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Sexism in Baby Death Decision Case–or Cynical Use of Traditionalism?
Monday, November 9, 2009, 5:39 PM
Wesley J. Smith

This is rich: A pediatrician for a hospital wanting to cut off the life support of a baby because he is seriously disabled–although cognitively fine, as discussed here before–says that the hospitals like to follow what mothers want in cases such as this.  From the story:

The parents of the chronically disabled one-year-old, who can only be identified as RB, are locked in a court battle over whether he should be allowed to die. Prof Bush, a world-renowned expert in paediatric care, said both parents were ‘genuine, loving and caring’ and that he respected both their opinions. But he told the court: ‘As a paediatrician I think the views of the mother are something that should always be taken very, very seriously. ‘That’s not to trivialise the views of the father but I think most paediatricians would find it very difficult to overrule the views of the mother, unless there was clear evidence that the mother was unreasonable.’

That seems awfully convenient to me.  How many times have we been told over the last twenty years that there is no difference between the sexes ?  That point aside, I wonder whether–if the mother wanted the baby’s care continued and the father didn’t–we would be hearing that the mother just can’t face the facts because she is so invested in her baby.  We’ve certainly seen doctors and ethicists say that in other cases.  Indeed, futile care cases in Texas, Michigan (Baby Terry) and Washington (Baby Ryan) saw doctors/ethicists testifying to just that point.

Surely, cases such as this, where it is clearly no slam-dunk and one parent wants the child to live, that is where any benefit of the doubt should be honored.  What matters most is the baby’s interests and welfare, and I don’t think we are yet to the point that ethicists will say unequivocally that it is in the baby’s best interest to die when it he or she is cognitively normal and enjoys music, etc.

With this case, the dehydration/ventilator cases are moving from the cognitivey disabled being deemed lives too burdensom to live, to the physical.  It is a very scary time to be a disabled person who is expensive for which to care.


Killing for Organs: Should We Harvest Those Wanting Euthanasia or Due to Receive Capital Punishment?
Sunday, November 1, 2009, 10:57 PM
Wesley J. Smith

I have been warning that the drive has been renewed to expand the number of organ donors by opening the door to killing for organs, in this column about.  Now, another article in the journal Bioethics, by Christian Coons and Noah Levin, add new targets to the list of potential (killed-for-organs) donors–people who want assisted suicide and prisoners due to receive capital punishment.

First, they claim that the Dead Donor Rule (DDR)–that prohibits killing for organs–is untenable and should be rejected.  They go into a lot of detail about the reasons, but that, I think, is too arcane to deal with here.  Then they argue that if someone is going to die inevitably anyway, why not take their organs even though it causes death.  They illustrate their point with a silly mind game. From the article (link to Abstract):

A prospective killer buys a top-of-the-line ‘killing machine’ with all the latest bells and whistles. After it is turned on, the machine will terminate a victim in 15 minutes – and once it is turned on, it cannot be stopped.  However, after it is activated, one can choose or change the method by which the machine kills…Suppose our killer selects a victim and turns the machine on. Before the 15 minutes elapse, the victim…requests that the machine be set to ‘anesthetize and remove vital organs’…

While changing the setting is a clear violation of DDR, we submit that if saving the patient is impossible in this case, then the killer does no wrong by changing the setting at the victim’s request. It also seems clear that third parties – including doctors – would do no wrong by doing the same. Three conditions make termination by RVO [removing vital organs] compelling in this case: First, the victim’s fate is sealed – she will be terminated, and terminated at a known time. Second, the patient requests the method. Third, the use of this method does not cause more harm to self or other than other possible methods

This mind game then justifies killing for organs for people who want euthanasia or who are to receive the death penalty:

We take no stand on the permissibility of voluntary active euthanasia (VAE) or capital punishment (CP). However, where these practices exist, termination by RVO may meet the conditions outlined above. We take it as obvious that termination by RVO would meet the first two conditions. Termination by RVO need not hasten death. The method of termination should have no significant bearing on the time selected for termination. Additionally, patients seeking VAE and the condemned could autonomously express a wish to be killed by RVO without choosing death for the removal of organs.

They proceed to argue that so doing would not violate any recognizable rights:

If a patient opts for VAE in a society that permits it, and then chooses termination via RVO, it seems clear that no more harm is done to others than if he were terminated by any other means. Indeed, the effect on others is quite the opposite because termination via RVO can save multiple lives. Admittedly, the case is less clear when we turn to CP. Again, multiple lives may be saved if the criminal chooses and receives termination by RVO.

