Читать книгу Culture of Death - Wesley J. Smith - Страница 11
Оглавление“Three generations of idiots is enough,” United States Supreme Court Chief Justice Oliver Wendell Holmes declared in authorizing the involuntary sterilization of Carrie Buck, age twenty-one, in Virginia.1
What had Carrie done to deserve this cruel fate? She was born poor and powerless, the daughter of a prostitute. In 1924, at the age of seventeen, she became pregnant out of wedlock, apparently after being raped by a relative of her foster father. To cover up this heinous act, Carrie’s foster family had her declared morally and mentally deficient, after which she was institutionalized involuntarily in an asylum.
Adding to Carrie’s woes, in 1924, the state of Virginia enacted a law permitting “mental defectives” to be involuntarily sterilized to better the welfare of society. Asylum doctors, believers in the pernicious theories of eugenics, decided that Carrie was a splendid candidate for sterilization. She was, after all, “a human defective.” Her mother was institutionalized and Carrie’s baby, aged seven months, did not look “quite normal” either.2 Best for society that Carrie’s genes be removed from the human race.
Carrie’s guardian tried to stop the involuntary surgery in court—although he may have been in collusion with those who wanted her sterilized. In any event, the trial judge ordered the sterilization to proceed, relying on “experts” who testified that Carrie had unfit genes. The case was eventually accepted for decision by the United States Supreme Court, where Chief Justice Holmes and seven of his colleagues sealed Carrie’s reproductive fate with but one lonely dissent, after which she was quickly sterilized and released. (Carrie’s daughter died in the second grade of an intestinal ailment. Her teachers considered her very bright.3 During her life, Carrie married twice, sang in the church choir, and took care of elderly people. She always mourned her inability to have more children. She died in 1983.4)
Carrie Buck’s fate—and that of approximately 60,000 other “defective” people involuntarily but legally sterilized in the United States between 1907 and 19605—was sealed by advocates of a pseudoscience in the scientific, artistic, and progressive political communities known as eugenics. The history of eugenics, its fundamental precepts, the manner in which it was imposed on society and in law, and the horror that flowed from its popular acceptance, are highly relevant to our exploration of modern bioethics. First, its history shows the inhuman consequences that invariably follow when the equality/sanctity of human life is disregarded in science, medicine, law, and greater society. Second, striking and disturbing parallels exist between the manner in which eugenic theories were developed and put into practice and the way in which bioethics ideology is coming to dominate the ethics of medicine and the laws of health. Third, modern bioethics, like eugenics before it, creates hierarchies of human worth intended to justify medical discrimination. Now, after decades of quiescence, eugenics itself is making something of a comeback as a result of the development of new genetic technologies and futuristic ideologies such as “transhumanism.”6 (We will look more closely at this movement later in the book.)
Eugenics originated with the English mathematician and statistician Francis Galton. A cousin of Charles Darwin, Galton believed that heredity “governed talent and character” just as it does eye color and facial features.7 Profoundly influenced by Darwin’s theories of natural selection and Gregor Mendel’s pioneering genetic experiments, Galton proposed, in 1865, that humans assume responsibility for their own evolution by using selective breeding techniques to improve society’s physical, mental, cultural, and social health. In 1883, Galton coined the term “eugenics” to apply to his theories, a word he derived from the Greek meaning “good in birth.”8
Eugenics took the same path to acceptability as bioethics would nearly one hundred years later. It first became the rage in the academy and then spread rapidly in the early years of the twentieth century among the cultural elite and the intelligentsia of the United States, Canada, England, and Germany. By 1910, “eugenics was one of the most frequently referenced topics” in the Reader’s Guide to Periodic Literature.9 In its boom years of the 1920s, eugenics, like bioethics today, became a serious and influential social and political movement. Courses in eugenics were taught in more than 350 American universities and colleges, leading to the widespread popular acceptance of its tenets.10 At one time, eugenics was endorsed in more than 90 percent of high school biology textbooks.11 As would happen later with bioethics, eugenicist societies formed for the promulgation and discussion of theories; academic eugenics journals sprouted; and philanthropic foundations, such as the Rockefeller and Carnegie Foundations, embraced the movement, financing eugenics research and policy initiatives. Many of the political, cultural, and arts notables of the time supported eugenics, including Theodore Roosevelt, Winston Churchill, George Bernard Shaw, and Margaret Sanger, leading to further expansion of the movement’s popular support.
The parallels of eugenics with contemporary bioethics extend into the realm of ideology. Both movements reject equal human moral worth. Both are utilitarian based, seeking to improve overall human happiness and reduce human suffering—sometimes at the expense of individual human rights. Like today’s bioethics theories, eugenics was taught in some of the world’s most prestigious universities, quickly becoming an integral part of professional training. And, again mirroring modern bioethics organizations, most eugenics societies “were dominated by professionals such as professors, social workers, lawyers, doctors, teachers, and ministers.”12
To be fair, there are important differences between the eugenics of yesterday and bioethics today. Eugenics equated human fitness and morality with overall intelligence,13 a concept that is not accepted generally in bioethics, although the depersonalization of infants and people disabled by significant cognitive injury or illness seems a disturbing echo of the past. Moreover, absolutely unlike contemporary bioethics, the eugenics movement was overtly racist, proclaiming the white race superior to blacks and Asians. (One eugenicist pronounced perniciously that the average black person in the United States had the average mental age of a ten-year-old.14) Eugenicists were profoundly self-satisfied, promoting the racial and personal characteristics they possessed as the highest human ideal. At the same time, they degraded the characteristics they associated with the lower economic classes and “inferior” races as those to be “bred” out of the human condition through eugenic practices. (Among the many “negative” human characteristics and/or behaviors eugenicists believed were genetically caused and which they wished to eradicate were feeble-mindedness, epilepsy, criminality, insanity, alcoholism, and pauperism.15)
There were two general approaches to effectuating the eugenics theory. Proponents of “positive eugenics” sought to persuade young people who possessed worthy traits to marry among each other and procreate liberally toward the end of strengthening these characteristics within the human gene pool. Worried that the “proper” people were not procreating in sufficient numbers, eugenicists filled the popular culture with notions of the ideal family, urging the “betters” among the population to have many children. (Four per marriage was “was the number thought necessary to maintain a given stock.”16) There were even prizes given to large families thought to be promoting the best eugenic human traits.
The real tyranny that eugenics unleashed flowed out of what came to be known as “negative eugenics,” which came to dominate the field. Negative eugenicists presumed the right to prevent those with undesirable physical and moral characteristics from procreating at all. (That was a big point of Margaret Sanger’s birth control push.) And if the so-called unfit wouldn’t limit their own kind, then eugenics theory held that society could force these limitations coercively through medical acts and public policies that exploited and oppressed the weak and medically defenseless.
Although eugenics originated in England, it was soon imported to the United States. In 1899, the Journal of the American Medical Association published an article that advocated the use of the newly developed vasectomy as a “surgical treatment” to keep undesirables such as “habitual criminals, chronic inebriates, imbeciles, perverts, and paupers” from reproducing.17 In 1902, an Indiana physician named Dr. Harry Sharp urged passage of mandatory sterilization laws that would require all men in prisons, reformatories, and paupers’ houses to be sterilized. (Before any law was passed permitting it, he had involuntarily sterilized more than 500 men.18) Following Sharp’s lead, 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, leading to the oppression of Carrie Buck.
“USELESS EATERS”
Eugenics helped feed—and was itself nourished by—the particularly harsh ethos of social Darwinism, which applied Darwin’s biological theories of natural selection and the struggle for survival to the human realm and relations among people and societies. “To the social Darwinists . . . human society had always been a battleground for competing individuals and races in which the fittest survived and the unfit were cruelly eliminated; and, for the sake of human progress, this struggle for existence must be allowed to continue unchecked by governmental intervention or social reform.”19 Believers in social Darwinism, thus, viewed the exploitation of the weak as a natural process. At the same time, social Darwinistic theories worked hand-in-glove with eugenic notions of hierarchies of human worth to classify exploited people as inherently inferior and thus deserving of their fate. This explosive combination never quite reached critical mass in the United States or Canada. In Germany, however, it combusted into the conflagration known as the Holocaust.
