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History, infanticide, and imperiled newborns.

History, Infanticide, and Imperiled Newborns

One of the most prominent dilemmas in neonatal intensive care is whether, once the decision not to prolong life has been made, active killing of newborns should be permitted. Medical ethicists have sharply disagreed in their responses to this question. [1] Yet those commentators who contend that active killing of neonates is morally acceptable have presented a one-sided and reductionist view of the history of infanticide to support their position. This over-simplification of the historical record has resulted in unwarranted moral extrapolations and conclusions.

Cultural and Moral Relativism

Helga Kuhse and Peter Singer recognize that their proposal to "allow active as well as passive euthanasia to be carried out before acceptance of the child into the community" is, at least with respect to active euthanasia, controversial. They attribute resistance to their view to "the Western attitude to human life," particularly the doctrine of sanctity of life, which affirms that "the life of a new-born baby is as much deserving of protection as the life of any adult." Kuhse and Singer intend to challenge the belief that sanctity of life, and its related protection of neonatal life, is intrinsic to civilized society, and draw heavily on cultural anthropology, which provides "a broader, less culturally-bound perspective on these problems." [2]

Their attention turns to societies that permit the active killing of infants. For example, the Netsiliks, an Eskimo society that placed importance on having enough sons as hunters to ensure food for its members, practiced female infanticide because suckling a female infant for several years would prevent the mother from having a son. The !Kung of the Kalahari were a highly nomadic group that practiced infanticide because of the difficulty of providing food for children. Kuhse and Singer also discuss the Tikopia of Polynesia, a group in which the father could decide to kill a newborn at birth, a decision "typically motivated by a comparison between potential food supplies and family size." [3]

To forestall criticism that the Netsilik, 'Kung, and Tikopia are "primitive uncivilized people, whose experiences are of no relevance to our own," Kuhse and Singer also examine practices in eighteenth and nineteenth century Japan, surely a "civilized" society by any measure. The Japanese practiced infanticide as the commonly accepted method of "thinning" (mabiki--a term taken from the peasant practice of thinning rice seedling) family size well into the nineteenth century. [4] Based on this evidence, the authors conclude that our Western conviction concerning the moral status of infants is "a deviant tradition." We differ from the majority of human societies in rejecting infanticide for purposes of sex selection, population control, and even ridding society of the burdens imposed by the handicapped.

Several commentators follow Kuhse and Singer in relying on cultural anthropological data to support a permissive attitude to infanticide. Earl E. Shelp, for instance, observes that while infanticide "tends to be viewed with horror by people in so-called civilized societies," it has in fact been practiced widely. Shelp concedes that cultural anthropological data does not "help us to reach a moral judgment regarding [infanticide] in the past or proposals to accept some form of it in the present," but his own assessment is most lenient. [5] In fact, despite his concession, it is evident Shelp uses such data for precisely such a purpose. We are admonished that cultural and historical data can be studied to "discern what moral sensibilities exist within it," and that contemporary efforts to confer "absolute value" on newborn life appear to be "aberrations within the human and moral record." In addition, Shelp provides economic, physical, and sociocultural reasons for infanticide to mitigate moral disapproval. [6]

This anthropological data can have an immense psychological effect. However, the moral significance, if any, of this data is subject to several qualifications. The fact that some form of behavior has existed--or does not exist--in another culture is not an argument either for or against it. Kuhse and Singer acknowledge this claim in part, as they contend that one "cannot validly argue from the fact that something is widespread to the judgement that it is good." [7] Understanding the sociological factors that explain a practice should not predispose us to condone it. Indeed, there is absolutely no reason why we should not judge infanticide as morally wrong in the name of universal human rights and endeavor to eradicate the conditions that make it a temptation.