The authors eventually put in the typical hedge seen in papers of this sort, claiming:

[W]e are not committed to a policy that allows subjects of VAE or CP to choose death by RVO we are not committed to a policy that allows subjects of VAE or CP to choose death by RVO, but we maintain that it is irrelevant that such policies would violate DDR. To our minds, the only relevant concerns here are whether VAE and CP are justified practices and the worry that legalizing RVO in these cases will cause the public to believe that subjects are being involuntarily killed for their organs.

The main point of this article was to argue against the dead donor rule. But I think it’s implicit utilitarian amorality illustrates something very disturbing about the current trend in bioethics and our public philosophical discourse.  Arguing on behalf of killing for organs as a part of euthanasia and the death penalty is the logical destination of the current moral direction in which we are traveling;

  • in which choice matters, not life;
  • killing is only wrong when the killed is capable of–and does–wish to live; and,
  • human beings can be looked upon as objects and used instrumentally as mere natural resources, etc..

Accept those and other such premises, and the kind of thinking exhibited by these writers becomes inevitable. Indeed, to show you how far it has already advanced, the authors express the exact view of Jack Kevorkian, once an outcast and now receiving a hefty $50 K per speech, as his values are elevated into a matter for respectable discourse in a major professional journal.  Meanwhile, China has been roundly condemned for harvesting (and selling)  the organs of its executed prisoners. If any of these unfortunates gave consent, do we now say that tyranny did nothing wrong in those cases?

Unless we return to a bold and unapologetic embrace of human exceptionalism, these kinds of arguments will become more mainstream in bioethics and among the medical and legal Intelligentsia.  Once that happens, policy often follows.


Discard Human Exceptionalism and You Discard Universal Human Rights
Saturday, October 31, 2009, 1:24 PM
Wesley J. Smith

I  am very concerned that too many of us complacently believe that the reigning societal value under which we were raised–the sanctity/equality of human life–continues to control society. But that is no longer true. We are in the midst of an attempted coup de culture that seeks to supplant human exceptionalism with a toxic mix of utilitarianism/hedonism/radical environmentalism-scientism as the sources of our personal values and public policies.

Thus, I take every chance offered to issue the warning.  Today, I have a piece up over at the Church Report, in which I assert that rejecting human exceptionalism is to reject human freedom. From “Knocking Human Beings Off the Pedestal of Exceptionalism:”

Society’s belief in the unique moral value and importance of human life is under unprecedented assault. Most people still believe in human exceptionalism and are unaware that powerful social and cultural forces are working diligently to dismantle the sanctity of life ethic as the fundamental value of our social order.  But the time has come to pay attention.  If human life is knocked off the pedestal, universal human rights will be impossible to sustain.

I get into issues many people don’t dwell upon; bioethics and personhood theory, animal rights “panience,” materialistic Darwinism’s “species differences are irrelevant,” and radical environmentalism’s casting of us as the villains of the planet–all of which we have discussed here at SHS.  Then, I close with this warning:

These, and other, attacks on human exceptionalism are profoundly dangerous to human life and liberty. It is our unique moral status in the known universe that gives rise to both universal (human) rights. It is the sanctity of life ethic that compels us to care for the weak, vulnerable, and elderly among us.

Either we all matter equally, simply and merely because we are human—or our value becomes relative, our rights, and indeed, our continued existence—determined by the reigning power structure of the day.  After all, if we are merely another animal in the forest—or worse, the planet’s enemies—why should any of us be treated as if we have any special meaning at all?

I’m tellin’ y’all, I know what I am talking about here. Let us hope that forewarned is forearmed.


Bobby Schindler Wants to “Kill” the PVS Diagnosis
Monday, October 26, 2009, 1:33 PM
Wesley J. Smith

Nobody knows the pain of the culture of death more profoundly that the Schindler family.  First, Terri Schiavo–Bobby’s sister–was dehydrated to death because of her profound cognitive incapacity. Her cruel death, the family believes, badly undermined dad Robert Schindler’s health.  He died earlier this year.

The family, through the Terri Schindler Schiavo Foundation, has used their horror and pain productively as “celebrity victims” (Ralph Nader’s evocative term for people who become famous after suffering an egregious wrong), to advocate on behalf of human exceptionalism by standing firm against the quality of life ethic and on behalf of the equal moral worth of people like Terri.

