Neonatal Euthanasia

[Guest guest]

In a message dated 7/19/2003 12:11:55 PM Pacific Standard Time, aprilgim writes:

 

 

I wondered if anyone has any few on neonatal euthanasia.

 

In what context would an acupuncturist be confronted with such a decision other than personally? Seems to me this topic falls under the debate on abortion. The comments painted a vague picture with a broad brush.

 

I suspect you might be attempting to stir up the list with a controversial topic. But if I am incorrect, I still feel there is not enough information to which to respond. It doesn't seem to be a TCM question, really, but more one of a general ethics question that is best answered by the individual(s) effected. But then again, perhaps you were attempting to address herbal-induced miscarriage?

 

If I have missed something and you can tell me how this is a TCM question, I am open to hearing your point of view.

 

be well,

Maya

[Guest guest]

In a message dated 7/19/2003 12:11:55 PM Pacific Standard Time, aprilgim writes:

 

 

Although the answer may not be straightforward, the question itself helps caregivers put self interests and biases aside in an effort to do the right thing for the patient.

 

Eunkyung,

 

I appreciate the point you made above. As practitioners, we are not here to judge people's choices and lives but to educate and facilitate where possible.

 

Maya

[Guest guest]

I wondered if anyone has any few on neonatal euthanasia. Below is an

abstract of an essay i recently wrote.

 

The TCM practitioner is caught between two realms of ethical theory,

ancient traditional ethics and modern medical ethics. Is it ethically

justifiable to conduct euthanasia on the grounds of neonatal illness,

genetic defeats or because of excessive population numbers? Is this

beneficence in relation to society rather than the individual? Is

euthanasia more enforceable when autonomy is removed from the

equation because of mental neonatal immaturity?

 

Ancient Chinese medical ethics is established on the foundation of

Confucian ethics. The current dominant ideology conflicts, even

though it is based upon, with ancient medical ethics to the point at

which the aggressive government-sponsored eugenics programs are not

compatible with traditional Chinese medical ethics.

 

Modern western bioethics is made up of four principles: autonomy,

beneficence, non-maleficence and justice. Considerations of religion,

nationality, race, party politics, social standing and lifestyle

should not interfere with this basic obligation to treat. Because

neonates are unable to form opinions regarding what would maximise

their short and long term best interests, those individuals caring

for newborns may offer " substituted judgements " .

 

The practitioner's ideal of suffering and life is the two-sided sword

of beneficence. What is more important, life or the need not to

suffer? What is in the infant's best interests? Although the answer

may not be straightforward, the question itself helps caregivers put

self interests and biases aside in an effort to do the right thing

for the patient.

 

Eunkyung Kim

[Guest guest]

The ethical issues i raise are those faced by the TCM practitioner in

China and may, to a degree, be transfered globally (this is a world-

wide discussion group). Below is the full essay for you to review.

 

INTRODUCTION

 

The TCM practitioner is pulled between these two realms of ethical

theory, ancient and modern and is faced with a complex conflict of

interest in regards to euthanasia. The TCM practitioner feels caught

between the patients' needs, the parent's wishes and the government

protocol.

 

In China during the last decade, one of the primary medical ethical

issues to be addressed is euthanasia. A New York Times editorial in

1993 wrote China's National People's congress is considering eugenics

and health protection legislation, including state-ordered

sterilizations and abortions to avoid births of inferior quality

(cited in Wu 1994, p367). Euthanasia in China is gaining increasing

acceptance among physicians, intellectuals, and even the people (Pu

1991, p131). An investigation conducted in 1987 showed that many

people, especially medical workers, accept active euthanasia (Hu

1993, p47).

 

Through ancient Chinese medical ethics, Chinese humanitarianism has

nurtured thousands of noble-mined medical workers and has contributed

to health and human well-being. However, in the contemporary era,

when science and society have developed at a tremendous pace, the

traditional philosophy cannot provide current and scientific

guidelines for physician's actions (Wu 1994, p368). Therefore, a

series of social problems has arisen and traditional ethics and

modern medical ethics clash.

