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Special Section: The Best Interests of a Child: Problematic Neuroethical Decisions
Introduction: Ethical Debates about Ashley
The case of Ashley, the pillow angel, has been extensively debated in the bioethics and medicolegal literature but continues to pose some important ethical issues relating to the best interests of children with severe developmental abnormalities.1It shares with the ethically challenging issues posed by some cases of conjoined twins an important key problem. In both cases the decisions turn on a plausible and principled clarification of the best interests of a child.2However, the clinical management of such cases and the ethical literature surrounding them has, on occasion, not only failed to focus on the crucial issues but also, to some extent, obscured the key features of the interests that ought to be heeded in such cases.3Because Ashley's case, unlike the more stark trade-off between conjoined twins (one of whom may not be viable), can be viewed as raising many ethical issues (treatment of severely neurologically impaired infants, disability, growth attenuation, the sterilization of children with developmental anomalies, and parental decisionmaking for children), the debates are highly relevant to a wide range of cases that continue to come to the attention of pediatricians and ethicists, and it is worth revisiting the arguments that are commonly rehearsed. I argue that, when we do, two abstract principles emerge that clarify the welfare principle (the primacy of the best interest of a child) and the kernel of the ratio decidendi in cases concerning the care of children.
I propose that the best interests of the child turn on two neo-Aristotelian principles:
1). The potentiality principle, whereby the life due to each and every child is a life in which its potential is given full chance of being actualized.
2). The principle of psychosomatic harmony, whereby each person should be allowed to live a mode of life and enjoy a physical status maximally coherent with his or her psychological constitution (or, for Aristotle, her "soul").
Between them, these ideas have an intuitive appeal in relation to current consensus in medical practice and bear up under philosophical scrutiny. I argue that they uniquely satisfy the requirements of reflective equilibrium in relation to the verdicts they yield.
Conjoined...