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Оглавление“My mother’s doctor is refusing to give her antibiotics,” the woman caller told me in an urgent voice.
“Why is he refusing to prescribe antibiotics?” I asked.
“He says that she’s ninety-two and an infection will kill her sooner or later. So it might as well be this infection.”
As disturbing as this call was, as outrageous the doctor’s behavior, I wasn’t particularly surprised. I have been receiving such desperate communications with increasing frequency for the past two decades. Not every day, not every week, but with sufficient regularity—increasing in volume since this book was originally published—to become very alarmed about the state and ethics of American medicine, and its impact on culture.
Among the more disturbing calls I received came from John Campbell, whose teenage son, Christopher, had been unconscious for three weeks because of brain damage sustained in an auto accident. The boy had just been released from the hospital intensive care unit when he developed a 105-degree fever in the hospital’s “step-down unit.” Campbell asked the nurses to cool his fever. They replied that they needed a doctor’s orders. Campbell asked them to obtain it, but Christopher’s physician was out of town and the on-call doctor said no. “It was an evening of hell,” Campbell says. “My son’s life meant less than hospital protocol. When the doctor refused to order treatment, the nurses said that there was nothing they could do.”
Campbell desperately tried to reach the doctor on call personally, but he refused to take Campbell’s phone calls or return his increasingly urgent messages. Meanwhile, Christopher’s condition worsened steadily, rising over a period of some twenty hours, to 107.6 degrees. Finally, the nurses, caught between a desperate father’s pleas and a doctor’s steadfast refusal to treat, put Campbell on the phone directly with the doctor.
Campbell demanded that his son’s fever be treated immediately. The doctor refused. When Campbell grew more insistent, the doctor actually laughed. The boy was unconscious. His life was effectively over. What was the point?
“By this time,” Campbell recalls with much emotion, “my son’s eyes were black, as if he had been in a fight. He was utterly still. He was burning up. The back of his neck was so hot you couldn’t keep your hand on it. I said to the doctor, ‘This is not a joke! This is my son. His life is at stake. His temperature is over 107 and you are going to do something about it.’” The doctor, hearing the angry determination in Campbell’s voice and perhaps fearing legal consequences if Christopher died untreated, finally acquiesced.
Christopher’s temperature subsided. Soon thereafter he was moved to a rehabilitation center for therapy and began a slow recovery. Not long after, he moved home with his parents, where he spent his time relearning to walk with assistance and worked at a local youth center where he fed animals and counseled at-risk teenagers. Oh yes, Christopher felt very glad to be alive, as were his parents and the many troubled people he helped everyday.3
As I have spent more than twenty years traveling the country (and internationally) speaking about assisted suicide and other issues involving the ethics of modern medicine, as people react to my appearances on talk radio, television programs, and to my newspaper and magazine columns, with multiplying frequency I hear similar medical horror stories. People are afraid. They are deeply worried about what is happening to medicine: the potential impact of the Affordable Care Act (ACA, also known as Obamacare), doctors pressured by HMOs to reduce levels of care, hospital nursing staffs cut to the bone, the sickest and most disabled abandoned to inadequate care, elderly people dying in filthy nursing homes or in agony because their doctors fail to prescribe proper pain control.4 There have even been reported instances of desperate patients in hospitals calling 911 because they were unable to access needed medical attention.5
These anecdotes are symptoms of a disintegrating value system in health care that disdains the sickest and most disabled among us as having lives that are not worth living; that views expensive medical treatments for such people as a waste of valuable resources; indeed, that accepts their demise—or increasingly, even their killing—as a legitimate answer to the difficulties caused by their serious illnesses and disabilities. In short, the ethics of health care are devolving into a stark utilitarianism that is quickly transforming the “do no harm” tradition of medicine that has for millennia been the cornerstone—and hope—of medicine.
At the same time, medical economics are exerting a gravitational pull into the moral abyss. For example, when Arizona’s Medicaid program—the state/federal health insurance for the poor—ran into significant money problems, it canceled organ transplant surgeries for 98 percent of those eligible for the procedure.6 As this book will explain—sometimes in painful detail—with medical technology growing ever more sophisticated and expensive, while the viability of the old sanctity/equality of life ethic comes under increased cultural pressure, these kinds of controversies are going to become increasingly common and the divisions they sow among us more deep and viscerally felt.
THE NEW HIGH PRIESTS
We have not entered this era of potential medical authoritarianism by chance. We were steered into it by an elite group of moral philosophers, academics, doctors, lawyers, and members of the medical intelligentsia—known generically as bioethicists—who have dedicated themselves over the last four decades to bending public and professional discourse about medical ethics and the broader issues of health care public policy to their desires. They are the cultural aggressors, as the mainstream view in the field is openly hostile to the traditional moral values and ethical traditions of our society.
Medical ethics focuses on the behavior of doctors in their professional lives vis-à-vis their patients. Bioethics focuses on the relationship between medicine, health, and society. This last element allows bioethics to pursue policies that go far beyond the well-being of the individual and to presume a moral expertise of breathtaking ambition and hubris. Many view themselves, quite literally, as the forgers of “the framework for moral judgment and decision making”7 who will create “the moral principles” that determine how “we are to live and act,” a “wisdom” they perceive as “specially appropriate to the medical sciences and medical arts.”8 Indeed, some claim that “bioethics goes beyond the codes of ethics of the various professional practices concerned. It implies new thinking on changes in society, or even global equilibria”9 (my emphasis). Not bad for a school of thought that has only existed for about forty years.
Bioethicists typically see their work as integrating “medical ethics and universal morality” beyond “a few general principles” toward the determination of “the meaning of the good life.”10 It is “both a discipline and a public discourse, about the uses of science and technology” and the “values about human life . . . with a view toward the formation of public policy and a teachable curriculum.”11 Put more simply, bioethics seeks to create the morality of medicine, define the meaning of health and wellness, and determine when life loses its value (or has less value than other lives) toward the end of forging the public policies and influencing the individual choices that will establish a new medical and moral order. More than a set of tenuous speculations, bioethics in recent years has ossified into an orthodoxy and perhaps even an ideology.
Many bioethicists rejected this claim after the publication of this book’s first edition. They act in good faith, these objectors contended. The “quality of life” ethic will create a better world. Besides, they argued, bioethics is not monolithic.12 After all, practitioners have widely divergent opinions about these issues and controversies—ranging from assisted suicide to cloning to the definition of “health”—with which bioethics discourse grapples. Moreover, many adherents claim, bioethics doesn’t have an end goal. It is more akin to a conversation among professional colleagues, a process that merely seeks consensus about the most pressing moral and medical issues of our time.
If that were ever true, I contend that it is true no longer. Bioethics, at least of the kind without a modifier (conservative bioethics, Christian bioethics, etc.) may not be a monolith—a claim I never made. Disagreements certainly exist within the field. But they are more akin—with some exceptions—to the arguing of people who agree on fundamentals but disagree on details—sort of like Catholics bickering with Lutherans.
Most bioethicists recoil at their depiction as “true believers” subject to orthodox precepts and the emotional zeal generated by intensely felt ideology. Their self-view is that of the ultimate rational analyzer of moral problems who, were pipe smoking still fashionable, would sit back, pipe firmly in mouth, acting as dispassionate “mediators” between the extremes of medical technology and the perceived need for limits.13
But that is self-deception. Once bioethics moved away from ivory tower rumination to actively influence public policy and medical protocols, by definition the field became goal oriented. Indeed, University of Southern California professor of law and medicine Alexander M. Capron noted that from its inception, “bioethical analysis has been linked to action.”14 If dialogue is linked to action, at the very least that implies an intended direction, if not a desired destination. Even bioethics historian Albert R. Jonsen, a bioethicist himself, calls bioethics a “social movement.”15 Has there been any social movement that was not predicated, at least to some degree, in ideology? Moreover, bioethics pioneer Daniel Callahan, cofounder of the bioethics think tank the Hastings Center, has admitted that “the final factor of great importance” in bioethics gaining societal respect was the “emergence ideologically of a form of bioethics that dovetailed nicely with the reigning political liberalism of the educated classes in America.”16 Thus, mainstream bioethics is explicitly ideological, reflecting the values and beliefs of the cultural elite.
