Book review: Ethics undone

Culture of death: the assault on medical ethics in America Wesley J. Smith San Francisco: Encounter Books; 2001 285 pp. US$23.95 ISBN 1-893-55406-6 Modern hospital practice occasionally puts caregivers and families in agonizing quandaries. When a baby is born with severe defects that are likely to be fatal, are doctors and parents ethically obliged to employ heroic measures, regardless of cost? Can a doctor ethically help terminally ill patients in intractable pain kill themselves? When a woman in the last stages of pregnancy permanently loses all brain function, should clinicians use advanced medical procedures to keep her body going until the baby can be delivered? Is infanticide ever acceptable? What about zenotransplantation? Such bioethical questions have been the subject of considerable academic discourse in recent years. In this thought-provoking and contrarian book Wesley J. Smith makes the case that a cadre of academic bioethicists (especially bioethics patriarch Joseph Fletcher and Princeton University's Peter Singer) has influenced contemporary bioethical thinking and legislation with an overly utilitarian and even heartless stance that devalues human life. (They, in turn, argue that we can no longer rely on traditional ethics for answers to bioethical questions and propose a “new ethics” meant to protect the quality, rather than the sanctity, of human life.) An attorney for the Anti-Euthanasia Task Force, Smith attempts to make the case that the ethical foundations of modern medicine are relentlessly changing from a system based on a profound respect for human life into a system devoid of heart and soul — a system in which severely impaired people have not just the right but sometimes even the duty to die (as in futile care theory). He wishes to redirect thinking and public opinion with this book. The author's approach, distinctly contrary to the utilitarian stance usually taught in medical school and residency, argues for a viewpoint based on the inviolability of human life. The book discusses a wide-ranging series of issues, including euthanasia, infanticide, organ transplantation, brain death, futile care theory and animal rights in the context of medical research. Smith regards respect for the sanctity of human life in all forms as the primary bioethical imperative. He dismisses current utilitarian bioethical thought as spiritually and ethically bankrupt and refers to Aldous Huxley's Brave New World as an example of fiction becoming reality in contemporary bioethical thinking. Smith is concerned that mankind is in grave danger of losing its capacity to be compassionate, considerate and kind-hearted by embracing a view of life that favours the swift disposal of whatever is infirm, old, disabled or even just simply ugly and upsetting. In short, Smith worries that modern culture now tends to cheapen and reject human life that is imperfect or flawed. Although I found Smith's arguments interesting and even provocative, I frequently found myself disagreeing with him. For instance, Smith strongly argues against euthanasia in all settings, even in the situation of terrible pain in terminally ill patients, suggesting that improvements in pain management and palliation are effective solutions. Certainly much can often be done along those lines, but my own clinical experience is that sometimes effective pain relief in terminal cancer can be achieved only by using pharmaceutical agents to the extent that consciousness and cognition are substantially impaired. Although I agree that legalized euthanasia is not necessarily the appropriate answer, I would nevertheless be reluctant to collectively condemn those who help patients who request help in escaping the agony of terminal illness should the pain become unmanageable. This book will interest readers who wish to examine a coherent conservative perspective on contemporary bioethical issues. The book is full of medical vignettes to support the arguments forwarded, although I suspect that some stories involve malpractice more than deliberate clinical decisions based on actual utilitarian analysis. I disagree with much of what the author has to say, but I certainly must agree that Smith does a fine job of offering a viewpoint refreshingly different from that of current bioethical culture. His book is a well-written and well-argued critique of modern-day bioethical teachings aimed at the nonmedical public. Readers will find themselves reviewing their beliefs.

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