To the Editor:
The gratuitously violent title of Paul McHugh’s article sets the tone for an unbalanced analysis of the Terri Schiavo case that typifies so much of the hyperbole and misinformation that have pervaded the public debate about it [“Annihilating Terri Schiavo,” June].
Dr. McHugh characterizes the “persistent vegetative state” (PVS) of patients like Terri Schiavo as “human life under altered neurological circumstances.” This sanitizes the permanent and devastating neurological symptoms of PVS, in which even an ostensibly awake patient is completely unaware of his environment.
Dr. McHugh then equates the cessation of unwanted life-support treatment with actions by physicians that “aim to kill.” But there is a subtle and vital distinction between ceasing treatment at a patient’s behest and, say, administering a lethal dose of morphine. This distinction was affirmed in the 1990 Cruzan case in which the Supreme Court ruled that an “incompetent” patient had the right to decline life-saving medical treatment through surrogates or through clear and convincing evidence that this had been his wish. At the time, there was no public outcry about a “culture of death.”
Most disturbingly, Dr. McHugh sets up a strawman in Michael Schiavo, implying that he viewed his wife’s condition as “life unworthy of life”—terminology Dr. McHugh borrows from pre-Nazi Germany. I do not recall seeing this despicable term applied to Terri Schiavo, but I do recall Michael Schiavo stating repeatedly that his wife had wished not to be kept alive indefinitely in a severely brain-damaged state.
Here, Dr. McHugh might have focused on an issue that deserves more attention and that can well be viewed as troubling by dispassionate critics. In the end, the basis for the removal of Terri Schiavo’s feeding tube came down to some offhanded comments she was said to have made years earlier after visiting a relative on life-support and while watching a television program about terminal illness. Whether or not the utterances of a healthy woman in her twenties should carry such legal weight is a matter for legitimate debate. But Dr. McHugh seems to call into question the entire notion of patient autonomy, suggesting that whether or not to be kept alive in a permanent state of unconsciousness is a decision best left to well-meaning physicians.
Finally, Dr. McHugh takes a swipe at bioethics. He posits the existence of two warring classes, bioethicists and medical practitioners, noting that the former are “generally shunned by doctors and nurses.” It might surprise him to learn that in many hospitals one person serves both functions. I myself have been practicing pulmonology for 32 years and have been doing bioethics consultations in my academic medical center for the last ten years.
In both capacities, I view the sanctity of life as one of the pillars of the practice of medicine. There is no “culture of death” at my hospital. But the increasing sophistication of modern medicine has meant that there frequently are difficult, gut-wrenching decisions that have to be made about the course of a patient’s treatment. In this regard, the two hats I wear are often of assistance to patients, families, fellow physicians, and nurses.
I do not share Dr. McHugh’s view of the nefarious impact of bioethics and an imagined “culture of death” on our society. The Schiavo case was a perfect storm in which a unique convergence of factors—involving medical ethics, law, family dynamics, and political alliances—produced a family tragedy and a media circus. But our country has weathered the storm.
Kenneth Prager, M.D.
Columbia College of Physicians and Surgeons
New York City
To the Editor:
Paul McHugh, a preeminent scholar and clinician in neuropsychiatry, argues that Terri Schiavo met “annihilation” at the hands of a “culture of death.” He contrasts this with the “culture of life” that is sustained by humane physicians, nurses, and hospice staff.
As a physician specializing in psychiatry, I find such Manichean divisions unhelpful. In my view, the physician’s duty is to engage in a difficult, ongoing dialectic between traditional medical ethics and the specific wishes, hopes, and directives of a particular patient. The former includes such core precepts as “First, do no harm” and “Treat the sick and injured with compassion.” The latter may extend to anything from the use of psychotropic medications during a psychotic episode to so-called living wills.
Unfortunately, physicians have only faint guideposts to lead them toward a humane resolution of this dialectic. The American Medical Association charges doctors to “respect human life and the dignity of every individual.” But does “human life” refer simply to physiochemical processes like those involved in cardiac function, or to life in the larger sense of willful, reasoning personhood? Does the “dignity” of every individual obligate the physician to preserve human life under all circumstances and irrespective of the expressed wishes of the patient, or does dignity sometimes allow for the removal of life-prolonging devices from a severely brain-damaged person who has made it clear that he would not want to be kept alive in such a state? Nobody should pretend to have easy answers to these questions.
Dr. McHugh is worried about “the increasingly assertive deprecation of medical expertise and understanding in favor of patients’ ‘autonomous’ decision-making” and about the intrusion into the medical process of “bioethicists” who lack a foundation in the everyday realities of medical practice. I share these concerns, but I do not go with him in assuming that “no document on earth can substitute for the one-on-one judgment . . . of a sensible, humane, and experienced physician.”
Consider a document like the do-not-resuscitate (DNR) order, which for Dr. McHugh is one of the “signposts of our culture of death.” Recently, I was involved in the care of a very elderly patient with severe end-stage cardiac disease. His experienced geriatrician had recommended that he sign a DNR order, explaining that at his age, cardiac resuscitation usually led to substantial cognitive impairment and a poor quality of life. The patient elected to sign, and I concurred. Had he been a twenty-year-old with no progressive disease of any kind, I am quite sure I would have recommended against his signing. One life is not “worth more” than the other, but the medical facts, prognosis, and human context differ markedly between the two scenarios.
We doctors struggle with determinations in cases like these not because we are bullied by bioethicists but because we are physicians, and because there is no “culture”—of life or of death—that can substitute for the judicious weighing of general ethical imperatives against the specific directives of an individual patient.
Ronald Pies, M.D.
Tufts University Medical Center
To the Editor:
Paul McHugh’s tendentious article misstates much about Terri Schiavo’s medical condition, the care she was given, and the legal battle that surrounded her demise.
First, Dr. McHugh draws a specious analogy between Terri Schiavo’s “persistent vegetative state” (PVS) before her death and the condition of “Dr. A,” a patient he attended to some four decades ago. Though Dr. A had suffered a grievous brain injury, after which he “gave little evidence of awareness,” on one extraordinary occasion he showed that he was able to receive sensory input, process it, and articulate a coherent response. In sharp contrast, Terri Schiavo showed no signs of consciousness over the course of fifteen years, never responding to stimuli other than reflexively.
