Unbeknownst to most Americans, a small but influential group of philosophers and health care policy makers are working energetically to transform our nation's medical practice and health care laws. They are turning away from the "do no harm" model established by Hippocrates more than two thousand years ago, and toward a stark utilitarian system that would legitimize medical discrimination against -- and even in some cases, the killing of -- the weakest and most defenseless people among us.

The first time most people become aware of this development is when they or a loved one experience a health care crisis. It is then, when they are at their most vulnerable, that suddenly they come face to face with the monster they did not know was lurking in the shadows. Why are the long-standing ethics of our health care system suddenly so threatened?

 Part of the reason, no doubt, lies in the culture of the times, in which objective truths are passd and the very concept of right and wrong is under assault. But the problem involves more than societal drift or some slow-motion cultural evolution. The challenges to medical ethics explored in this book are purposefully promoted by a cadre of "experts": moral philosophers, academics, lawyers, physicians, and other members of an emerging medical intelligentsia, known generically as "bioethicists."

How does one become a bioethicist? It may sound like a demanding discipline--indeed the most demanding imaginable, given the profound, life-and-death nature of the issues with which bioethics grapples. But in fact it is surprisingly, even depressingly easy to hang out a shingle: no tests have to be passed, no specific qualifications met. Indeed, practitioners are not licensed, as are other professionals such as attorneys, physicians, real estate agents, or, for that matter, hairdressers. Bioethics is not a formal university discipline. (Most university bioethics professors were trained in the arcane field of philosophy.) And while more than thirty universities now offer degrees in bioethics, there are no standards of knowledge or achievement that apply universally.

Bioethics education may range from postgraduate university courses, to training seminars that take mere weeks or even days. Health care professionals such as licensed vocational nurses or community ombudsmen can be appointed to a hospital ethics committee, take a few training courses and then self-identify as bioethicists. Lay members of bioethics committees at hospitals and other health care institutions may receive no formal training at all. Indeed, after writing and lecturing extensively over the last eight years on issues such as assisted suicide and initiatives to permit doctors to withhold desired medical treatment unilaterally from dying and disabled people, I could claim--although I won't--that I am a bioethicist too. This is not to say that the title "bioethicist" automatically confers influence in the medical community or the ability to sway society toward or away from a certain public policy path.

Rather, power belongs to a relatively small "insider" clique of elite and powerful philosopher, academic, attorney and physician practitioners--the "name" bioethicists who write most of the treatises and books and who speak at the many national and international symposia through which bioethics advocacy advances. It is they to whom government often turns when seeking ethical opinions regarding the many dilemmas and controversies in modern health care policy.

They teach our future doctors and other societal leaders in the country's best universities. They materially influence the opinions and practices of the thousands of men and women who labor in the trenches of clinical medicine at hospitals, nursing homes, and HMOs. They testify as expert witnesses" in court cases or write "friend of the court" briefs in important litigation involving health care. And they exert a steady and growing influence over the public health laws, the application of medical ethics, and the protocols of hospital care.

Many bioethics agenda items--particularly the issue of personal autonomy--have already been set into the bedrock of law. The 1999 Montana Supreme Court's decision in James H. Armstrong, MD v. The State of Montana is a case in point. The state had passed a law requiring that only doctors perform abortions, which the court invalidated on the basis of the Montana Constitution and Roe v. Wade. That should have been the extent of the decision. But rather than limit the ruling to the case at hand, a 6-2 majority used the occasion to impose an audacious, radical philosophical imperative on Montanans, threatening their right to regulate the practice of medicine effectively through the rule of law.

The language of the decision seems innocuous enough: "The Montana Constitution broadly guarantees each individual the right to make medical judgments affecting her or his bodily integrity and health in partnership with a chosen health care provider free from government interference." But the two justices who objected to this aspect of the ruling, Karla M. Cray and Chief Justice J. A. Turnage, understood the danger. They rightfully worried that the ruling's radical scope strongly suggested that "the Legislature has no role at all in matters relating to health care to be provided to the people of Montana." 

If under Armstrong almost anything goes medically in Montana, so long as a patient wants it and a health care professional is willing to do it--a reasonable interpretation considering the expansive language and philosophical thrust of the majority's decision--then the ruling could be construed to permit a doctor to amputate a patient's healthy limbs upon request when the patient wants to satisfy a neurotic obsession (a macabre surgery that has actually occurred in England); to allow patients to ask doctors to kill them for organ donation purposes; to permit infanticide of disabled newborns at the request of caregivers or parents; or, to allow people to be experimented upon in dangerous ways that are currently illegal. Indeed, the court's ruling is so broad, it decrees that only "a compelling interest ... to preserve the safety, health and welfare of a particular class of patients or the general public from a medically-acknowledged bona fide health risk," warrants state involvement in medical decision making.

