One of the occasional joys of popping in to view Mad Mel’s latest bout of inchoate raving is that even when life conspires to throw her the kind of bone that should see her securely anchored on the safest of ground, she still manages to make a complete pigs ear of her arguments.
The target of her latest foray into the realms of spitting fire and brimstone turns out to be the Royal College of Obstetricians and Gynaecologists, which she dubs the ‘Royal College of Infanticide’ as a consequence of a Sunday Times report (5 Nov), which claims that the RCOG is calling on the ‘health profession’ to ‘consider permitting the euthanasia of seriously disabled newborn babies’.
Now, to begin with one must understand a couple of things about Mad Mel.
First, she is not one to allow facts to get in the way of good old rant, and second, she is also not, so experience suggests, in the habit of double-checking source materials when commenting on matters that have been reported in the press, whether in her own or other newspapers, to ensure that whatever report she may have read to spark of here latest febrile ravings actually presents an accurate of picture of the subject at hand.
And so it is that by nothing more complex that a quick visit to RCOG’s website we find that far from advocating the active euthenasia of severely disabled newborns, as the Sunday Times claims, RCOG’s submission to the Nuffield Council of Bioethics’ consultation on The ethics of prolonging life in fetuses and the newborns actually does nothing of the sort.
What we have, in terms of the article in the Times, is a classic piece of journalistic licence in which statements have been extracted from RCOGs submission, which runs to thirteen pages of text and a half page of reference, and rearranged out of context to construct a story where none previously existed.
To illustrate precisely what I mean, this is relevant section of text from the Sunday Times, with element quoted directly from RCOGs submission highlighted in bold text…
The proposal by the Royal College of Obstetricians and Gynaecology is a reaction to the number of such children surviving because of medical advances. The college is arguing that “active euthanasia” should be considered for the overall good of families, to spare parents the emotional burden and financial hardship of bringing up the sickest babies.
“A very disabled child can mean a disabled family,” it says. “If life-shortening and deliberate interventions to kill infants were available, they might have an impact on obstetric decision-making, even preventing some late abortions, as some parents would be more confident about continuing a pregnancy and taking a risk on outcome.”
Geneticists and medical ethicists supported the proposal — as did the mother of a severely disabled child — but a prominent children’s doctor described it as “social engineering”.
The college called for “active euthanasia” of newborns to be considered as part of an inquiry into the ethical issues raised by the policy of prolonging life in newborn babies. The inquiry is being carried out by the Nuffield Council on Bioethics.
The college’s submission to the inquiry states: “We would like the working party to think more radically about non-resuscitation, withdrawal of treatment decisions, the best interests test and active euthanasia as they are ways of widening the management options available to the sickest of newborns.”
Looking now at RCOGs paper, what we find is that the phrase ‘active euthanasia’, which features three times in the Times report ((two of which are entirely out of context), appears in the paper only once, one the first page of the paper in what is RCOGs preamble to its full submission, which states, in full (and in context):
We look forward to the comprehensive and critical analysis of current law in the Report (clearly increased in the neonatal field since the Report was first envisioned). We believe that the best way to protect fetuses (whatever their moral status, and even assuming it is full) is by working with mothers. Present law, by being ‘hands-off’, raises maternal altruism and responsibility, and encourages trusting relationships with care-givers.Present abortion law allows a wider range of management options for the complex and unique dilemmas faced by pregnant women and restrictions might lead to perverse and hurried decision making. We remain opposed to the partial ‘fetal life’ consultation (as it stands), whilst very much supporting the important considerations of issues in neonatal life and where any changes in practice or law would impact in obstetrics. We would particularly like the Working Party to consider the wider issues of support and information for parents, and to think more radically about non-resuscitation, withdrawal of treatment decisions, the best-interests test and active euthanasia as they are means of widening the management options available to the sickest of newborns. Thus, potentially, there could be more flexibility in individualising care for each infant, and family. We recognise that neonates are extremely vulnerable, both to neglect but also to overzealous invasive treatments (as they do not have their own voice).
Straight away one can see that RCOG are not ‘advocating’ anything, merely asking that the Nuffield Council give consideration to the ethics of a wide range of treatments and ‘management options’. RCOGs request, here, is not for the right to ‘kill disabled babies’ but the Nuffield Council to give serious and far reaching consideration of the full scope of ethical questions and considerations that arise when dealing with the subject at hand, i.e. that of prolonging the life of fetuses and neo-nates by means of medical intervention. The request, here, is for guidance and ethical clarity – if such is indeed possible in such a difficult arena.