Dr. A was sentient, Terri Schiavo was not. It is wrong and seriously misleading for Dr. McHugh to describe her as “apathetic to inner needs and external events,” or to attribute her contractures to “apathy”—as though these things could have been helped. Nor can PVS patients be said to display “a lowered state of vigilance,” since any degree of vigilance, however minimal, would preclude a diagnosis of PVS.
Within five weeks of her cardiac arrest in 1990, Terri Schiavo had three CAT scans, then another in 1996, and another in 2002. These tests showed massive destruction of brain structures necessary for consciousness (as against mere reflexive opening of the eyes). Dr. McHugh finds it surprising that no functional assessment of her surviving cerebral tissue was performed. Actually, a structural MRI was done five months after her cardiac arrest, but after an experimental deep-brain stimulator was implanted later that year, no MRI of any kind could be done.
Contrary to what Dr. McHugh writes, Terri Schiavo’s electroencephalograms (EEG) were not “typical of a patient with severely impaired consciousness”; fewer than 5 percent of PVS patients have the extreme abnormality of her isoelectric (“flatline”) EEG. If Dr. McHugh knows of anyone with such structural and functional abnormalities whose condition subsequently improved significantly, he should bring it to the world’s attention. Otherwise, he should stop hinting that additional neuro-imaging might have shown that Terri Schiavo’s brain “tissue was recovering over time” and that her condition was other than permanent.
Dr. McHugh finds it troubling that in Terri Schiavo’s last days, “all—hospice staff, parents, siblings, onlookers—were forbidden by court order to give her food or drink orally,” and that her parents were not permitted “to feed her by mouth as one would any helpless person.” But the reason Terri Schiavo had to be fed through a gastric tube was that she was unable to swallow normally without risk of aspiration and pneumonia. Feeding by mouth would probably have hastened rather than postponed her death—an opinion shared by the treating doctors and by the medical examiner who performed her autopsy.
Dr. McHugh decries the fact that Terri Schiavo was “judicially prohibited” from being given “even a chip of ice to relieve the pain of a parched mouth and throat,” with “local sheriffs . . . alerted to prevent it.” But surely he knows that there can be no feeling, including the registering of pain, without sentience.
One of us examined Terri Schiavo, reporting his findings in court testimony and subsequently in a detailed article in a medical journal. Both of us believe in the paramount importance of getting the fundamental facts right, upon which all discussions of ethics and law must be predicated. The true and tragic facts of her case do not fit Dr. McHugh’s apprehension of “life under altered circumstances” being led down a slippery slope to “life unworthy of life.”
M. Louis Offen, M.D.
Ronald E. Cranford, M.D.
University of Minnesota
To the Editor:
As a physician with ten years’ experience in nursing-home and hospice care, I take issue with some of Paul McHugh’s assertions. Dr. McHugh writes that “the way [Terri Schiavo] died was most unusual”; that is not so. Many hospice patients with end-stage dementia and other consciousness-impairing neurological diseases die from dehydration due to the inability or refusal to eat or drink. If the patient is provided with proper oral care, this is not an uncomfortable way to die.
Contrary to what Dr. McHugh suggests, Terri Schiavo could not have taken fluids orally after her gastric tube was removed. She would have choked and aspirated, and would have appeared to be suffering. Since successive neurologists believed that she lacked the capacity to feel pain, it is false and almost defamatory to state of her husband and his advisers that “they were willing to have her suffer pain.”
Louise Benson, M.D.
To the Editor:
Paul McHugh suggests that MRI or PET scans would have demonstrated whether any neuronal activity persisted in Terri Schiavo’s brain and whether any cerebral tissue was recovering. These tools help physicians make clinical decisions when further evidence may be of value. But in Terri Schiavo’s case, the presence of neuronal activity would not have changed the fact that she had suffered a devastating brain injury, significantly altering her quality of life and leaving her in a persistent vegetative state (PVS).
At present, neither of those high-tech and expensive tests is required to predict the possibility of tissue recovery in a case like Terri Schiavo’s; once a central- nervous-system neuron is dead, it remains so permanently. As Dr. McHugh himself points out, patients in PVS “for more than eighteen months are generally unlikely to recover”; after fifteen years it is completely reasonable to come to this conclusion without the assistance of ancillary tests.
Since Dr. McHugh’s article was published, the results of Terri Schiavo’s autopsy have come out. They counter his statement that she was starved to death; according to the coroner, she died of dehydration. To be sure, neither the one nor the other sounds like a preferred way to die. But the feeling of hunger—if a neurologically devastated individual feels it at all—subsides after several hours. Medical literature also suggests that prolonged starvation leads to the release of natural substances in the bloodstream, producing a euphoric state that reduces discomfort at the end of life. If, as Dr. McHugh suggests, Terri Schiavo was indeed not provided with ice chips, moist sponges, or glycerin swabs once the decision was made to forgo assisted nutrition, then her treatment did not rise to the current standard of palliative care.
But it is not up to physicians like Dr. McHugh or myself to determine the path of care for our patients. These decisions must be made whenever possible by the patient and, barring that option, by a surrogate who adheres to the patient’s wishes. A physician’s role is to inform the decision-maker of all possible options, along with their associated risks and benefits, and then to respect the decision even if it contravenes his own beliefs. If we are unable to do so, we must step aside and allow someone who is comfortable with the chosen course to assume the patient’s care.
Adam Rapoport, M.D.
To the Editor:
In writing that “the overarching principle that hospice doctors and nurses strive to represent and exemplify is never to betray a patient to death,” Paul McHugh apparently does not consider that a patient can be also be “betrayed” to a life he does not want to live. Insofar as is possible, the way a person dies should be consistent with his values. Other people should respect him by doing what they can to preserve his integrity and his sense of identity. When he is beyond self-command, his agents, insofar as reason and ability allow, should fulfill his purposes according to his standards.
Dr. McHugh’s contention that nothing can substitute for the “one-on-one judgment, fallible as it may ultimately be, of a sensible, humane, and experienced physician” is more than a little self-serving. Only medical experts assure us that it is legitimate to substitute medical expertise for moral judgment. Indeed, people have entrusted me with living wills and health-care proxies precisely in order to prevent well-intentioned physicians who do not distinguish between bodies and persons from zealously keeping them alive in conditions that they scorn.
