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INTRODUCTION (TO ORIGINAL VERSION)

This book is the product of two years’ worth of intensive research and writing, but its genesis goes back much further than that. Since 1993, I have been an anti-euthanasia activist, during which time I have researched, written, appeared on national television and radio, lectured, and engaged in behind-the-scenes activism, fighting not only the euthanasia agenda but also the incursion of what I generally refer to as “related issues” into modern medical practice. My last book, Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder [the title was revised in a subsequent edition to Forced Exit: Euthanasia, Assisted Suicide and the New Duty to Die] dealt primarily with assisted suicide and euthanasia, as the title indicates. With this book, I explore related issues, many of which I believe are as dangerous and urgent as—if not more than—the ongoing public policy wrestling match over euthanasia.

Assisted suicide is just the tip of the iceberg of what has come to be known as the “medical culture of death.” Unbeknownst to most Americans, a small cadre of influential health care policymakers are working energetically and unceasingly to transform medical practice and the laws of health care away from the “do no harm” model established by the great Greek physician Hippocrates and toward a stark utilitarian model that would legitimize not only medical discrimination against the weakest and most vulnerable among us but also, in some cases, their active killing. To make matters worse, the first time many people become aware of what is happening to modern medicine is when they or loved ones experience a health care crisis and suddenly come face-to-face with the monster that they did not even know was lurking in their very midst.

Why are the ethics of our health care system so threatened? Some of it, no doubt, has to do with the times in which we live, in which objective truths are passé and the very concept of right and wrong itself is under assault. But make no mistake—more is at work than just societal drift or passive cultural evolution. The challenges to ethical medical practice and morality explored in this book are promulgated and promoted with great gusto by a cadre of so-called “experts,” a genre of moral philosophers, academics, lawyers, physicians, and other members of the medical intelligentsia known generically as “bioethicists.”

How does one become a bioethicist? It isn’t hard. A bioethicist is as a bioethicist does—no tests have to be passed, no qualifications met. Indeed, practitioners are not licensed, as are other professionals such as attorneys, physicians, real estate agents, or, for that matter, hairdressers. And while more than thirty universities offer degrees in bioethics, there are no standards of education or excellence that apply universally. A Catholic priest can be a bioethicist just as easily as an atheistic college professor. Health care professionals, such as nurses or community ombudsmen, can be appointed to hospital ethics committees, take a few training courses, and then self-identify as bioethicists. Indeed, by writing and lecturing extensively over the last eight years on bioethical issues, including assisted suicide and moves to permit doctors to unilaterally remove wanted medical treatment from dying and disabled people, I could say that I am a bioethicist, too—but I won’t.

Being designated a bioethicist in and of itself is of relatively little import. The title does not give one influence within the bioethics movement or the ability to sway society onto or away from the bioethics path. That is to say, there is a very big difference between being a bioethicist and the ideology of mainstream bioethics, the tenets of which will be described in the first chapter. It is the adherents to the ideology of bioethics—led by a relatively small “insider” group of elite practitioners—who are the bioethicists that hold a steadily increasing sway over the laws of public health, the application of medical ethics, and the protocols that govern hospital care. It is their agenda against which this book primarily warns.

As I began my research for this book, I had no idea the depth of the task that awaited me. Yes, I knew that matters were going badly akilter, but I really had little insight into how far bioethics has already helped push the practice of medicine away from the ideals and beliefs that most “regular” people count on to protect them when they or loved ones grow seriously ill or disabled. Indeed, the more I learned about the present being crafted by bioethicists and the future the mainstream movement seeks to create, the more I felt as if I had fallen through Alice’s looking glass into a Salvador Dalí painting. Our culture is fast devolving into a society in which killing is beneficence, suicide is “rational,” natural death is undignified, and caring properly and compassionately for people who are elderly, prematurely born, disabled, despairing, or dying is a “burden” that wastes emotional and financial resources. Perhaps most worrying: Bioethicists are constructing a system in which the rights of people in the medical system will be based on an explicit hierarchy of human life.