I asked the venerable author, medical ethicist, and physician Leon R. Kass, MD, whether he shares my opinion. Kass told me, “With due allowances for exceptions, I think there is a lot to be said for that view. There are disagreements about this policy or that, but as to how you do bioethics, what counts as a relevant piece of evidence, what kinds of arguments are appropriate to make, there is a fair amount of homogeneity. If you don’t hone to that view, you are considered an outsider.”17
The noted sociologist Renée C. Fox, a close observer of bioethics from its inception, told me in a similar vein, “I would call it an inadvertent orthodoxy. You could even call it ideology, depending on how you define the term.” Fox added, “I do think bioethics has gotten institutionalized. It is being taught in every medical school in this country. The training people receive and the content of the curriculum of the short courses as well as the masters’ and doctoral programs, can be quite formulaic. In that sense, I think you could talk properly about orthodoxy.” And while Fox told me that she does not believe (nor do I) that all bioethicists share the same “doctrinaire values and beliefs,” she noted, “If you are referencing that, again and again, bioethical reasoning, deliberation, and maybe even outcomes take certain forms, that may be correct.”18
British philosophy professor David S. Oderberg and Australian Supreme Court barrister Jacqueline A. Laing agree, writing, “It is plain that bioethics has been dominated by a certain way of doing moral philosophy,” what they call an “establishment view.”19 In this regard, Fox and her co-author, Judith P. Swazey, president of the College of the Atlantic in Bar Harbor, Maine, have written, “Bioethics is prone to reify its own logic and to formulate absolutist, self-confirming principles and insights,” as bioethicists “have established themselves, and their approach to matters of right and wrong, as the ‘dominant force’ in the field.”20 Those are pretty good descriptions of the mind-set of ideologues.
Sociologist Howard L. Kaye, PhD, author of The Social Meaning of Modern Biology,21 believes that this bioethics establishment view conceives of itself “less as an attempt to arrive at an ethical regulation of biomedical developments” and more as a system in which “biology [is] transforming ethics.” Kaye observes that many bioethicists “believe fervently that there needs to be a radical transformation in how we live and how we think based on new biological knowledge because our values, our ethical principles, our self conception are based on outmoded religious ideas or philosophical ideas that they think have been discredited.”22 If Kaye is correct—and there is abundant evidence that he is—the ultimate bioethics agenda is startlingly radical: dismantling the values and mores of our culture and forging a new ethical consensus in its own self-created image. There’s a word for such a breathtaking agenda: ideology.
Adding heft to my claim was the adverse reaction within the field generally to the appointment of Leon Kass by President George W. Bush to head the relatively conservative President’s Council on Bioethics in 2001. Never had a bioethics council received such a high profile. Moreover, as a prominent ethics professor at the University of Chicago and elsewhere, no one questioned Kass’s academic or intellectual credentials. But rather than being pleased that the field’s prominence had been recognized by the president of the United States, the attacks on Kass from prominent bioethicists and policy advocates flew fast and furious.
Liberal science writer Chris Mooney interviewed several prominent bioethicists for his piece “Irrationalist in Chief,” published in the American Prospect, which concluded that Kass brings “a sixteenth-century sensibility to guide us through twenty-first-century [bioethical] conundrums.”23 In a similar vein, bioethicist James Hughes castigated Kass as a “bio-Luddite,” while cloning-advocate Gregory E. Pence branded him as a “false prophet of doom.”
The torrent of criticism jumped the shark when (then) University of Pennsylvania bioethics professor and editor in chief of the American Journal of Bioethics Glenn McGee editorially attacked Kass for advocating the moral concept of intrinsic human dignity into ongoing bioethical debates:
It has become the era of Leon Kass, brought back to scholarly life by a call from President George W. Bush. It was a call to become a Presidential bioethics advisor [as head of the President’s Council] in the service of putting a stop to embryonic stem cell research, and if possible, putting a stop to a number of other scientific and clinical projects objectionable to the far right wing of the Republican Party, and in particular, Southern Baptists.24
Bioethicists pride themselves on rational discourse, but this was rank diatribe from the head of an influential bioethics journal. Kass is Jewish, not Southern Baptist (and for that matter, neither is former President Bush nor, as far as I know, were any council members.) Claiming his approach to be in the service of the “far right” of the Republican Party did an injustice to Kass’s nuanced and meticulous approach to bioethics. Moreover, demonstrating how politicized bioethics has become, McGee and his equally chagrined colleagues would have surely cheered if Kass had worked to “put a stop” to clinical projects held to be “objectionable” by the far left of the Democratic Party.
Why is this important? “Bioethics is a phenomenon of great social importance that extends far beyond medicine”25 and, as Dr. Kaye noted, many leading bioethicists are generally dismissive of Western values and traditions and indeed seek to dismantle them. That would be of little consequence if the movement were relegated to the cultural fringe. But mainstream bioethicists are among society’s most influential members. They serve on influential federal and state government public policy commissions, influencing the evolution of public policy. They are public advocates influencing popular views. They write health policy legislation. They consult in medical controversies at the clinical level, often influencing life and death decisions. They testify as expert witnesses in court cases and submit “friend of the court” briefs in legal cases of major significance. They appear on television and in the print media as “expert” commentators. Behind the scenes, they advise politicians from the local level all the way to the federal bureaucracies and, indeed, the president of the United States.
Every medical school teaches bioethics to every student, significantly influencing the attitudes of our doctors of tomorrow toward the health care system generally and their future patients specifically. Bioethics instruction is also provided to other university and postgraduate students studying to become lawyers, business executives, government policy makers, nurses, and educators. For those who wish to make a career in bioethics, many of our leading universities provide postgraduate degrees in the field, with graduates becoming consultants to nursing homes, HMOs, hospital organ procurement centers, and as scholars in think tanks.
Moreover, the influence of bioethicists has grown in the years since this book’s first edition. Bioethics is now an international movement, its advocacy pursued in virtually every developed country.
I was certainly not the first critic of the movement. Years before I entered the fray, the late philosopher and theologian Richard John Neuhaus succinctly described this oozing of bioethics into every nook and cranny of the West’s institutions when he wrote: “Thousands of ethicists and bioethicists, as they are called, professionally guide the unthinkable on its passage through the debatable on its way to becoming the justifiable, until it is finally established as the unexceptional.”26
It is worth reflecting upon what has become unexceptional in contemporary medicine and public policy since Neuhaus wrote those words in 1988. Then, most people would have found it unthinkable to dehydrate cognitively devastated people to death by removing their feeding tubes. It might even have been criminal. Today, due in large part to vigorous advocacy by bioethicists, which in turn led to court cases27 and then to new laws permitting the practice, withholding “artificial nutrition and hydration” has become routine—and not just for those diagnosed as unconscious.
In 1988, assisted suicide was illegal in every country. Today, euthanasia is administered to an ever-widening cohort in the Netherlands, Belgium, and Luxembourg. It is legal in Quebec and was transformed by the Canadian Supreme Court into a Charter right in 2015. In the USA, assisted suicide has been legalized by statute in California, Oregon, Washington, and Vermont—with new legislative proposals pouring forth with the start of every state legislative session.
