The Return of the Physician-Executioner

September 2001By David C. Stolinsky

David C. Stolinsky, M.D., who is of the Jewish faith, lives in Los Angeles. He is retired after 25 years of medical school teaching at the University of California at San Francisco and the University of Southern California.

Culture of Death: The Assault on Medical Ethics in America.  By Wesley J. Smith. Encounter Books. 285 pages. $23.95.

I will give no deadly medicine to anyone if asked, nor suggest any such council; and in like manner I will not give a woman a pessary to produce abortion.

— Hippocrates, “Father of Medicine,” c. 460-377 B.C.

Since neither a newborn infant nor a fish is a person, the wrongness of killing such beings is not as great as the wrongness of killing a person.

— Peter Singer, Professor of Bioethics, Princeton University

For millennia society assigned to physicians the task of saving life; if killing people was deemed necessary, that task was given to executioners. How these two opposite roles became confused is recounted by Wesley Smith, an advocate of the rights of the disabled. His book is well written and amply documented. But for me as a physician and the nephew of a Holocaust victim, reading it was alarming.

Smith introduces us to the leaders of the bioethics movement — and it is a movement, not an academic discipline. The best known is Peter Singer, who equates humans with animals and would allow parents to kill imperfect babies up to one month (later increased to one year) old. Nevertheless, Singer was chosen to write the article on ethics for Encyclopedia Britannica. It is distressing that he could hold views diametrically opposed to all monotheistic religions, and even to most people’s idea of secular humanism, and yet be embraced by many scholars.

Most bioethicists condemn paternalism, but they oppose it only when it is directed toward saving life. Thus it is “paternalism” for a physician to use his understanding of science in deciding what is best for his patient. Yet it is not “paternalism” for the ethicists (mainly upper-middle-class white males) to use their own subjective values in deciding who is unworthy to go on living. This decision may be affected by how closely the patient resembles the ethicist in age, appearance, and mental or physical ability. Unborn babies, infants, the elderly, the deformed, the disabled, the poor, and the mentally impaired do not resemble ethicists — unless one discerns that they are all in God’s image, which of course requires what Singer calls religious “mumbo-jumbo.” If a skinhead declares that those unlike himself are unfit to live, it is called racism; if a professor does so, it is called bioethics.

Smith reminds us that a cousin of Charles Darwin coined the term “eugenics” in 1883 and proposed selective breeding of humans on a purely utilitarian basis. The eugenics movement gained favor among the elites of America, Britain, and Germany in the early 1900s, much as the euthanasia movement is doing today. A milestone on the downhill road was the publication in Germany in 1920 of Die Freigabe der Vernichtung lebensunwerten Leben (Permission to Exterminate Life Unworthy of Life). The “unworthy” included the incurably ill, the mentally ill or retarded, deformed children, and the comatose, while the killing was to be “healing treatment” administered by physicians. For the first time, killing and healing were intermingled. Moreover, a physician’s loyalty was no longer to the individual patient but to “society” or the state.

Revealingly, once the Nazis took over Germany, medical graduates no longer took the Hippocratic Oath, but an oath to the health of the state. Most American medical graduates also no longer take the Hippocratic Oath, but a variety of other oaths, including one that refers to “humanity” but mentions neither abortion nor euthanasia. I believe the chief cause of the Hippocratic Oath’s demise is its ban on abortion. But in the quotation at the beginning of this review, only a semicolon separates euthanasia and abortion. Discarding the second prohibition has weakened the first. If all human life isn’t sacred, none is. Intermediate positions are weak and are being overrun, one by one. Who is worthy to go on living then becomes just a matter of opinion.

The phrase “life unworthy of life” was used by the Nazis, but it originated before the Nazi Party was founded and anyone had heard of Hitler. Nazism was a seed that fell on soil that had already been fertilized by the manure of viewing human beings not as having intrinsic worth because they are created in God’s image, but as having worth only insofar as they are useful to others. Those who now spread similar manure will not be able to claim innocence if similar seeds should sprout.

The Nazi euthanasia program utilized drugs, then gas, and was the physical and psychological prelude to the Holocaust. It was opposed so strongly by Catholic and Protestant Churches that it was stopped, though it continued unofficially. Sadly, there was no organized opposition by physicians, many of whom were Nazi Party members. One should not expect moral leadership from physicians.

Singer protests that he is unlike the Nazis because he is a social democrat, as if morality depended on political labels, and because his motives are different. Yet he asserts that infanticide at the request of the parents is ethical if it will promote the interests of the family or society. The father of Baby Knauer, the first person “euthanized” by the Nazis, stated, “Later, we could have other children, handsome and healthy, of whom the Reich could be proud.” Where, precisely, does this view differ from Singer’s? Singer says that babies are “replaceable.” This view is refuted not only by religion but also by genetics. No two humans have the same genetic make up except for identical twins, and even here environment causes differences — even middle-school students know these facts.

