From Medscape General Medicine

Letter: Culture of Death -- Letter to the Editor

Wesley J. Smith

[MedGenMed, October 10, 2001. Medscape, Inc.]

I was amused to note the anger and emotionalism with which Matthew K. Wynia and Arthur Derse criticize my book, Culture of Death: The Assault on Medical Ethics in America. [1] But what are they so angry about? That I am wrong? If so, I don't think they made a convincing case. Or, could their anger actually arise because most of what I write is true?

Wynia and Derse assert that I claim bioethics is a monolith. That is not what I write. What I do believe is that bioethics has, generally, crystallized into an orthodoxy, perhaps even an ideology. I acknowledge that disagreements certainly exist within the field. But I view them, with some exceptions, as the arguing of people who agree on fundamentals but disagree on details -- sort of like Catholics bickering with Baptists. 

What are these fundamental bioethics premises, as I see it? I'll mention just a few: a rejection of the sanctity of human life, by which I mean (and so state) that all human beings have equal moral worth. An acceptance of a so-called "quality-of-life" ethic by which some human beings are deemed to have greater moral worth than other human beings. A belief that there is such a thing as a born human being who is not a person, which means that in the end, there are no such thing as universal human rights. Sooner or later, such beliefs lead directly to advocacy for the permission to destroy life unworthy of life and/or the exploitation of some living humans as if they were mere natural resources (eg, as sources of organs or subjects for medical experiments). Indeed, many of bioethics' leading lights argue precisely on behalf of that point.

The reviewers also mischaracterize what I wrote. For example, I was surprised to learn from the review that I "repeatedly" quoted Robert Veatch as "an ardent supporter" of futile care theory when he actually opposed the imposition of futility in the Baby K case.  No, I quoted Veatch repeatedly as an ardent supporter of healthcare rationing. I quoted him only once in support of futile care and that being his assertion that futile care is a splendid place to start us down the road to explicit rationing.

I am also criticized for quoting extensively from Joseph Fletcher and Peter Singer. I do make much of Fletcher, and with good reason. Based on the flow of events, it seems to me that he was, perhaps, the most influential American philosopher of the last half of the 20th century. (Would that Paul Ramsey had had such influence! Bioethics would have taken a far different path.) I am faulted for calling Fletcher the "patriarch of bioethics." But I am not the first person to make that assertion. I was quoting Al Jonsen from his book on the history of bioethics. As to Peter Singer (who I like to call Son of Fletcher), he is probably the most publicly known and influential modern-day bioethicist, as painful as that may be to others in the movement. That is why he was brought from Australia to Princeton University, despite advocating the right of parents to kill unwanted infants during their period of nonpersonhood, among other travesties.

But to claim that I dwell almost exclusively on Fletcher and Singer is to do a real injustice to my work. I make it very clear that as important as these 2 are, they are not the sum and substance of bioethics. Indeed, I explore the thinking and advocacy of many prominent bioethics practitioners, including Callahan, Veatch, Harris, Glover, Beauchamp, Childress, Hardwig, Dworkin, Frey, Arnold, Youngner, Agich, and Caplan, among others. Most of these promote at least some "death culture" policies to one degree or another. For example, while Callahan opposes assisted suicide, he is the nation's foremost proponent of healthcare rationing and strongly supports futile care theory, both of which lead, at least implicitly in my view, to a duty to die. Meanwhile, Hardwig posited an explicit positive duty to die in a cover story for the Hastings Center Report. Battin also has supported the odious notion, among others. Frey believes that if we are going to vivisect animals we had better also be willing to vivisect those humans who have a lower moral status than animal subjects based on an inferior quality of life. Youngner believes in doing away with the dead donor rule in organ procurement. Veatch accepts redefining death to include a diagnosis of permanent unconsciousness. (I guess if such a person awakens, we would have to call it a resurrection.) Frankly, many among the general public are shocked and deeply disturbed when they learn that these are deemed respectable subjects in bioethics discourse.

I must say that I am growing weary of my critics' constant whine that my book paints with too broad a brush. In my view, that is merely a way of insulating bioethics from any meaningful or systemic criticism. But just as one can criticize the general belief system of, say, Republicans -- even though there are differences among those in the GOP -- it seems fair to me to mount a macrocriticism of bioethics.

I do admit using different terminology to describe thinkers such as Paul Ramsey and Leon Kass from others in bioethics. This isn't subterfuge. I make it quite clear in my book that these people were or are part of the overall bioethics discourse. I use different descriptive labels such as "ethicist" to avoid reader confusion and because their thinking differs markedly from the general mindset that I see as predominating in bioethics. As one prominent bioethicist told me with a smile about Leon Kass, "We respect Leon a lot, we [meaning, most bioethicists] just disagree with almost everything he says." Now that Kass has been appointed to chair the National Bioethics Advisory Commission, it will be interesting to see how the movement reacts overall to his leadership.

I am also criticized in the review for resisting futile care theory while also resisting assisted suicide, which the reviewers claim is inconsistent since both involve the bioethical principle of autonomy. But futile care is merely the flip side of hooking patients to machines and keeping them alive against their will by imposing professional or institutional values over those of patients and families. On the other hand, assisted suicide isn't even a medical act. (Was Jack Kevorkian's carbon monoxide suicide contraption really a piece of durable medical equipment that should have been covered by Medicare?) Just because a physician undertakes to do something to a patient, that does not make it medical.

Besides, what gives doctors any greater moral claim to end a life upon request than anyone else? A lawyer or a plumber could just as competently assist a suicide. All they would have to do is read Derek Humphry's latest how-to-commit-suicide guide that advocates the use of helium and a plastic bag. But could they conduct a competent physical examination? Could they perform surgery? Would they know what medications to prescribe for hypertension or anemia? No. Assisted suicide is many things, but medicine it ain't.

Actually, Wynia and Derse's connection of assisted suicide and medical futility has done me a great favor by illustrating one of my book's primary points: that assisted suicide and futile care theory are ethical first cousins. Allowing assisted suicide for some but not others means that those whose deaths are induced have lives of such little value or dignity that society need not engage in suicide prevention or other measures to protect their lives. At the same time, futile care theory presupposes a similar view about the value of some lives but posits that when these patients or their families want life-sustaining treatment, it can be unilaterally refused. That is
certainly a no-win situation for the most marginalized and vulnerable among us: heads death wins, tails life loses.

Finally, readers of the review are informed that I am a vitalist. This is absolutely false. I endorse the legal right to refuse medical treatment, and credit bioethics for helping craft it. This is hardly a vitalist position. Moreover, I am a hospice volunteer. Hospice, as the reviewers well know, explicitly rejects vitalism but believes that there is no such thing as a life unworthy of life.

Nice try fellows, but no cigar.


1.Wynia MK, Derse A. Medscape General Medicine Book Review. Smith WJ. Culture of Death: The Assault on Medical Ethics in America. September 4, 2001. Available at: http://www.medscape.com/Medscape/GeneralMedicine/journal/2001/v03.n05/mgm0904.01.wyni/mgm0904.01.wyni-01.htmlAccessed October 10, 2001

Wesley J. Smith is the author of Culture of Death: The Assault on Medical Ethics in America.