It was once unthinkable to procure organs from someone in a persistent vegetative state. Although that is not being done—yet—some of the most mainstream bioethicists and physicians in the organ transplant community dispassionately debate doing just that, in essence advocacy to permit killing for organs.28
Ironically, the medical ethics, public policies, and philosophical beliefs that mainstream bioethics espouses are being imposed on a public that does not share many of the underlying values upon which they are based. This results in a distinct and oppressive disconnection between the medical protocols and public policies forged by bioethics advocacy and the people impacted directly by them. Kass explains: “There is a kind of condescension toward the views of the general public [within bioethics] and a considerable divide about core moral views. The American people, as a whole, are a religiously affiliated or God believing people and it is on the basis of the wisdom of these traditions that they express their fears about the threats to sanctity of human life and to human dignity.” Kass further warns: “There is the very real danger that what constitutes a ‘meaningful life’ among the intellectual elite [who make up much of the bioethics establishment] will be imposed on the people as the only standard by which the value of human life is measured.”29
John Keown, former University of Cambridge law professor and current Rose F. Kennedy Professor of Christian Ethics at Georgetown University’s Kennedy Institute of Ethics, accurately identifies this fundamental conflict:
Traditional common morality, as its name suggests, comprises ethical principles common to civilized cultures. The notion that that there are certain objective principles which societies must respect if they are to quality as civilized, has been expressed in the West in the Hippocratic Oath in Judeo-Christian morality, the prohibition against killing the innocent, and in the common law. . . . [But] much of modern bioethics is clearly subversive of this tradition of common morality. Rather than promoting respect for universal human values and rights, it systematically seeks to subvert them. In modern bioethics, nothing is, in itself, either valuable or inviolable, except utility.
Much damage has already been done. Indeed, society is only vaguely aware of the extent to which their most basic presumptions about health care have been undermined.
CREATING A HIERARCHY OF HUMAN LIFE
“The traditional Western ethic,” a California Medicine editorial opined in 1970, “has always placed great emphasis on the intrinsic worth and equal value of every human life.” This “sanctity of life ethic,” the editorial continued, has been “the basis for most or our laws and much of our social policy” as well as “the keystone of Western medicine. . . . This tradition ethic is being eroded at its core and may eventually be abandoned. . . . Hard choices will have to be made . . . that will of necessity violate and ultimately destroy the traditional Western ethic with all that portends. It will become necessary and acceptable to place relative rather than absolute values on such things as human lives.”30
These chilling words were prescient. In the nearly fifty years since, that is exactly what has happened. Rather than believing in inherent human equality, most contemporary bioethicists measure the value of human life subjectively. Instead of embracing the human community—which means all of us—most bioethicists are concerned with the “moral community,” which in theory and often in practice excludes some of us. For most bioethicists, human rights—assuming they exist; not all believe in them—are not inalienable but must be earned based on criteria they created—and, as we shall see, may include animals. Thus, equality ceases to be a universal vision.
If these words seem harsh, consider the thinking of an influential philosopher, the late Joseph Fletcher, whose ideas had enormous impact on the West in the second half of the twentieth century. Fletcher is most famous for creating “situational ethics,” which emphasizes “cutting loose from moral rules” and “reasoned choice as basic to morality.”31 Applied to medical ethics and health care, situational ethics—along with Fletcher’s writing and pronounced persuasive skills—made him, in Albert R. Jonsen’s term, “the patriarch of bioethics.”32
Fletcher was a radical utilitarian whose stated goal was to maximize happiness and minimize suffering. That sounds good in the abstract, but once he had freed himself from “moral rules,” Fletcher developed a worldview that was paradoxically both anarchic and totalitarian. Thus, in the name of human freedom, he enthusiastically endorsed the wildest ideas, such as the manufacture of chimeras (part human, part animal) through genetic engineering.33 Yet individuals per se actually counted for little in his thinking, and those he perceived as interfering with the general pursuit of happiness were expendable.
Early on, Fletcher dismissed the traditional medical “reverence for life,” sniffing that “nobody in his right mind regards life as sacrosanct.” Developing his thesis from the then newly crafted right to abortion, Fletcher distinguished “human life” from what he called “personal life.” “What is critical,” he wrote in 1973, “is personal status, not merely human status.” He created a list of “criteria or indicators” that he hoped could be used to divide society between those individuals who possessed “humanhood” and those who did not—between “truly human beings” whom he saw as deserving of great moral concern and the “subpersonal,” or humans he deemed of scant consequence.34 He used the terms “humanhood” and “truly human” not as biological descriptions but as subjective terms to connote moral value.
The immediate problem facing Fletcher and those contemporaries who agreed with him was to devise a method for culling the human herd to prove that “we mean business.”35 Toward that end, Fletcher proposed a formula to gauge the quality of a human life “for the purposes of biomedical ethics.”36 These included a list of fifteen “criteria or indicators,”37 among which were:
• Minimum intelligence (score too low and one is deemed “mere biological life”);
• Self-awareness (“essential to the role of personality”);
• Self-control (i.e., if someone is not control of him or herself, “the individual is not a person”);
• A sense of futurity (“subhuman animals do not look forward in time”);
• Memory (“It is this trait alone that makes man . . . a cultural instead of instinctive being”);
• Concern for others (“The absence of this ambience is a clinical indication of psychopathology”);
• Communication (“Disconnection from others, if it is irreparable, is dehumanization”); and
• Neocortical function (“In the absence of the synthesizing function of the cerebral cortex, the person is non existent. Such persons are objects, not subjects”).
Fletcher also fashioned five “negative” points that he believed indicated true humanhood. For example, he claimed that man is not “anti-artificial.” To the “anything goes” Fletcher, “to oppose technology is self-hatred.” Thus, “a baby made artificially by deliberate and careful contrivance, would be more human than one resulting from sexual roulette—the reproductive mode of subhuman species” (my emphasis).38 Fletcher also dismissed the notion of innate human rights: “The idea behind this is that such things are objective, pre-existent phenomena, not contingent on biological or social relativities.”39 In other words, Thomas Jefferson was all wet.
To understand how dangerous that thought of bioethics’ “patriarch” really is, one need only read Fletcher’s 1975 essay, “Being Happy, Being Human,”40 in which he describes participating in a panel discussion of the treatment of babies born with serious birth defects. A physician who cared for a profoundly mentally retarded boy reported that while he possessed a very low IQ, the lad was clearly happy and clearly a human being. Fletcher coldly dismissed the human worth of this defenseless child—and that of many other developmentally disabled people: “Idiots are not, never were, and never will be in any degree responsible [because they cannot understand consequences of action]. Idiots, that is to say, are not human. The problem they pose is not lack of sufficient mind but of any mind at all. No matter how euphoric their behavior might be, they are outside the pale of human integrity. Indeed, sustained and ‘plateau’ euphoria is itself prima facie clinical evidence of mindlessness.”41
Such a provocation had a purpose: to gain support for the notion that killing “idiots” could, depending on the facts of each individual case, be ethical and right—decisions that Fletcher described as a merely “clinical” matter.42 In the case of disabled infants, he wrote elsewhere that killing should simply be considered “postnatal abortion.”43 As I will describe later, calls within bioethics to permit infanticide have proliferated in the years subsequent to Fletcher’s advocacy.
Not every bioethicist agrees with all of Fletcher’s ideas. Nor will every radical policy Fletcher promoted eventually become culturally or medically acceptable—although many of them, such as dehydrating to death cognitively disabled people, which Fletcher proposed as early as 1974,44 already have. But it is particularly telling that Fletcher was not dismissed by the fledgling bioethics movement as some fanatic kook when he advocated infanticide, “research on living fetuses outside the womb,”45 combining human and animal DNA,46 and dehumanizing cognitively disabled people. In fact, his ideas received immediate respect, allowing them to travel from the realm of the unthinkable, to borrow Richard John Neuhaus’s terminology, into the debatable, from whence many have become justifiable. Some are now unexceptional.
