Neonatal Euthanasia?

Abstract

To the Editor.—In the September 2005 issue of Pediatrics, Verhagen and Sauer1 again discuss their proposed protocol for euthanizing certain sick neonates. These rules, known as the Groningen Protocol, pertain to infants who would continue to survive after the withdrawal of medical care. Under the protocol, the decision to terminate an infant is based on perceived intractable severe suffering. Rather than performing an in-depth examination of the philosophical, ethical, and moral implications of this protocol, the authors focus on its technical details and acceptability within the European medical community.The ethical backbone of end-of-life decision-making for adults and adolescents is patient autonomy. When considering do-not-resuscitate orders, refusal of treatment, or withdrawal of care, the patient's wishes are held in highest regard. For children unable to comprehend or express their desires, such decisions have traditionally involved the withdrawal of care in light of treatment futility. Patient autonomy has always been the basis for legal euthanasia. In both the Netherlands and the state of Oregon, only voluntary euthanasia is legally permitted: the patient must specifically request to die. The Groningen Protocol centers not on patient self-determination but instead on the perception of the patient's current and future suffering. One wonders why the application of the protocol stops at the nursery door. Using the logic of the authors, a similar protocol could be applied to a 2-year-old devastated by meningococcemia or a 5-year-old in a chronic vegetative state after a motor vehicle crash. One could even apply it to any uncommunicative individual who has not expressed a personal desire regarding end-of-life issues and is presumed to be suffering. The scope and limits of this new approach must be extensively explored both ethically and legally. Although the authors note that an open discussion of these issues is “extremely important,” they fail to initiate it. Alleviation of suffering is an admirable goal, but using this standard rather than patient autonomy represents a major paradigm shift in end-of-life ethical thought.Verhagen and Sauer should be lauded for bringing to public scrutiny a practice that had been performed behind closed doors for many years. Perhaps there is a place for limited nonvoluntary euthanasia, but that decision should not be made without a thorough examination of the ethical and legal ramifications. We hope that thoughtful ethicists and legislators will initiate the open discussion that the authors advocate.