There is nothing so foolish that some philosopher has not said it, and there is nothing so evil that some bioethicist has not proposed it. Indeed, the entire purpose of the new discipline of bioethics often seems to be the finding of bad reasons for worse conclusions. Bioethicists are ever on the lookout for new categories of human beings to kill or to allow to be killed.
The most famous bioethicists live and advance their careers by using the logic of the arms race or that of the transgressive artist. The painter who incorporates elephant dung into his pictures of religious subjects soon finds that there are painters who use nothing but excrement as a medium, and he is therefore obliged to scour his imagination for ever more obscene methods and subjects if he wishes to remain a member of the avant-garde. In a world of soundbites, moreover, there is no point in being only moderately offensive; there must be no holds barred if that notoriety which is indistinguishable from success in our world of shallow sensation is to be achieved. A bioethicist is unlikely, therefore, to reach the top of the greasy academic pole by suggesting that the Hippocratic injunction “First do no harm” is the beginning of wisdom for doctors. If he wants to get on, he must be prepared to decimate a countryside, at least in theory.
There is little doubt, of course, that the accelerating Prometheanism of modern medicine has generated ethical dilemmas faster than it has improved the quality of life. Patients with totally incapacitating head injuries who, fifty years ago, would have died, are now kept alive indefinitely by artificial means. Organs can be transferred from one person to another; prenatal diagnosis and in vitro fertilization are now routine; human cloning, parthenogenesis, and various forms of genetic engineering are just around the corner. Financial constraints and the vastly increased costs of medical treatment, moreover, appear to make it morally necessary for doctors to choose courses of action based not upon what is best for individual patients, but upon what will produce the most good for the money spent. In a world of inevitably limited resources, is the doctor not responsible for his husbandry of those resources?
In Culture of Death: The Assault on Medical Ethics in America,  Wesley J. Smith, an attorney for the Anti-Euthanasia Task Force, mounts a spirited defence of the traditional Hippocratic code: that doctors should do no harm, that they should never kill, that they should treat each patient with equal concern and consideration no matter his personal qualities, and that they should never presume to ask themselves whether their patient’s life is worth living. Mr. Smith’s fundamental point, which he illustrates with a wealth of individual cases, is that once these tenets have been abandoned in the name of a supposedly higher imperative, we are already some way down the slippery slope that leads to earthly perdition.
The main criticism of the traditional Hippocratic code is that it leads either to an absurd and cruel inflexibility or worse still (from the point of view of academics) to an inconsistency that destroys its intellectual credibility. For example, most doctors have refrained at some time from prescribing antibiotics to an old and terminally ill patient who has secondarily contracted bronchopneumonia (a disease known as “old man’s friend,” because it leads to an easeful death), even if such antibiotics would prolong his life by a few hours or days. The doctors have estimated on their patients’ behalf that the additional short period of life is not worth having, especially when put beside the missed opportunity of a mostly painless death. It is not really true, therefore, that doctors never, under any circumstances, pass judgment on the worth of their patients’ life. On the contrary, when they struggle with all the technological ingenuity at their disposal to keep someone alive who is clearly beyond hope of anything more than merely mechanical existence, they are liable to be accused of heartless officiousness. Perhaps the most celebrated instance of this occurred during the last illness of General Franco, when Spanish doctors connected the Caudillo to every conceivable life-support machine. The manner of his death alerted the world to the astonishing, if not always entirely beneficial, powers of modern medicine.
The criticism of the Hippocratic code, therefore, is that it fails to meet every case. It has been the self-imposed task of philosophers (who are increasingly insinuating themselves into hospitals and clinics) to find a new intellectual foundation for medical ethics. And in a world grown ever more crassly utilitarian and impatient of any activity that has no obvious practical application, the rise of bioethics came just at the right time to rescue the careers of moral philosophers, for, as the fetuses are aborted and the life support machines are turned off, no one will ever again be able to say that they, the moral philosophers, have no practical effect on the world.
Moral philosophers promised to deliver doctors from the self-contradictions into which the Hippocratic code led them: they would find the indubitable Cartesian proposition from which all ethical decisions would follow syllogistically. Let the moral philosophers into the intensive care unit and all would be, if not light exactly, at least intellectually consistent. What greater benefit could there be than that?
But, as Mr. Smith shows, an appearance of philosophic consistency often requires the most brutal of conclusions. Just as in Britain the very discomforts of the National Health Service are taken as evidence of its social justice (what, after all, could be fairer than that everyone should have to wait months or years for his operation?), so there are people who are so impressed by the repugnance of a conclusion that they are inclined to suppose that the reasoning that led to it must have been sound. There is no smoke without fire, and there is no ethically repugnant principle without logic.
