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Abortion, infanticide and allowing
babies to die, 40 years on
Julian Savulescu
In January 2012, the Journal of Medical
Ethics published online Giubilini and
Minerva’s paper, ‘After-birth abortion.
Why should the baby live?’.1 The Journal
publishes articles based on the quality of
their argument, their contribution to the
existing literature, and relevance to
current medicine. This article met those
criteria. It created unprecedented global
outrage for a paper published in an aca-
demic medical ethics journal. In this
special issue of the Journal, Giubilini and
Minerva’s paper comes to print along
with 31 articles from some of the best
scholars in the world, from the broadest
range of perspectives on abortion and
infanticide, including those strongly crit-
ical of Giubilini and Minerva.
The killing of a baby is among the most
shocking of human practices. I am
strongly opposed to the legalisation of
infanticide along the lines discussed by
Giubilini and Minerva. But I would like
to explain why a journal of medical ethics
published an article examining infanticide
and now devotes a special issue to bring-
ing a wide range of perspectives for
further examination of these issues.
Infanticide has been practised through-
out human history for various reasons
and continues to be practised today
throughout the world. In rare cases,
infanticide can be practised openly and
legally—for example, as specified under
the ‘Groningen Protocol’, in the
Netherlands. The Groningen Protocol
allows doctors to end the life of neonates
at the request of their parents if the infant
is experiencing hopeless and unbearable
suffering.2
But medical infanticide arguably occurs
elsewhere other than in the Netherlands
today.
In neonatal intensive care, it is not
uncommon for a doctor to withdraw arti-
ficial ventilation with the consequence
that a baby dies.3 If anyone else per-
formed that act, including the parents of
the child, it would be viewed as an act of
homicide, in some cases murder. But
when a doctor performs that act, it is not
Correspondence to Professor Julian Savulescu,
Faculty of Philosophy, The Oxford Uehiro Centre for
Practical Ethics, Suite 8, Littlegate House, Oxford OX1
1PT, UK; julian.savulescu@philosophy.ox.ac.uk
J Med Ethics May 2013 Vol 39 No 5
murder. The active withdrawal of life-
prolonging medical care (an intentional
act that kills, even if not necessarily with
the intention to kill) is a standard part of
medical practice in relation to people who
experience severe disability and suffering,
including newborns. This is the case in
the USA, UK, the rest of Europe and
nearly all of the world. It is sometimes
called ‘selective non-treatment.’
Robert Young argues that the reason
active withdrawal of medical care is not
classified as murder in England is that a
legal judgement in the case of Tony Bland
redefined the act of withdrawing a life-
prolonging medical treatment as an ‘omis-
sion’. If the act of withdrawing a
life-preserving feeding tube (or other
medical treatment) had been properly
described as an act, then it would consti-
tute intentional killing and would have
been murder. Young argues this was a
legal redescription to protect doctors
from charges of murder.4 But withdrawal
of care was practised long before Bland
and not prosecuted.
And, as I have said, anyone else who
acted to withdraw life-prolonging medical
treatment who was not a doctor (or suit-
ably qualified medical professional) would
be judged to have acted in such a way as
to kill, not to be ‘omitting to save life’ or
letting die. The very same act is described
in law as an ‘act’ or an ‘omission’,
depending on whether or not a doctor
performs it. Whether it is right or wrong
might depend on whether a doctor per-
forms it, but the nature of some physical
event cannot logically depend on the
identity of the person involved. A parallel
is that ‘running’ is a certain kind of action
of the body, whether or not a doctor or
someone else is performing it.
Jeff McMahan has argued that with-
drawal of medical treatment is ‘letting
die’, not ‘killing’. He gives the analogy of
a person, call him Jim, swimming out to
rescue a drowning person. If Jim is drag-
ging the drowning person to shore but
changes his mind and releases him, he lets
that person die, but does not kill him.5
However, imagine that Jim sets out in his
boat and takes the drowning person into
it. While on the way to shore, he changes
his mind and throws the person over-
board, back into the sea. That would, in
Editorial
my view, be killing. It is like taking a res-
pirator away. (Of course, it might be justi-
fied to throw the person overboard—the
person might have a lethal contagious
disease and be about to die soon of that
anyway.)
McMahan and some others (eg,
Kamm6) argue that removing aid that one
is oneself providing is stopping saving,
not killing. But in some cases, such as
when Jim throws the drowning person
back out of his boat, refusing to continue
saving a person is morally just as bad as
killing him. The same is true for these
philosophers in some comparisons
between selective non-treatment of infants
and infanticide.
I am not here intending to suggest that
withdrawal of life-sustaining medical
treatment is unethical or should be illegal.
What I am pointing out is that actions to
end the life of newborns are widely prac-
tised and legally sanctioned—although
not called infanticide. Also, there is some
reason to think that these decisions are
made on a different basis from those
made for older children, and that parents
are given a broader discretion in such
decisions. If that is the case, it appears
that the societal antipathy to infanticide is
not as strong as it might seem at first
glance.
Another example of what is arguably
legal infanticide is the lethal separation of
conjoined twins. In a widely publicised
case, in 2000, the twin daughters of the