The phrase ‘A very disabled child can mean a disabled family,’ does not appear until page 12 of the paper, at the conclusion of a discussion factors included in (and presently excluded from) QALY assessments – QALY is an acronym (naturally) for Quality Adjusted Life Year, which is used by the medical profession to, amongst other things, identify public health trends for strategies to be developed, to assess the effectiveness and efficiency of health care interventions, or to determine the state of health in communities and is calculated, broadly speaking, in the following manner…
The Quality Adjusted Life Year (QALY) has been created to combine the quantity and quality of life. The basic idea of a QALY is straightforward. It takes one year of perfect health-life expectancy to be worth 1, but regards one year of less than perfect life expectancy as less than 1. Thus an intervention which results in a patient living for an additional four years rather than dying within one year, but where quality of life fell from 1 to 0.6 on the continuum will generate:-
4 years extra life @ 0.6 quality of life values 2.4
less 1 year @ reduced quality (1 – 0.6) 0.4
QALYs generated by the intervention 2.0
QALYs can therefore provide an indication of the benefits gained from a variety of medical procedures in terms of quality and life and survival for the patient.
Got that? Good…
What the report actually states is, as follows…
We discussed also the painful truth, that sometimes the best interests of the child (in continuing treatment) may be not be in the best interests of the mother, or of the family and that there might be ‘counter-QALYs’. The Children’s Act insists that giving or withholding care must depend on a child’s best interests, and the mother’s and family’s best interests do not legally have any role in such a decision, let alone an equal role. It may be that in practice they often do. We also discussed the differences in approach in individual families where there may be many demanding children already, or no other chance of ever having another child, and how difficult that might be if children are supposed to be inherently equally precious, but not equally cared for or found differentially burdensome. At the same time, it seems from the consultation paper that QALY deliberations can/do in fact take economic questions into consideration (such as cost effectiveness to NHS, rationing, bed blocking etc); surely that’s rather odd, if the law requires the best interests of the child to be paramount, along with the right to life? Isn’t there a certain amount of confusion here? We would want debate about the mother’s and family’s feelings, interests and rights and whether these should be agreed to be a highly relevant factor in decision making (as to giving or withholding treatment). A very disabled child can mean a disabled family.
So the actual context of RCOGs comment relates to what are perceived to be anomalies in the manner in which QALY calculations are undertaken in regards newborns, which have the effect of taking into account economic considerations of relevance only to the NHS (i.e cost effectiveness, rationing, bed blocking) but not the interest of the child’s mother/family – seems a perfect reasonable subject for an ethics debate to me.
The next quotation, which begins, ‘If life-shortening and deliberate interventions to kill infants were available’ and which looks the most ‘damning’ in its presentation actually occurs on page eight of the paper in a very specific context.
The question to which RCOG is responding appears on page 18 of the Nuffield Council’s consultation paper, and poses the question as to whether there is an ethical difference between ‘acting’ and ‘not-acting’, i.e. taking decision as to whether it its right to being (or withdraw) treatment, in the course of which the paper gives examples of potential care plans for newborn babies with little or no prospect of successful treatment or of recovery without serious disabilities for the reader to consider in this context, this list being:
a) Providing full intensive care (ie the whole range of medical neonatal care) with appropriate relief of pain or discomfort, until in most cases the baby dies
b) Providing fluids and nutrients and making the baby comfortable in other ways but not starting further treatment, such as respiratory support, antibiotics or surgery to combat breathing difficulties, infection or other circumstances that may threaten the baby’s life
c) Actively removing a baby from a ventilator so that it can die a ‘natural’ death in the arms of its mother and father
d) Giving a large dose of analgesics or other sedatives to ease pain, appreciating that this treatment may shorten life. Note: In the UK, deliberate intervention to cause the death of an infant constitutes homicide.
What RCOG suggested, beside noting some concerns as to the wording of the first three examples, which it felt were a bit too ’emotive’ and leading, was the incorporation of a fifth ‘example’ for debate, that of:
e) a deliberate intervention to cause the death of an infant.
About which it goes on to state:
Whilst pointing out that this presently would constitute homicide, this might be something the Working Party would wish to leave alone, or contrast with the Dutch system, or suggest a wider debate about changing in the law (as per the Assisted Dying Bill). The RCOG Ethics Committee does not have a view that we would like euthanasia to be discussed, but do feel that it has to be covered and debated for
completion and consistency’s sake, especially if you have been given a mandate to think widely. If life-shortening and deliberate interventions to kill infants were available, they might have an impact on obstetric decision making, even preventing some late abortions, as some parents would be more confident about continuing a pregnancy and taking a risk on outcome. It would be relevant to the inequity that a termination for a serious abnormality found on ultrasound might presently be possible in utero at 28 weeks for one couple, but another couple with a baby born without warning at 24 weeks, with just as bad a prognosis, have no choice about their parenting responsibilities. In particular, if assisted dying
legislation is to be anticipated or enacted at the other end of life, now would be a pertinent time to discuss this.
