New horizons in medical ethics. Severely malformed children

Results of treatment in myelomeningocele

A follow-up study was made in 48 surviving children with myelomeningocele, the material being derived from a time when all infants were operated upon in the newborn period without primary selection. The follow-up revealed several children with severe physical handicap, whereas relatively few were both physically and intellectually handicapped. The results were compared with two earlier published studies of which one from Sheffield comprised cases where selection had not been applied and the other from Edinburgh in which certain criteria had been set up as contra-indications to early closure of the lesion. The effect of a hypothetical selection applied to the Swedish material is discussed. It is recommended that a uniform system of assessment in grading of handicap is applied to facilitate a comparison between different follow-up investigations.

Ethical problems in the management of myelomeningocele and hydrocephalus. The Milroy Lecture 1975

Within the last generation the application of major advances in drug therapy, intensive care, transfusion techniques, surgery, anaesthesia, and radiotherapy, together with a vast expansion of knowledge due to increased investigative facilities, have led to an unprecedented, dramatic and beneficial increase in the number of persons who would previously have died, or lived with severe handicaps, but can now be cured. Techniques have also been developed to prolong the lives of many people who are now able to enjoy several extra years of productive and meaningful existence, and to alleviate and improve the quality of life of many seriously handicapped persons, enabling them to become integrated as useful and contented members of the community. Choosing from numerous examples of paediatric experience, it is notable that many more extremely premature infants now survive without physical or intellectual damage; infection can almost always be cured, including neonatal and all other forms of pyogenic meningitis and the now rare cases of tuberculous meningitis and miliary tuberculosis. The few remaining new cases of Rh-haemolytic disease are also readily cured. There are outstanding successes in the treatment of childhood malignancy. Paediatric surgery has made great strides. The prognosis of congenital heart disease, of obstructions of the alimentary canal and many other conditions has improved beyond recognition. Unfortunately, the indiscriminate use of advanced techniques of all types has also kept alive those who would have died but now live with distressing physical or mental handicaps or both, often for many years, without hope of ever having an independent existence compatible with human dignity. There are many examples, including those who have sustained major brain or spinal cord injuries.

Brave new world?

Recent developments in biology and medicine are raising new problems in the prevention and treatment of birth defects, and in research on these diseases. The problems include immediate issues such as genetic counseling, abortion for birth defects, the withholding of complex treatments from individuals in some situations, screening for genetic and other diseases, artificial insemination, and fertilization in vitro. Other problems, such as the dysgenic effects of modern medicine and the possibilities of cloning and gene therapy, are more remote. Each of these issues should be considered on its own merits and by its immediate and remote consequences rather than by a priori absolute criteria. Ways must be found to deal with these issues in a manner acceptable to most human beings. Open discussions and freedom from coercion are the best guarantees for ultimate success. The ethical human brain is the highest accomplishment of biologic evolution. By harmonizing our scientific, cultural, and ethical capabilities, the potentially achievable results can place us at the threshold of a new era of better health and less human suffering.

Parental involvement in the decision to treat spina bifida cystica

Twenty couples whose newborn baby had an open myelomeningocoele were given a detailed account of the baby's clinical state and likely future by the paediatrician. They each said how they wanted their child treated. I believe a high percentage of parents would like to be involved in the decision on how to treat their spina bifida baby. When parents are given all the facts (including an interpretation of the clinical assessment) by an experienced doctor-and who better for the job than the paediatrician-then the chances of reaching the right decision for child and family which that joint consultation offers are greater than when the doctor has to act as adviser and sole adjudicator.