In 1806, German physician Christoph Wilhelm Hufeland wrote presciently—and in words that remain relevant today—“It is not up to [the doctor] whether . . . life is happy or unhappy, worthwhile or not, and should he incorporate these perspectives into his trade . . . the doctor could well become the most dangerous person in the state.”20 Hufeland’s point is that the ethics of medicine are a good indicator of the moral health of society and that when medical practice is corrupted, society is soon to follow. “Physicians are central to the quality of life in any society,” agrees the American physician and notable Nazi hunter Michael Franzblau. “The minute physicians begin to see some of their patients as having greater worth than others, they will gain power over their patients that is unbelievable. That is what happened in Germany, beginning around 1910.”21
Most people believe that the medical horrors of the Holocaust were the sole creation of Adolph Hitler. In fact, the path to medical evil was laid long before Hitler was even a storm cloud on the German horizon. “Physicians in the pre-Nazi period began to view their skills as appropriate for killing as well as healing,” Franzblau says. Because of eugenic theories, social Darwinistic beliefs, and the deprivations caused by the war, half of Germany’s mental patients were starved to death during World War I. “But that was a mere prelude,” Franzblau told me. “In 1920, Binding and Hoche published their book, which really set the tone for what was to come.”22
That book was a tome entitled Permission to Destroy Life Unworthy of Life (Die Freigabe der Vernichtung lebensunwerten Leben).23 Its authors were two of the most respected academics in their respective fields: Karl Binding, a nationally renowned law professor, and Alfred Hoche, a physician and noted humanitarian. Permission to Destroy Life Unworthy of Life, in reality two extended essays—one by each author—was a full-throated assault on the Hippocratic tradition and the sanctity/equality of human life. The authors accepted wholeheartedly the concept that some humans had greater moral worth than others. The latter were disparaged as “unworthy” of life, a category that, like some contemporary euthanasia advocacy, included the dying, people who were mentally ill or retarded, and badly deformed children. People deemed life unworthy of life, the authors argued, should be allowed to be killed (euthanasia). More than that, the authors professionalized and medicalized the entire concept, making it seem compassionate by promoting medicalized killing of those deemed unworthy of life as a “purely a healing treatment” and a “healing work”; they also justified euthanasia as a splendid way to divert money from being spent on caring for unworthy life toward other important societal needs.24
Binding and Hoche listed three categories of patients who doctors should be allowed to kill ethically and legally:
1. Terminally ill or mortally wounded individuals, described by the authors as those “who have been irretrievably lost as a result of illness or injury, who fully understand their situation, posses and have somehow expressed and urgent wish for release.”25
2. “Incurable idiots,” whose lives Binding and Hoche viewed as “pointless and valueless,” and as emotional and economic burdens “on society and their families.” Hoche put it this way: “I have discovered that the average yearly (per head) cost for maintaining idiots has till now been thirteen hundred marks. . . . If we assume an average life expectancy of fifty years for individual cases, it is easy to estimate what incredible capital is withdrawn from the nation’s wealth for food, clothing, heating—for an unproductive purpose.”26
3. The “unconscious,” if they ever again were roused from their comatose state, would waken to nameless suffering.27
Permission to Destroy Life Unworthy of Life was thus a prescription for the medical cleansing of the most weak and vulnerable among Germany’s population, a prescription that would be filled with murderous precision by German doctors between 1939 and 1945.
Binding’s and Hoche’s philosophical approach was eerily similar to that espoused today by many contemporary bioethicists. It was utilitarian. It eschewed the Hippocratic tradition in favor of the quality of life ethic (ditto bioethics). Indeed, the Georgetown Mantra could be used to justify Binding and Hoche arguments (e.g., they described voluntary euthanasia as merely a matter of fulfilling the patient’s “urgent wish” [autonomy]; defined killing ill and disabled people as a “healing” act [beneficence]; and promoted euthanasia as necessary to fulfill other urgent societal needs that were going wanting because of the cost of caring for disabled people [distributive justice]).
Although modern bioethicists object to the manner in which Binding and Hoche’s proposals were ultimately implemented in Germany, and most would certainly object to the authors’ bigoted use of language, it is clear that the anti-sanctity of life values expressed in and the utilitarian philosophical foundation of Permission to Destroy Life Unworthy of Life fit snugly within the mainstream of the modern bioethics movement. As just one example, in 2010, Oxford bioethicists Dominick Wilson and Julian Savulescu advocated “organ donation euthanasia,” in which the dying unconscious could be killed via the process of organ harvesting.28
Permission to Destroy Life Unworthy of Life created a sensation among Germany’s intelligentsia, whose leadership—in conjunction with the growing acceptance of Social Darwinism, anti-Semitism, racial hygiene, and eugenics—helped the Binding/Hoche view to become soon accepted by much of German society. For example, a 1925 poll of the parents of disabled children reported that 74 percent of them would agree to the painless killing of their own children.29 Thus, by the time the Nazis came to power in 1933, much of Germany, including its medical establishment, accepted the existence of some human beings as “life unworthy of life.”
Upon assuming leadership of Germany, Nazi rulers immediately sought to act against these “useless eaters.” In 1933, the German government sought to legalize voluntary euthanasia. (A front-page New York Times article described the proposal as making it possible for physicians to end the torture of incurable patients.) Protective guidelines were to be included in the law, many of which were remarkably similar to those espoused by euthanasia advocates today, including voluntary requests “expressly and earnestly” made and, if decided by relatives for incompetent patients, that the motive for killing (ironically) “not contravene morals.”30
These proposals were eventually withdrawn because of vehement opposition from German churches. However, mandatory sterilization laws were officially enacted within six months of Hitler becoming Germany’s chancellor, which made the sterilization statutes in the United States seem pale by comparison. Based on eugenics theories, special “Hereditary Health Courts” were established to judge the “hereditarily sick.” Among those targeted were people who were mentally retarded, mentally ill, alcoholics, with epilepsy, and had “grave body malformations.” At the law’s inception, it was estimated that more than 400,000 people would be sterilized from the hospitals and mental institutions alone. Sterilization was actually imposed on up to 350,000 disabled and other “undesirable” people between 1933 and 1945.31
Throughout the 1930s, the idea of actually killing useless eaters gained increased popularity, and not by accident. The Nazi government molded German public opinion. Popular entertainment became an especially effective tool in this unremitting propaganda campaign, particularly motion pictures, an industry that Joseph Goebbels effectively controlled.
The movie I Accuse (Ich klage an), one of the most notable of these many propaganda films, is particularly relevant to today’s medical climate. Wildly popular among German audiences (more than 15 million paid to see it),32 I Accuse was an all-out call for legalizing voluntary euthanasia and an apologia for murdering disabled infants. According to Professor Sobsey, the I Accuse filmmaker/propagandists cleverly promoted killing as an acceptable answer to medical difficulties by both intensely personalizing the issue of suffering caused by serious illness while, at the same time, depersonalizing killing as it related to disabled infants to make their murder easier to accept.
The movie was pure melodrama. The primary plot concerned a woman pianist who grows progressively disabled because of multiple sclerosis. Unable to play her beloved piano and deeply worried about becoming a burden to her physician husband, she begs for euthanasia. “The audience was supposed to relate to her deeply and accept as correct and compassionate her desire to die,” Sobsey says. Thus, I Accuse promotes euthanasia as beneficial, compassionate, and supportive of autonomous decision making in the same manner as do contemporary euthanasia activists.
