domingo, 26 de junio de 2016

BioEdge: Interview: Dissecting the age of ‘do harm’ medicine

BioEdge: Interview: Dissecting the age of ‘do harm’ medicine


Interview: Dissecting the age of ‘do harm’ medicine
Wesley J. Smith is one of America's leading commentators on bioethical issues, especially assisted suicide and euthanasia. His columns are published in the National Review and he is the author of 14 books. BioEdge interviewed him about his latest, Culture of Death: The Age of “Do Harm” Medicine.
BioEdgeThis is a thoroughly revised edition of a book you published 16 years ago. In your view, is there less respect for life in American medical culture now? Are there any bright spots?
Wesley J. Smith: There is less respect for human equality and the sanctity of life in healthcare generally, I fear, and not only in the U.S. Indeed, I changed the subtitle of the book to “The Age of ‘Do Harm’ Medicine” because it now grapples with developments outside the United States as well as in my own country. We are all connected, so that what happens in Canada impacts Australia, what happens in the USA can have a pull on South Africa.
I have observed in the 15 years since the first edition of Culture of Death, that throughout the developed world and the West we see a terrible and increasing disrespect for the intrinsic value of the most weak and vulnerable among us. Euthanasia has spread like a stain and grown increasingly toxic. For example, in Belgium medicalized killing is now coupled with organ harvesting—including of the mentally ill. Health care rationing, which is blatant and invidious medical discrimination, is a growing threat. Advocacy continues to discard the dead donor rule in organ transplant medicine, even proposals for the live-harvesting of patients with profound cognitive disabilities.
If there is a “bright spot,” it is to be found among the medical professionals—doctors, nurses, pharmacists, physicians assistants, etc.—who continue to resist these utilitarian bioethical agendas and work in the trenches of clinical medicine with an ongoing commitment to the wellbeing and equal value of all patients.