City University of New York
Jamaica, New York
To the Editor:
One need only have read the inflammatory title of Paul McHugh’s article to know that the text would lack any pretense to objectivity. Dr. McHugh asserts that after Terri Schiavo’s gastric tube was removed, she died “within thirteen distress-filled days.” Unless Dr. McHugh was in Schiavo’s hospice room during her last days, he has no basis for this statement.
Most disturbingly, Dr. McHugh bemoans the fact that patients have become empowered to choose among their treatment options—or to choose none. He may be nostalgic for the paternalistic era when “doctor knew best,” but the explosion of interest in living wills in the wake of the Schiavo tragedy suggests that he has precious little company.
Brooklyn, New York
To the Editor:
Paul McHugh has written an insightful and poignant essay about our culture’s attitudes toward life and death. I share his disgust with the legal wrangling over Terri Schiavo’s fate. How did we reach this point where we are so fascinated with death, or look at it so cheaply, that no solution short of ensuring a slow death could be found within the law? Perhaps this is a simplistic or superficial answer, but I trace our society’s callous view of death to the Holocaust, when the techniques of modern science were first applied to the death process.
I take issue with one point that Dr. McHugh raises. He asserts that it is the sensible, humane, and experienced physician—and not the ethicist—who possesses the “one-on-one judgment, fallible as it may ultimately be,” to care for a patient at crucial moments in the dying process. But how many doctors nowadays have the kind of relationship with their patients that would generate the proper insight and understanding? Besides, the doctors closest to a person at the end of life tend to be specialists only recently called to the scene, with no sense of who a patient was prior to his final illness.
West Orange, New Jersey
To the Editor:
Language is at our disposal, but it also disposes of us; the way we talk creates the setting in which we conduct our moral calculus. Paul McHugh’s analysis of the Terri Schiavo illustrates this in a number of ways.
First and foremost, Dr. McHugh’s dramatic personal testimony about the submerged remains of consciousness in a patient with a condition not unlike Terri Schiavo’s is important both clinically and ethically. Second, his dissection of the term “persistent vegetative state” is a warning about how a single formula can be clinically accurate and at the same time subtly stretch moral possibilities. Finally, by calling attention to the chilling historical parallels between the Schiavo case and the bizarre, oxymoronic title of the 1920 German work Die Greigabe der Vernichtung Lebensunwertes Leben (“Lifting Constraints from the Annihilation of Life Unworthy of Life”), Dr. McHugh helps restore our own medical-moral talk to its first function as truth-telling.
Of course, the case of Terri Schiavo is awful and complex. But the understandable fear of the living that their minds could end up trapped and silenced inside a damaged body should not be what determines the outcome of cases like hers. Here is where the story of Dr. McHugh’s patient is important. In response to Dr. McHugh’s own voice at his bedside, this man with a damaged brain uttered a perfectly precise sentence—and then never spoke again. This is a cautionary tale. It makes us skeptical about what are still crude scientific measurements of human consciousness. It suggests that, rather than impose the gruesome imagination of the living upon those in “altered neurological states” (“I wouldn’t want to be in that condition and have all that attention and expense!”), doctors, family members, and the law should strive as much as possible to follow the Hippocratic Oath.
At what point do we judge that a person is no longer present in his or her body? Cases of severe dementia, last-stage Alzheimer’s, and massive brain injuries raise difficult questions. These are still unsettled issues. Yet we do know a person is someone with a history (even if plaque in the brain has destroyed his own access to it), someone who has been in relationships with others (even if he can no longer communicate with them), and someone who is alive (even if only by the aid of a machine). Beyond this, a person is a living entity to whom we accord certain kinds of respect and treatment. For a long time, Terri Schiavo was accorded the care that implied she was a person. Once she was cortically de-personalized, she could be dehydrated and starved to death.
Dr. McHugh has done caregivers for future Terri Schiavos—and all of us—a very humane service.
Robert F. Leavitt, S.S.
St. Mary’s Seminary and University
To the Editor:
As one who recently lost a beloved companion to cancer after fending off periodic attempts by third parties to end her life, and who would have gladly given years of his own life to see hers prolonged—if only for a few days, and even in her final, semi-vegetative state— I was deeply upset by the Terri Schiavo case.
Things have really gone topsy-turvy when a government that purports to act in defense of human life, and with due respect for rational will, in fact does the opposite. In the case of a mentally sound person who wishes to die—such as one suffering from persistent pain or just pervaded by tedium vitae—government not only ignores his will but endeavors actively to block its implementation. Yet when it came to Terri Schiavo, who found herself as defenseless as any human being can possibly be, government not only failed to protect her but actively participated in taking her life.
Oh, yes, Terri Schiavo is said to have expressed her will to die rather than live in a vegetative state. But this justification reflects a deep misunderstanding of the nature and expression of rational will. The courts knew of Terri Schiavo’s will only through her husband’s uncorroborated statements. With a human life at stake, one would expect a third party’s assertions to be subjected to the most stringent scrutiny and denied any weight absent incontrovertible supporting evidence. Yet the courts were prepared to find cause for the imposition of a death sentence in such naked assertions.
Even if we accept at face value Michael Schiavo’s characterization of his wife’s will, no person’s decision about the termination of his own life can be called rational when it is made at an undetermined distance from the moment it will actually be implemented—and if, at that moment, it cannot be revoked. Let us consider a circumstance like that in which Terri Schiavo was said to have expressed her “will.” Seeing on television a person fed by tubes, or carried miserably in a wheelchair, the viewer says, “I’d never want to live like that.” He might even be moved to express this in writing. How can he know that he will have the same attitude at a moment when his neurological state is radically different?
Dismally, the courts fail to accord this obvious paradox anything approaching the importance it merits. Yet it is the subject of a simple story penned a century ago by the Nobel laureate Luigi Pirandello. A man strolling in the park with his wife sees a stroke victim being led around in a wheelchair, and says: “I would never want to live in that condition.” A year later, he himself is felled by a stroke. As he is led in a wheelchair to the park in his vegetative state, he begins to feel—without being able to manifest it—the wonder of life, which he appreciates even more than he did in health and which he now clings to desperately. Fortunately for him, his society neither offered living wills nor dangled before his wife the possibility of securing his state-sanctioned annihilation.