As the wife and husband struggle with her MS, a subplot develops that is deeply utilitarian and dismissive of the moral worth of disabled people. The third main character, a university professor, lectures students on how in nature, only the “fit” survive. He illustrates his teaching with graphic documentary scenes of asylums from Nazi film archives, which depict the patients as grotesque and inhuman. It is in this context that the parents of a disabled infant beg the doctor to kill their child as an act of mercy. “The movie never shows the baby,” Sobsey says. “This is as a way of depersonalizing the infant and make its ultimate killing less shocking.”33
At the same time, as the husband desperately searches for a cure for MS, he cripples a mouse in his research laboratory and then thoughtlessly abandons it to suffer. A woman lab worker promises the mouse she will take care of him and later surreptitiously gives the animal a lethal injection as an act of compassion. The message is blunt and unremitting: the unfit should die, both as a matter of mercy and to keep the society healthy.
The parents of the disabled child continue to beg for the same consideration for their baby, and finally have their way. The baby is killed off camera, and depicted as a difficult but eugenically correct act that protects the overall health of the Volk. The wife commits suicide with her husband’s help, a scene played, to the sound of a mournful piano, for all the pathos it is worth. He is arrested. The movie ends with the husband’s impassioned accusation to the judges against the law for preventing euthanasia (the real accusation in I Accuse):
No! Now, I accuse! I accuse the law which hinders doctors and judges in their task of helping people. I confess . . . I have delivered my wife from her sufferings, following her wishes. My life and the lives of all people who will suffer the same fate as my wife, depends on your verdict. Now, pass your verdict.34
These words could have been taken from a transcript from one of the trials of Jack Kevorkian, many of whose victims were non-terminally ill women disabled by multiple sclerosis. Moreover, the word “deliverance” was once the favorite euphemism used by the Hemlock Society (now compassion and choices) to describe killing by euthanasia or assisted suicide. And that isn’t all. As we shall see, the moral values, philosophy, and even the words expressed through and in I Accuse are alive, well, and in practice in the United States, Canada, and much of the West more than seventy years after its release.
Indeed, in addition to the Kevorkian trials, the Debbie Purdy case in the United Kingdom tracks almost exactly with the view of the featured couple in I Accuse: Like the wife in the movie, Purdy was growing progressively disabled from MS and wanted her husband to be free from prosecution if he took her to a Swiss suicide clinic. In 2009, she won a case in the British Supreme Court requiring the public prosecutor to clarify prosecution standards.35 The clarification determined that family members would generally not be so prosecuted so long as their assistance in suicide was not done with improper motives. (Purdy died in hospice on December 23, 2014 after refusing to eat.36)
Back in 1930s Germany, the eugenicists and government propaganda continued to soften the ground for the eventual killing of “useless eaters.” One task remained before implementation could commence: that the medical profession had to reject the Hippocratic requirement that its sole loyalty is to be to each and every individual patient. “Between 1933 and 1945, German physicians did not take the Hippocratic Oath,” Dr. Franzblau told me. “Instead, they took an oath to the health of the state, known as the Gezuntheit. Thus doctors had a dual loyalty, to their patients yes, but their first loyalty was to Germany.”37
German doctors, to recall Dr. Hufeland’s warning, were now among society’s most dangerous members. Many physicians accepted wholeheartedly the eugenics-based theories, reinforced by Nazi racial ideology, that disabled people, mentally retarded people, and, of course, Jews, Gypsies, and others were life unworthy of life. At the same time, their first loyalty shifted to the state, away from their individual patients. Forced sterilization of the “unfit” had become commonplace and popularly accepted. Physicians and midwives voluntarily reported every child born with disabilities to authorities. Binding and Hoche’s notions of killing as a “healing” practice were accepted widely as ethical and moral. Dr. Karl Brandt, who Hitler had placed in charge of promulgating euthanasia bureaucratic procedures, had a plan of implementation firmly in place. The table was now set for the mass murder of hundreds of thousands of disabled people—the opening overture of the Holocaust.
Disabled infants became the first to suffer medical cleansing when Hitler signed a secret executive order in early 1939 permitting infanticide based on disability. No doctor was forced to kill patients. However, illustrating how effectively the Hippocratic tradition and the belief in the equality of all human life had been undermined over several decades in Germany, many physicians (as well as nurses and midwives) enthusiastically supported the policy, either directly by killing patients or indirectly by referring disabled babies to “health centers.” “The tragedy is that these doctors were not ogres,” Dr. Franzblau told me. “They were mainstream physicians who were exquisitely trained in German medical schools, which at the time were the best in the world. They went utterly wrong, in my judgment, because they no longer perceived these [disabled] patients as fully human.”38 Thus the German medical establishment participated in the euthanasia Holocaust, not because they were Nazis—although many had joined the Party—but because they had convinced themselves that they were performing, in Binding and Hoche’s words, a “healing” service for the child, the family, and the Reich.
Hitler and Brandt were so pleased with the success of their infanticide program that Hitler next issued an executive order expanding the categories of those to be medically cleansed to include disabled and mentally retarded adults. The order stated simply: “Reich Leader Bouhler and Dr. Brandt are charged with the responsibility for expanding the authority of physicians, to be designated by name, to the end that patients considered incurable according to the best available human judgment of their state of health, can be granted a mercy death [Signed,] Adolph Hitler.”39 This was the infamous “T-4 Program,” named after the address of the German Chancellery, Tiergarten 4. “Killables” included people with epilepsy, polio, schizophrenia, senile diseases, paralysis, and Huntington’s disease. As with the infanticide program, T-4 was officially a secret; death certificates listed phony causes of death.