 

Is it ethically justifiable to conduct euthanasia on the grounds of

neonatal illness, genetic defeats or because of excessive population

numbers? Is this beneficence in relation to society rather than the

individual? Is euthanasia more enforceable when autonomy is removed

from the equation because of mental neonatal immaturity? The aim of

this paper is to discuss and address these issues which form the

complex conflicts of interest faced by the modern TCM practitioner in

China. Euthanasia and modern bioethics is a large topic and includes

many different aspects. The focus of this paper shall be restricted

to neonatal euthanasia in relation to autonomy and beneficence. The

moral dilemmas and the conflicts of interest raised by neonatal

euthanasia in relation to Traditional Chinese Medical ethics and

contemporary Chinese medical ethics will also be discussed and

compared to modern western based bioethics.

 

DISCUSSION

 

Modern western bioethics is made up of four principles: autonomy,

beneficence, non-maleficence and justice. Autonomy – literally, self

rule, is probably better described as deliberated self rule.

Beneficence and non-maleficence – is to provide a net benefit to

patients with minimal harm. Justice is the fourth prima facie, and is

often regarded as being synonymous with fairness and can be

summarised as the moral obligation to act on the basis of fair

adjudication between competing claims (Gillon 1994, p184).

Ancient Chinese medical ethics is established on the foundation of

Confucian ethics. Confucian ethics was the dominant moral philosophy

and ideology of Chinese culture. Ancient Chinese medical ethics has a

strong deontological feature and reveals the nature of duty-based

ethics (Tsai 1999, p317). Wu states (1994, p369) that this approach

emphasizes the moral significance of the obligations physicians

should fulfil for patients to restrict their actions to a rational

scope and guarantee all treating measures are morally appropriate for

the benefit of patients. Ancient Chinese medical ethics as laid down

by Sun Simiao during the Tang dynasty (Pang 1999, p247), focuses its

moral doctrines of beneficence on humaneness and compassion to saving

every living creature (Tsai 1999, p319). As the influence of ancient

Chinese ethics subsides, it lags behind the more widely held views of

current society, that of contemporary Chinese medical ethics.

 

A 1985 survey of attitudes towards euthanasia in China, asked health

professionals, lawyers, students, and members of the general public

to examine four actual cases of euthanasia: a newborn with serious

heart disease, a 1-month-old female baby with micro-encephaly, an

irreversibly comatose patient, and a cancer patient dying in

intractable pain. The results were surprising when compared to

Western ideology but almost normal when perceived from a Chinese

point-of-view. They showed 14.7% approval of euthanasia for case 1;

62.4% approval for case 2; 37.1% for case 3; and 39.4% in case 4.

Although a 1-month-old baby is a person, it is permissible to take

life if the quality of that life is very low (Wu 1994 p370). The fact

that so many people approved in regards to 62.4% approval for case 2

(a 1-month-old female baby with micro-encephaly), illustrates the

disregard towards the ancient traditional principles of sanctity of

life. Active euthanasia is not yet legally permissible but active

euthanasia in general and that practiced in the case of seriously

defective newborns and low birth weigh infants seems to be getting

increased support form professionals as well as the public in China

(Hu 1993 p47).

 

Contemporary Chinese medical ethics has been developed in a country

with a backward economy, a power-centralized political system and a

population of one billion-one quarter. It has twinned with the

ethical issues in relation to social, political and the individual.

Contemporary Chinese medical ethics draws on China's major

traditions: Confucianism, Taoism, and Buddhism. Moral intuition and

moral attitudes towards medical ethical issues and the resolution of

ethical issues and ethical dilemmas (at lay, professional, and

societal levels) are affected by the longstanding, entrenched

traditional values and the current dominant ideology (Qiu 1993, p74).

