The century of dilemmas

Charlotte Haug About the author

New opportunities for diagnostics and treatment leave us with more rather than fewer dilemmas that we need to relate to.

Photo: Einar Nilsen

«I was also ridding the family of a calamity,» the midwife said to the author Xinran in the documentary book Message from an unknown Chinese mother –stories of love and loss (1, Chapter 3). She has just explained that part of her job was to put unwanted girl babies «out of the way», often by killing them. In the book, poor Chinese mothers recount how they have been robbed of their daughters, partly as a result of the Chinese one-child policy, partly because of tradition and financial realities.

Infanticide has been committed throughout history, with varying justifications, and is still being committed, Julian Savulescu, Editor-in-Chief, wrote in an editorial in the Journal of Medical Ethics one year ago (2). It introduced a special issue on abortion and infanticide, in response to the controversial article After-birth abortion – why should the baby live? by the philosophers Alberto Giubilini and Francesca Minerva (3). They argue that killing a newborn child ought to be acceptable in all situations in which abortion is regarded as morally acceptable, even when the child is healthy. They thus go a step further than they do in the Netherlands, where euthanasia of severely ill newborns is permitted according to the so-called Groningen protocol (4).

Savulescu was strongly criticised for having published the article by Giubilini and Minerva. In his defence, he stated that a serious debate on infanticide was necessary, and he was concerned with placing it in the context of termination of pregnancy as well medical practices that permit treatment to be discontinued or withheld: «practices that end life, which society already accepts, even if they are euphemistically redescribed» (2). The articles in the May 2013 issue of the Journal of Medical Ethics are worth reading, provided that you do not mind having your own views challenged.

So what is a life, and when is it acceptable to end it? As doctors we are obliged to address this question. We are all bound by medical ethics and the imperative primum non nocere (above all, do no harm). But how? At some point or other, on a line reaching from refusal of contraception through abortion, infanticide and euthanasia to participation in death penalties and homicide, most of us will approach a point at which we hold it to be unacceptable to end a life. Where this point lies may vary – with social realities, life conditions and value judgements. Moreover, we should tolerate these variations.

We should also tolerate that being one hundred per cent consistent may be difficult. If we reject euthanasia of ill newborns, why should it be easier to accept a termination of the pregnancy if the same symptoms can be detected by early ultrasound or examination of a fertilised egg? Most of us will find it atrocious to follow Giubilini and Minerva’s line of reasoning that killing healthy newborns may be acceptable. But why do we find it admissible to end the same life at an earlier stage, because we have the resources and technology to detect the pregnancy early enough? Some people claim that everything possible must be done to save a life, but it is that simple? This is also a question of whom to save: the person before you or others that will be affected by what you do to the person before you? Most anti-abortionists would choose to save a pregnant woman with a life-threatening disease, even when this would imply the death of the foetus. Another ethical dilemma will arise if a doctor chooses to devote all available resources to saving one life, thus choosing to disregard the queue of others in need who thereby will be robbed of opportunities for treatment and care – and life.

New opportunities in medical diagnostics and therapy provide us with a growing number of dilemmas that we need to address. We need to be prepared to deal with them when they occur. This will require ethical awareness on the part of doctors and patients, and politicians who have respect for the difficulties involved and the ability to handle disagreement. This does not mean that everything will be acceptable – but we need to choose our battles carefully.

In the ongoing debate on the doctors’ right to conscientious objection, the lines drawn up have become unnecessarily rigid. «Doctors must put the patient and not themselves at the centre of attention,» opponents are saying. Of course they must. A good doctor should listen to the patients and respect their wishes. However, this is not tantamount to always doing what the patient requests. Some maintain that it is inopportune for doctors to bring their own viewpoints into the consultation. However, if patients can have what they want from a machine that dispenses guidelines and rights, is it not unnecessarily costly to go through the doctor?

In another chapter of the book that I quoted in the introduction, Xinran has found a deeply hypothermic newborn girl abandoned on the pavement. She rushes the child to the nearest hospital, but is stopped in the reception because no newborns can be admitted unless the mother holds a valid birth permit. «I can’t believe you’re going to stand here and watch this baby die in front of your eyes?» Xinran shouts. «Our hospital has a responsibility to carry out our work in accordance with the one-child policy. No hospital personnel have the right to flout that policy. If we did, we’d all lose our jobs,» the doctor explains.

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