March 20, 2002
Dear Mr. Smith,
You have done a great service to the public as well as to the medical profession with your groundbreaking books, Forced Exit: The Slippery Slope From Assisted Suicide to Legalized Murder (1997) and Culture of Death: The Assault on Medical Ethics in America (2000).(1,2) You have brought to the forefront of popular discussion momentous medical issues, which up to now have been restricted to the ivory towers of academia or to acts conducted in the shadows by the likes of Dr. Jack Kevorkian.
You will be happy to learn that there is one medical organization that does not compromise principles for political expediency or social considerations. While other medical organizations have allowed the individual-based medical ethics of Hippocrates to be eroded piecemeal, the Association of American Physicians and Surgeons (AAPS) has remained firm in defending all of the Oath of Hippocrates, including the section that reads: "I will prescribe regimen for the good of my patients according to my ability and my judgment and never do harm to anyone. To please no one will I prescribe a deadly drug, nor give advice which may cause his death."
In the Medical Sentinel, the official, peer-reviewed journal of the AAPS, we have published articles opposing euthanasia, the duty to die, population-based and utilitarian ethics, distributive justice,(3-10) etc., as well as government intervention in medicine.
Again we applaud your efforts. Now that we have established that we are on the same side of the euthanasia debate, allow me to bring forth some critical points for discussion.
While you correctly denounce the iniquity of euthanasia, I believe you over emphasize the impact that withdrawal of care and euthanasia will have on minorities and the poor. The duty to die, once imposed, will affect all of us, except perhaps for the very rich, who continue to be a very small segment of our society, and the well connected. Most of the U.S. middle class is insured now through HMOs and other forms of managed care; the poor through Medicaid; the elderly through Medicare --- which means that we all are susceptible to the cost-cutting knife of both private and public sector bureaucrats. HMOs, whether for profit or not, are part and parcel of Corporate Socialized Medicine, which make profits by limiting services - the complete opposite of the workings of the free market.(11) Impetus for euthanasia and futile care philosophy is pervasive, both in for profits as well as in not for profit HMOs and public hospitals.
Fortunately, while in Forced Exit, you place a lot of emphasis on the iniquities of a "for profit" health care system, in Culture of Death, you seem to have gained significant insight and now realize that "economic questions present very real threats" in patients with government health insurance, such as Medicaid, Medicare, and the Veterans Administration hospitals as well. You even cited the specific case of Kate Cheney's ordeal (pages 113-115) with Kaiser-Permanente, the mother of the "not for profit" HMOs, exposing its engagement in cost-cutting efforts to the same extent, if not worse, than for profit HMOs.
The government is, in fact, the major force behind the machinery of cost containment and rationing of medical care. The uncontrollable growth of government programs is what drives statist bureaucrats to find ways to cut costs and staunch the flow of red ink. It is no coincidence that de facto euthanasia has been carried out in the Netherlands, a country that has universal coverage and fully socialized medicine. The practice of euthanasia blossomed, not in a "profit-driven" or fee-for-service health care system, but in a country with universal health care and government-run medicine. Death becomes the ultimate form of rationing only when governments become involved. Only the State has the required authority and monopoly of force to enforce drastic rationing measures. Private entities merely dovetail State policy and necessarily must rely on government to enforce corporativist policies, such as rationing by death and euthanasia, like in Nazi Germany or the Netherlands.
