From the President...

That Infinitely Small Wedged-In Lever

James P. Weaver, MD

The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans. But it is important to realize that the infinitely small wedged-in lever from which this entire trend of mind received its impetus was the attitude toward the nonrehabilitable sick.(1)

Leo Alexander, M.D. was a psychiatrist. He worked at Tufts Medical Center in the 1940s and served as consultant to the Secretary of War, on duty with the Office of the Chief of Counsel for War Crimes, Nuremberg, United States Zone of Germany, 1946-1947. He interrogated numerous German physicians involved in the practice of Germany's medical principles during the Nazi Holocaust. If there is a lesson for Medicine from his writings, I believe it is found in the simple statement, "But it is important to realize that the infinitely small wedged-in lever from which this entire trend of mind received its impetus was..."

After hours of dialogue with Nazi physicians, Dr. Alexander realized that this entire debacle began from an "infinitely small wedged-in lever." He realized that minds, intelligent minds, could be changed and led down a road that they surely had no intention of traveling when their journey began. It will be useful for today's physicians to step "out of the box" for a moment and examine our current professional milieu to see if there are any of these "wedges" that might be unobtrusively determining our future.

If there is one of these wedges that I would expose it would be "cost containment." I believe this wedge is separating physicians from their patients and from their professional souls. Cost containment is the siren song for our generation of physicians. It has been shrewdly broadcast by all of the payers in our current medical system, and is the bait that has been naively swallowed by all of the major medical organizations of physicians, save one: The Association of American Physicians and Surgeons.

I do not believe in irresponsible medical spending. Physicians must continue to advise what is best for the patient, but we must avoid unnecessary interventions, and futile care. On the other hand, we must not cross the line and side with the business men who would have us create and implement their systems of cost containment and rationing.

"We know best how to contain costs, and they will do it anyway, so we need to have a seat at the table," is the tempting rational that "our" duplicitous AMA uses to justify its misdirected leadership. Theirs is a hollow argument. What we actually know best is how to take care of our patients. That is the objective from which we physicians must not stray.

Once physicians have adopted the ethic of cost containment, we have necessarily sacrificed our ultimate calling. I do not believe we can serve two masters. The public media is rife with stories of the death, disillusionment and destruction, by those physicians who have adopted this new ethic and abandoned their previous societal promises to keep the interests of the individual patient first.

Those physicians who have traded their noble academic degree of "M.D." for the utilitarian label of "Medical Director" epitomize the abandonment of our profession. Making decisions from afar, while never touching or examining the patient, stands as a graphic symbol of their actual removal, far away from the principles which physicians have held sacred for more than two thousand years. I have publically stated my ethic when I received my "M.D." degree. Let the medical directors publically state their ethic when they adopt their new business ethic. Would it be to value the group's needs over the individual, to value profit over the delivery of improved quality of care, and not to disclose to patients all the options of care available if they endanger the bottom line of the plan?

Physicians must continue to take the "other side" of the discussion when dealing with the dialectic wedge of cost containment. We must not take up the banner of the rationers and, lured by their shallow arguments, inadvertently decimate the future of our profession and the care of our patients. So when the discussion drifts into concerns for cost containment, expose that "wedge" that is surely leading us down the slippery slope to professional extermination, and redirect it to where physicians must unabashedly stake their claim: the care of the patient.



1. Alexander L. Medical science under dictatorship. New Engl J Med 1949;241(2):39-47.

Dr. Weaver is a thoracic surgeon in Durham, North Carolina, and president of the AAPS. E-mail:

The interested reader may want to refer to my review of Dr. Leo Alexander's monograph (May/June 1998), Dr. Arthur Gale's commentary (Nov./Dec. 1998), and Dr. Joseph Scherzer's review of The Death of Medicine in Nazi Germany (March/April 1999) in the Medical Sentinel.---Editor.