Readers of NRO are by now pretty familiar with the horrific case of Alfie Evans, a British child who died a few days ago, weeks shy of his second birthday. Because I continue to read commentary about the case that appears to me to be based on mistakes — and on misguided thinking that would be relevant to future cases — I wanted to say a few more words about it. As it happens, some of the most misguided commentary I’ve seen on the case has come from Catholic sources who are wrongly applying Catholic teaching in ways that portray the treatment of Evans to seem less horrific than it was, or even justified. But since these confusions also appear among non-Catholics, they too may find it worthwhile to consider them.
Catholics, like reasonable people with different religious convictions, recognize that parental authority over sick children is not absolute and can legitimately be overriden by the government. Catholic teaching recognizes as well that doctors and public authorities are not morally required to do everything possible to keep all sick people alive for as long as possible. Cardinal Vincent Nichols has alluded to both points in his defense of the Alder Hey Hospital and the British courts, and the second point features heavily in the defense by Kevin Clarke for America magazine.
But while it can be justified for government authorities to overrule the medical decisions of parents, its warrant to do so is limited. Nichols carelessly implies that Catholic teaching holds that those authorities may overrule parents whenever they think the parents are wrong about a child’s interests. But Catholicism’s emphases on the importance of family, the duties of parents to their children, and the properly subsidiary role of central authority all buttress the case — again, a case with which reasonable non-Catholics agree — for preferring parental authority in these matters. Parental abuse, neglect, or some similar consideration can justify an override. Nothing of the sort was present in Evans’s case, as British courts repeatedly and to their credit noted. Judges merely asserted that the parents were wrong about Alfie’s interests, misled by their strong albeit understandable emotions.
Likewise, the fact that it is morally permissible to take a patient off a ventilator because the ventilator is causing him pain — even where death is a foreseeable consequence of that decision — does not mean that it is ever morally permissible to take a patient off a ventilator for the purpose of causing his death. The moral permissibility of discontinuing medical treatment under certain circumstances does not mean that it is ever morally permissible to discontinue treatment on the ground that the patient’s disability means that it is not in his interest to continue to live.
Clarke claims that Catholic teaching about medical care distinguishes between “ordinary” and “extraordinary” treatments and that it treats the quality of life of a patient as relevant to the distinction. That’s true: But what it means is that a treatment that reduces the quality of life may be refused; it does not mean that a treatment may be refused because a life is of low quality. An intervention may be refused because it is burdensome, that is, not because it prolongs life with a burdensome condition.
Similarly, an intervention may be declined or discontinued as extraordinary if it is “futile,” meaning that it fails to achieve its proximate end. A treatment is not futile because it will not restore the patient to normal functioning. The ventilator support in Alfie’s case was not futile: It helped to keep him alive. It was terminated because it was working. In the words of the court, it and the other measures could “sustain him for a long time.” But Alder Hey and British courts determined — see below — that Alfie’s life was no longer worth living.
While most people in our society accept that authorities should generally defer to parents about their children’s medical treatment, no broad consensus exists on these other questions: on whether it is permissible to make medical decisions with the purpose of causing death, and on how quality of life should figure in such decisions.
I do not claim that all people of good will agree that it is wrong to try to bring about someone’s death, or to refrain from trying to preserve his life, because he is disabled, even profoundly and permanently disabled, or because he is disabled and likely to experience continued decline. I do claim, however, that this view is in line with Catholic teaching; the views of most pro-lifers, whatever their religious beliefs; and the views of many other people besides. And I further claim that this pro-life, Catholic view is directly at odds with the assumptions that governed Alder Hey and the judges who considered Alfie Evans’s case.
While those governing assumptions pervade this February 20 decision, for example, they are made absolutely explicit in paragraph 46, which explains that life-sustaining treatment for children may be stopped when “the severity of the child’s condition is such that it is difficult or impossible for them to derive benefit from continued life.” The paragraph is, and is presented as, the linchpin of the case, the point where the court is outlining the relevant legal rule. It is reproduced, and treated the same way, in this March 6 decision as well. All the experts agreed that Alfie Evans was extremely unlikely to be cured, to achieve anything close to the normal cognitive functioning of a child of his age, or even to survive very long. The courts, applying British law, quite possibly soundly, ruled that this assessment meant that treatment was pointless.
There is plenty of evidence that the British courts considered his death to be preferable to his continued life on its likely terms, and acted on that preference. His parents disagreed.
Note well: The judgment that treatment should be withheld did not turn on the possibility that it would cause the boy pain. The possibility that transportation to and treatment in the Vatican hospital would cause him pain was raised at various points during the case, but it was a) contra-indicated by the courts’ rulings, when arguing for the pointlessness of treatment, that he was at so low a level of consciousness as not to be capable of pain; and b) not decisive given the legal standard. The judgment did not turn, either, on the courts’ repeated declarations that the child was likely to die as soon as ventilation was removed — a claim that turned out to be false without altering the authorities’ course. The decisive consideration was that Evans’s life was of such low quality as not to be worth saving. That’s not a slander of the position of the British courts and of Alder Hey; it is a statement of their position.
I don’t think that Mark Shea, in his angry attack on everyone who strongly objected to how Alfie Evans and his parents were treated, grasps this point. (There are other points I think he gets wrong, but that’s the most important one.) “There is no evidence, none, of a conspiracy to kill” the boy, he writes. Clarke closes his America article by quoting one of his principal sources saying, “Nobody wants a child to die.”
Both claims are true in the sense that everyone involved in the case would have been delighted if Alfie Evans had somehow made a miraculous recovery and been able to have a life similar to the lives of the vast majority of more-fortunate young boys. But there is plenty of evidence that the British courts considered his death to be preferable to his continued life on its likely terms, and acted on that preference. His parents disagreed. They should have been backed up in that disagreement, especially by Catholics.