Protest Views of Singer

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LETTERS

TO THE

EDITOR

261 “object

of affect”

for man;

commonly

the

human

is the

strongest source of emotive appeal to human kind. “Ours

is a situation that transforms the human spirit’s task, almost beyond recognition, to

one ofloftier

responsibility. It raises the lowliest human being conjointly with the highest, (and) we have, because human, an inalienable

prerogative

of responsibility

which

we cannot

devolve

...

we can share

it only

with

each

other.”

Despite

this

clear

expression

of species

responsibility

so elegantly expressed by Sherrington, the dog food and

dog grooming

counters

at my local

supermarket

take

up

more

space

than

the

counters

for baby

food

and

baby

grooming.

And

I would

speculate

that

the

four

health

procedures

(oral

rehydration

in diarrhea,

promotion

of

breast-feeding, universal immunization, growth monitor-ing) reported to save the lives of 20,000 children a da?

could be funded

by something

less than

our full US budget

for dogs and cats each year.

I would not argue that a child in pain should be allowed

to suffer any more than suffering is appropriate for an

adult

with bone cancer.

But we should

make

a very careful

distinction between the suffering of the child and the

emotional

or financial

distress

of the caretaker,

and

we

should make sure that we are not confusing one with the

other.

Handicapped

children

frequently

do not experience

suffering if their treatment is sensitively managed; rather they may exist with a different state of consciousness, a

limitation of perception rather than unpleasant percep-tion.3

REFERENCES

CHARLES N. SWISHER, MD

Division

of Pediatric

Neurology

Michael

Reese

Hospital

and

Medical

Center

Chicago,

IL

60616

1. Sherrington C: Man on His Nature. Cambridge, Cambridge

University Press, 1951

2. Grant JP: The State of the World’s Children. New York, UNICEF Publication, 1983

3. Uexkull JV: Umwelt und Innenwelt der Tiere. Berlin, Wass-muth, 1921

In

Reply.-Both

Bongiovanni

and

Callie

refer

to Nazi

Germany

as a warning against abandoning the sanctity-of-life view. This appeal to the slippery slope argument is a gross

oversimplification of the differences between our

society and Hitler’s Germany. Alexander, on whom Bon-giovanni relies, neglects the importance of Nazi racism

and of the fact that the Nazi euthanasia program was not

intended for the benefit ofthe patients-it was conducted secretly, relatives were deceived about what happened,

and

privileged

groups

such

as veterans

were

exempted

from it. Against Alexander’s opinion one can place that

of Lucy Dawidowicz, one of the most distinguished

his-torians of the Nazi genocide, who has said that the Nazi analogy is “historically irrelevant to the contemporary

debate”

about

euthanasia.’

I note

that

your

correspondents

have

not

denied

my

claim that other cultures, like Ancient Greece and the

Eskimoes, have combined more flexible attitudes to

pre-serving the lives of handicapped infants with a high level of protection for the lives of other members of society.

So the “slippery slope” is not at all an inevitable

progres-sion.

Bongiovanni misunderstands my point about the

par-allel

between

racism

and

“speciesism.”

It was

an

argu-ment against treating human beings as having special value merely because they are, biologically, members of a certain species. If Bongiovanni believes he can detect

an error

in this

argument,

he should

point

it out.

The

comment he does make does nothing to advance the

discussion.

Swisher addresses this point more directly, but I am not impressed by the speculations of Sir Charles

Sher-rington. Why should it be our task to treat every human

being,

no matter

how hopeless

its prospects

for a

mean-ingful life, in the same manner that we treat those who

can lead self-conscious, autonomous lives? The quotation

is more rhetoric than argument.

All the same, I should make it clear that I do not support the fact that we spend so much on “pets”; but then this is all part of the schizophrenic attitude to

animals evident in our society. We lavish love and

ex-pense on some animals, while blithely eating and

exper-imenting upon others.

I shall

leave

Callie

to his religious

opinions,

observing

merely that I am pleased not to live in an age in which governments seek to compel citizens to adhere to such

views, and to act accordingly. Callie is, however, deceiving himself if he thinks that the appeal to “extraordinary means” is going to preserve the traditional sanctity of life ethic. How is the distinction between “ordinary” and

“extraordinary”

means

to

be drawn?