Maltese couple Michaelangelo and Rina
Attard, Jodie (real name Gracie) and
Mary (Rose), were joined at the pelvis
with a fused spine. The facts of this case
are described by Lord Justice Ward in his
judgement:
Jodie and Mary are conjoined twins.
They each have their own brain, heart
and lungs and other vital organs and
they each have arms and legs. They are
joined at the lower abdomen. … (T)hey
can be successfully separated. But the
operation will kill the weaker twin,
Mary. That is because her lungs and
heart are too deficient to oxygenate and
pump blood through her body. Had she
been born a singleton, she would not
have been viable and resuscitation
would have been abandoned. She would
have died shortly after her birth. She is
alive only because a common artery
enables her sister, who is stronger, to cir-
culate life sustaining oxygenated blood
for both of them. Separation would
require the clamping and then the sever-
ing of that common artery. Within
minutes of doing so Mary will die. Yet if
the operation does not take place, both
will die within three to six months, or
257
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Editorial
perhaps a little longer, because Jodie’s
heart will eventually fail.7
The High Court authorised surgical
separation, knowing that this would kill
Mary. The legal justification for this is
striking.
Mary may have a right to life, but she has
little right to be alive. She is alive because
and only because, to put it bluntly, but
nonetheless accurately, she sucks the life-
blood of Jodie and she sucks the life-
blood out of Jodie. She will survive only
so long as Jodie survives. Jodie will not
survive long because constitutionally she
will not be able to cope. Mary’s parasitic
living will be the cause of Jodie’s ceasing
to live. If Jodie could speak, she would
surely protest, ‘Stop it, Mary, you’re
killing me’. Mary would have no answer
to that. Into my scales of fairness and
justice between the children goes the fact
that nobody but the doctors can help
Jodie. Mary is beyond help.
Hence I am in no doubt at all that the
scales come down heavily in Jodie’s
favour. The best interests of the twins is
to give the chance of life to the child
whose actual bodily condition is capable
of accepting the chance to her advantage
even if that has to be at the cost of the
sacrifice of the life which is so unnatur-
ally supported. I am wholly satisfied that
the least detrimental choice, balancing
the interests of Mary against Jodie and
Jodie against Mary, is to permit the
operation to be performed.8
This was, in my view, the correct judge-
ment and separation was in the interests
of Jodie, much more so than it was
against the interests of Mary. But it is also
my view that it is a convenient fiction to
describe Mary as a parasite using Jodie’s
body as a ‘life-support machine,’ as neo-
natal surgeon Adrian Bianchi reportedly
said.9
Conjoined twins arise when a single
embryo fails to completely divide into
identical twins. Both Mary and Jodie
arose from the same single embryo.
Neither has a greater claim on the shared
organs. Thus, it is my own view that it is
not ‘accurate’ to describe Mary as killing
Jodie. They were both dying because their
anatomy and physiology, as it happened
to develop, could not support both of
their lives. The common artery no more
belonged to Jodie than to Mary. There
were two brains, and so two minds,
sharing vital parts. Mary was killed, sub-
jected to infanticide, to save Jodie. Of
course, Lord Justice Ward did not accept
this view, seeing one twin, Mary, as an
aggressor against whom her sister needed
to be protected by the Court.
258
Another medical practice and example
of selective non-treatment that results in
the death of patients is the withholding of
life-sustaining medical treatment. Recent
articles10 11 and newspaper coverage12
draw attention to the practice of not
feeding severely disabled newborns.
Arguably, this is morally equivalent to
infanticide which, if it occurred outside of
medical practice, might be referred to as
‘starving a baby to death’ for this reason.
If a mother neglected to feed her disabled
baby, she would usually be guilty of a
criminal act. The medical practices of
‘allowing newborns to die’ are the topics
of ongoing ethical debate but are a part of
common medical practice and have been
for several decades.2 4 13 Discussions of
infanticide should be contextualised in
those practices that end life, which society
already accepts, even if they are euphemis-
tically redescribed.
There is a vigorous body of literature
on whether acts resulting in death (active
euthanasia) are morally equivalent to
omissions resulting in death (passive
euthanasia). Some philosophers have
argued that there is no moral difference,14
while others continue to dispute this.
Philippa Foot famously argued that to fail
to send a food parcel to a starving child is
not morally equivalent to sending a poi-
soned food parcel.15 This is a long-
standing debate but does not need to be
resolved to recognise that human beings’
(including infants’) lives are intentionally
shortened in our society. For even if omis-
sions were morally different from actions,
and so withholding life-sustaining treat-
ment morally different from killing, the
withdrawing of medical treatment is an
intentional action,4 16 though this is
denied by some.6 7 Withdrawing medical
treatment might be like a person acting to
intercept a food parcel sent to a starving
child, intentionally causing the death of
that child. It is an intentional act that
knowingly causes the death of the child.
Even if we can ignore omissions resulting
in death, it is important to ethically evalu-
ate the practice of the withdrawal of
medical treatment that results in death.
The ethical discussion of infanticide
dates back several thousand years. At least
100 articles have been published on
infanticide in the Journal of Medical
Ethics over its rather shorter history, with