Adult euthanasia victims were sent to specially designated hospitals that had been converted into centers of mass murder. Like the later Jewish genocide, T-4 was highly bureaucratized. Government workers “coldly and calculatingly organized the murder of thousands of people” and kept meticulous records of what they were doing. Secretaries, for example, “shared their offices with jars of foul-smelling gold-filled teeth, listening to dictation which enumerated ‘bridge with three teeth,’ ‘a single tooth,’ and so on.”40 With so many people involved in the killing, it wasn’t long before much of Germany became aware of what was going on. There were some public protests. Catholic Archbishop Clems August Graf von Galen even preached openly against the euthanasia policy,41 and dared the Gestapo to arrest him, stating that he would meet them in full regalia. Even some Party members objected, assuring themselves that the Führer must not know.42 Himmler soon recognized that the jig was up and pronounced euthanasia “a secret that is no longer a secret.”43
Because of public pressure, Hitler rescinded the T-4 program, although not the infanticide directive. Nevertheless, German doctors continued to murder disabled and ill infants and adults in a process known as “wild euthanasia” until stopped by the Allies at the end of World War II. The death toll is estimated to have been about 250,000 people. Every one of these deaths “required a physician’s review and order to determine that the individual’s life was not worth living.”44 Among those who participated in the killing programs were Dr. Ernst Wetzler, ironically the inventor of an incubator for prematurely born children, and Dr. Hans Joachim Sewerling, who was elected in the 1980s to the presidency of the World Medical Association but forced to resign due to the efforts of Dr. Franzblau and the American Medical Association. Neither German doctor ever expressed remorse. Indeed, Dr. Wetzler called his participation in the murder of disabled infants as “a small contribution to human progress.”45 Dr. Sewerling sought refuge in anti-Semitism, claiming his political troubles were the result of a “Jewish conspiracy.”46 Rather than receiving the calumny of his peers, after being forced to resign as president of the WMO Dr. Sewerling was named an honorary member of the German Medical Association’s board of trustees.47
IMMORAL MEDICAL EXPERIMENTS
Adding to the infamy of German medicine were the SS physicians who engaged actively in genocide and human medical experimentation. For example, at Auschwitz, doctors helped create “the murderous ecology” of the camp. They performed selections and supervised the killing in the gas chambers. They determined when all of the gassed victims were dead. Doctors lethally injected debilitated inmates and helped work out details of body disposal.48
A few SS doctors also carried out inhumane “medical” experiments on people in concentration and death camps, during which inmates, almost all of them Jewish, were subjected to horrible crimes of bodily violation. The horror of this is impossible to overstate: women had their cervixes injected with caustic substances in an attempt to invent sterilization-by-injection; men were subjected to intense X-ray exposures of their genitals to induce sterilization, with later castration to study the damage radiation caused to the testes; inmates were intentionally exposed to typhus contagion to determine the efficacy of various sera. At Auschwitz, Joseph Mengele engaged in a sadistic study of identical twins, including children who he physically examined over several months, measuring every part of their body and taking their blood, and then lethally injected them prior to dissection.49 “German physicians in the name of science,” Dr. Franzblau has stated, “froze people to death, asphyxiated them by denying them oxygen at high altitudes, forced them to drink seawater to the point of serious illness, injected them with tubercle bacilli, cut off arms and legs of war prisoners and attempted [tissue] grafting, and perfected the use of Zyklon B gas, the preferred method of death in the concentration camps.”50
CRUCIAL LESSONS LEARNED
The depth of depravity to which some German physicians sank seems unthinkable to us today. But it was unthinkable when it happened, too. How could German doctors, of all people, have gone so far astray? To exclusively blame the Nazis is to miss the mark and give us false comfort about our own flirtation with unethical health policies. Adolph Hitler did not blaze the road to medical depravity. He just goose-stepped with full fascist regalia down the boulevard already paved by Binding and Hoche with their advocacy that there is such a thing as a human life unworthy of life. Permission to Destroy Life Unworthy of Life gave the imprimatur of the academy to a subjective measurement of human life—the intellectual essence of the modern-day quality of life ethic. Indeed, Binding and Hoche’s book is so important to our understanding of the evil that followed that Lifton calls it the “crucial work.”51 For, as Dr. Franzblau noted sagely, “Once you breach the firewall of Hippocratic morality, only bad things can happen.”52
A second fundamental lesson of the euthanasia Holocaust is that doctors must never allow themselves to be seduced into accepting dual loyalties. Subject to the rules required in protecting public health, the welfare of each individual patient—not that of society, the patient’s family, the finances of health insurance companies, government mandate, or the doctor’s individual pocketbook—must be each physician’s unequivocal concern. For doctors to place other agendas before the welfare of their patients is to expose those in their care to significant danger of exploitation and oppression.
Finally, let us heed the words of Dr. Leo Alexander, who served as an investigator in the Nuremberg trials and became one of the world’s foremost experts on the medical aspects of the Holocaust. In 1949, Dr. Alexander attempted to summarize what he had so painfully learned through years of investigation. In the New England Journal of Medicine, he wrote:
Whatever proportions these crimes finally assumed, it became evident to all who investigated them that they started from small beginnings. The beginnings at first were merely a subtle shift in emphasis in the basic attitudes of physicians. It started with the acceptance of the attitude, basic to the euthanasia movement, that there is such a thing as a life not worthy to be lived. This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans.53
Dr. Alexander then issued a prophetic warning:
In an increasingly utilitarian society these patients [with chronic diseases] are being looked down upon with increasing definiteness as unwanted ballast. A certain amount of rather open contempt for the people who cannot be rehabilitated . . . has developed. This is probably due to a good deal of unconscious hostility, because these people for whom there seem to be no effective remedies have become a threat to newly acquired delusions of omnipotence. . . . At this point, Americans should remember that the enormity of the euthanasia movement is present in their own midst.54
In today’s enlightened world, we soothingly tell ourselves that the spirit of Binding and Hoche has been exorcised. But that is self-deception. In fact, it still lurks in hospital corridors, university seminars, medical school classrooms, legislative cloakrooms, and most particularly in the depth and breadth of bioethics advocacy. This is not to say, of course, that today’s bioethicists are similar to Nazi doctors. (But then, Binding and Hoche weren’t Nazis either.) Nor is it to say that Western health policies are the same as those of fascist Germany. But we are heading in a very wrong and dangerous direction. There are, after all, many ways to fall off an ethical cliff.
Neglecting Disabled Infants to Death: In 1972, Life magazine reported that Mrs. Phyllis Obernauer gave birth to a daughter with Down syndrome. The girl’s condition was complicated by heart problems and an intestinal blockage, the latter a common occurrence with Down’s babies. The Obernauers decided they didn’t want a disabled baby and ordered their doctors not to perform surgery to clear up the intestinal blockage. Their intent was that their baby would die by starvation. The doctors refused to deprive the child of life’s basic necessities, and the baby lived.55
Beginning at about the time of the Obernauer case—a mere fifty years after the publication of Permission to Destroy Life Unworthy of Life—some of the world’s most respected doctors and philosophers began to again suggest openly that it should be ethical to kill or neglect disabled babies to death. Many of these death advocates were among the cream of the scientific community. For example, Harvard professor and Nobel laureate James D. Watson, the co-discoverer of the genetic makeup of DNA, reacting to the emergence of new reproductive technologies argued, “we have to reevaluate our basic assumptions about the meaning of life.” Analogizing to the ancient practice of exposing disabled infants on hills, Watson further declared, “No one should be thought of as alive until about three days after birth,” adding that parents would then “be allowed the choice” to keep their baby or “allow” their child to die.56 Similarly, another Nobel laureate involved in the discovery of DNA, Francis Crick, declared in 1978 that “no newborn should be declared human until it has passed certain tests regarding its genetic endowment and that if it fails these tests it forfeits the right to life.”57
Demonstrating the prescience of Dr. Alexander’s 1949 worries about American medical ethics, such advocacy took root. In 1982, Baby Jane Doe’s doctors engaged willingly in the very medical neglect that Baby Obernauer’s doctors refused to countenance only ten years before. Like the Obernauer infant, Baby Doe was born with Down syndrome and an intestinal blockage. Routine surgery to clear the blockage could have saved the baby’s life. But the mother’s ob-gyn told Jane’s parents that they could refuse surgery. Deciding that she—and they—would be better off if she died, Jane’s parents refused consent to surgery and ordered the doctors to withhold food and fluids for their child, dooming her to death by dehydration.
When the news broke that Baby Jane was being neglected to death because she was disabled, several couples came forward asking, even begging, for the opportunity to adopt her. But Jane’s parents wanted their baby dead, not adopted. They refused to allow others to intervene. The matter was brought to court, where a judge sided with Jane’s parents and against Jane’s equal moral status as a human being. She died six days after her birth. If a “normal” child were neglected to death in this way, the parents and doctors would be brought to the docket for child abuse. But because Jane was disabled, she was made to die and no legal sanctions were applied against either the parents or the participating doctors, this despite that on her way to death, she became parched, dried out, and spit blood.58
Similar cases have occurred elsewhere in the United States, England, Canada, and the Netherlands. In England, a woman gave birth to a Down’s baby who did not have an intestinal blockage. Upon learning that her baby was disabled, she said, “I don’t want it, Ducks.” Despite the fact that the child had no physical abnormalities other than the genetic condition that causes Down’s, she ordered the doctors not to feed the baby. Dr. Leonard Arthur ordered the baby to be given morphine but not fed. The baby died at the age of four days. Dr. Arthur wasn’t tried for homicide but paradoxically for “attempted murder.” Several of Dr. Arthur’s medical colleagues testified that such medical neglect directed at babies born with significant abnormalities is “normal medical practice.” Sir Douglas Black, president of the Royal College of Physicians, told the jury that he thought it ethical for a “rejected child” to be put “upon a course of management that would end in its death,” declaring “it is ethical that a child suffering from Down syndrome . . . should not survive.” After only two hours, the jury decided the doctor was not guilty to sounds of rejoicing in the courtroom.59
Babies with spina bifida have suffered similar fates. Spina bifida is a condition in which the spine is exposed at birth, with hydrocephalus (water on the brain) a frequent accompanying malady. The proper treatment for the condition is to close the wound in the back and drain the fluid from the brain with a shunt. Babies with spina bifida generally are disabled by paralyzed legs and are sometimes incontinent.