Crawshaw (1989, p112) further supports this as contemporary Chinese

medical ethics provides an example of a Marxist socialist society's

alternative to Hippocratic and Liberal Western medical ethics. The

current dominant ideology conflicts, even though it is based upon,

with ancient medical ethics to the point at which the aggressive

government-sponsored eugenics programs are not compatible with

traditional Chinese medical ethics (Wu 1994, p367).

Practically speaking, the pragmatic fashion in political and economic

life has led the Chinese to consider the heavy economic burden of

supporting the increased numbers of handicapped people in the face of

an uncontrollable and unsustainable population growth along with

decreased living standards (Wu 1994, p370). Hence the political

idealism of " one couple, one child " , which was nothing more than a

futile attempt to control the population. The only true result form

this was a short term slowing of the population growth combined with

the great burden placed upon the patients to withdraw treatment from

the second child so that the first child may be raised healthy (Qiu

1992, p164). From the above review, neonatal euthanasia can be

beneficial for the patient's families who have the responsibility of

caring for its members and neonatal euthanasia for severely

compromised newborns and mandatory sterilization of the profoundly

mentally retarded conform to the long-term benefit and present

interest of Chinese society (Hu 1993, p50 and Wu 1994, p370). Most

Chinese ethicists argue that the principles of beneficence, autonomy,

and justice can be applied to justify euthanasia in certain

circumstances. However, the main objections brought forth against

euthanasia are:

 

• Ethical – the heavenly principle of medical ethics prohibits

a physician from doing anything that might bring the patient closer

to death (non-maleficence);

• Psychological – when people are close to death, they often

have a stronger will to continue living;

• Social – any form of euthanasia can be misused as a disguise

for murder;

• Medical – euthanasia will hinder the development of medicine

(Qiu 1993, p71).

 

In China, a strong practice of paternalism has been handed down from

ancient times to the present. Tsai (1999, p318) demonstrates that

patient autonomy appeared nowhere in traditional Chinese medical

ethics. Chinese doctors have seldom ever talked about the patient's

autonomy or self-determination, except when treating powerful

persons. In the making of a medical decision, the health care

professionals protect a patient's interests and their own, by

emphasising the wishes of the family, but at the expense of the

patient's right to self-determination in treatment decisions (Pang

1999, p250). Lowy et al. (1993) state that the principle of

beneficence and compassion with the suffering have been used as

arguments in favour of neonate euthanasia (cited in Forde et al.

1997, p887).

 

In comparison, in Western countries, the Hippocratic Oath, the

Declaration of Geneva and the International Code of Medical Ethics

all state that the duty of doctors is to put the welfare of their

patients first. Considerations of religion, nationality, race, party

politics, social standing and lifestyle should not interfere with

this basic obligation to treat. However, when it comes to limiting

treatment, the ethics of individual countries vary. Infants for whom

aggressive treatment might not be desirable fall into two groups:

those who will inevitably die whether or not there is medical

intervention (the no hope situation), and those who might live if

treatment is given but whose future outlook is extremely poor (the no

purpose situation). All countries permit non-treatment decisions to

be made for the first group but there is much more debate about

withholding treatment from an infant on the basis of future quality

of life (McHaffie 1999, p441).

 

From the western bioethical viewpoint, absolute prohibitions of

physician assistance in suicide have long been canonical in medical

ethics, but a powerful reformation of views on euthanasia and

physician-assisted suicide is now underway in several countries. The

law on physician-assisted suicide in the state of Oregon, social

approval of euthanasia in the Netherlands, and the legality of active

euthanasia in Japan are clear sings of the changing future. Until

very recently the consensus view in most countries was that a passive

euthanasia of letting die is acceptable, but an active euthanasia of

killing is not (Beauchamp 1999, p437). Neonates lack the ability to

make decision about their future, thus the conventional meaning of

autonomy has little moral bearing on the treatment of defective

newborn infants. Outside of neonatal and paediatric medicine,

paternalistic inclinations may conflict with the principle of

autonomy. In neonatal medicine, however, the principle of autonomy

naturally takes a backseat to the moral imperatives of beneficence

(Sklansky 2001, p6).