The most famous exponent of the culture of death, the bioethicist pur et dur as it were, whom Mr. Smith quotes more often and extensively than any other, is Professor Peter Singer of Princeton University. He is both typical and influential, and stands for all that Mr. Smith abhors. Singer’s train of thought is to him what the cliff is to a lemming—with this difference, that while the lemming throws itself over, Singer throws other people over. He is the philosophic massacrer of the innocents, compared with whose suggestions Swift’s Modest Proposal was modest indeed.
Singer has one great disadvantage as a moral philosopher: he writes as if he has heard of human beings, but never actually met any. In his search for the objective Archimedean point from which all solutions to ethical dilemmas may be levered, he alights upon the proposition that all sentient beings are morally equal. Their pains and their pleasures are all to count in the felicific calculus of whether an act is good or bad, permissible, forbidden, or obligatory, and human beings are not to be granted special status merely because they are human: not a sparrow falls, it seems, but Professor Singer takes it into his all-encompassing calculations. And the welfare of an unknown child in Outer Mongolia is to weigh as heavily with us as the welfare of the child next door, from the moral point of view, because they are alike in their capacity to suffer and to enjoy. Geographical distance from us is morally beside the point. Presumably the Outer Mongolian is supposed to reciprocate by being as concerned about children near to Professor Singer as about those in the yurt next door.
Singer half-recognizes that, in a world of 6 billion people, so Olympian a standpoint is likely to impose a strain on most people. “Perhaps,” he writes with a disarming and unaccustomed degree of uncertainty, “a viable ethic must allow us a moderate degree of partiality for ourselves, our family, and our friends.” We may picture the scene: Professor Singer is proposing to the woman whom he wishes to marry. “Darling,” he says, “I have decided that you are the person towards whom I should like it to be morally permissable to show a moderate degree of partiality.” What decent, upright woman could resist such an overture? Unfortunately, Singer fails to recognize that the allowance of even this milk-and-water partiality (to say nothing of a more realistic allowance for what human beings are actually like) completely destroys the very basis of his philosophy.
When it comes to public affairs, Singer is not so much Descartes or Archimedes as Mrs. Jellyby. His Left-Bank-of-the-Borioboola-Ghaism follows from the principle (learned at the feet of the Oxford philosopher Jonathan Glover) that we are as morally responsible for the consequences of the omissions as for those of our acts: indeed, there is no difference between an act and an omission. Thus a man who doesn’t do all in his power to prevent illness or starvation he knows to be happening on the other side of the globe, but chooses instead to go to a first-class restaurant, is actually guilty of murder. According to Singer, it is the duty of every decent, moral person to devote every single cent of his disposable income, after his necessities have been met, to relieving the poverty and suffering of the world.
There are one or two difficulties in the way of this rather strenuous philosophy. The first is that the distinction between necessity and luxury is not altogether clear, even to Professor Singer. The blurb of his book, The Ethical Life, states that he lives in New York City, where accommodation is notoriously not cheap. Could he not live somewhere more economical and donate the difference to, say, the elimination of river blindness in Burkina Faso? According to his own principles, is not Professor Singer a self-confessed blinder of blacks?
Second, his assumption that it is easy to do unequivocal good with one’s donations, and that therefore the more one gives, the more good one does, is staggering in its ignorance of the world. Professor Singer believes that, if it costs $1 to feed a man for a week in a starving country, a donation of $100 will feed one-hundred men. There is only one solution to Professor Singer’s state of arrested development: a five-minute visit to Kinshasa Airport.
Let us leave aside the fact that by far the greatest epidemic of arsenic poisoning in the history of the world has been brought about in Bangladesh by the UNICEF-funded drilling of thousands of boreholes into contaminated water (poison a baby: buy a UNICEF Christmas card). Let us consider Africa, the poorest of all the continents, and therefore the greatest object of Singer-Jellyby types’ concern. It is an almost indisputable fact, now accepted by the principal donors themselves, that aid to Tanzania (which for a time was greater per capita than to any other African state) financed the removal by force of three-quarters of its rural population into collectivized villages by its local little despot, a trauma from which it has still not fully recovered. In other words, aid of the type recommended by Singer actually made possible a great crime, and Tanzania would have been much better off had it not received a cent of it. It is possible, moreover, that several civil wars in Africa—for example, in the Sudan—have been greatly prolonged by foreign aid. The little old ladies who raise money at church fetes are therefore, by Singer’s reckoning, mass murderers.
