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PREFACE

This book had its genesis when the former editor of Encounter Books, Peter Collier, approached me to write about the modern bioethics movement. Immediately intrigued by the idea, I initially thought Culture of Death would be a “policy” book. But as I entered the subject of bioethics more deeply, it became quite personal. I should have known that it would be. Bioethics, as philosopher Leon Kass told me at the time, is about “ultimates,” by which he meant the meaning of life, the challenges of mortality, the rights and responsibilities that flow from being a member of the human family. How we deal with these ultimates defines who we are, both as individuals and as a people.

It is a bit jaw-dropping to consider how prophetic this book turned out to be. More than fifteen years have passed since the first edition, during which time the trends and themes about which I warned have accelerated. For example, in the original version I spent many pages cautioning about how dehydrating cognitively disabled patients to death by removing their feeding tubes was becoming normalized and a matter of clinical routine. In those years, people were often shocked at the very prospect. Then, Terri Schiavo burst into the headlines. In the aftermath, not only are people aware that we cause these cruelly slow deaths, but if polls are to be believed, most support so doing. Indeed, in the wake of the Schiavo imbroglio, the resistance to dehydrating helpless patients has all but collapsed. And what was once the ceiling has now become the floor as the bioethics discourse now debates withholding spoon-feeding from people with advanced-stage dementia—even if they willingly eat—if the patient so instructed in an advance directive.

The first edition of Culture of Death also warned against the growing euthanasia movement that threatened the soul of Hippocratic medicine. When the book was published in early 2001, the discussion about assisted suicide and euthanasia was mostly a caveat of what I thought was likely to come. At that time, only one jurisdiction in the world—Oregon—had explicitly legalized assisted suicide (although the Netherlands had decriminalized the practice and allowed death doctors to go unpunished if “guidelines” were followed). And, while the first edition of this book discussed the assisted suicide campaign of Jack Kevorkian with much concern, by the time the book hit the bookstores, he was safely imprisoned for murder.

Today, Kevorkian is dead, but the moral values and practices he so zealously espoused certainly didn’t succumb with him. Indeed, it is tempting to conclude that we are becoming a Jack Kevorkian world. Not only has the Netherlands formally legalized lethal injection euthanasia, but so too has Luxembourg. In 2002, Belgium instituted an even more radical regime of doctor-administered death than practiced by the Dutch—and the country subsequently embraced euthanasia with a deadly ardor that even surprised me. Meanwhile, Switzerland allows “suicide tourism”—in essence turning the land of the Alps into Jack Kevorkian as a country—to where many hundreds of suicidal people have taken a one-way trip to die in legal suicide clinics.

Worse is yet to come. Just before this revised edition’s completion, Canada’s Supreme Court imposed a very broad euthanasia license across the country as a Charter right in the wake of Quebec legalizing lethal injections as a form of end-of-life care known in the law as “aid in dying.” Euthanasia will also soon be legally administered in Colombia; the country’s parliament recently effectuated an old Supreme Court ruling.

The line against doctor-prescribed death has mostly held in the United States—despite scores of legalization attempts, including an unsuccessful 2012 voter referendum in Massachusetts. But that may be changing. Oregon legalized assisted suicide by a referendum in 1994. It took a long time for the next domino to fall, but Washington State and Vermont legalized assisted suicide in 2008 and 2013, respectively. The American assisted suicide movement, bounteously funded and supported by a boosting media, went into overdrive in 2015, a year in which more than half the states saw legislation introduced to legalize assisted suicide. That effort succeeded in California, capping more than twenty years of intense efforts in the Golden State, from where activists hope their agenda will sweep the country.

There is better news on the organ transplantation ethics front. In the first edition, I worried that the dead donor rule—which requires that vital organs only be removed from those who had died—was under threat. It was and still is. But at least on that flank the moral line has held. While advocacy for “redefining death” and allowing people to be killed for their organs has intensified, as we will discuss, organ transplant medicine remains—for the most part—an ethical and moral enterprise.

The same goes for (what I call) “futile care theory” (FCT), against which I spent much effort inveighing in the first edition. Medical futility—which allows doctors to refuse wanted life-sustaining treatments—remains a cogent threat, but it has not yet become normalized in most jurisdictions. Still, that is not for lack of bioethicists trying, and so the issue remains a matter of intense discussion and concern in these updated pages.

This brings me to describing the major differences between the original and revised editions. With so much having happened in the last fifteen years in bioethics and public policies around health care—most especially the passage of the Affordable Care Act—I had to make some significant changes from the original text to keep up with the times. Yet I also had to prevent bloating to keep the book intellectually digestible for the popular audience for which it is intended. That turned out to be a far more involved process than I thought it would be when I first undertook the updating project.