That is not to say that there was no intellectual resistance within the early bioethics movement to the steady growth of this sort of secularist, radically utilitarian thinking. A strong countermovement led by theologian Paul Ramsey provided a significant challenge to the Fletcher school for many years.
Ramsey believed that people owed each other a duty of fidelity based upon “covenant responsibilities” based in “justice, fairness, righteousness, faithfulness, canons of loyalty, the sanctity of life, hesed, agapé [steadfast love], or charity.” This meant, according to Ramsey, that there is “sacredness and in ‘bodily life’ from which flow our mutual duties to care for each other, including the most weak and vulnerable among us.”47
Where Fletcher’s approach was a bioethical version of anything goes, Ramsey stood firmly against the idea that the ends justify the means. Where Fletcher sought to create invidious divisions among people based on purported humanhood criteria, Ramsey explicitly rejected the entire approach as immoral: “Fletcher is simply a sign of the times,” Ramsey worried, as he asserted that creating criteria to judge how people should be treated in health care is wrong because it was to “play God as God plays God.”48 “To use such indices in the practice of medicine is a grave mistake,” Ramsey warned, because it would lead to inequality and “add injustice to injury and fate.”49
Gilbert Meilaender, the theologian and ethicist who has been a part of this struggle for decades, characterized this internal struggle for the soul of bioethics as a three-decade war. To make a long story short, the amoral Fletcher school (my term) prevailed over traditional moralists such as Ramsey, illustrated by the sad fact that few of Ramsey’s books remain in print while most of Fletcher’s books and articles are readily obtainable. In the end, Fletcher, not Ramsey, became the “patriarch” of modern bioethics. It is Fletcher’s views that predominate within the field. Fletcher, not Ramsey, was the one who “articulated where bioethics was heading well before the more fainthearted were prepared to develop the full consequences of their views.”50
Once Fletcher secured a beachhead, it was only a matter of time before someone like Peter Singer would stage his much-publicized landing in bioethics. If this were a movie, Singer’s appearance would be entitled “Son of Fletcher.” Beginning in the mid-1970s, Singer rose quickly in prominence to become one of the world’s most influential contemporary utilitarian bioethicist/moral philosophers. But being the radical that he is, Singer took Fletcher’s original formula and extended it to even more subversive ends. Where Fletcher sought to determine who had moral value strictly for the benefit of humans, Singer expanded the “moral community” into the world of animals.
Singer contended that being human in and of itself is irrelevant to moral status; what counts is whether a “being” is a “person.” Toward creating a formula to make this determination, Singer simplified Fletcher’s multi-point formula to “two crucial characteristics” that earn human being or animal the status of “person” (e.g., “rationality and self consciousness”).51 Species membership is irrelevant, Singer claimed. Indeed, he asserted that some animals are persons, including “whales, dolphins, monkeys, dogs, cats, pigs, seals, bears, cattle, sheep, and so on, perhaps even to the point which it may include all mammals.”52 On the other hand, some humans would not qualify, including newborn human infants (whether disabled or not), people with advanced Alzheimer’s disease or other severe cognitive disabilities—since Singer claimed they are not self-conscious or rational—along with other nonpersons that exhibit similar relevant characteristics (e.g., clams or sardines).
Yes, Singer explicitly made a moral comparison between some people and fish, writing, “Since neither a newborn infant nor a fish is a person the wrongness of killing such beings is not as great as the wrongness of killing a person.”53 Thus, to Singer, a newborn infant is the moral equivalent of a mackerel and an advanced Alzheimer’s patient is comparable to a pigeon. As we shall see later in the book, Singer, like Fletcher, asserted that his theories justify infanticide and non-voluntary euthanasia of cognitively disabled people.
In another world and time, Singer’s advocacy would make him an intellectual outcast. He actually is in bad standing in Germany and Austria, where he cannot speak without generating angry protests from people who consider his opinions Nazi-like.54 But many in academia and bioethics embrace him, or at least respect his intellectualism (and perhaps admire his radicalism). Far from being a fringe character, Singer is invited to present at seminars, symposia, and philosophy association conventions throughout the world. His 1979 book, Practical Ethics, which unabashedly advocates infanticide and euthanasia, and also decries “discrimination” based on species (a bizarre notion Singer labels “speciesism”), has become a standard text in many college philosophy departments. Singer is so mainstream that he even wrote the essay on ethics for the Encyclopedia Britannica. Most disturbingly, in 1999, he became a permanent member of the Princeton University faculty, where he is the Ira W. DeCamp Professor of Bioethics, a prestigious, tenured academic chair at the university’s Center for Human Values.
The person/nonperson moral distinction is generally accepted throughout bioethics and increasingly applied to animals, as Singer has advocated. Writing in the influential Kennedy Institute of Ethics Journal, British academic John Harris, the Sir David Alliance Professor of Bioethics and Director of the Institute of Medicine, Law, and Bioethics at the University of Manchester, England, defines a person as “a creature capable of valuing its own existence,” which he opines could include people, animals, extraterrestrials, and machines but does not include some humans, including infants “during the neonatal period.” To Harris, only the lives of persons are morally important. It is not wrong to kill nonpersons or fail to save their lives:
[T]o kill or to fail to sustain the life of a person is to deprive that individual of something that they value. On the other hand, to kill or to fail to sustain the life of a nonperson, in that it cannot deprive that individual of anything that he, she, or it could conceivably value, does that individual no harm. It takes from such individuals nothing that they would prefer not to have taken from them. . . . Nonpersons and potential persons cannot be wronged in this way [killing them against their will] because death would not deprive them of anything they can value. If they cannot wish to live, they cannot have that wish frustrated by being killed.55
Similarly, Georgetown University’s Tom L. Beauchamp, co-author of The Principles of Bioethics, similarly asserts in the Kennedy Institute of Ethics Journal that personhood and nonpersonhood designations may soon inform us whether we can use people as objects of exploitation in the ways that are presently restricted to our treatment of animals: “Because many humans lack properties of personhood or are less than full persons, they are thereby rendered equal or inferior in moral standing to some nonhumans. If this conclusion is defensible”—and Beauchamp clearly thinks it is—“we will need to rethink our traditional view that these unlucky humans cannot be treated in the same ways we treat relevantly similar nonhumans. For example, they might be aggressively used as human research subjects and sources of organs.”56
Making instrumental use of humans denigrated as having lesser value based on their capacities is definitely on the bioethics table. In 2010, British bioethicist Alasdair Cochrane eloquently identified the stakes in the debate over whether “intrinsic dignity” is an inherent human characteristic: “Under this conception, the possession of dignity by humans signifies that they have an inherent moral worth. In other words, because human beings possess dignity we cannot do what we like to them, but instead have direct moral obligations toward them. Indeed, this understanding of dignity is also usually considered to serve as the grounding of human rights. As Article 1 of the Universal Declaration of Human Rights states, ‘All human beings are born free and equal in dignity and rights.’”57 He also stated: “If all individual human beings possess dignity, then they should not be viewed simply as resources that we can treat however we please. To take an example, it may be that we could achieve rapid and significant progress in medical science if we were to conduct wide-ranging experiments on groups of human beings. However, because human beings have dignity, so it is argued, this means that they possess a particular quality that grounds certain obligations and rights.”58
Despite understanding the stakes, Cochrane took the familiar bioethics line, calling for an “undignified bioethics” that views humanhood per se as morally irrelevant and arguing that the ways we treat our fellow humans should depend on each individual’s perceived “moral status”—such as personhood. “Simply stipulating that all and only human beings possess this inherent moral worth because they have dignity is arbitrary and unhelpful,” he wrote.59 Hardly arbitrary, given the stakes and the deep traditions behind this view. Unhelpful, perhaps—it impedes using vulnerable humans as lab rats, prevents raising fetuses for harvest, and argues against other utilitarian horrors—real and proposed—that are the subject of this book.
