by Dominic Wilkinson @NeonatalEthics
On the 29th of January, Paediatric Palliative Care Specialist Dr Richard Hain gave th
e first St Cross Special Ethics Seminar for Hilary Term.
Dr Hain’s talk was titled “Mere Practicality? Infants, interests and the value of life”. The talk abstract and a link to a podcast of his talk can be found below.
The main focus of the talk was on contemporary accounts of medical ethics and in particular on the challenge of finding an adequate account that addresses the needs of human infants. Hain drew an analogy with a blood pressure cuff or “sphygmomanometer”. Blood pressure cuffs wrap around the upper arm, and air is pumped in to them until blood flow stops through the arm (this gives a reading of the pressure in the patient’s arteries). Adult-sized blood pressure cuffs don’t work well for children or infants. A too large cuff will usually give a reading that is too low because it doesn’t take as much air to cut off the blood flow. It underestimates a child’s true blood pressure.
By analogy, Hain suggested that many accounts of medical ethics – such as Beauchamp and Childress‘ Four Principles or Peter Singer’s Preference Utilitarianism are similarly inaccurate when it comes to infants. His talk implied two different, but related ways in which such accounts could be flawed. They may fail on procedural terms – in terms of telling us what to do when facing ethical dilemmas involving infants. However, they might also be thought to systematically undervalue infants. Accounts of medical ethics that place a great deal of emphasis on autonomy fail to be action-guiding when dealing with non-autonomous patients. Accounts of medical ethics that link moral status to self-consciousness may yield reduced or absent moral status for infants who are not self-conscious, or who possess only primitive self-consciousness.
[One interesting element of this analogy, which Hain didn’t address in his talk and may not have been keen to pursue is that adult cuffs may underestimate infants’ blood pressure. However, when appropriate cuffs are used infants actually have a true blood pressure that is considerably lower than that of adults (approximately half the value). By analogy, an accurate infant-sized medical ethics might also yield a smaller number or lower value for infants.]
In the second half of his talk Hain attempted to develop a positive account of a medical ethics more suited to infants. One key aspect to this account is the concept of ‘relationality’. Human infants, by their nature, are vulnerable and dependent. They all are born with existing relationships – to their biological parents and to the rest of society. Hain implied that those relationships give rise to moral duties to care and protect, to nurture and to support. In his talk he didn’t articulate this clearly, but this relational account might be thought to yield moral status for infants (in a way that is different from a self-consciousness view). Non-self-conscious infants have moral moral value because they are someone’s child and because they are automatically a member of a society. This account might yield practical answers by suggesting that what we ought to do in a particular ethical dilemma involving a newborn is to be guided by our relationship as a responsible parent or responsible member of society.
[However, there are also challenges to the relational view. Is this view descriptive, or normative? Does it simply describe the way that people do relate to a newborn, or does it tell us how they should relate to a newborn. Take, for example, the society of ancient Rome, with a socially condoned practice of abandoning unwanted or disfigured newborns who had not yet been named and welcomed into society. Such behaviour would appear to fit with the relationship between parent and infant and between society and infant in ancient Rome. What would a relational account of medical ethics have to say about the rights or wrongs of exposing infants?]
Title: Mere Practicality? Infants, interests and the value of life
Abstract: Anyone who has been present at the memorial service for an infant knows that, in practice, people accord the life of a child a special value. Those caring for infants, like those caring for children who are cognitively impaired, intuitively respond to their patients as though they were particularly precious, and feel an obligation to care for infants – that is, to act in their interests – that expresses that value.
Principlism is the dominant paradigm in medical ethics. It explains the value of life using both a utilitarian subjectivist account (there is a rational sense in which the individual’s continued existence will be in her own interests and/or those of others) and a deontological objective one (there are ‘contracts’ or ’ties of family’ whose nature, other things being equal, expresses an obligation to act in the interests of the individual, independently of any impact on the interests of others).
Both accounts are problematic in infants. Infants reason differently from adults, and they are by definition dependent on others. They apprehend the universe in a way that is meaningful, but probably does not link moral action with outcome. The infant therefore values its life in the moment, but does not have an interest in its continuing existence in the way a subjectivist account of intrinsic value requires. An obligation to act in the interests of an infant is complicated by the fact that those interests must be articulated by adults. Adults can be owner, carer, proxy or advocate for the infant, and may speak in all four voices simultaneously. It is often impossible in practice (it may not even be possible in principle), to explicate the interests of adults from those of an infant in the way the objective deontological account of an infant’s value requires.
In order to explain rationally the value of an infant’s life, we need to consider a different account of interests; one that does not depend on characteristics such a reason and independence that infants definitionally do not possess, but instead flows from characteristics such as meaning-making and relationality that they self-evidently do.
Dear Dominic,
Many thanks for this.
The only correction I’d like to make is that I did mention the fact that infants’ blood-pressure is actually lower than adults’, though only in passing. I also came back to it at the end, as an analogy for the fact that adults, too, are potentially victims of a poor-fitting ethic, since they also are not truly rationally autonomous in reality. I’m not sure the sphygmomanometer analogy supports an implication that the infant life is less valuable than the adult in the same way that blood pressure is less in the infant than in the adult, because there is a layer of subjective judgement in interpreting that result. You could argue with equal justice, for example, that the difference shows the infant is more healthy. But the analogy does (I hope) argue that we need to find some rational explanation for any difference that does not rely on the means we use to evaluate it. If the value of an infant life is different from the adult, we need a better explanation of it than what we currently conclude on the basis of adult-sized ethics.
Our conversation got me to reflecting on the idea that perhaps it is an illustration of a wider difference between the philosophical and ‘practical’ approach to ethics. I am constantly impressed by how well theologians and philosophers describe the way people are. But they often seem content to leave it there, rather than setting out how that description explains how we should treat persons, and why.
The symmetrical error of practical ethics, it seems to me, is a tendency to develop a normative approach that is based on an inadequate description. The illustration I gave of the infant is a good example, but there are many others. There is often, for example, an uncritical assumption that because rationality is a necessary characteristic of moral agents, it is also normative for the moral ‘patient’. I’m not really convinced by any of the explanations I have seen of what seems, on the face of it, to be an illicit logical step.
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