New York City
To the Editor:
Paul McHugh’s cool and reasoned reading of the Terri Schiavo case is a welcome relief from the political hue and cry that has surrounded this sad story. I wish to point out one small, inconsequential mistake in his article, perhaps a mere typographical error. He writes: “No functional assessment of her surviving cerebral tissue was performed by means of magnetic-resonance imaging (MRI) or proton-emission tomography (PET).” Proton? Protons are perfectly stable particles; were they to be emitted from our bodies, we would all disappear in short order. Dr. McHugh is referring to positrons, the antiparticles of the more familiar electrons. Positrons are positively charged, and they disappear in a flash when encountering (negatively charged) electrons because the latter are so much more abundant in the cosmos.
Positron-emission tomography is itself a bit of a misnomer, leading to the common belief, even in the medical profession, that positrons are emitted inside the body and detected by outside instruments. Actually, positrons so rapidly encounter electrons that they travel no more than about two millimeters inside the human body before being annihilated, thereby emitting highly energetic gamma rays. The gamma radiation is what the medical devices detect. The term “positron-emission tomography” was coined because the words “annihilation” and “gamma rays” were too frightening to patients. The same sort of euphemistic substitution is responsible for the “MRI,” which refers to a procedure that used to be known as NMR, or nuclear-magnetic resonance.
Didier de Fontaine
University of California
Paul McHugh writes:
An impressive feature of the Terri Schiavo case was the zealous public support that gathered behind her husband’s wish that she die. Some of my correspondents’ letters reflect that zeal; they deserve careful examination for the light they shed on the increasingly intrusive fact that ending a life, like living a life, has more than a purely private meaning.
Kenneth Prager’s letter is rather confusing. He seems at first to be of the opinion that Terri Schiavo was getting “unwanted” treatment; then he acknowledges that his basis for holding that opinion—namely, a number of “offhand” comments allegedly uttered by the young Terri Schiavo—is “a matter for legitimate debate.” Indeed: that debate is at the heart of the matter.
Dr. Prager also denies there was any “aim to kill” behind the efforts to deny food and drink to Terri Schiavo. But if that was not the aim, why were sheriffs brought in to guarantee that she got no fluids? In a spirit of compromise, I am willing to amend my statement and say that the aim was to make sure Terri Schiavo died. Is that a distinction with a difference?
More interesting to me is that Dr. Prager describes his work as “wearing two hats.” Here is my question to him and to others who play this double role: can they show that their second hat, that of the bioethics consultant, improves the fit of the first, that of the doctor? Until that question is settled by means of something more persuasive than testimonials, I would advise them to stick to being doctors.
Equally confusing is Ronald Pies. He wants to start with the principle of doing no harm. Fine; but how does he square that principle with the way in which Terri Schiavo’s life was disposed of? Wrestling with the concept of human life in the presence of debilitating disease or injury, Dr. Pies resists the effort to think through the implications of the term “life under altered circumstances,” a standard medical idea since Claude Bernard in the 19th century. He also mistakes as a “concern” of mine what is merely an observation: namely, the “increasingly assertive deprecation of medical expertise and understanding in favor of patients’ autonomous decision-making.”
Some of my other correspondents confirm the reality of this phenomenon. What actually concerns me, however, is that many doctors have grown wary of offering clinical guidance because they think patients distrust their judgment. Dr. Pies seems to be among those who believe this distrust is warranted; he himself would place his reliance on a document like a do-not-resuscitate (DNR) order. I am dumbfounded by this attitude.
Of all the new practices tied to the effort to support patient “autonomy,” DNR orders are probably the most injurious, and known to be so. Evidence from nursing journals is particularly telling here, documenting how patients on DNR orders are customarily moved to less accessible places in the hospital and shamefully neglected, becoming in effect non-persons. In short, DNR often translates into “do not care.” These documents represent a bad experiment, and should be junked.
M. Louis Offen and Ronald E. Cranford claim that, being closer than I to the Terri Schiavo case, they were better able to “get the fundamental facts right.” But they do not deny the most essential facts on which my argument rested. They do not deny that she slept and awoke on schedule, grimaced and groaned with pain, and turned responsively to sounds and touches. Nor, on the other hand, do they report that she was incapable of managing her oral secretions, which apparently she could swallow without difficulty. Nevertheless, they assert that she would have been incapable of swallowing nutrient fluids, and would have injured her lungs in the attempt.
Let us be real. The doctors did not want her fed because they worried about her lungs, but because they believed she was better off in the grave than living in the hospice. Everything else in this letter is simply science-bluffing in lieu of care-giving, and can be safely ignored.
Louise Benson similarly claims that Terri Schiavo could not have taken fluids orally. Was it, then, to avoid aspiration pneumonia that the courts sent police to guarantee that no innocuous ice chips could reach her mouth? I have had even more years of experience than Dr. Benson, but never have I seen a neuropsychiatric patient done to death by government order. Unless Colorado is different from most other states, I doubt that Dr. Benson has, either. Hence my claim that this death in a hospice was “most unusual.”
Adam Rapoport and I may seem at first to be engaged in a verbal quibble. I specifically stated that Terri Schiavo “died of dehydration”; he agrees that aspects of her treatment did not rise to “the current standard of palliative care.” But we part company definitively when, in his final paragraph, he describes a physician’s role as that of “inform[ing] the decision-maker,” thereby relinquishing the doctor’s tutelary responsibilities.
Patients are not doctors, and they need more than facts, which they can find readily enough on the Internet. What they seek is help in living with the facts, help in the form of guidance, counsel, and support from a person of experience and matured judgment—especially one who will see the problem through with them. If doctors, in response to culture-driven concerns over “paternalism,” deny this help to patients, they will leave them naked to their worst fears. Given the overall tenor of Dr. Rapoport’s letter, I would like to think that he could be brought to agree with me about this.
Although Robert Hoffman sees me as “self-serving,” I clearly stated that medical judgment is fallible. Does he, in turn, concur that clinical decisions provoked by “living wills” are also fallible? If we could get that far, we might then draw closer to the source of these respective fallibilities. With doctors, fallibility arises from lack of experience and/or lack of close attention to telling life details. With living wills, fallibility arises from their legalized rigidity even as life situations change, and attitudes along with them. If we agreed on that point, my next question would be: how can patient care be better improved, by concentrating on the education of doctors or by adding endless new codicils to living wills? I’d bet on the doctors, and I’d expect—hope—to see living wills eventually discredited.
