the superior physician

It was reported in the Lancet last month that over 100,000 Iraqi civilian deaths had occurred in the 18 months since the war started. The Lancet is a prestigious medical journal with one of history's finest reputations for exacting peer review. Their publication of this study immediately suggests it was done with rigor. However, given the political climate on the days the study was released (10/29/04), due consideration must be given prior to drawing any conclusions. I began with a benefit of the doubt that their methodology was sound. However that is certainly a matter for dispute. Fred Kaplan writes in Slate that the number could be "20,000 or 25,000, maybe 30,000 Iraqi civilians killed in a pre-emptive war waged (according to the latest rationale) on their behalf. That's a number more solidly rooted in reality than the Hopkins figure—and, given that fact, no less shocking." Now I am not sure what authority a journalist has to dispute a peer reviewed science journal, but his deflated conclusion isstill shocking indeed. To be clear, a conservative estimate is that as many as 30,000 or more innocent bystanders, mostly women and young children (not adolescent jihadis) have been killed a direct result of combat activities in the past 18 months. They are what is called collateral damage. Whether one accepts the low number or the high number, it is definitely agreed that this is an "excess" directly due to military activity.

One can argue that many of these people would have died or suffered anyway under the previous regime. That those who remain as well as all the rest of us will be better off in the long run. But all that is speculation. All the evidence suggests for now is that the activities of the coalition forces in Iraq have led to far more deaths than would have otherwise occurred. In addition, the quality of life under constant siege, with only sporadic water and electricity for over a year must be maddening to a largely middle class society, most oif whom are more highly educated than their American "liberators". Setting aside the issue of whether the world is better off this way or that way, I think those who are involved in healthcare need to ask themselves a more pressing question. What is the appropriate ethical role of the healer in wartime? In the yellow emperor's classic from ancient China, the student is taught that the superior physician does not solely treat diseases or even patients, but also seeks to heal the societal dysfunctions that are so often at the root of many illnesses through teaching the correct way of living (a prescient tale about combatting the effects of stress in the "modern" urban world of han China). Thus the tradition of Nourishing Life developed, a topic still given a thorough introduction in the most modern texts used in Chinese medical schools. But is that enough?

Here in the west, there is a certain ethic that has evolved regarding the role of the doctor. In one characterization well known from popular media, there is Alan Alda's rendition of Hawkeye Pierce on the long running and critically aclaimed 1970's sitcom, M*A*S*H. Hawkeye is the quintessential doctor who sees no distinction between friend and foe when medical care is necessary. He is a heroic character who has such impressive surgical skills that he gains a certain latitude in his otherwise poor behavior. He is constantly in conflict with the bumbling Frank Burns. Burns, the brainless ultrapatriot, who couldn't operate his way out of a paper bag would gladly watch a man die just because he was unsure of his political affiliation. There was a time when those who chose to become doctors wrestled with these issues of War and ethics. Organizations like Physicians for Social Responsibility and Doctors Without Borders implicitly promote an agenda where Doctors should be abhorrent to human suffering in all its forms and always work to resist and correct it. That it was more incumbent upon those involved in the healing arts to think twice and even thrice about the implicit or explicit support of any action by a person or government that led to immense human suffering, regardless of the supposed end. Amongst politicians, one can perhaps try and justify the means by the ends, but not so in any profession that would even feign to be one steeped in ethics. When in doubt, it never hurts to remember the most basic of basics and then its pretty much a no-brainer. First, do no harm.