Culture of Death: The Assault on Medical Ethics in America

At a recent conference on the ethics of withdrawing nourishment and fluids from mentally incompetent patients, I was approached by an acquaintance who is close to retirement age. “Richard,” he said in a grave tone, “when I become seriously ill, I want you to promise me one thing.” I told him I’d do my best. “Whatever you do,” he said, “keep those damn bioethicists out of my hospital room.”

Wesley Smith knows all about my friend’s concerns. Based on in“depth interviews and a careful survey of today’s bioethics literature, he has produced a compelling and frightening indictment of current trends in bioethics. In Culture of Death: The Assault on Medical Ethics in America , Smith argues that “a small but influential group of philosophers and health“care policy makers” is working to bring about a culture in which “killing is beneficent, suicide is rational, natural death is undignified, and caring properly and compassionately for people who are elderly, prematurely born, disabled, despairing, or dying is a burden that wastes emotional and financial resources.”

Smith has covered some of this ground before. An attorney and consumer rights advocate who has coauthored several books with Ralph Nader, he became alarmed at the rise of the assisted suicide movement in the 1990s and wrote Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder (1997) to combat it. Since then, Smith has become one of our most tireless and effective opponents of physician“assisted suicide.

His new book digs deeper to show that the drive for assisted suicide is the tip of a deadly iceberg. Scholarly apologists for euthanasia are working from an ideology that denies the equal dignity of all human beings, reordering traditional commitments to the sick and helpless in order to maximize the benefits for more worthwhile or “productive” members of society. This utilitarian “quality of life” ideology threatens not only Judeo“Christian teachings on the sanctity of life, but also American founding principles on unalienable human rights.

Smith is careful here to appeal to the broadest possible audience, for which he has been criticized by some reviewers. He notes that modern secular bioethics often sets itself against religion, and even quotes ethicist Daniel Callahan as saying that “the first thing” bioethics had to do to establish itself was “to push religion aside.” But he does not present a sustained argument as to why bioethics needs religious values to avoid slipping into mere procedure and crass cost“benefit analysis. He does not even present a view of abortion (except, briefly, partial“birth abortion), although many bioethicists began their slide into the abyss of value relativism by seeking to justify abortion. He wants to tell a general audience”an audience divided on abortion and diverse or ambivalent on religion”that an unelected but powerful elite is quietly undermining everything they once took for granted regarding the treatment of themselves or their loved ones when they are seriously ill. Whatever your views on abortion or religion, he says in effect, you should take up arms against the bioethics elite because the life you save may be your own.

There’s nothing wrong with that message as far as it goes, but some believe it is important to go further. For example, Christian bioethicist Gilbert Meilaender, reviewing the book in the February 12 issue of the Weekly Standard , faults Smith both for downplaying religion and abortion and for presenting almost the entire profession of bioethics as an enemy of human freedom and dignity. For Meilaender, this oversimplifies the problem and neglects important aspects of the needed solution. Indeed, Meilaender’s own masterful Body, Soul, and Bioethics (1995) does provide a deeper account of the problem of modern bioethics than Smith does. Yet Smith is such a good prosecuting attorney against people with clearly dangerous ideas that he should not be faulted too much for presenting an incomplete account.

Other critics of Smith’s book (including some ethicists who are its targets) make a different charge. They claim that Smith simply exaggerates, falsely equating mainstream bioethics with the views held by a few extremists like the infamous Peter Singer of Princeton University. I disagree. To be sure, Singer is a man pro“life advocates would have to invent if he didn’t already exist. He has long held that various animals are more sentient than”and hence have greater moral status than”unborn and newborn humans. His recent assertion that there is nothing inherently wrong in having sexual relations with animals, published after Smith’s book was written, has sent more of his colleagues scurrying to distance themselves from his views. But Smith is very effective in showing that Singer’s basic ideas about human worth are widely shared (even if not followed through with as much lunatic consistency) throughout the ill“defined profession of bioethics.

In some ways, the problem may be even worse than Smith indicates.

First, Peter Singer is not at the most radical fringe of modern bioethics. He at least believes that some people (and animals) deserve to be respected as persons because of an attribute they possess, like the ability to feel pleasure and pain. More radical bioethicists assert that all claims of personhood are merely social constructs, that there is no objective quality in any human being that requires us to treat him or her as a person.

