Bioethics — The Life and Death Issue

Since the time of Hippocrates (460-370 B.C.), the Father of Medicine, physicians have traditionally subscribed to doing no harm and prescribed what is in the best interest of their individual patients; in other words, putting their patients first. This concept is known as individual-based ethics.

The new bioethics movement, on the other hand, subscribes to population-based ethics, in which physicians become obligated to make decisions for their patients in concert with what is in the best interest of society or the state.

The above distinction is how the ethics expert and renowned attorney Wesley J. Smith frames the controversial debate in his book, Culture of Death — The Assault on Medical Ethics in America (2000): "Medical ethics deals with the behavior of doctors in their professional lives vis-à-vis their patients. Bioethics, as it has developed over the last few decades, focuses on the relationship between medicine, health, and society. This last element allows bioethics to espouse values 'higher' than the well-being of the individual and to perform the philosophical equivalent of triage. Because of the almost imperialistic view of their mandate, many bioethicists presume a moral expertise of breathtaking ambition and hubris. Many view themselves, quite literally, as forgers of 'the framework for moral judgment and decision making,' those who will create 'the moral principles' that determine how 'we are to live and act,' fashioning a 'wisdom' they perceive as 'specially appropriate to the medical sciences and medical arts'." (Smith 2000, pp.4-5)

Bioethics and the "right to die" movement are bolstered by those in government and academia who believe that health care resources are finite and scarce and thus should be allocated properly and rationed among the population. The old and infirm should yield to the young and healthy.

Smith explains, “Put more simply, bioethics seeks to create a new morality of medicine that will define the meaning of health, determine when life loses its value, and forge the public policies that will promote a new medical and moral order.” (p. 5)

The Individual-Based Ethics of Hippocrates

A recapitulation of the traditional ethics and legacy of Hippocrates is in order to better understand the current trend toward bioethics.

The bedrock of medical ethics, 2500 years after its proclamation by Hippocrates and his followers in the School of Cos in the fourth and fifth centuries B.C., reads in part:

"...I will follow that method of treatment which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel. Into whatever houses I enter I will go into them for the benefit of the sick and will abstain from every voluntary act of mischief and corruption...

"Whatever, in connection with my professional practice, or not in connection with it, I may see or hear in the lives of men which ought not to be spoken abroad I will not divulge, as reckoning that all such should be kept secret..."

As seen by the words of the Hippocratic Oath, active euthanasia was strictly proscribed by Hippocrates and his followers. The Oath of Hippocrates comprises the first set of precepts to formulate systematically a voluntary, self-imposed code of ethics — an edification of professional morality unsurpassed in history.

The oath also provides for ethical conduct in treating the ill and vulnerable and protects patient confidentiality, noble concepts heretofore unknown in any other profession, except the clergy.

Unfortunately, some of the newly compiled oaths of bioethics are not so faithful to the tradition of Hippocrates, and many medical schools have written or followed their own codes of ethics to "keep up with the times" so to speak. These modern codes almost universally have a tendency to subordinate individual autonomy to the collective, be it "the greater good of society" or the will of the state.

Not surprisingly,a controversy is raging regarding the direction that bioethicists have taken as it relates to medical ethics. Many medical ethicists believe that the ethics of the profession are being perverted and transmogrified through the trivialization and deliberate misinterpretation of the core principles of the Oath of Hippocrates. They also decry how his oath is being replaced with more up-to-date oaths that allow the applications of more flexible ethics (situational ethics and moral relativism) supposedly more attuned to the zeitgeist of the twenty-first century. This controversy corresponds with the switch from medical ethics to bioethics.

The medical editor Robert Lowes writing in The New Physician, the official journal of the American Medical Student Association, states: "Although reciting a pledge at graduation has become more widespread in recent years, the Hippocratic Oath isn’t necessarily hip among new docs anymore." Dr. Robert M. Veatch, director and professor of medical ethics at the Kennedy Institute of Ethics at Georgetown University in Washington, D.C., affirms: "Another major flaw in the [Hippocratic] Oath is a narrow individualism that fails to balance the needs of society. As such, the Oath offers no guidance to today’s health-care reformers." (Lowes 1995, p. 14)

Other more recent oaths have, therefore, been recited to assuage or circumvent "troublesome" passages in the Hippocratic Oath, like, for example, where the latter states, "I will prescribe regimen for the good of my patients according to my ability and my judgment and never do harm to anyone. To please no one will I prescribe a deadly drug, nor give advice which may cause his death."