Which brings me to Lonny Benamy, who notes correctly that the media reporting on Terri Schiavo prompted many fearful people to write living wills. That, indeed, was one of the reasons that prompted me to write my own counterreport, which I undertook not out of any nostalgia for the day when “doctor knew best” but out of a hope that readers might talk more with, and learn more from, their doctors—and that they would look for doctors who want to care for them through thick and thin.
In his very thoughtful response, David Lentz observes that such doctors are now hard to find, and that most people go from specialist to specialist in the course of their illnesses, particularly their terminal ones. Needless to say, I deplore this state of affairs, which perhaps more than any other has opened the door to new and chilly specialists in ending life. I can only say that I know many doctors—neuropsychiatrists and oncologists especially, but many others as well—who provide exactly the kind of long-term care I describe, and I hope that if he or someone close to him needs such a physician, we will always be able to find one for him.
Father Robert F. Leavitt and Mauro Lucentini could obviously have written better than I on this whole subject. It is clear that they understood my essay from the ground up, and I thank them for their efforts to enlarge upon its message. I also thank Didier de Fontaine for his kind comments and for his clear demonstration of how the use of abbreviations can often lead to embarrassment. I have sat through hour-long lectures on PET’s and MRI’s and learned less than what he taught in 238 words.
To the Editor:
Charles Krauthammer alleges that after September 11, “many realists were brought to acknowledge the poverty of realism,” but his description of the “realist” perspective on foreign policy is not one that most realists would recognize [“The Neoconservative Convergence,” July-August].
Mr. Krauthammer’s statement that “the classic shortcoming of realism” is “a failure of imagination” is hard to take seriously. Leaders like Benjamin Disraeli, Otto von Bismarck, Henry Kissinger, and Richard Nixon had no shortage of imagination or vision. His notion that realists are “centered on the illusion of stability and equilibrium” is an oversimplication at best. This charge was frequently made against the Nixon-Kissinger team in the 1970’s, when for a period of time the United States was preoccupied with Vietnam and on the defensive elsewhere. But even then, Nixon and Kissinger were not afraid to use brutal force or to put American forces on global alert to outmaneuver the Soviets in the Middle East.
Realists throughout history have been second to none in pursuing robust foreign policies, including preemptive attacks when the potential benefits have justified the costs. Many realists did not oppose the invasion of Iraq. Indeed, Kissinger and James Schle-singer supported the war clearly and publicly. I myself wrote in February 2003 that “the path to war is not only inevitable but desirable.” This opinion was not based strictly on the belief that Iraq had weapons of mass destruction but rather on the view that a policy of containment was unsustainable after 9/11 and that, accordingly, the Iraq situation had to be resolved by force.
What most realists (myself included) opposed was not the defeat and removal of Saddam Hussein, but making a grand democracy-building project in Iraq into a paramount objective of American foreign policy at a time when we face other major challenges. By now it is clear that the administration and its neoconservative supporters grossly underestimated the cost and complexity of building a democratic Iraq.
The dispute between neoconservatives and realists (and there are obviously varied perspectives in each group) is not about whether “the desire for freedom is indeed universal and not the private preserve of Westerners.” Henry Kissinger, a refugee from the Nazis and the dean of contemporary realists, certainly believes firmly in the virtues of democracy. And I know from many personal conversations that Richard Nixon always viewed the cold war as more than a struggle against a rival superpower; it was also a war to protect and expand the free world.
But even if the desire for freedom is universal, that does not mean that all people prefer freedom at all times under all circumstances. Those of us who live in mature democracies are prepared to sacrifice some of our freedoms for secu-rity—physical, economic, and otherwise. Those with less security than we enjoy may be willing to give up more of their freedom. Moreover, democracy is not a panacea against terrorism. If it were, there would have been no Atlanta or Oklahoma bombings and no recent attacks in London.
Both sides of the political spectrum want simple explanations for terrorism, whether it is the Left’s belief in the suffering of the Palestinians and America’s imperial foreign policy or the Right’s new myth that terrorism is a result of the lack of freedom in the Arab world. But extremist Islamist terrorists are not asking for the right to be heard—they want to create a Muslim caliphate and to impose their own practices on the societies in which they live. And while liberalization of the Arab world would probably slow terrorist recruiting, trying to impose democracy by force in places where it has no history, where minority rights are not protected, and where tribal mistrust runs deep may generate more terrorism rather than less.
I am glad that Mr. Krauthammer understands the need to be selective and to define priorities in our foreign-policy objectives. I hope that he is one of the neoconservatives who have been “mugged by reality” and see that while policy without convictions is defensive and empty, policy based on blind faith—even if it is faith in the righteous cause of democracy—may have unintended and devastating consequences. Clearly, some have not yet come to this conclusion. One hopes that their education will not be too costly for them and the rest of us.
Dimitri K. Simes
To the Editor:
Charles Krauthammer offers a systematic and judicious review of the evolutionary character of neoconservatism, reminding us of its unheralded success while at the same time belying the caricatures of its critics. I would add only a small note.
Mr. Krauthammer cites my article in the May Commentary, “The Bush Doctrine’s Next Test,” and suggests that I advocate “going after” the “three principal Islamic autocracies: Egypt, Saudi Arabia, and Pakistan.” “Not so fast” is his reply; “relentless and ruthless means” are “better applied to enemies.”
Though my suggestions for encouraging the evolution of Middle-Eastern countries toward democracy might be characterized as “relentless,” I did not advocate “ruthless” means, and certainly not the use of American military force against our autocratic allies. Just the opposite: as I wrote, we should apply multifaceted pressures and incentives—with candor, tact, and firmness—to Egypt, Saudi Arabia, and Pakistan. Such policies are the only way to avoid implosions in those countries—as in Iran in 1979 or Lebanon and Algeria in the 1980’s—while at the same time remaining true to our ongoing sacrifices for democracy in Afghanistan and Iraq.
Indeed, Secretary of State Rice’s address to the American University at Cairo on June 20, 2005 was a model of this consistent approach to our recalcitrant friends. She duly noted the limitations of past American realism: “For 60 years, my country, the United States, pursued stability at the expense of democracy in this region here in the Middle East—and we achieved neither. Now, we are taking a different course.” While noting our “strategic relationship” with Egypt and praising the “wisdom and counsel” of President Mubarak, she refused to back away from tough talk of the inevitable reform ahead. As she said, “The Egyptian government must fulfill the promise it has made to its people—and to the entire world—by giving its citizens the freedom to choose.”