Philosopher Mary Midgley has focused on where we "draw the line" on tolerance of cultural diversity by citing the example of the famous Samurai practice tsujigiri, or "crossroads-cutting," in which an innocent wayfarer was sliced from the upper shoulder through to the lower abdomen by those "trying out their new swords." Midgley argues that this act contradicts the respect owed to human life on any theory of morality, and that even "moral isolationists" will concur. [8]

Granted, cultural relativism does remind us of the dangers of assuming that all our practices and preferences are based on some absolute moral standard. Yet at some point all societies must come before the court of moral criticism. The fact is that we do make moral judgments about practices that violate basic moral principles such as nonmaleficence, veracity, beneficence, and justice. Ultimately, the question is not whether we do or should condemn practices of other cultures (as well as our own), but the grounds for doing so. While open-mindedness and humility are appropriate, moral blind spots must be pointed out. Otherwise, we might just as well conclude that we only become truly human when we begin killing our children.

The Western moral tradition itself is certainly susceptible to revision in the light of moral principles. Some aspects of this tradition are worthy and others are not. However, there seems no reason to undermine one of its obvious strengths, a conviction that newborns are not simply parental property but rather are a part of the moral community. We have seen the evil consequences of past practices of infanticide and, over the last century, have concluded that such practices conflict with standards protecting the best interests of children. The marshalling of data indicating that infanticide has and does occur tampers with the rights that newborns and children have at long last gained. [9]

It may well be the case that communities should be forgiving when parents, for economic and other reasons, kill infants with severe disabilities. Society surely does not do enough to support such families. This provides no reason, however, to unravel the conviction that newborns have moral status equal to that of adults, which has been gradually and painstakingly arrived at by those who correctly saw the wrongness of viewing infants as of lesser moral value. This conviction, even if "deviant" and "aberrant" is nevertheless "good" and progressive.

Infanticide in Western History:

A Brief Correction

Significantly, in order to bring the practice of infanticide into the moral mainstream, commentators on neonatal ethics who advocate active killing of newborns once treatment has been withdrawn or withheld overstate the extent to which infanticide has occurred in Western history. The result is a fixed ideological litany of particular sources that is both selective and misrepresentative of history.

Examples of this selective historiography abound. Based on his analysis of Western history, William A. Silverman recently observed that even in the most developed countries, "Centuries of effort had been unsuccessful in obliterating the ancient view that distinguished between the death of a neonate and the loss of life of a self-conscious, rational human being." Silverman concluded that "Infanticide is the oldest method of human family planning," and that "child murder was common" in past cultures. [10]

While it is unclear whether Silverman supports active killing of impaired newborns, the absence of critical assessment of the "ancient view" raises concerns. Roman society had many practices that demonstrated disrespect for human life, and its acceptance of infanticide should be seen in the context of a range of societal practices that we would now condemn. There is reason to be suspicious of any association of infanticide with "family planning" that fails to bring this practice before the court of moral criticism.

Moreover, "child murder" has not been especially common historically. The historial John Eastburn Boswell has corrected this misunderstanding relative to both the ancient and the medieval family. Boswell notes that expositio was "the most widespread form of abandonment in the ancient world." However, this practice is often misunderstood because of a mistranslation of expositio into the English "exposure," a term that conveys a sense of harm or risk "so that exposure of children suggests consigning them to death or nearly certain risk of injury." In fact, exposition means "offering" or "putting out" and is best understood as "exposition." The practice meant removal or separation rather than risk or destruction and "provided a means of removing a child from the family's responsibility, not from life." [11]

According to Boswell, "scholarly studies often conflate infanticide and abandonment"; given that a few abandoned children might die, "moralists exploited this obvious fact, suggesting that expositio was tantamount to infanticide...." However, Boswell's analysis shows that expositio was an alternative to infanticide, and played "an enormously important role" in ancient societies. There was an "overwhelming" expectation that abandoned infants would be taken in by someone and raised as slaves, servants, or very often as "free sons and daughters."

Wealthy women who wished to avoid pregnancy of couples without children would find these infants at a well-known location, the Roman lacteria. During the medieval period, the Church incorporated the practice of expositio "by acting as a clearing house for unwanted children." This practice, instead of infanticide, was the norm in Western history; even in times of severe famine, destitute mothers, rather than killing their infants, brought them to monasteries.