The Oath of Lasagna, written in 1964 by the clinical pharmacologist Louis Lasagna, dean of the Sackler School of Graduate Biomedical Sciences at Tufts University in Boston, reads in part: "If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God." And, "I will remember that I remain a member of society...."

The trend toward bioethics and population-based ethics from individual-based medical ethics is obvious. Good intentions do not always lead to beneficence, but detrimentally to partisan politics as substantiated in Lowe’s article.

Bioethics and Population-Based Ethics

The recent revisions in the American Medical Association’s (AMA) code of medical ethics try to walk a tightrope balancing individual autonomy and the needs of society. The preamble to the AMA "Principles of Medical Ethics" states: "As a member of this profession, a physician must recognize responsibility not only to patient but also to society...." Furthermore, Principle 7 states: "A physician shall recognize a responsibility to participate in activities contributing to an improved community." One might ask, "So, what’s wrong with that?"

Many physicians and medical ethicists such as Jane M. Orient, M.D., professor of medicine at the Oregon Institute of Science and Medicine, the eminent pulmonologist Jerome C. Arnett Jr., M.D., and Edward Annis, M.D., past president of the AMA, agree that the attitude of trying to compromise on what should be absolute moral principles lead to a perilous slippery slope in the transmutation of medical ethics. More pointedly, the problem with compromising ethics and subordinating the individually based patient-doctor relationship based on trust between the patient and his/her physician to the purported needs of society, the community, and/or the collective good is that it opens the door to the transmogrification and perversion of medical ethics, and the subjugation of the individual to the collective and the profession to the state.

In authoritarian societies, bioethics may lead to physicians becoming merely an instrument of political control "for the good of society."

How, one might ask, does the present situation in America compare to that of Nazi Germany? How could civilized physicians be transformed into dark angels of death for the national socialist Nazis? In the highly civilized society of Germany, physicians participated in "direct medical killing and systematic genocide" because of lebensunwertes leben ("a life unworthy of life") — an "ethical" concept carried out voluntarily by German physicians under the auspices of the state for the good of German society. Over 200,000 German citizens died in this fashion before the Holocaust. Joseph M. Scherzer, M.D., who was cited in Vandals at the Gates of Medicine, writes, "Physicians were no longer caretakers of an individual patient, but rather promoters of the general health of the German people. Physicians were servants of the state rather than independent [Hippocratic] practitioners." (Faria 1995, p. 238)

The lessons of history sagaciously reveal wherever the government has sought to alter medical ethics and control medical care, the results have been as perverse as they have been disastrous. In the twentieth century, in the Soviet Union, in Nazi Germany, and in fascist Italy, medicine regressed and, after perverting the "ethics" of the medical profession, descended to unprecedented barbarism under the aegis of, or in partnership with, the state. German medicine’s dark descent into barbarism was a product of doctors willingly cooperating with the state at the expense of their individual patients.

The "Right to Die" Becomes the "Duty to Die"

An article in the New Oxford Review illustrates how "a right to die” easily becomes "a duty to die” once society labels some lives as “not worth living (lebensunwertes leben). Two case histories were briefly outlined.

In one instance, Harold Cybulski, visited by his family while in his hospital bed in Ontario, Canada, woke up from a coma just as his physicians were about to "pull the plug and let him go.” As the grieving family filed in, Cybulski’s two-year-old grandson ran ahead crying, “Grandpa! Grandpa!” Cybulski opened his eyes, sat up in bed, and reached down for the little boy."

In another instance, 83-year-old Marjorie Nightbert had suffered a stroke and, impaired of swallowing and possible aspiration, required a feeding tube. Her brother, who had durable power of attorney, instructed her doctors to withhold feedings. As Mrs. Nightbert starved, she began to request and a nurse gave her "a little milk." For this offense, the nurse was reprimanded. After fourteen days without food and water, a pro-life activist heard of the affair and brought the case before the state protective system and the attention of a judge who ruled in favor of the patient. Unfortunately, at a final hearing a different circuit judge ruled that Mrs. Nightbert was "not competent to ask for food" and ruled in favor of her brother. Mrs. Nightbert, unlike Grandpa Cybulski, died after another torturing two weeks of starvation.