 In other words, regardless of the individual or societal consequences and absent extraordinary exigencies such as preventing a plague, virtually any medical procedure is possible in Montana if it can be construed to involve obtaining "medical care from a chosen health care provider." How was such a sweeping decision justified?

The court did look to Roe v. Wade and a smattering of other cases; but the primary authorities that the majority relied upon in expanding the reach of its ruling were philosophical treatises. Indeed, the most frequently cited authority was not a statute, a law case, or even a legal essay, but a philosophical discourse on the modern meaning of the "sanctity of human life" contained in a book--Life's Dominion: An Argument about Abortion, Euthanasia, and Individual Freedom--written in 1993 by the influential attorney/bioethicist, Ronald Dworkin.

His thesis: a true adherence to the sanctity-of-life ethic requires that we all should be permitted to "decide for ourselves" about abortion and euthanasia (and presumably, all other such life and death decisions), and that such "choices" must be accepted by society and tolerated by those who disagree if society is not to become "totalitarian." The Montana majority opinion cited Life's Dominion so frequently and applied its reasoning so enthusiastically that it is no exaggeration to say the decision transformed Dworkin's philosophy into the court-mandated health care public policy of the entire state of Montana, without a single citizen or legislator having the opportunity to cast a vote.  Dworkin's influence upon the Montana Supreme Court epitomizes the growing power of the bioethics movement.

What makes this development especially worrisome is that the movement's leaders generally reject what until now has been the core value of Western civilization: that all human beings possess equal moral worth. That denial leads bioethicists--and through them, us--into very dark and dangerous places, as this book will reveal. Our culture is fast devolving into one 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.

 Indeed, it is alarming how far the movement has already pushed medical ethics away from the ideals and beliefs that most people count on to protect them when they or a loved one grows seriously ill or disabled. Cutting edge bioethics now holds that there is nothing special per se in being human, and thus bioethicists have generally abandoned the sanctity-of-life ethic that proclaims the inherent moral worth of all people.

 The favored term for humans used by movement advocates is not "people" or even "individuals," but "beings"--a term that includes nonhumans. According to the movement's leading lights, a "being" may or may not be entitled to membership in the "moral community," which is what truly matters. As we shall see, one earns this status by possessing certain "relevant characteristics"--usually a minimum level of cognitive functioning--that bioethicists consider essential for significant moral standing. Those with sufficient cognitive qualifications to achieve membership in the moral community are often called "persons," who have moral rights.

Those who fail this test, on the other hand, are denigrated as nonpersons, who have little or no moral worth. Why is this important? Because theoretically--and in our era, theory too easily becomes practice--non-persons can be killed, abandoned medically, experimented upon, or otherwise exploited as a natural resource. It is as if we are being pushed, slowly but steadily into a Salvador Dali painting. By disparaging the sanctity of human life, bioethics has already led us into some shadowy ethical back alleys:  

    * Desired medical treatment is refused in hospitals and nursing homes around the country to patients who are dying or disabled. This abandonment is justified as ethical under a new theoretical construct Imown as Futile Care Theory, which proclaims the right of doctors (and health care executives) to refuse to provide wanted care based on their subjective views of the quality of patients' lives.  

    * Doctors, nurses, and other hospital staff in hospitals and nursing homes often pressure family members to permit their seriously brain-damaged relatives (stroke victims, demented patients, and others with profound cognitive disabilities) to be dehydrated to death by the removal of tube-supplied food and water, a practice now occurring in all fifty states. Research animals enjoy greater legal protection of their welfare under federal law than do many human subjects who participate in medical experiments. 

    * Oregon, which has legalized assisted suicide, has decreed that the act is a form of "comfort care," i.e. pain control, that must be paid for by Medicaid--although the state's Medicaid health rationing scheme denies some curative treatments to late-stage cancers and very low birth-weight babies. 

    * In New York, a man who smothered his wife with a plastic bag after her purported assisted suicide attempt failed, and who then covered up the crime with a falsified death certificate and a quick cremation, was given a mere two-week jail sentence. In Canada, Robert Latimer was convicted of murdering his twelve-year-old daughter by asphyxiation because she had cerebral palsy. Instead of receiving significant punishment, he was embraced by a majority of Canadians as a "loving father," which resulted in his "mandatory" ten-year sentence being reduced to one year by a judge who labeled the girl's murder "altruistic." In England, the parents of an infant born with Down's syndrome and the treating doctor who intentionally allowed the baby to starve to death were acquitted of all criminal wrongdoing.