Smith describes partial-birth abortion, of which 3,000 to 5,000 may be performed annually, and dehydration of the cognitively disabled, which is now common practice in America. He quotes Dr. Fred Rosner, an opponent of starving and dehydrating patients to death, as protesting that this “attacks the very foundation of medicine as a profession.” To me, this is a crucial problem. If physicians are no longer independent professionals, exercising their best judgment for the patient’s benefit, but mere technicians hired by HMOs or the state, surely there will be fewer problems for administrators, regardless of what they are administering. Lest this worry seem paranoid, note the case of a man brain-damaged in an auto accident but able to maneuver his wheelchair down a corridor. His wife wanted to dehydrate him to death. The case reached the California Court of Appeals, which ruled, “there should be no presumption in favor of continued existence.” Accused murderers are presumed innocent until proved guilty, but the disabled must have their “continued existence” argued from a neutral standpoint. As Smith says, death is becoming a value judgment, not a biological event.

The book goes on to discuss autonomy, competence, substituted judgment, “rational” suicide, “terminal” illness, the use of unborn babies or the disabled as organ donors, the importance of animal research, as well as the “duty to die,” health-care rationing, and “futile-care theory” — and the economic benefits of shortening the lives of the disabled (the university president who appointed Singer is an economist). Interestingly, in America only 15 percent of those who die have hospice care, while in Britain, where hospice care is free, 65 percent do so (but was active care abandoned prematurely to cut costs?). In Britain only one request for euthanasia was received from about 1,800 AIDS patients in a hospice. Polls show that 40 percent of Americans would hasten their own deaths to avoid being a burden on others, but only 14 percent would do so to end their own pain. If we cannot do as well as the underfunded British National Health Service, but respond to fear of being a burden by killing the patient, what does that say about us?

Smith takes note of Cicely Saunders, a British nurse and devout Anglican. She cared for a Polish Jew who had escaped from the Warsaw Ghetto but lay dying in a London hospital. Saunders identified with him, despite their different backgrounds, then extended this empathy to all the weak and dependent. She became a physician and inspired the hospice movement. For her work she was knighted by Queen Elizabeth. Peter Singer — an avowed atheist — learned that his grandfather had been murdered in the Holocaust. Rather than identifying with his own relative, he apparently identified with the strong and the self-sufficient. He went on to equate humans with animals and justify killing imperfect babies and brain-damaged adults. For his work he was appointed a professor at Princeton. What people learn from life’s events reveals more about the people than about the events. Whom we select to honor reveals much about us.

In a secular culture life has no meaning beyond itself, so loss of health becomes terrifying indeed. In a culture that worships youth, beauty, and physical fitness, the elderly, the unbeautiful, and the disabled may be seen as abhorrent. Physicians too are afraid of disability, as shown by their rating disabled patients’ quality of life lower than the patients themselves rate it. The healthy are poor judges of what is unbearable. Our denial of biological death and urge to be in control are threatened by naturally occurring death, the final proof that we are not in control. These repressed fears may be projected onto the patients, making it unclear whether physicians wish to hasten their deaths in order to relieve suffering or the physicians’ own uneasiness. Physicians then would never recognize that a patient’s expressed wish to die may really be a complaint about inadequate care or an appeal for reassurance that his life is still valued, rather than an autonomous request to be taken literally.

Peter Singer defines a “person” as one who is rational and anticipates the future. A good test of rationality is the ability to learn from experience. Have we learned anything from 2,400 years of Hippocratic tradition? Have we learned anything from psychiatry about repressed fears and projection? Have we learned anything from the hospice movement about adequate palliative care? Have we learned anything from the Netherlands, where over 1,000 patients are “euthanized” annually without their consent, and where psychiatric illness is now an acceptable cause for euthanasia? Have we learned anything from the Holocaust? Can we not see where the current Culture of Death is heading? If not, can we claim to be rational and to anticipate the future? By Singer’s criteria, do we qualify as “persons”?

Smith quotes Fr. Richard John Neuhaus: “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 justifiable, until it is finally established as the unexceptional.” When I graduated from medical school in 1958, “physician-assisted death” meant a concerned doctor committed to caring for the patient until the end. That it now means something quite different is not a source of joy. Over 3,000 years ago, we were instructed in Deuteronomy, “I have put before you life and death, blessing and curse. Choose life…” (30:19). We would do well to heed this lesson, rather than the teachings of “ethicists” who cannot distinguish human babies from fish.

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