Recent eLetters

To the Editors,

In your statement explaining why you chose to publish Giubilini and Minerva's paper you wrote, "If an argument was based on clearly and obviously mistaken premises, then we would reject it." However, in their paper, Giubilini and Minerva state, "Merely being human is not in itself a reason for ascribing someone a right to life."

This begs the question: What, exactly, would one have to say for the editors to deem that a mistaken premise? What conditions does an individual have to fulfill to earn a right to life?

Giubilina and Minerva also state that, "We take 'person' to mean an individual who is capable of attributing to her own existence some (at least) basic value such that being deprived of this existence represents a loss to her."

Does that, therefore, mean that dementia patients are not persons?

Your decision to honor this paper with publication is just as reprehensible as Giubilini and Minerva's decision to write it. I am very grateful that none of you has the authority to decide whether I have done enough to earn a right to life.

Conflict of Interest:

None declared

In a recent article Glubilini and Minerva (G&M) present arguments that they say show that infanticide (which they term "after-birth abortion") is morally acceptable. The argument can be summarized as follows: A) Newborns have no properties that would make them persons, and therefore are not actual persons. (In this way they are similar to fetuses; potential persons but not actual persons) B) Moral considerations such as the right to life apply only to actual persons, not to potential persons. C) One cannot harm a potential person by preventing it from becoming an actual person, since there will be no person existing to which harm is done. D) Conclusion: It is morally acceptable to prevent newborn babies from becoming persons by killing them when our own ends require this.

