6–31. 5. “Wizard of Id” cartoon strip, Dallas Morning News, May 3, 1965.