The growing indifference to the value of the lives of aged, ill, and disabled individuals within the health care system, academia, and the courts should be big news. Yet, with the exception of assisted suicide--due mostly to the widespread media coverage of the bizarre antics of Jack Kevorkian--most people are but dimly aware of what is happening. Popular culture promotes many of these practices as a compassionate response to the trials and tribulations of illness and a necessary adjustment to an obsolete, religiously based ethical system.

The growing relativism of our culture increasingly incapacitates people from "imposing their own beliefs on others" by making well-honed ethical judgments. The mainstream media do not cover these important issues adequately (or sometimes even cover them at all), and when they do, the issues are rarely placed in a proper and understandable context. While stories involving death culture issues sometimes make the news, they are typically covered as if they occurred in a vacuum. Thus we are like the proverbial frog slowly boiled to death in a pot: it doesn't perceive the water growing progressively hotter.

This book is intended to prove that we are really being cooked. It is primarily about how bad ideas hurt real people. Although I quote many philosophical treatises, this is not a study in philosophy. And while I explore many laws and ethics protocols, I have tried to avoid getting bogged down in specific policy proposals.

My purposes are these: to alert my readers to the intentional undermining by bioethicists of the fundamental moral principles that have long governed our society, and to invite them into the crucial, ongoing debates about their health care--debates that will, quite literally, determine the future of Western medicine.  The steam is rising. The water is already scalding. Unlike the poor frog, however, we can do more than simply stew. We can feel the heat, sense the danger, and hop quickly away.

• http://www.encounterbooks.com/mainstory/mainstoryCUDE_content.html

One of the most important forces working in the culture of death is the field known as "bioethics"—that is, the ethical standards being embraced to deal with medical and biological questions. 

In his new book, appropriately entitled The Culture of Death, J. Wesley Smith chronicles what he calls "the assault on medical ethics in America." Smith analyzes the practices and philosophies that have taken the medical profession away from the moral certainty provided by the maxim of the Hippocratic Oath, "First, do no harm."

As Smith tells readers, the bioethics establishment "[rejects] what until now has been the core value of Western civilization: that all human beings possess equal moral worth."

As a result of this rejection, bioethicists increasingly embrace the idea that there are lives that are not worth living—that the right to life is contingent on an arbitrary idea known as "quality of life." 

This idea leads to the conclusion that some patients, especially the elderly, have an affirmative duty to die, so as not to waste scarce resources. Unbelievable.

Well, this is more than theory. As Smith points out, the fruits of this worldview are visible in the increased talk about "patient autonomy," a term used to justify abandoning patients to hasten their deaths. We see it in the increasingly routine withdrawal of feeding tubes from disabled or terminal patients. 

If talk of "lives not worth living" reminds you of the Third Reich, you’re not alone. Columnist Nat Hentoff makes the same connection in a recent column. He reminds readers that it was the Nazis who coined the expression "lives not worth living," to describe the incurably ill and disabled. They called them "useless eaters"—a phrase that anticipates the removal of feeding tubes.

Unfortunately, Smith doesn’t make the connection between abortion and the "assault on medical ethics" he describes. It’s unfortunate because it was legalized abortion, more than anything else, that taught Americans that human beings—especially at the beginning and end of life—don’t all possess equal moral worth. It was abortion that introduced Americans to the concept of disposable human life. 

Still Smith’s book provides an invaluable service to the cause of life. It’s both a warning as to how much our culture has embraced the culture of death, and it’s a resource for helping us to spread the word about the deadly consequences of this fatal embrace. 

Even if our neighbors roll their eyes at the mention of the words "pro life," they’ve still got a stake in this debate. As Smith concludes: 

"We all age. We fall ill. We grow weak. We become disabled. A day comes when our need to receive from our fellows adds to far more than our ability to give in return. When we reach that stage of life . . . will we still be deemed persons entitled to equal protection under the law?"

And all that stands between us and that bleak prospect is the Gospel of Life.

• FORCED EXIT: Book Review:  
  Wesley J. Smith
   

FORCED EXIT : The Slippery Slope from Assisted Suicide to Legalized Murder by Wesley J. Smith  Hardcover - TimesBooks Random House May 1997 304 pages

Euthanasia is first step to legalized murder By John Attarian

Proponents of euthanasia and physician-assisted suicide often invoke the "slippery slope" - a small initial change resulting in more and more, producing unintended, far worse outcomes. Thus, euthanasia on request for terminally ill patients would lead to euthanasia of many other patients against their will. Put another way, euthanasia is the entering wedge for legalized murder. Alarmist nonsense, advocates scoff.