This is a rather frightening argument with implications that are ghastly. G&M claim that they are in favour of infanticide within a few days after birth only, and then only in cases that would have justified abortion such as severe disability or economic strain on the family. However, the argument they present goes much further, and shows that no newborns have any source of moral consideration with regards to a right to life. They mention an argument along the lines of the moral worth of newborns coming from the value their parents attribute to them; but this is a much lesser consideration than a right to life and does not afford a newborn much moral weight. Also, newborns that are not valued by their parents have no source of moral value; children of mothers with postnatal depression or unwanted babies are therefore excluded. The crux of their argument lies in the idea that personhood is the determinant for moral worth. According to that argument only persons are included in the moral community and only persons are subjects of moral rights and moral consideration. In question specifically is the right to life, and only persons are attributed the right to life. What is the criterion for personhood? A being that has the ability to (in even some basic way) value its own existence. This also seems to be time sensitive; potential persons do not count and presumably previous persons are excluded as well. The only ones who count in the moral equation are actual persons, those who qualify in the present. Now, when one's ethical theory provides conclusions that are decidedly immoral, the correct response is to reject one's ethical theory. So, for example, if one were an adherent to the Nazi ethical theory, and one saw the necessary outcome being the killing of millions of Jews and the plunging of the world into war, the moral response would be to reject the Nazi ethical theory. Even if one is not certain where the error crept in, there surely is an error. Careful re-examination of the premises one brought to the moral argument is in order. This is why Nazi soldiers who hid behind "befehl ist befehl" were not met with sympathy in the after-war legal hearings; they should have known better. They were ordered to kill innocent people in a way contrary to morality; they should have known that the ethical code of their superiors was incorrect. Similarly, we have the United States legal case of Dred Scott in 1840. Scott was a black man and a slave who pursued legal avenues to obtain his freedom. The court ruled against him and in language that makes one gasp for air declared that black people were not fit to be attributed human rights and that they were natural born slaves. Again, when we see an argument such as this, we have to question the whole ethical theory that it is based on. To their credit, Western civilization responded to this challenge. Incidentally, it is worth noting that the structure of G&M's argument is exactly the same as it is for the Nazis or for the Dred Scott case. It runs "X does not have properties that would qualify it for Y", "Y is the only property that would confer moral consideration", conclusion: "X has no right to life/no moral worth". It is interesting to note how similar these arguments are in structure and conclusion. So then, if I hold to a theory of ethics where I suddenly get to the conclusion that it is morally acceptable to torture or to kill innocents, where my conclusion is obviously at odds with morality, the conclusion casts doubt on the truth of the premises I brought to the argument and on my ethical theory as a whole. Let us be clear about it. The conclusion of G&M's argument is at odds with what we know of morality. Firstly, the idea that babies have no moral worth is profoundly immoral. Also, there are further implications of their argument that are equally immoral. Any human that does not fit their narrow definition of personhood does not carry moral weight. This includes just the kind of people where morality demands from us the most: the sick, the aged, the disabled and newborns. G&M's argument is not just merely mistaken; it is wrong. It is evil. It is in the same category of moral error as the death camps by the Nazis or the moral irrelevance of the African American slaves. No morally serious person could adhere to such conclusions. As such, this casts the premises brought to the argument in serious doubt. Is it really so that it is only personhood (as defined by G&M) that matters morally? This is a questionable claim, one which the authors spend no time defending. Together with this there is another implied premise, namely that there is no other source of moral worth when attributing the right to life. This also is an astounding claim that G&M do not bother to defend. The idea that human beings are intrinsically valuable and worthy of moral consideration seems much more in line with morality itself, no matter which moral tradition one turns to. Basing moral worth solely on actual present-time personhood is problematic. As stated before, this criterion excludes a vast number of the human race that morally requires a lot of us such as the senile or handicapped. But also, taking the G&M line of reasoning further as far as actual personhood goes leads to morally dubious scenarios. Let us take take our friend B. The four of us want to share his possessions between us, but we cannot harm him since he is an actual person. However, we know he has a weakness for tranquilizers. We arrange a party, and ensure there are enough tranquilizers around. Soon he is reduced to a stupor; he is not responsive to pain and is barely breathing. Clearly, at present he is not able to value his life in any sense. Right now we have to say he is no actual person. He is a past person and he is a potential person, since he will be a person tomorrow when the drugs wear off. Happily we kill him and divide the loot, concluding we have done no harm. We cannot harm potential persons by preventing them from becoming actual persons, and it turns out there is no actual person B in the present who can be harmed. The fact that B was a person does not count; only actual present-time persons count in the moral equation. Similarly, there are issues with murder. Once we have killed X, there is no more X to which harm could have accrued. Therefore no harm has been done. But wait, X was a person with goals and ideals, and frustrating them harms X. It would have, if X were in existence; if there is no person to whom harm could accrue, there is no harm. When it comes to children, when do we say that they have sufficient capacity for personhood? Does a 2-year-old value its own existence? Does a 1 year old? Do we have a sliding scale of moral worth as children age? Can we really answer such questions? No we cannot. And we should not bother, because if there is one conclusion to be drawn from the argument presented by G&M, it is that the idea of moral worth being solely based on personhood is incorrect. The premises are faulty; there is more to morality than a narrow definition of personhood. There are various other moral approaches which produce much more satisfactory and coherent results. The outcome of the argument presented by G&M is that the whole project of basing moral rights on attributes of personhood is faulty. Perhaps it is time that we abandon the project of personhood; certainly there are better criteria for inclusion into the moral community and surely there are better ethical theories that deliver more acceptable conclusions.

Conflict of Interest:

None declared

Dear Editor,

We read this paper (1) and the responses with interest and would like to recommend adding some important things to the discussion.

We would firstly like to respond to the ethical vision depicted by the paper. We strongly deplore some of major pitfalls in the authors' argumentation.

Lejeune, discovering the genetic cause of Down Syndrome, said "the quality of a civilization is measured by the respect it pays to its weakest members. There is no other outcome" (2). This is the fundamental valor of our modern societies, as stated in the Human Rights Law (3). From an ethical point of view, it may even be the only reason for our existence and the only way to make sense to our life.

If criteria such as the costs (social, psychological, economic) for the potential parents are good reasons to justify the killing a newborn or an infant, such as proposed, which model of society do the authors recommend? Taking into account that psychological distress could be a good reason, the authors would actually justify infanticides "on demand" (1). Which message do the authors intend to convey to people now living with some congenital or accidental debilitating condition? Are they to be regarded as a problem for our society because they have not been eliminated in the perinatal period? In fact, this cost is the "exact price the civilization has to pay to remain humane", continued Lejeune (2).