Not all bioethicists are as candid as Fletcher, Singer, Harris, Beauchamp, and Cochrane. The late Ronald Dworkin, an influential law professor and author whose effect on the Montana Supreme Court I mentioned earlier, argued in his book Life’s Dominion that killing the weak and helpless can actually be a method of upholding the inherent value of human life.60 Dworkin claimed that the argument between those who support abortion or euthanasia and those who oppose these practices isn’t even an argument about whether the sanctity of life is a sound principle. Everyone agrees that it is, he claims: “We disagree so deeply because we all take so seriously a value that unites us as human beings—the sanctity or inviolability of every stage of every human life. Our sharp divisions signal the complexity of the value and markedly different ways that different cultures, different groups, and different people, equally committed to it, interpret its meaning.”61
Yet, in Dworkin’s hands, the meaning of the “sanctity of life” is left to each person to determine individually. Thus, Dworkin says, having an abortion is not denying life’s sanctity to the human fetus but upholding life’s sanctity for the woman who doesn’t want a baby. “It may be more frustrating to life’s miracle when an adult’s ambitions, talents, training and expectations are wasted because of an unforeseen or unwanted pregnancy than when a fetus dies before any significant investment of that kind has been made.”62 Regardless of where one stands in the great pro-life/pro-choice cultural divide, to assert that having an abortion is somehow to embrace “the inviolability of every stage of every human life,” as Dworkin does, is simply ludicrous.
Dworkin similarly asserts that euthanasia isn’t actually a rejection of the sanctity of life but an embracing of it: “People who want an early, peaceful death for themselves are not rejecting or denigrating the sanctity of life. On the contrary, they believe that a quicker death shows more respect for life than a protracted one.” Active killing of people promoted, without a hint of irony, as an embrace of life’s sanctity is to suck all meaning from language. For Dworkin, the “sanctity of life” is not a principle but a mere contingency, defined essentially by where a person stands in his or her life at any given moment. Such a porous concept is incapable of protecting the weak and vulnerable from medical discrimination or killing, and that—as with the distinction between human beings based on personhood criteria—is exactly the point.
Dworkin repeatedly confused feelings with morality, arguing that since the deaths of some people cause more grief and sense of tragedy than do the deaths of other people, it is somehow justifiable to view the inviolability of individual human lives in relative terms: “Most people’s sense of that [death-caused] tragedy, if it were rendered as a graph relating the degree of tragedy to the age at which death occurs, would slope upward from birth to some point in late childhood or early adolescence, then follow a flat line until at least very early middle age, and then slope down again toward extreme old age. . . . [Thus] The death of an adolescent girl is worse than the death of an infant girl because the adolescent’s death frustrates the investments she and others have made in her life.”63
Determining the value of life with such an emotional yardstick is a quixotic enterprise. One could just as easily argue that the newborn’s life is more valuable because it is all potential—a blank slate—while the adolescent has already acquired a character and experiences that limit her range. Such opinions are at best an underwriter’s version of morality and not worth the time it takes to make them.
EUTHANIZING HIPPOCRATES
“To regard life as sacred,” Leon Kass wrote, “means that it should not be violated, opposed, or destroyed, and that positively, it should be protected, defended and preserved.”64 These precepts are especially important in medicine, considering the power accorded physicians to cut, drug, and manipulate the bodies of their patients. Meilaender summarized the obligation as a positive obligation of physicians to “be committed to the bodily life of their patients.”65 A robust belief in the equality/sanctity of human life takes these prescriptions one step further by positing the obligation of physicians to view each of their patients as having equal moral worth. Thus physicians are not free to pick and choose among the patients to whom they will give optimal care. All patients are owed the same level of dedication, excellence, loyalty, and fidelity, regardless of their physical or cognitive condition.
These worthy concepts are famously embodied in the Hippocratic tradition. Indeed, medicine may actually have been the first field in which the underlying principles of the equality of life ethic were recognized as applying generally rather than parochially. The Oath, bearing the name of Hippocrates (approximately 470–360 BCE) was created hundreds of years before the advent of Christianity. It required physicians to “apply dietetic measures for the benefit of the sick according to my ability and judgment,” to “keep them from harm and injustice,” foreswear abortion, and “give no deadly medicine to any one if asked, nor will I make a suggestion to this effect.” The Oath taker promised, “Whatever house I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of all sexual relations with both female and male persons, be they free or slaves.” Physicians further pledged to keep patient confidences, holding what the doctor sees or hears “in the course of treatment” to be “shameful to be spoken about.”66 These life- and dignity-affirming doctrines of the Oath are generally summarized by a familiar summarizing phrase: “do no harm” (the exact phrase is not found in the great document itself, although it is discussed in Hippocratic literature). These principles were and are upheld by physicians in myriad ways: by rendering optimal care to each patient; promoting bodily healing; alleviating pain and suffering; respecting patient dignity; refusing to disclose patient confidences, even in a court of law; and refusing to kill patients.
As we move further into the twenty-first century, the Hippocratic tradition is ailing and in acute danger of collapse. “It was when bioethics came on the scene that the Hippocratic tradition of the physician/patient relationship started to fall apart,” philosopher Dianne N. Irving, PhD, a longtime critic of bioethics, told me. “Once it was weakened, bioethics began to replace it with medicine practiced for the greater good of the society rather than the individual patient. That threatens patient welfare and denigrates medicine into a business rather than a profession.”67 Irving’s criticisms find support among many mainstream bioethicists who celebrate their calling as “post professional.”68
A recent study of physician oath taking published in the Journal of Clinical Ethics69 illustrated how far modern medicine has strayed from the traditional values of the Hippocratic Oath. The authors analyzed contemporary medical oaths and compared them to the Hippocratic original. Considering Roe v. Wade, it is not surprising that 8 percent of doctors pledged to forswear abortion, but only 14 percent promised not to commit euthanasia (active killing by doctors). In 1977, only 31 percent of oaths required the taker to “respect life,” and only 43 percent of present-day oaths require physicians to be “accountable to their profession.” There has also been a stunning “nearly complete” disappearance of the proscription against sexual relations between physicians and patients, a key factor in professionalism, since it is a matter “of character and justice . . . and not taking advantage of vulnerable patients.”70
Many of the most prominent doctors and bioethicists could care less. Thus the late author and physician Sherwin Nuland of Yale University School of Medicine wrote in the New England Journal of Medicine, “Those who turn to the oath in an effort to shape or legitimize their ethical viewpoints must realize that the statement has been embraced over approximately the past 200 years far more as a symbol of professional cohesion than for its content. . . . Ultimately, a physician’s conduct at the bedside is a matter of individual conscience.”71 Yikes!
When I tell my lecture audiences that most doctors no longer take the Hippocratic Oath upon becoming physicians and that many no longer see it as relevant to their profession, they are shocked and disturbed. They believe, quite correctly, that the Oath exists for their protection. They want their doctors to practice a do-no-harm style of medicine. “Why have they abandoned a tradition that has served medicine—and us—so well?” they ask.