Victor Davis Hanson
To the Editor:
Charles Krauthammer correctly argues that neoconservatism has matured into a governing ideology over the last four years. Many of its opponents have accepted its basic rationale for the war in Iraq: to establish democracy there and inspire Arabs across the Middle East to do the same. If that does not indicate a neoconservative triumph, I do not know what does.
Mr. Krauthammer attributes this ideological realignment to a “compromise with reality, and a convergence to the middle.” But questions remain. If what he calls “democratic realism” leaves room for friendly dictatorships in the Middle East, then how do we draw the line with respect to currently friendly but potentially adversarial nations like China and Russia? At what point does his own brand of neoconservatism cease to be neoconservative?
Mr. Krauthammer also fails to mention that while the neoconservative camp has indeed grown, several prominent conservative figures have jumped ship and have yet to reboard, at least not publicly. The list of wobblers and defectors is not limited to David Brooks and Francis Fukuyama, for it also includes William F. Buckley, Jr., who told the New York Times in 2004 that “[i]f I knew [before the war] what I know now about what kind of situation we would be in, I would have opposed the war”; George F. Will, who called for “a dose of conservatism without the prefix”; Tucker Carlson, who called the war “a major mistake”; and Owen Harries, who described neoconservatism as “profoundly unconservative.” Does not the absence of their support put a dent in the Right—and in Mr. Krauthammer’s thesis of “convergence”?
Charles Krauthammer writes:
If I understand Dimitri K. Simes correctly, he is saying that the realist position on the war in Iraq is that we should have invaded, yes, but instead of “imposing democracy” we should have simply substituted a more pliant Baathist thug for Saddam Hussein.
Of all the possible policies one could have adopted toward Saddam’s Iraq, this is the most absurd. It is absurd to risk American blood and treasure simply to perpetuate precisely the same kind of corrupt, corrupting, and ultimately self-defeating support of local thugs that helped create the conditions for 9/11. If that is the objective, far better simply to do nothing, as the liberal isolationists would have it.
The rest of Mr. Simes’s letter is so filled with caricatures of neoconservatism that it should have been accompanied by a cartoon. They are hardly worth responding to. I would make only two points.
First, no one is claiming that the absence of democracy is the only cause of Arab-Islamic radicalism. But it certainly is a central cause. Who would deny that the local dictators have provided unending encouragement, support, and even incitement for the kind of anti-Western, anti-Semitic, anti-American Zeitgeist in which bin Ladenism thrived and metastasized?
Second, the idea that neoconservatives were promising some sort of democratic Arab paradise is merely silly. In my own writings I have stressed at every opportunity how difficult, risky, and problematic the enterprise would be. Nonetheless, I came to the conclusion that it was necessary. The question put to Mr. Simes and other realists—what is your alternative policy for fighting Arab/Islamic radicalism, other than going cave to cave in the mountains of Afghanistan and Pakistan?—receives no answer, as Mr. Simes’s letter once again confirms.
I did not mean to overstate Victor Davis Hanson’s position on Egypt, Saudi Arabia, and Pakistan. I simply wanted to suggest that these well-argued concerns should be assigned to the second tier for now, at a time when our hands are full in Iraq and when the greatest promise lies in Lebanon and possibly Syria.
Windsor Mann points out that George F. Will, William F. Buckley, Jr., Owen Harries, and several others have either jumped ship or never signed up for the journey. That is perfectly true. I would only emphasize that neither they nor many of the others cruising far over the horizon would take lightly the suggestion that they are neoconservatives. It is, therefore, not surprising that they are not part of the neoconservative convergence. My subject was the convergence of the major strains of neoconservatism—the more idealist and the more realist—into a new governing consensus.
To the Editor:
I was disappointed by Paul Johnson’s article, “The Anti-Semitic Disease” [June]. Mr. Johnson suggests that anti-Semitism is, quite literally, a “disease of the mind.” This is essentially a deterministic argument: if anti-Semitism is a disease, there is no personal responsibility, no free will. This is a strange argument coming from one of the great admirers of American freedom. In essence, it is much closer to the brand of Marxism that Mr. Johnson embraced in his youth than to the philosophy of freedom he has so passionately defended over the past three decades.
Mr. Johnson sees Germany as again caught in the grip of this “disease”—now in the form of anti-Americanism—which, he claims, has led to a decline in Germany’s fortunes. He offers no proof for this thesis, and one could very well argue that the opposite is true.
Germans will never forget America’s help during the cold war and the reunification of their nation. Since then, Germans and Americans have worked side by side to spread freedom and democracy in the Balkans and in Afghanistan. No country has contributed more troops to NATO-led operations than Germany. And we have helped to stabilize Iraq with training programs for Iraqi police and armed forces.
Mr. Johnson’s deterministic view of anti-Semitism also leads him to embrace the conspiracy theory of a French “hegemony” over Europe. But the notion that any state “dominates” the European Union shows an astonishing lack of knowledge of contemporary Europe. The reconciliation between Germany and France after centuries of war was one of the key elements in the process of integration. Having sacrificed so much for the cause of peace and freedom in Europe, Americans should be the first to recognize that integration has created an extraordinary zone of peace and stability, today encompassing 450 million people.
To support his argument, Mr. Johnson paints a dark picture of the German economy. He fails to see that Germany has taken a number of steps to adjust to the process of globalization. Some important reforms have been implemented; more will follow. Germany has the third largest economy in the world, was the world’s biggest exporter in 2004, and is the most important European trading partner of the United States.
Yes, anti-Semitism does exist in Europe (as well as in the United States), as recent data collected by the American Jewish Committee show. In Germany, government and civil society are working together with partners in the U.S. and all over Europe to fight anti-Semitism through education and exchange programs, as well as through law enforcement. We should not let ourselves be distracted from this common cause by indulging in overly simplistic arguments.
Ambassador of Germany
To the Editor:
Though Paul Johnson is a historian with a special interest in the tragedies of our age, he seems unaware of how closely the language with which he condemns anti-Semitism resembles the language of its foremost practitioners in Nazi Germany. Mr. Johnson asserts that anti-Semitism is “an intellectual disease, a disease of the mind, extremely infectious and massively destructive.” Hitler called the Jews “vermin,” spoke of “cleansing” the Reich of the “Jewish infection,” and used an insecticide, cyanide gas, to rid Germany of its “plague.”