Toward that end, Bobby has a column out today that gives examples of the unreliability of the persistent vegetative state diagnosis.  He also vividly reminds us of the consequences to the most vulnerable of writing them out of the human condition.  From his commentary:

To be clear: there is no indignity more final and brutal than forcing a living person to die the death of dehydration and starvation. Try to imagine the torture my sister endured in the last two weeks of her life. Being unable to defend herself, very likely aware of precisely what was happening and having absolutely no ability to escape it. For nearly two weeks, Terri was denied food and fluids. Not so much as an ice chip was given to her. It was pitiful, it was barbaric and it was clear that she was made to suffer. When my sister expired, she was a shell of her former self.

It is because of the suffering my sister and others endured that I believe the PVS diagnosis must be either reevaluated or completely abolished. With so many medical and neurological professionals admitting that there are inaccuracies and with the diagnosis being a death sentence, it is time to rethink disability and the way we regard it and our fellow human beings.

Bobby concludes:

In the United States alone, more than 50,000 people live with profound neurological or cognitive disabilities. They live, quite literally, at the pleasure and by the mercy of others. There is the very real possibility that a large number of those individuals have been misdiagnosed yet, they are living in the crosshairs. Wouldn’t reasonableness and a simple sense of humanity dictate that we stop forcing people to die miserable deaths, based on a diagnosis with such a tremendous margin of error?

If some people had their way, most or all of those 50,000 people would be dehydrated to death after (or perhaps, one day, lethally injected, which Jack Kevorkian advocates) a brief waiting period from injury.  That would be a profound moral wrong.  Bobby’s continuing call to conscience is a great service to his sister’s memory.


Hastings Center Article Opposes “Scripted” Medical Counseling
Wednesday, October 21, 2009, 4:22 PM
Wesley J. Smith

A blog article over at the Hastings Center opposes legislation that “scripts” what doctors must say during medical counseling. From the column by Howard Minkoff and Mary Faith Marshall, “Government-Scripted Consent: When Medical Ethics and Law Collide” (registration required):

The American College of Obstetricians and Gynecologists’ (ACOG) Committee on Ethics has noted that “free consent is an intentional and voluntary choice that authorizes someone else to act in certain ways . . . Consenting freely is incompatible with [a patient] being coerced or unwillingly pressured by forces beyond herself. It involves the ability to choose among options and to select a course other than what may be recommended.” Though physicians’ beliefs may be legitimate bases for recommendations, physicians are expected to avoid manipulation or coercion. However, potential for undue bias exists even when physicians frame their counseling carefully, since their choice of words, of emphasis, and even of body language unwittingly transmits bias.

So, this is against the end of life counseling in the House version of Obamacare, right?  Of course it isn’t!  It is about a South Dakota law requiring abortionists to tell women that their fetus is a distinct human being:

A recently enacted policy in South Dakota threatens to abrogate the process described above; a consent discussion grounded in dogmatic and uncompromising ideological speech is now the de jure standard in that state. Several articles have focused the medical community’s attention on these newly implemented requirements, which include a script that must be given to a woman prior to abortions. The script asserts, among other things, that the fetus is “a whole, separate, unique, living human being.” It also requires the physician to give the patient a description of all known medical risks of the procedure and statistically significant risk factors to which the pregnant woman would be subjected, including depression and related psychological distress and increased risk of suicidal ideation and suicide—none of which has been scientifically substantiated. In addition, a statement is required that sets forth an accurate rate of deaths due to abortions, including all deaths in which the abortion procedure was a significant contributing factor, and all other known medical risks to the physical health of the woman, including the risk of infection, hemorrhage, danger to subsequent pregnancies, and infertility. The probable gestational age of the fetus at the time the abortion is to be performed and a scientifically accurate statement describing the development of the fetus at that stage must be shared as well.

I don’t know anything about the SD law other than that the authors don’t like it.  But what about Obamacare end of life counseling scripting in HB 3200?   They’re against that too, right?  I might have missed it, but I haven’t seen any objections to that scripted counseling provision–required to be followed if providers want to be compensated for their discussion–from these authors in specific, or the Hastings Center, in general. 

Huh: Go figure.


Liverpool Care Pathway (UK): Deadly Danger of Treating Patients as Category Members Instead of Individuals
Sunday, October 11, 2009, 9:08 PM
Wesley J. Smith

Many hospitals and nursing homes in the UK have adopted something called the Liverpool Care Pathway, in which dying patients are sedated–whether or not they need it to control unrelievable pain, apparently–and then denied food and water until death.