articles both for and many against it.
Some of the world’s most famous living
philosophers have written about its merits
and justification over the last 40 years,
including Michael Tooley,17 Jonathan
Glover,18 Peter Singer,13 19 Jeff
McMahan5 20 and John Harris.21 Four of
these five have contributed to this issue.
McMahan argues that the permissibility
of infanticide in some circumstances is not
only implied by certain theories, but by
beliefs that are widely held and difficult to
reject.22 Michael Tooley’s book is entitled
Abortion and infanticide. Peter Singer
wrote a book in 1985 with Helga Kuhse
called Should the baby live?
Over the last 40 years, there has been
an active debate on the ethics of killing or
allowing severely ill or disabled newborns
to die. Jonathan Glover’s landmark
Causing death and saving lives notes that
‘Dr Francis Crick (the Nobel Laureate
who discovered DNA with Jim Watson in
1956) once proposed a two-day period
for detecting abnormalities, after which
infanticide would not be permissible’.22
Such debates are a continuation of very
ancient theological and philosophical
debates on abortion, on whether there is a
moral difference between the effects of
acts and omissions, on ‘ordinary and
extraordinary means’ and on ‘double
effect’—whether there is a moral differ-
ence between the effects of actions that
are intentional and those that are merely
foreseen, but not intended.
In the case of abortion, termination of
pregnancy is now permissible in many
countries not only for severe disability but
also for reasons of maternal welfare (or
other reasons). Giubilini and Minerva
extend the long-running debate on
infanticide to ask: if abortion is permis-
sible both for social as well as medical
reasons, why is infanticide permissible
only for medical reasons (assuming that
selective non-treatment is a form of
infanticide)? They ask: what is the moral
difference between a fetus and a neonate?
As McMahan points out in this issue,
there is at least a 4-month period during
which a human being could be either a
fetus or an infant, depending on whether
delivery has yet taken place.23 Giubilini
and Minerva point out that both have
similar capacities and if one is permissible,
why not the other? The presence of
disease or disability should not make a
difference to moral status, so if infanticide
is permissible for medical reasons, why is
it not permissible for social reasons?
Their extension of the existing debate
about infanticide from medical indications
to social indications is relatively novel.
I personally don’t agree with the authors’
conclusion. (One obvious difference
between early abortion and infanticide is
that infanticide involves killing a human
being who could be adopted or cared for
by people other than the mother. Indeed,
I have previously argued on this basis that
J Med Ethics May 2013 Vol 39 No 5
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we should encourage the donation of
excess frozen embryos produced by IVF
to non-genetically related parents rather
than discarding them.24) The important
debate is rather about the nature, permis-
sibility and limits of euthanasia in society.
But their arguments—based on the similar
moral status of the fetus and neonate—
call for rebuttal. (Of course their argu-
ment can cut both ways—I understand
that one relatively common response
amongst the online community was to
assume the paper was written from a
pro-life perspective as a reductio ad absur-
dum of the permissibility of abortion.)
Giubilini and Minerva’s paper was
handled by Associate Editor Professor
Ken Boyd, a distinguished theologian and
medical ethicist with over 10 years editor-
ial experience with the Journal. It was
scrutinised by three peer reviewers and
revised in light of their comments. The
Journal neither publishes nor declines to
publish articles because of the controver-
sial nature of their conclusion; rather, edi-
torial decisions are made on the basis of
the quality of the argument. If an argu-
ment were based on clearly mistaken
premises or obvious failings in logic, then
we would expect the review process to
detect it and require its correction or
reject the paper. But in this case, there has
been a long and ongoing debate on the
moral status of early human life—includ-
ing neonates—and many protagonists in
this debate have taken the same premises
seriously, or even endorsed them, and
have made similar logical inferences.
The Journal aims in this issue to
promote further and more extensive
rational debate concerning this
J Med Ethics May 2013 Vol 39 No 5
controversial and important topic by pro-
viding a range of arguments from a
variety of perspectives. We have tried to
be as inclusive as possible and provided a
double issue to include as many as pos-
sible of the submissions we received.
Infanticide is an important issue and
one worthy of scholarly attention because
it touches on an area of concern that few
societies have had the courage to tackle
honestly and openly: euthanasia. We hope
that the papers in this issue will stimulate
ethical reflection on practices of euthan-
asia that are occurring and its proper justi-
fication and limits.
Contributors Thanks to Ingmar Persson, Jeff
McMahan, Peter Singer, Raanan Gillon, Guy Kahane,
Imogen Goold, Tom Douglas and Dominic Wilkinson.
Competing interests None.
Provenance and peer review Commissioned;
internally peer reviewed.
To cite Savulescu J. J Med Ethics 2013;39:257–259.
Received 4 February 2013
Accepted 26 February 2013
J Med Ethics 2013;39:257–259.
doi:10.1136/medethics-2013-101404
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Abortion, infanticide and allowing babies to

die, 40 years on
Julian Savulescu

J Med Ethics 2013 39: 257-259

doi: 10.1136/medethics-2013-101404

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http://jme.bmj.com/content/39/5/257

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