So, RCOGs view is that euthanasia could be discussed in the context of this debate for the sake of completeness and consistancy, although its own ethics committee has no string views on the advisability or conduct of such a debate.
It does, however, note the existence of an anomaly arising out of existing abortion laws in which the premature birth of a baby with a serious abnormaility closes off the option of termination that might otherwise have been open to the mother had the abnormality been discovered before the child was born, which poses, as far as I can see, a whole raft of complex and difficult, but entirely valid ethical questions that deserve serious and careful consideration by bio-ethicists.
Only, after it has misrepresented RCOGs view does the Sunday Times, rather grudgingly concede the following:
Initially, the inquiry did not address euthanasia of newborns as this is illegal in Britain. The college has succeeded in having it considered. Although it says it is not formally calling for active euthanasia to be introduced, it wants the mercy killing of newborn babies to be debated by society.
In other words, RCOG has asked for full ethics debate and nothing more – the suggestion that RCOG actively supports the use of euthanasia is no more than an invention of a Sunday Times with column inches to fill and no story to fill them with – The Nuffield Council actually launched its working party in 2004 and conducted its public consultation in 2005. RCOGs response, was actually published in July 2005, making this story more than a year old, and of relevance only because the Nuffield Council is due to launch its report in a couple of weeks.
Thus far we’ve established two things:
a) The report in the Sunday Times presents a false and grossly over-sensationalised account of what is otherwise a fair mundane and eminient reasonable response by RCOG to a complex bio-ethics debate, and
b) As usual, Mad Mel has not bothered to check the background to the story before putting fingers to keyboard.
Consequently, several passages in Mad Mel’s article are enitely redundant from the outset as the consist of nothing more than efforts to castigate RCOG for its advocacy of a position on euthanasia that is simply hasn’t adopted and does not advocate for.
Elsewhere, however, Mad Mel succeeds, as one might well expect, in proving that while she might me consider herself to be one of the UK’s foremost public moralists, the one thing she isn’t is an ethicist, and all by blundering into the usual trap that those of a religious bent wander effortlessly into when complex questions of the ethics of medical intervention arise.
So it is that she starts off promisingly enough with the observation that:
It is one thing not to prolong the life of a baby who is dying, or not to perform invasive procedures on a desperately sick infant whose life will be inescapably short and full of suffering.
The proper ethical course is indeed to allow such babies to pass away in their own time. But it is quite another thing to take actions deliberately intended to end a baby’s life.
Well, quite – if only life were quite so simple and straightforward. However, a little further on we come to…
In any event, doctors are not soothsayers. Look at the example of the badly-damaged premature baby Charlotte Wyatt. Doctors thought she would not live past infancy and accordingly decided no longer to resuscitate her. Her parents fought an epic and ultimately successful battle against this decision.
Now three years old, Charlotte is well enough to have left hospital (although she is still badly disabled). Sadly, her parents have now separated, and the impact on them of her plight cannot be overestimated.
But would anyone apart from the Royal College say now that Charlotte’s life should have been ended for their benefit?
And so the contradictions start to emerge. In one sentence Mad Mel argues that its right not to prolong the life of a child who is dying by use of invasive procedures, but a couple of paragraphs later she applauds the parents of Charlotte Wyatt for having gone to court to compel those doctors treating their child to carry out those same invasive procedures that she thinks it right that doctors be permitted to withhold.
What we have here is that ‘have your cake and eat it’ view that is peculiar to some religious believers, which holds that matters of life and death should be left to ‘god’s will’, but only so long at ‘god’s will’ includes access to a fully staffed medical team and a shedload of expensive medical technology.
Cases such as that of Charlotte Wyatt are necessarily extremely complex and difficult to decide, in both ethical and practical terms, which is why decisions on invasive treaments in extremis are rightly, and properly, subject to the deliberations of a Court of Law in the UK. Nevertheless, such cases also raise complex ethical questions, which Mel happily ignores, about whose interests are being served when such decisions are taken, question in which the concept of an individual’s quality of life have considerable bearing, matters upon which Mel appears to harbour few doubts as to who the villains of the piece are likely to be.
That is a line which the law does not permit doctors to cross, and rightly so. Concern to alleviate suffering develops very quickly into indefensibly subjective decisions about whether a particular life is worthwhile.