With regard to general culture, Singer is not so much Descartes or Archimedes or Mrs. Jellyby, he is Attila the Hun. He is a true barbarian, who does not see the point of civilization. In an effective but dishonest rhetorical maneuver, he several times cites a luxurious meal in an expensive restaurant as an example of frivolous expenditure that could and should be put to humanitarian purposes such as feeding the hungry. Luxurious meals have, of course, frequently been used as symbols of moral turpitude. For example, in one Chekhov short story, there is a description of a long banquet organized by a country district’s gentry, who eat far more than anyone could possible want to assuage their hunger, in order to raise money for relief of the famine raging around them. But the geographical proximity of the starving to the banquet surely does make a symbolic difference: to eat a good meal in New York while there is hunger in Ethiopia is not at all the same thing. And the symbolic difference could hardly exist unless there were a moral one.
If all expenditure beyond that necessary for one’s own subsistence is tantamount to murder, it is not only luxurious eating that would be impermissible according to Singer’s Calvinist utilitarianism. All artistic, scientific, and intellectual endeavor whatever that was not directed at the relief of hunger and poverty would have to be abandoned as mere callous self-indulgence. Indeed, if Singer or his philosophy had been in charge down the ages, man would still be living in the caves: for hunger and deprivation have always accompanied the rise to civilization. No Bach cantatas or Sistine Chapel for Professor Singer; for him it is strictly grub first, then culture. There is one real benefit that the implementation of his scheme would bring about: no one would buy his books, since philosophy is, ex hypothesi, a murderously self-indulgent pursuit. To buy a Singer book is to murder a baby in Bolivia who might have been saved by the diversion of its cost to medical treatment there. Since Singer’s books have sold by the hundreds of thousands, he has clearly been responsible for untold numbers of deaths. He should withdraw his books from the market at once.
The expensive comforts of modern medicine should not be available to us, according to Singer’s philosophy, at least until they are available also to the last Eritrean peasant. And it is our moral duty should we fall ill of a disease that can be cured or relieved only by expensive treatment to forgo it in the name of universal equity.
It is hardly surprising that when a reasoner such as Singer turns his attention to bioethical questions he should arrive at pitiless conclusions. The man who wants us selflessly to devote our lives and labor to the welfare of hundreds of millions of people whom we have never met and never could meet is like the fifth horseman of the apocalypse when it comes to the people—babies and old folk—next door. Instinctive revulsion to the positions he adopts might give pause to a lesser man than Singer, but he has more faith in his premises and his deductions therefrom than in the wisdom of the ages. He is a very modern man.
It was his discovery that men treated sentient beings abominably—especially animals raised for food—that caused him to lose his equilibrium. Starting from the premise that it was wrong to inflict suffering without good cause, he came too swiftly to the utilitarian conclusion that this was the only possible wrong. If a being were not capable of self-conscious suffering, it could be done no wrong. A new-born baby is not capable of such suffering, and therefore infanticide is permissible. The following beautiful thought occurred to him:
To take the lives of [infants], without their consent, is not to thwart their desires for the future. Killing a snail or a day-old infant does not thwart any desires of this kind, because snails and newborn infants are incapable of such desires.
Ontogeny follows phylogeny: at birth, man is a mollusc. Admittedly, Singer finds contingent utilitarian reasons for not doing away with baby, if that is what one feels like; for it so happens that there are many couples who would like to adopt it, and to kill it is therefore to deprive them of the satisfaction of their desires. But there is no inherent objection to infanticide: if potential adoptive parents should cease to exist, unwanted baby had better beware. And to justify his indifference to baby’s fate, Singer cites all the societies that have openly practiced infanticide, granting them a moral authority he would never grant his own society.
Since self-consciousness and sentience are for Singer the only characteristics that confer moral significance on living beings, he has to decide at what point it becomes impermissible to do away with infants. He suggests that it should be a month after birth: up till then, like customers given a cooling-off period by consumer-protection laws after a large purchase, parents should be allowed to dispose of their offspring if they are imperfect or inconvenient.
Now Singer admits that the dividing line is arbitrary: it is certainly not a scientific fact that babies achieve self-consciousness twenty-nine days after birth. The line, Singer says in a rare concession to reality, has to be drawn somewhere. But if, as he admits, the dividing line he has chosen is arbitrary, his entire pretension to a consistent and fully rational ethics falls apart. All we are left with is his personal taste for death. He will have nothing to do, however, with the idea that a baby’s life is sacred, because—as we have seen—he does not value it above a snail’s. Nor will he have any truck with the idea that a baby’s life is worthy of respect and protection because of the baby’s potentiality. What counts is what the baby is now, not what it might become, and for the moment it lacks self-consciousness. It does not follow from the fact that it will have rights that it has them now.