Needless to say, citizens should be quite concerned when the government enters the picture to enforce the "rational allocation of 'scarce and finite' health resources" via rationing and euthanasia, as cost-cutting tools. An example of the "rational allocation of resources" is Oregon's Medicaid health plan, which, as you have noted, offers assisted suicide as "comfort care," while refusing to pay for the care of severely ill, premature infants and the treatment of certain advanced cancers. It's worth repeating: Private entities may increase profits, but unlike the State, they cannot backup policy with the use of force as governments can do. Again, let us not forget Nazi Germany.(12,13)
The war on drugs is becoming a deleterious, unending conflict in American society. Yet, not until page 245 of Forced Exit do you allude to the fact that the problem with pain control may also be related to fear aroused by the war on drugs and the trepidation of physicians in being singled out and prosecuted for making inadvertent errors or violating some Drug Enforcement Administration (DEA) rule in prescribing narcotic analgesics for the control of chronic pain. I don't think this was emphasized enough in your books. It needs to be: Doctors fear using narcotics to alleviate their patients with chronic pain, not only because of the fear of addiction but particularly because of the growing police state of medicine.(14-16)
I would like to praise you for recognizing the fundamental differences in fee-for-service medicine as we have had in the U.S. as opposed to the transformation rapidly taking place in American medicine towards corporate socialized medicine --- i.e., managed care, whether "for profit" or "not for profit" HMOs. Frankly, whether the money goes to investors (i.e., "for profit") or to HMOs officers or staff (i.e., "not for profit") makes no difference. Fee-for-service, on the other hand, for those who can afford it and charitable medical care for the indigent have been the underpinning of the practice of medicine for centuries, according to the ethics and tradition of Hippocrates.
In Forced Exit, you correctly talked about how euthanasia advocates use language and choose their words as to mislead and obfuscate rather than reveal their true intentions. You also mentioned Timothy Quill, M.D., a respectable euthanasia proponent, as speaking out of both sides of his mouth. The same may be said to some extent about the renowned medical (bio)ethicist, Edmund D. Pellegrino, M.D., who over the years swam with the tide of bioethics --- i.e., being highly critical of paternalism in the patient-doctor relationship but slow and soft on denouncing the real dangers of the bioethics movement.(17,18) His steady denunciation of paternalism, while ignoring the more serious assault against traditional medical ethics, has helped to dismantle piecemeal the patient-doctor relationship in the tradition of Hippocrates.
The ethics of Hippocrates necessarily contain a certain amount of inherent paternalism, which, tempered by the virtue and honor of enlightened physicians sworn to the tenet of "doing no harm," simply enhances the patient-physician relationship and the sanctity of life ethic. Even when these physicians acted with some degree of paternalism in the patient-doctor relationship, they were expected to (and for the most part they did) place the interest of their patients first, taking into consideration the patient's wishes, doing no harm, and in the case of seriously ill patients unable to express their wishes, acting with the input and consent of their families. All of this worked well for 2500 years with fee-for-service medicine, compassion, and charity. On the other hand, in the name of personal autonomy, bioethicists have promoted not only assisted-suicide but also have advanced the notion of "pulling the plug" of non-terminally ill, cognitively impaired patients because of the poor quality of life ethic.
Unfortunately with the advent of third-party payers and the development of employer-provided health insurance coverage in World War II, government health care with Medicare and Medicaid in 1965, and finally the massive growth of managed care and HMOs (i.e., corporate socialized medicine) in the 1990s --- that beneficial, moral, and ethical tradition is coming to an end. Dr. Pellegrino may be decrying now the path that the bioethics movement may have blazed for medicine today, but rather than opposing it with all the power of his prestige and influence, he directed most of his energy and prolific writing output elsewhere rather than confronting head on the harmful effects of the bioethics movement.
Finally, I do want to provide a solution to the sophistry of "the philosopher and the dupe" conundrum, as it regards the moral equivalence of Dr. Peter Singer's "non-human animals" and "cognitively-disabled human patients" in the context of medical experimentation and euthanasia.2 As you wrote in Culture of Death, the dupe says, "Only people use tools." The philosopher replies, "Not so. Chimps use tools." The dupe then says, "Only humans create, empathize, and think in moral terms." The philosopher then springs his sophistric trap, "Ah, but not every human can do those things. Those individuals who cannot create, empathize, rationalize, or think morally must be treated differently from those who can." Then the game is finished, "fixed."(2)
I would have said, "Only humans, Homo sapiens, have members who can do all of those things. All humans, except for brain dead patients (who are of course dead), can potentially do all those things. Therefore, all must be equally protected, treated humanely, and their lives considered sacred because of their exclusive power of reasoning, which no animal possesses. This is why an ethical code must recognize the sanctity of human life, rather than the quality of life ethic that the bioethics movement promotes.