Culture of Death will tell the story of how these nihilistic attitudes are dismantling traditional medical ethics and endangering weak and vulnerable patients. The book will detail how bioethicists have generally abandoned the sanctity of human life ethic that proclaims the equal inherent moral worth of all human beings. Most do not believe in the Hippocratic Oath. Indeed, believers in what I call bioethics ideology reject the very notion that there is anything “special” per se about being a human being. Rather, they assert that being human is a relative thing and what matters morally is whether a “being” is entitled to membership in the “moral community,” which, as we shall see, each individual must earn by possessing “relevant characteristics”—usually a minimum level of cognitive functioning—that bioethicists claim give rise to significant moral standing, including the right to life.

In the surrealist world of bioethics philosophy, those with sufficient cognitive qualifications to achieve membership in the moral community are often called “persons.” Ironically, many bioethicists assert that persons may include “entities” that are not human. For example, animals are said by some bioethicists to qualify for personhood, which would give these beasts greater moral worth than some humans.

The influence of bioethics is pervasive. From their positions in the academy, in medical and bioethics think tanks, in law schools, and as editors of elite medical journals, financed by grants, honoraria, and book royalties, bioethicists are changing the very face of American health care. Here are just a few examples—a preview of coming attractions, if you will—of some of the topics I will detail later in these pages:

• Dr. Marcia Angell, editor of the New England Journal of Medicine, has editorialized that the definition of death be expanded to include a diagnosis of permanent unconsciousness or that other policies be implemented with the stated purpose of requiring that unconscious people be dehydrated to death—even if their families object.

• A peer reviewed article in the Lancet, one of the world’s most famous medical journals, took this idea one step further, opining that unconscious people should be lethally injected to allow their organs to be harvested. This is not an isolated notion. The idea of permitting disabled people to be killed for their organs is gaining steam among many members of the organ transplant community.

• Peter Singer, an internationally renowned philosopher from Australia with a worldwide following, has declared that parents should have twenty-eight days in which to decide whether to keep or kill their newborn children. Rather than becoming a pariah, as one would expect of an infanticide advocate, he was appointed to a prestigious, tenured professorship at Princeton University.

• Daniel Callahan, one of the country’s most influential bioethicists, has called for a harsh system of medical rationing in which research into the cures and causes of disease would be drastically reduced and health care resources diverted from medical treatment into public education programs intended to convince—and, if necessary, coerce—people into healthy lifestyles.

• Some bioethicists want to create a market for the sale and purchase of human organs. Others promote the creation of suicide clinics. A few have even proclaimed a “duty to die” upon reaching old age or becoming a financial or emotional burden.

That such discriminatory policies are ardently advocated in the world’s most respected medical and academic journals would be enough cause for alarm. But bioethics is about much more than intellectual theory. Many bioethics agenda items have already imbedded themselves into the bedrock of law.

The 1999 Montana Supreme Court’s decision in James H. Armstrong, MD v. The State of Montana is just one example. The state had passed a law requiring that only doctors perform abortions, which the court invalidated based on the Montana Constitution and Roe v. Wade. That should have been the extent of the decision. But rather than limit the ruling to the case at hand, a 6-2 majority decided to use the cultural flashpoint of abortion as a pretext for imposing a radical and audacious philosophical imperative on the people of Montana, unwarranted by specific facts of the case and unnecessary to its prudent adjudication. As a consequence, the ruling’s extraordinary legal implications extend far beyond abortion, opening a Pandora’s box of expansive litigation in Montana for years to come and threatening the right of Montana to effectively regulate the practice of medicine through the rule of law.