At

the

Monash

Centre for Human Bioethics, we recently interviewed

nearly 200 obstetricians and pediatricians. The

inter-views included questions about this distinction, and the

answers showed that when future quality-of-life prospects

are poor, certain forms of intensive care will be considered

extraordinary

and

the patient

will be allowed

to die; yet these same forms of treatment are considered ordinary

when the quality-of-life prospects are good, and the

doc-tors would not dream of withdrawing them. Clearly,

qual-ity of life criteria, not sanctity of life doctrines, are doing

the work here.2

Some of your correspondents appear to have leaped to

conclusions about my views which are not justified by my commentary, or by anything else I have written. Why, for instance, does Feroli think I need to be told that “in a pluralistic society even religious views should be

toler-ated”? Of course people should be free to practice the religion of their choice. But should the state in a pluralist society compel all doctors and all parents to treat infants

in a particular manner, if this coercion can only be

justified on the basis of a religious doctrine? That is the issue I was raising.

Why, too, does Lasater think I have informed him that “man as a moral agent is dead”? Rather, I was suggesting that we act as thinking moral agents in assessing each

case on its facts, rather than simply accepting one doc-trifle to deal with them all. (As for Lasater’s question as to whether pigs publish bioethics journals, I could, of

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262 PEDIATRICS

Vol. 73

No.

2 February

1984

course, ask him if profoundly mentally handicapped in-fants have ever been known to publish such journals.)

Why does Stewart believe that I espouse some

Darwin-ian ethic of the survival of the fittest? The prospects a child may have for a minimally decent standard of life have little to do with his or her evolutionary fitness for survival, whatever that expression might mean in the context of a modern society with its myriad forms of (highly desirable) intervention in the survival process.

Where in my commentary does Geisler find me

claim-ing that children with Down’s syndrome are not as val-uable as animals? What I said was that if we compare a severely defective human infant with a nonhuman ani-mal, “we will often find the nonhuman to have superior

capacities.” Since some severely defective infants are

permanently incapable of any form of communication or

independent action, and many nonhuman animals can communicate and act independently, my assertion is obviously accurate. Down’s syndrome is only one form of

mental handicap, and it is not what I had in mind.

Why does Warriner imagine that I have anything but

total abhorrence for the policies of the Communist and Nazi regimes to which he refers? Is it not obvious that the killing of beings who have a tolerable quality of life

and who wish to continue to live is utterly different from

a decision against preserving the lives of beings whose only future is a life of misery without even such possibly redeeming features as rationality or the ability to com-municate with others?

And to pick up just one more misattribution, but a very fundamental one, why does Bachl think that I

be-lieve morality to be a matter of “subjective taste”? This is the very reverse of my view: indeed I would never have

written my commentary if I had not believed that reason

has a crucial role to play in moral debates like this one.

On this point,

I confess

that

the evidence

provided

by the

resulting correspondence is not encouraging. While the letters have been strong on expressions of religious belief, they have been short on arguments against my central contention that the life of a being cannot have unique value simply and solely because that being is a member

of a particular species, Homo sapiens. (Though it may offend some readers, I persist in my view that there are

no rational grounds for belief in the religious doctrines referred to; this is, however, an issue which I must leave

for some other occasion.)

Williamson complains that you have published a

corn-mentary that does not reflect the attitudes of American

‘

physicians. He apparently considers this shameful. I con-sider it shameful that anyone should wish to stifle

inde-pendent thought in this manner. Surely academic

jour-nals should not be influenced by the fact that a view is unorthodox-except perhaps to seek to publish such opinions, in order to challenge tendencies toward gray

conformity in our thinking.