Bioethics is the perversion of medical ethics because it is based on utilitarianism, the quality of life ethic (i.e., that some lives are not worth living), and the concept that the individual should be subordinate to the "greater good of society" or the State (i.e., the population-based ethic). The medical profession should reject the culture of death and return to the sanctity of life ethic of Hippocrates that placed the interest of the individual patient above that of the collective. The ethical question of who is to decide for the patient cannot be answered by third parties, be that insurance, the government, or "society," but only by the patient in concert with her trusted physician.
Again, I'm greatly gratified that from your book, Forced Exit (an important book favorably reviewed in the Medical Sentinel),(19) to your even greater sequel, Culture of Death (discussed at length in this issue of the Medical Sentinel),(20) you have been able to clearly recognize not only the egregious ramifications of the bioethics movement, as well as the engine and the awesome power behind it --- the threat of government coercion in the most serious matter of termination of medical care for those most vulnerable in our society --- rationing by death.
Miguel A. Faria, Jr., MD
Editor-in-Chief, Medical Sentinel
Re: Bioethics and the Culture of Death, Mr. Smith Replies
March 29, 2002
Dear Dr. Faria
Thank you for your fine and thoughtful letter. I appreciate your thoughts, comments, and constructive criticisms.
The threat of withdrawing wanted life-sustaining treatment, I believe, presents a more immediate danger to vulnerable patients than assisted suicide --- although I believe both flow from the same anti-equality of life belief system. Assisted suicide advocates believe that some lives are so undignified and unworthy of being lived that physicians should not only not seek to prevent their suicides but should actively participate in making such patients dead. Futile care theorists believe that some lives are so undignified and unworthy of being lived that physicians should be permitted to refuse to sustain their lives --- even when the patient and/or family want their lives saved. Thus, both have the same ultimate agenda --- making certain people dead. I believe we agree that both approaches violate the professionalism and tradition of Hippocrates and should be denounced and rejected unequivocally at every possible opportunity.
As to your comment that I place too great an emphasis when discussing these issues on the risks to the poor and minorities as opposed to the middle class; I both agree and disagree. I disagree because the first victims of the assisted suicide mentality are white middle class patients with an obsession about autonomy. The poor tend to be far less enthusiastic about medicalized killing, perhaps because they have difficulty receiving quality care. As for futile care, I believe that the first victims will tend (and are tending) to be poor, uneducated, marginalized, cognitively and physically disabled people, and minorities --- patients who do not have the same wherewithal to defend themselves as others might have. But certainly, once the principle is established that physicians, bioethicists, and/or administrators can ration care at the bedside, these practices would swiftly infect the rest of society and expand beyond "futile" or "inappropriate" care. This would lead eventually to an explicit regimen of health care rationing, which is just a polite word for medical discrimination.
I don't like the use of the term "paternalism" when discussing the ethics of Hippocrates. I think that "professionalism" is a more appropriate word. One of the primary and most destructive purposes of the bioethics enterprise is to transform medicine into a post-profession. For example, many bioethicists believe that doctors should have a dual mandate to both individual patients and society or care groups. This, of course, destroys physicians' fiduciary duties to all patients as individuals and would result in some patients receiving optimal care while others receive less. Such a system would be dangerous to any individual who was generally devalued and/or specifically devalued by his or her physician. As the 19th Century German physician Christoph Wilhelm Hufeland wrote, "It is not up to [the doctor] whetherlife is happy or unhappy, worthwhile or not, and should he incorporate these perspectives into his tradethe doctor could well become the most dangerous person in the state."