Mr. Johnson states that “[i]t is not clear from the record exactly how, why, and when Hitler became a strident anti-Semite.” Why is it important to know this? Why is it not enough to know that Hitler came to believe and do what he believed and did, like the rest of us, because that is what he chose to believe and do? Mr. Johnson’s ostensible intention is to excoriate anti-Semitism by using the fashionable rhetoric of psychiatric dehumanization. But by doing so, he perhaps inadvertently excuses Nazi anti-Semitism.
We moderns do not believe in punishing diseases or patients for having diseases. We do not imprison, much less kill, mentally ill persons; we excuse them of their crimes and hospitalize them. John Hinckley is still being treated for his anti-Reaganism. If anti-Semitism is a disease, then the Nazi leaders were very sick indeed, and the Nuremberg trials were one of the great injustices of the 20th century.
Mr. Johnson says he has been trying to understand anti-Semitism. But to understand human behavior, we must be able to put ourselves in the shoes of the person whose behavior we want to understand. “Nothing human is alien to me,” said the Roman philosopher and playwright Terence, in a declaration that became the credo of the Enlightenment. The credo of psychiatry, by contrast, is that “nothing alien is human to me.”
Thomas Szasz, M.D.
Manlius, New York
To the Editor:
Paul Johnson bestrides the world of journalism and historiography like a colossus; to write a letter dissenting from his article fills me with a considerable amount of condign dread. But I must wonder whether “disease” is the right trope for discussing the phenomenon of anti-Semitism. I certainly agree with Mr. Johnson that disease and anti-Semitism both prove debilitating for their respective host bodies. But the danger in speaking too readily of a moral failure like anti-Semitism in terms of disease and pathology is that it ignores the question of will.
As Pope John Paul II said in his address to the people of Israel in 2000, “anti-Semitism is a sin.” Not a disease, but a sin.
Edward T. Oakes, S.J.
University of St. Mary of the Lake
To the Editor:
I am slightly amused and slightly appalled that Paul Johnson would claim and argue that Hitler’s anti-Semitism was the entire motive, cause, and reason for the failure of Germany’s aggression in World War II. Undoubtedly, Mr. Johnson knows of Hitler’s vision of a greater Germania (a competing motive) and of the famous decision to open up a front against Russia (a competing cause of Germany’s failure).
Moreover, in support of his argument, Mr. Johnson’s list of Hitler’s “good qualities” seems to outweigh his bad ones. Is he claiming that it was anti-Semitism that led to Hitler’s psychotic behavior instead of claiming (as I believe) that it was Hitler’s psychosis that fed his hatred and his maniacal actions? Was he a maniac or was he not?
San Diego, California
To the Editor:
The novelty of Paul Johnson’s article seems to lie in its almost complete disregard for established views of anti-Semitism. Though most students of the subject maintain that fierce anti-Semitism, from Roman times to our own, tends to arise amid economic decline and social disarray, Mr. Johnson holds that these conditions are not the prerequisites of anti-Semitism but rather its inevitable, almost God-sent consequences. As he sees it, doom and poverty descend upon nations that persecute their Jewish citizens.
Some of Mr. Johnson’s historical examples serve his case rather well, but most of them stretch history too far. To say, for instance, that England and particularly the U.S. won World War II because they embraced Jews persecuted elsewhere is a very shaky assertion (even putting aside the fact that both nations could have saved many more Jews). After all, another victorious country in the same war was Russia, where popular hatred of Jews and thinly veiled state anti-Semitism continue to this day.
To the Editor:
Paul Johnson does his usual masterful job in “The Anti-Semitic Disease.” He demonstrates how numerous countries and civilizations throughout history—Spain, France, czarist Russia, Germany—fell by the wayside once they allowed themselves to be infected by the self-destructive disease of anti-Semitism. And he points out that the current anti-Semitism of the Arabs has undoubtedly weakened their societies. Conversely, countries like the United States that have been welcoming to Jews have prospered.
All this is true, but Mr. Johnson neglects a significant point. It is not only that virulent anti-Semitism has deprived countries of a talented and motivated labor force, one that possesses great financial and organizational skills; nor is it just that the anti-Jewish obsession has sapped national energies and prevented countries from dealing with more important issues. Perhaps it is also the case that in hating Jews, people hate what Jews historically have stood for: God’s presence in history. And hatred of God’s ideals—justice, charity, love, discipline, ethics, sacrifice—inevitably leads to self-destruction, whether of individuals or of civilizations.
Rabbi Emanuel Feldman
To the Editor:
As Paul Johnson perceptively notes, a critical element of the disease of anti-Semitism is that it causes damage not only to those who are the hated outsiders, but also to the carrier. Specifically, it causes the anti-Semite to lose the ability to see himself and his society and its faults.
Examples of this abound, including most notably in recent times in the Arab world, which slips further into medievalism while blaming the Jews for everything from the World Trade Center attack to the corruption of the Palestinians.
New York City
Paul Johnson writes:
The German ambassador is mistaken in thinking I have reverted to Marxism. I have never been a Marxist—God forbid! I have always been a Roman Catholic. I reject determinism and always have rejected it.
I call anti-Semitism a disease for want of a better word. It is clearly not an ordinary form of racism. Whereas racist feelings are an almost inevitable part of uneducated human nature, anti-Semitism seems to me unnatural and perverse. It appears to me to have some of the characteristics of a mental disease, particularly in its destruction of the judgment.
But I was using disease merely as a metaphor, and metaphors should not be pushed too far. To call a habitual and violent anti-Semite a person suffering from a disease of the mind is not to absolve him from blame. My object in writing my article was to try to inject a new element into the subject of anti-Semitism, and to start a debate that may eventually prove fruitful. Let the debate continue.
To the Editor:
Since my book Why the Jews Rejected Jesus: The Turning Point in Western History came out, it has been met by impassioned responses from every quarter, including the two major evangelical Christian magazines, World and Christianity Today. In each of those reviews there was no doubt where the reviewer himself stood. I wish I could say the same for Commentary’s critic.
Hillel Halkin’s review essay, “Jews for Jesus—and Vice Versa” [June], describes some questions raised by my book. But Mr. Halkin decides not to offer his own views about the book’s main topic: what Jews have believed about Jesus and the role of Christianity—its role, as I put it in a phrase Mr. Halkin finds unacceptable, from “God’s perspective.” In other words, how are Jews to understand the curious fact that there is another biblical religion hard at work trying to bring humanity closer to God, as we are supposed to be doing, as our own Torah instructs us? What does God mean to communicate to us by allowing this rival faith to flourish? In my book, I seek to answer these questions in the form of a two-thousand-year history of the Jewish-Christian debate about Jesus.
