Should we have on-call philosophers in midwifery? Philippa Foot (1920–2010) suggested that just as we summon a plumber to fix a leaking tap, a ‘jobbing philosopher’ could be called when ethical issues show signs of getting out of hand (Foot, 1986).
But philosophers think differently about many things. For example, Professor Peter Singer's views may be inferred from the title of the fourth chapter of his book ‘Practical ethics’ (Singer, 1979) – ‘What's wrong with killing?’ – the last sentence of which contends that ‘the life of a being that has no conscious experiences is of no intrinsic value.’ Arguably, this echoes the views expressed in the book ‘Release and Destruction of Lives Not Worth Living’ published in 1920 by Alfred Hoche and Rudolf Binding – professors of medicine and law, respectively – who asserted that the right to live ‘must be earned and justified, not dogmatically assumed’ (Proctor, 1988).
So, when Wilkinson et al (2020) ask whether extremely preter m infants should receive chest compressions and/or epinephrine, how might a ‘jobbing philosopher’ who shares Professor Singer's views be welcomed in the delivery room? But leaving philosophers outside the delivery room means that those left inside have an ethical dilemma to address.
Wilkinson et al (2020) point out that, in 2009, the British Association of Perinatal Medicine recommended against advanced resuscitation measures (delivery room cardiopulmonary resuscitation) in extremely preterm infants, citing no evidence supporting epinephrine by any route, or chest compressions, during resuscitation at gestational age of less than 26 weeks. Yet a decade later the opposite conclusion was reached, with a working group recommending the application of newborn resuscitation algorithms as used in more mature babies. This, as Wilkinson et al (2020) observe, ‘was one of the more controversial elements of the new framework, generating a number of comments during the consultation phase’.
Epinephrine was one of the 30 most used medications on infants born between 22–24 weeks of gestation when Puia-Dumitrescu et al (2020) evaluated their use on 7 578 infants from 195 sites. The commonest morbidities were bronchopulmonary dysplasia (41%) and grade III or IV intraventricular haemorrhage (20%), with overall survival ranging from 46%−57%.
However, Mercurio (2009) highlights one of many problems associated with reported survival at 22 and 23 weeks: the self-fulfilling prophecy, whereby if newborn resuscitation is rarely or never provided for 22-week-old infants, their survival statistics for that age approach zero. When trying to decide whether resuscitation of a 22-week-old infant should be attempted or withheld for ethical reasons however, Mercurio (2009) suggests that the question should not be about survival statistics for all such infants born at that gestational age: ‘Rather, the relevant question is “what would be the chance of survival if we tried?”’
Vogelstein (2020) states that while it is one matter to assert that in some cases newborn resuscitation might not be in the best interests of the child, it is another matter to provide sound reasons when that is the case. Using the mathematical tool of ‘expected value analysis’, Vogelstein (2020) shows how this works; argues that newborn resuscitation serves the best interests of extremely preterm babies in a greater range of cases than is often thought; and concludes that ‘if we want to act in the best interests of the child, then – as a matter of course – we ought to save the lives of even the youngest viable micro-preemies: those born at 22 weeks’ gestational age.’
But what are ‘the best interests of the child’? Sklansky (2001) states that our most considered moral judgments should be reflected in, but not defined by, the law and that the optimal legal solution should include a decision-making process which minimises the risk of abuses and mistakes. But, significantly, ‘specific criteria for the “best interests of the newborn” should not and cannot be enumerated by the law’ (Sklansky, 2001).
Establishing the best interests of the newborn requires medical, midwifery and parental input; the case for input from ‘jobbing philosophers' is not a compelling one.