Problems of birth defects, from Hippocrates to thalidomide and after : original papers / with commentaries by T.V.N. Persaud.

Date:
1977
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Licence: Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)

Credit: Problems of birth defects, from Hippocrates to thalidomide and after : original papers / with commentaries by T.V.N. Persaud. Source: Wellcome Collection.

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    3H5 From R В. Zíiclidry (1968). Lancet, ii, 274-276, Copyri^t (1968), by kind permission of the author and The Lancet Ltd ETHICAL AND SOCIAL ASPECTS OF TRE.\TMENT OF SPINA BIFIDA* R. B. Zachary M B. Leeds, F.R.C.S. CONSULTANT P.tDIATRIC SURGEON, CHILDREN'S HOSPITAL, SHEFFIELD SlO 3BR In our society the actions of one individual towards another are not without their effect on the rest of the community. Our plans of action in the treatment of myelomeningocele and their attainment are directed in the first place to the patient, but there are also important and significant effects on the family and on the community. Although we acknowledge and accept these wider effects of our treatment, we have always thought that our primary duty is to the patient, and that the most important decision is to do what is right and best for him. I shall therefore consider first the question of the treatment of the patient and afterwards the important social implications of this treatment. the child The first and the most serious ethical problem arising in the case of a child with myelomeningocele is whether he should receive medical treatment or not. The relative merits of early operation, secondary operation, or no operation at all, can only be decided when this basic principle has been established. When a baby is born with a serious spina bifida (i.e., a myelomeningocele with a plaque of neural tissue exposed on the surface and with all the associated complications) there are three possible lines of thought: (1) he should be killed; (2) he should be encouraged to die, either by giving no treatment at all (e.g., no feeding) or by not treating complications (e.g., no treatment of infection by anti¬ biotics); or (3) he should be encouraged to live. • Extended from an address given to the Société Française de Chirurgie Infantile, in Lausanne, on June 8. The ethical principle that the direct and deliberate killing of a human being is wrong is widely accepted on a religious and philosophical basis, and has been the basis of medical practice since the time of Hippocrates, and even earlier. (I am talking of medical matters here, not of crime and war.) The second alternative has no better justification. To leave a child without food is to kill it as deliberately and directly as if one was cutting its throat. Even the prescribing of antibiotics for infection, such as pneumonia, must now be considered as ordinary care of patients. Once the principle has been established that the child should be encouraged to live, we are then in a position to consider which method of management gives the child the best chance to live, and secondly, which method of treatment will reduce the handicap to a minimum. There is a widely held but mistaken view that the purpose of early operation in myelomeningocele is to save the child's life—that if operation is undertaken the child will live, and if operation is not undertaken the child will die. Pœdiatric surgeons will at once recognise that this is untrue, and that it contrasts with the treatment of many other congenital abnormalities. For example, in œsoph- ageal atresia we know for certain that the child will die unless a neonatal operation is undertaken, but quite a number of patients with myelomeningocele survive without any operation at all on the back, and some die as a direct result of operation when otherwise they might have survived. In other words, there is no necessary connection between early operation and survival. It is true that in a large series of cases treated with and without operation, the results favour surgery as far as monality is concerned. Yet this is probably not a valid reflection of the effect of operation on survival-rates. Surgical patients are receiving active treatment from all points of view : infections are treated vigorously whether they are local infections, systemic infections, or ventriculitis, and the child will probably be getting better attention to the renal tract than those who are receiving no treatment at all. I do not think it has been proved, from a concurrent study of two large series of cases, that the mortality is less in those receiving early operation than in those who do not have early operation but, in every other respect, receive the same care and attention as the surgical series.