Culture of Death. Wesley J. Smith

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Culture of Death - Wesley J. Smith

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is already happening. People with disabilities are seriously discriminated against in health care as well as in other areas of life.”110

      Coleman is no alarmist. Bioethicists widely embrace the “quality adjusted life year” (QALY) approach to health care rationing—one of the destinations to which the quality of life ethic would take us. Here’s a brief—and very simplified—overview of how the QALY system operates: Let’s say I have a serious heart ailment. Medicine A will give me two years of life at my current quality of life as an able-bodied man. That would be worth roughly 2 QALYs (fewer if I am elderly, but let’s not get too complicated here).

      My friend Mark has MS and is a triplegic. Let’s say he contracts the same heart illness I have, and Medicine A would also give him two years of life at his current level as a man with a serious disability. Because he only has the use of one arm, his two years of actual life might only be deemed a .5 QALY.

      The cost/benefit for providing the medicine is determined by a QALY formula to judge whether the cost of Medicine A is worth the number of QALYs it would provide. Let’s say that the total cost of the heart medicine for two years is $100,000 for 2 QALYs. The technocrats in charge of the rationing system might think this price is worth paying for my care.

      But even though Mark would receive the same actual efficacy from the medicine, his supposed lower quality of life changes the equation dramatically. Mark might be denied coverage for the medicine because the $100,000 would only pay for .5 QALY: pure health care discrimination.

      The United Kingdom already imposes the QALY system on the National Health Service. It isn’t yet used in the United States. Indeed, the Affordable Care Act prohibits using the QALY system in its eventual goal of establishing cost/benefit guidelines. But note: that prohibition might not stand. Powerful forces wish to repeal that protection in the law and import QALY rationing to America, including the New England Journal of Medicine.111

      As this book will document, the growing acceptance of the quality of life ethic has already led to immoral and life-devaluing public policies and medical practices—with more threatened—undermining the virtue of our public policies and the ethics of health care.

      The Georgetown Mantra: Having rejected the sanctity/equality of human life, the Hippocratic tradition, and concepts of objective right and wrong, bioethicists realized they needed to forge new analytical guidelines that would “be respected unless some strong countervailing reason exists to justify overruling them.”112 This need was filled in 1979 by the philosophy professors and bioethics pioneers Tom L. Beauchamp and James F. Childress in their book Principles of Biomedical Ethics.

      Beauchamp and Childress posited four primary guidelines that have generally directed bioethics analysis ever since. The “four clusters of principles” are:

       • Autonomy: “respecting the decision making capacities of autonomous persons”;

       • Beneficence: “providing benefits and balancing benefits against risks and costs”;

       • Nonmaleficence: “avoiding the causation of harm”; and

       • Justice: “distributing benefits, risks, and costs fairly.”113

      Since bioethics is generally a relativist pursuit, these four principles are not cast in stone but merely “general guides that leave considerable room for judgment in specific cases and that provide substantive guidance for the development of more detailed rules and policies.”114 Still, they are taught in medical schools, nursing schools, medical professional continuing education courses, short bioethics courses given to members of hospital ethics committees, community patient ombudsmen, hospital administrators, health insurance executives, and, indeed, to almost everyone who has taken a course in bioethics in the last twenty years. “The four-principle tradition is now so widely accepted,” Dr. Pellegrino wrote, “that some of its more whimsical critics have labeled it a mantra, implying that it is often supplied automatically and without sound moral grounding.”115 The influence of the Georgetown Mantra (so called because of the author’s affiliation with Georgetown University) in the application of bioethics in health policy and clinical decision making is hard to overstate.

      There is of course nothing inherently wrong with any or all of the guidelines that make up the Georgetown Mantra and very much that is right with them. But in the relativist context in which they exist, unanchored in objective morality (such as equality/sanctity of life), these guidelines are entirely malleable and subject to manipulation in order to justify an answer desired by the ethics analyzer. Thus rather than being proper guides for principled decision making, as was envisioned by their creators, the guidelines are often reduced to mere outcome justifiers: A bioethicist or medical clinician decides what action or inaction to take in a particular situation and then selects the particular Mantra guideline that best justifies the previously made decision. Thus the four guidelines can be manipulated to justify nearly any ends. (The same kind of unprincipled decision making sometimes happens in law. A lawyer may sense that a judge wants to make a favorable ruling, despite it being contrary to the weight of law. The lawyer then looks for any law or previous court ruling for the judge to use as a cover to rationalize the already made decision. Among lawyers, this is known as “providing the judge with a hook upon which to hang his hat.”)

      The ultimate amorality of the Georgetown Mantra is amply illustrated by an article written by K. K. Fung, PhD, in the American Journal of Economics and Sociology entitled “Dying for Money.” Fung, a professor of economics at Memphis State University, recommended allowing seriously ill and disabled people to convert their health insurance benefits into a lump-sum cash payment—at less than the market exchange rate—if they agree to commit assisted suicide. How did Fung justify such an odious, exploitative proposal? Why, with the Georgetown Mantra:

      Benefit conversion coupled with dignified death go a long way towards resolving these conflicting principles [of the Mantra]. Because resources released from one patient’s refusal of medical treatment (autonomy) can be specifically requested to be used for other patients or beneficiaries with greater need (full beneficence), autonomy and full beneficence need not conflict. Once the patient is allowed to choose death, the caregiver does not have to impose treatment for fear of malpractice liability. Thus, patient-centered beneficence is satisfied. Since benefit conversion is equally available to all who are insured, and the amount of converted benefits varies only with the severity of the illness, justice is also served. All that remains to be done is to educate the terminally or chronically ill how to allocate their converted benefits once death is chosen. Because these four ethical principles [of the Mantra] are largely taken care of, the sense of tragedy connected with the death and denial of treatment to the hopelessly ill can be mitigated.116

      As to the abuses that even Fung admits would follow if his proposal were accepted, they are of little concern. Proving that economists can be as amoral as bioethicists, Fung shrugs, “the world is full of slippery slopes.”117

      Bioethicists are fond of pointing out that there is no going back to the era when the West was culturally homogenous and primarily Judeo/Christian in outlook, or to a time in which health care decisions were relatively simple. They note correctly, the United States, Canada, and Western Europe are now fundamentally heterogeneous societies, racially and culturally mixed, and fundamentally secular in civic and public policy outlook. Moreover, they argue, the era in which medicine was primarily concerned with keeping people alive for as long as possible and public health policy sought essentially to uphold a (misapplied) religious approach to the sanctity of human life is archaic in a Darwinian world in which too many people compete for too few resources.

      The purposes of modern medicine have indeed expanded beyond preserving life, treating maladies, and promoting wellness. Healthcare is now deemed to achieving

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