Boswell notes that ancient societies might permit killing of "unhealthy or deformed offspring" but in the medieval period this, for the most part, was not practiced. Instead, monastic literature reveals "constant complaints...about the flood of physically or mentally defective children filling the monasteries: the blind, the lame, one-eyed, one-armed, leprous or deaf children whom parents could not bear to keep." Boswell concludes that Western morality in this area affirms "that humans can triumph over natal adversity and transcend biological limitations."

Rewriting the Historical Tradition

It is doubtful that such a conclusion could be reached by relying on the historical analysis of infanticide in the neonatal literature of this decade. Almost every account draws on a study published in 1978 by Maria W. Piers. Piers' central thesis is that human beings are by nature inclined towards infanticide:

"The total helplessness of the human child at birth and the near endless years of subsequent dependence on adults make him a ready target for their destructive impulses." [12]

Yet there is scanty evidence for this position.

A contrasting view has been expressed by Willard Gaylin, who maintains that the prolonged period of infant helplessness characteristic of the human species favors the development of caring rather than destructive inclinations. [13] In addition, even if the evidence of sociobiology indicates that certain environmentally challenging circumstances might necessitate infanticide, for the most part the parent-child relation is the primary locus of altruism, for the "selfish gene" wants nothing more than to survive the present generation. [14]

Piers's history itself is hardly persuasive. At one point in her analysis, she notes that four infant corpses were discovered one year in an urban sewer system. This evidence leads Piers to the conclusion that parents view their offspring as "strange things--not as fellow human beings or as helpless creatures, but as waste...." [15] Such generally astute ethicists as Silverman, Shelp and Robert W. Weir cite Piers, however, without raising any questions about the validity of her claims.

The recent literature on neonatal ethics has also drawn substantially and uncritically on the views of Lloyd de Mause and Phillipe Aries. De Mause presents a complicated interpretation that identifies certain stages of history in which infanticide was prevalent. The French historian Aries meanwhile concluded that until the seventeenth century, children in the West were "neglected, forsaken or despised." [16]

Professional historians have not been so tolerant of erroneous historiography as have medical ethicists. Linda A. Pollock, whose own important work on the history of parent-child relations is ignored in the literature on neonates, holds that the views of de Mause are so extreme as to be discounted and that Aries's conclusions are unfounded and rest on ambiguous and questionable deductions from paintings of the period. [17] Aries's thesis that parents treated children with disdain is simply unwarranted.

The neonatal literature should reconsider its assumption that the attitudes of parents toward their children underwent a dramatic shift to benevolent care in some prior century. It may well be that the supposed "deviant" attitudes in contemporary Western views of children are not easily substantiated, and that if any obvious shift has occurred, it has been exaggerated. Perhaps there is truth in the claim of sociobiologists that good parental care is selectively adapted for a species with low birth rates and prolonged postnatal caring requirements. In certain societies the destruction of infants under strenuous circumstances or when survival is at stake has occurred. [18] Even so, it is still relevant to raise Pollock's question as to whether socioeconomic factors could even override the genetic bonds to the extent that parents stopped caring for their children in any but the most exceptional cases.

Ethicists must begin to question assumptions indicating that there were periods in Western history when parents "despised" infants and newborns were commonly killed. The monotonous appeal to historians who "appear to be more concerned with finding additional evidence to support the [shift] argument than with critically appraising it" must be interrupted. [19]

If the de Mausean school is to be cited in moral analysis, due consideration should be given to the opposing views of Hanawalt, Helmholtz, and Wrightson, who have concluded that the incidence of infanticide was relatively low in England and throughout Europe. [20] De Mause, for example, maintains that the practice of wet-nursing was common in all classes, and was often intended to allow for the infant's destruction. Wrightson, by contrast, shows that the practice of wet-nursing was confined to the upper classes who could afford it, and that it seldom resulted in infanticide. And, contrary to the de Mausean exaggeration of infant mortality rates in late medieval England, recent studies indicate that "80 to 85 percent" of all infants survived for at least a few years, allowing maternal attachment to develop. Indeed, a considerable number of historical sources used in neonates literature in association with advocacy of active killing of newborns have been shown by later research to be completely unjustified.