 

According to the principles of contemporary medical ethics, autonomy

has become the centrepiece of Western contemporary theories about how

patients and physicians should relate to one another. It is the

individual, seen as an autonomous, self determining entity rather

than in relationship to significant others, that is the starting

point and the foundation stone of American bioethics (Fox 1984,

p339). Kant excluded children and the insane from the principle of

respect of persons who are autonomous and Mill applied liberty only

to those who are in " The maturity of their faculties " (cited in

Childress 1989, p235). Thus the principle of autonomy hold

that " competent " individuals have the right to determine their own

course of action, even if this means refusing medical treatment which

is contrary to the individual's best interests (Muller 1992 p325).

 

In a Western point-of-view, the principle of beneficence relates to

the moral virtue of a beneficial action given to another person and

thereby maximising benefit to that person. Because neonates are

unable to form opinions regarding what would maximise their short and

long term best interests, those individuals caring for newborns may

offer " substituted judgements " . However, whether the principle of

beneficence supports prolonging the life of a critically defective

newborn may not always be clear (Sklansky 2001, p6). The parents have

the authority to make decisions on behalf of their child, and their

consent should be sought to treatment except in cases of emergency

(McHaffie 1999, p441). In the UK and the Netherlands, where clinical

judgments about the Child's best interests are permissible, doctors

must use their intuition to determine what is best for this child and

this family and what is and is not an intolerable burden (McHaffie

1999, p445).

 

A scenario in which these complex issues arise is this: a TCM

practitioner is asked by two parents to help them end the life of

their second child. The second child sufferers from a crippling

disability. The view of the parents is the financial aswell as the

emotional burden placed upon them. The financial burden is two-prong:

as the child is disabled there are huge costs involved in rearing and

looking-after indefinitely the child throughout their life, the

second point is from the governments protocol of `one family-one

child', which means a second child receives no state funded help.

Therefore the TCM practitioner is acutely aware of the parent's

dilemma. However, they are faced with the paternalism state

governments will in wanting them to take life, the parent's decision

and their own autonomy as to what action to take. Therefore, the

practitioner has " interests that may incline away from fulfilment of

their obligations to patients " (Meyers 1999, p383). Putting the

parent's wishes and that of a pro-active euthanasia government aside,

there lies at the heart of this issue, the practitioner's ideal of

suffering and life. This is the two-sided blade of beneficence. What

is more important, life or the need not to suffer? Is the TCM

practitioner, God crouched down into human form? Above all, a TCM

practitioner's role is to the benefit of their patient and any

decisions should be based upon this simply notion.

 

CONCLUSION

 

It can be said from this paper that different cultures, society's

contexts and historical influence practice between traditional and

contemporary medical ethics within different countries. For

practitioners, they face conflicts of interest in an array of

complicated aspects. Regarding neonatal euthanasia, in matters of

ethics, law and conscience create dilemmas to which there are no easy

answers.

 

What is in the infant's best interests? Although the answer may not

be straightforward, the question itself helps caregivers put self

interests and biases aside in an effort to do the right thing for the

patient. In this context, once one has determined the infant to be a

potential person in the strict sense, quality of life, familial and

social resources, and costs of treatment may become relevant, but

only insofar as they help predict what treatment choice would

ultimately be in the patient's best interests (Sklansky 2001, p8).

 

Eunkyung

 

Chinese Medicine , YinTangSong@a...

wrote:

> In a message dated 7/19/2003 12:11:55 PM Pacific Standard Time,

> aprilgim writes:

>

>

> > I wondered if anyone has any few on neonatal euthanasia.

>

> In what context would an acupuncturist be confronted with such a

decision

> other than personally? Seems to me this topic falls under the

debate on abortion.

> The comments painted a vague picture with a broad brush.

