What is a child worth?
Jamie Bulger, a month short of his third birthday, was beaten to death by two ten-year-old boys, having first been dragged for two-and-a-half miles through city streets with an obvious injury to his head. The crime is incomprehensible, but why did not one of the thirty-eight witnesses to that journey intervene to end it?
That failure is in stark contrast to the extraordinary interest in another child from northwest England. Laura Davies was born without a functioning gut; the defect was detected in utero, but abortion was declined. Intravenous feeding produced its side-effect of liver failure. The only hope of survival was a liver and bowel transplant, performed in Pittsburgh in 1992 when she was four years old. In summer 1993, after she rejected that transplant, an experimental transplant of liver, kidneys, pancreas, stomach, and large and small intestine was proposed.
Some, like this author, argued that it was very difficult to see how this second transplant could be in Laura's best interests. It was performed, however, with initial good results. Widespread malignancies then developed rapidly as a side-effect of immunosuppression, and two months after the multiple transplant her parents asked that her life support be switched off. The total cost of her care had been about $1.5 million, most of it raised by appeals to the general public.
Jamie Bulger was not worth a few minutes of anyone's time to find out what was happening and to get him to a place of safety. Laura Davies, with a rare condition from which long-term survival is virtually unknown, received all sorts of support and health care worth fifteen times more than the U.K. National Health Service spends on an average citizen during her entire life. The contrast may be stark but it does not exaggerate the vast differences in the levels of care provided to different children worldwide.
Traditionally, physicians and others have held that the cost of treating an individual does not matter: what is important is to do everything possible for the individual patient. That attitude is not merely blinkered, but dangerous. It feeds a Western greed for health care regardless of the marginal health gains that increasingly expensive technology now produces. Greed for health care is just part of the pattern of the world's richest countries using a totally disproportionate share of the world's resources. Were the whole world to have health care similar to that of Western Europe or North America, it would require two-thirds of total global economic activity to support it!
The blinkers affect bioethicists as much as physicians. Amid all the writings on justice in the distribution of scarce health resources, it is exceedingly rare to find any acknowledgment that if our concepts of justice have any value they must apply equally to humans who have outside the borders of our own countries. A few years ago Robin Attfield, a Quaker philosopher, wrote, "There are specific obligations for medical ethicists to ensure that the international aspects of medical ethics are much more extensively pursued." Onora O'Neill has produced virtually the only response to that challenge, examining what makes international boundaries in the provision of health care.
It is in our failure to value the world's children equitably that one sees the starkest miscarriage of any Western concept of justice. Although the 1980s saw a massive reduction in childhood deaths worldwide from vaccine-preventable diseases, there were still 1.7 million such deaths in 1991, over half of them from measles. UNICEF has calculated that it would cost only $25 billion per annum to
* control the major childhood illnesses
* halve the rate of childhood malnutrition;
* bring clean water and safe sanitation
to all communities;
* make family planning universally
* provide universal primary education;
* thereby reduce child deaths worldwide
by at least 4 million per
The sum needed is less than half that spent by Europeans on cigarettes each year, less than a quarter of the costs of administering U.S. health care. It is less than the interest incurred each year by developing countries on their loans from the West. Yet there has been minimal progress toward those eminently reachable goals since UNICEF started in 1990 to point out how little, relatively, it would cost. The unwillingness to give any value to the lives of children beyond our shores indicates just how empty are the concepts of justice in modern Western philosophy.
[1.] Richard Nicholson,"Dignity and the Doctor's Duty," The (London) Guardian, 2 September 1993. [2.] Robin Attfield, "The Global Distribution of Health Care Resources," Journal of Medical Ethics 16 (1990): 153-56. [3.] Onora O'Neill, "International Justice and Health Care," in Solidarity, Justice and Health Care Priorities, ed. Zbigniew Szawarski and Donald Evans (Linkoping, Sweden: CMT, 1990). [4.] James P. Grant, The State of the World's Children 1993 (Oxford: Oxford University Press for UNICEF, 1993).
Richard H. Nicholson is a physician and editor of the Bulletin of Medical Ethics, London, England.
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|Title Annotation:||medical care for children|
|Author:||Nicholson, Richard H.|
|Publication:||The Hastings Center Report|
|Date:||Jan 1, 1994|
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