Dr. John Lorber was once a leading proponent of treating babies with spina bifida. At some point, he had a change of heart and became a leading advocate for nontreatment, developing protocols for deciding which spina bifida babies to care for and which to abandon to death by neglect. He subsequently traveled to the United States and Canada, urging pediatricians not to operate on these helpless infants. His justification?
Humanity demands that such badly affected infants should not be put through such constant and severe punishment. Criteria had to be found, preferably on the first day of life which could reliably separate those infants who may die early but even more importantly those who would live but would suffer from severe multi-system handicaps and would be unable to live an independent and dignified existence in spite of the best possible treatment. . . . [In such cases,] nothing should be done to prolong life.60
What does this mean in actual practice? According to the approving Peter Singer, who interviewed Dr. Lorber, “The wound should be left open. If an infection develops, no antibiotics should be given. If excess fluid accumulated in the head, this should not be drained. If the babies did not eat and lost weight, they should not be tube-fed. . . . Few if any would live longer than six months.”61
How does this practice differ from those of German doctors circa 1939–1945? Then, countless disabled babies were similarly neglected to death or killed based on doctors’ decisions as to which children had livable lives. Now, as then, a decision is made to take action, or rather, not to act, thus ensuring that the babies die. As before, the physicians believe they are providing a service to their soon-to-be-made-dead patients, the babies’ families, and society. (And this doesn’t include prenatal eugenic cleansing in which approximately 90 percent of fetuses testing positive for Down’s are aborted.62) Binding and Hoche would approve.
In response to the Baby Doe tragedy, the federal government passed regulations to prevent medical discrimination based on disabilities, which, unfortunately, were invalidated by courts. Congress then passed amendments to federal child abuse statutes as they affect the laws of the states to prevent medically beneficial treatments from being withheld due to quality of life criteria. The law permits the withholding of treatment for babies in irreversible comas if treatment would only prolong dying, if it would be virtually futile, and if it would be inhumane. Do these laws actually protect disabled infants? That is unclear. Former Surgeon General C. Everett Koop, who was instrumental in getting the Baby Doe laws enacted, has opined that they “are probably not legally effective” and that the “greatest protection that handicapped newborns have in the [United] States today is the concern on the part of physicians and surgeons who care for newborns that someone is watching.”63 Considering the increasingly utilitarian state of medical ethics and the pressures placed on doctors by managed care health insurance companies to cut the costs of health care, that protection may be scant indeed.
Active Infanticide: Most people know that it is wrong to kill babies. They view the intentional killing of medically incompetent people as murder. At least, they used to. As modern bioethics looms, that certainty comes under increasing attack.
In the 1970s, Joseph Fletcher, the patriarch of bioethics, advocated killing disabled children, an act he euphemistically called “post birth abortion,”64 dismissing the ethical and moral constraints against infanticide as a mere “taboo.” For Fletcher, the rightness of killing disabled babies could be determined through a simple utilitarian equation: If killing a baby increased happiness or reduced overall human suffering, than the baby should be made dead. If not, the baby should live. He wrote, “This view assigns value to human life rather than merely being alive and holds that it is better to be dead than to suffer too much or to endure too many deficits of human function.”65 (Emphasis in original.)
What was shocking in the 1970s is shocking no longer. Arguing in favor of infanticide is now respectable and mainstream. The Australian moral philosopher and Princeton bioethicist Peter Singer began arguing decades ago that infants have no moral right to live because, as discussed in the previous chapter, they are not “persons.” He views infanticide at the request of parents as an ethical act so long as it will promote the overall interests of family or society.
Singer originally suggested that parents have twenty-eight days within which to keep or kill their newborn child. He then broadened this putative license, telling an interviewer, “I no longer think that will work. It’s too arbitrary. I don’t think you would get people to recognize that there’s a big difference in the wrongfulness of killing a being at twenty-seven or twenty-nine days. So, what do you do? I think you need to look at it on a case-by-case basis given the seriousness of the problems and balance that against the age of the child.”66 Earlier in the interview, Singer supposed that a child became a person “sometime during the first year of life,” and thus his “case-by-case” approach could apply to murdering a baby for many months after the child is born.
When Singer’s views are discussed in the media, he is often portrayed as “only” calling for the infanticide of “severely disabled” babies. In and of itself, that would be terribly wrong, but this alleged mitigation simply isn’t true. Singer views all infants, not only disabled babies, as nonpersons who are “replaceable . . . in much the same way as . . . non-self conscious animals [e.g., bird and fish].”67 Since nonpersons have no right to life, so long as utilitarian principles are applied properly, there is nothing in his philosophy that explicitly limits infanticide to the killing of babies born with disabilities.
That being duly noted, Singer knows that it would not pay for him to discuss the killing of healthy babies, and so he almost always addresses the issue in connection with disabled infants. But even here the examples he gives of babies whom it should be ethically and legally permissible to murder are not “severely disabled.” In Practical Ethics, for example, Singer supported infanticide of newborns with hemophilia, writing: “When the death of a disabled infant will lead to the birth of another infant with better prospects of a happy life, the total amount of happiness will be greater if the disabled infant is killed. The loss of the happy life for the first infant is outweighed by the gain of a happier life for the second. Therefore, if the killing of the hemophiliac infant has no adverse effect on others it would . . . be right to kill him.”68
Thus, to Singer, it is okay to kill a child for the benefit of hypothetical future siblings who have not yet been conceived!
Singer reiterated his anti-disability bias using a different type of disability as an illustration in Rethinking Life and Death: The Collapse of Our Traditional Ethics (1994, St. Martin’s Press, New York, NY), in which he wrote:
To have a child with Down syndrome is to have a very different experience from having a normal child. . . . (W)e may not want a child to start on life’s uncertain voyage if the prospects are clouded. When this can be known at a very early stage of the voyage we may be able to make a fresh start. . . . Instead of going forward and putting all our efforts into making the best of the situation, we can still say no, and start again from the beginning.69
Singer’s advocacy of infanticide (and for the morality of euthanizing profoundly cognitively disabled people as an ethical act) caused a tremendous uproar in Europe, particularly in Germany and Austria, countries with an acute memory of the euthanasia Holocaust. Indeed, so many Germans and Austrians despise Singer’s views that he is unable to lecture in those countries because of angry demonstrations that erupt against him whenever he appears to speak. These protests deeply disturb Singer. As a child of German/Austrian Jews who lost family members in the Holocaust, he resents his philosophy being linked in any way to the Nazis.
Singer defends himself by claiming that the acts he espouses are nothing like those of the German doctors who participated in infanticide, claiming that his proposals are merely predicated upon “avoiding pointless suffering.” But that was precisely what Binding and Hoche claimed when they labeled their proposal to kill disabled people a “healing process.” Singer also says that the German doctors’ motives in killing babies were different from the ones he espouses. That is not entirely true. As we saw, most German doctors who participated in killing believed fervently that they were benefiting all concerned: baby, family, and society. Singer attempts to distinguish himself further by claiming that he does not agree with racial hygiene theory. That much is true, but so what? A murdered baby is a murdered baby is a murdered baby, regardless of why the baby is killed. That Singer does not grasp that basic moral concept speaks volumes about his philosophy.
Another tack Singer takes to distance himself from the German experience is by claiming that “Nazi euthanasia was never voluntary.”70 Here, Singer is simply wrong.