Currently about 16.5  percent of deaths in the UK occur while sedated–which is far more than the hospice experts I have talked with have told me is necessary to actually alleviate suffering.  Indeed, they tell me sedation is rarely necessary in hospice practice  If that is true, and I intend to do some more research on this, the Pathway misuses the legitimate treatment of palliative sedation, and mutates it in some cases into a method of causing death, known as terminal sedation.  This means that sedation is sometimes administered, not because the individual patient actually needs the procedure, but because he or she has been reduced to a category member, and that’s how members of the category are treated.

That’s a prescription for disaster. And now, a woman was almost dehydrated to death after being put mistakenly on the Pathway.  From the story:

AN 80-year-old grandmother who doctors identified as terminally ill and left to starve to death has recovered after her outraged daughter intervened. Hazel Fenton, from East Sussex, is alive nine months after medics ruled she had only days to live, withdrew her antibiotics and denied her artificial feeding. The former school matron had been placed on a controversial care plan intended to ease the last days of dying patients.

Doctors say Fenton is an example of patients who have been condemned to death on the Liverpool care pathway plan. They argue that while it is suitable for patients who do have only days to live, it is being used more widely in the NHS, denying treatment to elderly patients who are not dying.

Why are we surprised? The Pathway is a blunt intstrument, and the uniqueness of each case is lost in the drugs sedating effects.  Even though its authors believed they had created a nuanced protocol, that is never how these things are actually applied in clinical practice.  Eventually, such “pathways” threaten to transform medicine into a paint-by-the numbers technocracy.

And look at what it took to save Hazel from dehydration:

Fenton was admitted to hospital suffering from pneumonia. Although Ball acknowledged that her mother was very ill she was astonished when a junior doctor told her she was going to be placed on the plan to “make her more comfortable” in her last days. Ball insisted that her mother was not dying but her objections were ignored. A nurse even approached her to say: “What do you want done with your mother’s body?” On January 19, Fenton’s 80th birthday, Ball says her mother was feeling better and chatting to her family, but it took another four days to persuade doctors to give her artificial feeding.

This is a consequence of surrendering care approaches to cost/benefit/best care bureaucratic panels.  It becomes an excuse to merely write people off, particularly in a utilitarian environment where “quality of life” may determine the way the patient’s life is perceived by caregivers.

How many Hazel Fosters have died by dehydration who might have lived, or who could have spent their last days–pain controlled but awake and aware–surrounded by family?  There is no way to know.


Obamacare: Richard “Old People Have a Duty to Die and Get Out of the Way” Lamm Wants Rationing
Sunday, September 27, 2009, 9:32 PM
Wesley J. Smith

Former Colorado Governor Richard Lamm got a bad reputation by stating in a speech some years ago, “We [meaning when we get old] have a duty to die and get out of the way.”  When I interviewed Lamm for the “duty to die” discussion in Culture of Death, he told me that he had not meant precisely what he said, rather that the immortality project is a mistake (I agree), adding as quoted on page 152:

The human way is to make way for the next generation by living our lives to the full, and when the time goes, letting go gracefully. That by no means translating into bumping off the infirm.

Maybe not, but then again, maybe so.  Lamm was an enthusiast for health care rationing back then, and he is even more passionately for it now as Obamacare looms.  From his article in the Huffington Post (where all radical bioethical ideas go to gestate):

Let me present a more positive case for rationing. I suggest that a society will not start to maximize its health case access and quality until it fully confronts the issues involved in rationing. It is my passionate belief that we can all have better health care through rationing.

That’s nonsensical on its face. We “all” won’t receive better care.  The people being rationed out–the frail elderly, profoundly disabled, and other expenseive patients for whom to care–not only won’t be getting “better health care,” they won’t be getting any health care at all, except of the palliative variety.

Lamm tries to put a respectable patina on this ugly fact:

All nations ration — some by price, some by queuing, and some by setting priorities. I believe a nation does not maximize its health care until it starts to ask the hard question: How can we prioritize our expenditures to buy the most health care for the most people? We should not apologize for rationing; we should promote it and advance it. We cannot explore the “opportunity costs” of limited dollars unless we admit that we cannot pay for everything for everyone and spend our limited money where it will do the most good. In a world of public policy, we cannot say “yes” unless we say “no.” It is an inevitable dialogue, and we ought to make a virtue out of necessity.