The answer to this important question is complex, having much to do with who we are as a culture and a people. According to the late physician and sanctity-of-life bioethicist Edmund D. Pellegrino—who spent a long and productive career as a professor of medical ethics—the Hippocratic system came under attack both from without and within the medical profession: “These constructs first came into question in the mid-1960s as part of the general upheaval of moral values that occurred in the United States. Concomitantly, the character of medicine was being altered by the specialization, fragmentation, institutionalization, and depersonalization of health care. At the same time, the number and complexity of medical ethical issues expanded as the power of medical technology presented new challenges to traditional values.”72
These challenges could have been met without destroying the “do no harm” tradition. However, medicine, perhaps having lost confidence in its own ethical instincts, “turned to the philosophers”73 of bioethics. Unfortunately, by this time, the most influential practitioners in the field had enlisted in the relativist branch epitomized by Fletcher rather than the more traditional equality-of-life-affirming approach espoused by Ramsey. In a philosophical milieu in which the most helpless patients were already viewed widely as less than fully human, the Hippocratic tradition didn’t stand a chance. This sad fact is illustrated by the treatment given the tradition in The Principles of Biomedical Ethics, first published in 1979, in which Beauchamp and Childress blithely dismiss it as “a limited and unreliable basis for medical ethics.”74 As for the do-no-harm ethic the Oath spawned, readers are informed that it is merely a “strained translation of a single Hippocratic passage.”75 So much for more than 2,000 years of applied ethics and medical wisdom.
BIOETHICS AND RELIGION
The antipathy of mainstream bioethics to religion began early. It is not coincidental that Joseph Fletcher, the “patriarch,” insisted on forming his views upon the premise that “man is not a worshipper.”76 In recounting the reasons why he believed that bioethics became so influential in such a short time, Daniel Callahan wrote, “The first thing that . . . bioethics had to do—though I don’t believe anyone set this as a conscious agenda—was to push religion aside.”77 Dan Brock, a prominent philosopher and member of the bioethics elite, was similarly blunt in an article urging the legalization of euthanasia: “In a pluralistic society like our own, with a strong commitment to freedom of religion, public policy should not be grounded in religious beliefs which many in that society reject.”78
After welcoming theologians in its formative years (ironically, Fletcher was a lapsed Episcopal priest), bioethics now stresses that morality and proper behavior are best determined through “rational analysis” based on secular philosophical precepts. Theology, religious values, spirituality, faith—these are considered “external” and thus “unconvincing” in determining wrong from right.79 Moreover, unlike most of the general population that bioethics supposedly serves, many (although certainly not all) modern bioethicists are agnostic or atheistic, a personality factor that colors their entire approach to these important issues as much as the Pope’s Catholicism does his. Indeed, some bioethicists view religion with utter disdain, as mere “mumbo jumbo,” to use Peter Singer’s pejorative term.80 Even those bioethicists who have strong spiritual beliefs—including some Catholic priests—are so worried about imposing their religion upon secular society that they leave their personal faith-inspired values at the door when discussing public health policies.
This near-absolute rejection of religious values as a proper moral underpinning for debating and creating secular public policies is a fatal flaw of modern bioethics. “Ninety percent of the population identifies with the Judeo-Christian tradition,” writes the Loma Linda University professor of Ethical Studies James W. Walters. As an obvious consequence, “our society’s most fundamental moral views are rooted in religion.”81 If Walters is right, then bioethics isn’t merely reflecting a new ethic to meet changing times—it is imposing it on and applying it to a population that profoundly disagrees with bioethics’ most basic assumptions.
That is not to say that religion in the public square does not have its problems. (Murdering doctors in the name of “life” comes readily to mind.) But it is also true that religion played an indispensable role in creating an ethic of humanity that gentles the savage injustices of life.
Consider the modern hospice movement that owes its origin to the dedication and compassion rooted in the deeply held religious values of its founder, Dame Cicely Saunders. Dame Cicely, as she is known affectionately in England, was a nurse and devout Anglican who was a medical social worker in a London hospital in the years immediately following World War II. She met a Jewish émigré named David Tasma, who had escaped the Warsaw ghetto only to lie dying in a London hospital at the age of forty. Tasma was alone in the world, and Saunders made a special point to visit him every day. Their friendship changed our world.
As Saunders and Tasma spoke of his impending death, she began to comprehend “what he needed—and what all of the other dying patients and their families needed.” Saunders had an epiphany. She told me, “I realized that we needed not only better pain control but better overall care. People needed the space to be themselves. I coined the term ‘total pain’ from my understanding that dying people have physical, spiritual, psychological, and social pain that must be treated. I have been working on that ever since.”82 Tasma left Saunders 500 British pounds to begin her work, telling her, “I will be a window in your home.” Saunders told me, her eyes moistening, “It took me nineteen years to build the home around that window.”83
Saunders epiphany was not “rational” but spiritual, coming from a deep empathy inspired by her religious faith. Her work was a “personal calling, underpinned by a powerful religious commitment,”84 wrote David Clark, an English medical school professor of palliative care and Saunders’s biographer, to whom she has entrusted the organization of her archives. So strong was Saunders’s faith in what she perceived as her divine call that she began volunteering as a nurse at homes for the dying after work.85 Urged on by her deep desire to help dying people, she went to medical school at the age of thirty-three, this at a time when there were few women doctors.
Saunders focused her medical practice on helping dying people and alleviating pain. She obtained a fellowship in palliative research and began work in a hospice run by nuns, where pain control was unevenly applied, a nearly universal problem at the time, causing much unnecessary misery. Saunders conceived of putting patients on a regular pain control schedule, which, in her words, “was like waving a wand over the situation.”86
Saunders’s faith pushed her toward founding a hospice based on her concept of treating the total patient. Believing firmly that “the St. Christopher’s project [was] divinely guided and inspired,”87 she became an activist, energetically raising money for the new project and in the process raising the consciousness of the medical establishment. Based as it was on religious inspiration (“I have thought for a number of years that God was calling me to try to found a home for patients dying of cancer,” she wrote to a correspondent88), Saunders’s initial idea was for St. Christopher’s hospice to be a “sequestered religious community solely concerned with caring for the dying.” But the idea soon expanded from a strictly religious vision into a broader secular application; in Clark’s words, a “full-blown medical project acting in the world.”89
Saunders succeeded beyond even her own wildest hopes. St. Christopher’s opened in a London suburb in 1967 and jump-started the modern hospice movement. “We started in-home care in 1969,” Saunders said. “The majority of our work is out in the community.” Saunders soon exported hospice to North America. In 1971, she sent one of her team doctors to New Haven, Connecticut, to help found the first modern hospice in the United States, from whence it spread nationwide. Hospice has been a certified medical specialty in Britain since 1987.90
There is a direct line of compassion, succor, and love from David Tasma in 1948 to the millions of others who have benefited from hospice care since 1967—including my father, who died under hospice care in 1984, and my aunt in 2013. None of this would have happened without the religious values manifesting in the secular milieu of medicine through Dame Cecily, specifically the belief that no matter what our state of health, no matter our age, no matter how much help we need, no matter how we look or smell, we all have equal moral worth.
To promote such values is not to support theocracy. It does not divide a pluralistic society by imposing religion on an unwilling public. Rather, it is a secular application of the sanctity of life. How sterile and harsh the world would be if the values that inspired Dame Cicely were barred from the public square simply because they were founded in religious faith. How dangerous to exclusively base our approach to issues of public health policy and clinical medical ethics on amoral “moral philosophy.” It is true that religion not tempered by secular restraint and rationalism can lead to the tyranny of theocracy. But secularism not enriched by the values inspired by spirituality and religious faith, as this book demonstrates, will lead to the creation of “hierarchies of human worth,”91 the building blocks for a medical culture of death.
