Culture of Death. Wesley J. Smith
guidance.”97
Bioethicists and euthanasia advocates claim that modern infanticide differs from wartime German euthanasia because most cases in the Netherlands involve parental consent, while most German cases involved physician decision making without parental involvement. But this is a distinction without a significant moral difference. Infants are people, not chattel. Parents have no more right to decide to have them killed than do doctors, or, for that matter, government bureaucrats.
The first sentence of the Universal Declaration of Human Rights states, “Whereas recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world.”98 If that is true, it must apply to all of us, not just the healthy and able-bodied. Unless we want to devolve to the ancient morality that allowed disabled and unwanted infants to be abandoned on hills, we must condemn infanticide unequivocally, whether in actual practice, as in the Netherlands, or as a matter of “respectful intellectual debate,” as occurs within bioethics and among some euthanasia advocates.
DEHYDRATING COGNITIVELY DISABLED PEOPLE
Disabled infants are not the only ones at risk of medical cleansing. Today, in the United States, as a matter of almost medical routine, cognitively disabled people who receive their food and fluids medically through a “feeding tube” are intentionally dehydrated and starved to death, and it is deemed ethical and moral.
In few areas of modern medicine have bioethicists been so influential and destructive to the tenets of the equality of human life than in the care of brain-damaged, cognitively disabled people. First, they dehumanized them. Next, they gave moral permission to families and physicians to withdraw basic sustenance. Then, waving the medical consensus they forged like a bloody flag, they urged legal authorities in court cases and in statute writing to make dehydration a matter of the legal “right to die.” Due largely to the energetic efforts of bioethicists, causing death by dehydration to cognitively disabled people who receive their sustenance medically is legal in all fifty states.
The first individuals to be targeted for dehydration were people diagnosed as persistently unconscious. The medical term for this condition (coined in 1972) is “persistent vegetative state” (PVS), perhaps the only medical diagnosis that contains a pejorative—from which comes the dehumanizing term “vegetable,” as if any human being can be a carrot or a turnip. PVS is “a form of eyes-open permanent unconsciousness in which the patient has periods of wakefulness and physiological sleep/wake cycles, but at no time is the patient aware of him or herself or the environment.”99 People in PVS “are not terminally ill.” What they need to survive is simply what every other human being does: food, water, warmth, shelter, cleanliness, and movement (in their cases, by way of turning). With one crucial exception, these services are considered humane care, which can never be withdrawn ethically (although even that patient protection is now under attack in bioethics, as we shall discuss below).
That exception is food and water when it is delivered via a feeding tube, which is considered a medical treatment, not a basic human requirement. Defining artificial nutrition and hydration (ANH) as a treatment was a crucial step in crafting the medical culture of death. As will be described in more detail later on, medical treatment, unlike humane care, can be withdrawn or withheld from patients legally and ethically as a matter of respecting the patient’s personal autonomy—even if the decision is expected to lead to death.
Not too many years ago, it was considered unethical—indeed, potentially a criminal act—to stop feeding and hydrating an incompetent patient. Then, beginning roughly in the early 1980s, some bioethicists began to grapple with their belief that profoundly disabled and frail elderly people were living too long. At that time society would not have accepted euthanasia—and to be fair, some prominent bioethicists opposed mercy killing. (A few still do.) A consensus solution was required to solve this newly conjured “ethical problem.” Bioethicists found it in intentional dehydration. Thus, in 1983, Callahan wrote, “A denial of nutrition may in the long run become the only effective way to make certain that a large number of biologically tenacious patients actually die. Given the increasingly large pool of superannuated, chronically ill, physically marginalized elderly, it could well become the non treatment of choice.”100
For several years the debate raged among bioethicists as to the appropriateness of pulling feeding tubes from people diagnosed as persistently unconscious, who, after all, are not terminally ill. A few resisted the rising tide. Paul Ramsey, for instance, argued that only the “objective medical condition of the patient” should be considered when determining whether to cut off treatment, “not the subjective, capricious, and often selfish evaluations of the quality of future life that are often to the detriment of the most vulnerable and voiceless.”101 Ramsey’s point—a good one—was that when someone is actively dying and can no longer assimilate food and water, they will often stop eating. At such times, it is humane to allow nature to take its course by not forcing food and water on an unwilling patient; indeed, the practice is a proper and compassionate component of good end-of-life care in particular circumstances. But withholding sustenance from an aged or disabled person to cause death is simply wrong, as such decisions are not based on the patient’s actual medical needs but rather on the perceived moral worth of a human life.
Dr. Fred Rosner, director of medicine at Queens Hospital Center, also agued strenuously, if in vain, against countenancing intentional dehydration as an ethical medical act. Denial of food and fluids is different than other forms of care, he wrote in the New York State Journal of Medicine, because it is “biologically final”; that is, it can have only one result: death. Second, unlike surgery or other forms of treatment, “food and fluids are universal human needs.” Rosner worried that for physicians to remove food and fluids “attacks the very foundation of medicine as a profession.” He further suggested that just because nutrition is delivered through a tube, it “does not change into an exotic medical substance”; food and fluids do not become medical therapy simply because another person is needed to provide them.102
Ramsey, Rosner, and the relatively few others who fought against transforming ANH from humane care to medical treatment were unable to stanch the fast-running tide. And although Ramsey had been one of the first bioethics luminaries to promote the appropriateness of ceasing life-supporting medical treatment at the patient’s request, few of his colleagues were swayed by his doubts.
The advocacy of bioethics profoundly influenced court decisions and legislation on the issue of removing food and fluids from people diagnosed as persistently unconscious. In a 1983 California case, for example, an appeals court refused to sustain an indictment of doctors who had withdrawn food and fluids from a patient in PVS, citing bioethics literature as assisting the court in its reasoning.103 That case was soon followed up by another appeals court decision overturning a trial judge’s refusal to permit the dehydration of another man in PVS at the family’s request. Indeed, the court ruled, families can order doctors to pull feeding tubes from people in PVS without asking a supervising court’s permission.104
At about the same time, in 1986, the American Medical Association (AMA) issued a momentous ethical opinion. While asserting that doctors should never “intentionally cause death,” the AMA opined that it was ethical to terminate life support, even if “death is not imminent but a patient’s coma is beyond doubt irreversible.” In and of itself, that wasn’t big news. What was significant is that, for the first time, the AMA listed “artificially supplied . . . nutrition and hydration” as a form of medical treatment.105 Needless to say, despite the AMA’s declaration that doctors should never “intentionally cause death,” removing all sustenance necessarily causes that very result.
The ultimate legal blow came in the landmark United States Supreme Court case of Nancy Beth Cruzan, who, on January 11, 1983, lost control of her car on an icy road in Missouri and crashed. She was thrown from her car and landed facedown in a water-filled ditch. Nancy’s heart stopped, but paramedics revived her. Nancy’s injuries included profound cognitive disability: a diagnosis of PVS. While that diagnosis is disputed in some circles, there is no contradicting the fact that her care did not require “high tech” medicine. She