I looked around. A big ward, or cell, with twenty beds. Bars on the windows. Naked men lie on the beds, tied down, writhing in convulsions, issuing wild cries. From time to time an orderly comes up and gives them a hefty punch in the stomach. From the awful pain they quieten down for a time, just moan, then again they start to shout. From morning to night almost all of them are injected with several doses of Aminazin [a tranquilizer].…The ward is permeated by a sickening smell of rotting: the patients perform their natural functions on the beds they are tied to.…It is forbidden to go out into the corridor. Also to walk around the ward.
These words were, in fact, written by one of those "patients": Andrei Dubrov, a 22-year-old Muscovite who had asked to emigrate to the West. In 1972 he and his mother received permission to leave, but at the last minute it was revoked on the grounds that he was to go to the army. He refused, hence the diagnosis of "insanity" and incarceration in the conditions described above. We have learned about his ordeal, luckily, because his testimony managed to reach the West—but his case is only one in thousands.
A gnawing question haunts the spectator: How is it possible that doctors—not policemen, not soldiers, but doctors—should cold-bloodedly participate in such terror? The answer is to be sought at least in part in the very nature of the oath to which the Soviet physician is explicitly committed—a hypocritical, un-Hippocratic, yet nonetheless binding oath that not only permits such behavior but, truly, requires it.
THE ANCIENT OATH
The adage has it that men are known not by their words—and wisdom will surely advise against the study of a merely written code as evidence for what its advocates profess—yet such is human communication that appearance is often all we know of reality. I offer this by way of justification for returning to the Hippocratic Oath as a springboard for comparison with the recently revised oath of the Soviet physician. After noting some disparities, I invite the reader to ponder some implications of that revision in light of the realities of modern-day Soviet psychiatry. Those who can learn from such ponderings may be the wiser, else we should witness the recycling of some historical truths better left for the chronicles.
By turning back the dusty pages we find the Hippocratic physician gazing heavenward as he proclaims,
I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant.
—as befits an ancient oath, for the invocation of the deities makes the protestation all the more solemn. Since Apollo and his son Asclepius are the patrons of medicine, their initial invocation is especially appropriate. It had been Apollo, after all, who first taught humans the act of properly selecting their regimen, while his grandchildren Panaceia and Hygieia reveal their significance in their very names—few physicians even today will deny that secret hope of finding the former, and none would dare shun the latter.
In the presence of holy company, the swearer then proceeds ultimately to promise to apply his art "for the benefit of the sick according to [his] ability and judgment." Nor is this an overly modest claim, for he continues: "I will keep them from harm and injustice," no mean task for a mere mortal. Much the same idea is repeated once more before the oath is over: "Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief"—at least, we must suppose, of all intentional mischief, but that is reassurance enough. Whatever the disadvantage of dubious verifiability in the case of divine sanctions against breaking a promise, we may be certain that many a believer took his word seriously.
There is no reason prima facie, of course, to assume that with the decline of Apollo's reputation the Hippocratic oath was bound to be ignored. The modern physician may look to the benefit of the sick as did his sandaled ancestor, if only from kindness and concern. The Soviet doctor's oath differs from the Greek not primarily in its conspicuous deletion of the deities, for this has also been true of the various codes adopted by the American Medical Association. No, what is especially startling is the new object of a Soviet physician's concern. Put quite simply, his allegiance is to ideology and the State, not to the individual who happens to be sick or under care.
To cite from an article that appeared in the Medical Journal of Australia in 1976, written by the Russian doctor Sergei Alexeyeff:
On March 26,1971, The Supreme Soviet issued a decree which changed the wording of the Soviet doctor's oath. The passage committing the doctor to strive primarily for the healing of the individual was deleted and replaced by a new one. Accordingly, the doctor now pledged himself to follow "the Communist moral principles," promising to take heed of his responsibility towards "the Soviet State and Soviet people." Under cover of this new oath the Soviet authorities can demand and obtain the assistance of physicians in the treatment of sane dissidents in mental institutions.
This implicitly requires that a doctor also violate the Hippocratic duty to protect a person under his care from harm and injustice, for even the briefest look at the Soviet system of mental health will reveal the embarrassing prevalence of those twin evils.
Were an ancient physician to hurt the innocent sick, Apollo's wrath would have been kindled to summon the other gods who, however pagan, could not have refused to raise their voices in protest. Not even the vainest of those populating Mount Athos could have demanded that a physician renounce his duty to the sick at a mere command from above; yet this is precisely what is asked of a healer in the worker's paradise. And since there is exactly one employer, the choice can be only to obey. Thus the swearing of the Soviet oath requires far less than the entire universe of gods: an announcement in Pravda will do, perhaps with a nod from one's local KGB agent.
