A review of The Culture of Death: The Assault on Medical Ethics in America, by Wesley J. Smith

My medical school was among several that abandoned the practice of new graduates taking the Hippocratic Oath. The times were ripe for the rejection, coming on the heels of the 1960s' cultural rebellion and then Roe v. Wade. But even though the famous oath still informs medical practice, cultural and political changes steadily erode its influence.

Chief among these changes is the ascendance of biomedical ethics, according to attorney and activist Wesley J. Smith. The author dedicates his book to Ralph Nader, with whom he has collaborated on four books. But in his dedication to safeguarding the disabled and dying, Smith eschews his mentor's famously quick reliance on government coercion to achieve social good. Instead, Smith makes a plea for the honoring of individual rights—natural rights—in convoluted decisions regarding life, death, and the growing gray area between them.

Because of technology, life and death themselves are subject to increasingly malleable interpretations. Much of the Bush Administration's struggle over federal funding of embryonic cell research simply reflects the profound ambiguity of those concepts. Smith addresses the whole formidable array of contemporary medicine's ethical quandaries—stem cell research, animal experimentation, organ donation, and more—with a great respect for human life. This refreshing view appears to be losing favor among the secular priests of bioethics, who offer sterile utilitarian answers to the big questions.

Redefining life for political purposes began long before the stem cell debate. Lest we forget, Smith charts the rise of the eugenics movement in the 19th and early 20th centuries. In this pre-Holocaust era, the idea of using science to create better human specimens appealed to such luminaries as Theodore Roosevelt, George Bernard Shaw, and Margaret Sanger. Eugenics as social theory evolved into social policy in the United States. Smith reports, "in 1907 Indiana became the first state to pass a eugenics-based sterilization law. By 1912, eight states had sterilization laws. Eventually nearly thirty states followed suit, including Virginia."

The most perverse application of eugenics and its Darwinian ethic materialized in Germany. It began in earnest with the book Permission to Destroy Life Unworthy of Life (Die Freigabe der Vernichtung lebensunwerten Leben), published in 1920 and authored by law professor Karl Binding and physician Alfred Hoche. They called for triage of the disabled into three groups—"incurable idiots," comatose patients, and the terminally ill or mortally wounded. Under prescribed conditions doctors would have been allowed legally to kill such people. The notion of culling "useless eaters" from the population garnered wide public support before it was withdrawn because of opposition from the German clergy.

But the seeds had been sown, and as Smith points out, "mandatory sterilization laws were officially enacted within six months of Hitler's becoming chancellor of Germany."

The bioethics movement arising in the second half of the 20th century revived the notion of "life unworthy of life" in futile-care theory. "Futile care" is a term of art now firmly entrenched in the argot of every hospital medical ethics committee. It refers to medications, operations, and invasive procedures that have little or no chance of restoring a decent life to gravely ill or injured patients.

The sobering reality is that a natural conflict arises between these patients and those charged with their support, both the caregivers and the payers for that care. Physicians and nurses frequently must go through the motions of laboring to save an unsavable patient. Those motions typically involve subjecting the patient, whose welfare is the doctors' and nurses' sworn priority, to needless pain and fear through surgery, insertion of central venous lines, and defibrillation of the heart by application of direct current to the chest. None of these interventions is without risk, and the balancing of risks and benefits is a constant task in managing the crises of such a patient.

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Another unrelenting truth is the enormous expense of maintaining life toward its end, whether that end comes by advancing years or by catastrophic illness or injury. As our ability to prolong life has become matched only be the expense, medical ethicists have begun to consider that expense in the calculus of benefits and burdens. In this case, the burden is borne by hospitals, which are ultimately businesses, and by employers, who were enticed into the devil's bargain of providing tax-favored health insurance for their workers after World War II. Now, the burden will fall increasingly on taxpayers, as we move slowly but inevitably toward publicly funded health care.

Smith rightly warns of the danger these pressures pose to the elderly or terminal patients, who are seen by some as having a duty to die. His only omission is not acknowledging the economy of health care and the momentous decisions it now requires of us. Employer-provided health insurance is faltering as costs rise beyond realistic budget limits. In the managed care hotbed of California, hospitals are failing and medical groups are going bankrupt. Yet the public demands, on pain of litigation or criminal sanctions, that doctors and health plans provide every service that holds even faint hope of prolonging life, even in the face of death. And we expect that someone else will pay for it all.

Perhaps Smith can be forgiven a lawyer's one-sided argument. His uncompromising advocacy for the natural right of life is most welcome, given our apparent flirtation with the slippery utilitarian slope. In the chapter "Organ Donors or Organ Farms?" he illuminates the powerful forces pushing back the definition of death to include "heart-beating" organ donors.

Great strides in transplant surgery have created an insatiable demand for donor organs. In day-to-day hospital work one sees a subdued impatience with those not quite ready to part with their organs. Federal and state laws require hospitals to talk up organ donation with the families of terminal patients, exerting a subtle but unmistakable pressure to "live and then give." The Presumed Consent Foundation (www.presumedconsent.org) makes possible the most brazen demand on the sick and injured to give up their warm and well-perfused organs. The founder, a lung transplant recipient, insists that all persons be considered fair game for harvest of their organs unless they opt out. Thus the death tax would be paid not only with money, but also literally with a pound of flesh (or more, depending on the transplant surgeon's appetite). 

Partisans of utilitarianism bend the definitions of life and death to their own purposes. That many of those purposes are noble makes life-and-death decisions so much more arduous. We can look to the wisdom of both science and philosophy to guide us in the fray of competing harms and goods that is applied bioethics. Universal truths cannot decide particular cases, to be sure; but neither can hard cases be decided without intelligent reference to first principles.