Mr. Halkin’s response is merely skeptical: “Yet even if I were such [an Orthodox Jewish] reader, arguments formulated in terms of God’s ‘purpose’ or ‘perspective’ would leave me, I suspect, uneasy.” Why uneasy? Because “such speculations, whatever their heuristic value for religious debate, are ultimately of limited persuasiveness.” So Mr. Halkin lets himself—and Jews as a whole—off the hook. Because some people may not be persuaded, none of us has to make the effort. Mr. Halkin also dismisses my book because he feels that neither conservative Christians nor Orthodox Jews nor secular Jews will, on the basis of my attempt to make sense of Christianity, be moved to join in a political alliance.
I had hoped that Mr. Halkin, a serious and thoughtful writer, would grant us a view of what he believes—about God, about Judaism, even about the role of the messiah. It is too easy to use politics or other practical concerns as an excuse not to do the thinking that God wants us Jews to do—the thinking that will bring us closer to Him. I assume that Mr. Halkin has done such thinking. Why does he not tell us what he has come up with?
One of the reasons I wrote my book is that I have often been struck by the complacency of modern Jewish culture. Whether religiously involved or not, Jews tend to be satisfied with the vaguest sorts of answers to the questions posed by religion, or with no answers at all. We bequeath this bland, content-free “Jewishness” to our children, who go out into the world and are confronted by religious cultures that actually mean something when they speak. Pity the bar-mitzvah boy who grows up and meets serious evangelical Christians who seek to introduce him to their faith. They have definite beliefs founded on a certain understanding of religious texts. In the encounter with their beliefs, our young Jew is intellectually disarmed, utterly defenseless. No wonder Jews wander off into foreign spiritual wildernesses in the numbers they do.
If my book makes just one young Jew contemplate the problem of what it means to anticipate the messianic future, I will consider my efforts to have been worthwhile.
Mercer Island, Washington
Hillel Halkin writes:
David Klinghoffer challenges me to tell him and Commentary’s readers what I think is “God’s perspective” on the relations between Judaism and Christianity. I wish I could oblige. I wish I knew what God’s perspective was on anything. But I don’t, and Klinghoffer (who, I will repeat for the record, has written a serious and articulate book) will just have to take me as I am.
Bush & Israel
To the Editor:
In a letter to the editor in your July-August issue, commenting on Norman Podhoretz’s article, “Bush, Sharon, My Daughter, and Me” [April], Allan Leibler asserts: “At the end of March, the American ambassador to Israel, Daniel Kurtzer, stated emphatically that there was no understanding with the U.S. regarding Israel’s retention of major Jewish population centers on the West Bank.” In his response, Mr. Podhoretz refers to “the Kurtzer flap.” Both Mr. Leibler’s assertion and Mr. Podhoretz’s offhanded response have no basis in fact.
The reality is that President Bush made a clear statement of U.S. policy in his April 14, 2004 letter to Prime Minister Sharon (an excerpt of which Mr. Podhoretz quotes accurately), and I, as the United States ambassador to Israel, have emphasized repeatedly and publicly that this letter reflects American policy. There is no misunderstanding between Israel and the United States in this regard. Unfortunately, a totally false article in an Israeli newspaper in late March 2005 got its facts wrong about statements attributed to me, apparently leading Messrs. Leibler and Podhoretz to draw erroneous conclusions. My own public statements on the day the false report was published, as well as statements for the record by senior U.S. officials in Washington, clearly underscore the continued applicability of the understandings conveyed by President Bush to Prime Minister Sharon.
Daniel C. Kurtzer
United States Ambassador to Israel
Tel Aviv, Israel
Norman Podhoretz writes:
The “flap” to which I referred did indeed take place, and it did indeed concern Ambassador Kurtzer’s reported denial that the United States had agreed to Israel’s retention of the major Jewish population centers on the West Bank. Furthermore, Allan Leibler was—to put it mildly—far from the only Israeli who remained unconvinced by Mr. Kurtzer’s insistence at the time that he had never made the statement attributed to him by an Israeli newspaper.
In my own response, I neither endorsed nor rejected Mr. Leibler’s interpretation of Mr. Kurtzer’s disavowal as “damage control.” I must confess, however, that Mr. Kurtzer is not altogether wrong in suspecting me of having leaned toward Mr. Leibler’s skepticism. Even so, I strongly disagreed with Mr. Leibler’s idea that the Bush administration was using its ambassador to distance itself from the plain sense of the letter President Bush wrote to Prime Minister Sharon on April 14, 2004. (Here, yet again, is the crucial passage: “In light of new realities on the ground, including already existing major Israeli population centers, it is unrealistic to expect that the outcome of final-status negotiations will be a full and complete return to the armistice lines of 1949 [i.e., the ’67 borders].”)
Unlike Mr. Leibler, I thought it more likely that if Mr. Kurtzer had in fact denied that these words meant what they certainly seemed to mean, he was acting not as a spokesman for the President’s policy but as an opponent. But if so, how could a sitting ambassador have dared to come out openly against the President he was supposed to be representing?
My guess was that the answer—if the case were truly such as to require one—might lie in Mr. Kurtzer’s continuing thralldom to the old policy (according to which it is axiomatic that law and justice and peace require a withdrawal by Israel to the ’67 borders and the removal of all Jewish settlements from the West Bank). If this too were so, he might simply have been unable to believe that President Bush had actually committed the United States to what could easily have struck anyone like himself—anyone, that is, who had cut his diplomatic teeth on the old axioms—as the political equivalent of declaring that parallel lines will eventually meet.
And now? Well, persuaded as I am that (1) President Bush most definitely did repudiate the old policy in his April 14 letter; (2) that he intends to stick by the assurance contained in that historic document; and (3) that Prime Minister Sharon is therefore right in claiming American backing for the inclusion within Israel’s future borders of “the already existing major Jewish population centers” in Judea and Samaria—persuaded of all this, I am more than happy to drop my initial suspicions and to take Mr. Kurtzer at his word when he writes above that he never questioned “the continued applicability of the understandings conveyed in April 2004 by President Bush to Prime Minister Sharon.”