BRAVE NEW BIOETHICS
Having rejected the core values and virtues of Western civilization as bases for determining what is moral and good, bioethics turned to secular moral and analytical philosophy for the answers. This approach accepts no moral standard or ethical rule, no matter how deeply valued, as a self-evident truth. Every moral principle must be reassessed and deemed “rational” if it is to pass bioethical muster. Not surprisingly, the people bioethicists deem best able to perform this task are themselves, especially those trained in the arcane schools of secular philosophy. Needless to say, that stacks the deck in favor of those values and approaches to morality that the most influential bioethicists embrace personally. Unfortunately, some critics (me included) find that important human values such as “decency, kindness, empathy, caring, devotion, service, generosity, altruism, sacrifice, and love” are too often omitted from their equations because they are perceived to have little value in determining “what is ethical or moral.”92
Ironically, mainstream bioethics, which explicitly eschews religious values in public policy and medical ethics discourse as well as proudly proclaims itself the epitome of rationality, has itself become something of a secular faith among its adherents. Renée Fox notes, “Bioethics has always been a societal happening, dealing with issues that have religious import and ramifications. It deals with real dilemmas, issues of how society deals with ultimate beliefs. Bioethics uses medicine as a metaphor for discussing with each other issues of ultimate values and belief, questions that are as religious as they are ethical.”93 Adds Leon Kass: “While bioethics is not formally a religion, it is absolutely faith-based and is as equally indemonstrable. They purport to grapple with First Principles. Yet, they step into the public square with no greater claim to wisdom than does someone who believes in the resurrection or in the revelation of the Law at Sinai.”94
Bioethicist Daniel Callahan clearly perceives bioethics in quasi-metaphysical terms. “Above all,” he wrote in 1994, “bioethics needs to develop the capacity to help individuals make good moral decisions in their own lives and to do so in the context of the most basic moral questions: how ought I to live my life? The health of the soul (as they might have put it in an earlier day) is even more important than the health of the body.”95 In the same article, Callahan advocated a bioethics that helps “people shape their inner, private lives, assisting them in knowing how to make good personal judgments…”96 Thus it seems that bioethics didn’t actually “push religion aside,” as Callahan wrote elsewhere, as much as it changed the venue of belief.
We have seen what the new secular faith or ideology of bioethics rejects. But what does it embrace? Again, it is important to concede that the field is not monolithic. Not everyone who claims to be a bioethicist necessarily accepts some or all of the concepts I will discuss below, just like not every Christian adheres to the same tenets of faith. That being duly noted, it is fair to say that predominate bioethics adheres to the following general belief systems with the following dominant features:
Utilitarianism: Whether explicit or implicit—in intent or outcome—bioethics advocacy is predominately utilitarian. “All [leading] bioethicists,” claims author Anne Maclean, accept “some version of utilitarianism.”97 Professor Keown told me similarly, “Much of modern bioethics is largely utilitarian. Utilitarianism is fast establishing itself as the new orthodoxy.”98 Fox and Swazey write, “Since the mid-1970s . . . moral philosophy has had the greatest molding influence on the field,” especially “analytic philosophy—with its emphasis on theory . . . and its utilitarian outlook.”99 That theme has continued since this book was first published, with the emergence of younger voices in the field, such as Julian Savulescu, professor of practical ethics at the University of Oxford, and Thaddeus Mason Pope, director of the Health and Law Institute at Hamline University.100
Generally stated, utilitarians hold that “what people want, is the ultimate measure of right and wrong.”101 Joseph Fletcher was a wild utilitarian, writing that “a moral agent’s business is to maximize good,” which he defined as “happiness”: “Whatever increases human happiness is good; whatever reduces human happiness is evil.”102 Peter Singer, one of the world’s foremost contemporary utilitarians, does not look to happiness so much as whether the “interests” of those affected (which in his view includes animals) are furthered or hindered.103 Peter Singer himself admits that “ethical ideals, like individual rights, the sanctity of life, justice, purity . . . are incompatible with utilitarianism.”104 Thus, to the utilitarian, there is neither objective right nor objective wrong: actions are measured subjectively based on desired or actual outcomes and the ends justify the means. Unfortunately, what the Singers and Fletchers of the world forget is that the means themselves often subsume the ends.
Lacking a firm commitment to the sanctity/equality of human life, utilitarians may justify profoundly dangerous and immoral schemes and not even blush. As described by Anne Maclean in her book The Elimination of Morality,105 bioethicist John Harris—whose views on personhood we have already discussed—proposed a scheme to eliminate the shortage of transplant organs under which the few would be murdered to benefit the many: “[E]veryone [shall] be given a sort of lottery number. Whenever doctors have two or more dying patients who could be saved by transplants, and no suitable organs have come to hand through ‘natural deaths,’ they can ask a central computer to supply a suitable donor. The computer will then pick the number of a suitable donor at random and he will be killed so that the lives of two or more others may be saved.”106
To the radical utilitarian Harris, saving two or more lives at the expense of one murder would bring greater overall happiness than would the suffering caused by the killing of one man or woman. And since under utilitarianism no individual possesses human rights per se, at least if the exercise of such rights would impede the highest overall utility, why not perform the human sacrifice?
Obviously, Harris’s proposal will never become public policy—although it is worth noting here that Belgium and the Netherlands have joined voluntary euthanasia with organ harvesting. (More about that later.) Nor, I hope, will most bioethicists accept his ideas. Still, that Harris’s proposal was presented straight-faced as a respectable point-of-view in an important philosophy primer (Applied Ethics, edited by Peter Singer) illustrates the amorality of utilitarian thought and much of what has gone so dreadfully wrong in bioethics discourse.
The Quality of Life Ethic: As skeptical as mainstream bioethicists are about “the sanctity/equality of life,” they are equally enthusiastic about the “quality of life” ethic. What do they mean by this phrase as applied to health policy and medical practice? In Clinical Ethics, a bioethics book designed for everyday clinical use by working medical professionals, Albert Jonsen and his co-authors write, “In general, the phrase expresses a value judgment: the experience of living, as a whole or in some aspect, is judged to be ‘good’ or ‘bad,’ ‘better’ or ‘worse.’”107
Such issues are, of course, a proper part of medical decision making. For example, I once snapped a knee ligament while skiing. My orthopedist told me that I could have it repaired surgically, but it would be a delicate and painful process that would take more than a year to heal. My other option was to simply quit skiing and engaging in other sports requiring lateral movements. I decided to give up the slopes because I believed that choice best protected my life’s quality—although I might have made another decision if the injury had left me in constant pain. The same kind of cost/benefit analysis goes into more serious medical decisions, such as whether to accept a last-ditch round of chemotherapy or ask for medical technology to extend life.
The problem with the concept of quality of life arises when it ceases to be a factor in medical decision making and instead not only becomes the factor but is used as a measurement of moral worth. When applied in this manner, it is often called the “quality of life ethic,” which Peter Singer describes in his book, Rethinking Life and Death:
We should treat human beings in accordance with their ethically relevant characteristics. Some of these are inherent in the nature of being. They include consciousness, the capacity for physical, social, and mental interaction with other beings, having conscious preferences for continued life, and having enjoyable experiences. Other relevant aspects depend on the relationship of the being to others, having relatives for example who will grieve over your death, or being so situated in a group that if you are killed, others will fear for their own lives. All of these things make a difference to the regard and respect we should have for such a being.108
The danger of Singer’s approach should be obvious to every reader. The standards Singer uses to measure human worth are his standards based on what he considers important and “relevant.” And therein lies the heart of the problem. Subjective notions of human worth, in the end, are about raw power and who gets to do the judging. In our not-so-distant past, for example, decisions denigrating the moral worth of a subset of people (i.e., blacks) were made to justify their oppression and exploitation based on the allegedly relevant characteristics of skin color and cultural stereotypes. The quality of life ethic is no different—only the “relevant characteristics” have changed, not the wrongness of the approach. Quality of life, as a moral measure, strips worth and dignity from people based on health or disability, just as surely as racism does based on skin pigment, hair texture, or eye shape.
