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In the best interests of....

In the Best Interests of...

For a notion that is either incoherent or inadequate, the "best interests of the infant" has enjoyed a remarkable vogue in medical ethics. [1] Its popularity is more puzzling than that of the withdrawing-withholding distinction, which has long been a favorite of practitioners but was never granted much credence by philosophers. "The infant's best interests," by contrast, has been used not only by practitioners, but even by those who are supposed to earn their livings by subjecting questionable concepts to intense critical scrutiny. I must therefore explain, first, why the notion is incoherent or inadequate, and second, why it has nevertheless enjoyed so much popularity.

The concept of "best interests of the infant" arose in reaction to support of wide parental discretion and a limited role for the physician in treatment decisions. More recently, authors who disagree on many issues--which infants should be treated; which conditions count as exceptions to the general duty to prolong life; whether parents, physicians, and/or ethics committees ought to have a major say in the decision--nevertheless claim that the infant's best interest is the sole moral criterion upon which to base an ethically sound decision. [2] On this position, any appeal to economic interests or to the interests of parents or siblings is inadmissable. There are, however, four lines of argument that challenge this view.

Infants have no interests in continued life. It has been argued that it order for me to have an "interest" in something, whether or not I have that something must make a difference to me; and this requires in turn that I have the mental capacity to be aware of that something, and of myself as possessing or lacking it. [3] It follows that it is coherent to speak of a human neonate having an interest in being fed and being kept warn. But since an infant is incapable of forming a conception of itself as existing or not existing in the future, and is incapable of forming any plans or aspirations for its own future, it cannot coherently be said to have an interest in its own continued existence. [4] It follows from this that a decision to allow a severely malformed infant to die might violate other moral rules, but could not violate the infant's best interests. Indeed, if the infant develops later into a child capable of the necessary degree of cognitive awareness, keeping it alive may violate the interests of that later person, if its life is marked by extreme suffering unrelieved by substantive benefits. But if we now allow that infant to die, no future person ever comes into existence, and so no interests have been violated. [5] Thus, ironically, consulting an "interests" standard will, according to this line of argument, favor nontreatment but never treatment.

Infants' interests are unknowable. This view (as well as the next two) differs from the first in leaving open the possibility that the "infant's best interests" can, in principle, be given a coherent meaning. However, in practice those interests that would be most relevant to treatment decisions are unknowable. Once we move beyond very basic needs such as food and shelter, we cannot know what is in someone's interests without knowing a good deal about that person's individual plans and desires. But a newborn infant is much more a promise of preferences and plans to come than it is the sort of entity for whom those things could be known in advance.

To suggest that parents should consult their newborn's best interests before making a medical treatment decision in an important way misconstrues the task of raising a child. An infant is born into a situation over which it has no control--where it will live, its sex and ethnicity, the socioeconomic condition of its parents, and so on. Parents then proceed to interact with the infant in ways that further limit its possible futures. They offer their newborn certain amounts and types of visual and verbal stimulation; they encourage some innate patterns of behavior and discourage others; they later send the child to certain schools and a certain church, or none at all. Our of all these givens, the infant develops into a discrete individual with its own preferences and abilities. Based on those emerging preferences and abilities, one can then begin to determine what is and is not in the child's best interests. But to claim that the parents should, or could, consult a "child's best interests" first in order to decide how to raise the child is to put the cart before the horse. [6]

To see the relevance of this point forneonatal decisions, consider a debate over how aggressively to treat an infant born with a high meningomyelocele and hydrocephalus. One neonatologist might argue that the infant's best interests are served by early surgical intervention, noting the high probability of death, or life with worse retardation, if surgery is not performed. He might recount the occasional success story of an infant with an equally severe defect who turned out to have only mild retardation and physical impairment. A second neonatologist might argue that an early death is in the infant's best interest, and point to the very high odds of major mental and physical handicap, plus the need for repeated, painful surgical interventions to treat the disorder and its sequelae. It is clear that what these neonatologists are arguing about is what they think ought to be done. The phrase, "the infant's best interests," is a rhetorical flourish that does no useful work in the discussion.

An interests appeal can yield counter-intuitive results. John Arras has challenged the value of a best interests appeal by discussing children who are so severely retarded as to be unable to recognize other people or form any human relationship, who can perceive only primitive sensations such as light and color, touch and pain, but show no sign of suffering. Since these children get some pleasure (however primitive) out of living and suffer no pain, any best interests analysis would insist that any newborn who can confidently be predicted to have such a future should have its life prolonged, even by invasive or aggressive means. But Arras argues that this conclusion is simply incorrect. [7] To save a child in order to let it live such a life may well do nothing of any real, substantive benefit for the child; and to use expensive resources to save it may well squander those resources.

On this view, how much benefit an infant or child derives from its continued existence is relevant to treatment decisions--that is, all such decisions are in part quality of life judgments. But the "best interests" standard suggests incorrectly that wherever benefits outweigh burdens even to a slight degree, then that fact alone determines the obligation to treat--even if the benefits are minuscule, or the burdens horrendous.