But attorney and anti-euthanasia activist Wesley Smith argues urgently in Forced Exit that the slippery slope exists - indeed, we're already on it - and he makes an overwhelmingly persuasive case. The euthanasia movement, Smith acknowledges, was provoked by real problems: families' despair at the sufferings of loved ones inadequately medicated for pain; the "very reasonable" fear of victimization by our heath care system; and community breakdown.

But far from solving these problems, euthanasia is "a surrender to them." Moreover, something sinister is happening, Smith argues: repudiation of the "equality-of-human-life ethic," which holds that all human lives have "equal inherent moral worth." Traditionally, "protecting human life has been viewed as the central purpose of organized society," with intentional killing by individuals and state alike severely restricted. Instead, we now have a "death culture" unequally weighting lives.

Underlying this are a radical individualist obsession with autonomy, and what Smith calls "terminal nonjudgmentalism," a failure to acknowledge or condemn evil beliefs and actions. Of his persuasive examples, the case of journalist Lonny Shavelson - passively weighing the complexities while watching a Hemlock Society member asphyxiate a would-be suicide who'd changed his mind and was resisting - is especially appalling. So is Smith's history lesson. Doctors, not Adolf  Hitler, took the initiative in German euthanasia and practiced it ever-more indiscriminately, even after Hitler suspended the program. The Netherlands' example is more alarming still. Proving that "the slippery slope is very real,"

Dutch euthanasia, while formally illegal, has expanded from terminally ill patients who request it, to the chronically ill who request it, to the depressed who request it, to newborns with birth defects. Euthanasia guidelines are routinely flouted and seldom enforced. Moreover, medical killing in Holland is often involuntary. Of the 11,140 patients euthanized or assisted in suicide in 1990, 5,981 - more than half - were involuntary lethal injections or intentional overdoses. These probably understated figures would translate into more than 170,000 American euthanasia cases or assisted suicides, including 85,000 murders.

Worst of all, America is sliding down the slippery slope. Food and fluids are being withdrawn from terminally ill, unconscious but not terminally ill and conscious but cognitively disabled patients.

Some bioethicists, doctors and others are arguing that patient and family treatment requests should be denied, and patients allowed to die, if the "experts" deem the care futile. This "futilitarianism" is already operating.

Elderly patients and newborns have been denied desired lifesaving care. State bureaucrats have even stripped parents of their parental rights for wanting to continue "futile" life support for their children.

Given this, claims that euthanasia will only be a last resort ring hollow. "What would prevent doctors from coming to believe they were entitled to actively kill patients whose continued care they deemed futile?" Smith argues. "It is a very sort stride from refusing wanted lifesaving care to actively killing patients without request, as Dutch doctors already do."

Crisply, Smith dispatches several euthanasia arguments. Guidelines can prevent abuses. They don't. Euthanasia would only be for "hard cases." Its expanded application is pushed constantly. We put animals to sleep, don't we? Humans are not animals. Besides, he rightly argues, there's no need to take the socially risky step of legalizing euthanasia. Medicating adequately for pain, hospice care and independent living for the disabled are better alternatives. We should improve control over health maintenance organizations (HMOs), make pain control more accessible and improve hospital ethics committees.

Forced Exit's appendix lists organizations offering information, guidance and referral service on pain control, hospice care, disability issues and advance medical directives. Money, Smith claims, is "perhaps ultimately the most influential and dangerous force driving the euthanasia juggernaut." America's shift from a fee-for-service health care system to one dominated by for-profit HMOs that make money by cutting costs will create strong pressure save money by killing terminally ill or disabled patients.

Undeniably, Smith has fingered a problem. Obsession with money increasingly dominates American life, and manic cost-cutting dominates business. But his answer, national health care, is no answer. Budget constraints would impose an analogous pressure to minimize costs by denying treatment - especially once America gets swamped with retirees. And the Dutch euthanasia that so horrifies him is occurring under socialized medicine. Egalitarianism also is an unconvincing rationale for valuing life and opposing euthanasia. We do so because it's self-evident that life is precious, not out of belief in equality. Nevertheless, Smith's evidence of "terminal nonjudgmentalism," nihilism and, especially, the slippery slope is outstanding. After Forced Exit, dismissing the slippery slope argument will be impossible.

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