In the spring of 1975, C. Everett Koop, M.D., addressed a conference of Christian laymen in New Orleans on the topic of abortion—more specifically, on the implications of Roe V. Wade. Among the changes he foresaw were a growing acceptance of infanticide as the “treatment of choice” for defective newborns and an increasing resort to euthanasia. All of these things evolved within the context of a modern/postmodern world that no longer takes seriously the biblical teaching that human beings are made in the image of their Creator (Genesis 1:26).

After Dr. Koop, the connection between abortion and euthanasia—which Prof Hans Millendorfer of Vienna called “methods in which killing represents a solution”—was stressed by other authorities, some equally eminent, others less so. The pro-abortion forces constantly denied it—at least then. Now the infanticide of “defective” newborns has become common, usually by simple neglect and deprivation of nourishment, and euthanasia is on the march. Britain legalized abortion in 1968; soon afterward, the Spectator predicted that “The abortion wave of the ‘sixties will be the euthanasia wave of the ‘eighties.” It may not have come to pass so quickly in Britain, but in the United States we can fairly say that the abortion wave of the 70’s has led to a euthanasia wave of the 90’s. In the 21st century, the abortion wave is still washing over us, and the tide of euthanasia is rising.

In Culture of Death, Wesley J. Smith, an attorney for the International Anti-Euthanasia Task Force and a leading writer on medical ethics, identifies the growing prevalence of euthanasia as a “treatment of choice” in an ever-broadening range of “cases” (human beings), and demonstrates what the acceptance of euthanasia has already done to medical ethics and where these developments are heading.

In 1982, Prof Charles Liechtenthaler, a German physician and historian of medicine, wrote in “The Oath of Hippocrates” that “Our old ethical fixed stars are no longer visible. We are wandering in an ethical no-man’s-land.” Mr. Smith’s work shows us just how wide and barren this land has become. The Hippocratic Oath, with its vow neither to perform an abortion nor to give a patient a deadly remedy (even on request), was already rendered “inoperative” by the abortion culture. Now, its even more fundamental principle, “Primum non nocere” (“First, do no harm”), is all but forgotten. The former rationale for the promotion of euthanasia was mercy, which seemed so plausible at the time that its advocates did not shun the term “mercy killing.” Recently, as the term “killing” could not be purged of its unpleasantness, and as “patient autonomy” came to be a watchword, “physician-assisted suicide” has become the expression of choice. Of course, Mr. Smith is aware of the connection between abortion and euthanasia, but he explicitly avoids all reference to the former topic, apparently in the hope of gaining a hearing for his views on euthanasia without entangling them in the ongoing abortion debates.

On visits to the United States, both Pope John Paul II and the late Mother Teresa evoked the idea of a “culture of death.” Smith, having adopted the term for his book, shows that what was a prophecy of doom not so long ago is now a reality, and well on the way to becoming routine. Writing as though he hopes that his book will reach a wide public, Smith makes use of many touching personal anecdotes, damaged lives ready to be given over to a convenient death by overworked or overzealous health-care personnel. Some of these lives were saved by bucking the medical system, while others were lost because the system prevailed, or because their condition was hopeless and further care was futile. Although he writes soberly. Smith offers a gruesome vision of the future, which may explain why he has dedicated his book to “Ralph Nader: friend, mentor, visionary.” (Perhaps this dedication will reassure concerned readers that Smith is not just a garden-variety, reactionary conservative.)

According to Dr. Koop, the study of medical ethics during his medical-school days consisted largely of “medical etiquette”—lessons in how to treat one’s colleagues. Back then, the Hippocratic Oath was not merely a rote phrase recited at medical-school commencement ceremonies but was taken for granted across the profession—rather like the generic Protestant-Catholic-Jewish ethics of the larger society. Unfortunately, as has been the case in other areas of ethics (notably the sexual variety), things long taken for granted cannot long withstand the corrosive climate of postmodernity. In the absence of a powerful ethic based—like that of Hippocrates, Christianity, and Judaism—on the assurance of man being made in the image of God, the patient ceases to be a person possessed of a divinely endowed dignity and becomes a mere “case,” considered in utilitarian terms.