If Singer really believed this, could anyone sleep easy in his bed? It is true that in the morning we shall recover self-consciousness, but we are not self-conscious as we snore. If unselfconscious babies can be killed, so can unselfconscious adults, if, that is, we are to be consistent. It will surprise no one by now that Singer is a strong proponent of euthanasia. He is stung by the accusation that his ideas resemble those of the Nazis (his own parents were refugees from Austria after the Anschluss) and he draws attention to the difference between his own noble conception of doing people in and the ignoble one of the Nazis. His euthanasia will always be carried out for the benefit of the people killed, whereas the Nazis carried out euthanasia for the benefit of the race. Singer will kill people for their own good; the Nazis killed people for the good of others. Actually, the difference between Singer and the Reichsgesundheitsführer, Prof. Dr. Conti, is rather less than Singer supposes. As a matter of historical fact, the Nazi euthanasia program was first undertaken to relieve the suffering of individuals. Moreover, as Paul Weindling shows in exhaustive detail in his Health, Race, and German Politics Between Unification and Nazism 1870–1945, the Nazi denouement grew out of a long tradition and style of reasoning, some of which bears an uncanny resemblance to Singer’s.
It is simply not true that Singer’s conception of euthanasia is designed to benefit the individual rather than a collectivity. Some of the people Singer wants to kill are, by his definition, not persons at all, for example those in a persistent vegetative state: they are therefore people who, according to him, can have no interests, since only self-conscious beings have interests. They therefore cannot be killed for their own sake. If they are to be killed, then, it must be in someone else’s interest. People are thus to be killed because their families want it or to save the hospital or the government money, or to make available an intensive-care bed for someone who stands a better chance of returning to an independent existence.
It is worth examining Professor Singer’s views at length because he is so typical an example of the modern moral philosopher, whose reflections, instead of exerting an enlightening effect, exert a coarsening and brutalizing one. There are some modern moral philosophers who are less extreme than he, but also some who are more extreme. Ronald Dworkin is less extreme, for example: he believes in the sacredness of human life. But he also manages to persuade himself that the sacredness of human life is better protected by the permission of abortion and euthanasia than by their prohibition. This is because both, in his view, allow human beings the freedom to mold their own lives, the freedom that makes human life unique (as far as we know) in the universe. And because human life is sacred to him, he says that the decision to abort a fetus should never be taken for frivolous reasons. At the same time, the law should make no attempt to restrict a woman’s choice in the matter. But I find it hard to see how the decision could long remain a serious one in the absence of any social condemnation for taking it or of any legal restriction. Professor Dworkin evidently hopes for people who will behave well from sheer unadulterated inner goodness, uninfluenced by any social pressure or convention. T. S. Eliot wrote of the delusory nature of the belief in a society in which arrangements are so perfect that no one will have to be good, but it is equally delusory to believe in the possibility of people who are so good that society will have to make no arrangements to encourage virtue.
Mr. Smith has also managed to find ethicists who are more extreme than Professor Singer, for example those who believe that some patients have a duty to die. No doubt Singer will manage by a leap of philosophical imagination once more to overtake them, but for the moment Professor Hardwig of East Tennessee outdoes him. There are, according to him, “many cases [when] family members often ought to override those of the patient.… Only when the lives of family members will not be importantly affected can one rightly make exclusively or even predominantly self-regarding decisions.” In other words, old people, who, by refusing to die, so selfishly hold up the legacies that their children badly need in order to finish their swimming pool or pay for their Caribbean cruise, should be helped on their way by doctors with the whole family’s interest at heart.
It was all too predictable that the right to die would be succeeded by the duty to die. After all, there are no rights without duties. Mr. Smith demonstrates in his book how far philosophers have already succeeded in degrading the ethical sensibilities of doctors and indeed of society in general. In the imaginations of the bioethicists, anencephalics (that is to say, children born without brains) and those whom they revealingly persist in calling human vegetables loom disproportionately large, as if most doctors spent most of their time tending to them. They take extremely marginal cases as if they were typical, establish general principles from them, and then apply them across the board. Their arguments are driven by the conclusions they wish to reach, and their desire to reach these conclusions is itself driven by the need to have something new to say.
Hard cases make bad law; they also make bad medical ethics. The extreme difficulty of establishing a completely self-consistent system of such ethics means that to criticize any such system because it does not answer every conceivable case is therefore hardly to criticize it at all, a thought that is obvious to any mature person. The fact is that the Hippocratic tradition has served humanity well, and Mr. Smith convincingly demonstrates that its competitors are no more consistent in theory and vastly worse in practice.
- Culture of Death: The Assault on Medical Ethics in America, by Wesley J. Smith; Encounter Books, 285 pages, $23.95. Go back to the text.