A Jewish doctor, an anti-vaxxer, and a Nazi with rectal prolapse walk into a bar...

It is cold outside and snow is falling, along with COVID infection rates. 

But while the Omicron surge is receding fast, hospitalization rates are still high, consisting mostly of the unvaccinated. Likewise, deaths, which are still above 2,500 a day - 74% of last winter’s peak - are twenty times as high in the unvaccinated.

I have heard of this species called the anti-Vaxxer, endemic to the Red states and certain other parts of the country; in New York City, however, at least in the Westside Family Medicine patient population, the anti-vaxxer is a rare bird to find. 

Much more common in our neck of the woods is its opposite: the anti-anti-Vaxxer.

Anti-anti-vaxxer sentiment is everywhere, ranging from bemusement to pity to resentment to anger. Mostly anger. 

A letter to the editor in the New York Times last week presents an ethical dilemma: two women roll into the emergency department, one with a heart attack, one unvaccinated with COVID pneumonia. 

Both need an ICU bed, but only one is available. Who should get it? Should the woman with the heart attack be “denied” appropriate care because of the unvaccinated woman’s “personal choice”? Should the unvaccinated woman be “rewarded” for her choice with a “precious” ICU bed? 

The writer is a doctor and his questions are rhetorical: it’s obvious that in his opinion, the unvaccinated woman should certainly not be rewarded with the ICU bed.

When I was a young attending at Columbia, supervising a group of residents and medical students on their hospital rotation, we had a patient on our service who, shall we say, triggered the team.

He was a white skinhead in his early thirties, tattooed with swastikas and Iron Crosses, admitted with rectal prolapse (look it up). He was humiliated by his condition, hostile and threatening.

Rachel has a similar story from medical school at Dartmouth: a New Hampshire man in his sixties, a Nazi with swastika tattoos, admitted with atrial fibrillation.

(What are the odds? Could it be that every Jewish doctor has a Nazi patient story…?) 

I used the case to teach not only about rectal prolapse, but also about how to deal with the difficult patient. We talked about transference, countertransference, and medical ethics.

It went without saying that the goal was to give him the best care we could - to find a way to overcome our antipathy toward the Nazi in order to sympathetically treat the patient.

Rachel remembers that her attending had a similar approach.

Nazis are great for clarifying moral dilemmas. 

In 1978, the ACLU defended the Nazis’ right to march in the heavily Jewish neighborhood of Skokie, IL. The message was clear: if the first amendment applied to Nazis, then it applied to everyone.

Similarly, if you can show that the basic ethics of patient care apply to Nazis, then you have clearly established that they apply to everyone. 

So who should get the ICU bed? Easy - whoever qualifies for it based purely on medical criteria, regardless of their politics, beliefs or behavior, however responsible they are for their current situation.

In an age of hyperpolarization and cancel-culture, I find it highly refreshing to have a job that demands from me this level of impartiality.

I am not so naïve as to think that medicine is free of bias, discrimination, politics, racism, sexism, or any other -ism for that matter. Of course it’s not - systemic examples abound, and we have all been guilty of individual ones.

But I like to think that, despite our personal shortcomings, most doctors still share the ideal that to bring bias into the exam room is to fall short of the high standards of the profession. 

Put another way: as a physician, my responsibility to treat the patient outweighs any perceived right not to be triggered.

It is interesting to note that this ethic of impartiality and patient equality - so central to my medical training and teaching and one of the pillars of my conception of medical professionalism - is nowhere to be found in the Hippocratic Oath.

The Hippocratic Oath, well known as the foundational “mission statement” of medicine, has lots of good stuff: share knowledge; honor your teacher; do no harm; avoid sexual relations with patients. It even has a HIPAA clause requiring the physician to maintain patient confidentiality.

No mention from Hippocrates, however, of treating all patients equally, regardless of status, wealth, or beliefs.

For that, we have to turn to another classic code of medical ethics: The Oath of Maimonides.

For those unfamiliar with him, Maimonides was the greatest Jewish theologian and philosopher of the medieval period. He made his living as a physician and wrote many medical treatises, including one on the aphorisms of Hippocrates.  He was personal physician to the legendary sultan, Saladin; after spending long days at the royal court, Maimonides would return home to a house full of patients whom he would treat late into the night.

The Oath of Maimonides (which he probably did not write, but that’s OK, Hippocrates probably did not write his oath either) has a section about medicine being God’s work, as well as one on the limitations of knowledge and the importance of CME, continuing medical education.

But the part that concerns us goes like this: May I never see in the patient anything but a fellow creature in pain.

Hippocrates was a prominent Greek physician during the classical Greek period, a member of the ruling class. Maimonides was Jew living under Muslim rule, a second class citizen at best. 

I’ll leave it for the historians to decide if the contrast in the material and social circumstances of Hippocrates and Maimonides had anything to do with the differences in their oaths.

For my part, I'm with Maimonides when it comes to seeing anti-vaxxers as fellow creatures in pain, and with Hippocrates when it comes to HIPAA.