In fact, however, I wonder which of us is more repre-sentative of the views of pediatricians in the United States. In reading the new proposed rules issued by the Secretary of the Department of Health and Human Ser-vices in the Federal Register,3

I note

that

the Secretary

cities several surveys of pediatricians, and the results suggest that views contrary to the sanctity of life doctrine

are common. For instance, a 1977 survey of 400 members

of the Surgical Section of the American Academy of

Pediatrics indicated that 76.8% of pediatric surgeons

responding would “acquiesce in parents’ decisions to

re-fuse

consent for surgery in a newborn with intestinal

atresia if the infant also had Down’s syndrome.” A

smaller, but still significant number-23.6%-said they would actually encourage parents to refuse consent in

such a case. (The survey was first published in Pediatrics [1977; 60:590-592].) This is a striking result, for if so many pediatricians would act in this way in the case of Down’s syndrome, presumably many more would do so in the case of a worse condition that really did mean a miserable life for the child.

While on the subject of the new proposed rules (which had not been made public at the time when I wrote my commentary), it is interesting to note that even the Department of Health and Human Services has backed away from the absolutist sanctity of life stance of its original “Notice to Health Care Providers.” The

supple-mentary information given with the new rules now states that:

Section 504 does not require the imposition of futile therapies which merely temporarily prolong the process of dying of an infant born terminally will, [sic

-

even the Federal Register can have misprints] such as a child with anencephaly or intra-cranial bleeding. Such medical decisions, by medical personnel and parents, concerning whether to treat, and if so, what form the treatment should take, are outside the scope of Section 504.

This is an obvious attempt to have things both ways.

Why is an infant with intra-cranial bleeding “terminally

ill”? Could the baby not be kept alive, with appropriate

technologic support, almost indefinitely? On what basis, then, is a decision to discontinue treatment said to be a “medical decision” and one not related to the infant’s handicap? If all human life is sacrosanct, why not the weeks, months, or even years that a brain-damaged infant might survive on a respirator? Clearly the fact that such

a life lacks any positive qualities is the real factor behind the acquiescence of the DHHS in the decision to end

such a life while it could still be prolonged.

Even the US Surgeon General, Dr C. Everett Koop,

who is widely admired by supporters of the sanctity of

life view, told Judge Gerhard Gesell’s Court that the

Department regulations did not intend that an infant

with essentially no intestine should be “put on

hyper-alimentation and carried for a year and a half.” Koop

goes on to say, “Incidentally, I was the firstphysician that ever did that, so I know whereof I speak” (Official

Tran-script ofAmerican Academy ofPediatrics et al v Margaret Heckler, US District Court, Washington, DC, March 21, 1983, pp 44-45). But if such a child can survive so

long-and perhaps even longer-he or she can scarcely be

regarded as “dying” from the moment of birth. So if all human life is sacred, why should such an infant not have

one year or two of life? Would a normal adult who needed and wanted such life-support be denied it? If not, the

decision to provide it for the adult but not for the child must have something to do with the poor quality of that child’s existence, and the absence of any prospect of

improvement.

So

we all use quality

of life criteria

in the difficult

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LETTERS

TO

THE

EDITOR

263

and-death decisions that must be made in these tragic

cases. My commentary has provoked opposition, not be-cause I have abandoned the doctrine of the sanctity of

human life in favor of quality of life criteria, but because I have done so openly, without disguising what I was doing behind talk of medical decisions or the distinction between ordinary and extraordinary means. In my corn-mentary, I said that change is often alarming, “especially

change in something that for centuries has been spoken of in such hushed tones that to question it is

automati-cally to commit sacrilege.” It seems that to be open about

one’s use of quality of life criteria is still, at least among some readers, sacrilege. I regret the fact that some readers

find such open discussions disturbing, horrifying, and even “shameful”; nevertheless, I see no other way of

raising the issues for critical, rational examination.

REFERENCES

PETER SINGER,

MA,

BPHIL,

FAHA

Centre for Human Bioethics

Monash University Wellington Road

Clayton, Victoria, Australia 3168

1. Biomedical Ethics and the Shadow of Nazism, special supple-ment to Hastings Cent Rep 1976;6:10

2. Singer P, Kuhse H, Singer C: The treatment of newborn infants with major handicaps: A survey of obstetricians and paediatricians in Victoria. Med J Aust 1983;2:274-278

3. Proposed rules for health care providers. Federal Register

1983;(July 5) 30847

Biostatistics

Articles

Needed

To the

Editor.-I read

with great interest Hayden’s article,

“Biostatis-tical Trends in Pediatrics: Implications for the Future”

(Pediatrics 1983;72:84-87). While emphasizing the im-portance of the care with which journal editors review the statistical analyses employed in the articles

pub-lished, the author does not dwell on the readers’ low level

of knowledge.