>

> I suspect you might be attempting to stir up the list with a

controversial

> topic. But if I am incorrect, I still feel there is not enough

information to

> which to respond. It doesn't seem to be a TCM question, really,

but more one

> of a general ethics question that is best answered by the individual

(s)

> effected. But then again, perhaps you were attempting to address

herbal-induced

> miscarriage?

>

> If I have missed something and you can tell me how this is a TCM

question, I

> am open to hearing your point of view.

>

> be well,

> Maya

[Guest guest]

Hi Eunkyung Kim,

 

The question of the ethics and morality of euthanasia (neonatal or

otherwise) is very difficult. Each practitioner comes with cultural

and religious conditioning, which colour his/her decision in any

given case.

 

As individuals, we can do little to influence the decisions taken in

other countries. I know that huge nations, like China and India, for

example, have huge problems with population control. But the idea

of euthanasia horrifies me. I even have nightmares when I [as a

Vet] have to kill a terminally-ill dog.

 

The thought of killing humans makes my hair stand on end. I would

hate to think of killing a foetus or baby, or an adult human being,

even in self-defence or war.

 

I am not God. IMO, God gives Life, and God takes it away. I would

prefer to leave that decision to God. That said, there are times

when one must decide whether or not to WITHDRAW TREATMENT

in hopeless cases. I faced that question last October, when I gave

my family's permission to allow the noradrenalin-pump to be

switched off when my son was diagnosed as not responding to

treatment for hopeless brain trauma. It was the hardest decision of

my life.

 

I do not want to kill a human being, and pray to God that I may

never be in the position of having to make a decision on that issue.

 

Peace to you all,

Best regards,

Phil

 

Eunkyung Kim wrote:

> I wondered if anyone has any view on neonatal euthanasia. Below is

> an abstract of an essay i recently wrote. The TCM practitioner is

> caught between two realms of ethical theory, ancient traditional

> ethics and modern medical ethics. Is it ethically justifiable to

> conduct euthanasia on the grounds of neonatal illness, genetic

> defeats or because of excessive population numbers? Is this

> beneficence in relation to society rather than the individual? Is

> euthanasia more enforceable when autonomy is removed from the

> equation because of mental neonatal immaturity? Ancient Chinese

> medical ethics is established on the foundation of Confucian

> ethics. The current dominant ideology conflicts, even though it is

> based upon, with ancient medical ethics to the point at which the

> aggressive government-sponsored eugenics programs are not

> compatible with traditional Chinese medical ethics. Modern western

> bioethics is made up of four principles: autonomy, beneficence,

> non-maleficence and justice. Considerations of religion,

> nationality, race, party politics, social standing and lifestyle

> should not interfere with this basic obligation to treat. Because

> neonates are unable to form opinions regarding what would maximise

> their short and long term best interests, those individuals caring

> for newborns may offer " substituted judgements " . The

> practitioner's ideal of suffering and life is the two-sided sword

> of beneficence. What is more important, life or the need not to

> suffer? What is in the infant's best interests? Although the answer

> may not be straightforward, the question itself helps caregivers

> put self interests and biases aside in an effort to do the right

> thing for the patient. Eunkyung Kim

 

 

Best regards,

 

 

WORK : Teagasc Staff Development Unit, Sandymount Ave., Dublin 4, Ireland

WWW :

Email: <

Tel : 353-; [in the Republic: 0]

 

HOME : 1 Esker Lawns, Lucan, Dublin, Ireland

WWW : http://homepage.eircom.net/~progers/searchap.htm

Email: <

Tel : 353-; [in the Republic: 0]

[Guest guest]

Dear Phil,

 

Firstly, i'm very sorry to hear about your son. It's something that

i just cannot imagine and hope i never have to face.

 

I've read Eunkyung's article closely and i've found that she doesn't

sway in favour of neonatal euthanasia but rather in the closing

sentences states that 'caregivers (should) put self interests and

biases aside in an effort to do the right thing for the patient'.

This is of course extremeley difficult to determine and must be

exaimed on a case to case basis.