This paper is, however, not only unacceptable from an ethical point of view. The paper also fails in its argumentation. The authors agree with the fact that newborns can feel pain and pleasure. As a consequence, pain and unnecessary privations must be avoided. But at the same time, the authors claim that privation of life (and the associated self accomplishment) is not a problem (1). Could they defend the point of view where any experiment, except painful ones, could be acceptable in newborns if killed in the first weeks of life? In fact, in our opinion, it is not possible to consider that harm to newborns is acceptable if they become killed thereafter.

Anyway, this paper also suffers from other inconsistencies, which are opinion-driven rather than presented scientifically. As an example, no data support the argument that the irreversibility of the infant's death could be more comfortable than adoption. And why presenting the loss of a partner and social, psychological or economic difficulties as difficulties without solution while this is obviously often not the case? With such argumentation, the authors would prevent a possible harm on the cost of a real death.

Finally, the authors seem to be uncomfortable with the problem of a "limit" to define the passage from the status of a "potential" to an "actual person". If we could kill our newborns, why not our infants and maybe our small children, who are often not able to make plans for their life nor do they understand the irreversibility of death? Why not all the handicapped persons of whom we think that they are not able to aim for life perspectives? In fact, could it, for the authors, not be also an interesting way to eliminate our boring neighbours of whom we think that they are not able to understand and to plan anything in their lives, often being sick or unemployed?

As a conclusion, we are convinced that the medical community can absolutely not agree, and even struggles against the idea that killing our population for cost reasons is acceptable. We take this strong statement to avoid placing parents as well as physicians in very difficult conditions.

References

(1) After-birth abortion: why should the baby live? Giubilini A, Minerva F. J Med Ethics. 2012 [Epub ahead of print]

(2) Lejeune J. [online] [consulted on 26 April 2012]. Available online <http://publications.fondationlejeune.org/CompleteListe.asp>

(3) United Nations. [online] [consulted on 26 April 2012]. Available online <www.un.org/fr/documents/udhr>

Conflict of Interest:

None declared

Dear Editor,

Muirhead argues that Beauchamp and Childress' principalist approach to ethics is of little practical relevance to the majority of commonly occurring clinical ethical scenarios. Through analysis of three cases which involve conflict between the principles of autonomy and benefice, he demonstrates that many scenarios are well rehearsed with the "correct" answers enshrined in guideline and statute. His paper belittles the need of ethical deliberation from healthcare workers, but stops short of suggesting a limited role of merely knowing and applying the appropriate law or guideline.

Clinical scenarios can rarely be summarised into neat vignettes without overlooking vital details. Each case presented is one-dimensional, with no conflict between existing guidelines and statutes. Ethical guidance provides standardised framework for common dilemma, in much the same way that clinical guidelines, protocols, checklists and pathways assist clinical decision making. However, guidance is open to abuse when applied to unintended situation. For this reason, a clinician must not only know the appropriate guidelines and legislation, but also have an understanding of how such guidance was developed in order to apply it correctly.

Even if appropriate guidance could fully replace the need for in- depth, case-by-case deliberation, one must question how these guidelines came into being and are subsequently developed? Current guidelines and laws will change over time to incorporate ethical dilemma raised by emergent technologies, shifts in public attitude and failures of previous guidance. The next generation of guidance and legislation will require discourse within society; healthcare workers will bring their experiences from the clinical realm to this discussion.

Conflict of Interest:

None declared

Dear editor,

When has the human life become of such little value? We cannot create it but so readily destroy at a mere whim, because we don't want to be bothered with responsibility for our own actions. Just because someone at the moment is incapable of making a decision to save their life does not give you the right to take it. it is not yours regardless of whether it is in utero or newly born. May GOD have mercy on you, and may someday you realize the sick and demented nature of abortion, partial-birth abortion and this so called after-birth abortion. Your so called justification is not necessary as it does not have higher value than that of a human life. Because your life has no value to me, I should be able to kill you without any punishment or consequences. When you are dead how can you defend yourself? In closing I must say this article is a disgrace to the Medical Journal I am astonished that you published it.

Conflict of Interest:

None declared