In some cases that nod will be, let us say, logically superfluous—in those not so exceptional situations where the doctors, notably the psychiatrists, are themselves KGB agents. Dr. Daniel Lunts of the Serbsy Institute is without doubt their most sinister exemplar: a Stalinist informer and colonel in the KGB parading as a man of science, who condemned many of the best-known modern-day Soviet dissidents to torture and even death. Perversions of truth in his diagnoses, documented by Soviet sources themselves, have for years been designed to "prove" that perfectly sane political prisoners must be considered deranged. His definition of insanity follows easily from Soviet ideology. There being no social or economic cause for crime in the USSR, all criminals must be lunatics, and that includes "dissidents." The thesis is elucidated in Dr. Lunts's monograph "The Theory and Practice of Forensic Psychiatric Examination" for all to see and wonder at its perversion.
Actually, the expression political prisoners is misleading. For consider the following from the Chronicle of Current Events:
A number of facts indicate that the reception rooms of the highest official bodies in Moscow either have an ambulance on permanent duty from the psychiatric first-aid service, or are in direct and speedy contact with this service. In many cases, people who have come to the reception rooms of the party Central Committee, the Council of Ministers, the Presidium of the Supreme Soviet, the All-Union Central Council of Trade Unions, the K.G.B., and other organizations with complaints, generally of a non-political nature, have not been allowed to put their case, but have been forcibly driven off to Moscow psychiatric hospitals, and then, after a psychiatric diagnosis, to their local hospitals.
Although general psychiatric hospitals, scattered throughout the country, have facilities for such "political inmates," most of those unfortunate creatures reside in the nine "special psychiatric hospitals" (SPHs), which are under strict supervision of the KGB.
These outfits house people who have been declared psychologically defective for having given information to Western newsmen about the SPHs, alongside idealists mad enough to defend religious rights in the USSR; even psychiatrists who have spoken out against detaining people in SPHs are considered insane. More specifically, according to Vladimir Bukovsky and Semyon Gluzman, all such dissidents are labeled "schizophrenic," either "latent" or "paranoid"—nomenclatures of dubious scientific but clearly much political value. There are an estimated 10,000 political prisoners, but the number may well be much higher.
Once inside, the innocent suffer unspeakable cruelties. The Chronicle describes the SPHs:
All these institutions have the following features in common: political prisoners, although of sound mind, are kept in the same wards as seriously disturbed psychiatric patients; if they will not renounce their convictions they are subjected, on the pretext of treatment, to physical torture, to injections of large doses of Aminazin and Sulfazin, which cause depressive shock reaction and serious physical disorders; the regime is the same as for closed prisons, with one hour's exercise a day. Sometimes sodium aminate, a strong narcotic, is administered by injection, to weaken the patient, and after the injection he is interrogated.…The most terrifyingly arbitrary regime prevails at the Sycheyovka and Chernyakhovsk hospitals, where the sick patients, and the politicals with them, are the victims of daily beatings and sadistic humiliations on the part of the supervisory personnel and the nurses, whose rights are absolutely unlimited. For instance, in the spring of 1969 the patient Popov was beaten to death in the Chernyakhovsk hospital, and in the medical record it was stated that he had died of a brain hemorrhage.
A PERIL TO ALL
Which brings me back to the Hippocratic code. One might argue that the Soviet doctor mistreats, when required by "State security," only the unruly; the truly sick, if obedient, will nevertheless receive good health care without charge. As indicated, however, the evidence will not support even this feeble defense without qualification. For when the doctor no longer has the individual's interest at heart, everyone is in danger—the more and the less outraged alike.
Neither is injustice restricted to adults. Dr. William M. Easson, a member of an American delegation to the USSR in charge of studying the Communist system of child care, noticed, for example, that a surprisingly large number of children there were diagnosed as "schizophrenic"; for it seems that "socially deviant or disruptive behavior is considered to be an important sign of serious emotional illness far more readily than in the United States. Rebelliousness and undue individuality are neither expected nor tolerated." Action is thus taken early and drastically. The Soviet psychiatrist will readily prescribe strong medication—and doses are "at much higher levels" than in the United States. He will even make liberal use of that most medieval of devices, backed by medieval theories: "Frequently, children receive galvanotherapy—electric stimulation—'to stimulate the vegetative system.'" All this, naturally, without a fee. But one hesitates to call it, ambiguously, free.
The literature dealing with Soviet psychiatry is filled with examples of abuse, as is readily indicated by the hearings of the Senate Subcommittee on Internal Security in 1972 and 1975, as well as of the House Subcommittee on International Organization in 1976—to mention but the best publicized. A reader interested in further gory details can satisfy his appetite to indigestion. Mentioning this fact does not, however, exhaust the purpose of my project. For I had promised at the start to warn against our own failure to learn from history's cyclic turns—or, as Copernicus might have put it, its revolutions.