The first known German government-approved infanticide, the killing of Baby Knauer, occurred in early 1939. The baby was blind and had a leg and an arm missing. Baby Knauer’s father was distraught at having a disabled child. So he wrote to Chancellor Hitler, requesting permission to have the infant “put to sleep.” Hitler had been receiving many such requests from German parents of disabled babies over several years and had been waiting for just the right opportunity to launch his euthanasia plans. The Knauer case seemed the perfect test case. He sent one of his personal physicians, Karl Rudolph Brandt, to investigate. Brandt’s instructions were to verify the facts, and if the child was disabled as described in the father’s letter, he was to assure the infant’s doctors that they could kill the child without legal consequence. With the Führer’s assurance, Baby Knauer’s doctors willingly murdered their patient at the request of his father. Brandt witnessed the baby’s killing and reported back to Hitler, who was pleased all went as planned. Based on this case of requested infanticide, Hitler signed the order permitting doctors to kill disabled infants.71
The murder of Baby Knauer is precisely the scenario Singer espouses when he argues that parents should be allowed to have their unwanted babies killed. Indeed, Baby Knauer’s father was quoted by Lifton in The Nazi Doctors, stating in 1973 that Brandt assured them “we wouldn’t have to suffer from this terrible misfortune because the Führer had granted us the mercy killing of our son. Later, we could have other children, handsome and healthy, of whom the Reich could be proud.”72 Note the exact juxtaposition of Brandt’s justification for murder with Singer’s philosophy.
It appears that the protesters in Germany and Austria who see a moral equivalence between Singer and the German euthanasia Holocaust don’t have it so wrong after all. While there is not an exact match at every level of substantive ideas—Singer does not support the involuntary killing of physically disabled people, and most babies were killed without their parents’ consent—the similarities between Singer’s beliefs and those of the German doctors who willingly slaughtered tens of thousands of disabled babies are too striking to be ignored.
In addition to being a utilitarian philosopher, Singer is also a very political animal. Having received much grief for infanticide promotion, a few years ago he (sort of) walked back his advocacy, stating at a bioethics conference held at Princeton: “Maybe the law has to have clear bright lines and has to take birth as the right time, although maybe it should make some exceptions in the cases of severe disability where parents think that it is better for the child and better for the family that the child does not live.”73 In other words, “maybe”—Singer always advocates odious acts with such equivocal language—we should be able to kill babies, but only if they would have very difficult lives, and then, only because we care.
Singer and Fletcher are far from the only bioethicists to seriously advocate permitting infanticide in some situations. An icon of bioethics in Britain, Jonathan Glover, wrote quite bluntly that infanticide is not morally wrong because babies are “replaceable.”74 Glover’s reasoning, like Singer’s, doesn’t require that the killed baby be disabled: “It is wrong to kill a baby who has a good change of having a worth-while life [a life worthy of life], but . . . it would not be wrong to kill him if the alternative to his existence was the existence of someone else with an equally good chance of a life at least as worth-while.”75
As to those who oppose infanticide because babies cannot “choose” to be killed—autonomy, after all, being an overarching value in bioethics—Glover casually dismissed the objection: “Killing someone overrides his autonomy where it goes against his own preference for staying alive. This objection to killing provides no argument against infanticide, for newborn babies have no conception of death and so cannot have any preference for life over death. . . . The objection to infanticide is at most no stronger than the objection to frustrating a baby’s current set of desires, say by leaving him to cry unattended for a longish period.”76
Since the first edition of this book, other bioethicists have jumped enthusiastically onto the infanticide bandwagon. In 2014, for example, the prominent Canadian bioethicist Udo Schuklenk—an enthusiastic adherence to the quality of life ethic—wrote, in essence, that infants judged to have a life unworthy of life should be euthanized: “A quality-of-life ethic requires us to focus on a neonate’s current and future quality of life as relevant decision making criteria. We would ask questions such as: Does this baby have the capacity for development to an extent that will allow him or her to have a life and not merely be alive? If we reach the conclusion that it would not, we would have reason to conclude that his life is not worth living.”77 What makes a life worth living? Well, that would be in the eye of the utilitarian beholder, wouldn’t it?
As Binding and Hoche did in Permission to Destroy Life Unworthy of Life, Schuklenk cited strained resources as a rationale for committing medical infanticide: “The question of whether it would be a wise allocation of scarce health care resources to undertake the proposed surgical procedures invariably arises in circumstances such as this. Continuing life-prolonging care for the infant would be futile, it would constitute a waste of scarce health care resources. Health care resources ought to be deployed where they can actually benefit patients by improving their quality of life.”78 And he expressed zero qualms about violating the sanctity and equal dignity of all human life:
A quality-of-life proponent could just as well argue that respect for human dignity demands that the infant’s life be terminated on compassionate grounds. Human dignity is mostly a rhetorical cloak for other—more controversial—ideologic convictions. Incidentally, this applies to other types of nonarguments, too. For instance, opponents of infanticide frequently ask whether we would want to live in a society that permitted such a course of action. Proponents could simply reply affirmatively. We would be better served to avoid this kind of rhetoric in public and professional discourse altogether.79
How does that old song go? “Everything old is new again.”
Usually, arguments in bioethics for infanticide escape public notice because they take place in professional journals or at symposia where academics read their papers to each other. For example, Schuklenk wrote in the Journal of Thoracic and Cardiovascular Surgery, hardly a publication on most people’s “must read” list.
But once in a while, people get a glimpse of what utilitarian bioethicists have planned for them, leading often to angry controversy. That is what happened in 2012 after the Journal of Medical Ethics published “After Birth Abortion: Why Should the Baby Live?” by Alberto Giubilini and Francesca Minerva. The article argues, á la Singer, that infants are not “persons,” and hence—harking back to Fletcher—“after-birth abortion” is morally permissible.80 But unlike many infanticide-promoting articles, Giubilini and Minerva confront head-on the question of whether healthy and able-bodied babies can be killed, arguing that whatever justifies abortion—and in the USA, that means anything and everything—also supports a right for parents to have unwanted born babies painlessly killed.
Such logic flows easily from the rejection of the idea that human life matters morally simply because it is human. Moreover, that premise allows rank bootstrapping to justify expanding the killing license. Never mind that abortion wasn’t legalized to grant a woman the “right” to a dead fetus but to ensure a woman’s right to control her own body. Thus once the baby is born, the entire issue of protecting “choice” should be factually irrelevant.
But having blithely dismissed intrinsic human value, the authors easily inflate autonomy to include a putative right not to be personally inconvenienced or burdened by the infant or the child she would later become. And since an infant isn’t a “person”—having yet to develop desires or goals—the baby’s life is of secondary concern to the desires of her mother.
The article is too lengthy to completely recount, but here are a few representative excerpts:
• “In spite of the oxymoron in the expression, we propose to call this practice ‘after-birth abortion,’ rather than ‘infanticide,’ to emphasize that the moral status of the individual killed is comparable with that of a fetus . . . rather than that of a child.”
• “Therefore we claim that killing a newborn could be ethically permissible in all circumstances where abortion would be.”
• “If the death of a newborn is not wrongful to her on the grounds that she cannot have formed any aim that she is prevented from accomplishing, then it should also be permissible to practice after-birth abortion on a healthy newborn too.”
• “Merely being human is not in itself a reason for ascribing someone a right to life.”