The editorial by Feinstein, “Prophylactic and

Reme-dial Therapy for the Intellectual Ailments of ‘Biostatis-tics,’ “ in the same issue (Pediatrics 1983;72:131-133)

reiterates the points made in the article. Again, the author essentially glosses over the need for more knowledge in

the reader. Both authors are more interested in the issue from the writers’ viewpoint.

Itook one statistics course in my undergraduate years. Instead of a practical course, it turned out to be a semester

long sermon on the joys of Bayesian statistics. The med-ical school I went to did not require a statistics course

for admission, nor did it offer one to its students. The

residency I served was excellent, but also did not teach

statistics.

I suspect that my experience is not unique (except for

my voluntarily taking a course-most clinicians have

never studied the subject). I feel incompetent to evaluate the statistical analysis in the simplest of articles and have to rely on the verbal conclusions of the authors.

What

these

papers

imply,

but do not directly

address,

is the need for a series of articles on basic statistical methods, written for the pediatrician in practice. The authors should assume no previous knowledge. Ideally, tutorials could be published using current literature for

examples. This approach could make the information

much more interesting.

Pediatrics is, to the perception of most, the journal for

the practicing pediatrician. As such, it would be an ap-propriate place for a series of tutorials on the subject. I hope you will seriously consider this suggestion as I

believe it could be of great value to your readers.

STEPHEN

E.

JACOBS MD 1540 Florida Ave Suite 205

In

Reply.-Modesto,

CA

95350

As Jacobs suggests, his experience is far from unique.

Many physicians have had little or no training in

bio-statistics and research design and, therefore, feel

ill-prepared

to understand

the methods

ofpublished

studies.

Responding to this need, several medical schools have

recently developed new courses in clinical epidemiology

and biostatistics. This trend, if it continues and spreads, should help to relieve the problem in the years ahead.

For a more immediate solution, I applaud Jacobs’

enthusiasm for a series of biostatistical tutorials, and

note that three prominent journals have already pub-lished, or announced their intentions to publish, such articles.’3 Those ambitious readers too impatient to wait for this type of slow, serialized instruction may wish to

consult several newer books designed to make the phy-sician a better and more critical reader.47 Unfortunately, it is uncertain how many readers share Jacobs’ enthusi-asm and will be anxious or able to borrow the necessary

time from their busy clinical routines to pursue

biosta-tistical studies. In any event, placing additional respon-sibility upon the writers and editorial staff, as suggested by Feinstein and myself, can only help to reduce the

current difficulties.

REFERENCES

GREGORY

F.

HAYDEN, MD

Department

of Pediatrics

University of Virginia Medical Center Charlottesville, VA 22908

1. Relman AS: A new series on biostatistics. N EngI J Med

1982;306:1360-1361

2. Altman DG: Statistics and ethics in medical research (series).

BrMedJ 1980;281:1182-1184, 1267-1269, 1336-1338,

1399-1401, 1473-1475, 1542-1544, 1612-1614, and 1981;282:44-47

3. O’Brien PC, Shampo PA: Statistics for clinicians (series).

Mayo Clinic Proc 1981;56:45-49, 126-128, 196-197, 274-276,

324-326, 393-394, 452-454, 513-516, 573-575, 639-640,

709-711, 753-756

4. Gehlbach SH: Interpreting the Medical Literature: A Clini-cian’s Guide. Lexington, MA, The Collamore Press, 1982 5. Fletcher RH, Fletcher SW, Wagner EG: Clinical

Epidemiol-ogy-The Essentials, Baltimore, Williams & Wilkins, 1982 6. Reigelman RK: Studying a Study and Testing a Test: How to

Read the Medical Literature. Boston, Little, Brown and Co,

1981

7. Feinstein AR: Clinical Biostatistics. St Louis, CV Mosby Co, 1977

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1984;73;261

Pediatrics

CHARLES N. SWISHER