And are the decisions that face a parent of severely disabled newborn, at older person whose life is slowly ebbing away, a cancer patient in the advance stage of their terminal illness or the family of an individual who is hospitalised and in a persistant vegetative state any less subjective?
Can we be any more sure that a parent or family member facing such a decision is acting upon the best interests of the patient than would the case for a doctor. Of course not. Much as one may point to a doctor’s professional detatchment and lack of personal/emotional investment in such a decision as a factor that may unduly colour their judgment and cause them to give undue weight to factors other than those of the best interests of the patient, so the emotional attatchment that a parent feels toward their offspring, a child to their parent or between siblings may equally skew their judgment in the opposite direction towards a decison based on their own perceived emotional needs and not the interests of the patient – and this is without factoring into the equation such abstractions as those to be found in strongly held personal/religious beliefs.
The sad (and protracted) case of Terry Schiavo is an object lesson in the capacity of everyone from family members to opportunist ‘snake oil’ salesmen to politicians to seek to put their own interest ahead of those of a patient and the clearest possible reminder of the complex ethical questions where decisions are to be taken on matters of life and death. It’s also worth reminding ourselves that in such situations, medical professionals are required to consider the ethical dimensions of such decisions in full, hence the need for debates such as that initiated by the Nuffield Council: family members are not.
If Mad Mel has a purpose at all in pursuing an article, and line of argument, that is predicated on the wholesale misrepresentation of RCOGs submission to the Nuffield Council’s consultation, its to permit her to move onto one of her favourite personal hobby-horses…
Indeed, we are already well down that slippery slope. By allowing doctors to withdraw the feeding and hydration tubes from certain incapable patients, we have permitted intentional killing disguised as ‘allowing someone to die’. Case by case, decisions are taken which, at the time, may appear to be caring and compassionate. But then suddenly we realise that, as a result, we have transformed our society into a moral wasteland.
Yes, its that old favorite the ‘slippery slope’, the problem with which is that it invariably relies on the making of inexact and histrionic comparisons that have no basis in fact.
Thus we find, from Mel, that an otherwise serious attempt by RCOG to inform a complex ethical debate conducted under the aegis of a Bioethics Council of which thirteen of its seventeen members hold the title ‘Professor’ – the remaining members are a Doctor (and Fellow of Royal Society of Edinburgh), a Baroness, a Bishop (of Oxford) and Nick Ross (?) – will pave the way to…
‘withdrawing vital protection from individuals who are in most need of it through their extreme helplessness and vulnerability’,
‘Parents of newborns… put under pressure to have their babies killed by doctors conscious of the scarcity of resources in the NHS.’, and
‘the kind of inhumanity that lay behind the eugenics movement and the ideology of the Nazis.’ – not up on Godwin’s Law eh, Mel?
Oh, and while we’re on the subject of slippery slopes, lets not forget to throw in the ‘evils’ of abortion and embryo research while were on…
The same thing happened with legalised abortion and embryo research — introduced to relieve suffering, but responsible in large measure for the steady brutalisation of our attitude to human life.
So, if Mad Mel is to believed (daft idea, I know) doctors are long overdue for a change in uniform, swapping their traditional white lab coat from a natty red number complete with integral horns, tail and hooves… right?
Well, not quite. You see the real villains of Mad Mel’s morality play turn out not to be doctors after all…
For some years now, the medical establishment has fallen under the spell of academic ethicists and philosophers who, in accordance with fashionable dogma, have no respect whatever for the intrinsic value of human life — or indeed any absolute values.
Run for the hills! The world is being overrun by those damn secular ethicists and philosophers and the sky is falling…
Except, as ever, Mad Mel’s stated position is constructed without adequate foundations and located entirely on an intellectual swamp – if only she’d rather just sing…
Faced with such trenchant nonsense, the question one needs to ask is if such complex ethical questions as those raised by RCOG and the Nuffield Council are not to be tackled by means of consultation, deliberation and ethical debate then what, exactly is the alternative?
Take rational inquiry and reason out of the equation and what are we actually left with?
The solution to all the complex ethical questions posed by advancing medical technology are to be found, in Mad Mel’s world, in a book codifed more than 17 centuries ago at a time when bleeding the patient was thought to be the height of medical sophistication and the standard textbook of pharmacology was Pliny the Elder’s Naturalis Historia, in which the majority of ‘cures’ seemed to entail wearing or smearing the body with most of the least appetising bits of whatever wild animals the Romans had to hand at the time.
After all, who needs ethics when you can deal with any medical problem you care to name with a few prayers, a psalm and a pair of pigs testicles wrapped around your neck.
Oh, and yes, the title is deliberately ironic.