BioEdge: A serious problem in dealing with issues like stem cell research, surrogacy, futile care and so on is that people (including politicians) just don’t seem to be interested – at least until it touches them. How can we get voters and policy-makers to think about these issues more deeply?
Smith: It’s a difficult problem. The popular media is increasingly tabloid in its approach to reporting. It is the rare story that informs the general population about the threatening and radical ideas emanating from the academy, in the professional journals, and from among the leaders of the bioethical/medical establishments.
One of the purposes of the book is to help readers be forewarned of the potential threat they or their loved ones could face in a clinical setting—note, I don’t say will, but could—to enable them to mount a defense should an attempt be made to push a vulnerable patient out of the lifeboat.
Ironically, the media can be very helpful in such circumstances, because while the journalistic sector does a terrible job generally of reporting about bioethical issues—and are very boosting of assisted suicide—they often cast klieg lights on individual cases of medical oppression against particular patients, which can personalize the issue in such a way as to gain the attention and sympathy of the general public.
The great disinfectant of “light” can be very powerful at such times. Indeed, I am convinced this is why organ transplant medicine remains a generally moral and ethical enterprise. It is also the greatest defense against medical futility. Because the people generally reject such bad ideas and that acts as a popular bulwark against utilitarian incursions.
BioEdge: You have spent decades writing and debating about life issues. Amongst the hundreds of bioethicists you have read and interviewed, who represents represent the best and worst?   
Smith: There are several bioethicists whom I believe offer a splendid way forward in thinking about the complex issues with which bioethics grapples. First and foremost is the late Paul Ramsey. His concept of the “patient as a person,” was a crucial insight, indeed one that sparked one of the truly positive developments in bioethics, e.g., the right to refuse unwanted medical interventions. The problem we see in bioethics today is that many in the field want to treat some patients as non-persons.
I think Leon Kass brings a powerful intellectual advocacy for applying and analyzing bioethical issues through the prism of intrinsic human dignity, which was why his appointment by President George W. Bush to head the President’s Council on Bioethics met with so much criticism within the bioethics movement.
Dame Cecily Saunders, the great medical humanitarian who conceived the modern hospice concept is a great hero of mine. I was honored to interview her at St Christopher’s Hospice for the first edition of the book, and that material remains in this edition.
There are so many others worthy of mention. My friends William Hurlbut of Stanford quickly comes to mind, Jennifer Lahl of the Center for Bioethics and Culture, with whom I have worked closely, Richard Doerflinger, who helped me tremendously when I first became interested in the field, and my mentor in opposing assisted suicide, Rita Marker, head of the Patients Rights Council.
I hope it won’t hurt his reputation in the field, but I am fond of Art Caplan. We have crossed swords on more than one occasion and I often disagree with him. But he is very good on organ transplant issues. We co-authored a piece in USA Today calling for important reforms of hospice. I find him more open to contrary opinions than most, and willing to see the dangers in the policies he supports.
I disagree fundamentally with Thaddeus Mason Pope about everything, but respect his candor—he doesn’t sugarcoat the hemlock—and deeply appreciate the work he does in archiving various court cases involving bioethics around the world.
In terms of the “worst,” there are so many (he said with a chuckle)! Joseph Fletcher poisoned the field, in my view. Very toxic ideas, backed by magnificent persuasive writing skills. Peter Singer, whom I call “son of Fletcher,” popularized what I “personhood theory” in bioethics which devalues the intrinsic value of human life so invidiously. I am not a fan of Julian Savulescu, to say the least.
Sadly, I think one of the most influential, if crude, bioethical influences on society was Jack Kevorkian whose odious ideas of using euthanasia for utilitarian purposes and his more death-on-demand approach to assisted suicide have taken hold in places like Belgium and the Netherlands, and soon I fear, Canada. 
BioEdge: You describe bioethics as a kind of religion. What is the creed of this new faith?   
Smith: It is more an orthodoxy, I think. Unless a “bioethicist” has a modifier in front of her name, such as “conservative” or “Catholic,” most are very liberal politically, activist culture warriors, and utilitarian in their approach, either explicitly or in outcomes. The movement seems increasingly disdainful of religious belief as well. I think the most remarkable aspect of all of this is that the values of mainstream bioethics do not comport with the views of most people. And yet we are supposed to follow their “expert” lead in establishing crucial public policies and medical ethics. I think not.
BioEdge: Let’s peer into the future. What are the battles you are preparing for, the big issues?    
Smith: Assisted suicide and euthanasia are going to continue to be bioethical hot potatoes. Medical futility. Protecting medical conscience rights for health care professionals who wish to adhere to Hippocratic values is going to be huge internationally. I mean, if we are not careful, in 20 years one may not be able to find a doctor who would not be willing to kill you under some circumstances, which I find a very frightening prospect.
I think health care rationing will also become an increasing hot button issue in the US, particularly if Hillary Clinton is elected and the Affordable Care Act’s centralized control over American medicine becomes more centralized. And dealing with the ethical implications of CRISPR is going to be a daunting prospect.
BioEdge: In the new edition, you have added a chapter on transhumanism. Aren’t they just a bunch of harmless Trekkies?    
Smith: More akin to Star Trek’s tribbles, individually they are harmless, but if allowed to proliferate, could be deadly.
Like eugenics and bioethics before it, transhumanism is a top-down movement being driven from among the intelligentsia. I am not so much concerned about the development of transhumanist technologies or an actual “seizing control of human evolution”—as if we have the wisdom for such a task. But I think the values of the movement are explicitly anti-human exceptionalism, eugenic in outlook, would use genetic engineering to predesign offspring in the image and likeness of transhumanist goals, which would inhibit the individual freedom of designed progeny through the naked power of genetics.
On a more practical plain, transhumanist lobbying could divert resources away from practical concerns and toward quixotic or narcissistic quests. What is interesting is how transhumanism is becoming a materialistic religion, complete with prophets, eschatology, and a belief in eternal life in the here and now, rather than the great beyond.
How did Dylan put it? “You gotta serve somebody.” For transhumanists, that “somebody” is technology and the yearned for “singularity.” More like spitting into the howling winds of nihilism in my book.
BioEdge: I was pretty touched by your own experience with suicide, disability and care for the elderly. How have these experiences shaped your views?    
Smith: I got into this mess after a friend committed suicide under the influence of Hemlock Society literature. She killed herself on her 76th birthday, and I saw first-hand how the insidious Hemlock message convinced her that suicide was empowering.
I am currently taking care of my 98-year-old mother in my home, with serious Alzheimer’s. I have seen at very close quarters how devastating that disease is—it’s not just memory loss—and how easy it would be to manipulate her into a hastened exit. Coercion happens behind closed doors, which no “guidelines” can protect against.
I have been impressed with the importance of treating the dying as equals and “us” by my training as a hospice volunteer. The courage and fortitude of families I have observed caring for their dying loved ones regardless of the emotional cost touched me at a very fundamental place. The disability rights community has revealed, I think the power and dignity of resisting the dismissive and discriminatory attitudes too commonly seen in the medical context, which perceives the lives of people with disabilities are less worthy of total care than those of other people.
I especially appreciate their insistence that nobody should have to “earn” their moral value by possessing “characteristics” that those with the power to decide determine provide greater importance.
BioEdge: You can’t escape without a question about the US presidential election. Which of the presumptive nominees is more likely to wind back the “culture of death”?  
Smith: None of the above, I’m afraid. If Hillary Clinton becomes president she will accelerate current trends with great gusto, not only in the USA but internationally. I don’t think Donald Trump has thought—or much cares about—bioethical issues, and I am under no illusion that he will grapple with bioethics in any fundamental manner. However the election turns out, for issues I care most about, winter is coming. It’s just a matter of how cold that winter will be and how well we can insulate ourselves against the chill.
Wesley J. Smith is a lawyer and author who lives in San Francisco. He is the author of 14 books. The most recent is Culture of Death: The Age of "Do Harm" Medicine
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What does Brexit mean for bioethics?” is our lead story today. Given that the Leavers were not expected to win and that the pundits have widely different views of the future of the politics and economies of the UK and the EU, it is unwise to be dogmatic on the issue.
However, the question highlights the importance of Britain in the world of bioethics. Britain is the home of utilitarianism, which is the dominant philosophy in bioethical discourse at the moment. The medical and scientific establishment is dominated by a utilitarian mindset which has set the agenda for debates on embryo research, stem cell research and assisted dying around the world. As one cynical writer commented, “when it comes to bioethics, Europe might be better off without Britain”.
There is something in this. Although I am handicapped by a big language barrier, my impression is that from Norway to Italy there is much more depth and diversity in bioethical discourse across the Channel. The Greens and the Christian Churches are much more influential, to say nothing of Continental philosophy, which despises utilitarianism as vacuous and naïve. If England (the pundits all agree that Scotland will secede) loses its biomedical industry to the EU, perhaps utilitarian bioethics will lose some of its funding and its influence. That would be no bad thing, I think.
Sorry, guys, but BioEdge will be taking a holiday during July. Our next issue will be in the first week of August. 

Michael Cook



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BioEdge: Interview: Dissecting the age of ‘do harm’ medicine

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