How to murder a Bolivian boy.(Critical Essay)

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,(1) 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 dearly 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?