Better Dead than Disabled?

Concern about infanticide may seem kooky—the kind of alarmist talk that comes from extremist prolifers who won’t stay in their abortion lane. Sure, there was systematic infanticide in the ancient world. Sure, it still happens in rural areas of China and India. Regrettably, there are stories of it taking place in some Western bathroom stalls or dumpsters. As a concern of social justice, though, it may seem as if our attention ought to be focused elsewhere.

But prolifers are not imagining things: arguments in favor of the autonomous moral and legal choice to commit infanticide are easy to find. Back in the 1970s and ’80s, such arguments were the province of respected moral philosophers like Michael Tooley and Peter Singer. Indeed, though Singer was a groundbreaking philosopher on issues like global poverty and concern for nonhuman animals, he became famous (or infamous) for his views connecting abortion and infanticide.

I’ve always found the logic of these arguments surprisingly compelling. They usually go something like this: (1) Being a living organism of the species Homo sapiens does not make one a person with a moral or legal right to life. Otherwise fetuses would count as persons with a legal right to life. But that is absurd. (2) Picking a lower threshold for personhood (like the ability to feel pain) would not only include some fetuses, it would include many billions of nonhuman animals, including rats, fish, and perhaps insects. But that is also absurd. (3) Picking a higher threshold for personhood (like self-awareness and the ability to care about one’s life) would exclude fetuses and include only a few nonhuman animals (like dolphins and the great apes). This is the most reasonable position. (4) Because newborn infants do not yet have this higher threshold for personhood, they do not yet count as persons. Therefore, infanticide does not violate a person’s right to life.

In the mid-1980s, this kind of reasoning began to gain currency with some clinicians. In perhaps the most famous case in the history of Western medical ethics, Baby Doe was born with both Down syndrome and a serious but easily treatable problem with her esophagus. Her medical team and parents declined to give her this lifesaving treatment, almost certainly because of an ableist judgment on the quality of life a child with Down syndrome could have. Christian prolifers teamed up with disability groups to resist this turn toward infanticide, working with the Reagan administration to install clinical protocols (called “The Baby Doe Rules”) that would prevent such things from happening again. This was a huge policy and cultural victory against infanticide.

Just a few years later, however, one would see the reasoning behind the Baby Doe Rules directly challenged. In 1997 Steven Pinker took to the pages of the New York Times Magazine to explain why arguments for infanticide are difficult to refute. When it comes to what is required to be a person, Pinker argues, “our immature neonates don’t possess these traits any more than mice do.” Pinker also rejected the whole concept of human dignity. In a 2008 piece he wrote for the New Republic (titled “The Stupidity of Dignity”), he linked the concept of dignity to a kind of stealth religious belief. “It’s not surprising,” wrote Pinker, “that ‘dignity’ is a recurring theme in Catholic doctrine: The word appears more than 100 times in the 1997 edition of the Catechism and is a leitmotif in the Vatican’s recent pronouncements on biomedicine.” In support of his position, he cited the well-known clinical bioethicist Ruth Macklin who, in a paper titled “Dignity is a Useless Concept,” argued that dignity is better thought of as a shorthand for “respect for persons or their autonomy.” Invocations of human dignity were to be regarded as religious sleight-of-hand, inconsistent with the Enlightenment values of autonomy, rationality, and self-awareness.

As anti–human dignity arguments continued to win adherents, those who support infanticide felt emboldened to make their case more publicly and aggressively. A 2012 article by moral philosophers Alberto Giubilini and Francesca Minerva, which appeared in the respected Journal of Medical Ethics, was provocatively titled “After-Birth Abortion: Why Should the Baby Live?” It received considerable backlash, especially from prolifers, but JME’s editor, Julian Savulescu (a former student of Singer’s), stood by his decision to publish the article and even devoted an entire issue to the topic the following year (“Abortion, Infanticide, and Allowing Babies to Die, 40 Years On”). The special issue featured articles by thinkers with different views, but several of them argued in support of infanticide.