Not surprisingly, disabled people are especially worried about using quality of life as a yardstick of moral worth: they are the target. “Many in society consider disability as worse than death and a drain on our limited resources,” says attorney Diane Coleman, a disability rights activist and the founder of Not Dead Yet, a national organization that battles medical discrimination against disabled people and resists the legalization of assisted suicide. “There is a great revulsion against disabled people that is visceral. This disdain is masked as pity but many people believe that in an ideal world, disabled people wouldn’t be there.”109
That being true—and who can deny it—what would happen to the rights of disabled people if the equality of life ethic were supplanted in law and in medical ethics by a quality of life approach? Coleman worries, “Anti-disabled bias would become especially dangerous. If it becomes respectable to label us ‘inferior’ or even, ‘less human’ based on perceptions of the quality of our lives, it will become acceptable to oppress, exploit, and even kill disabled people. To some degree, this is already happening. People with disabilities are seriously discriminated against in health care as well as in other areas of life.”110
Coleman is no alarmist. Bioethicists widely embrace the “quality adjusted life year” (QALY) approach to health care rationing—one of the destinations to which the quality of life ethic would take us. Here’s a brief—and very simplified—overview of how the QALY system operates: Let’s say I have a serious heart ailment. Medicine A will give me two years of life at my current quality of life as an able-bodied man. That would be worth roughly 2 QALYs (fewer if I am elderly, but let’s not get too complicated here).
My friend Mark has MS and is a triplegic. Let’s say he contracts the same heart illness I have, and Medicine A would also give him two years of life at his current level as a man with a serious disability. Because he only has the use of one arm, his two years of actual life might only be deemed a .5 QALY.
The cost/benefit for providing the medicine is determined by a QALY formula to judge whether the cost of Medicine A is worth the number of QALYs it would provide. Let’s say that the total cost of the heart medicine for two years is $100,000 for 2 QALYs. The technocrats in charge of the rationing system might think this price is worth paying for my care.
But even though Mark would receive the same actual efficacy from the medicine, his supposed lower quality of life changes the equation dramatically. Mark might be denied coverage for the medicine because the $100,000 would only pay for .5 QALY: pure health care discrimination.
The United Kingdom already imposes the QALY system on the National Health Service. It isn’t yet used in the United States. Indeed, the Affordable Care Act prohibits using the QALY system in its eventual goal of establishing cost/benefit guidelines. But note: that prohibition might not stand. Powerful forces wish to repeal that protection in the law and import QALY rationing to America, including the New England Journal of Medicine.111
As this book will document, the growing acceptance of the quality of life ethic has already led to immoral and life-devaluing public policies and medical practices—with more threatened—undermining the virtue of our public policies and the ethics of health care.
The Georgetown Mantra: Having rejected the sanctity/equality of human life, the Hippocratic tradition, and concepts of objective right and wrong, bioethicists realized they needed to forge new analytical guidelines that would “be respected unless some strong countervailing reason exists to justify overruling them.”112 This need was filled in 1979 by the philosophy professors and bioethics pioneers Tom L. Beauchamp and James F. Childress in their book Principles of Biomedical Ethics.
Beauchamp and Childress posited four primary guidelines that have generally directed bioethics analysis ever since. The “four clusters of principles” are:
• Autonomy: “respecting the decision making capacities of autonomous persons”;
• Beneficence: “providing benefits and balancing benefits against risks and costs”;
• Nonmaleficence: “avoiding the causation of harm”; and
• Justice: “distributing benefits, risks, and costs fairly.”113
Since bioethics is generally a relativist pursuit, these four principles are not cast in stone but merely “general guides that leave considerable room for judgment in specific cases and that provide substantive guidance for the development of more detailed rules and policies.”114 Still, they are taught in medical schools, nursing schools, medical professional continuing education courses, short bioethics courses given to members of hospital ethics committees, community patient ombudsmen, hospital administrators, health insurance executives, and, indeed, to almost everyone who has taken a course in bioethics in the last twenty years. “The four-principle tradition is now so widely accepted,” Dr. Pellegrino wrote, “that some of its more whimsical critics have labeled it a mantra, implying that it is often supplied automatically and without sound moral grounding.”115 The influence of the Georgetown Mantra (so called because of the author’s affiliation with Georgetown University) in the application of bioethics in health policy and clinical decision making is hard to overstate.
There is of course nothing inherently wrong with any or all of the guidelines that make up the Georgetown Mantra and very much that is right with them. But in the relativist context in which they exist, unanchored in objective morality (such as equality/sanctity of life), these guidelines are entirely malleable and subject to manipulation in order to justify an answer desired by the ethics analyzer. Thus rather than being proper guides for principled decision making, as was envisioned by their creators, the guidelines are often reduced to mere outcome justifiers: A bioethicist or medical clinician decides what action or inaction to take in a particular situation and then selects the particular Mantra guideline that best justifies the previously made decision. Thus the four guidelines can be manipulated to justify nearly any ends. (The same kind of unprincipled decision making sometimes happens in law. A lawyer may sense that a judge wants to make a favorable ruling, despite it being contrary to the weight of law. The lawyer then looks for any law or previous court ruling for the judge to use as a cover to rationalize the already made decision. Among lawyers, this is known as “providing the judge with a hook upon which to hang his hat.”)
The ultimate amorality of the Georgetown Mantra is amply illustrated by an article written by K. K. Fung, PhD, in the American Journal of Economics and Sociology entitled “Dying for Money.” Fung, a professor of economics at Memphis State University, recommended allowing seriously ill and disabled people to convert their health insurance benefits into a lump-sum cash payment—at less than the market exchange rate—if they agree to commit assisted suicide. How did Fung justify such an odious, exploitative proposal? Why, with the Georgetown Mantra:
Benefit conversion coupled with dignified death go a long way towards resolving these conflicting principles [of the Mantra]. Because resources released from one patient’s refusal of medical treatment (autonomy) can be specifically requested to be used for other patients or beneficiaries with greater need (full beneficence), autonomy and full beneficence need not conflict. Once the patient is allowed to choose death, the caregiver does not have to impose treatment for fear of malpractice liability. Thus, patient-centered beneficence is satisfied. Since benefit conversion is equally available to all who are insured, and the amount of converted benefits varies only with the severity of the illness, justice is also served. All that remains to be done is to educate the terminally or chronically ill how to allocate their converted benefits once death is chosen. Because these four ethical principles [of the Mantra] are largely taken care of, the sense of tragedy connected with the death and denial of treatment to the hopelessly ill can be mitigated.116
As to the abuses that even Fung admits would follow if his proposal were accepted, they are of little concern. Proving that economists can be as amoral as bioethicists, Fung shrugs, “the world is full of slippery slopes.”117
Bioethicists are fond of pointing out that there is no going back to the era when the West was culturally homogenous and primarily Judeo/Christian in outlook, or to a time in which health care decisions were relatively simple. They note correctly, the United States, Canada, and Western Europe are now fundamentally heterogeneous societies, racially and culturally mixed, and fundamentally secular in civic and public policy outlook. Moreover, they argue, the era in which medicine was primarily concerned with keeping people alive for as long as possible and public health policy sought essentially to uphold a (misapplied) religious approach to the sanctity of human life is archaic in a Darwinian world in which too many people compete for too few resources.
The purposes of modern medicine have indeed expanded beyond preserving life, treating maladies, and promoting wellness. Healthcare is now deemed to achieving individual life goals and fulfilling personal desires. And, yes, we now contend with more complicated ethical issues than our forbears faced: cloning, genetic medicine, the societal and individual consequences of increased life expectancies, the impact of permitting wide latitude in individual medical choices, and the difficulties imposed by limited resources.
But this doesn’t mean that ethical analyses need to be as complex as bioethicists make them, nor that contemporary bioethics ideology has the best answers to these emerging moral problems. In a question that evokes the case of the emperor’s new clothes, Anne Maclean cogently asks, “Why should we attach more weight to the pronouncements of philosophers on moral issues than to those of other people?”118
