IV. CASES OF CONFLICT: WHO SHOULD DECIDE?
I think you will all remember the dilemma several years ago over the conjoined twins “Mary” and “Jodie”. If they were left without an operation, both would die. There was no chance of saving Mary, but Jodie could be saved. But the operation that would save Jodie would kill Mary. The parents were opposed to the operation, but the courts allowed the medical team to carry it out.
I was one of those who thought that, if I had to take part in such a decision about children of mine, I would support the operation. One of the babies would be saved rather than neither of them. But I still regretted the courts’ judgement. They were not my children and the couple whose children they were thought differently from me. I thought their view should have been respected.
One reason for this is that they would have to live with the results. Their lives would be affected to a degree far surpassing any effects on the lives of the medical or legal people who became involved in the decision.
Another reason is that the parents came from another culture. Most of us in this country are unlikely to have anything like their understanding of the support that would or would not be available in their country for them and their surviving daughter. They also will have known the moral climate of their society, and how far the response to the decision to operate would be supportive or hostile.
But there is a more general reason, independent of those circumstances of that particular case, for respecting the views of parents in such a decision. For parents, the decision is about their lives and those of their children. I have mentioned Thomas Murray’s point that in parents’ concern for their children, self-interest and altruism become hopelessly blurred. Either way, the parents will have an intensity of emotional involvement unmatched by any of the medical or legal professionals.
Sometimes this is cited as part of the case for giving greater weight to the professional judgements, undistorted by emotional bias. But there are reasons for being cautious about this. The professionals aim to reach a group or committee decision. But this means that no one of them need feel any intense sense of personal responsibility for the decision. I have sometimes sat on academic committees where we have reached decisions that perhaps none of us would have taken if we had to make them on our own. There is a lightness to the committee vote that does not necessarily give better results than the anguished decision of an involved parent.
More generally, there are reasons for doubting the view that emotions are primarily distorting of rational judgment. There are reasons for thinking that emotional responses play a valuable part in much decision making.
In artificial intelligence there is the “frame problem”. If an intelligent machine is asked to perform a simple task, such as fetching a package, and given access to whatever information it wants about all the alternative strategies, it may never actually start the job. After several years, it may still be calculating that going out of the door will have no effect on the number of geese in Canada or on the price of vodka in Poland. Difficulties in the project of designing a satisfactory relevance detector for such a machine have given support to the suggestion that, in people, emotional responses may function as relevance-prompts. There may be no general intellectual strategy for a relevance search. Instead we may notice a lot of what is relevant by its “feel”.
The work of Antonio Damasio 7 has brought the cognitive role of emotions in human decisions into prominence. He describes the case of “Elliot”, who had undergone surgery to remove a brain tumour. After the operation he seemed incapable of completing tasks to time. The job might be to read and classify some documents: “he might spend a whole afternoon deliberating on which principle of categorization should be applied. Should it be date, size of document, pertinence to the case or another?” Elliot seems the frame problem come to life. His neurological condition left his intellectual abilities unimpaired, except that he was unable to plan activities over time and to take decisions. He was also emotionally blank. He no longer felt the emotional responses that used to come before his operation. Damasio links the emotional blankness with the inability to take decisions: “I began to think that the cold-bloodedness of Elliot’s reasoning prevented him from assigning different values to different options, and made his decision-making landscape hopelessly flat”.
Of course, I do not want to suggest that the decision-making landscape of a medical team or of judges in court is hopelessly flat. But there is something to be said for the view that, when parents are properly informed about the medical issues, the degree of concern and emotional involvement they have may deepen rather than disrupt the decision they reach.
Of course the ideal is for the parents and the medical team to agree, and I am sure that many medical teams put a lot of effort in trying to bring this about. And, where there are deep and irresolvable differences, the courts are rightly the judgement of last resort. Where there is parental commitment (for religious or other reasons) to a “life at all costs” view, there is a need for the child to be protected from having to pay those costs through a prolonged period of agony or distress. And this may be the right view to take of the two court cases with which this lecture started.
But the impersonality of a court decision should be avoided if possible. Dame Elizabeth Butler Sloss said that the mother has a duty to “listen to what is proposed by those who have a great deal of medical and nursing experience”. She was right to say this. But it is not wrong to add a footnote to what she said. The medical team also should listen to those whose thinking has the peculiar intensity and weight that comes with the involvement and intimacy of being a parent.