Ethicists must be very careful not to oversimplify or selectively use history. In the case of infanticide, suspect historical sources combined with the data of cultural anthropology can significantly undermine the moral conviction that the active killing of infants is wrong. Where there have been instances of infanticide, they ought to be neither the basis of grandiose historical exaggerations nor, more importantly, moral direction.

Prohibiting the Active Killing of

Newborns

While it may in some cases be permissible to withdraw or withhold medical treatments from newborns, there are several reasons why active killing by lethal injection or some other means should be opposed as morally wrong.

First, there is no reason to suppose that in most, if not all cases, the pain felt by some newborns cannot be managed. Recent research has established that the human neonate can respond to pain just as adults do. [21] In the past, it was wrongly assumed that neonates were insufficiently developed neurologically to experience pain. Moreover, as Henry J. Bigelow stated in 1848, it was thought that neonates lacked the "remembrance of pain." [22] Consequently, neonates were not provided analgesic or anesthetic agents. Fortunately, neonatologists are now using various and sophisticated means of pain management. [23] There is nothing joyful about waiting for a newborn--or anyone else for that manner--to die. But death is a fact of life, and we must be very cautious about attributing to imperiled newborns our distress at seeing them linger. In some cases, massive pain management may be called for as part of the supportive care due dying patients generally.

Second, particularly in the field of neonatology, there is tremendous uncertainty in prognosis. Premature infants can surprise caregivers by doing quite well despite an initially dim assessment. Active killing closes the "last door" on such infants and is therefore less acceptable than normal nursing care as a safeguard against mistaken diagnosis or prognosis. This reason applies as well to neonates with congenital impairments: Were a policy of active killing established, a great many potentially healthy children would be deprived of life.

A policy of active killing would, moreover, inevitably be abused. Some physicians have convictions about "fates worse than death" that are by no means universally shared; some parents will want their child killed to serve their own purposes rather than those of the infant. A policy of normal nursing care for the neonate allows for monitoring bias and discrimination.

There is also valid insight in the received wisdom that doctors and nurses should not be agents of death. As Leon Kass has warned in his discussion of the Hippocratic Oath, the healing art must be kept separate from the killing art. [24] If the active killing of impaired neonates were to be condoned, the public perception of the medical healer would certainly be damaged. While revisionists might argue that the distinction between "killing" and "allowing to die" has no moral significance, the public wo uld generally view methods of active killing such as lethal injection as violations of the fundamental professional and moral prohibition against killing.

Finally, the "slippery slope" or "wedge" argument that once active killing is permitted in the medical sphere it will spread to others cannot be entirely ignored. Kuhse and Singer refer to a 1976 Hastings Center Conference on "The Proper Use of the Nazi Analogy in Ethical Debate," and accurately indicate that several participants viewed the German extension of medicalized killing into genocide as a singular experience attributable to Nazi racist ideology. [25] But Daniel Callahan has recently written that the conference has erroneously been "cited as if it provided some definitive repudiation of the Nazi analogy." [26] Consequences are difficult to predict, of course, but there is reason to be wary of any exceptions to the general moral rule against taking life. Respect for life is one of those several basic moral principles that rational persons would consent to through a social contract simply because without it society would collapse into the brutal and utterly insecure "ware of all against all." This basis moral principle is independent of any religious creed and language of "sanctity"; simply put, respect for life is a requirement of any stable social order. No viable society can afford to allow for any but the most absolutely necessary exceptions to the prohibition against one individual taking the life of another. Given the sophistication of pain management and the possibility of various forms of support for the dying, it is difficult to justify a policy of active euthanasia. As Robert Jay Lifton has pointed out in his study of medicalized killing in Germany--which began, incidentally, with the destruction of newborns with impairments--we must always be aware of "our universal potential for murder and genocide." [27]

References

[1] For a negative view on active killing, see Kathleen Nolan, ed., "Imperiled Newborns," Hastings Center Report 17:6 (December 1987), 5-32; for acceptance of active killing, see Helga Kuhse and Peter Singer, Should the Baby Live? The Problem of Handicapped Infants (New York: Oxford University Press, 1985); also Earl E. Shelp, Born to Die? Deciding the Fate of Critically Ill Newborns (New Y ork: Free Press, 1986); and Robert Weir, Selective Nontreatment of Handicapped Newborns (New York; Oxford University Press, 1984).