• “Why should we kill a healthy newborn when giving it up for adoption would not breach anyone’s right but possibly increase the happiness of the people involved? . . . On this perspective . . . we also need to consider the interests of the mother who might suffer psychological distress from giving up her child for adoption.”81
Unlike most pro-infanticide journal articles, this one was published online and noticed by the popular media—leading to the rare case when a major bioethics article received widespread public scrutiny, sparking a firestorm of popular outrage. Indeed, the criticism became so intense that the Journal of Medical Ethics took it offline and the authors wrote a public non-apology apology—not recanting anything they wrote, mind you, but claiming to be harmless philosophers merely chewing intellectual cud: “When we decided to write this article about after-birth abortion we had no idea that our paper would raise such a heated debate. ‘Why not? You should have known!’ people keep on repeating everywhere on the web. The answer is very simple: the article was supposed to be read by other fellow bioethicists who were already familiar with this topic and our arguments [as] . . . this debate has been going on for 40 years.”82
But that is precisely why it was important that the public reacted so viscerally. As I described in the last chapter, bioethics is not a mere debating society. Rather, the field is—and has been since its inception—about changing societal values and public policies. Moreover, bioethicists haven’t discoursed about infanticide for forty years because they enjoy exploring novel concepts, but rather because it isn’t easy to convince people—not even bioethicists—that killing babies is acceptable. Should infanticide ever become “unexceptional,” in Richard John Neuhaus’s formula, killing babies would become the launching pad for the next radical proposal.
Giubilini and Minerva disingenuously pretend they are not part of that process of persuasion: “We never meant to suggest that after-birth abortion should become legal. This was not made clear enough in the paper. Laws are not just about rational ethical arguments, because there are many practical, emotional, social aspects that are relevant in policy making (such as respecting the plurality of ethical views, people’s emotional reactions etc.). But we are not policy makers, we are philosophers, and we deal with concepts, not with legal policy.”83
Whatever. That which we don’t condemn we may ultimately allow. Thus the strong public pushback against Giubilini and Minerva’s philosophical apology for infanticide was not only justifiable but absolutely necessary. Indeed, the fact that bioethicists deem promotion of infanticide debatable—even those who “respectfully disagree” with permitting it—speaks volumes about the danger posed by the contemporary bioethics movement.
Killing Babies in Holland: Peter Singer and Udo Schuklenk’s infanticide-friendly philosophy has been turned into lethal practice in the Netherlands, where seriously disabled and terminally ill babies are killed in their cribs by pediatricians and neonatologists. According to a 1997 study published in the British medical journal The Lancet, approximately 8 percent of Dutch infants who died in 1995 were killed by doctors who administered drugs “with the explicit aim of hastening death.”84 If the study, which looked into the deaths of 338 infants between August and November 1995 is accurate, and with approximately 1,000 infants dying in the Netherlands each year (1,041 in 1995), approximately 80 babies are murdered each year by their doctors without legal consequence. A follow-up investigation in the same journal in 2005 came to a nearly identical conclusion.85 According to the 1995 study, 45 percent of surveyed neonatologists and 31 percent of surveyed pediatricians had “given drugs explicitly to end life.”86
Most of the babies were killed because the doctors believed they would not survive, but 18 percent of the killings were due to “a poor prognosis,”87 meaning disabilities. Life was shortened by more than five years in 16 percent of the cases. Some of the killed babies didn’t even need life support to survive: “… a drug was given to hasten death to neonates not dependent on life-sustaining treatment in 1 percent of all death cases,” which “represents 10–15 deaths of this type per year in the Netherlands.”88 Most—but not all—of the killings were at the request of parents, as per the Peter Singer and Udo Schuklenk formulas.89 Despite legal requirements that euthanasia deaths be disclosed to the coroner’s office for review, “physician-assisted deaths for neonates is . . . virtually never reported.”90
Few cases of infanticide have been prosecuted in the Netherlands; those that have been have not been attempts to punish doctors but rather to establish a “precedent.” (Dutch prosecutions are not necessarily adversarial in nature, particularly as they involve physicians involved in euthanasia. As Dutch lawyer and euthanasia proponent Eugene Sutorius told me, “The public prosecution, as a body, sees that this is not criminality in the normal sense. . . . So, even the prosecutor, while bringing the case, he’s more interested in making sure that we have strict definitions and order than he is in punishing the professional. He’s trying to create a precedent.”91)
The first Dutch infanticide precedent that essentially decriminalized infant euthanasia involved a Dutch gynecologist named Henk Prins who killed a three-day-old infant who was born with spina bifida, hydrocephalus, and leg deformities. When prosecuted (in order to create a precedent), Dr. Prins testified that he killed the child with her parents’ permission because of the infant’s poor prognosis and because the baby screamed in pain when touched. Yet the child was in agony because she was neglected medically. The open wound in her back, the primary characteristic of spina bifida, had not been closed; the fluid had not been drained from her head either, even though these treatments are standard in spina bifida cases and would have substantially reduced the infant’s pain.
The trial court refused to punish the doctor for killing the baby. Indeed, the judge praised Dr. Prins for “his integrity and courage” and wished him well in any further legal proceedings he might face.92
The Royal Dutch Medical Association (KNMG) published a report in 1990 that set forth guidelines for killing incompetent patients, including infants. The standard for pediatric euthanasia is what is called “a livable life,”93 a more tactful way of expressing the Binding and Hoche idea of a life unworthy of life. According to Dutch medical ethics, and echoing Fletcher’s “humanhood” concept described in the last chapter, the “livableness” of an infant’s life depends on a combination of factors, including the following:
• The expected measure of suffering (not only physical but emotional);
• The expected potential for communication and human relations, independence (ability to move, to care for oneself, to live independently);
• The child’s life expectancy.94
If the infant’s prospects don’t measure up to what the doctor and parents believe is a life worth living, the child can be medically neglected to death, or if that doesn’t work, killed by the doctor via lethal injection.
Dutch infanticide came completely out of the shadows—albeit remaining technically illegal, for what that might be worth—in 2004 with the publication of the “Groningen Protocol for Euthanasia in Newborns” by the Groningen University. The protocol was drawn up by doctors at the Groningen Academic Hospital, led by Dr. Eduard Verhagen, head of the hospital’s pediatric department. Infanticide is a clear violation of the existing euthanasia law, which requires competent patients to voluntarily request death.
No matter. Verhagen explained, “It’s time to be honest about the unbearable suffering endured by newborns with no hope of a future,” adding that he hoped the Groningen protocol would serve as a nationwide guide to the killing of seriously ill or disabled infants.95
Even more alarmingly, some of the world’s most respected bioethical and medical journals embraced the Groningen protocol as a respectable approach. It was published, for example, with all due respect in the New England Journal of Medicine.96 The bureaucratic infanticide checklist was even applauded in the Hastings Center Report—in which, reminiscent of Binding and Hoche—bioethicists Hilde Lindermann and Marian Verkerk lauded the protocol because it allows the infanticide of babies who aren’t dying: “Critics charge that the protocol does not successfully identify which babies will die. But it is precisely those babies who could continue to live, but whose lives would be wretched in the extreme, who stand in most need of the interventions for which the protocol offers guidance.”97
Bioethicists and euthanasia advocates claim that modern infanticide differs from wartime German euthanasia because most cases in the Netherlands involve parental consent, while most German cases involved physician decision making without parental involvement. But this is a distinction without a significant moral difference. Infants are people, not chattel. Parents have no more right to decide to have them killed than do doctors, or, for that matter, government bureaucrats.
The first sentence of the Universal Declaration of Human Rights states, “Whereas recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world.”98 If that is true, it must apply to all of us, not just the healthy and able-bodied. Unless we want to devolve to the ancient morality that allowed disabled and unwanted infants to be abandoned on hills, we must condemn infanticide unequivocally, whether in actual practice, as in the Netherlands, or as a matter of “respectful intellectual debate,” as occurs within bioethics and among some euthanasia advocates.
DEHYDRATING COGNITIVELY DISABLED PEOPLE
Disabled infants are not the only ones at risk of medical cleansing. Today, in the United States, as a matter of almost medical routine, cognitively disabled people who receive their food and fluids medically through a “feeding tube” are intentionally dehydrated and starved to death, and it is deemed ethical and moral.