These thinkers may have felt emboldened not just by cultural shifts in the West but also by the fact that a Western country, the Netherlands, already had a recognized legal protocol for infanticide. In 2005, Eduard Verhagen and Pieter J. J. Sauer took to the pages of the New England Journal of Medicine to argue for the “Groningen Protocol,” a set of general governing principles for the killing of newborn human beings. Like Savulescu, Verhagen and Sauer are at pains to point out that deciding “not to initiate or to withdraw life-prolonging treatment in newborns” is “good practice for physicians in Europe and is acceptable for physicians in the United States.” After all, the goal of such treatment “is not only survival of the infant, but also an acceptable quality of life.” Infants have an unacceptable quality of life if they are likely to have “unbearable suffering.” In that case, the only decent thing to do is to euthanize them—either by withholding care and nourishment, or by killing them directly.

If this seems like it might be an outlier position—a marginal case of some rogue physicians trying to push a radical agenda—think again. It has been largely accepted in the Netherlands as being quite consistent with their cultural understanding of medicine—one that has, for decades, seen euthanasia as an appropriate way to deal with patients whose lives are deemed no longer worth living. Indeed, when I visited the Netherlands twelve years ago as part of my dissertation research, nearly everyone I talked with seemed on board with the Groningen Protocol. Severe spina bifida is one of the most common reasons for infanticide in the Netherlands, but, interestingly, Verhagen has pointed out that the number of documented infanticides in the Netherlands is going down—mostly because better prenatal detection has made aborting disabled fetuses more common. After a conference presentation in which Dr. Sauer defended the Groningen Protocol, I asked him during the Q&A why there wasn’t also a euthanasia protocol for older children. After all, it is only after a child can communicate that we are likely to get a good sense of whether or not his or her suffering is truly “unbearable.” His answer: “We’re working on it.”

But that was several years ago and there is still no accepted Dutch euthanasia program for non-infant children. That this has not happened is a strong indication that the moral status of newborn infants is doing much of the work in these arguments; at a visceral level at least, people seem to believe that twelve-year-old children are persons in a way that newborns aren’t. (Belgium, it should be pointed out, has outpaced the Netherlands when it comes to child-killing. Since 2014 it has been legal in Belgium to euthanize children of any age.)

One should not imagine that this kind of reasoning is limited to Europe’s low countries. The recent cases of Charlie Gard and Alfie Evans show that similar ideas about when a life isn’t worth living are current in the United Kingdom and America. Some have argued that such comparisons are alarmist and imprecise, insisting that Catholic teaching permits the removal of life-sustaining treatment in cases like those of Gard and Evans. It is true that Catholic teaching allows us to weigh the burdens against the benefits of a medical treatment itself. If, say, the burden of chemotherapy or of an amputation without pain medication outweighs its benefit, then the Catholic tradition is clear: such treatments may be foregone even it one foresees—but does not intend—that the result will be death.

This was not the case with either Gard or Evans. On the contrary, the treatments that were ultimately withdrawn were working just as intended with virtually no burden on the patients. The burden some were worried about was the very life of these two boys. According to those who wanted life-sustaining treatment removed, there was nothing dignified about the kind of profoundly disabled life Charlie or Alfie was likely to have and so it was in their own best interest that they be allowed to die. That their death was achieved by omission does not change the fact that it was killing, for it was precisely their death that was intended. Their lives were deemed (by doctors with no special moral training or authority) to be without dignity; their suffering deemed to be pointless.

In the view of Savulescu, Verhagen, and Sauer, if it is permissible to let children die by withholding nourishment and medical care, then it must also be permissible to kill them directly. Indeed, once we have decided that it is in a child’s best interest to die, then it may be more humane to kill the child directly than to let her suffering continue while one waits for her to die.

For about fifteen years now, one of the first things I do when having an argument about abortion is to ask prochoicers whether they think Peter Singer is wrong to support infanticide. If they think he is wrong, I then attempt to walk them back from their reasoning about infanticide to see how it might affect their reasoning about abortion. In public debates and private conversations, Singer and I have discussed the likely results of this strategy. He is convinced that prochoicers are more likely to become prochoice for infanticide as well as abortion than to question their views on abortion. Until recently, I’ve been convinced that prochoicers are more likely to change their minds about abortion than to become pro-infanticide. After witnessing the reaction to the Charlie Gard and Alfie Evans cases, I’m no longer so confident. Indeed, I worry that we are likely to see more aggressive public defenses of infanticide. And I also worry that, unless we can find a way to defend a non-ableist and non-ageist conception of human dignity, we simply won’t have the moral resources to resist.