Others' interests also deserve consideration. Carson Strong has argued that a refusal to consider any interests other than the infant's own is an arbitrary rather than a principled choice. [8] He holds that in many cases, where treatment will yield clear and substantial benefits to the infant, its own interest is overriding. But in cases where the benefit to the infant is lessor more questionable, and where treatment would impose grave burdens on the family, the interests of the family ought to be weighed alongside those of the infant.

Strong's reminder that others have interests too sets up our second question: Why, given the combined strength of these four rejections of the best interests standard, has it been so widely accepted? I suggest that this results from an unfortunate but understandable urge to oversimplify a distressingly complex set of moral problems. The more one can render an ethical decision unidimensional, and the more factors one can exclude from consideration beforehand, the easier the choice becomes. Finally, the 1982 "Baby Doe" case in Bloomington, Indiana, which seemed to many to prove conclusively the dangers of parental discretion, prompted the hope that if the "infant's best interests" were ruled sacrosanct, no such abuses could occur in the future.

The best interests standard might be of value if moral issues in the newborn nursery were basically simple problems made to seem complex by moral obtuseness and emotional conflicts. But this is not the case. Besides the near-impossibility of reliable, early prognostication and the difficulty of predicting which medical interventions will help and which will hurt, we must face the problem that a newborn is a different sort of individual than an adult--more of a stand-in for a person-yet-to-be than a person already. [9] To point this out is not to devalue newborns, or still less to defend indifference to their proper care and upbringing, but simply to note what it means to respect them as the sorts of beings they are. When all these factors are combined, we can see how the essential complexity and moral ambiguity of neonatal decisionmaking arises--and this is even before we consider the substantial changes that must occur in the life of a family with the birth of a severely malformed neonate, and the vast differences among families in their ability to adapt to those changes.

This complex and ambiguous set of issues can be satisfactorily adjudicated only with a willingness to tackle them as they actually arise. The issues cannot be made to disappear through the artificial clarity promised by the "best interests of the infant."


This paper represents an expansion upon my discussion in Stories of Sickness, (New Haven: Yale University Press, 1987), ch. 9. I am grateful to Martin Benjamin and Bruce Miller for comments on an earlier draft, though they might still disagree with some of my assertions.

[1] I will use this commonly-accepted phrase despite the fact that it is susceptible to Mark Twain's criticism of Fenimore Cooper's literary style. Commenting on a passage in which an Indian carried that "more preferable fragments" of a freshly killed fawn, Twain said, "We don't care why he saved the 'more' preferable ones when the merely preferable ones would have amounted to just the same thing and couldn't have been told from the more preferable ones by anybody, dead or alive" ("Cooper's Prose Style" in Letters from the Earth, B. DeVoto, ed. [New York: Harper and Row, 1962]. I can hear Mark Twain challenging us to explain how the infant's best interests could be distinguished from the infant's interests.

[2] Norman Fost, "Counseling Families Who Have a Child with a Severe Congenital Anomaly," Pediatrics 67 (1981), 321-24; President's Commission for the Study of Ethical Problems is Medicine and Biomedical and Behavioral Research, Deciding to Forego Life-Sustaining Treatment, (Washington, DC: U.S. Government Printing Office, 1983); Robert F. Weir, Selective Nontreatment of Handicapped Newborns, (New York: Oxford University Press, 1984).

[3] Joel Feinberg, "Is There a Right to be Born?" in Understanding Moral Philosophy, ed. James Rachels. (Encino, CA: Dickinson, 1976); Michael Tooley, "A Defense of Abortion and Infanticide," in The Problem of Abortion, ed. Joel Feinberg, (Belmont, CA: Wadsworth, 1984).

[4] Martin Benjamin, "The Newborn's Interest in Continued Life: A Sentimental Fiction," Bioethics Reporter (December 1983), 5-7.

[5] Feinberg, "Is There a Right to be Born?"

[6] Bruce L. Miller, "The Baby Doe Rules: Can They Be Met?" Bioethics Reporter 1 (1984), 45-48.

[7] John D. Arras, "Toward an Ethic of Ambiguity," Hastings Center Report 14:2 (April 1984), 25-33.

[8] Carson Strong, "Defective Infants and Their Impact on Families: ethical and Legal Considerations," Law, Medicine and Health Care 11 (1983), 168-81; "The Neonatologist's Duty to Patients and Parents," Hastings Center Report 14:4 (August 1984), 10-16.

[9] For other versions of this argument see H. Tristram Engelhardt, The Foundations of Bioetics (New York: Oxford University Press, 1986), ch. 6: and Jack Bemporad, "From Biology to Spirit: The Artistry of Human Life," Journal of Medicine and Philosophy 3 (1978), 74-87.

Howard Brody is professor of family practice and director of the Medical Humanities Program at Michigan State University, East Lansing, MI.
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Title Annotation:infants and children
Author:Brody, Howard; Bartholome, Wiliam G.
Publication:The Hastings Center Report
Date:Dec 1, 1988
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