Readers of the original edition will find two major changes. The most sweeping is the deletion of the entire chapter on the ethical questions surrounding animal research, despite much positive reaction about its content in the years since the book was released. It isn’t that the issues raised were not, and are not, important. Quite the opposite: I believe the ethics and moralities surrounding the human/animal relationship are so ethically portentous and crucial to human thriving that I wrote an entire book, A Rat Is a Pig Is a Dog Is a Boy: The Human Cost of the Animal Rights Movement, on the subject.¹ Since that book dealt in far more detail with the issues raised in the animal research chapter, among many other matters, it seemed superfluous to retain the original material here.

I have replaced the animal chapter with a discussion on what I call “biological colonialism.” The exploitation of human body parts and functions—particularly gestation—is becoming a big business, sparking a cultural whirlwind. The new material explores the contentious debate over paying for organs—with special attention paid to the international black market in kidneys—and decries how women, particularly the destitute in developing countries, are used as “gestational carriers.” In short, I believe that the bodies of the world’s poor are being exploited by the well-off and powerful in much the same way that the original colonialists did to weak nations’ natural resources.

For many of the same reasons, I also omitted the original section on embryonic stem cell research and human cloning. Those issues similarly remain important. Indeed, in the years after this book’s publication, embryonic stem cell research became, for a time, one of the country’s most contentious political and moral issues. That being so, I believed I could not do justice to—nor adequately describe—the intricate controversies involving our fast-emerging biotechnologies in one section of a general chapter, like in the first edition. Indeed, as with animal issues, I believed these issues to be so important I wrote an entire book about them—Consumer’s Guide to a Brave New World²—to which I refer interested readers.

I have replaced the stem cell discussion in the original book with an exploration of a related but distinct futuristic social movement gaining a lot of steam in the last few years. Known generally as “transhumanism,” this materialistic quasi-religion challenges traditional Judeo/Christian moral principles about the intrinsic dignity and importance of human life, as it pursues policies it hopes will culminate in our recreation into a “post human” species. While I was unable to give the subject the full attention it requires, I hope the reader finds the discussion sufficiently provocative to stimulate further exploration.

Before we begin, a few words about the general approach I took to upgrading and revising a book fifteen years on the shelves: Culture of Death is not an “issues” book so much as one based on themes. I maintained that approach in this edition. That made the revision more challenging to me as a writer because I couldn’t simply append new stories and cases like so many Lego© pieces onto old chapters. In other words, it wouldn’t do to simply add new assisted suicide cases onto “the euthanasia chapter,” as the issues involving doctor-administered death are discussed across most of the book. This structure thus presented me with the creative challenge of weaving new material into the existing themes in a way that I hope is both seamless and edifying to the reader.

But that required difficult choices. I could have deleted all the older material and replaced it with newer stories and issues bearing on the same themes. Or I could have kept all the old material, adding in only a few updates. I chose a middle ground, removing significant sections of dated material but maintaining sufficient original text to show the continuity between what I foresaw then, what has happened since, and the reasons for my even greater alarm about where we seem to be heading now. I hope I have integrated the old and the new in a way that illuminates how we didn’t “just arrive” at our current peril but were brought intentionally to this place step by intentional step.

That noted, here are the most prominent changes readers will find in this new edition, beyond simple updating of case studies:

• Detailed material about the Terri Schiavo controversy;

• Updated text across several chapters on assisted suicide and euthanasia, including a discussion of the new horrors out of Belgium and reference to the late Brittany Maynard, who became a media-driven celebrity at the end of 2014 for committing assisted suicide;

• Continued and updated discussion of futile care theory;

• A more detailed focus on advance medical directives and a brief discussion of a new form of advance health care planning known as the POLST (physician’s order for life-sustaining treatment);

• Updating the question of health care rationing;

• A discussion of the impact the Affordable Care Act—also known as Obamacare—could have on bioethics;

• A greater discussion of the abortion question while omitting the issue of partial-birth abortion because a federal law was enacted that banned the procedure; and

• New discussion of the question of medical conscience protections and the threat of what I call “medical martyrdom” to health care professionals.

My primary purpose in writing this book has not changed since its original iteration: to alert readers to the subversive impact of bioethics and other ideological agendas on the fundamental moral principles that have long governed the practice of medicine specifically and our society’s values and mores generally. In so doing, I hope to help make these crucial debates about medical ethics and health care public policy accessible to those beyond the so-called expert caste that not only dominates these deliberations but also threatens to transform our health care system into a sclerotic technocracy. Thus, I invite those who will be directly affected by these matters—in other words, each and every reader—to enter into these debates with the understanding that the decisions we make in the next decade about issues such as euthanasia, medical rationing, end-of-life care, and organ transplant ethics—just to name a few—will determine both the future of Western medicine and—dare I say it—the continuing morality of our society.

The hour is late. The cause is urgent. The risks are real. As a greater writer than I once put it, ask not for whom the bell tolls, it tolls for thee.

WESLEY J. SMITH

Castro Valley, California

June 5, 2015