[2] Kuhse and Singer, Should the Baby Live?, 98-117.

[3] Kuhse and Singer, Should the Baby Live?, 100-104.

[4] Kuhse and Singer, Should the Baby Live?, 108.

[5] Shelp, Born to Die?, 154.

[6] Shelp, Born to Die?, 163-64.

[7] Kuhse and Singer, Should the Baby Live?, 108.

[8] Mary Midgley, "Trying Out One's New Sword," in Vice and Virtue in Everyday Life: Introductory Readings in Ethics, Christina Hoff Sommers, ed. (New York: Harcourt Brace Jovanovich, 1985), 136.

[9] "United Nations Declaration of the Rights of the Child," in Having Children: Philosophical and Legal Reflections on Parenthood, Onora O'Neill and William Ruddick, eds. (New York: Oxford University Press, 1979), 112-14.

[10] William A. Silverman, "Mismatched Attitudes About Neonatal Death," Hastings Center Report 11:6 (December 1981), 12-13.

[11] John Eastburn Boswell, "Expositio and Oblatio: The Bandonment of Children and the Ancient and Medieval Family," The American Historical Review 89:1 (February 1984), 10-33.

[12] Maria W. Piers, Infanticide (New York: W.W. Norton, 1978), 13.

[13h Willard Gaylin, Caring (New York: Avon Books, 1979).

[14] Garret Hardin, "Discriminating Altruisms," Zygon 17:2 (June 1982), 163-86.

[15] Piers, Infanticide, 15.

[16] Lloyd de Mause, "The Evolution of Childhood," in The History of Childhood (London: Souvenir Press, 1976), 1-74; Philippe Aries, Centuries of Childhood: A Social History of Family Life, trans. Robert Baldick (New York: Vintage Books, 1962), 128.

[17] Linda A. Pollock, Forgotten Children: Parent-Child Relations from 1500 to 1990 (Cambridge: Cambridge University Press, 1983), 2.

[18] Glenn Hausfater and Sarah Blaffer Hardy, eds., Infanticide: Comparative and Evolutionary Perspectives (New York: Aldine Publishing Company, 1984).

[19] Pollock, Forgotten Children, 1.

[20] Barbara Hanawalt, "Childrearing Among the Lower Classes of Late Medieval England," Journal of Interdisciplinary History 8:1 (1977), 1-22; R.H. Helmholtz, "Infanticide in the Province of Canterbury during the Fifteenth Century," History of Childhood Quarterly 2 (1975), 379-90; Keith Wrightson, "Infanticide in Early Seventeenth-Century England," Local Population Studies 15 (1975), 10-21.

[21] K.J.S. Anand and P.R. Hickey, "Pain and Its Effects in the Human Neonate and Fetus," New England Journal of Medicine 317:21 (November 19, 1987), 1321-27.

[22] Martin S. Pernick, Letter to the Editor, New York Times, December 17, 1987, A34.

[23] Anne B. Fletcher, "Pain in the Neonate," New England Journal of Medicine 317:21 (November 19, 1987), 1347-1348; Nolan, "Imperiled Newborns," 25.

[24] Leon Kass, Toward a More Natural Science: Biology and Human Affairs (New York: Free Press, 1985).

[25] Kuhse and Singer, Should the Baby Live?, 94.

[26] Daniel Callahan, "At the Center," Hastings Center Report 18:1 (February/March 1988), front cover.

[27] Robert Jay Lifton, The Nazi Doctors: Medical Killing and the Psychology of Genocide (New York: Basic Books, 1986), 503.

Stephen G. Post is assistant professor of biomedical ethics, Case Western Reserve School of Medicine, Cleveland, Ohio.
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