 

However painful this topic of neonatal euthanasia is, of which i

don't agree with, it does exist in this often cruel world and

therefore needs to be addressed and discussed.

 

As i stated in a message a few days ago, TCM practitioners need to

look at ethical issues closely, although in this case it's only

found in China (i hope). Here in the West, we are not asked to

undertake such difficult and impossible tasks.

 

Aren't we the lucky ones...

 

Attilio

 

Chinese Medicine , " "

<@e...> wrote:

> Hi Eunkyung Kim,

>

> The question of the ethics and morality of euthanasia (neonatal or

> otherwise) is very difficult. Each practitioner comes with

cultural

> and religious conditioning, which colour his/her decision in any

> given case.

>

> As individuals, we can do little to influence the decisions taken

in

> other countries. I know that huge nations, like China and India,

for

> example, have huge problems with population control. But the idea

> of euthanasia horrifies me. I even have nightmares when I [as a

> Vet] have to kill a terminally-ill dog.

>

> The thought of killing humans makes my hair stand on end. I would

> hate to think of killing a foetus or baby, or an adult human

being,

> even in self-defence or war.

>

> I am not God. IMO, God gives Life, and God takes it away. I would

> prefer to leave that decision to God. That said, there are times

> when one must decide whether or not to WITHDRAW TREATMENT

> in hopeless cases. I faced that question last October, when I gave

> my family's permission to allow the noradrenalin-pump to be

> switched off when my son was diagnosed as not responding to

> treatment for hopeless brain trauma. It was the hardest decision

of

> my life.

>

> I do not want to kill a human being, and pray to God that I may

> never be in the position of having to make a decision on that

issue.

>

> Peace to you all,

> Best regards,

> Phil

>

> Eunkyung Kim wrote:

> > I wondered if anyone has any view on neonatal euthanasia. Below

is

> > an abstract of an essay i recently wrote. The TCM practitioner is

> > caught between two realms of ethical theory, ancient traditional

> > ethics and modern medical ethics. Is it ethically justifiable to

> > conduct euthanasia on the grounds of neonatal illness, genetic

> > defeats or because of excessive population numbers? Is this

> > beneficence in relation to society rather than the individual? Is

> > euthanasia more enforceable when autonomy is removed from the

> > equation because of mental neonatal immaturity? Ancient Chinese

> > medical ethics is established on the foundation of Confucian

> > ethics. The current dominant ideology conflicts, even though it

is

> > based upon, with ancient medical ethics to the point at which the

> > aggressive government-sponsored eugenics programs are not

> > compatible with traditional Chinese medical ethics. Modern

western

> > bioethics is made up of four principles: autonomy, beneficence,

> > non-maleficence and justice. Considerations of religion,

> > nationality, race, party politics, social standing and lifestyle

> > should not interfere with this basic obligation to treat. Because

> > neonates are unable to form opinions regarding what would

maximise

> > their short and long term best interests, those individuals

caring

> > for newborns may offer " substituted judgements " . The

> > practitioner's ideal of suffering and life is the two-sided sword

> > of beneficence. What is more important, life or the need not to

> > suffer? What is in the infant's best interests? Although the

answer

> > may not be straightforward, the question itself helps caregivers

> > put self interests and biases aside in an effort to do the right

> > thing for the patient. Eunkyung Kim

>

>

> Best regards,

>

>

> WORK : Teagasc Staff Development Unit, Sandymount Ave., Dublin 4,

Ireland

> WWW :

> Email: <@e...>

> Tel : 353-; [in the Republic: 0]

>

> HOME : 1 Esker Lawns, Lucan, Dublin, Ireland

> WWW : http://homepage.eircom.net/~progers/searchap.htm

> Email: <@e...>

> Tel : 353-; [in the Republic: 0]

[Guest guest]

I am not God. IMO, God gives Life, and God takes it away. I would prefer to leave that decision to God

>>>That is a value statement. Not all people see human life that way. What about taking life of a patient that clearly indicated he/she want the Dr to do that?

Alon