I came across this article from a philosopher who apparently does bioethics, the title is, ‘what should we do about severely impaired newborns?’ The article is a report (by the philosopher) of a debate at the American Association of Thoracic Surgery.
The problem, simply put, is this: Every year a small number of fetuses are carried to term who have no reasonable chance of living a life worth living. They are so severely impaired that they will live a miserable, short life until they eventually expire. The good news is that, courtesy of prenatal screening, only few such births take place and the numbers are decreasing. We have some data from the Netherlands, where a few hundred out of about 200,000 newborns annually tend to fall into this category.
We can immediately here see the problem. He is ignorant. He has no idea what he is talking about: what antenatal diagnosis gives a fetus ‘no reasonable chance of a life worth living’? One could perhaps include anencephaly, and complete hydranencephaly where there is no ability to perceive the world at a conscious level, but apart from those 2 rare diagnoses, I am not sure there is anything else that would fit that definition, in my opinion. There are many diagnoses that are life-limiting, many that lead to serious impairment, but to automatically assume that a short life with impairments is not worth living is to ignore the experience of families who have been there. Furthermore a life with impairments is not necessarily miserable, at all. In Saroj Saigal’s study, if I remember right, the only person who rated their quality of life as being below zero, i.e. worse than being dead, was one of the non-impaired full term controls (probably someone suffering from depression).
The ‘good news’ as he puts it, also has nothing to do with predictions of being miserable. The majority of terminations for fetal anomaly are of fetuses who could easily survive and have long happy lives, such as trisomy 21, or surgically treatable lesions. Termination for an ‘impairment’ that is severely life limiting and predicts a miserable life, if we could even do that, is rare. In addition the title of the debate was ‘Can a Physician Ever Justifiably Euthanize a Severely Disabled Newborn’. Confusing impairments and disability is something a philosopher should certainly not do, I thought the meaning and implications of words were quite important to them.
In addition, where on earth does he get the figure ‘a few hundred’ from? It seems he made it up. In a recent publication covering 5 years in the Netherlands there were 2 cases of neonatal euthanasia, both of them for epidermolysis bullosa letalis, which is certainly not what most people would consider an impairment (even though it is a very serious and unpleasant disease, where the skin forms blisters at the slightest contact, and then separates, leading to pain and infections, and eventually, as the name implies, death).
Well, the topic of our debate was a dicey one. We were given a scenario whereby the child’s prospect were sufficiently miserable that the attending doctors suggested to parents – among other options – the withdrawal of nutrition and hydration while providing palliative care to ensure the newborn does not suffer unnecessarily, as well as active euthanasia. The outcome of both scenarios: the death of the child. The jurisdiction where our case played out permitted the active ending of the newborn’s life.
There are only 2 scenarios where withdrawal of fluids and nutrition are considered in neonatology, one is in severely brain injured (almost always full-term) newborns, who are so profoundly injured that they show no signs that they experience hunger or thirst, or alternatively, cases of lethal intestinal failure, where there is no way to provide fluids and nutrition by the GI tract. Both of these are ethically challenging; in the first group the infants tend to have a brain which is so severely damaged that they don’t appear to be conscious, make no eye contact and don’t usually show signs of ‘suffering’, although certainly everyone around them is suffering. These are infants for who, the only prospect is a life without human interaction and supported by medically administered nutrition, i.e. tube-feeding. There may be a debate to be had for such children, what kinds of interventions around the end of life are appropriate? But that certainly is not the kind of infant that is implied in the title of the debate, nor in the other comments he makes in this article
…… Would it make much sense to undertake significant surgery with the – unlikely but possible – result that the newborn might live a miserable life for another year or two before his impairment eventually catches up with him and kills him?
This is incomprehensible drivel, I don’t know how Udo Schuklenk (the philosopher’s name) thinks we can predict misery, although there are certainly some situations where children experience pain, these usually have nothing to do with impairment, and pain can almost always be controlled. What kind of impairment catches up with children and kills them? I know he is trying ot use colorful, metaphorical language, but it conjours up images of cerebral palsy chasing after children trying to suffocate them!
…On the one hand we have – typically – religiously motivated opponents of euthanasia for severely impaired newborns.
I am certainly not religiously motivated, far from it, and the fact that I value the lives of all babies, regardless of impairment, is based on our common humanity, on the belief that being smart doesn’t make you more worthwhile as a person than someone who is less smart, that the value of a life is not correlated with the number or severity of impairments
The distinguished theologian panel member who I debated argued that we should let nature takes its course, that we should provide clinical care not aimed at shortening the newborn’s life and that we should eventually let nature takes its course. The problem with the nature-takings-its-course argument is that we invented medicine to stop or delay nature from taking its brutal course. So, the letting nature take its course argument was a non-starter.
I agree that this argument is a non-starter, if we let nature take its course, then the average life expectancy would still be about 25 years!
….If we merely go by the newborn’s quality of life and life prospects it seems indeed best to end the unfolding tragedy sooner rather than later, but probably a decision should be arrived at with parental consent as opposed to against the unfortunate parents. It turns out that one can reasonably answer the rhetorical question of whether one would want to live in a society that terminated the lives of certain severely impaired newborns if one held the view – as I do – that the newborn’s current and future quality of life is all that matters here. I could live in such a society where empathy for human suffering trumps religious conviction.
And so could I, but you need to have some understanding of what you are dealing with, some experience of dealing with families who are going through these terrible ordeals, and some basic medical understanding of the conditions that they face. Knowledge of the quality of life as experienced by families, and whether children with impairments are often ‘suffering’ or not would be a good start. The idea that we can predict misery is profoundly misled. The lives of children with impairments may sometimes be considered to be an ‘unfolding tragedy’ but that is more commonly the case when you ask the opinions of caregivers, rather than parents or families. Finding ways to support and assist these families, to provide respite care and counseling, to improve rather than shorten their lives; those are goals that I think we should be aiming for as a society.
I won’t say much more about the debate, but I think it is very strange that a society of thoracic surgeons would ask a theologian and a philosopher to debate things that neonatologists actually have to deal with. I actually think that people with those backgrounds might sometimes have important things to add to such a debate, but first of all we need to educate them, and make sure they have some basic understanding of the issues. A medically trained participant in that debate could have, primarily, clarified the question and made the case description appropriate to the question, then could have explained the real dilemmas that are faced, and could have described the medical options that most philosophers and theologians have no training to consider.