The scope of the majority ruling is almost unlimited: “The Montana Constitution broadly guarantees each individual the right to make medical judgments affecting her or his bodily integrity and health in partnership with a chosen health care provider free from government interference.” This is far more alarming than it may appear at first reading. As the two justices who objected to this aspect of the ruling, Karla M. Gray and Chief Justice J. A. Turnage, rightfully worried, the ruling’s broad breadth and radical scope strongly suggests that “the Legislature has no role at all in matters relating to health care to be provided to the people of Montana” and “sweeps so broadly as to encompass and decide such issues as the right to physician-assisted suicide and other important health and medical-related issues which simply were not litigated in this case.”

If, indeed, almost anything goes medically in Montana, so long as a patient wants it and a health care professional is willing to do it—a reasonable interpretation considering the expansive language and philosophical thrust of the majority’s decision—then it could be construed to permit a doctor to amputate a patient’s healthy limbs upon request when the patient wants it removed to satisfy a neurotic obsession (a macabre surgery that has actually occurred in England); allow patients to ask doctors to kill them for organ donation purposes; permit infanticide of disabled infants at the request of caregivers or parents; or allow people to be experimented upon in dangerous ways that are currently illegal. Indeed, the court’s ruling is so broad, it decreed that only “a compelling interest . . . to preserve the safety, health and welfare of a particular class of patients or the general public from a medically-acknowledged bona fide health risk” warrants state involvement in medical decision making. In other words, regardless of the individual or societal consequences, absent extraordinary exigencies, such as preventing a plague, virtually anything may be allowable in Montana if it can be construed to involve obtaining “medical care from a chosen health care provider.” That’s an astonishing result from a little-noticed ruling overturning a law that would have simply required doctors to perform all abortions.

How did the court justify such an encompassing decision? Yes, the court looked to Roe v. Wade and a smattering of other cases. But the primary authorities that the majority decision relied upon for the broader context of its ruling were philosophical treatises. Indeed, the most frequently cited authority was not a statute, a law case, or even a legal essay but a philosophical discourse on the modern meaning of the “sanctity of human life” contained in a book—Life’s Dominion: An Argument about Abortion, Euthanasia, and Individual Freedom—written by the attorney/bioethicist Ronald Dworkin in 1993. Dworkin’s thesis: A true adherence to the sanctity of life ethic requires that all be permitted to “decide for ourselves” about abortion and euthanasia and that such decisions be accepted by society and tolerated by those who disagree; otherwise society is “totalitarian.” The majority opinion cited Life’s Dominion so frequently and applied its reasoning so enthusiastically that the Ronald Dworkin’s philosophy may now be the court-mandated health care public policy of the entire state of Montana without a single vote even being cast—quite a triumph for a philosopher who is little known outside the world of the academy and another step down the road toward the new medicine of mainstream bioethics.

As this book will demonstrate, bioethicists and their allies are pushing the laws of the nation and the public discourse increasingly toward accepting killing and death as a legitimate answer to life’s difficulties. This is leading to a rising human toll:

• Oregon, which has legalized assisted suicide, decreed that the act is a form of “comfort care” that must be paid for by Medicaid; this in a state that denies some curative treatments under the state’s Medicaid health rationing scheme.

• Desired medical treatment is refused in hospitals and nursing homes around the country to patients who are dying or disabled, with the intent that the patients die. This abandonment is justified as ethical under a new theoretical construct known as futile care theory (FCT), which proclaims the right of doctors (and health care executives) to refuse wanted care based on their subjective views of the value of their patients’ lives.

• Doctors, nurses, and other hospital staff in hospitals and nursing homes often pressure family members of stroke victims, demented patients, and other cognitively disabled people to permit their brain-damaged relatives to be dehydrated to death by removing tube-supplied food and water.

• In New York, a man who smothered his wife with a plastic bag after her purported assisted suicide attempt failed, and who then covered up the crime with a falsified death certificate and a quick cremation, was given a mere two-week jail sentence.

• In Canada, Robert Latimer was convicted of murdering his twelve-year-old daughter by asphyxiation because she had cerebral palsy. Instead of receiving significant punishment, he was embraced by a majority of Canadians as a “loving father,” resulting in his “mandatory” ten-year sentence being reduced to one year by a judge who labeled the girl’s murder “altruistic.” Latimer remains free on appeal nearly ten years after his daughter’s killing.