The Soviet health care system is, let us recall, fully socialized, which is to say that the State pays for everyone's medical bills. The doctor and his patient are both sustained from the same public purse. And "rights" to care bring with them certain obligations: the doctor is required to treat the patient considered ill, and the patient must comply.
To quote David L. Bazelon, member of the US delegation to the Soviet Union:
To promote a comprehensive health system, the Russians publicize the availability of services and, more importantly, stress the obligation of the citizen to conform to society's expectation that he will seek treatment so that he may usefully function as a citizen. Indeed, the whole health care system is focused on reinforcing the individual's value to the state by getting him back to work.
And since the citizen must want the good of all—would it not be irrational to think otherwise?—he should comply with the decisions made for him.
Indeed, not wishing to be "treated" so as to become "useful" again is to be mad. I cite again:
Even if a patient opposes hospital commitment, it is deemed voluntary if it is sought by the patient's family, his trade union, business organization, or polyclinic doctor. The Russian attitude seems to be that under these circumstances the patient himself would want hospitalization if he could make a rational decision. As a result, only three or four percent of all commitments are termed involuntary.
The right to treatment becomes, grotesquely, the obligation to receive treatment whether or not the "sick" wishes it and even, sometimes, whether or not it destroys him in the process. A curious but not unexpected turn of events, for the One who pays the bill and writes the doctor's oath may well use His muscle unjustly, arbitrarily. Unlike Apollo, moreover, the modern police state has easily testable means of flexing its biceps.
Warnings against the State's potential for repression under the guise of treatment—a potential easily actualized after gaining national control over health care—are not new. Dr. Thomas Szasz, one of the most vocal Cassandras in this area, has made the argument many times in many forms. After citing instances of psychiatric torture in the USSR, for instance, he comments in Ideology and Insanity:
This point of view is characteristic of the collectivist ethic. It is also indistinguishable from that of contemporary American institutional psychiatry. In both systems, a person who has harmed no one but is considered "deviant" is defined as mentally ill; he is ordered to submit to psychiatric examination; if he resists, this is viewed as a further sign of his mental abnormality.
To say, as does Szasz, that the Soviet viewpoint is "indistinguishable" from that of American institutional psychiatry is to carry the point farther than I wish to do, for surely important differences can be easily detected by the unaided eye. Still, the main idea remains: Will the people be sufficiently blinded by "free" health care to risk perverting even the loftier (not to mention the pecuniary) meaning of that word?
Those who might protest that American doctors will never succumb to governmental pressures similar to the Soviet should consider most carefully what HEW secretary Joseph Califano, Jr., told the gathered physicians at the June 1977 AMA meeting in San Francisco: "Whether they liked it or not," proclaimed the secretary, "the government would soon take greater control over health care costs including such things as geographic distribution of doctors, the services they may order and the equipment available to them." How long will it be before HEW rewrites the doctors' code and tells them not only what services they may order but which they must order—or risk geographic redistribution to much cooler climates?
Indeed, the scenario could become more macabre yet: the physician who treats the mentally ill may well be expected—nay, ordered—to serve society and his patients best by using that most barbaric of devices, psychosurgery. That day, again, seems much nearer than one would like to imagine. In a chilling piece in the February 1979 issue of Inquiry magazine, Dr. Lee Coleman observes that "the government is now promising eventual funding through Medicare and Medicaid for psychosurgery as accepted medical practice. This may trigger a new wave of psychosurgery similar to the thousands of lobotomies performed in the 1940's and 1950's."
A SECULAR FIST
Apollo must be watching us dumbfounded, wondering which of his brethren had cast a spell upon the clever race below. But why blame the charming cast of mythological personages? History has since advanced, and the Hippocratic code has carved its way into the conscience of the West. The well-known scholar Ludwig Edelstein observes:
As time went on, the Hippocratic Oath became the nucleus of all medical ethics. In all countries, in all epochs in which monotheism, in its purely religious or in its more secularized form, was the accepted creed, the Hippocratic Oath was applauded as the embodiment of truth. Not only Jews and Christians, but the Arabs, the mediaeval doctors, men of the Renaissance, scientists of the Enlightenment, and scholars of the nineteenth century embraced the ideals of the Oath.
Edelstein declines "to outline the successive stages of this historical process." But we may observe that when the physician no longer saw his activities as being in conformity with the desires of a higher divine power, a vacuum appeared and with it the temptation of a new presence: that of a higher secular fist. This is not to claim an iron necessity in the philosophical, let alone in the political, sphere, for temptations are by definition resistible. Whether or not our generation will be able to recognize the mortal danger it faces is a matter very much for conjecture and, let us hope, for refutation. Few, however, should dispute its remarkably lethal quality.
Juliana Geran Pilon is the author of Notes from the Other Side of Night, recently published by Regnery/Gateway. She has taught at several universities. Currently, she is at the Hoover Institution writing a book on human rights.
This article originally appeared in print under the headline "Doctors as Instruments of Repression".