No one is saying that everything should be covered.  For example, cosmetic surgery isn’t covered by health insurance, nor should it be (as opposed to reconstructive surgery).  But that isn’t rationing: It is making people pay for their own purely voluntary procedures  engaged in for non medical reasons–e.g., to look prettier or younger.  That isn’t the same thing as a formal rationing system based on age or quality of life that will prevent undervalued categories of people from receiving necessary care based on invidiously discrmininatory attitudes reflected in rationing public policies.

So, I guess that Lamm does, in a certain way, want to “bump off the infirm” after all.  Or perhaps he just doesn’t see the crucial difference between “graciously” refusing life-extending treatment and being prevented from obtaining it by faceless bureaucrats when it is wanted.

One more point relevant to the Obamacare debate: Lamm’s view is wildly supported within the greater bioethics movement.  Indeed, the blog for the American Journal of Bioethics–which reliably reflects the attitudes and views of the mainstream bioethics movement–supports Lamm’s piece enthusiastically and wants “rationing” to cease being thought of as “a dirty word.”

Remember: These are the people who would be appointed to the cost/benefit rationing panels if Obamacare is passed.  Add it all up and it menas that Obamacare is rationed care: Be afraid. Be very afraid.


Obamacare: The Bioethicists Must Think We Are Not Paying Attention
Tuesday, September 8, 2009, 3:58 PM
Wesley J. Smith

The bioethics Establishment is at it again, desperately trying to pretend that the general movement doesn’t support what it supports in regard to Obamacare. From the statement, “Three Myths About the Ethics of Healthcare Refrm,” by the Association of Bioethics Program Directors:

Myth #1: Health care reform will mean giving up control of my own health care decisions. Fact: The field of bioethics has long championed the rights of individual patients to make their own health care decisions in consultation with their physicians. If we thought the major proposals being considered posed a serious threat to these rights, we would be the first to speak out. But that is NOT the case. The right of individuals to make decisions about their health care is engrained in the ethics of American medical practice and that won’t change under any of the approaches to health care reform currently under discussion.

Except: Most bioethicists support Futile Care Theory, the idea that wanted life-sustaining treatment can be withdrawn over patient and family protest based on “quality of life” and economic considerations. The bioethics movement generally, also supports explicit forms of health care rationing. And these would be the people appointed to the many cost containment boards Obamacare would establish. That, along with the tens of thousands of pages of regulations would undoubtedly lead to centralized restrictions being imposed on individual choices and access to care.

Myth # 2: Health care reform will control health care costs by depriving patients of important, but costly, medical treatments. Fact: This is also untrue. If anything, the provisions in current health care proposals will increase the likelihood that patients will get quality medical care and decrease the likelihood of medical errors that kill thousands of patients every year. There are unethical ways to control costs, including refusing to treat the uninsured or those who have insurance but cannot afford the exorbitant out of pocket costs of expensive treatments—that is the status quo. Health care reform offers a more coherent approach to delivery of health care that aims to control costs while maintaining the quality Americans have come to expect and deserve.

Clintonism alert! Note the hedge about depriving patients “of important” treatments.  One of the fears about the cost/benefit control boards is that they will get to decide what is an important treatment–as happens in the UK continually with NICE and happens all the time in Oregon’s Medicaid rationing scheme.  Indeed, a story out of the UK today shows NICE restricting osteoporosis patients from receiving the best medications for their conditions. (I will write an “NHS Meltdown” post about that later.)

The statement also gets into the end of life counseling issue, but I have addressed that matter previously here so many times, I don’t want to repeat myself.

The statement ends with the following claim:

We commend efforts to reform the health care delivery system with commitments to cover all Americans while protecting choice and maintaining the high quality care that our fellow citizens deserve. We stand ready to aid however we can in this vital effort.

That’s nothing but a talking point soundbite, and a bad one at that.  The goals are mutually exclusive.  And the people know it. And how is it that these bioethics leaders couldn’t address the $500 billion cuts in Medicare proposed to fund this monster?

This is just proof that bioethics is highly political, overwhelmingly liberal, and wildly supportive of not only of nationalized care, but the single payer approach.  We already knew that.  But the truth is that Obamacare will come at a substantial cost in quality and accessibility currently received by the majority, to benefit the minority who currently have inadequate access.  Don’t get me wrong: The problem of expanding access is important, but it should not come at the cost of dismatling what works pretty well for most people. 


