Critical care decisions in fetal and neonatal medicine: ethical issues
Deliberately ending life
2.35 Viewing withholding and withdrawing treatment as morally equivalent and acceptable in certain circumstances invites the question of whether the deliberate ending of life should also be seen as equally morally acceptable, given that the outcomes of all three options may be the same. On balance, the Working Party rejects the argument that they are equally morally acceptable, as we explain below. 24Consider the case of a seriously ill premature newborn child with no realistic prospect of survival and whose life can reasonably be thought of as one of intolerable suffering (see paragraph 2.16). Why might it be thought permissible to allow a baby to die by withdrawing or withholding life-saving treatment, but impermissible to take the life of a baby deliberately, for example by means of a lethal injection?
2.36 In principle, doctors have a professional obligation to preserve life where and when they can25, using the appropriate course of action to achieve that end (see Appendix 9). By contrast, taking intentional measures to end the life of a newborn baby, even one whose condition is reasonably judged as one of intolerable suffering (see paragraph 2.16) with no prospect of survival or improvement, is commonly regarded as a violation of the duty to protect the life of the patient.26 The professional guidelines of the RCPCH sanction the withdrawal of life-prolonging treatment in appropriate situations but remain opposed to “causing death by intended lethal action”.27While reference to legal and professional instruments cannot by itself be sufficient to settle the moral question of the responsibility of doctors, these guidelines appear to reflect the current UK consensus on these matters and give
expression to the ethos of healthcare professionals, factors that the Working Party holds as important.28Furthermore, although we recognise that evidence on such matters is difficult to obtain, we take the view that permitting doctors to end life deliberately would be likely to have a negative impact not only upon those doctors psychologically but on how the medical profession is perceived more widely. This is especially relevant where parents may lose trust in the impartiality of advice provided by doctors during the decision-making process.
2.37 There is also a problem of ensuring consistency (see paragraph 2.2). A newborn baby cannot express his or her wishes. It is therefore appropriate to appeal to what is believed to be in his or her best interests. If it were permissible to take the life of a newborn baby on the grounds that it was in his or her best interests to do so, we have to ask why would it not be permissible to kill an incompetent adult on the same grounds. Those who reject adult euthanasia but who are sympathetic to the proposition that it is permissible actively to end the life of a newborn child whose life is intolerable, would need to show that, further to the fact that the adult has had many life experiences and has entered into social relationships, there is a morally relevant difference. In summary, the Working Party unreservedly rejects the
active ending of neonatal life even when that life is ‘intolerable’.
24 In what follows the Working Party must be understood to be speaking about what can reasonably be foreseen as the consequences
of continuing treatment, withholding treatment, withdrawing treatment, or of actively seeking to hasten death. We are clear that the possibility of a dramatic life-saving scientific discovery does not fall within the scope of what can reasonably be foreseen. Equally if doctors act with a well-grounded conviction that a baby will die as a consequence of their actions, they cannot be condemned if the actual outcome is otherwise.
25 “A physician shall always bear in mind the obligation of preserving human life.” World Medical Association (1949, as amended) International Code of Medical Ethics. Doctors are not obliged to provide what they consider to be futile treatment.
26 For a brief introductory discussion of the intentional ending of life by a doctor see Kuhse H (1991) Euthanasia, in A Companion to EthicsSinger P (Editor) (Oxford and Massachusetts: Blackwell), pp 294–302 and Tooley M (2003) Euthanasia and Assisted Suicide,
in A Companion to Applied Ethics, Frey RG and Wellman CH (Editors) (Oxford: Blackwell), pp 326–41.
27 Royal College of Paediatrics and Child Health (2004) Witholding or Withdrawing Life Sustaining Treatment in Children: A framework for practice, 2nd edition (London: RCPCH). The RCPCH also notes that “withdrawal of life sustaining treatment in appropriate
circumstances is not viewed by the courts as active killing, nor as a breach of the right of life under article 2 of the European Convention on Human Rights”.
28 British Medical Association (2006) Assisted Dying – A summary of the BMA’s position, available at:
http://www.bma.org.uk/ap.nsf/Content/assisteddying?OpenDocument&Highlight=2,euthanasia, accessed on: 12 Oct 2006.