In few areas of modern medicine have bioethicists been so influential and destructive to the tenets of the equality of human life than in the care of brain-damaged, cognitively disabled people. First, they dehumanized them. Next, they gave moral permission to families and physicians to withdraw basic sustenance. Then, waving the medical consensus they forged like a bloody flag, they urged legal authorities in court cases and in statute writing to make dehydration a matter of the legal “right to die.” Due largely to the energetic efforts of bioethicists, causing death by dehydration to cognitively disabled people who receive their sustenance medically is legal in all fifty states.
The first individuals to be targeted for dehydration were people diagnosed as persistently unconscious. The medical term for this condition (coined in 1972) is “persistent vegetative state” (PVS), perhaps the only medical diagnosis that contains a pejorative—from which comes the dehumanizing term “vegetable,” as if any human being can be a carrot or a turnip. PVS is “a form of eyes-open permanent unconsciousness in which the patient has periods of wakefulness and physiological sleep/wake cycles, but at no time is the patient aware of him or herself or the environment.”99 People in PVS “are not terminally ill.” What they need to survive is simply what every other human being does: food, water, warmth, shelter, cleanliness, and movement (in their cases, by way of turning). With one crucial exception, these services are considered humane care, which can never be withdrawn ethically (although even that patient protection is now under attack in bioethics, as we shall discuss below).
That exception is food and water when it is delivered via a feeding tube, which is considered a medical treatment, not a basic human requirement. Defining artificial nutrition and hydration (ANH) as a treatment was a crucial step in crafting the medical culture of death. As will be described in more detail later on, medical treatment, unlike humane care, can be withdrawn or withheld from patients legally and ethically as a matter of respecting the patient’s personal autonomy—even if the decision is expected to lead to death.
Not too many years ago, it was considered unethical—indeed, potentially a criminal act—to stop feeding and hydrating an incompetent patient. Then, beginning roughly in the early 1980s, some bioethicists began to grapple with their belief that profoundly disabled and frail elderly people were living too long. At that time society would not have accepted euthanasia—and to be fair, some prominent bioethicists opposed mercy killing. (A few still do.) A consensus solution was required to solve this newly conjured “ethical problem.” Bioethicists found it in intentional dehydration. Thus, in 1983, Callahan wrote, “A denial of nutrition may in the long run become the only effective way to make certain that a large number of biologically tenacious patients actually die. Given the increasingly large pool of superannuated, chronically ill, physically marginalized elderly, it could well become the non treatment of choice.”100
For several years the debate raged among bioethicists as to the appropriateness of pulling feeding tubes from people diagnosed as persistently unconscious, who, after all, are not terminally ill. A few resisted the rising tide. Paul Ramsey, for instance, argued that only the “objective medical condition of the patient” should be considered when determining whether to cut off treatment, “not the subjective, capricious, and often selfish evaluations of the quality of future life that are often to the detriment of the most vulnerable and voiceless.”101 Ramsey’s point—a good one—was that when someone is actively dying and can no longer assimilate food and water, they will often stop eating. At such times, it is humane to allow nature to take its course by not forcing food and water on an unwilling patient; indeed, the practice is a proper and compassionate component of good end-of-life care in particular circumstances. But withholding sustenance from an aged or disabled person to cause death is simply wrong, as such decisions are not based on the patient’s actual medical needs but rather on the perceived moral worth of a human life.
Dr. Fred Rosner, director of medicine at Queens Hospital Center, also agued strenuously, if in vain, against countenancing intentional dehydration as an ethical medical act. Denial of food and fluids is different than other forms of care, he wrote in the New York State Journal of Medicine, because it is “biologically final”; that is, it can have only one result: death. Second, unlike surgery or other forms of treatment, “food and fluids are universal human needs.” Rosner worried that for physicians to remove food and fluids “attacks the very foundation of medicine as a profession.” He further suggested that just because nutrition is delivered through a tube, it “does not change into an exotic medical substance”; food and fluids do not become medical therapy simply because another person is needed to provide them.102
Ramsey, Rosner, and the relatively few others who fought against transforming ANH from humane care to medical treatment were unable to stanch the fast-running tide. And although Ramsey had been one of the first bioethics luminaries to promote the appropriateness of ceasing life-supporting medical treatment at the patient’s request, few of his colleagues were swayed by his doubts.
The advocacy of bioethics profoundly influenced court decisions and legislation on the issue of removing food and fluids from people diagnosed as persistently unconscious. In a 1983 California case, for example, an appeals court refused to sustain an indictment of doctors who had withdrawn food and fluids from a patient in PVS, citing bioethics literature as assisting the court in its reasoning.103 That case was soon followed up by another appeals court decision overturning a trial judge’s refusal to permit the dehydration of another man in PVS at the family’s request. Indeed, the court ruled, families can order doctors to pull feeding tubes from people in PVS without asking a supervising court’s permission.104
At about the same time, in 1986, the American Medical Association (AMA) issued a momentous ethical opinion. While asserting that doctors should never “intentionally cause death,” the AMA opined that it was ethical to terminate life support, even if “death is not imminent but a patient’s coma is beyond doubt irreversible.” In and of itself, that wasn’t big news. What was significant is that, for the first time, the AMA listed “artificially supplied . . . nutrition and hydration” as a form of medical treatment.105 Needless to say, despite the AMA’s declaration that doctors should never “intentionally cause death,” removing all sustenance necessarily causes that very result.
The ultimate legal blow came in the landmark United States Supreme Court case of Nancy Beth Cruzan, who, on January 11, 1983, lost control of her car on an icy road in Missouri and crashed. She was thrown from her car and landed facedown in a water-filled ditch. Nancy’s heart stopped, but paramedics revived her. Nancy’s injuries included profound cognitive disability: a diagnosis of PVS. While that diagnosis is disputed in some circles, there is no contradicting the fact that her care did not require “high tech” medicine. She was not on a respirator. She did not need kidney dialysis. She was not terminally ill.
In May 1987, the Cruzans filed suit in Missouri seeking to force hospital employees where Nancy resided to remove their daughter’s food and fluids. Hospital administrators and especially nurses who treated her daily and who saw her as a living, breathing human being who was deserving of respect and proper care resisted the request. The trial judge disagreed. Nancy was ordered dehydrated.
The state of Missouri appealed, basing its disagreement on a state law requiring clear and convincing evidence that a patient would want life support removed before allowing it to be done. On this basis, the Missouri Supreme Court reversed the trial judge, ruling, “This is not a case in which we are asked to let someone die. . . . This is a case in which we are asked to allow the medical professional to make Nancy die by starvation and dehydration.”106
The Cruzans appealed to the United States Supreme Court. But the Supreme Court affirmed the lower ruling, finding the evidentiary standard constitutional, ruling that such a strict standard was properly in keeping with the state’s obligation to protect the lives of its citizens. Since no clear and convincing evidence had been offered at trial that removing food and fluids was what Nancy would have wanted—as opposed to what her parents wanted for her—Missouri could properly require her life support to continue.
What at first appeared a resounding victory for those who opposed Nancy’s dehydration soon turned to ashes. First, it became clear that the Supreme Court, by implication, had agreed that tube-supplied food and water was a medical treatment that could be withdrawn. The Cruzans went back to court in front of the same trial judge who had originally ordered Nancy dehydrated. This time there was testimony from two of Nancy’s former coworkers of a few vague conversations with Nancy that she would not want to live in a coma. Nancy’s exact words could not be described, and whether she made the statement or simply agreed with someone else’s opinion could not be proven. But that sparse testimony was all the judge needed to rationalize doing what he had wanted to do all along. Once again, he ordered Nancy dehydrated. This time Missouri did not appeal the decision and none of the many opponents of Nancy’s killing had legal standing to enter the case. Nancy Cruzan died on December 26, 1990, twelve days after the removal of her feeding tube.
