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 patients first. This concept is known as individual-based ethics or patient-oriented medical ethics.
Today’s bioethics movement, as actively being practiced in Canada, the Netherland, and many other Western countries, and some states in the U.S. 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. Medical ethics expert and attorney Wesley J. Smith the issue as follows:
“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 ‘especially appropriate to the medical sciences and medical arts’.”
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.
THE INDIVIDUAL-BASED ETHICS OF HIPPOCRATES
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...”
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 subordinate individual autonomy to the collective, be it “the greater good of society” or the will of the state.
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.
Robert Lowes writing in the official journal of the American Medical Student Association, states, “…the Hippocratic Oath isn’t necessarily hip among new docs anymore.” Dr. Robert M. Veatch, professor of medical ethics at the Kennedy Institute of Ethics 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.”
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 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… 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 submerges individual autonomy to the needs of society. The problem with that lies with the attitude of compromising absolute moral principles to the collectives and subordinating the patient-doctor relationship based on trust between the patient and his/her physician to the purported needs of society and the collective and yoking the profession to the state. In authoritarian societies, bioethics may lead to physicians becoming merely an instrument of political control.
How, one might ask, does the present situation in countries with assisted suicide and other forms of euthanasia, 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, before the war and before the holocaust, physicians participated in medical killing 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. A medical ethicist noted, “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.”
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 (for example, 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.” 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.
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... 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.”
In short, bioethics movement transmutes the traditional, individual-based ethics of Hippocrates into the utilitarian, population-based ethics providing cover for medical rationing and burgeoning a culture of death we are seeing today in “medical care.”
Dr. Miguel A. Faria is Associate Editor in Chief in neuropsychiatry and world affairs of Surgical Neurology International (SNI). This article is excerpted from his book, Controversies in Medicine and Neuroscience: Through the Prism of History, Neurobiology, and Bioethics (2023).