Despite mounting stories such as these, article after article in the medical literature has subtly and not-so-subtly extolled the virtues of utilitarian (collectivist) ethics in its various incarnations (e.g., population-based medicine, shared ethics, futility of care, and distributive ethics). All of these proposals seek to submerge the heretofore supremacy of the individual-based ethics of Hippocrates for a collectivist (authoritarian) ethic in which the physician is no longer beholden to his individual patients, but to the greater, collective "good of society." This is necessary, medical professionals are told by the proponents of bioethics, because physicians must participate in the allocation of scarce and finite health resources (i.e., rationing). Traditional medical ethicists counter that if society has learned anything from recent history, particularly the closing days of the twentieth century, it is that death is the ultimate and most efficient form of rationing.

Increasingly physicians and hospitals in the United States, following the lead of countries with universal health care (socialized medicine), are being pressured to ration health care for the elderly and the seriously ill. And private insurers and managed care companies following the government lead are likewise participating in the "rational" allocation of resources.

Physicians serving on ethics committees in various specialties have been persuaded to legitimize medical care rationing under the concept of the "duty to die," veiled in the more euphemistic terms such as "futile care" or "end-of-life" care initiatives, leading to the same ends. For example, the "shared ethics" espoused by British bioethicists in the Tavistock Group reflect a growing collectivist attitude in bioethics that many medical ethicists believe is destroying the medical profession piecemeal and embrace a collectivist morality in which individual rights take a back seat to the prerogative of society, government, and insurers.

Some bioethicists, such as Daniel Callahan, director of the Hastings Center and author of Setting Limits, Medical Goals in an Aging Society (1988), Peter Singer, bioethics professor at Stanford University, and particularly John Hardwick, of East Tennessee State University, have openly insisted that elderly patients who have lived a full life have a "duty to die" for the good of society and the proper utilization of societal health resources.

Traditional medical ethicists, on the other hand, insist that the ethics of Hippocrates state that the doctor must place the interest of individual patients first, above monetary considerations, the medical professional's own self-interest or the interest of society. They maintain that the doctor must also reject utilitarian ethics; that he or she must place the interest of the individual patient above that of the collective, be that the third-party payer, the government, or the more lofty-sounding entities such as society or the "greater good.”

To do otherwise is the first step down a slippery slope of government-imposed rationing and active euthanasia.

Interestingly, Dr. Leo Alexander, an eminent psychiatrist and chief U.S. medical consultant at the Nuremberg War Crimes Trials described how German physicians became willing accomplices with the Nazis in Ktenology, "the science of killing." This was done we learn for the good of German society and the improvement of "the health of the German nation." And in this light Alexander addresses the critical question: "If only those whose treatment is worthwhile in terms of prognosis are to be treated, what about the other ones? The doubtful patients are the ones whose recovery appears unlikely, but frequently if treated energetically, they surprise the best prognosticators." Once the "rational allocation of scarce and finite resources" enters the decision-making process in the doctor’s role as physician, the next logical step is: "Is it worthwhile to do this or that for this type of patient"

As cited in the Medical Sentinel article, "Euthanasia, medical science, and the road to genocide," Dr. Alexander wrote "from small beginnings" the values of an entire society may be subverted, and "it is the first seemingly innocent step away from principle that frequently decides a life of crime. Corrosion begins in microscopic proportions." (Faria 1998, p. 79)

Many scholars believe that the movement of bioethics to transmute the traditional, individual-based ethics of Hippocrates into the utilitarian ethics and the rational allocation of resources is the first step down the slippery slope of determining who lives and who dies — rationing by death.

References

1. Annis ER. Code Blue: Health Care in Crisis. Washington, DC, Regnery Publishing, 1993.

2. Arnett JC Jr. The "Tavistock Principles" of medical ethics. Medical Sentinel 2001;6(2):63-65.

3. Arnett JC Jr. Bad Ethics is not For the Patient's Good. Medical Sentinel 1999;4(5):182-183.

4. Callahan D. Setting Limits, Medical Goals in an Aging Society. New York: Simon and Schuster, 1988.

5. Collison J. Just a human weed? Grandpa! Grandpa! New Oxford Review, April 1999, pp.23-25.

6. Faria MA Jr. Transformation of medical ethics through time. Parts I and II. Medical Sentinel 1998;3(1):19-21 and Medical Sentinal 1998;3(2):53-56.

7. Faria MA Jr. Euthanasia, medical science, and the road to genocide. Medical Sentinel 1998;3(3):79-83.

8. Faria MA Jr. Vandals at the Gates of Medicine — Historic Perspectives on the Battle Over Health Care Reform. Macon, GA, Hacienda Publishing, Inc., 1995.

9. Haydon S. Nazi eugenics disclosure sends Swedes into shock. The Washington Times, National Weekly edition, September 7, 1997, p. 24.