• In England, the parents of an infant born with Down syndrome and the treating doctor who intentionally allowed the baby to starve to death were acquitted of all criminal wrongdoing.

• In the United States, the requirements of the Nuremberg Code to protect human beings in medical experiments are routinely violated without legal consequence. Indeed, thanks to the advocacy of “animal rights” activists, animals often receive greater protection in medical research than do people.

This growing indifference to the value of human life within the health care system and courts should be big news. Yet most people are but dimly aware of what is happening. There are several reasons for this. Popular culture promotes many of these practices as a positive, thereby camouflaging the evil that is taking place. Nonjudgmentalism reigns supreme as the growing relativism of our culture increasingly incapacitates people from “imposing their own beliefs on others” by making well-honed moral judgments. The mainstream media neither cover these important issues adequately (or sometimes even at all) nor place them in a proper and understandable context when they do. Thus, while stories involving death culture issues sometimes make the news, they are generally covered as if they have occurred in isolation. The overarching themes that would alert the populace to the bigger picture are generally ignored, and the dots remain unconnected. In this sense, we are like the proverbial frog slowly being boiled to death, unaware that the water is getting hot and that destruction is fast approaching.

A prime purpose of this book is to cast a bright light on the rising steam of the not-yet-boiling pot. Also, by focusing greater attention on the culture of death, I hope to help lead our society away from the immoral path we are on and toward a more profound commitment to the sanctity of human life, not necessarily in the spiritual sense but as a societal commitment that each and every one of us are moral equals. Just as we should not discriminate against each other on the basis of race, religion, nationality, or gender, neither should we cast aside people in the health care system because they are disabled, elderly, brain-damaged, or dying, these latter forms of invidious discrimination being mainstays of the culture of death movement.

Although I quote many philosophy treatises, this is not a philosophy book. And while I explore many laws and ethics protocols, this book does not get bogged down in specific policy proposals. Nor, I hasten to add, am I under the illusion that I can change the minds of the inbred denizens of the ivory tower who move bioethics forward in their never-ending discourse in academic journals and books, and at symposia; most are far too committed to their cause for that. Rather, this is a book primarily about how bad ideas lead to harmful consequences that hurt real people, inviting the people of the general public into the important debates that are already occurring beneath—or, better stated, above—the radar, debates that will not only determine the future of their health care but also the very morality of the society their children will inherit.

One last note before we get under way. In these pages, I take no position on whether abortion should be legal or illegal. I know this will frustrate some of my readers, but I am convinced it is the right thing to do to best accomplish my objectives. Abortion is the black hole of public discourse from which little light escapes. Were I to discuss the issue in depth, any publicity this book eventually receives would likely focus on that issue and divert attention away from the many important bioethics policies upon which this book seeks to shine the bright light. Moreover, many articulate and thoughtful voices already address abortion from both sides of the issue, and nothing I have to say would add substantially to that which has already been written. Finally, Roe v. Wade has settled for the foreseeable future whether abortion will or will not be a legal right. Thus anything I might write, either for or against abortion, would be quite superfluous and beside the point of what I hope to achieve in this writing.

That is not to say that Roe v. Wade is irrelevant. In a way, this book can be said to begin at the exact point where Roe leaves off. The people endangered by the culture of death policies about which I write (e.g., born people) are protected under Roe v. Wade but endangered by policies and protocols with which this book is filled. Indeed, whether one is pro-life or pro-choice, it is my sincere hope that the book’s readers will agree with me that, regarding born people, each and every one of us should be treated as an unqualified equal in the health care system. None of us is expendable. No one should be abandoned to death because he or she fails to pass the muster established by the few elite academics and philosophers who, for the last thirty years, have taken upon themselves the power to decide when a life is not worthy to be lived.

WESLEY J. SMITH

Oakland, California

March 2000