COMMENTARY on the Culture of Death

031105 Pulling Back the Curtain on the Mercy Killing of Newborns

·  An ethics expert urges us to think twice before decrying Dutch doctors' report.

By Peter Singer, Peter Singer is a professor of bioethics at Princeton University and the author of "Rethinking Life and Death: The Collapse of Our Traditional Ethics" (St. Martin's Press, 1994).

In Thursday's New England Journal of Medicine, two doctors from the University Medical Center Groningen in the Netherlands outline the circumstances in which doctors in their hospital have, in 22 cases over seven years, carried out euthanasia on newborn infants. All of these cases were reported to a district attorney's office in the Netherlands. None of the doctors were prosecuted.

Eduard Verhagen and Pieter Sauer divide into three groups the newborns for whom decisions about ending life might be made.

The first consists of infants who would die soon after birth even if all existing medical resources were employed to prolong their lives.

In the second group are infants who require intensive care, such as a respirator, to keep them alive, and for whom the expectations regarding their future are "very grim." These are infants with severe brain damage. If they can survive beyond intensive care, they will still have a very poor quality of life.

The third group includes infants with a "hopeless prognosis" and who also are victims of "unbearable suffering." For example, in the third group was "a child with the most serious form of spina bifida," the failure of the spinal cord to form and close properly. Yet infants in group three may no longer be dependent on intensive care.

It is this third group that creates the controversy because their lives cannot be ended simply by withdrawing intensive care. Instead, at the University Medical Center Groningen, if suffering cannot be relieved and no improvement can be expected, the physicians will discuss with the parents whether this is a case in which death "would be more humane than continued life." If the parents agree that this is the case, and the team of physicians also agrees — as well as an independent physician not otherwise associated with the patient — the infant's life may be ended.

American "pro-life" groups will no doubt say that this is just another example of the slippery slope that the Netherlands began to slide down once it permitted voluntary euthanasia 20 years ago. But before they begin denouncing the Groningen doctors, they should take a look at what is happening in the United States.

One thing is undisputed: Infants with severe problems are allowed to die in the U.S. These are infants in the first two of the three groups identified by Verhagen and Sauer. Some of them — those in the second group — can live for many years if intensive care is continued. Nevertheless, U.S. doctors, usually in consultation with parents, make decisions to withdraw intensive care. This happens openly, in Catholic as well as non-Catholic hospitals.

I have taken my Princeton students to St. Peter's University Hospital, a Catholic facility in New Brunswick, N.J., that has a major neonatal intensive care unit, where Dr. Mark Hiatt, the unit director, has described cases in which he has withdrawn intensive care from infants with severe brain damage.

Among neonatologists in the U.S. and the Netherlands, there is widespread agreement that sometimes it is ethically acceptable to end the life of a newborn infant with severe medical problems. Even the Roman Catholic Church accepts that it is not always required to use "extraordinary" means of life support and that a respirator can be considered "extraordinary."

The only serious dispute is whether it is acceptable to end the life of infants in Verhagen and Sauer's third group, that is, infants who are no longer dependent on intensive care for survival. To put this another way: The dispute is no longer about whether it is justifiable to end an infant's life if it won't be worth living but whether that end may be brought about by active means, or only by the withdrawal of treatment.

I believe the Groningen protocol to be based on the sound ethical perception that the means by which death occurs is less significant, ethically, than the decision that it is better that an infant's life should end. If it is sometimes acceptable to end the lives of infants in group two — and virtually no one denies this — then it is also sometimes acceptable to end the lives of infants in group three.

And, on the basis of comments made to me by some physicians, I am sure that the lives of infants in group three are sometimes ended in the U.S. But this is never reported or publicly discussed, for fear of prosecution. That means that standards governing when such actions are justified cannot be appropriately debated, let alone agreed upon.

In the Netherlands, on the other hand, as Verhagen and Sauer write, "obligatory reporting with the aid of a protocol and subsequent assessment of euthanasia in newborns help us to clarify the decision-making process." There are many who will think that the existence of 22 cases of infant euthanasia over seven years at one hospital in the Netherlands shows that it is a society that has less respect for human life than the United States. But I'd suggest that they take a look at the difference in infant mortality rates between the two countries.

The CIA World Factbook shows that the U.S. has an infant mortality rate of 6.63 per 1,000 live births, the Netherlands 5.11. If the U.S. had infant mortality rates as low as the Netherlands, there would be 6,296 fewer infant deaths nationwide each year.

Building a healthcare system in the U.S. as good as that in the Netherlands — as measured by infant mortality — is far more worthy of the attention of those who value human life than the deaths of 22 tragically afflicted infants.