I am afraid I am not an expert on the drug war. I do believe that the DEA unduly chills aggressive palliation and that these policies need to be reformed. But I also believe that some assisted suicide advocates exaggerate that threat. Whether this problem --- which clearly needs a strong corrective --- also means that we should legalize destructive drugs such as cocaine and PCP, is another issue altogether. That stated, I will leave advocacy about the pros and cons of a wider drug war to others with greater knowledge about those issues. My hands are full with bioethics, assisted suicide, cloning, etc., etc., etc.
The economics of medicine is a true crisis that requires a great deal of contemplation and soul searching from all of us. As you noticed, I have come to believe in recent years that people have to be responsible for more of the cost of their own health care than is currently the general case. I also now understand that we need market forces to stimulate price competition in fees, the cost of drugs, testing, etc. (Why we pay medical schools to not turn out doctors is beyond me!) Also, not being an economist, I do not understand why technology has not moderated the price of durable medical equipment and high tech diagnostic machines. For example, when I was working my way through law school in the early 1970s as a TV salesman for J.C. Penny, I paid $40 for a handheld calculator, when I could buy a much superior machine today for $15. Why such price moderation does not seem to have penetrated high tech medicine is beyond me. In any event, I believe we need to recognize that pure socialistic approaches (whether corporate or government) are not going to work.
That being conceded, I don't believe a pure market system will work either. I say this with all due respect for your organization and its beliefs. But can anyone deny that the costs of caring for a patient with a catastrophic injury or illness is beyond the means of almost all families to pay for? Indeed, a serious chronic condition would tax most families' resources. Nor would charity care --- a crucial aspect of the medicine and tradition of Hippocrates that AAPS correctly asserts was profoundly undermined by programs such as Medicare --- in my view be sufficient to bridge the gap. And what about people with preexisting conditions that would preclude them from ever obtaining health insurance? How are they to be helped?
Lately, I have been pondering what I call a Forbes/Nader system that would be a hybrid. But frankly, I haven't put in enough thought to this to know whether it would be wise or feasible.
Whatever the economic system we have in place the keys to maintaining a moral medical system are the medical values of Hippocrates and a firm commitment to the equality/sanctity of all human life. If we anchor medicine to those overriding principles, in the end, I think we will be all right. Of course, that is easier said than done, for many of the reasons you mentioned in your letter.
What a pleasure and honor it will be for me to travel to Tucson to address the members of AAPS at its annual meeting. I look forward to meeting you all and beginning what I hope will be a fruitful relationship.
With warmest regards,
Wesley J. Smith
Attorney at Law
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17. Faria MA Jr. Modern medical ethics. Vandals at the Gates of Medicine: Historic Perspectives on the Battle Over Health Care Reform. Macon, GA, Hacienda Publishing, Inc., 1995, pp. 255-263. 18. Arnett JC Jr. Bad ethics is not For the Patient's Good. Medical Sentinel 1999;4(5):182-183.
19. Meyer DH. Review of Forced Exit-The Slippery Slope From Assisted Suicide to Legalized Murder by Wesley J. Smith. Medical Sentinel 1999;4(6):228.
20. Arnett JC Jr. Critical analysis of Wesley J. Smith's Culture of Death: The Assault on Medical Ethics in America. Medical Sentinel 2002;7(2):48-49, 57.
Dr. Faria is editor-in-chief of the Medical Sentinel, author of Vandals at the Gates of Medicine (1995), Medical Warrior: Fighting Corporate Socialized Medicine (1997), and Cuba in Revolution --- Escape From a Lost Paradise (2002).
Mr. Smith, author of Forced Exit: The Slippery Slope From Assisted Suicide to Legalized Murder (1997) and Culture of Death: The Assault on Medical Ethics in America (2000), will be the featured guest speaker at the 59th annual meeting of AAPS this fall in Tucson, Arizona.
Originally published in the Medical Sentinel 2002;7(2):44-47. Copyright ©2002 Association of American Physicians and Surgeons.