10. Humber JM, Almeder RF (eds). Is There a Duty to Die? Totwa, NJ, Humana Press, 2000.

11. Kim TF. Tavistock Group Proposal — 'Shared ethics' for all providers a Quixotic quest. Internal Medicine News, March 1, 1999, p. 5.

12. Lowes R. Swearing off the oath. The New Physician, April 1995, pp. 13-16.

13. Orient JM. Your Doctor Is Not In: Healthy Skepticism About National Health Care. New York: Crown Publishers, 1994.

14. Pellegrino ED, Thomasma DC. For the Patient's Good — The Restoration of Beneficence in Health Care. New York: Oxford University Press, 1988.

15. Smith WJ. Forced Exit — The Slippery Slope from Assisted Suicide to Legalized Murder. New York: Times Books, 1997.

16. Smith WJ. Culture of Death — The Assault on Medical Ethics in America. San Francisco: Encounter Books, 2000.

Written by Dr. Miguel A. Faria, Jr.

This article was written in 2002 but was edited and published exclusively for HaciendaPublishing.com on October 29, 2012. The article can be cited as: Faria MA. Bioethics — The life and death issue. HaciendaPublishing.com, October 24, 2012. Available from: http://www.haciendapub.com/randomnotes/bioethics-%E2%80%94-life-and-deat...

Copyright ©2002 Miguel A. Faria, Jr., M.D.

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Comments on this post

Ethics of Hippocrates

The principles of the Oath of Hippocrates are an ideal, not necessarily attainable in today's world of medical care, but the more physicians strive to achieve them, the better for their patients and themselves.

You mentioned the need to release information to third party payers, "contrary to what the Hippocratic Oath states, physicians routinely divulge patient information to third parties when the latter pay for the care." True, but in reality patients acquiesce, or rather are passive partners in this situation by entering in a contractual basis with the third party payers, so in effect they are giving, wittingly or unwittingly, tacit consent for physicians to do so, and therefore not a violation of the ethics of Hippocrates.

Admittedly, cost of health care has spiraled, but the difficulty of paying for needed medical care existed from time immemorial, even before the time of Hippocrates.And it will remain with us and worsen as patients in the zeitgeist of the times expect miracles whatever the cost (as most of the time someone else, as you adumbrated, pays). They are misled by "the great advances of science and medicine," frequently touted by the media.

Suffice to say and reiterate despite the problems we faced in medical care, the more physicians strive to abide by the individual-base ethics of Hippocrates, the better for their patients, the physician themselves, and society at large.

Your reply to the article is a very well thought out that reflects the view of many physicians in the trenches. As time allows, you are invited to use our search engine under Ethics of Hippocrates (or any other topic of your interest) to read some of my other articles and comment as you did on this one. Your thoughtful remarks would be very welcomed and may trigger further discussion— MAF

Reply to Dr Poulet

Actually, I can not disagree either with much of what you say! 
This article discusses bioethics vs medical ethics, and the individual-based ethics vs the collective, as an introductory essay on the subject. It was written for an encyclopedia sacrificing depth for clarity and comprehension. It does make a clear and fundamental distinction between the two ethical paradigms that must be consider by the physician in making clinical decisions.

The great fear is that the state or the third party payer may come in the decision making process, not on behalf of the patient's best interest, but in the context of financial considerations. The physician must consider his/her priorities in the interest of the patient first and the collective good second.

Therefore, "As cited in the Medical Sentinel article, 'Euthanasia, medical science, and the road to genocide,' Dr. Alexander wrote 'from small beginnings' the values of an entire society may be subverted, and 'it is the first seemingly innocent step away from principle that frequently decides a life of crime. Corrosion begins in microscopic proportions.'

"Many scholars believe that the movement of bioethics to transmute the traditional, individual-based ethics of Hippocrates into the utilitarian ethics and the rational allocation of resources is the first step down the slippery slope of determining who lives and who dies — rationing by death."

While it is true that a physician may be confronted with the dilemma of serving an individual patient vs society at large, I am yet to have seen a situation of a physician (except theoretical or in war) of having to make a decision that may favor one of his patients vs some other patient.

I Invite and welcome you to peruse some of my other articles on this subject and comment. Your comment in fact was informative, clarifying, reasoned, and very welcomed! MAF

P.S. On our search engine, please feel to use our useful search engine and the tags to locate them. For example search under: bioethics, managed care, medical rationing, duty to die, ethics of Hippocrates, euthanasia, veterinary ethic, health care reform, patient-doctor relationship, etc.