NHS Meltdown: Death Panels!
Wednesday, September 2, 2009, 6:50 PM
Wesley J. Smith

Pallliative care experts in the UK are charging that terminally ill patients are being intentionally misdiagnosed as being close to death in order to enable doctors to stop treatment and instead dehydrate the patient to death. My contacts in the UK have been warning me about the “Liverpool Care Pathway” for some time and now, here it is in the Telegraph.  From the story:

Patients with terminal illnesses are being made to die prematurely under an NHS scheme to help end their lives, leading doctors warn today. In a letter to The Daily Telegraph, a group of experts who care for the terminally ill claim that some patients are being wrongly judged as close to death. Under NHS guidance introduced across England to help doctors and medical staff deal with dying patients, they can then have fluid and drugs withdrawn and many are put on continuous sedation until they pass away.

But this approach can also mask the signs that their condition is improving, the experts warn. As a result the scheme is causing a “national crisis” in patient care, the letter states. It has been signed palliative care experts including Professor Peter Millard, Emeritus Professor of Geriatrics, University of London, Dr Peter Hargreaves, a consultant in Palliative Medicine at St Luke’s cancer centre in Guildford, and four others.

“Forecasting death is an inexact science,”they say. Patients are being diagnosed as being close to death “without regard to the fact that the diagnosis could be wrong. As a result a national wave of discontent is building up, as family and friends witness the denial of fluids and food to patients.”

Here’s the thing: Every hospice expert I have spoken with say that palliative sedation is rarely necessary to stop suffering.  If some 16% of dying patients die under sedation as the story states, something is very wrong.

I am sorry, but this is a direct consequence of the rejection of human exceptionalism and the embrace a quality of life ethic. Indeed, it shows where utilitarianism leads, where in the drive to stop suffering we end up turning on the sufferer. Think about it: How often these days do we hear bioethicists bemoaning the “drawing out of the dying process,” when what we are really discussing is extending life?

Not coincidentally to our discussion of Obamacare, it was pushed by the NICE utilitarian bioethics board–the very kind that the highly influential former Sen. Tom Daschle wants for America–which could arise from the proposed cost/benefit boards in the current health care plans:

Developed by Marie Curie, the cancer charity, in a Liverpool hospice it was initially developed for cancer patients but now includes other life threatening conditions. It was recommended as a model by the National Institute for Health and Clinical Excellence (Nice), the Government’s health scrutiny body, in 2004. It has been gradually adopted nationwide and more than 300 hospitals, 130 hospices and 560 care homes in England currently use the system.

If these allegations are  true, it is a scandal of virtually unprecedented proportions: A detailed investigation should be conducted.  And if people were truly sedated and dehydrated to death without consent before their time, heads should, figuratively roll, medical licenses should be revoked, and–if the facts warrant–criminal charges filed.


How Bioethicists “Talk”
Friday, August 28, 2009, 1:25 PM
Wesley J. Smith

Reading bioethics literature is sometimes a challenging task. Bioethics-ese is replete with buzz words, such as “rich,” “robust,” “fruitful,” etc.  The verbiage often seems self-congratulatory and frequently masks some  hard-edged and very radical advocacy.

Here’s an example  of the lexicon–not radical advocacy–to which I refer.  British bioethicist Deborah Bowman, writing in the Journal of the American Medical Association, reviews a new book called The Future of Bioethics by bioethicist Howard Brody.  I have put the buzz gobbedlygook in italics. by which I mean it sounds good and erudite, but really communicates very little. From the review (no link, JAMA August 12, 2009—Vol 302, No. 6, p. 695):

While the chapters cover discrete topics, this coherent and powerful book argues the case for a more reflective, engaged, humble, and activist approach to the practice of bioethics. It is also an apposite and timely text when considered in the context of the changing nature of medicine and health care. As many Western societies grapple with the increasing demands of chronic disease and increased longevity on health care systems, and as inequities between societies and populations widen, the ways in which Brody reiterates the value of care, vulnerability, inclusiveness, and multiple narrative are fundamental not merely to the flourishing of bioethics but to a good society. It is, Brody argues convincingly, not merely “nice” for bioethics to engage with the marginalized, underrepresented, absent, or powerless; it is essential to meaningful intellectual advancement as well as the future practice of bioethics.

I am not criticizing Brody’s book, which I have not read. I would note, however, that the most weak and vulnerable  in society–those with significantly impaired cognitive capacities and deemed to have a poor quality of life– have the most to fear from bioethics, not the other way around.

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