Smith, Wesley J., Culture of Death: The Assault on Medical Ethics in America, Encounter Books, 2000.

Smith, an attorney with the International Anti-Euthanasia Task Force exposes the historical shift away from traditional Hippocratic ‘do no harm’ medicine into a culture that suggests ones duty to die.
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Book Review by Kevin B. Peet, B.A., Senior Fellow, The Center for Bioethics and Culture

Culture of Death: The Assault on Medical Ethics in America

Slippery slope.

It is a phrase and a notion that occurs quite often in Wesley Smith’s book The Culture of Death: The Assault on Medical Ethics in America. The book is Smith’s description of the deterioration in how human beings, especially the very sick and the poor, are viewed within much of the medical culture, and how these attitudes are then bleeding down into the general population and being absorbed as normative.

Early on, he quotes Dr. Leo Alexander, from a 1949 article in the New England Journal of Medicine. Dr. Alexander had served as an investigator into the medical aspects of the Nazi Holocaust, and described how a society could descend to the level of the Holocaust, and how these attitudes can become all too common in contemporary Western culture:

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 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.

Mr. Smith, an attorney based in Oakland, California for the International Anti-Euthanasia Task Force, has written a heavily annotated and well-documented book of smoldering outrage over the direction of medicine and “bioethics” especially in the past thirty years. He quotes Richard John Niehaus from a 1988 essay in Commentary, “The Return of Eugenics,” in which Niehaus describes a shift in thinking very similar to what Alexander has said: “Thousands of ethicists and bioethicists, as they are called, professionally guide the unthinkable on its passage through the debatable on its way to becoming the unjustifiable, until it is finally established as the unexceptional.” Smith then goes on to depict in case after case how the formerly unthinkable has indeed become the unexceptional.

After laying the groundwork in the first chapter and discussing some cases known to him personally, he writes in the second chapter about “Life Unworthy of Life,” a phrase taken from the title of a book published in Germany in 1920. The book represented the culmination to that point of the utilitarian thinking which decreed, in Smith’s summary, that “some humans had greater moral worth than others.” In fact, as he shows, the absorption of these sorts of ideas into the general culture of late 19th- and early 20th-century Western culture is almost exactly parallel to the absorption of current utilitarian bioethics views into our own culture. The unspoken conclusion is that it is either hubris or the sheerest na?et?to think that contemporary society couldn’t possibly descend to the levels of the Nazi atrocities Indeed, whether it is the Tuskegee syphilis study, the victims of involuntary sterilization, or a 1980s study in Oklahoma in which 24 babies born with spina bifida were left untreated to see how they would fare-they all died-Smith makes the case that the difference between some contemporary American viewpoints and deeds and those of Nazi Germany are more of degree than of kind.

He deals also with the very real fear that many people have of ending their life tied to a machine, living in pain and humiliation and feeling that they are a burden to their loved ones, both emotionally and financially. While not denying either the substance or the basis for this fear, he then shows how the “culture of death”-so eager either to let patients die or else to kill them-has painted a false picture of the prospects, denying the valuable work that hospices can accomplish and belittling the substantial benefits of palliative medications. This has left these individuals (and increasingly the society at large) to believe that the only reasonable course of action is to die, whether voluntarily or with the help either of family members or of physicians. Considering Smith’s role with the Anti-Euthanasia Task Force, he understandably has much to say about euthanasia; what is perhaps more revealing than the mere recounting of Jack Kevorkian’s brazenness or similar stories is his depiction of how it appears inevitable that, once the culture of death gets its foot in the door, there’s a gradual shoving and nudging until the door-opening is wider and wider. As a case in point, the Oregon death-with-dignity law was supposed to have rigorous safeguards so that no one else would administer the deadly cocktail except for the patient, yet within only a few years after passage of the law, this guideline was circumvented because a man claimed his brother was incapable of self-administering the poison, so he administered it to him. And as far as either the actions of Jack Kevorkian or those which are becoming commonplace in the Netherlands, he simply has too many examples from which to choose.

Next examined is Futile Care Theory and the resulting “duty to die” imposed upon some of the very ill. This appalling situation-still in its nascent stages-is resulting in certain kinds of people being viewed as or used as “organ farms,” that is to say, people whose only contribution should be seen as donors of organs (again, the majority are the very sick or the very poor, precisely those who lack the political, financial, or societal clout to protect themselves). Here again, though initially there were strict safeguards erected to protect people, the sheer scope of the need for organs and the cost of keeping the donors alive on the one hand is being used in a deadly calculus, the purpose of which is to justify harvesting the useful organs while the donor is still alive, so that the organs do not undergo the deterioration of ‘warm ischemia.’

It was only in his treatment of use of animals in medical research that Smith seems to go a bit wide of the mark. The matter is certainly both significant and relevant, and he does point to the considerable irony of the culture being eager to defend animals on the one hand, while on the other the bioethicists, using their famous utilitarian calculators, are ready to hand over various people whose lives are not worth living as suitable subjects of medical research. Yet, while relevant, it also seemed at least somewhat peripheral.

For one new to this whole area of bioethics, the material in this book is both comple

tely novel and generally appalling. I am neither a Luddite nor a hermit, yet I consistently found myself still at the point of considering certain things to be ‘unthinkable’ (in Niehaus’s characterization), whereas they had already progressed, completely unnoticed, to the unexceptional. (As an example, early in the book he presents a suggestion, admittedly quite radical, by a prominent bioethicist that everyone be provided with a sort of lottery number unique to them. If the number of available organs for donation through ordinary means should slip below a certain threshold, the lottery would be run, and whoever was chosen would have to give up his or her life so that greater numbers of lives could be saved through donation of the “winner’s” organs.) Smith quotes a physician from Loma Linda University after the guidelines for their progressive organ-donation program were repeatedly ignored by physicians elsewhere, who sent them babies that were merely disabled rather than the anencephalic babies specified in the protocol: “I have become educated by the experience? The slippery slope is real.”

The question of how far down the slippery slope our Western culture has gone is of course dependent on where one believes the bottom to be. In reading this book, one encounters case after case which causes the thought to arise, “Surely it cannot get much worse than this?” In response, Smith’s final chapter deals with four steps that can be taken both individually and corporately to try to turn back the tide: a) Reject assisted suicide/euthanasia, b) Close the door to Futile Care Theory, c) Hold the line in dehydration cases, and d) Grapple with the moral dimensions of abortion.

Wesley Smith’s book can and should serve as an eye-opener, particularly because much of the changes in thinking are taking place where they are seldom prominent publicly, leaving them both insidious and relatively invisible. It is a grim and perverse thing to have to stand up and say, “Physicians should not be involved in killing people,” yet Smith has done an admirable and thorough job of it.