This is the view of Professor Ronald Green of Dartmouth College, as set forth in his essay “Toward a Copernican Revolution in Our Thinking About Life’s Beginning and Life’s End” ( Soundings , Summer 1983). Green’s “revolution” amounts to the stunning insight that those of us who wield power in society can band together and define other people (especially the very young and very old) in and out of personhood, depending on how urgently we feel the need to do lethal experiments on them to benefit ourselves. And Ronald Green is no peripheral figure. He was a vice“chair of the National Institutes of Health’s Human Embryo Research Panel in 1994, and his essay was cited by the Panel as providing an ethical foundation for the policies it recommended on federally funded embryo research. Compared to some contemporaries who are in the forefront of applying bioethics to public policy, then, Singer may count as a moderate.

Second, the tendency to resolve moral dilemmas by denying the worth of some human lives is not only found among bioethicists and those in their immediate sphere of influence. Unfortunately, a trend toward utilitarian thinking and moral relativism can be found nowadays in many segments of our society, and it would be hard to attribute all of this to the influence of bioethicists. To some extent, the profession has gained influence by telling people what they want to hear and are already inclined to believe.

Smith is masterful in showing that in many cases appeals to patient autonomy mask another agenda. Many in the bioethics elite worship autonomy if patients choose death, but they suddenly become communitarians concerned about social resources when patients and families want life“saving treatment. However, in opposing rationing schemes and “futile care” policies that seek to deny treatments, Smith himself may rely too heavily on individual autonomy. For instance, he proposes obtaining “clear and convincing evidence” of a patient’s own wishes before life“preserving care is withdrawn. But this would still allow a great many objectively bad treatment decisions, and its absolute reliance on the patient’s own wishes may fuel arguments by others for voluntary euthanasia.

Moreover, Smith occasionally comes close to arguing that hospitals and physicians should have no ethic at all”that because some medical professionals use bad values to deny needed treatments, all value judgments by doctors and hospitals are suspect, and “conscience clauses” protecting them from having to act against their moral convictions may be unwise. Here I must side with critics (like Meilaender) who suggest that inculcating sound values is better than treating doctors as technicians who should blindly follow the wishes of patients.

The issue of health“care rationing and “futile care” policies is complex and cries out for a more thorough analysis than Culture of Death can be expected to provide. As we explore solutions other than those rightly criticized in the book, we must acknowledge real problems: health“care resources are not infinite, cost can indeed be part of the “burdens” of treatment, and some patients and families make re­ quests that may have little to do with the objective benefits of treatment.

Smith’s book also leaves unresolved precisely what it is in “futile care” policies that is most objectionable. Is it the importing of social cost considerations into individual treatment decisions? Is it the fact that these decisions are made without patients’ consent and sometimes against their express wishes? Or is it that the decisions are often based not on the burdens and benefits of a given treatment, but on the judgment that certain patients’ lives are not worth living? The last of these possibilities seems most ethically troubling, and it no doubt plays a part in some decisions. And yet, Smith sees it as playing a decisive role in certain decisions to limit care even when that is not clear from the evidence he presents.

On one other point I think Smith has not thought through the full implications of an issue. His critique of the “animal rights” movement is perhaps the harshest section of his book. And to be sure, he demonstrates that many of this movement’s theorists (not only Peter Singer) have little regard for the sanctity of human life. But his fierce insistence that those who oppose animal experimentation are endangering human lives by slowing down medical progress is, for me, too familiar from contemporary debates on human embryo research.

I do not think animals have the same fundamental rights as humans. But if I did, I would certainly hold the position that Smith ridicules in animal rights advocates”that possible medical benefits are “morally irrelevant” if they require doing something intrinsically wrong. Here Smith misses an opportunity to point out that some thoroughly modern bioethicists have renounced utilitarian thinking and embraced the traditional idea of moral absolutes”even if they may have picked the wrong moral absolute.

But if these are misjudgments, they are minor indeed compared to the great service Wesley Smith has provided. The dangers he documents are quite real”and we are long overdue in waking up to them.

Richard M. Doerflinger is Associate Director for Policy Development at the Secretariat for Pro“Life Activities, National Conference of Catholic Bishops.