The old legal proverb “Hard cases make bad law” seems to have a medical corollary: “Hard cases make bad medicine.” Seventy-five years ago, as a noted French hematolbgist has written, medicine was relatively ineffective, but it was also relatively inexpensive. Now, it is vastly more effective but immensely more expensive. In the United States, medicine has virtually ceased to be a liberal profession and become just another aspect of commerce. Instead of being hopeless, hard cases have become too expensive, encouraging physicians to cut costs. In medicine, many cases —and virtually every case near the end of life—is deemed a hard case, and hard cases cost cold, hard cash—lots of it. The commercialization of medicine has led to an increased (if not altogether absolute) preoccupation with profit and, hence, with cost-effective practices. Traditional medical ethics made the patient’s well-being the physician’s first concern; the commercialization of medicine makes maximizing profit and limiting loss more important.

To this end, in the last decades of the 20th century, a concept called “futile-care theory” was developed. This concept drives the current assault on medical ethics in America, as Smith effectively demonstrates. The old Hippocratic ethic acknowledged that it is neither obligatory nor desirable to perform on patients procedures that will not benefit them. When “futile care” first appeared, many of us who are interested in medical ethics thought it merely a convenient way to state an old truth: Useless care is not required and should not be given. But in the interval between then and now, as Smith shows, futile care has taken on a dramatic new significance. The term has superseded the older word “mercy” as the slogan that increasingly justifies what we might call a utilitarian and cost-effective coup de grâce where hard cases are concerned.

In other words, futile care gives healthcare personnel power, first, to designate further treatment of a hard case as “futile,” then to terminate it, thereby saving the funds that could have been expended on the patient (and perhaps pocketing some of the cash in the process). Smith argues persuasively that futile-care theory may be the tool that will finish off the Hippocratic ethic. Indeed, when medicine replaces the “Primum non nocere” of Hippocrates with Emperor Vespasian’s “Pecunia non olet” (“Money doesn’t stink”), then it will have replaced what Dr. Liechtenthaler called “ethical fixed stars” with the all-important bottom line.

To the concept of futile care is added that of “life not worth living.” German euthanasia pioneers Karl Binding and Alfred Hoche introduced the term lebensunwertes Leben in their groundbreaking little book on euthanasia in 1920. For decades, it was regarded with revulsion in American circles as a rationalization for what the Nazi doctors did, first to ill and infirm Germans, then to Jews en masse in the gas chambers. In the 1930’s, euthanasia was paired with eugenics as poor racial specimens were prevented from reproducing—or even from living. In the context of Nazism and World War II, both terms were considered abhorrent. Now, euthanasia is already socially acceptable, and eugenics is certainly likely to follow.

Smith devotes some attention to the growing power of the animal-rights movement, led by the newly installed Princeton University ethics professor Peter Singer and Ingrid Newkirk of PETA (People for the Ethical Treatment of Animals). This movement, broadly speaking, wants to grant animals rights resembling those that belong to humans. The act of preferring humans to other sentient beings is branded “speciesism” (a new word coined to facilitate the acceptance of animal rights). If the principle of animal rights is adopted, then the longstanding policy of performing experiments on laboratory animals before trying them on humans will be reversed. (To some extent, it already has been.) Of course, it is self-evident that, if animals are the same as humans, then humans are the same as animals and should be treated as animals (cared for and nurtured as long as they are useful, and quietly done away with when they are no longer productive). As an added advantage, the animal-rights movement may retard advances in medicine, thus making “futile care” ever more relevant.

The rejection of one key belief ties euthanasia, futile care for human beings, animal rights, survival of the fittest, and, ultimately, eugenics together: the biblical doctrine that man, male and female, is created in the image of God. Although Hippocrates was neither a Jew nor a Christian, this conviction grounded his ethic. And it is the rejection of the same conviction that ultimately will mean that, as Smith’s book implies, “Anything goes.”


[Culture of Death: The Assault on Medical Ethics in America, by Wesley J. Smith (San Francisco: Encounter Books) 244 pp., $23.95]