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A commentary on the paper by Cuttini et al
Active euthanasia has been mainly discussed in geriatric medicine, allowing old people to be relieved of unacceptable suffering. It is often a question of assisted suicide when the patient’s will can be respected. This has been practiced in the Netherlands since the 1970s and is now also legal. The question considered here is whether active euthanasia can be allowed for infants. This is not yet permitted in the Netherlands or any other country, but practiced in both Holland and France.
Cuttini et al present an international survey on attitudes towards euthanasia among nurses and doctors working in neonatal intensive care units. This is a part of a bigger interview study, the EURONICS, performed 1996–1997 before the amendment to the Dutch legislation allowing euthanasia was passed.
Seven countries belonging to the EU (Italy, Spain, France, Germany, Netherlands, United Kingdom, and Sweden) and three candidate countries (Hungary, Estonia, and Lithuania) were included. It is pity that every country in the EU was not included. The attitudes in the Nordic countries may be different in spite of other similarities.
More than 60% of the Dutch neonatologists felt that the law should be made more liberal, whereas less than 20% of their Swedish colleagues had the same opinion. Doctors in Spain and Hungary seemed to view euthanasia more favourably, whereas those in the United Kingdom and Germany fell somewhere in between. French doctors were in general more negative towards legalisation, but it is well known that euthanasia is performed in that country often without the knowledge of the parents.
As a Swede I want to try to explain the Swedish attitude. I think it has to do with a long tradition of respect for the child. Habilitation of handicapped children is a very important political question. The use of involuntary abortion and sterilisation of mentally retarded women was debated until the 1970s. This was practiced since the 1930s based less on the influence of the Third Reich than sociodemocratic ideas of social engineering to develop the so called Folkhemmet (Swedish Welfare State).
This paper reports only the attitudes of professionals with great experience in neonatal care but less in caring for children with handicaps. I feel that the question is awkward. Can I as a neonatologist judge whether the life of a baby with a chromosomal abnormality should be terminated? He/she may develop into a happy individual in spite of a severe handicap. Interviews with very preterm graduates with deficiencies in sensory-motor and cognitive abilities have revealed that they are pleased to be alive and do not suffer as much from their handicaps as expected.1
I think that it is wrong to ask if euthanasia of infants should be legal. It is better to retain respect for a personal life defined as a human individual with consciousness or the potential to become conscious. However, this raises a new question—how do we define consciousness? This is perhaps more difficult than defining human life. Consciousness is “to retain what no longer is, to anticipate what as yet is not”—according to Henri Bergson—and “the hump from electrochemistry to subjective feeling”—according to John Searle.2
A full term healthy newborn child fulfils five of nine psychological criteria for being conscious. He/she has perception, records sensory stimulation (pain), can be awakened, shows emotions, and interacts socially. However, he/she has a limited long term memory, cannot speak, and lacks symbolic thinking and free will.3 An extremely preterm infant with severe brain damage or a full term infant with hypoxic-ischaemic encephalopathy grade 3 with a very limited ability to develop a reasonable level of consciousness (more than three criteria) should not be resuscitated and receive intensive care. I also think moderate doses of pain relievers could be given. I do not regard this as euthanasia, because the infant is not a conscious, or a potentially conscious, person. This may be difficult to determine. However, the use of cerebral function monitoring seems to have a fairly good predictive value with regard to full term infants.4 More sophisticated methods using magnetic resonance imaging, magnetic resonance spectroscopy, functional magnetic resonance, and near infrared spectroscopy may help the neonatologist to assess the level of potential consciousness in preterm infants.5 From this approach, I do not think that it is necessary to change our laws against euthanasia.
A commentary on the paper by Cuttini et al