In his book Culture of Death – The Assault on Medical Ethics in America, Wesley Smith takes issue with what he perceives as the systematic erosion of regard for the sanctity of human life in medicine. One of the main culprits that he makes out for this development is philosophical biomedical ethics. Culture of Death is a sequel to his Forced Exit – The Slippery Slope from Assisted Suicide to Legalized Murder (Random House, 1997), in which Smith had focused on the social, legal and institutional processes that have led to an increasing general acceptance of assisted suicide in the past decades. Both books are directed towards a general audience, and their author intends them as wake-up calls for the American public. Much of their argument is based on individual cases (and their media coverage) and on the author’s interviews with prominent participants in these debates.

Smith’s principal aim in his earlier book, Forced Exit, was to alert to the dangers that are inherent in any practice of legitimized assisted suicide and to prove the disquieting social reality of the much invoked “slippery slope”. Many of his arguments and cases feature again in Culture of Death – and the overlap is large enough to be wondering at times what exactly is the point of the new book. However, there are some important differences: Whereas Forced Exit was mainly concerned with the specific problem of assisted suicide and focused above all on its social background and implementation, Culture of Death has not only a much broader scope (e.g. it includes a chapter on animal rights), but has also identified a main culprit for the changing attitudes toward death in the medical profession, namely biomedical ethics.

Smith claims that bioethics contributed significantly to a development in the medical profession that he describes as leading to a broad acceptance of medical participation in terminating life. In drawing on writings of well-known bioethicists, e.g. on the topics of personhood, quality of life and distributive justice, he tries to establish that in some way or other utilitarianism is pervasive in most bioethical reasoning. Smith sees utilitarian ideology as promoting not only a dangerous shift in loyalty from the individual patient to society in general, but above all as supporting the arrogant devaluation of certain forms of human life. In particular, Smith points to the use of bioethical writings and definitions in court decisions, law-making and medical policy formulations, e.g. on what counts as “medical treatment” (e.g. providing nourishment through feeding tubes) or as “futile care”, – decisions that effectively turn philosophical hypotheses into social facts.

From the standpoint of philosophy, such observations are important, given that ethicists often tend to hover between seeing their role as purely theoretical, i.e. not to be constrained by practical, prudential considerations, on the one hand, and assuming confidently that their ethical expertise might help solve some urgent ethical problems in the practical realm on the other hand. Smith shows that bioethics clearly does not operate in a social vacuum and that therefore it better be careful with the ideas it promotes as well as the degree of confidence with which it does so – especially if these ideas affect whose lives will be judged worth living.

However, what makes his arguments in Culture of Death unsatisfactory at times is his insistence that everything boils down to the pernicious influence of a widely shared and philosophically based utilitarian ideology. Even though it is an interesting thought that much of bioethics that does not perceive itself as remotely utilitarian might nevertheless be buying unwittingly into utilitarian assumptions, this underestimates not only the philosophical complexities of the issue. Most of all, what gets largely lost in this kind of picture is the undeniable importance of the interplay between (i) the widespread social ideology that only a fully autonomous, non-dependent subject can have a life worth living, (ii) a health system that operates openly on a for-profit basis (as exemplified most glaringly in the HMO “revolution”), and (iii) medical technology that has expanded the scope of possible treatments enormously (and therefore made the question of limited resources much more pertinent). Explaining the receptiveness of the medical profession – that has generally not been too prone to fall under the influence of philosophers – to some ideas (but not others) proposed by philosophical ethics, requires such a broader perspective. Even though Smith is clearly aware of these issues, as especially shown in his Forced Exit, in focusing predominantly on the role of bioethics in Culture of Death he presents an unnecessarily skewed picture.

Copyright Heike Schmidt-Felzmann 2001.

Heike Schmidt-Felzmann holds graduate degrees in philosophy and psychology from the University of Hamburg, Germany. She is currently a doctoral candidate in philosophy and works on “Ethics in Psychotherapy.”

Categories: Philosophical